bluuebunny/crossref_metadata_2025 huggingface dataset:
Concomitant use of nitrates, calcium channel blockers, and beta blockers for optimal antianginal therapy
Authors: Cohn Peter F.
Published: February 2009

Despite the introduction of new mechanical techniques for revascularization, pharmacologic therapy continues to be the mainstay of antianginal therapy. The conventional antianginal medications, which include nitrates, beta blockers, and calcium channel blockers, act to correct the imbalance between myocardial supply and demand by increasing coronary blood flow, reducing myocardial oxygen requirements, or both. All three are appropriate for the management of angina caused by a fixed coronary obstruction, but nitrates and calcium channel blockers, which not only reduce demand but also increase supply, are preferred in cases of angina believed to involve a significant increase in vasomotor tone. Because of the different yet complementary mechanisms of action of the three classes of anti‐ischemic drags, use of these agents in combination is a rational approach to the treatment of angina unresponsive to monotherapy. Such combinations have been shown to enhance the therapeutic response achieved with single‐agent therapy. In addition, the pharmacologic action of one of the components of the combination regimen may serve to offset side effects typically associated with the other.
ST‐segment computerized monitoring before and after angioplasty: Clinical correlation with recurrent angina during the short‐term follow‐up
Authors: Gurfinkel E. , Duronto E. , Manos E. , García N. , Mejaíl R. , Mendiz O. , Cerdá M. , Mautner B.
Published: February 2009

The purpose of this study was to determine whether computerized ST‐segment monitoring previous to percutaneous transluminal coronary angioplasty (PTCA) and after performance of this procedure may be useful to discern a pattern of recurrent angina. For this purpose, we analyzed 57 patients (11 women and 46 men, mean age 60 years) before and after treatment with balloon procedure. These patients were followed up during the next 3 months. A computerized electrocardiographic (ECG) device was used which was capable of recording simultaneously all 12 leads at rest. It was programmed to store a complete ECG every 5 min and was capable of detecting any abnormal ST alteration > than 0.5 mV at 80 ms after J junction, including R‐wave amplitude. Measurements were started before (mean time 7.26 h) and after (mean time 7.96 h) the procedure. The value for ST amplitude at the J junction was used as the 0 point; then the most negative depression or the most positive elevation value was considered as the most abnormal ST alteration during monitoring. The patients were followed up for 3 months for the purpose of recognizing recurrent angina or establishing the occurrence of death. Twelve patients (30%) had recurrent angina. Discriminant function analysis revealed that ST monitoring in these patients showed significant difference after PTCA in comparison with controls, both in the frontal plane [ST depression 170 ± 52 mV vs. 231 ± 23 (p = 0.02)J and in precordial leads [176 ± 16 vs. 80 ± 6.19 mV (p = 0.0001)]. Among patients who had no recurrent angina there were significant changes in the horizontal plane [171 ± 18.3 mV vs. 156 ± 14.7 mV (p = 0.007)] but not in the frontal plane [213 ± 17.67 mV vs. 195 ± 75.2 mV (p = NS)]. There were no significant changes when the ST slope was evaluated as elevated among patients with or without recurrent angina. In this pilot study, the computer method using continuous recording data to determine whether significant differences existed among groups showed that ST‐segment depression in the frontal leads before PTCA could contribute to identifying a group of patients at risk of developing recurrent angina soon after PTCA.
Transesophageal echocardiography in the intensive care unit: Impact on diagnosis and decision‐making
Authors: Chenzbraun Adrian , Pinto Fausto J. , Schnittger Ingela
Published: February 2009

Transesophageal echocardiography (TEE) is widely used in the management of patients in intensive care units. The present study assesses the specific value of this technique in various categories of these patients. We reviewed 113 studies performed in 100 such patients for: suspected aortic dissection (25), suspected endocarditis (33), source of emboli assessment (19), hemodynamic instability (15), and miscellaneous (21). TEE provided diagnostic information in all patients with aortic dissection, in 53% of the cases with hemodynamic instability, in 50% of the cases with septic states with high likelihood of endocarditis, and in 29% of the cases where the question was the source of emboli. When the clinical probability for endocarditis was low, all transesophageal echocardiograms performed in septic patients were negative. The information provided by TEE was considered crucial in one‐third of the positive cases; in about one‐half of these special cases, the results were instrumental for further surgical management. There were no significant side effects related to the procedure. TEE is easily performed in the intensive care unit setting and yields useful information in almost half of the cases. Special benefit is expected in suspected aortic disease, hemodynamic instability, suspected endocarditis, and embolic events. The overall yield as screening procedure in febrile patients is low.
The effect of limited handrail support on total treadmill time and the prediction of vo2 max
Authors: Manfre Michael J. , Yu Guan‐Hiok , Varmá Andre A. , Mallis George I. , Kearney Kevin , Karageorgis Mario A.
Published: February 2009

Holding onto the front handrail during treadmill testing significantly increases total treadmill time (TT) and predicted VO2 max when compared with tests without front handrail support. By limiting the amount of handrail support to the tips of two fingers of one hand, the difference in TT can be substantially reduced. In the present study, the difference in TT between tests with and without handrail support for healthy men was not significantly different. However, this was not true for healthy women and for male patients with coronary artery disease and myocardial infarction.
Clinical value of transesophageal atrial stimulation and recording in patients with arrhythmia‐related symptoms or documented supraventricular tachycardia—correlation to clinical history and invasive studies
Authors: Pehrson Steen M. , Blomströ‐LUNDQVIST Carina , Ljungströ Erik , Blomströ Per
Published: February 2009

