bluuebunny/crossref_metadata_2025 huggingface dataset:
Stress‐induced hemodynamic and hemostatic changes in patients with systemic hypertension: Effect of verapamil
Authors: Gebara Otavio C. E. , Jimenez Alfredo H. , Mckenna Carol , Mittleman Murray A. , Xu Ping , Lipinska Izabella , Muller James E. , Tofler Geoffrey H.
Published: February 2009

Stress‐induced hemodynamic and hemostatic responses may acutely trigger atherosclerotic plaque disruption and thrombosis leading to myocardial infarction. This study was designed to evaluate the responses to three stressors and to determine if once‐daily sustained release verapamil (Verelan®) modified these responses. We studied 13 patients with mild to moderate hypertension in a randomized, double‐blind, placebo‐controlled crossover trial. After 4 weeks of therapy, patients were evaluated following assumption of the upright posture, mental stress, and cold pressor test. During placebo, the stressors produced an increase in systolic pressure (144 ± 2 to 167 ± 3 mmHg, p < 0.001), heart rate (70 ± 2 to 77 ± 2 beats/ min, p< 0.001), and platelet aggregability to adenosine diphosphate (threshold concentration fell from 2.8 ± 0.4 to 1.9 ± 0.1 μM, p = 0.05)and epinephrine (3.4±0.9 to 1.6 ±0.6 μM, p < 0.001). Verapamil lowered systolic pressure at baseline (144 ± 2 to 134 ± 2 mmHg, p < 0.001), and after stress (167 ± 3 to 154 < 3 mmHg, p < 0.001), but did not alter the absolute increase with stress. During verapamil, platelet reactivity did not increase with stress, and the post‐stress response to epinephrine was reduced (higher threshold concentration) compared with placebo (3.9 ± 1.3 vs. 1.5 ± 0.3 μM, p = 0.05). Verapamil also reduced the response to collagen (increased lag time) at baseline and after stress (111 ± 9 vs. 91 ± 3 s, p < 0.01). We conclude that verapamil blunted potentially harmful stress‐induced hemodynamic and hemostatic changes. Further studies are required to determine whether these effects translate into a lower incidence of acute cardiovascular events.
Transesophageal echocardiography in the detection of inferior vena cava and cardiac metastasis in hepatocellular carcinoma
Authors: Tse Hung‐Fat , Lau Chu‐Pak , Lau Yuk‐Kong , Lai ChinL‐gung
Published: February 2009

Antemortem diagnosis of inferior vena cava (IVC) and cardiac metastasis of hepatocellular carcinoma (HCC) is difficult but important before consideration of curative resection. There are only a few cases of cardiac metastasis of HCC which have been diagnosed antemortem by echocardiography. Accordingly, 18 consecutive patients with HCC who were potential candidates for curative resection were studied by transthoracic (TTE) and transesophageal echocardiography (TEE). One (6%) and two (11%) patients had cardiac and IVC metastasis of HCC, respectively, which was detected by two‐dimensional TTE. In contrast, by using TEE, four patients (22%) showed tumor invasion of the IVC, of whom two (11%) had tumor mass extending into the right atrium (RA). There was no significant difference in age, serum level of alpha‐fetoprotein, and percentage of right liver lobar involvement between those with and without cardiac metastasis. Patients without cardiac metastasis detected on TTE or TEE had significantly longer mean duration of survival (5.0 ±2.1 vs. 2.1 ± 1.0 months; p < 0.05). In summary, TEE may be more useful than TTE in the detection of cardiac metastasis of HCC, which occurred in 22% of patients whose primary tumor was considered to be surgically resectable in our series. This can be safely performed in patients with HCC and can provide optimal visualization of the IVC and RA. The high prevalence of subclinical cardiac metastasis in HCC mandates the use of TEE in all patients with HCC prior to surgical intervention.
Reproducibility of head‐up tilt test in patients with syncope
Authors: Ruiz Graciela A. , Scaglione Jorge , González‐Zuelgaray Jorge
Published: February 2009

As the head‐up tilt test (HUT) is employed to verify the efficacy of undertaking a treatment, we prospectively evaluated the reproducibility of positive and negative results, as well as that of the response type in 64 consecutive patients (mean age 34.6 ± 22.9 years) with syncope of unknown cause. Two HUTs (60 min, 75° ), separated by an interval of 9.77 ± 8.21 days, were performed on each patient. Positive responses were reproduced in the second HUT in 54.5% of the patients. A greater reproducibility (84.3%) was observed for negative responses. Of the 31 patients with a negative first test, 5 had a positive response during the second HUT. Using a multivariate analysis, no clinical variable correlated with the reproducibility of positive or negative results. Likewise, neither arterial pressure nor heart rate observed during the test were correlated with reproducibility. Of 18 patients who reproduced positive responses, 12 (66.6%) did so with the same response modality. In three patients with documented monomorphic sustained ventricular tachycardia, which was hemodynamically well tolerated, and in one patient with temporal spike wave activity in the electroencephalogram, HUT was also positive. It was concluded that the low reproducibility of HUT limits its usefulness as a tool for evaluating treatment efficacy. The variability of the type of response suggests a common mechanism leading to cardioinhibitory and vasodepressor reactions. A positive result in only the second study shows the rationale of performing two tests when the first one is negative.
Peripheral artery recanalization in humans using balloon and laser angioplasty
Authors: Barbeau Gérald R. , Seeger James M. , Kaelin Lawrence D. , Abela George S. , Jablonski Sharon , Friedl Stephan E.
Published: February 2009

