bluuebunny/crossref_metadata_2025 huggingface dataset:
Characteristics of patients with abnormal stress technetium Tc 99m sestamibi SPECT studies without significant coronary artery diameter stenoses
Authors: Ammann Peter , Naegeli Barbara , Rickli Hans , Buchholz Susanne , Mury Raymond , Schuiki Ernst , Bertel Osmund
Published: June 2007

Background: Single‐photon emission computed tomography (SPECT) sestamibi (MIBI) is an excellent tool for detection of coronary artery disease (CAD), preoperative risk assessment, and follow‐up management after coronary revas‐cularization. While the sensitivity of MIBI SPECT for detecting CAD has been reported to exceed 90%, the specificity ranges between 53–100%.

Hypothesis: The study was undertaken to assess characteristics of patients with abnormal stress technetium Tc 99m sestamibi SPECT (MIBI) studies without significant coronary artery diameter stenoses (< 50%).

Methods: Between January 1999 and November 2000, 270 consecutive patients were referred for coronary angiography due to reversible MIBI uptake defects during exercise. In 41 patients (15%; 39% women, mean age 59 ± 9 years), reversible MIBI uptake defects were assessed although coronary angiography showed no significant CAD. These patients were compared with age‐ and gender‐matched patients with perfusion abnormalities (39% women, mean age 60 ± 9 years), due to significant CAD (coronary artery stenosis > 50%).

Results: There were no significant differences between the two groups regarding body mass index, left bundle‐branch block (LBBB), or method of stress test (dipyridamole in patients with LBBB or physical inactivity [n= 11] and exercise in all the others [n= 30]). Left ventricular hypertrophy (44 vs. 23%, p = 0.05) and left anterior fascicularblock (LAFB) (17 vs. 0%, p = 0.005) were more common in patients with perfusion abnormalities with no significant CAD, whereas ST‐segment depression during exercise (17 vs. 37% p = 0.05) and angina during exercise (15 vs. 29%, p = 0.02) were significantly less common than in patients with abnormal MIBI perfusion studies and angiographically significant CAD. Sestamibi uptake defects during exercise were significantly smaller in patients without significant CAD than in matched controls with significant CAD (p < 0.0004).

Conclusion: Of 270 consecutive patients, 41 (15%) referred to coronary angiography due to reversible MIBI uptake defects showed coronary artery stenoses <50%. Twenty‐six (10%) of these presented angiographically normal coronary arteries. The significantly higher proportion of left ventricular hypertrophy and LAFB in patients with reversible MIBI uptake defects without significant CAD suggest microvascular disease, angiographically underestimated CAD, and conduction abnormalities as underlying mechanisms.
Additive value of low‐dose dobutamine to technetium‐99m sestamibi‐gated single‐photon emission computed tomography for prediction of wall motion improvement in patients undergoing coronary artery bypass graft
Authors: Zafrir Nili , Arditi Alexander , Ben‐Gal Tuvia , Solodky Alejandro , Hassid Yosef , Sulkes Jaqueline , Battler Alexander
Published: June 2007

Background: The two most useful methods for myocardial viability assessment are perfusion imaging and dobutamine echocardiography.

Hypothesis: The present study investigated the additive value of a new method, dobutamine technetium 99m (99mTc)‐sestamibi‐gated single‐photon emission computed tomography (SPECT), which combines these two modalities, to the prediction of wall motion improvement after revascularization.

Methods: Fifty‐five consecutive patients with ischemic cardiomyopathy, who were referred for viability evaluation, underwent resting and dobutamine (dose, 5–10 μkg/kg/min) gated SPECT with 99mTc‐sestamibi. Of these patients, 36 underwent coronary artery bypass graft (CABG) within 1 month of the study and 32 had repeat resting gated SPECT within 1 year. Global and regional wall motion, wall thickness, and perfusion were simultaneously analyzed at rest and after dobutamine using the 20‐segment model; the sestamibi uptake and wall motion response to dobutamine of each segment were rated quantitatively. Based on these findings, the segments were categorized as normal, viable, or nonviable. The predictive values for wall motion improvement were assessed by perfusion, using cutoffs of 50 and 60% of sestamibi uptake, and thereafter by the addition of dobutamine response in the segments that were rated nonviable.

Results: Of the 1,080 myocardial segments studied, 906 (84%) had abnormal wall motion and were analyzed for viability. Concordance between perfusion and wall motion response to dobutamine was 60% with the 50% cutoff of sestamibi uptake, and increased to 65% with the 60% sestamibi cutoff (p < 0.04). The respective predictive values of wall motion improvement using the 50 and 60% cutoff points were as follows: sensitivity 93 and 70%, respectively, (p<0.01); specificity 59 and 86% (p < 0.001), respectively; accuracy 77% for both. The addition of the wall motion response to dobutamine to the assessment of the nonviable segments by perfusion (60% cutoff) increased the sensitivity from 70 to 85% (p = 0.001) and the negative predictive value from 70 to 81% (p = 0.009); the positive predictive value remained high (86 vs. 82%). No additive value of wall motion response to dobutamine was demonstrated for nonviable segments by perfusion with a 50% cutoff.