The main objective of the present study was to evaluate the clinical applicability of transesophageal atrial stimulation (TAS) and recording with regard to inducibility of supraventricular tachycardia (SVT) in patients with either an ECG‐documented paroxysmal SVT or a clinical history of palpitations suggesting this disease. A further objective was to assess the inducibility of SVT and to compare the inducibility by TAS with that obtained by an invasive electrophysiologic study (EPS). A total of 64 patients (aged 13‐74 years) with ECG‐documented paroxysmal SVT (n = 50) or only a history of palpitations (n = 14) was referred for TAS. Preexcitation was present in 35 patients. The study protocol included single and double extrastimuli delivered at a basic paced interval of 500 ms, and incremental atrial stimulation until a cycle length of 275 ms or a second‐degree AV block appeared. In 10 patients atropine intravenously was required for induction. The same protocol was used in 34 of the patients who also underwent invasive EPS. TAS was completed in 56 of 64 patients (88%). In this group SVT was induced during TAS in 84% (47/56). Of patients with ECG‐documented tachycardia, clinical tachycardia was induced in 90% (35/39) with ECG‐documented regular paroxysmal SVT and in 67% of patients (4/6) with ECG‐documented atrial fibrillation. In patients without ECG‐documented tachycardia, clinically relevant arrhythmia was induced in 73% (8/11). In 30 of 32 patients (94%) with an inducible tachycardia during invasive EPS, it was also possible to induce the tachycardia by TAS. We concluded that TAS is a simple and noninvasive diagnostic tool for evaluation of clinical arrhythmia in patients with documented or suspected paroxysmal SVT. The inducibility of SVT seems comparable to that obtained by invasive EPS.
Spontaneous echo contrast on transthoracic echocardiography and left atrial thrombus in rheumatic mitral valve disease patients: A clinicopathologic study
Authors: Wanishsawad Chad , Puavilai Wilai , Roongsrttong Chanwtt , Sitthi‐Amorn Chitr
Published: February 2009

The association of spontaneous echo contrast and thrombus in the left atrium in patients with mitral valve disease is controversial. This study was undertaken to determine whether there is an independent association between spontaneous echo contrast on transthoracic echocardiography (TTE) and intraoperative evidence of left atrial thrombus and to evaluate the clinical implications of spontaneous echo contrast in patients with symptomatic rheumatic mitral valve disease. A total of 255 patients who underwent surgery for rheumatic mitral valve disases were preoperatively evaluated by transthoracic two‐dimensional and Doppler echocardiography. Spontaneous echo contrast in the left atrium was carefully sought. The left atrium was carefully searched for evidence of thrombus intraoperatively. The association of spontaneous echo contrast and left atrial thrombus was determined by univariate and multivariate analysis. Of the patients studied, 77 (30%) had left atrial thrombus. Left atrial thrombus was found in 47 and 21 % of patients with and without spontaneous echo contrast, respectively (p < 0.001). Spontaneous echo contrast and atrial fibrillation were found to be the only two independent predictors of left atrial thrombus (odds ratio = 2.16; 95% confidence interval 1.15‐4.04 p < 0.05, and odds ratio = 6.98; 95% confidence interval 3.45‐14.16, p < 0.001, respectively). It was concluded that there is an independent association between spontaneous echo con trast on TTE and left auial thrombus in patients with mitral valve disease requiring surgical correction. These patients are at high risk for left atrial thrombus and should, therefore, be con sidered for long‐term anticoagulation.
Emergency and long‐term extracorporeal life support following acute myocardial infarction: Rescue from severe cardiogenic shock related to stunned myocardium
Authors: Kurose Mrsuro , Okamoto Kazufumi , Sato Toshihide , Kukita Ichiro , Taki Kenichiro , Goto Hiraaki
Published: February 2009

There has been no report regarding therapy of extracorporeal life support (ECLS) that showed stunned myocardium echocardiographically and electrocardiographically in patients with acute myocardial infarction. ECLS was performed in eight patients with cardiogenic shock or arrest unresponsive to catecholamines and intra‐aortic balloon pumping following myocardial infarction; these patients required prolonged external cardiac massage. After the initiation of ECLS, both blood pressure and metabolic acidosis improved in all patients. Four of eight patients were weaned from ECLS after a mean of 69.3 h, which was far longer than previously reported in patients with ischemic heart disease. Three of these patients survived, and cardiac function recovered to NYHA class II in two of the survivors and class III in the other. The other five patients did not recover from coma during ECLS and died. A marked improvement of ventricular wall motion was seen in two survivors with the disappearance of pathologic Q waves after the initiation of ECLS. No occlusion of the coronary arteries or bypass grafts was observed in any of the survivors. These findings suggested the existence of stunned myocardium with myocardial reperfusion. The recovery of stunned myocardium may be delayed for days or even weeks, hence the extended period of ECLS therapy was theoretically justifiable. We conclude that long‐term ECLS is a useful therapeutic method for patients with severe cardiogenic shock that is related to stunned myocardium.
Refractory hypoxemia in inferior myocardial infarction from right‐to‐left shunting through a patent foramen ovale: A case report and review of the literature
Authors: Silver Marc T. , Lieberman Eric H. , Thibault George E.
Published: February 2009