The treatment of patients with complex peripheral arterial disease and those who have had previous unsuccessful attempted revascularization procedures can be clinically challenging. Initial treatment was begun using therapy by percutaneous balloon and laser angioplasty, then proceeding to bypass surgery if severe ischemia persisted. Both percutaneous and cut‐down approaches were used to access totally occluded arteries. An attempt was made to cross the occlusion mechanically with either a guide wire or an activated laser probe. If laser recanalization was not successful, the patient underwent bypass surgery or was managed with medication unless an amputation was necessary. Following initial screening of 381 patients, 115 procedures were performed on 103 patients. In 31 procedures (28 patients), only balloon angioplasty was performed. In 84 procedures (75 patients), laser recanalization was attempted: 55 percutaneously and 29 by cut‐down. Overall technical success (crossing the obstruction without perforation) was 86/115 (75%). Technically successful procedures were characterized by shorter arterial occlusions than were technical failures (8.4 ± 1 cm vs. 14.3 ± 1.9 cm; p< 0.004). Clinical success (residual stenosis < 50%, symptom relief, improved ankle brachial index ≥ 0.15, and no complications) was achieved in 22/31 (71 %) of balloon angioplasty procedures alone. The stenoses decreased from 98 ± 4% to 31 ± 24%, p < 0.00001. Combined percutaneous laser and balloon angioplasty had a technical success of 36/55 (65%). Stenoses were reduced from 99 ± 2% to 56 ± 14% after laser angioplasty, to 30 ± 15% after balloon angioplasty, p < 0.0001. Laser angioplasty performed via a cut‐down had a clinical success of 9/29 (31%). However, major complications were rare. Device staging for treatment of peripheral vascular disease provides additional options for patients who are at high surgical risk and/or in whom standard therapy has failed.
Endocardial fibroelastosis and primary carnitine deficiency due to a defect in the plasma membrane carnitine transporter
Authors: Bennett Michael J. , Hale Daniel E. , Pollitt Rodney J. , Variend Sadick , Stanley Charles A.
Published: February 2009

Endocardial fibroelastosis (EFE) has previously been shown to be associated with tissue carnitine deficiency, although the basis for the carnitine deficiency has not been documented. A patient with the classical features of EFE and marked deficiency of carnitine in heart muscle, skeletal muscle, and liver is presented in this report. Cultured skin fibro‐blasts from both parents demonstrated levels of carnitine uptake at 50% of the normal rate. This is consistent with het‐erozygosity for the plasma membrane carnitine transporter defect, indicating likely homozygosity for this recently recognized inborn error in the index patient.
Anomalous origin of the right coronary artery from the pulmonary trunk: Is surgical reimplantation into the aorta a method of choice?
Authors: Kautzner Josef , Veselka Josef , Rohac Jan
Published: February 2009

The origin of the right coronary artery (RCA) from the pulmonary trunk (PT) is a rare congenital anomaly. Although most of the patients remain asymptomatic, prophylactic reimplantation of the RCA into the aorta has been recommended to prevent an adverse outcome. The report describes postoperative results in two patients following uneventful RCA reimplantation. A 47‐year‐old man, with coexisting diffuse atherosclerotic involvement of the left coronary artery, remained symptomatic despite the establishment of a two‐coronary system. The second patient, a 36‐year‐old woman, with isolated anomalous origin of the RCA from the PT, continued to present with myocardial ischemia on exertion. The original observation of an angiographic “slow‐flow” phenomenon in the reimplanted RCA in both patients implies the impairment of myocardial microvessels. These findings give rise to the question of whether the reimplantation of the anomalous artery is really superior to simple ligation of its origin in order to relieve the “coronary steal” effect.
Antiplatelet and anticoagulant use after myocardial infarction
Authors: Almony Gregory T. , Lefkovits Jeffrey , Topol Eric J.
Published: February 2009

Coronary thrombosis leading to myocardial infarction is a complex process involving the interaction of the arterial wall, the coagulation cascade, and platelets. Increased understanding of the molecular biology of thrombosis has prompted an evolution in antithrombotic therapy, from the early use of warfarin following myocardial infarction to agents targeting specific receptors or modulators in the thrombotic process. The complexity of thrombosis allows for numerous sites of pharmacologic intervention the multiple pathways leading to platelet aggregation and thrombin formation provide the opportunity for combined therapies. This review presents the current clinical data on antiplatelet, anticoagulant, and specific antithrombin therapies following myocardial infarction.
Symptoms of hypertrophic cardiomyopathy, with special emphasis on syncope and postprandial exacerbation of symptoms
Authors: Gilligan David M. , Nihoyannopoulos Petros , Sbarouni Eftichia , Dritsas Athanase , Oakley Celia M. , Fletcher Astrid
Published: February 2009

We undertook a prospective study of the symptoms of hypertrophic cardiomyopathy with the aim of profiling symptomatic morbidity in detail, determining the prevalence of anxiety and depression, and describing the prevalence and associations of syncope and postprandial symptom exacerbation. A questionnaire was administered to consecutive outpatients;70 with hypertrophic cardiomyopathy, 43 with coronary artery disease, 32 with idiopathic dilated cardiomyopathy, and to 40 normal subjects. Hypertrophic cardiomyopathy patients underwent exercise testing, echo‐cardiography, and Holter monitoring. Hypertrophic cardiomyopathy patients had a high frequency of cardiac symptoms and, on average, had a level of symptomatic morbidity equivalent to that of chronic stable angina and dilated cardiomyopathy. There was no evidence for an excess of anxiety (14%) or depression (6%) in patients with hypertrophic cardiomyopathy. Syncope and presyncope, especially provoked by exertion or posture change, were characteristic and common symptoms in hypertrophic cardiomyopathy. A history of syncope was associated with an abnormal blood pressure response to exercise in over 50% of cases that may be the mechanism of syncope in some. Postprandial exacerbation of symptoms occurred in over one‐third of hypertrophic cardiomyopathy patients, half of coronary disease patients, and infrequently in dilated cardiomyopathy. Hypertrophic cardiomyopathy patients with postprandial symptoms had a greater frequency of angina, were more symptomatic, and had a reduced exercise capacity, suggesting that postprandial symptoms are a marker for more severe disease.
Acute infarction of the left ventricular papillary muscle: Electrocardiographic pattern and recognition of its location
Authors: Dabrowska Barbara , Prejs Robert , Zdzienicki Marcin , Walczak Ewa
Published: February 2009