Conclusion: Dobutamine sestamibi‐gated SPECT is a feasible method for the analysis of myocardial perfusion, function, and contractile reserve of individual myocardial segments in patients with ischemic cardiomyopathy. Viability assessment based on a threshold of 60% uptake of sestamibi, with the addition of the wall motion response to dobutamine in the nonviable segments, seems to yield better predictive values for wall motion improvement after CABG.
Osborn waves in the electrocardiogram, hypothermia not due to exposure, and death due to diabetic ketoacidosis
Authors: Sheikh Abdul M. , Hurst J. Willis
Published: June 2007

Hypothermia usually occurs because a patient has been exposed to a cold environment; however, a number of nonenvironmental conditions may produce hypothermia. This report relates the clinical course of a patient whose hypothermia was due to severe diabetic ketoacidosis. In addition, we review the causes of hypothermia and Osborn waves beyond exposure to cold temperature. Hypothermia due to diabetic ketoacidosis is an uncommon complication of a common disease that carries with it clinically significant consequences. Accordingly, we believe that all clinicians should be aware of this potential complication of diabetic ketoacidosis and should be able to recognize the importance of the electrocardiogram in such patients.
Association of aortic valve sclerosis and coronary artery disease in patients with severe nonischemic mitral regurgitation
Authors: Rossi Andrea , Bertagnolli Gerald , Cicoira Mariantonietta , Golia Giorgio , Zanolla Luisa , Santini Francesco , Cemin Claudio , Ferrario Gabriele , Zardini Piero
Published: June 2007

Background: The presence of aortic valve sclerosis accounts for a higher rate of ischemic events and increased cardiovascular mortality. It may reflect coronary artery disease (CAD) because of a shared pathologic background.

Hypothesis: We aimed to analyze whether the presence of aortic valve sclerosis might help in identifying patients with coronary atherosclerosis among those with severe nonischemic mitral regurgitation (MR), who undergo coronary angiography before surgery for screening, and not because of suspected ischemic heart disease.

Methods: In all, 84 patients (mean age 64 ± 9 years; 71% men) with mitral valve prolapse and severe regurgitation underwent echocardiography and coronary angiography. Aortic valve sclerosis was defined as focal areas of increased echogenicity and thickening of the leaflets without restriction of leaflet motion on echocardiography. Coronary artery disease was defined by the presence/absence of atherosclerotic plaques, independent of the degree of stenosis.

Results: Coronary artery disease was diagnosed in 47.6% of patients with and 15.8% of those without aortic valve sclerosis (p = 0.008). On logistic regression analysis, the presence of aortic valve sclerosis predicted CAD (odds ratio 3.3,95% confidence interval 1.03‐10.5; p = 0.04) independent of age. In female patients, the risk ratio for CAD in the presence of aortic valve sclerosis was 9.

Conclusions: Coronary artery atherosclerosis and aortic valve sclerosis are closely associated in patients with severe nonischemic MR.
Optimizing adjunctive antithrombotic therapy in the treatment of acute myocardial infarction: A role for low‐molecular‐weight heparin
Authors: Brieger David
Published: June 2007

Thrombotic complications account for a large proportion of in‐hospital deaths from acute myocardial infarction (MI). Although thrombolytic therapy has greatly improved clinical outcomes following MI, thrombin released during clot lysis has a prothrombotic effect, and the thrombolytic agents themselves may directly activate platelets. Antithrombotic therapy as an adjunct to thrombolysis improves the speed and extent of artery recanalization and reduces the incidence of secondary ischemic complications. The current treatment standard is unfractionated heparin (UFH) administered intravenously for 24‐48 h. However, UFH has not been unequivocally shown to improve outcomes in large‐scale, randomized clinical trials, and shows no evidence of benefit when used as an adjunct to streptokinase‐based thrombolysis. Unfractionated heparin also has several clinical and practical disadvantages, such as the need for coagulation monitoring, difficulties attaining a stable and reliable anticoagulant effect, and the risk of hemorrhagic side effects. Low‐molecular‐weight heparin (LMWH) represents a safe and effective alternative antithrombotic therapy, with a stable and predictable anticoagulant effect, potential for use in combination with either fibrin‐specific or streptokinase‐based thrombolysis, no need for anticoagulation monitoring, and a low risk of hemorrhagic and other heparin‐related complications. Several randomized clinical trials have shown that adjunctive LMWH is at least as effective as UFH in the acute phase of MI, is associated with fewer in‐hospital recurrent ischemic events, and has an acceptable safety profile.
Marked low‐density lipoprotein cholesterol reduction below current national cholesterol education program targets provides the greatest reduction in carotid atherosclerosis
Authors: Kent Steven M. , Coyle Louis C. , Flaherty Patrick J. , Markwood Thor T. , Taylor Allen J.
Published: June 2007

Background: Current National Cholesterol Education Program (NCEP) guidelines recognize low‐density lipoprotein cholesterol (LDL‐C) below 100 mg/dl as an optimal level. Evidence supporting this is scant. Both LDL‐C and C reactive protein (CRP) are known correlates of atherosclerosis progression.

Hypothesis: We examined the effect of final LDL‐C and CRP obtained with statin therapy on carotid intima‐media thickness (CIMT), a valid surrogate for clinical benefit of lipid‐lowering therapies.

Methods: In a randomized, single‐center trial, 161 patients were assigned to statin therapy of different potencies (pravastatin 40 mg, n = 82; atorvastatin 80 mg, n=79). The effects on CIMT were assessed in relationship to LDL‐C and CRP levels obtained after 12 months of therapy.

Results: Changes in CIMT were directly related to the final LDL‐C level obtained on statin therapy after 12 months (R = 0.219, p = 0.015). Carotid intima‐media thickness regression was seen in 61% of the subjects in the lowest quartile of final LDL‐C (≤ 70 mg/dl) versus 29% of the subjects with the highest quartile of final LDL‐C (≥ 114 mg/dl, p = 0.008). No threshold value was seen, with more favorable effects on absolute change in CIMT with lower values of LDL‐C (decrease in CIMT of 0.06 ±0.17 mm in the lowest quartile compared with an increase of 0.06 ± 0.09 in the highest quartile of LDL‐C, p = 0.008). On‐treatment LDL and CRP concentrations both below the group median values were associated with the greatest likelihood of CIMT regression.