Right ventricular (RV) infarction is a well‐recognized complication of some acute inferior myocardial infarctions. Recently, there have been numerous case reports of RV infarctions complicated by severe refractory hypoxemia secondary to right‐to‐left shunting through a patent foramen ovale. An additional case missed by transthoracic echocardiography and cardiac catheterization is reported and the English literature on the subject is reviewed.
Bilateral renal artery occlusion: An unusual presentation of atrial fibrillation and hypertrophic cardiomyopathy
Authors: Fu Gene Y. , Candela Richard J. , Yakubov Steven J. , Mishkind Michael , Obarski Timothy
Published: February 2009

Hypertrophic cardiomyopathy predisposes patients to atrial fibrillation and the development of systemic embolization. We describe a rare case of bilateral renal artery thrombosis which presented as acute renal failure requiring dialysis. The patient was successfully treated with a selective, continuous infusion of urokinase which resulted in the return of adequate renal function.
Sleep apnea and complete heart block
Authors: Rama Pamela R. , Sharma Satish C.
Published: February 2009

Sleep apnea has been associated with various types of cardiac dysrhythmias; however, complete heart block has not been reported to occur in this condition. This brief report describes the case of a patient who developed episodes of prolonged complete heart block during sleep apnea. Nasal continuous positive airway pressure resulted in complete resolution of the heart block.
Risk indicators for death and prognosis among patients in whom acute myocardial infarction was not confirmed in relation to prescription of beta blockers at discharge
Authors: Herlitz J. , Karlson B. W. , Hjalmarson ÅA.
Published: February 2009

A large number of studies have shown the prognosis after acute myocardial infarction (AMI) to be favorably affected by treatment with beta blockers. Whether such treatment also will have a favorable effect on the prognosis in patients in whom AMI was not confirmed has not been shown. A study was undertaken at Sahlgren's Hospital, Göoteborg, to determine risk indicators for death and prognosis among 1,443 patients in whom AMI was not confirmed and who survived hospitalization in relation to whether or not beta blockers were prescribed at discharge. One‐year mortality was determined and p values were corrected for differences at baseline. Of the 1,443 patients who participated in the analyses, 44% were prescribed beta blockers. They differed from the remaining patients by younger age, predominance of men, a more frequent history of AMI, angina pectoris, and hypertension, and a less frequent history of congestive heart failure. Patients in whom beta blockers were prescribed had a 1‐year mortality of 6% compared with 16% in those not on beta blockers (p < 0.001). The difference was similar in various subgroups according to clinical history.
Percutaneous transluminal coronary angioplasty versus thrombolysis in acute myocardial infarction: A meta‐analysis
Authors: Vaitkus Paul T.
Published: February 2009

While percutaneous transluminal coronary angioplasty (PTCA) as a primary modality for treating acute myocardial infarction (MI) has been shown to have important advantages over thrombolysis, a survival benefit has not been demonstrated because of the small size of the individual trials. To increase the statistical power to detect a survival benefit, we performed a meta‐analysis of trials of PTCA and thrombolysis. We pooled the data for all randomized, controlled trials; randomized, controlled trials stratified according to thrombolytic agent [streptokinase vs. tissue plasminogen activator (TPA)]; and all trials. Pooling was performed by calculating the Mantel‐Haenszel odds ratio with the Robins, Greenland, and Breslow estimate of variance. Calculation of the Q statistic was performed to assess heterogeneity. For all four analyses, the odds ratio indicated a significant survival advantage of PTCA over thrombolysis: all randomized controlled trials [0.57,95% confidence index (CI): 0.48,0.68)]; streptokinase trials [0.61,95% CI: 0.43,0.87); TPA trials (0.52,95% CI: 0.36,0.76); all trials (0.51,95% CI: 0.43,0.61). The Q statistic was not significant for any of the analyses. The results of our meta‐analysis support the hypothesis that PTCA is associated with a significant reduction in mortality compared with thrombolysis.
Successful radiofrequency catheter ablation of atrial muscle reentry tachycardia in a young adult
Authors: Douglas Dane E. , Case Christopher L. , Shuler C. Osborne , Gillette Paul C.
Published: February 2009

Atrial muscle reentry as a mechanism of tachycardia has been well illustrated in isolated animal atrial muscle. It has infrequently been reported as an etiology of supraventricular tachycardia in young patients. A case of atrial muscle reentry tachycardia and its successful elimination using radiofrequency catheter and its successful elimination using radiofrequency catheter ablation is reported.
Is ventricular wall stress rather than left ventricular hypertrophy an important contributory factor to sudden cardiac death?
Authors: James Michahl A. , Macconnell Thomas J. , Jones John V.
Published: February 2009

