bluuebunny/crossref_metadata_2025 huggingface dataset:
Identifying high yield sources of patients with coronary artery disease for clinical trials: Lessons from the asymptomatic cardiac ischemia pilot (ACIP) experience
Authors: Handberg‐Thurmond Eileen , Baker Ann , Coglianese Mary Ellen , Forman Sandra , Pepine Carl J. , Geller Nancy , Chaitman Bernard ,   For The ACIP Study Group
Published: February 2009

Background and hypothesis: Successful recruitment strategies for ischemic heart disease (IHD) clinical trials must identify high yield sources and efficient methods for selecting patients likely to have coronary artery disease (CAD) and ischemia, but such information is lacking.

Methods: Data from the recently completed Asymptomatic Cardiac Ischemia Pilot (ACIP) Trial were used as a model contemporary CAD/IHD trial to determine the relative patient yields, within a specific time frame, for various recruitment sources.

Results: Over 15 months, a total of 88,881 patient records was screened at 10 sites. The highest yield source was found by screening records of patients directly referred by a physician for possible study entry. This source accounted for 595 of 814 or 73% of potential patients and for 30% of patients eventually randomized. The largest volume of potential patients was observed from coronary angiographic laboratory record screening, and this source accounted for 39% (n = 7,542) of potential patients and for 24% of those randomized. The exercise electrocardiography (ECG) laboratory patient records yielded only 16% (5,340/33,784) of potential patients and 35% of patients randomized, but this source required considerably more time and resources for screening.

Conclusions: Considering that time and resources for screening are fixed by budget in any trial, there is a need to balance high volume‐moderate yield sources with low volume‐high yield sources in order to optimize recruitment in future larger scale trials, and these data provide information and direction to focus such screening efforts.
Electrocardiographic crotchets or common errors made in the interpretation of the electrocardiogram
Authors: Willis Hurst J.
Published: February 2009

Irritating errors are called crotchets. This paper discusses the following electrocardiographic crotchets: memorizing patterns rather than using basic principles, failure to use the electrocardiogram as a diagnostic tool, failure to correlate all available data, failure to appreciate the limitation of the computer interpretation, failure to appreciate the diagnostic value of P‐wave abnormalities, the identification and misuse of abnormal Q waves, the misuse of left or right axis deviation of the QRS complexes, the misuse of the amplitude of the QRS complexes as a sign of left ventricular hypertrophy, identification of left ventricular hypertrophy, failure to identify uncomplicated and complicated bundle‐branch block, failure to identify secondary and primary T‐wave ibnormalities, failure to identify secondary and primary S‐T abnormalities, and lack of knowledge of the U waves.
Left ventricular diastolic collapse in low‐pressure cardiac tamponade
Authors: Dwivedi Sudhanshu Kumar , Saran Ramkirti , Narain Varun Shanker
Published: February 2009

A case of systemic hypotension with volume depletion not responding to intravenous fluids was found to have features of cardiac tamponade on two‐dimensional (2‐D) echocardiography. Intracardiac pressures were normal on cardiac catheterization. An interesting observation was the presence of left ventricular (LV) collapse on 2‐D echocardiography. To the authors' best knowledge, such a case of low‐pressure cardiac tamponade with LV collapse has not been reported earlier.
Hypocalcemic heart failure: A reversible form of heart muscle disease
Authors: Suzuki Takaaki , Ikeda Uichi , Fujikawa Hideyjuki , Shimada Kazuyuki , Saito Ken
Published: February 2009

This paper reports the case of a 53‐year‐old woman with hypocalcemia‐induced reversible cardiomyopathy. Laboratory tests showed hypocalcemia caused by idiopathic hypoparathyroidism. Her left ventricular dysfunction persisted for a long period even after normalization of the serum calcium level. Observations suggest that physicians should be aware that hypocalcemia can be a reversible cause of cardiomyopathy and congestive heart failure.
Are technetium‐99m‐labeled myocardial perfusion agents adequate for detection of myocardial viability?
Authors: Caner Biray , Beller George A.
Published: February 2009

The noninvasive assessment of myocardial viability in patients with coronary artery disease and depressed left ventricular function has proven clinically useful for identifying those patients with ischemic cardiomyopathy who benefit most from coronary revascularization. Thallium‐201 (201T1) imaging at rest has been the radionuclide imaging technique most often utilized for distinguishing viable myocardium from scar. However, new technetium‐99m (99mTc) perfusion agents such as 99mTc‐sestamibi and 99mTc‐tetrofosmin have emerged as alternatives to 201T1 for imaging of regional myocardial perfusion. Whether these new agents, which have better physical properties for imaging with a gamma camera than 201T1, are valid for use in assessing myocardial viability is still uncertain. Recent clinical studies have demonstrated that these agents, when imaged using quantitative SPECT, can identify patients with myocardial hibernation who exhibit improved regional systolic function following revascularization. Experimental laboratory studies have shown that the uptake of 99mTc‐sestamibi and 99mTc‐tetrofosmin in ischemic myocardium is only slightly lower than the uptake of 201T1. These 99mTc‐labeled agents remain bound intracellularly in mitochondria of viable myocytes under conditions of myocardial stunning and short‐term hibernation, producing severe myocardial asynergy. With respect to determination of viability, the inferior wall region is at times problematic since attenuation of 99mTc‐sestamibi and 99mTc‐tetrofosmin is greatest in this area. Demonstration of preserved systolic thickening on ECG‐gated SPECT images is indicative of viability in the instance of decreased regional 99mTc counts due to attenuation and not scar. Administration of nitrates prior to tracer injection improves the sensitivity for identifying viable myocardial segments using rest imaging with 99mTc‐sestamibi or 99mTc‐tetrofosmin.