Background and hypothesis: ST‐segment depression during acute myocardial infarction (AMI) is known to herald serious hemodynamic complications. Since the mechanism of this dependence is not clear, we reinvestigated the old concept of papillary muscle infarction (PMI) as a cause of marked ST depression.

Methods: Autopsies and morpho‐electrocardiographic correlations were performed in 53 patients with AMI involving one or both left ventricular papillary muscles, and in 10 patients with AMI, but without acute PMI.

Results: ST‐segment depression ≥l mm in at least two leads (mean 3.6 ± 2.2 mm) was found in 46 (86.8%) patients with, and in one without acute PMI. Thus, the sensitivity and specificity in selecting patients with acute PMI from among those with AMI were 86.8 and 90%, respectively, with an overall accuracy of diagnosis of acute PMI in the course of AMI of 87.3%. Among 26 patients with ST elevation consistent with diagnosis of AMI, ST depression, recorded in 22 patients, was insignificantly greater than in 24 of 27 patients without ST elevation: 4.1 ± 2.9 versus 3.1 ± 1.2 mm. Localization of ST depression in the limb leads allowed recognition of which papillary muscle suffered from acute infarction: ST depression in the inferior leads was seen only in patients with anterolateral PMI, whereas in leads I and/or aVL it was seen only in cases with posteromedial PMI. This rule was also valid in patients without concomitant ST elevation.

Conclusion: Patients with acute PMI show marked ST‐segment depression. Its location in the limb leads allows recognition of which papillary muscle has undergone necrosis. This cause of marked ST depression in patients with AMI may explain the high mortality in this particular group.
Intravenous propafenone in paroxysmal atrial fibrillation: A randomized, placebo‐controlled, double‐blind, multicenter clinical trial
Authors: Fresco Claudio , Proclemer Alessandro , Pavan Alessandro , Buia Gianfranco , Vicentini Alfredo , Pavan Daniela , Morgera Tullio ,   on behalf of the Paroxysmal Atrial Fibrillation Italian Trial (PAFIT)‐2 Investigators
Published: February 2009

Background: Pharmacological conversion of paroxysmal atrial fibrillation is frequently necessary. The aim of this study was to compare intravenous propafenone, a class Ic antiar‐rhythmic agent, with placebo in paroxysmal atrial fibrillation (AF) of recent onset (<72 h).

Patients and methods: We randomly allocated 75 patients, aged 18 to 70 years, with paroxysmal AF to receive intravenous propafenone (2 mg/kg in 15 min followed by 1 mg/kg in 2 h) or the matching placebo. Patients were followed for 3 h. Exclusion criteria were the presence of one of the following: clinical heart failure, recent acute myocardial infarction, hypotension, atrioventricular block, Wolff‐Parkinson‐White syndrome, or current treatment with antiarrhythmic agents or digitalis.

Results: No sign of heart disease was found in 74.7% of the patients. Echocardiographically determined left atrium diameter was similar in the two groups. Conversion to sinus rhythm occurred in 24 of 41 patients allocated to propafenone and in 10 of 34 patients allocated to placebo (odds ratio 3.2, 95% confidence intervals 1.3‐7.9;p<0.01). Mean conversion time was 34 ± 29 and 71 ± 55 min, respectively, for propafenone and placebo. Mean heart rate in nonconverters decreased from 146 to 109 beats/min in patients treated with propafenone while it remained virtually unchanged in those treated with placebo. Only minor side effects were noted.

Conclusions: Intravenous propafenone is an effective therapeutic option for restoring sinus rhythm in patients with paroxysmal AF of recent onset.
Correlation between left ventricular contractility and relaxation in patients with idiopathic dilated cardiomyopathy
Authors: Kato Ryozo , Ishihara Hitoshi , Sobue Toshikazu , Yokota Mitsuhiro
Published: February 2009

Background and hypothesis: It is not fully understood whether alterations in left ventricular (LV) relaxation in patients with idiopathic dilated cardiomyopathy (DCM) precede or follow alterations in LV systolic function. Accordingly, we investigated the relationship between LV systole and diastolic relaxation in patients with DCM using LV pressure‐volume analysis.

Methods: Hemodynamic data were collected for 38 consecutive patients with DCM in normal sinus rhythm and in the resting steady state (New York Heart Association functional class II to III). Continuous simultaneous pressure‐volume relationships were obtained by conductance catheter. Left ventricular end‐systolic elastance (Ees) was determined during transient occlusion of the inferior vena cava.