Conclusions: Regression of carotid atherosclerosis is directly related to the absolute LDL‐C level on statin therapy. The greatest regression was obtained with an LDL‐C <70 mg/dl, supporting marked LDL‐C reduction to levels below current NCEP guidelines.
Comparison of hemostatic activation created by right‐ and left‐heart radiofrequency catheter ablation
Authors: Charng Min‐Ji , Lin Yenn‐Jiang , Chiu Ting‐Yu , Cheng Chien‐Min , Ding Philip Yu‐An
Published: June 2007

Background: Thromboembolic complications commonly occur in radiofrequency (RF) ablation procedures (0.6‐1.3% of cases). Comparison of hemostatic activation between left and right RF ablation is limited.

Hypothesis: The purpose of this study was to evaluate platelet and hemostatic activation before, immediately after, and 48 h following left and right myocardial RF ablation procedures.

Methods: The subjects were two groups of patients who underwent right‐heart (24 patients) and left‐heart (20 patients) RF ablation. Blood samples taken before, immediately after, and 48 h after the procedure were tested for changes in platelet and hemostatic activation.

Results: No indication of clinically symptomatic thrombo‐embolism and no major differences in baseline characteristics and procedure were apparent in either group, except for a higher temperature mode setting (p < 0.001) in the left‐heart group. The hemostatic evaluation levels increased significantly by the end of the procedure in both groups and the platelet activation level remained elevated for 48 h after the procedure. The platelet activation level increased insignificantly at the end and 48 h after the procedure. Of the other changes in levels of platelet and hemostatic activation, only an increase in one of the hemostatic levels in the right‐heart group at 48 h after procedure was significant (p = 0.01).

Conclusions: Our findings suggest that similar hemostatic activation occurred during and immediately after RF ablation in both groups. Sustained elevation of the hemostatic marker after the ablation procedure in the right‐heart group was observed as of significant therapeutic and prognostic implications.
Do the right precordial leads during exercise testing contribute to detection of coronary artery disease?
Authors: Ueshima Kenji , Kobayashi Noboru , Kamata Junya , Saitoh Masahiko , Yamazaki Takuya , Chiba Ikuo , Hiramori Katsuhiko
Published: June 2007

Background: It is still unknown whether or not the additional right precordial leads (RPL) during exercise testing contribute to detection of coronary artery disease (CAD).

Hypothesis: The aim of this study was to evaluate the RPL during exercise testing for the detection of CAD.

Methods: The study included 157 consecutive patients (116 men and 41 women, mean age 66 years) suspected of having CAD, who underwent conclusive treadmill exercise testing (heart rate reached at least 85% of the predicted maximum or positive electrocardiogram [ECG] changes were exhibited) and coronary angiography. During exercise testing, the ECG was recorded with the standard 12 leads and 4 RPL (V3R, V4R, V5R, V6R).

Results: Of the 157 patients, 67 had CAD (> 75% stenosis in at least one major coronary artery), and 64 had positive ST changes in the standard ECG leads during exercise testing. Using the conventional 12‐lead method, sensitivity and specificity were 76 and 86%, respectively. Only three patients exhibited positive changes in the RPL leads; all had > 0.1 mV ST elevation in one of the RPL leads with > 0.1 mV ST elevation in aVR. Two of these patients had significant right coronary artery lesions and the other had a lesion of the left anterior descending artery which perfused the inferior as well as the anteroseptal area. In the standard 12 leads, one of the patients with an abnormal RPL and a right coronary lesion was negative, while the other two patients were positive. Combining RPL with the conventional 12‐lead method, sensitivity and specificity were 78 and 86%, respectively. Therefore, RPL did not improve the accuracy of the exercise ECG.

Conclusion: The use of RPL during exercise testing may contribute to the detection of ischemia perfused by the right coronary artery; however, it does not improve the diagnostic accuracy of the exercise test.
A perspective on rate control in the treatment of atrial fibrillation
Authors: Waldo Albert L.
Published: June 2007

Until recently, the standard approach to therapy of atrial fibrillation (AF) in most cases was restoration and maintenance of sinus rhythm (rhythm control). Although difficult to accomplish, and associated with potential serious adverse effects of antiarrhythmic agents, this therapeutic approach was influenced by the belief that rhythm control was associated with better survival, fewer symptoms, better exercise tolerance, lower risk of stroke, better quality of life, and absence of need for long‐term anticoagulation. However, four clinical trials comparing rate control with rhythm control have failed to demonstrate these advantages, indicating that rate control should be considered a legitimate primary therapeutic option, particularly in patients at risk for stroke. Pursuit of rate or rhythm control should be decided on a case‐by‐case basis.
Classification and risk stratification of patients with acute chest pain using a low discriminatory level of cardiac troponin T
Authors: Solymoss B. Charles , Bourassa Martial G. , Cernacek Peter , Fortier Annik , Théroux Pierre
Published: June 2007

Background: Cardiac troponins are the biochemical markers of choice for the evaluation of acute coronary syndromes (ACS). Using the first‐generation test, most studies related adverse outcome to > 0.20 or 0.10 μg/l cardiac troponin T (cTnT) levels. With the highly sensitive and specific second‐ and third‐generation assays, cTnT is undetectable in most healthy individuals.