Thus, it appears that the new 99mTc perfusion imaging agents can be successfully employed for the determination of myocardial viability in the setting of severe regional dysfunction and chronic coronary artery disease. The greater the myocardial uptake of these agents in the resting state, the greater the probability of improved systolic function after coronary revascularization.
Dextrocardia and corrected transposition of the great arteries (I, D, D) in a case of kartagener's syndrome: A unique association
Authors: Bitar Fadi F. , Shbaro Roula , Mroueh Salman , Yunis Khalid , Obeid Mounir
Published: February 2009

Kartagener's syndrome (KS) usually includes mirror‐image dextrocardia. The incidence of congenital heart disease in KS is comparable with that in the general population. This paper reports on a case of Kartagener's syndrome associated with dextrocardia, corrected transposition of the great arteries (I, D, D), ventricular septal defect, and valvar pulmonary stenosis in an 8‐year‐old girl.
Noninvasive coronary angiography by contrast‐enhanced electron beam computed tomography
Authors: Achenbach Stephan , Moshage Werner , Bachmann Kurt
Published: February 2009

Electron beam computed tomography (EBCT) is a cross‐sectional imaging method with high temporal and spatial resolution. So far, it has mainly been applied for the detection of coronary artery calcifications which permit the very sensitive detection of coronary atherosclerosis even in the very early stages. However, after intravenous injection of a contrast agent, EBCT also permits the direct visualization of the coronary artery lumen. For these investigations, a volume data set is acquired that consists of 40 axial cross‐sections of the heart (3 mm slice thickness). To evaluate the coronary arteries as to the presence of stenoses and occlusions, various forms of postprocessing, including shaded surface display, maximum intensity projection, and multiplanar reconstruction, are applied. The sensitivities and specificities for the detection of coronary artery stenoses and occlusions are about 90%. Best results are obtained for coronary artery bypass grafts, the left main coronary artery, and the left anterior descending coronary artery, while reduced image quality impairs the results for the right coronary artery and the left circumflex coronary artery.
Influence of smoking status on progression of endothelial dysfunction
Authors: Pepine Carl J. , Schlaifer Jay D. , Mancini G. B. John , Pitt Bertram , O'Neill Blair J. , Haber Harry E.
Published: February 2009

Background: Cigarette smoking is a major risk factor for developing coronary artery disease and is associated with increased coronary morbidity and mortality in patients with established atherosclerosis. This report describes the influence of smoking on coronary endothelial function in normotensive patients with coronary artery disease, but without left ventricular dysfunction, severe hypercholesterolemia, or insulin‐dependent diabetes mellitus.

Methods: Placebo‐treated patients (n = 54) from a larger study assessing coronary endothelial function were classified at baseline as smokers or nonsmokers for this subgroup analysis. Patients underwent coronary angiography at baseline and again after 6‐month follow‐up.

Results: At baseline, there was a trend for a greater decrease in target segment diameter (n = 54) in smokers compared with nonsmokers (‐ 17.2 ± 5.3% vs. ‐8.0 ± 2.5%, acetylcholine 10−4 mol/1). All measured coronary artery segments (n = 202) showed similar responses (‐ 7.3 ± 2.7% vs. ‐ 3.8 ± 1.3%, acetylcholine 10−4 mmol/1, for smokers vs. nonsmokers, respectively). After 6 months, smokers showed an even greater vasoconstrictor response to acetylcholine whereas nonsmokers did not (‐ 21.7 ± 5.3% vs. ‐ 8.3 ± 2.5%, acetylcholine 10−4 mmol/1). The vasodilatory response to nitroglycerin was similar in smokers and nonsmokers.

Conclusions: In current smokers, a marked decline in endothelium‐dependent vasomotor response was observed over a 6‐month period.
Atheromatous plaque reflects serum total cholesterol levels: A comparative morphologic study of endarterectomy coronary atherosclerotic plaques removed from patients from the southern part of India and caucasians from Ottawa, Canada
Authors: Varghese P. Jacob , Walley Virginia , Arumugam Sarasa Bharati , Cherian K. M. , Farb Andrew , Virmani Renu
Published: February 2009

Background: Natives of South India have a very high incidence of coronary artery disease, despite low calorie and fat intake.

Hypothesis: This study was undertaken to determine whether morphologic features of atheromatous plaque reflect the serum total cholesterol.

Methods: Fifty‐three endarterectomy specimens from patients (mean age 47 ± 9 years, mean cholesterol 203 ± 47 mg/dl) obtained from one cardiac surgeon working in a single institution in South India were evaluated. Morphologic findings were compared with 40 endoarterectomy specimens obtained from age‐matched Caucasians from Ottawa, Canada, with a reported mean cholesterol of 262 ± 47 mg/dl. Morphometric measurements of the vessel size, percent stenosis, and the various components of the atherosclerotic plaque were determined by computerized planimetry.