Results: Left ventricular ejection fraction, peak negative dP/dt, and peak positive dP/dt were depressed (31 ± 11%, ‐ 1242 ± 351 mmHg/s, and 1118 ±253 mmHg/s, respectively ). The LV end‐diastolic volume index, the time constants of isovolumic LV pressure decay Tl and Td were increased (141 ±38 ml/m2, 54+14 ms, and 69 ± 17 ms, respectively). Ees was markedly depressed (0.9 ± 0.5 mmHg/ml) and was not correlated with established systolic or diastolic indices except for peak positive dP/dt. Our results showed that abnormalities of relaxation were not correlated with contractile dysfunction in patients with DCM in the resting steady state however, most patients (79%) had both prolonged relaxation and extremely depressed contractility. Abnormal relaxation may have been transient or compensated in some patients (21%) with DCM who had preserved relaxation despite severely depressed contractility.
Nonlipid primary and secondary prevention strategies for coronary heart disease
Authors: Maron David J.
Published: February 2009

Widespread application of proven primary and secondary preventive strategies for coronary heart disease would result in substantial savings of life and health care dollars. Proven strategies (excluding lipid therapy) include quitting smoking, treating hypertension, physical activity, aspirin therapy, and appropriate use of anticoagulants, beta blockers, and angiotensin‐converting enzyme inhibitors in survivors of myocardial infarction. Estrogen replacement therapy is currently under clinical investigation. Avoidance of obesity and tight control of diabetes are prudent interventions as yet unproved by clinical trials. Unfortunately, preventive strategies are frequently underutilized. The greatest challenge for preventive cardiology is to put into practice what we already know to prevent the development and progression of atherosclerosis.
Monitoring right‐sided chest leads during chest pain in patients with obstructive lung disease
Authors: Alidina Amyn , Jamal Nasiruddin M.
Published: February 2009

Isolated nondominant right coronary artery stenosis causing significant angina and right ventricular infarction has been reported previously, but the importance of monitoring right‐sided precordial leads during chest pain in patients with obstructive lung disease has not been documented.
Intramural hematoma of the aorta caused by a penetrating atheromatous ulcer
Authors: Wann Samuel , Jaff Michael , Dorros Gerald , Sampson Cynthia
Published: February 2009

Aortic dissection is a life‐threatening condition which is difficult to diagnose because of its variable clinical presentation and diverse pathophysiologic manifestations. We present a case in which intramural hematoma of the thoracic aorta occurred in the absence of an intimal flap. Computed tomography and magnetic resonance imaging both showed hemorrhage in the wall of the aorta. Transesophageal echocar‐diography also revealed a penetrating atherosclerotic ulcer in the transverse aorta as a cause of the hematoma. A high index of clinical suspicion and a combination of diagnostic procedures resulted in proper diagnosis and successful surgical treatment.
Angina pectoris refractory for conventional therapy—Is neurostimulation a possible alternative treatment?
Authors: Hautvast R. W. M. , Dejongste M. J. L. , Blanksma P. K. , Lie K. I. , Ter Horst G. J.
Published: February 2009

The treatment of angina pectoris as a symptom of coronary artery disease usually is focused on restoring the balance between oxygen demand and supply of the myocardium by administration of drugs interfering in heart rate, cardiac pre‐ and afterload, and coronary vascular tone. For nonresponders to drug therapy or for those with jeopardized myocardium, revascularization procedures such as coronary bypass surgery and percutaneous transluminal coronary angioplasty are at hand. However, the atherosclerotic process is not stopped by these therapies and, at longer terms, angina may recur. It is not always possible to revascularize all the patients who do not positively react to medical treatment. Those with angina, not responding to adequate medication and who are not suitable anymore for revascularization, are considered to suffer from refractory angina pectoris. This group of patients has a poor quality of life, for their exercise tolerance is severely afflicted. For these patients, neurostimulation has been described repeatedly as an effective and safe therapy. The mechanism of action of neurostimulation is not completely known, but recent studies suggest an anti‐ischemic effect, exerted through changes in myocardial blood flow. As soon as its safety is sufficiently established, it may become a useful alternative in the treatment of refractory angina pectoris.
Markedly improved skeletal muscle function with local muscle training in patients with chronic heart failure
Authors: Gordon Allan , Sylven Christer , Tyni‐Lennaé Raua , Persson Helene , Kauser Lennart , Hultman Eric
Published: February 2009

Background: Reduced heart pump function and skeletal muscle abnormalities are considered important determinants for the low physical exercise capacity in chronic heart failure. Because of reduced ventricular function, traditional physical rehabilitation may cause underperfusion and low local work intensity, thereby producing suboptimal conditions for skeletal muscle training.

Hypothesis: The study was undertaken to determine the effects of local exercise training, designed as one‐ or two‐legged knee extensor training, on exercise capacity in patients with moderate chronic heart failure. Because such exercise models use only about one quarter to half the muscle mass used in cycle ergometer training, the influence of a restricted circulatory capacity should therefore be limited. Further, we aimed to determine whether or not chronic heart failure skeletal musculature abnormalities are counteracted with such training.

Methods: Fourteen patients with chronic heart failure [age 58 ± 3 years, ejection fraction (EF) 28 ±4%] were randomized to two different training protocols three times a week for 8 weeks and compared with a nontraining control group (n = 7, age 62 ± 3, EF 27 ± 3%). Group 2L (n = 7) underwent simultaneous two‐legged knee extensor training (about 4 kg working muscle) for 15 min at 65–75% of VO2 max of the two‐legged kick. Group 1L (n = 7) trained each leg at a time for 15 min of continuous one‐legged dynamic knee extensor work with the same training load per muscle mass, that is, at 35% of VO2 max of the two‐legged kick (about 2 kg working muscle). Peak VO2 of two‐legged knee extensor exercise (1/min), two‐legged endurance (W), and strength (Nm) were determined before and after the training period. The activity of citrate syn‐thase (CS) was estimated in tissue samples from the quadriceps femoris muscle.