Sudden cardiac death comprises a significant proportion of cardiac mortality in Western society. Left ventricular hypertrophy has been identified by many authors as a possible risk factor for sudden cardiac death, however, left ventricular hypertrophy develops in response to external stimuli on the heart as a means of normalizing wall stress. It is possible that the fundamental abnormalities in wall stress, rather than the left ventricular hypertrophy itself, pose the increased risk of sudden death. Left ventricular hypertrophy, the consequence of raised wall stress, is easy to measure and easy to study and it is understandable why this parameter should have received more attention. Wall stress by contrast is difficult to measure, and worse, is variable throughout the ventricle so that it cannot be measured in a single quantifiable figure. As a consequence, only a limited amount of attention has been paid to wall stress as a possible trigger mechanism for cardiac arrhythmia. However, there is evidence from both basic and clinical research to suggest that raised wall stress may be a risk factor for sudden cardiac death and cardiac arrhythmia. This review discusses the evidence for and against left ventricular hypertrophy and wall stress as risk factors for sudden cardiac death, and also presents recent evidence that left ventricular hypertrophy in isolation can protect the heart against the arrhythmogenic effects of raised wall stress.
Complications of warfarin therapy monitored by the international normalized ratio versus the prothrombin time ratio
Authors: Andrews Thomas C. , Peterson David W. , Doeppenschmidt Dennis , Foster Jeff S. , Lucca Michael J. , Deering Joseph A. , Laveau Paul J.
Published: February 2009

The objective of our study was to determine the rates of bleeding complications and thromboembolic events in patients receiving oral anticoagulant therapy monitored with the prothrombin time (PT) ratio versus therapy monitored with the International Normalized Ratio (INR) using a retrospective time‐series study design. Over 650 patients enrolled in a large anticoagulation clinic were studied during two time periods corresponding to the use of the PT ratio versus the INR to guide anticoagulant therapy, with over 400 patient‐years of follow‐up for each time period. The rate of bleeding complications using the PT ratio to guide therapy was 6.7% (1.2% major, 5.5% minor) per patient‐year, compared with 2.9% (0% major, 2.9% minor) using the INR (p = 0.02). The rate of thromboembolic complications was 1.0% using the PT ratio, compared with 0.2% using the INR (p = NS). Therapy monitored with the INR required 19.8 visits per year, compared with 20.7 visits per year using the PT ratio. We conclude that the INR should be used to monitor oral anticoagulant therapy in an effort to reduce bleeding complications while maintaining an acceptable rate of thromboembolic events.
Importance of the time of onset of supraventricular tachyarrhythmias on prognosis of patients with acute myocardial infarction
Authors: Serrano Carlos V. , Antǒnio José , Ramires F. , Mansur Antǒnio P. , Pileggi Fúlvio
Published: February 2009

It is known that left ventricular (LV) function, severity of coronary artery disease, and the presence of ventricular arrhythmias are major determinants of prognosis in patients surviving an acute myocardial infarction (AMI). However, little is known about the relationship between the time of onset of supraventricular tachyarrhythmias (SVTs) and mortality. Therefore, this study was carried out in a 48‐month period on 131 patients with AMI who presented with SVT during hospitalization. Of these, 53 patients (40.5%) had arrhythmia within < 12 h of MI, while 78 patients (59.5%) had arrhythmia between 12 h and 4 days. The arrhythmias studied were atrial fibrillation, atrial flutter, and paroxysmal supraventricular tachycardia. The patients were similar for age, gender, coronary risk factors, creatine kinase‐MB peak, cardioversion and LV function. Angiographic features for patients with the < 12‐h onset of arrhythmia were: 86.7% of the patients had uniarterial lesions, 8.9% had biarterial lesions, and 4.4% had triarterial lesions. Patients with the 12‐h‐4‐day onset had 16.1%, 53.2%, and 30.6% (p≤0.05) of the respective lesions. Inferior wall myocardial infarction was more frequent among patients with the earlier onset (60.4%), while patients with the later onset presented more anterior wall infarctions (50.0%). Only 11.3% of the patients with the earlier onset presented with severe in‐hospital congestive heart failure (Killip classes III‐IV), versus 62.8% of the patients with the later onset (p≤0.0001). Patients with the earlier onset of arrhythmia had fatality rates of 7.6 and 15.1% during the first month and subsequent 47 months post‐MI, respectively, while the other set of patients presented rates of 37.2 (p≤0.0003) and 24.4% (p≤0.01), respectively. These data suggest that the relationship between SVT occurrence between 12 h and 4 days after MI and poor prognosis is apparently linked to the occurrence of more severe coronary artery disease in these patients.
Evaluation of new self‐learning techniques for the generation of criteria for differentiation of wide‐QRS tachycardia in supraventricular tachycardia and ventricular tachycardia
Authors: Dassen Willem R.M. , Mulleneers Rob G.A. , Smeets Joep L.R.M. , Wellens Hein J.J. , Karthaus Vincent L.J. , Talmon Jan L.
Published: February 2009

This study presents a comparison of three different methods for differentiating between supraventricular and ventricular tachycardias with wide‐QRS complex. One set of criteria, derived using classical statistical techniques, was compared with two new self‐learning computer techniques: the artificial neural networks and the induction algorithm approach. By analyzing the results obtained in an independent test set, using these new techniques, the criteria defined by the classical method could be improved.
Malignant coronary artery disease in young asian indians: Thoughts on pathogenesis, prevention, and therapy
Authors: Enas Enas A. , Mehta Jawahar
Published: February 2009