Results: The vessel size was smaller in the Indian than in the Canadian population (4.6 ± 2.9 vs. 5.6 ± 3.0 mm2, p = 0.07), the plaque area was less (4.3 ± 2.3 vs. 5.3 ± 2.8 mm2, p = 0.055) and the calculated percent stenosis was significantly less (93 vs. 96%, p = 0.028). Of all the parameters evaluated, only necrotic core in the Indian population (7.1 ± 10.9% vs. Canadian 16.7 ± 19.7%, p <0.001) and proteoglycan deposition (7.9 ± 11.2% vs. Canadian 3.7 ± 5.3%, p<0.023) were significantly different. Despite the Indians having low total cholesterol, there was greater diffuse double and triple‐vessel disease and at a younger age than in the Caucasians.

Conculsions: From our data, it appears that the mechanism of development of atherosclerotic disease in the Indians may be different because they have smaller vessels, smaller necrotic core, and greater proteoglycan deposition. Other etiologies, especially those related to a high carbohydrate diet (which is typical for South Indians), should be considered.
Acute coronary syndromes in the united states and united kingdom: A comparison of approaches
Authors: Adams Philip C. , Skinner Jane S. , Cohen Marc , Mcbride Ruth , Fuster Valentin ,   The Antithrombunc Therapy In Acute Coronary Syndromes Research Grow
Published: February 2009

Background: Patients with coronary artery disease are managed differently in different countries.

Hypothesis: These variations in patient management may affect clinical outcome, a possibility that should be taken into consideration in multicenter studies.

Methods: In a binational, 3 months study of antithrombotic treatment of patients with unstable angina and non‐Q‐wave infarction (ATACS), we compared the experience in the four enrollment centers in the United States (US) with the three centers in the United Kingdom (UK). The 59 US patients and the 299 UK patients were similar with regard to age, rates of prior revascularization, prior positive exercise tests, medication use, and aspirin use.

Results: US patients were more commonly women (45 vs. 28%), diabetic (30 vs. 4%), or hypertensive (52 vs. 31%), and had a prior coronary angiogram (30 vs. 18%). After enrollment, coronary angiography was performed more frequently in the US than in the UK (61 vs. 22%). Although the distribution of coronary disease was similar, revascularization without recurrent angina (19 vs. 4%, p<0.001), or following recurrent angina (8 vs. 3%), was significantly more frequent in the US. Combined primary end points (recurrent angina, myocardial infarction, or death) did not differ between US (29%) and UK (25%) patients.

Conclusion: Therefore, international studies of acute coronary disease need to account for different treatments in different countries. These differences, in the small ATACS study, did not have a major impact on the composite primary outcome variables.
Adjunctive therapy after reperfusion therapy in acute myocardial infarction
Authors: Dries Daniel L. , Solomon Allen J. , Gersh Bernard J.
Published: February 2009

The current era has witnessed dramatic improvement in the treatment of acute myocardial infarction, due in large part to the more widespread use of thrombolytic therapy aimed at quickly restoring perfusion in the infarct‐related artery. This review addresses the role of adjunctive pharmacologic therapy in the thrombolytic era, recognizing that much of the available clinical trial data supporting the role of adjunctive pharmacologic treatment strategies was conducted in patient populations not widely exposed to reperfusion therapy. This review, therefore, explores the data supporting the incremental benefit of therapy with beta blockers, nitrates, angiotensin‐converting enzyme inhibitors, or magnesium in addition to thrombolytic therapy. Heparin and aspirin will not be discussed.
Evaluation of hemolysis in patients with prosthetic heart valves
Authors: Maraj Rajiv , Jacobs Larry E. , Ioli Alfred , Kotler Morris N.
Published: February 2009

The primary mechanism and most common cause of hemolytic disease in patients with prosthetic heart valves are mechanical trauma to red blood cells and paraprosthetic valvular regurgitation, respectively. Presenting features in patients with this condition include anemia, congestive heart failure, fatigue, jaundice, dark urine, and a regurgitant murmur. Various laboratory studies can be utilized to diagnose hemolytic anemia and to assess the severity of hemolysis. Transthoracic echocardiography, transesophageal echocardiography, and Doppler studies including color Doppler are useful imaging methods to assess valve function. Treatment is usually medical (oral iron); however, in patients with paravalvular regurgitation, surgery is often required to correct the anemia.
Inducible nitric oxide synthase and atherosclerosis
Authors: Ikeda Ulchi , Maeda Yoshikazu , Shimada Kazuyuki
Published: February 2009

Nitric oxide (NO) synthase induction in vascular smooth muscle cells may play a role in local vascular injury associated with atherosclerosis or postangioplasty restenosis by inhibiting smooth muscle cell proliferation and contraction, as well as by preventing leukocyte and platelet adhesion. The expression of inducible NO synthase is increased in balloon‐injured arteries of experimental animals or in human atherosclerotic lesions. Replacement therapy with NO donors or NO synthase gene transfer may improve the clinical course of atherosclerosis or restenosis.
Restoration of coronary blood flow by single bolus injection of the gpiib/iiia receptor antagonist c7e3 fab in a patient with acute myocardial infarction of recent onset
Authors: Domanovits Hans , Janata Karin , Laggner Anton N. , Hornykewycz Stephan , Nikfardjam Mariam , Maurer Gerald , Huber Kurt
Published: February 2009