Results: Peak VO2 did not change with training. Two‐legged knee extensor endurance exercise capacity increased by an average of 40–50% (p<0.01) in all training patients in both the 2L and 1L groups, while no change was observed in the control group. Depressed skeletal muscle CS activity increased by 25–35% in both training groups (p<0.01). Strength increased by 16% in the 2L group after training (p<0.05), while no change was seen in the 1L and control groups.

Conclusions: Skeletal muscle changes in stable moderate chronic heart failure are not entirely irreversible. A major factor contributing to these changes and to exercise limitation is deconditioning. Local muscle training is efficient and can at least partially improve skeletal muscle function in these patients. Different degrees of local activation, that is, one‐ or two‐legged knee extensor exercise, do not seem to differ in terms of their effect on exercise capacity. Depressed skeletal muscle oxidative capacity adapts to such physical training with increased activity to an extent not different from that for healthy volunteers.
Cardiac electrophysiology: A cost‐effective approach
Authors: Dimarco John P.
Published: February 2009

Clinical cardiac electrophysiology is a relatively new discipline, heavily dependent upon new technology that is often expensive. In cardiac pacing, no effective alternative to permanent pacing usually exists for patients with Class I indications, so cost‐reduction strategies involve appropriate selection and utilization of hardware and facilities. Cost‐effective utilization of radiofrequency ablation and implantable cardioverter‐defibrillators requires that these techniques be compared with alternative therapies, usually antiarrhythmic drugs. Both ablation and defibrillator implantation can be shown to be cost effective in selected populations, but a cost‐conscious approach to procedures and patient selection can make them cost effective in a broad range of patients.
Computer errors in electrocardiography
Authors: Hurst J. Willis , Treasure Charles B. , Sathavorn Charn S.
Published: February 2009

Computer interpretation of electrocardiograms is far from adequate. This paper highlights a particular type of computer error that is merely symbolic of the large number of errors the computer can make. In addition to computer errors in electrocardiography, it is likely that computer interpretation has diminished the ability of physicians to interpret electrocardiograms.
Factors limiting the enrollment of women in a randomized coronary artery disease trial
Authors: Steingart Richard M. , Gambino Anthony , Coglianese Mary Ellen , Forman Sandra , Knatterud Genell , Bittner Vera , Mueller Hiltrud , Frishman William , Handberg Eileen , Richard Conti C.
Published: February 2009

Background and hypothesis: Although it is recognized that women have been underrepresented in clinical trials of cardiovascular disease, the reasons for their limited enrollment have not been elucidated.

Methods: A prospective tracking system was established in the Asymptomatic Cardiac Ischemia Pilot study (ACIP) to monitor recruitment and identify protocol issues that interfered with the recruitment of women. Patients with stress test evidence for ischemia during the course of routine clinical care were screened for asymptomatic ischemia with an ambulatory electrocardiogram (ECG).

Results: Those with at least one episode of asymptomatic ischemia and angiographic evidence of coronary artery disease suited for revascularization could be randomized. Women comprised only 17% of the 1,820 patients screened for asymptomatic ischemia, and only 14% of the 558 patients randomized. The limited number of women screened for ischemia was largely due to the limited number of women (25% of all patients) found to have test evidence for ischemia or coronary artery disease suited for revascularization during the course of routine clinical care. Once patients were identified as having ischemia on stress test and ambulatory ECG, the major difference in eligibility was the difference in disqualifying angiograms, occurring 21/2 times as frequently in women as in men (p < 0.001).

Conclusion: The percentage of women recruited was lower than the prevalence of ischemic heart disease in the general population because at participating centers (1) women were found to have ischemia less often than men during the course of routine clinical care, and (2) screening tests for ischemia were less predictive of protocol‐defined coronary disease in women than in men.
Relationship between late potentials and the predischarge electrocardiographic pattern in patients with acute anterior wall myocardial infarction
Authors: Kusniec Jairo , Solodky Alejandro , Strasberg Boris , Klainman Eliezer , Abboud Shimon , Imbar Shula , Sclarovsky Samuel
Published: February 2009

Hypothesis: The presence of late potentials on the signalaveraged electrocardiogram (SAECG) identifies patients at high risk for development of ventricular tachyarrhythmias after myocardial infarction (MI).

Methods: The electrocardiogram and left ventricular function in 65 patients recovering from a first acute anterior wall MI were analyzed. We compared the pattern of the ST segment (isoelectric or elevated) and of the T wave (positive or negative) with the SAECG using an orthogonal bipolar lead configuration (X, Y, Z) with bidirectional Butterworth filtering (Simson's method).

Results: Abnormal SAECG was found in 17 (26%) patients; 11 of 18 patients with ST elevation had abnormal SAECG, and only 6 of 47 patients with isoelectric ST segment developed abnormal SAECG (p<0.0001, odds ratio = 10.74). Of 19 patients with positive T waves, 10 had abnormal SAECG, and abnormal SAECG was found in 7 of 46 patients with negative T waves (p<0.003, odds ratio = 5.27). When both parameters were considered together, 9 of 12 patients with ST elevation and positive T wave developed abnormal SAECG, and 35 of 40 patients with isoelectric ST and negative T wave had normal SAECG (p<0.0002). Left ventricular ejection fraction was similar in patients with abnormal SAECG (43 ± 14%) and normal SAECG (46 ± 11 %).