Hypothesis: We evaluated whether a lower cTnT level, within 24 h of admission, could indicate an increased risk of future complications.

Methods: During 1998–1999, clinical data were collected in 260 patients with ACS. Cardiac troponin T was measured at arrival, and 4, 8, and 12–24 h thereafter. The maximum cTnT value was then used to assess, over a 15‐month follow‐up period, the cumulative risk of death or myocardial infarction (MI), as well as rates of events according to quartiles of cTnT values.

Results: Patients with ≤ 0.03 μg/l cTnT levels had the lowest rate of adverse events and the best Kaplan‐Meier event‐free survival curve. Increasing cTnT levels were associated with stepwise increases in mortality rates and with a constant 10fold increase in MI rates during follow‐up.

Conclusions: A low threshold cTnT elevation is recommended to assess the risk of ACS. All cTnT elevations > 0.03 μg/l predict a higher risk of MI during follow‐up, whereas increasing values predict mortality in relation to the amount of elevation.
Peripheral arterial tonometry: A diagnostic method for detection of myocardial ischemia induced during mental stress tests: A pilot study
Authors: Goor Daniel A. , Sheffy Jacob , Schnall Robert P. , Arditti Alexander , Caspi Avraham , Bragdon Edith E. , Sheps David S.
Published: June 2007

Background: Mental stress testing is considered a reliable method for diagnosing patients with coronary heart disease (CHD) who may be at risk for future events. It has been shown recently that myocardial ischemia induced during mental stress tests is speciFICAlly associated with peripheral arterial vasoconstriction.

Hypothesis: The study was undertaken to test the diagnostic capability of peripheral arterial tonometry (PAT) to detect peripheral arterial vasomotor changes.

Methods: We monitored pulsatile finger blood volume changes using a specially designed finger plethysmograph, PAT that can detect peripheral arterial vasomotor changes. Equilibrium radionuclide angiography (ERNA) was simultaneously performed in 18 male patients at rest and during a mental arithmetic stress test with harassment. All patients had previously diagnosed coronary disease and positive exercise tests. Myocardial ischemia was diagnosed by ERNA when global ejection fraction fell ≥ 8% during mental stress or new (or worsened) focal wall motion abnormalities occurred. Peripheral arterial tonometry tracings were considered abnormal when the pulse wave amplitude decreased by ≥ 20% from baseline.

Results: In 18 patients there were 16 usable studies. In eight patients, both ERNA and PAT were abnormal, and in six patients the tests were negative by both methods. In two cases, the results were discordant. Therefore, when considering an abnormal PAT tracing as indicative of mental stress‐driven myocardial ischemia, concordance of the two methods was 88%.

Conclusion: The use of PAT may facilitate both clinical testing and research during mental stress.
Myoglobin—A marker of reperfusion and a prognostic indicator in patients with acute myocardial infarction
Authors: Iqbal M. Perwaiz , Kazmi Khawar A. , Mehboobali Naseema , Rahbar Abdul
Published: June 2007

Background: Early noninvasive identiFICAtion of patients with occluded infarct‐related arteries after thrombolysis has important prognostic and therapeutic implications. Recent reports indicate that plasma kinetics of cardiac marker proteins could be very useful in diagnosis of myocardial reperfusion. Although angiographic assessment remains the ideal procedure for determining patency, it is expensive, invasive, not within the reach of most patients in developing countries, and the long‐term follow‐up data are still sparse.

Hypothesis: The present study was undertaken to investigate whether plasma kinetics of myoglobin in conjunction with clinical markers and another biochemical marker, creatine kinase, could be used to predict myocardial reperfusion more accurately and to investigate the correlation between myoglobin release after thrombolysis and mortality in patients with acute myocardial infarction (AMI) over a follow‐up period of 18 months.

Methods: Eighty‐three consecutive patients with AMI receiving streptokinase treatment were studied for plasma kinetics of myoglobin in conjunction with clinical markers and creatine kinase to predict reperfusion and were followed for a period of 18 months.

Results: Increased baseline mean ± standard deviation levels of myoglobin were observed among “nonresponders” to streptokinase treatment compared with “responders” (469 ± 386 μg/l vs. 270 ± 211 μg/l). There was signiFICAntly more release of myoglobin following thrombolytic treatment among the responders than among the nonresponders (mean ratio of myoglobin levels at 90 min to 0 min 6.01 ± 9.2 vs. 1.03 ± 0.64). In a follow‐up of 61 patients over a period of 18 months, 31% mortality was observed in the nonresponder group compared with 11.7% in the responder group. In responders, the mean ratio of myoglobin levels at 90 and 0 min was signiFICAntly less among those who died (p = 0.019) than among those who survived.

Conclusion: A myoglobin release profile in combination with other clinical markers offers inexpensive, noninvasive, and a reasonably reliable way of assessing coronary artery patency after thrombolytic treatment.
Increased blood coagulation and platelet activation in patients with infective endocarditis and embolic events
Authors: Buyukasýk N. Semnur , Ileri Mehmet , Alper Aysin , Senen Kubilay , Atak Ramazan , Hisar Ismet , Yetkin Ertan , Turhan Hasan , Demirkan Deniz
Published: June 2007

Background: Inflammation‐induced procoagulant changes and alterations in platelet activity appear to play an important role in thromboembolic complications of infective endocarditis (IE).

Hypothesis: The aim of this study was to investigate systemic coagulation activity, fibrinolytic capacity, and platelet activation in patients with IE with and without embolic events by measuring the plasma levels of prothrombin fragment 1+2 (PF1+2), thrombin‐antithrombin III complex (TAT), plasminogen activator inhibitor‐1 (PAI‐1), beta‐thromboglobulin (3‐TG), and platelet factor 4 (PF4), respectively.