It has been debated that primary coronary angioplasty could be more effective if immediate antithrombotic therapy would contribute to a faster recanalization of the infarct‐related artery. This is the first report of a patient who presented at the emergency department with acute anterolateral myocardial infarction, in whom a single bolus injection of c7E3 Fab (0.25 mg/kg body weight) led to complete reperfusion of the infarct‐related coronary artery during organization time for planned acute coronary angioplasty. Pain relief 15 min after initiation of therapy and ST‐segment resolution of >50%, as well as occurrence of idioventricular rhythm 30 min thereafter, were suggestive of successful recanalization before the coronary intervention was started. Diagnostic coronary angiography at 90 min revealed TIMI‐grade 3 flow in the infarctrelated coronary artery with only moderate luminal irregularities. Bolus administration of c7E3 Fab could be effective for dissolving platelet‐rich thrombi in the early stage of acute myocardial infarction (AMI) and may therefore represent a promising “bridging” therapy in patients with AMI elected for primary coronary angioplasty.
Relative value of clinical and transesophageal echocardiographic variables for risk stratification in patients with infective endocarditis
Authors: Lancellotti Patrizio , Soyeur Daniel , Piérard Luc A. , Galiuto Leonarda , Albert Adelin
Published: February 2009

Background: Infective endocarditis remains a life‐threatening disease, and its optimal management is of paramount importance. Transesophageal echocardiography (TEE) is useful for the diagnosis of endocarditis‐induced lesions, but the prognostic significance of the method remains controversial.

Hypothesis: The purpose of this study was to relate clinical and TEE characteristics to the occurrence of mortality and/or systemic embolization in a consecutive series of 45 patients with a diagnosis of infective endocarditis.

Methods: All patients underwent at least one monoplane TEE. Clinical data, episodes of embolization, and echocardiographic characteristics were prospectively recorded. Stepwise logistic discriminant analysis was performed to identify the independent variables that best predicted three binary outcomes: systemic embolization, death, and systemic embolization and/or death.

Results: Twelve of the 45 patients (27%) died from the endocarditis. Significant univariate predictors of death were the presence of paravalvular abscess (p = 0.025), number of vegetations (p = 0.021), Staphylococcus aureus isolated in blood cultures (p = 0.002), medical treatment alone (p<0.002), and systemic embolism (p<0.001). In multivariate analysis, systemic embolism (χ2 = 29.3; p<0.01), echocardiographic evidence of paravalvular abscess (χ2 = 5.6; p = 0.018), Staphylococcus aureus endocarditis (χ2 = 5.5; p = 0.016), and medical treatment alone (χ2 = 5.11; p = 0.024) emerged as optimal predictors of death. Systemic embolization occurred in 12 patients. Independent variables predicting systemic embolization were a total length of vegetations > 14 mm (p = 0.01), greater age (p = 0.02), and medical treatment alone (p = 0.03). When two or more vegetations were observed, the total length is the sum of the individual sizes. Independent risk factors for the development of systemic emboli and/or death as a combined end point were total length of vegetations on TEE (χ2 = 6.4; p = 0.003) and medical treatment alone (χ2 = 4,1; p = 0.047).

Conclusions: High‐risk patients may be identified by the combination of clinical variables and TEE characteristics.
Ischemia‐induced reflex sympathoexcitation during the recovery period after maximal treadmill exercise testing
Authors: Dilaveris Polychronis E. , Zervopoulos George A. , Michaelides Andreas P. , Sideris SKEVOS K. , Psomadaki Zoi D. , Gialafos ELIAS J. , Gialafos John E. , Toutouzas Pavlos K.
Published: February 2009

Background: Heart rate variability (HRV) analysis is problematic during maximal treadmill exercise testing (ET) due to rapidly changing heart rate.

Hypothesis: The aim of this study was to assess HRV spectral components during treadmill ET in patients with coronary artery disease (CAD) and in healthy controls, and to search for possible differences between the two groups.

Methods: Thirty patients with CAD and 30 age‐matched healthy controls underwent symptom‐limited ET and continuous electrocardiographic monitoring. For adequate assessment of HRV during maximal ET, we calculated the HRV measures [normalized units (NU)]—low‐frequency (0.040‐0.150 Hz) power (LF), high‐frequency (0.150‐0.400 Hz) power (HF), and the LF/HF ratio—from all the sequential stages of the ET with limited changes (20 beats/min) in heart rate (stress 80‐100, 100‐120, 120‐140, 140‐160, 160‐180/ recovery 180‐160, 160‐140, 140‐120, 120‐100, 100‐80).

Results: Both LF and HF were found to decrease gradually during ET and to increase during the recovery period in both patients and controls (p<0.001). LF values were higher during the recovery period than during the respective stages of exercise time in both patients and controls, and LF/HF ratio was higher during recovery in patients only.

Conclusions: During maximal ET (1) vagal tone withdraws during the exercise time and increases during the recovery period; (2) the sympathetic activity predominates during the recovery period, especially in patients with CAD and exercise‐induced myocardial ischemia. This finding raises the possibility of ischemia‐induced cardiocardiac sympathetic excitatory reflexes.
Potential cardiovascular applications of glutamate, aspartate, and other amino acids
Authors: Arsenian Michael
Published: February 2009