Conclusion: These findings suggest that patients with anterior wall MI and a predischarge pattern of ST elevation and positive T wave have a higher incidence of abnormal SAECG and therefore may have a worse prognosis, especially related to the subsequent development of ventricular arrhythmias.
Cost‐Effective treatment of coronary artery disease—the new imperative
Authors: Robert Superko H.
Published: February 2009

Large lipid‐lowering clinical trials have demonstrated a significant reduction in cardiovascular events and the need for cardiovascular procedures. These clinical end point trials used relatively weak treatment modalities, and when the cost savings of the reduced number of events is balanced against the estimated cost of treatment, the average difference is approximately $ 1,500 per patient per year. Arterio‐graphic trials have used similar or more aggressive lipoprotein therapy over shorter periods of time. Estimates of cost savings from reduced clinical events balanced against the cost of treatment in these studies indicate a wide spectrum of estimated patient costs. These estimates range between a cost of $2,273 per patient per year to a cost savings of—$ 901 per patient per year. Extrapolation to the United States population with coronary artery disease (CAD) suggests that greater than one billion dollars per year could be saved if patients with CAD received similar treatment and responded in a similar manner. volves both excellence in medicine and attention to cost containment issues. The need to practice medicine in a cost‐effective manner creates a challenge and an opportunity to provide a better cardiovascular treatment service that reduces costs and at the same time provides patients with a treatment arm previously relegated to a second or third level of importance. Preventive cardiology has now achieved a status that makes it an essential part of a complete cardiovascular service. Disorders of lipoprotein metabolism is one component of preventive cardiology, and recent investigations have demonstrated that proper diagnosis and treatment directed at the specific underlying disorder can significantly reduce the number of cardiovascular events, as well as the rate of arteri‐ographically determined progression. This article will focus on the potential cost savings that may accrue if appropriate diagnosis and treatment is undertaken.
Directional coronary atherectomy for coronary artery spasm refractory to medical therapy
Authors: Hilton Thomas C. , Blackshear Joseph L. , Utset Bernardo , Kern Morton J.
Published: February 2009

A patient with severe medically refractory coronary artery spasm was treated successfully with coronary atherectomy of a mild (40%) left anterior descending artery stenosis. Before the procedure, the patient was dependent on intravenous nitroglycerin because of daily episodes of angina with ST‐segment elevation despite receiving multiple combinations of antianginal therapies. Clinical response to coronary atherectomy was prompt and dramatic.
Ventricular tachycardia initiated solely by reduced pacing rate during routine pacemaker follow‐up
Authors: Alt Eckhard , Coenen Martin , Baedeker Wolfgang , Schmitt Claus
Published: February 2009

Ventricular arrhythmias during a pacemaker follow‐up have been previously reported, usually in conjunction with temporary asynchronous stimulation of a demand pacemaker through magnet application or by increased myocardial excitability, for example, following a myocardial infarction. The subject of this report, an 82‐year‐old pacemaker patient, had been VVI‐paced without problems for the past 11 years. As an aid in determining the sensing threshold, the pacemaker lower rate was reduced from 70 to 40 beats/min. A ventricular tachycardia of 240 beats/min was induced, most likely following short‐long cycles; syncope resulted. To our knowledge, this is the first report of induction of a ventricular tachycardia during pacemaker follow‐up solely by reduction of pacing rate and not by asynchronous pacing. This case demonstrates an additional potential risk associated with pacemaker rate manipulation during pacemaker follow‐up.
Aortic valve endocarditis in an acutely rejecting orthotopic heart transplant recipient
Authors: Brian Fazia R. , Mills Roger M. , Richard Conti C. , Staples Edward D.
Published: February 2009

Infective endocarditis is an infrequent but serious complication in heart transplant recipients. We report successful treatment for this serious complication.
Monotherapy with hMG‐CoA reductase inhibitors and secondary prevention in coronary artery disease
Authors: Rackley Charles E.
Published: February 2009

Although thrombolytic drugs, percutaneous transluminal coronary angioplasty, and coronary artery bypass grafting have provided major advances in the treatment of coronary artery disease, the use of lipid‐lowering drugs for secondary prevention has significantly reduced cardiovascular events in the population with coronary artery disease. Secondary prevention trials using HMG‐CoA reductase inhibitors include the Familial Atherosclerosis Treatment Study (FATS), the Monitored Atherosclerosis Regression Study (MARS), the Canadian Coronary Atherosclerosis Intervention Trial (CCAIT), the Asymptomatic Carotid Artery Progression Study (ACAPS), the Multi Anti‐Atheroma Study (MAAS), the Scandinavian Simvastatin Survival Study (4S), the Pravastatin Limitation of Atherosclerosis in Coronary Arteries (PLAC I), the Regression Growth Evaluation Statin Study (REGRESS), the Pravastatin Multinational Study, and the Pravastatin, Lipids, and Atherosclerosis in Carotids (PLAC II). Mean changes from baseline of lipid fractions in these trials included: total cholesterol 18 to 35% reduction low‐density lipoprotein (LDL) cholesterol 26 to 46% reduction high‐density lipoprotein (HDL) cholesterol 5 to 15% increase and triglyceride 7 to 22% reduction. Angiographic regression or lack of progression was statistically demonstrated in the FATS, MARS, CCAIT, MAAS, PLAC I, and REGRESS trials. Cardiovascular events decreased 25 to 92% in all trials, and there was a significant reduction in both cardiovascular and total mortality in the 4S. The greater reduction in cardiovascular events than in anatomic changes suggests that the HMG‐CoA reductase inhibitors stabilized the surface of plaques. Monotherapy with HMG‐CoA reductase inhibitors provides the clinical opportunity to modify the natural history of coronary artery disease.
Systemic side effects of topical beta‐adrenergic blockers
Authors: Stewart William C. , Castelli William P.
Published: February 2009