Methods: The study included 76 consecutive patients (female = 55, male = 21, mean age 26 years, range 8‐64 years) with definite IE according to the Duke criteria; of these, 13 (17.1%) had embolic events.

Results: Plasma concentrations of PF1+2 (3.2 ± 1.3 vs. 1.7 ± 0.7 and 1.4 ± 0.7 nmol/l, p < 0.001, respectively) and TAT (7.3 ± 1.5 vs. 2.9 ± 1.2 and 2.2 ± 1.1 ng/ml, p < 0.001, respectively) were elevated in patients with embolic events compared with patients without embolic events and control subjects. Similarly, patients with embolic events had increased plasma levels of (3‐TG 63.3 ± 10.9 vs. 33.1 ± 11.6 and 19.1 ± 10.6 ng/ml, p < 0.001, respectively) and PF4 (106.0 ± 28.7 vs. 50.3 ± 16.7 and 43.0 ± 15.8 ng/ml, p < 0.001, respectively) compared with those without embolic events and the control group. Embolic patients also had higher PAI‐1 levels than nonembolic patients and healthy subjects (14.4 ± 6.4 vs. 8.6 ± 5.9 and 5.4 + 4.3 ng/ml, p = 0.002, respectively).

Conclusion: Patients with IE and with subsequent thromboembolism have increased systemic coagulation activation, enhanced platelet activity/damage, and impaired fibrinolysis. The resulting imbalance produces a sustained hypercoagulable state, which contributes to the increased risk of thromboembolic events in this particular group.
The relation between preprocedural C‐reactive protein levels and early and late complications in patients with acute myocardial infarction undergoing interventional coronary angioplasty
Authors: Magadle R. , Hertz I. , Merlon H. , Weiner P. , Mohammedi I. , Robert D.
Published: June 2007

Background: Inflammation is an important feature of arteriosclerotic disease, and the vulnerability of coronary plaques in acute myocardial infarction (AMI) may be related to the levels of serum C‐reactive proteins (CRP). While some risk factors for early and late complications have been suggested, an accurate and definitive preprocedural risk stratiFICAtion of patients undergoing percutaneous transluminal coronary an‐gioplasty (PTCA) is still lacking.

Hypothesis: The study was undertaken to investigate whether early and late complications after PTCA could be predicted by evaluation of baseline serum CRP levels in patients with AMI.

Methods: Levels of serum CRP were measured in a total of 230 patients with AMI undergoing PTCA and provisional stent. They were divided into two groups: Group 1 (n = 48) with elevated CRP levels (≥5 mg/l) and Group 2 (n = 182) with normal CRP levels (< 5 mg/l).

Results: There were no signiFICAnt differences in baseline clinical, angiographic, and procedural characteristics between the two groups. However, the incidence of in‐hospital adverse coronary events (reinfarction, coronary reocclusion, target vessel revascularization, and death) and severe left ventricular dysfunction was signiFICAntly higher in Group 1 (18.3 vs. 6.1%, p < 0.05 and 20.9 vs. 6.1%, p < 0.05, respectively). In addition, bailout stenting was performed more frequently in Group 1 than in Group 2 (60.4 vs. 36.3%, p < 0.005). No signiFICAnt late complications were noted. The serum levels of CRP were the only independent predictors of early adverse events.

Conclusions: Preprocedural serum CRP level might be considered a powerful predictor of early but not late complications in patients undergoing PTCA/stent procedures.
Transforming growth factor β1genotype and change in left ventricular mass during antihypertensive treatment–results from the swedish irbesartan left ventricular hypertrophy investigation versus atenolol (Silvhia)
Authors: Hallberg Pär , Lind Lars , Billberger Katarina , Michaelsson Karl , Karlsson Julia , Kurland Lisa , Kahan Thomas , Malmqvist Karin , Öhman K. Peter , Nyström Fredrik , Liljedahl Ulrika , Syvänen Ann‐Christine , Melhus Håkan
Published: June 2007

Background: Angiotensin II, via the angiotensin II type 1 (AT1) receptor, may mediate myocardial fibrosis and myocyte hypertrophy seen in hypertensive left ventricular (LV) hypertrophy through production of transforming growth factor β1(TGF‐β1); AT1‐receptor antagonists reverse these changes. The TGF‐(β1G + 915C polymorphism is associated with in‐terindividual variation in TGF‐ β1production. No study has yet determined the impact of this polymorphism on the response to antihypertensive treatment.

Hypothesis: We aimed to determine whether the TGF‐ β1G + 915C polymorphism was related to change in LV mass during antihypertensive treatment with either an AT1‐receptor antagonists or a beta1 ‐adrenoceptor blocker. The polymorphism was hypothesized to have an impact mainly on the irbesartan group.

Methods: We determined the association between the TGF‐β1genotype and regression of LV mass in 90 patients with essential hypertension and echocardiographically diagnosed LV hypertrophy, randomized in a double‐blind study to receive treatment for 48 weeks with either the AT1‐receptor antagonist irbesartan or the beta1 ‐adrenoceptor blocker atenolol.

Results: Irbesartan‐treated patients who were carriers of the C‐allele, which is associated with low expression of TGF‐β1, responded with a markedly greater decrease in LV mass index (LVMI) than subjects with the G/G genotype (adjusted mean change in LVMI –44.7 g/m2vs. –22.2 g/m2, p = 0.007), independent of blood pressure reduction. No association between genotype and change in LVMI was observed in the atenolol group.