Cardioplegic solutions rich in the hydrophilic, basic amino acids, glutamate and aspartate, have enhanced myocardial preservation and left ventricular function. This has been demonstrated in assorted animal preparations involving ischemia with and without reperfusion. Published clinical data, though limited, strongly support the contention that these amino acids have myocardial protective properties. Several biochemical mechanisms exist by which certain amino acids may attenuate ischemic or reperfusion injury. Glutamate and aspartate may become preferred myocardial fuels in the setting of ischemia. They may also reduce myocardial ammonia production and reduce cytoplasmic lactate levels, thereby deinhibiting glycolysis. Some amino acids may become substrate for the citric acid cycle. Glutamate and aspartate also move reducing equivalents from cytoplasm to mitochondria where they are necessary for oxidative phosphorylation and energy generation. A rationale exists for the use of an amino acid‐rich cardioplegia‐like solution in myocardial infarction. These solutions are safe and inexpensive.
Comparison of epirubicin and doxorubicin cardiotoxicity induced by low doses: Evolution of the diastolic and systolic parameters studied by radionucide angiography
Authors: Cottin Yves , Louis Pierre , Wolf Jean Eric , Touzery Claude , Dalloz Florence , Coudert Bruno , Toubeau Michel , Riedinger Alina , Brunotte Francois
Published: February 2009

Background: Previous studies have demonstrated that epirubicin (EPI) has a lower propensity to produce cardiotoxic effects than doxorubicin (DXR) at high doses.

Hypothesis: The aim of the study was to compare the cardiotoxicity induced by low doses of EPI and DXR in patients before and 1 month after the end of chemotherapy.

Methods: In a prospective study, 99 patients with a mean age of 51 ± 12 years and without cardiac disease were studied before and 1 month after the end of chemotherapy. Group 1 included 38 patients receiving 246 ± 96 mg/m2 of DXR and Group 2 included 61 patients receiving EPI with an equivalent dose of 219 ± 92 mg/m2 of DXR. Ejection fraction (EF) of the left ventricle (LV), peak ejection rate (PER), and peak tilling rate (PFR) [expressed in end‐diastolic volume/s (EDV/s)] were evaluated by gated radionuclide angiography; PFR/PER were also calculated.

Results: Moderate and similar alterations of left ventricular ejection fraction were shown for low doses of anthracyclines. The EF of the LV decreased from 57 ± 6% to 54 ± 6% for DXR group (Group 1) (p = 0.005), and from 58 ± 5% to 55 ± 5% for the EPI group (Group 2) (p = 0.001). The PER of the left ventricle fell from 3.08 ± 0.46 EDV/s to 2.79 ± 0.49 in Group 1 (p = 0.004) and from 2.98 ± 0.50 to 2.73 ± 0.34 EDV/s in Group 2 (p = O.001). In contrast, no significant alteration of PFR appeared in Group 2 (from 2.72 ± 0.51 to 2.62 ± 0.41 EDV/s) for the equivalent dose of anthracycline, while PFR of the LV dropped from 2.82 ± 0.76 (EDV/s) to 2.41 ± 0.55 after doxorubicin (p = 0.004). No difference was found between 1 and 12 months after the end of the treatment in 25 patients in Group 1 and 28 patients in Group 2. These results confirm the advantage of EPI over DXR in terms of cardiotoxicity and help explain the relationship of cellular damage mechanisms with the functional parameters of nuclear investigation.

Conclusion: A possible explanation for specific alteration after DXR could be the increased production of semiquinone free radicals, which are known to induce membrane damage and, consequently, myocardial edema and diastolic alteration.
Acute myocardial infarction in two adolescent males
Authors: Duvernoy Claire S. , Bates Eric R. , Fay William P. , Farrehi Peter M. , Werns Steven W.
Published: February 2009

Acute myocardial infarction in previously healthy children is rare in the absence of congenital anomalies. We describe two cases of acute anterior myocardial infarction in adolescent males with no congenital heart disease, without prior history of or risk factors for coronary heart disease, and with no history of drug abuse. These cases illustrate that myocardial infarction in the absence of systemic illness or coronary anomalies can occur in an adolescent population.
Doxorubicin‐induced cardiomyopathy treated with carvedilol
Authors: Fazio Serafino , Palmieri Emiliano Antonio , Ferravante Beatrice , Bon È Filomena , Biondi Bernadette
Published: February 2009

Even today, heart failure due to doxorubicin‐induced dilated cardiomyopathy seems to have a poor prognosis, as it is often irreversible and relatively unresponsive to standard medical treatment. This paper describes the first case of a patient complaining of severe symptoms of congestive heart failure due to doxorubicin‐induced dilated cardiomyopathy unresponsive to standard medical treatment (digoxin, diuretics, and angiotensin‐converting enzyme inhibitor), who showed complete clinical recovery and significant improvement of left ventricular dysfunction after carvedilol treatment. It also illustrates the possibility that carvedilol may be a first‐choice drug for the treatment of this disease.
Rapidly reversible cardiomyopathy associated with chronic ipecac ingestion
Authors: Ho Paul C. , Dweik Rifat , Cohen Mylan C.
Published: February 2009

Ipecac, an over‐the‐counter emetic agent, has been a drug of choice for abuse by patients with eating disorders. Its alkaloid emetine has been associated with serious cardiac toxicity; however, the dose effect has not been well established. We present a patient with anorexia and bulimia nervosa who ingested ipecac chronically and developed the characteristic manifestations of ipecac toxicity. Unexpectedly, her induced left ventricular dysfunction returned to normal after only 10 days of withholding the drug. This finding, in contrast with the findings of other reports, establishes that ipecac cardiomyopathy can be readily reversible. The cumulative experience thus far, nonetheless, provides no discernible pattern of the effect of ipecac on the myocardium. Thus, in the continuum of poisoning, the point at which the myocardium becomes irreversibly damaged is undetermined. With continued abuse, potentially lethal outcome, and limited experience with ipecac cardiotoxicity, further investigation and perhaps heightened restriction of the drug are warranted.
Optimum lead positioning for recording bipolar atrial electrocardiograms during sinus rhythm and atrial fibrillation
Authors: Waktare Johan E. P. , Gallagher Mark M. , Murtagh Annmarif, , Camm John , Malik Marek
Published: February 2009

Background: To date, Holter monitoring has been predominantly utilized in the investigation and monitoring of ventricular arrhythmias and myocardial ischemia. Whether currently employed lead configurations are optimal for recording atrial electrocardiograms (ECGs) is unknown.