Asian Indians have the highest rates of coronary artery disease (CAD) of any ethnic group studied, despite the fact that nearly half of this group are life‐long vegetarians. CAD occurs early in age and generally follows a malignant course. Although the incidence of classic risk factors is low, high triglyceride and low high‐density lipoprotein cholesterol levels, high lipoprotein(a) levels, hyperinsulinemia, and apple‐type obesity all show a substantial prevalence in this population. Aggressive modification of life style beginning before adolescence seems justified in view of the malignant nature of CAD in this population. Pharmacologic intervention similar to that of secondary prevention of CAD seems justified as primary prevention in high‐risk Asian Indians.
Effects of flecainide on exercise hemodynamics and electrocardiography in patients without structural heart disease
Authors: Wang Jian‐An , Lau Chu‐Pak , Tai Yau‐Ting , Wu Bi‐Zhen
Published: February 2009

Although exercise testing has been advocated to unmask proarrhythmic potentials in patients receiving flecainide acetate, the effects of this drug on exercise parameters in individuals without structural heart disease have not been reported. This study was undertaken to assess the effects of flecainide on hemodynamics and electrocardiographic changes during exercise testing in 24 patients with paroxysmal supraventricular tachyarrhythmias, who had normal cardiac structure and sinus node function. Paired treadmill exercise tests using the Bruce protocol were performed after 1 week of treatment with flecainide (200 mg/day) or placebo in a double‐blind, randomized design. Exercise testing was terminated because of either fatigue or dyspnea in all subjects. Although resting heart rate was unaffected, flecainide reduced the exercise heart rate (expressed as a percentage of age‐predicted maximum) compared with placebo (84±12% vs. 92±9%, p<0.001). Neither resting and exercise systolic blood pressure nor exercise duration were affected. PR interval shortening with exercise was not affected by flecainide, whereas QRS was prolonged compared with placebo (20±9% vs. 0±8%, p<0.01). Compared with placebo, flecainide significantly shortened QTc (‐7±12% vs. 0±8%, p<0.05) and JTc (‐34±11% vs. ‐21±11%, p<0.01) intervals during exercise. During exercise, flecainide produced significant depression in the sinus node automaticity and manifested use‐dependent slowing of ventricular conduction and acceleration in ventricular repolarization.
Prognostic value of clinical variables for recurrent ischemic events after acute myocardial infarction
Authors: Piombo Alfredo C. , Gagliardi Juan A. , Ulmete Elisabet R. , Ramos Alberto O. , Bertolasi Carlos A.
Published: February 2009

Recurrent ischemia after acute myocardial infarction (AMI) has been largely associated with a poor prognosis. This study was carried out to analyze the relationship among different clinical variables and both postinfarction angina and reinfarction after AMI. A total of 452 consecutive patients (mean age 58.2±12 years) were admitted to the coronary care unit and were studied prospectively. More than half of the patients received some type of thrombolytic therapy. Death occurred in 45 patients (9.9%) during hospital stay. Postinfarction angina was diagnosed in 81 patients (17.9%) and reinfarction in 22 (4.9%). Patients who developed reinfarction had a high mortality rate (45.5%) compared with those who did not develop such an event (8.1%) (p<0.0001; odds ratio: 9.4; 95% confidence interval 3.5–25.4). On the other hand, postinfarction angina had no significant association with mortality. Multivariate analysis revealed that a history of angina (> 1 week) was predictive of the occurrence of postinfarction angina and that the use of fibrinolytic treatment, prodromal symptoms, and postinfarction angina were significantly related to reinfarction. We conclude that several simple clinical variables are clear independent predictors of postinfarction angina and reinfarction following AMI and should be taken into account in routine clinical practice or when planning intervention trials.
Localization of a misplaced coronary artery stent by magnetic resonance imaging
Authors: Mohiaddin Raad H. , Underwood Richard , Roberts Robin H. , Rothman Martin
Published: February 2009

Coronary artery stents have been developed to overcome arterial abrupt closure and restenosis following balloon angioplasty. Complications of stent insertion include loss of the device from its delivery system into the peripheral circulation. Certain types of stents are almost radiolucent, making localization of the lost devices difficult. Nonferromagnetic metallic biomedical implants induce alteration of the local magnetic field and this leads to loss of signal from the surrounding tissues. We have used this property to localize a misplaced coronary artery stent in a 53‐year‐old man who underwent unsuccessful stent insertion. A 0.5 Tesla magnetic resonance scanner was used to acquire gradient‐echo and spin‐echo images. An in vitro experiment was first carried out on a stent similar to that used in our patient to establish that it was nonferromagnetic and to determine the optimum imaging technique. Gradient‐echo images with a relatively long echo time (22 ms) gave the largest area of signal loss around the stent, and this sequence was used for localization of the stent found in the patient's left profunda femoris artery. This was subsequently confirmed by digital radiography. We have demonstrated the convenience and practicality of using magnetic resonance imaging for the localization of a misplaced coronary artery stent in a patient. The technique is safe, noninvasive, and uses no ionizing radiation.
Sudden cardiac death in patients with hypertrophic cardiomyopathy: From bench to bedside with an emphasis on genetic markers
Authors: Marian Ali J.
Published: February 2009