Conclusions: The TGF‐ β1G + 915C polymorphism is related to the change in LVMI in response to antihypertensive treatment with the AT1‐receptor antagonist irbesartan.
Dynamic assessment of myocardial involvement in patients with end‐stage renal disease by ultrasonic tissue characterization and serum markers of collagen metabolism
Authors: Fatema Kaniz , Hirono Osamu , Masakane Ikuto , Nitobe Joji , Kaneko Kazuyoshi , Zhang Xuehua , Takeishi Yasuchika , Kubota Isao
Published: June 2007

Background: Congestive heart failure is the most common cause of mortality in patients with end‐stage renal disease (ESRD). However, noninvasive assessment for cardiac involvement in ESRD has not been established.

Hypothesis: Assessment of ultrasonic tissue characterization and serum markers of collagen degradation is useful for defining myocardial involvement in ESRD.

Methods: Cyclic variation of ultrasonic integrated back‐scatter of the ventricular septum (CV‐IBS) and the serum levels of free matrix metalloproteinase‐I (MMP‐I) and tissue inhibitor of metalloproteinase‐I (TIMP‐I) were measured in 30 patients with ESRD undergoing routine hemodialysis (HD) and in 40 patients with essential hypertension (HTN).

Results: Compared with the group with HTN, ESRD (before HD) showed larger left ventricular (LV) mass index (217 ± 56 vs. 146 ± 45 g/m2, p < 0.01), worse LV diastolic function (E/A, 0.6 ± 0.2 vs. 0.9 ± 0.3, p < 0.05), smaller CV‐IBS (9.0 ± 1.3 vs. 12.4 ± 0.9 dB, p < 0.01), and larger TIMP‐I/MMP‐I (46 ± 10 vs. 34 ± 10, p < 0.05), in spite of the comparable ventricular wall thickness. Thus, these indices may possibly reflect myocardial interstitial fibrosis. After HD (after the improvement of myocardial interstitial edema), a negative linear relationship between CV‐IBS and TIMP‐I/MMP‐I was observed (r = −0.52, p< 0.05).

Conclusions: Noninvasive assessment of ultrasonic tissue characterization and serum markers of collagen type I degradation may be a new diagnostic tool for defining myocardial interstitial fibrosis in patients with ESRD and LV hypertrophy.
Patterns of congenital heart disease in unoperated adults: A 20‐year experience in a developing country
Authors: Hannoush Hwaida , Tamim Hala , Younes Hussein , Arnaout Samir , Gharzeddine Walid , Dakik Habib , Obeid Mounir , Bitar Fadi F.
Published: June 2007

Background: The number of patients with congenital cardiac disease reaching adulthood is increasing steadily. Many adults with such disease face both medical and surgical difficulties.

Hypothesis: This retrospective study was undertaken to assess the frequency and outcome of congenital heart disease (CHD) in unoperated adults.

Methods: The charts of all patients with unoperated CHD, who were admitted to a tertiary care center in Beirut, Lebanon, between 1980 and 2000 were reviewed. Of these, 206 patients (52% men, age at admittance 18–71 years [32.8 ± 13.3 years]) with a diagnosis of CHD were evaluated. Atrial septal defect (ASD) was the most common cardiac malformation with a relative frequency of 53%, followed by ventricular septal defects (11%), tetralogy of Fallot (11%), aortic anomalies (7%), pulmonary stenosis (6%), and Ebstein anomaly (4%). Most patients were symptomatic upon presentation, with dyspnea on exertion being the most common presenting symptom. Twenty‐seven patients (13%) had cyanotic CHD. Of 179 acyanotic patients, 113 (63%), and 17 of 27 cyanotic patients (63%) underwent surgical intervention. In‐hospital surgical complications for the acyanotic group included cerebrovascu‐lar accident (2%) and heart block (1%). Total surgical mortality was 4 of 130 (3%). One patient with tetralogy of Fallot presented with endocarditis and died.

Conclusion: Atrial septal defect is the most common defect reported in our experience; however, it occurs more frequently than that reported in the literature. Although most patients were symptomatic on presentation, their functional status was stable. Accordingly, their hospital course, whether managed medically or surgically, held a relatively low complication rate. This could be attributed to the uncomplicated nature of pathologies in our series. The surgical mortality and in‐hospital complications were slighter higher than those reported for similar lesions if repaired during childhood. This study reflects the relative frequency of various cardiac malformations in selected patients with “grown up” congenital heart disease (GUCH) and their natural survival pattern.
Lipoprotein(a): New insights into mechanisms of atherogenesis and thrombosis
Authors: Deb Arjun , Caplice Noel M.
Published: June 2007

Lipoprotein(a) (Lp[a]) continues to be a controversial molecule regarding its role in human vascular disease. Although the physiologic role of this molecule is still unclear, novel discoveries within the last few years have suggested numerous mechanisms whereby Lp(a) may contribute to atherosclerosis and its complications in human subjects. These effects may differentially occur in vascular tissue and circulating blood compartments. A complex interplay between tissue‐specific effects is probably more relevant to the pathogenicity of this molecule than one single effect alone. This review briefly describes the structure of Lp(a) in relation to its biochemical function, summarizing the current literature on various patho‐physiologic mechanisms of Lp(a)‐induced vascular disease and the role of cell and tissue‐specific effects in promoting atherogenesis and thrombosis.
Plasma vascular endothelial growth factor level is elevated in patients with multivessel coronary artery disease
Authors: Nakajima Kei , Tabata Shinji , Yamashita Takeshi , Kusuhara Masatoshi , Arakawa Koh , Ohmori Reiko , Yonemura Atsushi , Higashi Kenji , Ayaori Makoto , Nakamura Haruo , Ohsuzu Fumio
Published: June 2007

Background: Vascular endothelial growth factor (VEGF) has been implicated in both angiogenesis and ischemia. However, the relationship between plasma VEGF level and coronary artery disease remains unknown.