Hypothesis: This study was undertaken to determine which conventional and novel lead configurations are optimal for recording atrial electrical activity during sinus rhythm and atrial fibrillation.

Methods: Recordings were performed on eight healthy volunteers in sinus rhythm and four patients in atrial fibrillation. Each subject had 10 ECGs of three bipolar and three augmented unipolar leads recorded during supine rest, while rising to upright, and during standing rest, yielding a total of 60 leads (30 bipolar leads). Each tracing was inspected by two observers, and parameters such as P‐wave amplitude and duration, whether the P‐wave onset was clearly seen, atrial fibrillatory‐wave amplitude, and amplitude of noise during standing were scored.

Results: Leads recording interiorly and leftward orientated bipoles provided the best registration of sinus P waves. The Pwave amplitude in the standard bipolar C5 lead (0.12 d̊ 0.02 mV) was, however, inferior to others such as recordings between Cl and C6 positions (P‐wave amplitude 0.16 d̊ 0.02 mV) or from below the right clavicle to the left upper quadrant of the abdomen (0.16 d̊ 0.01 mV). Optimal recording of fibrillatory waves was from different leads, such as a bipole from below the left clavicle to a low C1 position (fibrillatory wave amplitude 0.27 d̊ 0.03 mV).

Conclusion: When Holter recordings are performed for the investigation of atrial arrhythmias, nonstandard lead configurations provide superior recording of atrial electrical activity. We advocate the use of electrodes positioned from C1 to C6, from below the left clavicle to a low C1 position, and a vertically orientated lead from the manubium to the twelfth vertebra or the xiphisternum.
Diabetic cardiomyopathy
Authors: Spector Kenneth S.
Published: February 2009

Prior to 1972, the increased cardiovascular morbidity and mortality that diabetics endure had been attributed to vascular disease. in 1972, Rubler et al. proposed the existence of a diabetic cardiomyopathy based on their experience with four adult diabetic patients who suffered from congestive heart failure (CHF) in the absence of discernable coronary artery disease, valvular or congenital heart disease, hypertension, or alcoholism. Alternative explanations for CHF, such as anemia and vascular and renal disease in these four patients, gave rise to criticisms, but a wave of subsequent studies in the 1970s and 1980s provided credence to this new disease entity. This review of the studies done since 1972 appears to support the concept of a diabetic cardiomyopathy independent of atherosclerotic cardiovascular disease. The exact mechanism is still questionable, and several mechanisms have been proposed including small and microvascular disease, autonomic dysfunction, metabolic derangements, and interstitial fibrosis. However, the weight of evidence leans toward the development of fibrosis, possibly caused by the accumulation of a peroxidase acid schiff (PAS)‐positive glycoprotein, leading to myocardial hypertrophy and diastolic dysfunction.
Early repolarization
Authors: Mehta Mahaveer , Jain Abnash C. , Mehta Anurag
Published: February 2009

Early repolarization (ER) is an enigma. The purpose of this review is to reemphasize the overall electrocardiographic (ECG) pattern of this normal ST variant which continues to challenge the clinician because of its similarity to the current of injury potential to myocardium or an acute pericarditis. The data were provided from the studies identified through computerized searches of Medline, Toxline, Oxford, Agricola, and Bios Afterdark, Cumulative index, and a review of bibliographies of relevant articles on the related subjects. Early repolarization has elevated, upward, concave ST segments, located commonly in precordial leads, with reciprocal depression in a VR, tall, peaked and slightly asymmetrical T waves with notch, and slur on the R wave. The other accompanying features in the ECG are vertical axis, shorter and depressed P‐R interval, abrupt transition, counterclockwise rotation, presence of U waves, and sinus bradycardia. Males dominate and patients are often younger than 50 years of age. The incidence of 1 to 2% is found equally common in all races. Degree and incidence of ST elevation decrease as age advances. Exercise or isoproterenol administration may normalize the ST segment. Early repolarization is a benign condition. If the ECG conforms to a classical pattern of ER on serial ECGs, it would exclude the unnecessary hazards of present day revascularization therapy for myocardial infarction such as primary angioplasty or thrombolytic therapy, or aggressive management of acute pericarditis, and so forth. This review concludes with a discussion of comparative ECG features of ER, pericarditis, and myocardial infarction, and provides an algorithm for diagnostic management of patients suffering from these conditions.
Early mitral regurgitation after acute myocardial infarction does not contribute to subsequent left ventricular remodeling
Authors: Nešković Aleksandar N. , Marinković Jelena , Bonjić Milovan , Popović Aleksandar D.
Published: February 2009

Background: It is well known that mitral regurgitation may lead to left ventricular dilation; however, the relationship between progressive left ventricular dilation after acute myocardial infarction (MI) and mitral regurgitation has not yet been clarified.

Hypothesis: This study tested the hypothesis that early mitral regurgitation contributes to left ventricular remodeling after acute MI.