Hypertrophic cardiomyopathy (HCM) is the most common cause of death in the young, particularly in young competitive athletes. Death often occurs suddenly in asymptomatic, apparently healthy individuals. Several clinical parameters as well as genetic factors have been characterized that can identify those HCM patients who are at high risk for sudden cardiac death (SCD). The clinical parameters that have some predictive values for SCD in HCM patients are the following: a prior history of SCD, a family history of SCD, history of syncope, symptomatic ventricular tachycardia on Holter monitoring, inducible ventricular tachycardia during electrophysiologic studies, and myocardial ischemia in children with HCM. Recent identification of mutations in the beta myosin heavy chain gene and genotype‐phenotype correlation in HCM patients have shown that the beta myosin heavy chain mutations are also prognosticators in HCM families. Several mutations such as Arg403Gln and Arg719Gln are associated with a high incidence of SCD, while Leu908Val mutation is associated with a benign course and a low incidence of SCD in HCM families. Additional genetic factors such as a polymorphism in angiotensin‐converting enzyme I gene may also contribute to a high incidence of SCD in HCM families. Identification and characterization of HCM patients at high risk for SCD provide the opportunity to render prophylactic therapeutic interventions, such as implantation of defibrillators, in these individuals.
Pathology of tricuspid valve stenosis and pure tricuspid regurgitation—part III
Authors: Waller Bruce F. , Howard Jane , Fess Stephen
Published: February 2009

This three‐part article examines the histologic and morphologic basis for stenotic and purely regurgitant tricuspid valves. In Part III, morphometric analysis of tricuspid valve annular circumference, leaflet area, and the product of annular circumference and leaflet area are shown to be useful in establishing etiology for the purely regurgitant tricuspid valves and in assessing the anatomic basis of pure tricuspid regurgitation in the presence of mitral stenosis.
A case of cardiac sarcoidosis with remarkable atrophy of the left ventricular septum on two‐dimensional echocardiography
Authors: Matsumura Akihiko , Yanase Osamu , Motomiya Takeshi , Tokuyasu Yoshiki , Sakurada Harumizu , Nomura Shuzo , Teshima Tamotsu , Hiyoshi Yasunaga , Sugiura Masaya
Published: February 2009

Sarcoidosis is a multisystem granulomatous disorder of unknown etiology which mainly affects the lungs, skin, the lymphoreticular system, and the heart. We report a case of cardiac sarcoidosis in which a remarkably thin ventricular septum was demonstrated on two‐dimensional echocardiography.
Dobutamine stress echocardiography for the diagnosis and management of coronary artery disease
Authors: Tanimoto Masato , Pai Ramdas G. , Jintapakorn Woravut , Shah Pravin M.
Published: February 2009

Infusion of dobutamine in low and high doses in combination with echocardiography can be used for the assessment of myocardial viability and functional significance of coronary artery disease. Improvement of contractile function of hypokinetic or akinetic ventricular wall segment with low‐dose dobutamine has a high predictive value for the detection of hibernating and stunned myocardium. High‐dose dobutamine stress is of value for noninvasive diagnosis of coronary disease, assessment of its clinical significance, risk stratification of patients after myocardial infarction, preoperative evaluation of patients undergoing major noncardiac surgery, and assessment of the efficacy of coronary revascularization. It has an excellent safety record even in the immediate postmyocardial infarction period.
Initial depolarizing potentials in wolff‐parkinson‐white syndrome using signal‐averaged electrocardiograms: Correlation with reciprocating tachycardia
Authors: Kubo Masahiro , Matsuoka Suguru , Kuroda Yasuhiro
Published: February 2009

Initial depolarizing potentials were examined in patients with Wolff‐Parkinson‐White (WPW) syndrome using signal‐averaging techniques. In all, 25 WPW patients and 21 agematched healthy children were studied. Ten of the patients were symptomatic and 15 were asymptomatic. Symptomatic patients with supraventricular tachycardias had longer durations of lowamplitude signals (LAS) < 40 μ V in the initial portion of the QRS complex (initial LAS, 49 ± 7 ms vs. 37 ± 9 ms, p < 0.01) and lower root‐mean‐square (RMS) voltage in the initial 40 ms of the QRS complex (initial RMS, 12 ± 4 μ V vs. 23 ± 8 μ V, p < 0.01) compared with asymptomatic patients. When a symptomatic patient was defined as having an initial LAS of > 46 ms or an initial RMS of < 15 μ V, the sensitivity and specificity for predicting documented supraventricular tachycardia were 100 and 67%, respectively. These SA‐ECG findings may reflect instability of conduction in symptomatic patients through an accessory pathway and may identify those at high risk for supraventricular tachycardia.
Myocardial dysfunction and abnormal left ventricular exercise response in autonomic diabetic patients
Authors: Scognamiglio Roldano , Fasoli Giuseppe , Nistri Stefano , Miorelli Manuela , Egloff Carlo , Buja Gianfranco , Dalla‐Volta Sergio , Fedele Domenico , Ferri Marcello
Published: February 2009

In diabetic patients, the pathophysiologic mechanisms of exercise‐induced left ventricular (LV) dysfunction remain controversial. In this study, the role of myocardial contractility recruitment in determining an abnormal LV response to isometric or dynamic exercise has been investigated in 14 diabetic patients with autonomic dysfunction. Ischemic heat disease was excluded by the absence of LV wall motion abnormalities induced by isotonic and isometric exercise and by coronary angiography. Left ventricular and myocardial function were studied at rest, and during isometric and isotonic exercise, by two‐dimensional echocardiography; moreover, recruitment of an inotropic reserve was assessed by postextra‐systolic potentiation at rest and at peak handgrip. An abnormal response of LV ejection fraction to isometric (9/14) or to dynamic (8/14) exercise was frequent in study patients. In these patients, baseline myocardial contractility was normal, and the significant increase in ejection fraction by postextrasystolic potentiation indicated a normal contractile reserve (65 ± 7% vs. 74 ± 6%, p=0.001). Nevertheless, the downward displacement of LV ejection fraction‐systolic wall stress relationships during exercise suggests an inadequate increase in myocardial contractility. However, the abnormal ejection fraction at peak handgrip was completely reversed by postextrasystolic potentiation (67 ± 6% vs. 58.1 ± 10%, p=0.008), a potent inotropic stimulation independent of the integrity of adrenergic cardiac receptors. A defective inotropic recruitment, despite the presence of a normal LV contractile reserve, plays an important role in deexercise LV dysfunction in diabetic patients with autonomic neuropathy.
Transesophageal echocardiography in the evaluation of cardiac myxoma: A case of familial myxoma
Authors: Kazakis D. James , Lewis Jannet F. , Conti C. Richard
Published: February 2009