Hypothesis: Plasma VEGF level may be associated with severe coronary artery disease and other cardiovascular risk factors.

Methods: We examined plasma VEGF concentration and coronary risk factors in 73 patients who underwent coronary angiography and 70 apparently healthy control subjects. According to the number of the three major coronary vessels with significant (≥ 75%) stenosis, we divided the patients into two groups: the mild stenosis group (0‐ and single‐vessel disease, n = 36) and the severe stenosis group (double‐ and triple‐vessel disease, n = 37).

Results: The log VEGF value of the severe stenosis group was significantly higher than that of the mild stenosis (p < 0.05) and control groups (p < 0.05). Furthermore, there was a significant positive trend in the log VEGF value according to the number of vessels with significant stenosis (p = 0.016). However, there was no significant difference in log VEGF value between the mild stenosis and control groups. Soluble vascular cellular adhesion molecule, soluble intracellular adhesion molecule, and other coronary risk factors were found to be associated with the presence of vessel stenosis.

Conclusion: Unlike established coronary risk factors, the plasma VEGF level may be associated with only severe coronary ischemia such as multiple coronary vessel disease.
Gender as a risk factor for contrast nephropathy: Effects of hydration and N‐acetylcysteine
Authors: Gill Nikita K. , Piccione Elizabeth A. , Vido Diane A. , Clark Barbara A. , Shannon Richard P.
Published: June 2007

Background: In a few studies, N‐acetylcysteine has been shown to prevent contrast‐induced nephropathy in patients with chronic, stable renal failure undergoing elective procedures. Other studies have shown variable outcomes. Furthermore, the majority of prior studies have mainly studied men, and gender as a risk factor has not been studied.

Hypothesis: The study sought to evaluate the effectiveness of N‐acetylcysteine and hydration in unselected patients with both acute and stable renal insufficiency (RI) undergoing urgent or elective cardiac or peripheral angiography.

Methods: We evaluated records of 146 patients with RI undergoing angiography. We compared patients receiving periprocedure hydration and acetylcysteine with patients who were only hydrated or received no pretreatment. We evaluated the 48‐h change in serum creatinine between groups and further analyzed the effect of hydration and gender on outcomes.

Results: Demographics and baseline creatinine were similar between groups. Post procedure, the creatinine increased significantly in both groups, but less so in the acetylcysteine group (control: 0.35 ± 0.08 mg/dl; acetylcysteine: 0.14 ± 0.04 mg/dl, p < 0.05). When the control group was further stratified by hydration, the increase in creatinine for the hydrated patients was only 0.17 ± 0.10 mg/dl compared with 0.54 ± 0.12 mg/dl in patients with inadequate hydration. In the control group, women were more likely to receive no preprocedural hydration (59 vs. 40%), had a bigger rise in creatinine, received less protection from hydration alone, but were equally well protected by hydration plus acetylcysteine. In the acetylcysteine group, change in creatinine for women was minimal (+ 0.14 ± 0.07 mg/dl) and not different from men (+ 0.15 ± 0.05).

Conclusion: Unselected patients with acute and chronic RI had no benefit from acetylcysteine beyond that seen with hydration alone. Gender may be a risk factor for contrast‐induced nephropathy, with hydration offering less protection in women. Acetylcysteine (with hydration) seems to minimize the gender difference.
Characteristics of contemporary patients with hypertension and coronary artery disease
Authors: Cooper‐DeHoff Rhonda M. , Handberg Eileen M. , Cohen Jerome , Kowey Peter , Messerli Franz H. , Mancia Giuseppe , Cangiano Jose L. , Gaxiola Efrain , Garcia‐Barreto David , Hewkin Ann C. , Pepine Carl J.
Published: June 2007

Background: Despite a high prevalence of hypertension in the population with CAD, there are limited data describing the clinical characteristics and treatments, as well as their interrelations in these patients. This is particularly true for black and Hispanic patients who have been underrepresented in randomized CAD trials.

Hypothesis: There exist racial and ethnic differences that define the characteristics of patients with both coronary artery disease (CAD) and hypertension.

Methods: This report describes the characteristics of Caucasian, Hispanic, and black patients enrolled in the International Verapamil SR/trandolapril Study (INVEST), a prospective trial undertaken exclusively in patients with CAD and hypertension.

Results: In all, 10,925 Caucasian, 8,045 Hispanic, and 3,029 black patients are described. An abnormal angiogram or documented myocardial infarction was observed more frequently in Caucasian patients (73%), while angina pectoris was more prevalent in Hispanic patients (87%). Diabetes and left ventricular hypertrophy were most common in black patients (33 and 29%, respectively), while hypercholesterolemia and prior revascularization (coronary artery bypass graft or angioplasty) were most common in Caucasian patients (64 and 41%, respectively). More than 60% of Hispanic and black patients were women—a unique characteristic for randomized CAD trials. Comparing race/ethnic cohorts, there were significant differences for all characteristics. More than 80% of patients in all race/ethnic groups were receiving antihypertensive therapy; however, only fewer than 25% had controlled blood pressure according to guidelines from the sixth report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure.