Glaucoma, a disease that affects between 1 and 3% of the population above the age of 60, is most commonly treated by topical beta‐adrenergic blockers. Although effective in lowering intraocular pressure and helping to preserve sight, beta blockers also may have adverse influences on the cardiac, pulmonary, and central nervous systems, and on endocrine functions. Clinicians' awareness that their patients may be treated with topical beta blockers will help them to elicit this information and the history, prescribe the medicine correctly, and be cognizant of a possible role this medicine may have in any deterioration of a patient's systemic clinical status.
Hemodynamic effects of creatine phosphate in patients with congestive heart failure: A double‐blind comparison trial versus placebo
Authors: Ferraro Sergio , Codella Cinzia , Palumbo Fabrizio , Desiderio Alfonso , Trimigliozzi Pasquale , Maddalena Giovanni , Chiariello Massimo
Published: February 2009

Background: The use of metabolic drugs effective in addition to conventional therapy represents a significant challenge in patients with left ventricular dysfunction.

Hypothesis: The aim of this double‐blind, placebo‐controlled study was to investigate the hemodynamic effects of acute intravenous (IV) administration of creatine phosphate (CP) and of short‐term treatment in patients with congestive heart failure (CHF) from ischemic heart disease (IHD) or dilated cardiomyopathy in addition to conventional therapy.

Methods: We compared the hemodynamic effects of exogenous creatine phosphate (CP) and placebo in a double‐blind, crossover design study in 13 hospitalized patients (12 men, 1 woman, mean age 52 ± 8 years) with CHF. All patients were in New York Heart Association (NYHA) class II‐III and received conventional pharmacologic therapy for CHF this was not changed during the study period. The study design consisted of two treatment periods (CP or placebo and placebo or CP, respectively) of 4 days each, separated by a 2‐day washout interval. The intravenous infusion consisted of 6 g CP or placebo (acute treatment) or 6 g CP or placebo daily for 4 days (short‐term treatment) diluted in 50 ml of NaCl 0.9%;infusion duration was about 10 min. Mono‐bidimensional echocardiographic examination (Hewlett Packard So‐nos 1000, with a 2.5 MHz transducer) was performed at baseline, after acute infusion, and 12 h after the end of short‐term treatment. Data were analyzed by ANOVA and Student's t‐test for paired data the results obtained after acute and short‐term therapy were compared with the baseline values.

Results: After placebo therapy, no significant change was observed. The results after treatment with CP showed a significant reduction of end‐systolic diameter [baseline: 4.5 ± 0.6;acute: 4.2 ± 0.5, (p<0.001);short‐term 4.3 ± 0.6 cm, (p<0.05)] and systemic vascular resistance (baseline: 1064.9 ± 483.7;acute: 947.5 ± 390.2 (p<0.05);short‐term: 950.7 ± 394.3 dynescm‐5 (p<0.05);moreover, a significant increase of percent ejection fraction [baseline:48 ± 12%;acute 53 ± 12% (p<0.01);short‐term 52 ± 11 % (p<0.01)], and of percent fractional shortening [baseline: 25 ± 7;acute 28 ± 8 (p<0.05);short‐term 28 ± 7% (p<0.05)] was observed.

Conclusion: CP was shown to improve cardiac function, even in the presence of a conventional CHF pharmacologic therapy.
Pathophysiologic significance of left ventricular hypertrophy in dilated cardiomyopathy
Authors: Iida Keiji , Sersi Magdi El , Fujieda Katusuji , Kawano Satoru , Tabei Fumiko , Iwasaki Yuko , Masumi Tomoko , Yamaguchi Iwao , Sugishita Yasuro
Published: February 2009

Background and hypothesis: Patients with dilated cardiomyopathy (DCM) with left ventricular hypertrophy (LVH) have been found to have a better prognosis than patients without LVH. However, the pathophysiologic mechanism for that has not been investigated. We sought to clarify the pathophysiologic significance of LVH in DCM.

Methods: We performed isoproterenol infusion echocar‐diography (0.02 m̈g/kg/min) in 17 patients with DCM, and measured plasma epinephrine and norepinephrine levels at rest and at the end of ergometer exercise in 14 of the 17 patients. Patients were classified into groups according to the presence (9 patients) (LVH+) or absence (8 patients) (LVH‐) of LVH. Left ventricular hypertrophy was defined as an inter‐ventricular thickness or posterior wall thickness ≥13 mm.

Results: Although there was no significant difference between groups in fractional shortening at rest during isoproterenol infusion, fractional shortening was significantly higher in the LVH (+) group than in the LVH (‐) group (29 ± 9 vs. 17 ± 8%;p<0.025). Although there was no significant difference in plasma norepinephrine level, it was significantly lower in the LVH (+) group than in the LVH (‐) group (233 ± 169 vs. 519 ± 258 pg/ml;p<0.05) at the end point of the exercise.