Methods: We prospectively evaluated 131 consecutive patients by serial two‐dimensional and Doppler echocardiography on Days 1,2,3, and 7, after 3 and 6 weeks, 3 and 6 months, and 1 year following acute MI. Patients were divided into two groups: those with mitral regurgitation in the first week after acute MI (Group 1, n = 34) and those without mitral regurgitation (Group 2, n = 81).

Results: Over 1 year, a significant increase in end‐diastolic volume index (from 62.1 ± 12.9 to 70.5 ± 23.6 ml/m2, p = 0.001) with a strong linear trend (F = 15.1, p<0.001) was noted. Initial end‐diastolic volume index was higher in Group 1 (65.6 ± 13.3 vs. 60.4 ± 12.5 ml/m2, p = 0.047), but this difference remained constant throughout the study (F = 1.76, p = NS). Therefore, the pattern of end‐diastolic volume changes was similar in both groups during the period of observation.

Conclusions: These data indicate that early mitral regurgitation after acute MI does not contribute to subsequent left ventricular remodeling in the first year after myocardial infarction.
Effects of digoxin on electrocardiogram in patients with acute atrial fibrillation—a randomized, placebo‐controlled study
Authors: Hornestam Björn , Held Peter , Edvardsson Nils
Published: February 2009

Background: Studies of healthy volunteers or patients in sinus rhythm have indicated that treatment with digoxin produces characteristic changes in the electrocardiogram (ECG). No randomized, placebo‐controlled studies are available and no study has investigated the effect on ECG in patients with atrial fibrillation.

Hypothesis: In a substudy to a trial comparing the therapeutic effect of intravenously administered digoxin with placebo in patients with acute atrial fibrillation, we investigated these effects as well as the relation between ECG changes and serum concentration of digoxin.

Methods: In all, 167 patients were included. Standard ECGs recorded at baseline, and at 2,6,12, and 16 h after randomization were digitized, and changes in RR‐intervals, QRS width, ST‐segment amplitude at 60 ms after the J point, T‐wave amplitude, and QTc interval were calculated. Furthermore, the correlation between the serum concentration of digoxin at 16 h after inclusion and changes on the ECG was analyzed.

Results: Compared with placebo, digoxin resulted in an increase in RR‐interval (p < 0.0001), a decrease in ST‐segment and T‐wave amplitude (p = 0.009 and p = 0.002, respectively), and in the QTc interval (p = 0.01). These changes were present 2 h after the first dose, but were more pronounced after 16 h. There was no significant correlation between serum concentration of digoxin and ECG changes at 16 h.

Conclusion: Compared with placebo, digoxin produces significant changes on ECG in patients with acute atrial fibrillation. The changes are in accordance with previous findings in individuals in sinus rhythm. There was no correlation between serum concentration of digoxin and ECG changes.
Thrombolysis of mobile right atrial thrombi following severe pulmonary embolism
Authors: Cracowski Jean‐Luc , Tremel Fréderic , Baguet Jean‐Philippe , Mallion Jean‐Michel
Published: February 2009

Thrombolysis may favorably affect the clinical outcome of mobile right atrial thrombus following pulmonary embolism (PE). We report the case of three patients with mobile right atrial thrombus following PE, in whom fibrinolysis was performed. Atrial mass disappeared on the control echocardiogram, but control ventilation perfusion scan showed new perfusion defects in all patients. Thrombolysis seems successful for the treatment of patients with mobile right atrial thrombus following PE; however, recurrent PE may be induced by fibrinolysis. This may affect the benefit of such therapy and should be taken into account when using this therapeutic treatment.
Periprocedural creatine kinase‐mb elevations: Long‐term impact and clinical implications
Authors: Jennifer Adgey A. A. , Mathew T. P. , Harbinson M. T.
Published: February 2009

Since the introduction of percutaneous transluminal coronary angioplasty (PTCA), percutaneous intervention with balloon catheters, stents, and atherectomy devices has become a widely accepted practice. The persistent complication of non‐Q‐wave myocardial infarction (MI), as evidenced by increased cardiac enzyme levels after intervention, has aroused only moderate concern because its incidence was perceived to be small and not clinically relevant. With more systematic assessments of cardiac enzymes—specifically, creatine kinase (CK) and its MB isoform—evidence has begun to clarify both the incidence and the prognosis of periprocedural non‐Q‐wave MI: It appears to occur nearly three times more often than is clinically evident across all device types (8 to 9% of all interventions) and is directly and continuously associated with adverse outcomes, including late death. Although directional and rotational atherectomy improve angiographic outcome compared with PTCA, periprocedural infarction occurs at least twice as often with these newer technologies; the incidence associated with stent placement is comparable to and possibly higher than that of PTCA. Factors that may cause elevated CK‐MB levels include distal embolization, side branch occlusion, thrombus, and coronary spasm. Analyses of the major trials of platelet glycoprotein (GP) IIb/IIIa receptor inhibitors, a class of potent antiplatelet agents, show striking effectiveness of these drugs in reducing the incidence of “enzyme‐only” or “silent” MI and in improving long‐term clinical outcomes. The findings implicate platelet mediation in the occurrence of periprocedural infarction and suggest an important role for antiplatelet therapy, particularly GP IIb/IIIa receptor inhibition, in protecting patients undergoing percutaneous intervention.
Survival without surgical repair of acute rupture of the right ventricular free wall
Authors: Sherer Yaniv , Levy Yair , Leibovich Livio , Shoenfeld Yehuda , Shahar Amir , Konen Eli
Published: February 2009