Conclusions: This high‐risk population of hypertensive patients with CAD has been undertreated and does not have well‐controlled B P. Race/ethnic differences were observed for clinical characteristics and medication use.
Dyslipidemia in patients with angiographically confirmed coronary artery disease—an opportunity for improvement
Authors: Khanal Sanjaya , Obeidat Omar , Lu Mei , Douthat Lori , Hudson Michael P. , Greenbaum Adam B. , Kugelmass Aaron , Weaver W. Douglas
Published: June 2007

Background: There are few data about lipid profiles in unselected patients with angiographically confirmed coronary artery disease (CAD).

Hypothesis: The study was undertaken to investigate the demographics, clinical characteristics, angiographic findings, and baseline lipid status of 1,000 consecutive unselected patients with angiographically confirmed CAD.

Methods: Between April 2001 and July 2002, we obtained informed consent and prospectively collected clinical characteristics, fasting lipid profiles, and angiographic results from 1,000 sequential patients with CAD confirmed by angiography.

Results: In these patients with confirmed CAD, 78% had history of hyperlipidemia. Although 62% were receiving lip‐id‐lowering therapy, only 46% had a low‐density lipoprotein target of < 100 mg/dl, and only 20% had achieved all four National Cholesterol Education Program‐recommended lip‐id targets.

Conclusions: Better strategies to ensure optimal lipid levels are required. One such method using computerized workflow is being evaluated in this population.
An oxidized low‐density lipoprotein receptor gene variant is inversely associated with the severity of coronary artery disease
Authors: Ohmori Reiko , Momiyama Yukihiko , Nagano Makoto , Taniguchi Hiroaki , Egashira Tohru , Yonemura Atsushi , Nakamura Haruo , Kondo Kazuo , Ohsuzu Fumitaka
Published: June 2007

Background: A lectin‐like oxidized low‐density lipoprotein (LDL) receptor‐1 (LOX‐1) is the major receptor of oxidized LDL in endothelial cells. The expression of LOX‐1 was shown to be upregulated in atherosclerotic lesions. Recently, LOX‐1 gene polymorphism (G501C) was reported to be associated with myocardial infarction (MI).

Hypothesis: Our study was undertaken to elucidate the association between this polymorphism and coronary artery disease (CAD).

Methods: We evaluated LOX‐1 gene polymorphism using Invader assay in 586 patients undergoing coronary angiography.

Results: Study patients were categorized into three groups: normal/minimal stenosis (≤25%) (n = 128); mild stenosis (26‐50%) (n = 39); and significant stenosis (> 50%) (n = 419). Of the 419 patients with significant stenosis, 163 had single‐vessel, 165 had double‐vessel, and 91 had triple‐vessel disease. Myocardial infarction was present in 171 patients. The frequency of LOX‐1 gene variants (C/C or C/G) was lower in patients with significant than in those with normal/minimal stenosis (36 vs. 49%, p < 0.01). The frequency of LOX‐1 gene variants did not differ between patients with and without MI (34 vs. 37%). However, a stepwise decrease in the frequency of such variants was found depending on the severity of CAD: 49% in normal/minimal stenosis, 41% in mild stenosis, 39% in single‐vessel, 35% in double‐vessel, and 32% in triple‐vessel disease. Multivariate analysis demonstrated LOX‐1 gene variants to be inversely associated with the presence of significant stenosis (odds ratio = 0.61; 95% confidence interval = 0.41‐0.92).

Conclusions: The LOX‐1 gene variants at 501 were found to be inversely associated with the severity of CAD. This polymorphism may be modifying the severity of CAD.
Prognostic value of heterogeneity of ventricular repolarization in survivors of acute myocardial infarction
Authors: Batchvarov Velislav N. , Hnatkova Katerina , Poloniecki Jan , Camm A. John , Malik Marek
Published: June 2007

Background: The expansion of indications for implantation of cardioverter‐defibrillators (ICD) has enhanced the need for risk stratification of patients post myocardial infarction (MI), while the improved treatment of acute MI has decreased mortality and diminished the prognostic power of traditional risk variables.

Hypothesis: Increased heterogeneity of ventricular repolarization quantified by TCRT (total cosine R‐to‐T, angular difference between spatial QRS and T loops, decreased with increase in repolarization heterogeneity) is an independent predictor of mortality in patients post MI.

Methods: Left ventricular ejection fraction (EF), QRS duration on signal‐averaged ECG, number of ventricular ectopic beats (VE)/h, heart rate variability (HRV) triangular index, heart rate turbulence slope on 24‐h Holter recording, and TCRT were analyzed in 334 survivors of acute MI followed up for 41 ± 20 months.

Results: In multivariate analysis, EF < 35% (relative risk [RR] 2.3, 95% confidence interval [CI] 1.1‐4.7, p = 0.023), VE > 10/h (RR 2.2, CI 1.0‐4.6, p = 0.044), HRV < 20 U (RR 2.2, CI 1.1‐4.5, p = 0.032), and TCRT < −0.896 (RR 4.3, CI 2.2‐8.5, p = 0.00001) were independent predictors of cardiac mortality (11%). Independent predictors of arrhythmic mortality (5%) were VE, HRV, and TCRT (RR 5.8, CI 2.1‐15.6, p = 0.0004). Cardiac and arrhythmic mortality of patients with both EF < 35% and TCRT < −0.896 were > 60 and > 30%, respectively, compared with 17 and 7% in those with only EF < 35% or TCRT < −0.896.

Conclusion: Decreased TCRT, which reflects increased repolarization heterogeneity, is a strong and independent predictor of cardiac and arrhythmic death in patients post MI.