The vast majority of atrial myxomas are readily apparent on standard transthoracic echocardiography. We present the case of a young woman with known history of familial myxoma, in whom a large left atrial mass was identified on transthoracic echocardiography. Transesophageal study more clearly delineated the extent and origin of the tumor. In addition, an unsuspected tumor in the right ventricle was also identified. These findings were confirmed at surgery, and both masses were excised. The advantages of transesophageal echocardiography in evaluation and management of this unusual subset of patients with cardiac tumor are discussed.
Beneficial clinical effect of very early enalapril treatment in patients with acute left ventricular failure complicating myocardial infarction
Authors: Hüttl S. , Lehmann K. , Delius W. , Nussberger J. , Brunner H.R. , Hasford J.
Published: February 2009

Acute myocardial infarction (AMI) leads to left ventricular dysfunction, the extent of which predicts mortality. We studied the effect of very early enalapril treatment in patients with left ventricular failure (Killip classification II‐III) resulting from AMI. In a double‐blind randomized trial, patients on conventional treatment were started on placebo (PL, n = 15) or 2.5 mg enalapril (EN, n = 15) twice daily as early as 24 to 30 h after AMI and were followed up over a period of 21 days. One patient died in each treatment group. There were three dropouts in the placebo group (progressive heart failure requiring antiotensin‐converting enzyme inhibition) and one dropout in the enalapril group (malignant ventricular arrhythmias). Plasma atrial natriuretic peptide (ANP) and norepinephrine decreased similarly in both groups from elevated baseline concentrations. The patients with the highest baseline ANP levels died in both groups: EN: 579 fmol/ml (mean 65.3 ± 34.4 fmol/ml), PL: 403 fmol/ml (mean 63.5 ± 37.6 fmol/ml). Killip classification improved in 9 of 13 patients on enalapril but only in 5 of 11 patients on placebo. On echocardiography an increase in fractional shortening (FS) (3.2 ± 7.5%, p < 0.05) was found with enalapril only. Patients on placebo required more diuretics, and plasma aldosterone increased threefold. Thus, very early enalapril treatment may help prevent left ventricular failure after AMI. Extremely high initial plasma ANP concentrations may predict an unfavorable outcome.
Right ventricular apical view—A new window for doppler echocardiography of aortic valve stenosis
Authors: Hust Martin H. , Metzler Birgit , Fritz Stephan , Braun Bernd , Röcker Kai , Dickhuth H.‐H.
Published: February 2009

We studied a new Doppler echocardiographic approach in 56 patients with valvular aortic stenosis from the right ventricular apex (AS‐RV) and compared the transvalvular gradients with the results of the standard view from the left ventricular apex (AS‐LV). AS‐RV resulted in good or acceptable velocity curves in 59% of patients. The correlation between the two apical views for the peak/mean gradients were close (r = 0.95/0.96). Using all typical positions for Doppler investigation of aortic stenosis, highest peak gradients were best recorded in five cases by AS‐RV. In one woman with a narrow left ventricular cavum and severe aortic stenosis, only AS‐RV yielded a technically good spectral curve. Thus, in selected patients—probably those with a small left ventricular cavity or an enlarged right ventricle—AS‐RV may be the best window or even the only possibility in Doppler investigation of aortic valve stenosis.
Exercise metabolism during 1 hour of treadmill walking while taking high and low doses of propranolol, metoprolol, or placebo
Authors: Head A. , Kendall M.J. , Maxwell S.
Published: February 2009