Rupture of the myocardial free wall is an infrequent complication of acute myocardial infarction. Unless it occurs in a space confined by pericardial adhesions, only surgical emergency repair of ruptured myocardium can prevent death. In this paper we report the case of an 81‐year‐old woman who was admitted to the emergency room with cardiac tamponade, resulting from inferolateral acute myocardial infarction and a subsequent rupture of the right ventricular free wall, with the formation of pericardial thrombus and effusion. The patient refused to undergo any surgical or invasive intervention, and therefore she was only treated conservatively. Nevertheless, her condition improved dramatically, as her blood pressure increased and echocardiography abnormalities almost disappeared. Follow‐up echocardiography 7 months post discharge was unremarkable. We believe that this rare case emphasizes that in special circumstances, such as creation of a thrombus that prevents more blood from extravasating, free‐wall rupture without surgical repair is compatible with long‐term survival.
Diagnosis and management of cardiac tamponade in the era of echocardiography
Authors: Tsang Teresa S. M. , Oh Jae K. , Seward James B.
Published: February 2009

Cardiac tamponade is a life‐threatening condition. Accurate diagnosis and prompt intervention are necessary. Classically, clinical features of tamponade include pulsus paradoxus, tachycardia, increased jugular venous pressure, and hypotension. With the advent of echocardiography, confirmation of an effusion and accurate assessment of its hemodynamic impact can be achieved, frequently in the absence of overt clinical manifestations. The decision regarding treatment and timing of intervention must take into account the clinical presentation and echocardiographic findings, along with careful weighing of risks and benefits to the individual patient. Echocardiographically guided pericardiocentesis is the best available therapy for initial management of cardiac tamponade. It is simple, safe, and effective for removing pericardial fluid and reversing hemodynamic instability, and the use of a pericardial catheter for extended drainage has been associated with significant reduction in recurrence of fluid accumulation.
Examining the psychosocial impact of implantable cardioverter defibrillators: A literature review
Authors: Camm A. John , Sears Samuel F. , Todaro John F. , Lewis Tara Saia , Sotile Wayne , Conti Jamie B.
Published: February 2009

Background: The implantable cardioverter defibrillator (ICD) has proven to be superior to medications in treating potentially life‐threatening ventricular arrhythmias, resulting in reduced mortality rates. Despite the number of patients receiving this therapy, its psychosocial impact is not well understood.

Hypothesis: The purposes of this paper are (1) to review the available literature documenting the psychosocial impact of the ICD on patients, (2) to hypothesize possible mechanisms for this psychosocial impact, and (3) to suggest clinical risk profiles and indications for psychological consultation.

Methods: Electronic and library searches (e.g., MEDLINE, PsychLit) were used to gather studies examining the psychosocial impact of the ICD. Only studies investigating psychosocial outcomes (e.g., psychological distress, quality of life, social and role functioning), either prospectively or cross‐sectionally, were admitted into the review. No literature reviews or secondary sources were included.

Results and Conclusions: Current research suggests that ICD‐specific fears and symptoms of anxiety (e.g., excessive worry, physiological arousal) are the most common psychological symptoms experienced by ICD recipients, with approximately 13–38% of recipients experiencing diagnosable levels of anxiety. Depressive symptoms are reported at rates that are generally consistent with other cardiac populations. Although the incidence of psychological disorders appears to be similar to that found in general cardiac populations, specific ICD‐related concerns such as fear of shock, fear of device malfunction, fear of death, and fear of embarrassment have been identified. Selected psychological theories such as classical conditioning, learned helplessness, and a cognitive appraisal model help to explain the occurrence of psychological symptoms post implantation. Psychosocial adjustment risk profiles indicate that young ICD recipients and those with high discharge rates may experience the most adjustment difficulties.
Different prognostic significance of right and left ventricular diastolic dysfunction in heart failure
Authors: Yu Henry C. M. , Sanderson John E.
Published: February 2009

Background: Left (LV) and right (RV) ventricular diastolic dysfunction is common in heart failure but the prognostic value of RV diastolic dysfunction is not known.

Hypothesis: As a follow‐up to a previously undertaken study, this study was carried out to investigate whether LV and RV diastolic dysfunction affect prognosis differently and, in addition, whether changes in diastolic filling patterns over time correlate with clinical outcome.

Methods: We studied a cohort of 105 patients (mean age 62.7± 1.3 years, 66% male) with heart failure (ejection fraction < 50%) by Doppler echocardiography in both RV and LV.

Results: An LV restrictive filling pattern (RFP) was present in 48% of the patients and, when compared with non‐RFP subgroups, it was associated with poorer systolic function, higher New York Heart Association functional class, and higher cardiac mortality at 1 year (all p < 0.001). The coexistence of an LV‐RFP and poor LV systolic function (ejection fraction < 25%) markedly decreased the 1‐year survival that was significant when compared with other subgroups (p = 0.001). In contrast, RV diastolic dysfunction that occurred in 21% of patients was not a prognostic factor for mortality either alone or in combination with LV diastolic dysfunction, but predicted nonfatal hospital admissions for heart failure or unstable angina (p = 0.016).

Conclusion: An LV restrictive filling pattern is a powerful predictor of a poor prognosis, especially when combined with low ejection fraction, but in this study RV diastolic dysfunction did not appear to be an independent predictor of subsequent mortality.