Conclusion: Systolic reserve, represented by the response to isoproterenol, is greater in patients with DCM with LVH than in those without LVH, and a lower plasma level of norepinephrine is needed to activate the myocardium during ex ercise in patients with DCM with LVH. This pathophysiologic characteristic could be one of the mechanisms which explain a better prognosis in patients with DCM with LVH.
Echocardiographic assessment of wall motion in ST‐segment alternans during coronary angioplasty
Authors: Kerensky Richard A. , Lewis Jannet F. , Azar Gordon J. , Franco Elizabeth A. , Hill James A.
Published: February 2009

ST alternans occurs in the setting of severe and extensive myocardial ischemia. In this particular case, ST alternans occurred well after the onset of ischemia‐induced left ventricular dysfunction. There is no echocardiographic evidence of beat‐to‐beat variation in contractility to correspond to this ST‐segment phenomenon. Further studies of left ventricular function during ST alternans in patients are needed to determine whether this finding applies to all patients with is‐chemic heart disease.
Elevated serum Lp (a) concentration and the rare apo (a) phenotype in a patient with myocardial infarction
Authors: Hibino Takeshi , Sakuma Nagahiko , Hashimoto Takeshi , Ohte Nobuyuki , Yoneyama Akihiko , Satoh Takaaki , Fujinami Takao
Published: February 2009

Lp (a) is considered to be an independent risk factor for the development of cardiovascular disease. A case of myocardial infarction with elevated serum Lp (a) concentration and the rare apo (a) phenotype and its successful recanal‐ization using tissue plasminogen activator is reported.
Increased frequency of organ‐specific cardiac antibodies in healthy relatives of patients with dilated cardiomyopathy: Evidence for autoimmunity in polish families
Authors: Bilińska Z.T. , Kuśmierczyk‐Droszcz B. , Michalak E. , Grzybowski J. , Rydlewska‐Sadowska W. , Ruzyłło W. , Caforio A.L.P. , Goldman J.H. , Haven A.J. , Mckenna W.J.
Published: February 2009

Background and hypothesis: Autoantibodies represent markers of autoimmune involvement and are found with increased frequency in patients and their symptom‐free relatives at risk compared with normal controls. Cardiac‐specific autoantibodies, detected by immunofluorescence, were found in 20% of symptom‐free relatives of patients with dilated cardiomyopathy (DCM) from England and Italy. The role of autoimmunity may vary in DCM patients from Poland due to ethnic differences in genetic susceptibility to autoimmune disease.

Methods: We assessed the frequency of the organ‐specific cardiac autoantibodies in 162 symptom‐free relatives of DCM patients [85 male, mean (SD) age 27 (18) years] and 80 control subjects from Poland. Familial DCM (>1 affected member) was present in 4 families, nonfamilial DCM in the remaining 24 pedigrees. We performe

Results: The frequency of cardiac‐specific autoantibodies was higher among patients with documented DCM (probands and relatives) (50%) and their symptom‐free relatives (38%) than in unrelated normal subjects (10%;p=0.0001). In 24 (86%) of the pedigrees studied, autoantibodies were found in the proband and/or in at least one family member and tended to be more common in familial than in nonfamilial DCM (50 vs. 35%, p=NS). Echocardiographic indices of left ventricular size and function were similar in relatives with and without detectable antibodies.d antibody screening and noninva‐sive cardiological assessment in the whole group.

Conclusions: The presence of cardiac‐specific autoantibodies in symptom‐free relatives of DCM patients provides evidence for autoimmunity in the majority (86%) of our pedigrees, including both familial and nonfamilial forms of DCM.
Comparison of time domain and spectral turbulence analysis of the signal‐averaged electrocardiogram for the prediction of prognosis in idiopathic dilated cardiomyopathy
Authors: Yi Gang , Keeling Philip J. , Goldman Jonathan H. , Hnatkova Katerina , Malik Marek , Mckenna William J.
Published: February 2009

Background: Despite significant advances in the treatment of heart failure, the prognosis of patients with idiopathic dilated cardiomyopathy remains poor. Although several of prognostic variables have been shown to be useful in risk stratification of patients with idiopathic dilated cardiomyopathy, their predictive accuracy is low and clinical usefulness uncertain.

Hypothesis: This study was undertaken to assess the signal‐averaged electrocardiogram (SAECG) in patients with idiopathic dilated cardiomyopathy and to compare the ability of time domain and spectral turbulence analytic techniques to predict clinical outcome.

Methods: SAECG analysis was performed in 80 patients with idiopathic dilated cardiomyopathy. Nineteen patients had left bundle‐branch block and eight were taking low‐dose ami‐odarone for life‐threatening arrhythmias. Conventional time domain and spectral turbulence analyses of the SAECG were performed using Del Mar 183 software.

Results: During a follow‐up of 27 ± 19 months, 24 patients developed progressive heart failure, while the others remained clinically stable. Late potentials were detected in 28% of patients and were equally frequent in patients with and without progressive heart failure (38 vs. 23%, p = 0.20). Spectral turbulence analysis was abnormal in 34% of patients, and patients with abnormal results developed progressive heart failure more frequently than those with normal results (50 vs. 17%, p = 0.01). All spectral turbulence analysis parameters were significantly different in patients with progressive heart failure compared with those who remained clinically stable (p≤0.01). Furthermore, progressive heart failure‐free survival at 2 years was significantly lower in patients with abnormal compared with normal results (63 vs. 87%;p<0.05), but was similar in patients with and without late potentials (72 vs. 83%;p = 0.30). The relative risk for developing progressive heart failure using spectral turbulence analysis was 3.4 (95% confidence interval 1.2–9.7) and 2.8 (95% confidence interval 1.1–8.7) using time domain analysis. The sensitivity, specificity, and the positive and negative predictive accuracy for identifying patients who developed progressive heart failure were 50,83,50, and 83%, respectively, (p = 0.01) for spectral turbulence analysis, and 36,85,45 and 80%, respectively, (p = 0.09) for time domain analysis.

Conclusion: Abnormalities in the SAECG of patients with idiopathic dilated cardiomyopathy are common and appear to provide a noninvasive marker for development of progressive heart failure.