Aerobic exercise and beta‐blocking drugs are regularly prescribed as treatment for hypertension and as a prophylactic for patients at risk from coronary heart disease and for those recovering from an infarct. Some beta blockers, particularly non‐beta1‐selective drugs, may make exercise more difficult, possibly by interfering with substrate metabolism during exercise. This study examined the effects of low and high doses of a beta1‐selective blocker, metoprolol, and a nonselective beta blocker, propranolol, on exercise metabolism. The study involved 20 healthy subjects (10 men, 10 women) who walked on a treadmill at 50% of their maximal oxygen uptake for 1 h on five occasions, separated by 7 days. On each of the five occasions they received one of the following treatments, given in random order: placebo, metoprolol 50 mg, metoprolol 100 mg, propranolol 40 mg, or propranolol 80 mg, all taken twice daily. Fat oxidation, expressed as a percentage of total energy expenditure, was significantly lower than with placebo for all of the active treatments except metoprolol 50 mg (placebo: 42.7 ± 11.6%; metoprolol 50 mg: 38.7 ± 14.1%, p = NS; metoprolol 100 mg: 36.3 ± 13.7%, p = 0.05; propranolol 40 mg: 31.2 ± 9.3%, p = 0.01; propranolol 80 mg: 29.5 ± 10.9%, p = 0.01); and significantly lower with propranolol than with metoprolol (propranolol 40 mg: p = 0.0036; propranolol 80 mg: p = 0.01). Plasma ammonia concentration was significantly higher than with placebo with propranolol 40 mg, propranolol 80 mg, and metoprolol 100 mg (p = 0.01 for all); with metoprolol 50 mg, there was no difference from placebo (p = NS). Both beta blockers in this study reduced fat metabolism and increased perceived exertion to some degree. Additional inhibition of fat oxidation occurred with the nonselective drug, probably in intramuscular rather than adipose lipolysis, and was probably beta2 mediated. The results of this study suggest that a selective beta blocker has less of an adverse effect on substrate metabolism than does a nonselective beta blocker. Beta1‐selective drugs may offer advantages in patients who undertake regular aerobic exercise.
In consecutive patients hospitalized with acute myocardial infarction, infarct location according to routine electrocardiogram is of minor importance for the outcome
Authors: Karlson Björn W. , Herlitz Johan , Hjalmarson Åke
Published: February 2009

Most studies have suggested that patients with anterior myocardial infarction have an adverse prognosis compared with patients with inferior infarction. The objective of this study was to compare the mortality and morbidity in anterior versus inferior acute myocardial infarction (AMI) during 1 year in a consecutive series of patients hospitalized with AMI. All patients fulfilling the criteria for AMI who were admitted to a single hospital during 21 months (n = 921) participated in the study. Patients with anterior infarction (n = 312) had a 1‐year mortality rate of 26% versus a rate of 24% for patients with inferior infarction (n = 269) (p > 0.2). The corresponding figures for patients with no previous infarction who developed Q waves were 27 and 21%, respectively (p > 0.2). Reinfarction, thromboembolic events, and other aspects of morbidity during longterm follow‐up appeared with similar frequency in the two groups. Thus, in a nonselected group of patients admitted to a single hospital because of AMI, the prognosis was found to be similar among patients with inferior and those with anterior infarction. In the subset of patients with a first myocardial infarction who developed Q waves, there was a trend indicating higher mortality in anterior infarction.
Long‐Term denopamine therapy for hemodialysis patients with chronic heart failure
Authors: Takata Yutaka , Tsuchihashi Takuya , Nakamura Sadatoshi , Hirota Yasuo
Published: February 2009

Denopamine was orally administered for more than 12 months to patients with chronic heart failure on maintenance hemodialysis. The plasma level in subjects treated with denopamine at 30 mg/day tended to be higher than that in subjects on 15 mg/day. There was no gradual increase in plasma level as the duration of therapy prolonged. Left ventricular end‐diastolic and end‐systolic diameters as well as ejection fraction on echocardiography showed a tendency to be improved by denopamine. Similarly, the cardiothoracic ratio was improved temporarily. No adverse effects were detected by electrocardiography and laboratory tests. These observations suggest that denopamine is safe and effective for hemodialysis patients with chronic heart failure.
Progression and regression of coronary artery disease—Linkage of clinical, pathologic, and angiographic findings
Authors: Matsuda Yasuo , Kramer John R. , Matsuda Masako
Published: February 2009

Progression and regression of coronary artery disease are analyzed with respect to clinical, pathologic, and angiographic findings. Clinically, progression of coronary artery disease is a highly unpredictable process. The pattern of progression is not linear in time but sometimes is rapid and other times is slow. The atherosclerotic lesion is not pathologically homogeneous. Regression therapies, therefore, might be effective depending on the composition of the lesion and the phase of atherosclerotic evolution. True clinical regression should be concordant with the clinical improvement of symptoms as well as prognosis. Further studies are required to establish the effectiveness of therapy for the prevention of progressive coronary artery disease.
Electroconvulsive therapy‐induced transient T‐wave inversions on ECG
Authors: Cockey George H. , Richard Conti C.
Published: February 2009

Electroconvulsive therapy (ECT), regarded as safe, well tolerated, and one of the most effective treatments for depression, is used frequently in patients with underlying coronary artery disease. ECT has been associated with ST depression and arrhythmias probably due to increased myocardial demand in patients with coronary artery disease. This report describes a case of transient new T‐wave inversions in precordial leads V2 and V3 and flattening of T waves in leads III, V3, V4, V5, and a VF after two courses of ECT in a patient with minimal cardiac risk factors, normal echocardiogram, and normal pre‐ECT electrocardiogram (ECG). These T‐wave changes may represent increased sympathetic activity induced by ECT. Previous prospective studies of 26 and 21 patients undergoing serial ECT found only one new T‐wave inversion and no pathologic Q waves on serial ECGs, suggesting that this is a rare finding.
Acute reversal of pheochromocytoma‐induced catecholamine cardiomyopathy
Authors: Nanda Ardaman S. , Feldman Adam , Liang Chang‐Seng
Published: February 2009

Pheochromocytoma is a rare neuroendocrine tumor. We report a case of pheochromocytoma‐induced cardio‐myopathy in an 18‐year‐old white female. A review of the literature indicated that this is the most dramatic reversal of pheochromocytoma cardiomyopathy reported. With aggressive medical management, there was complete recovery of the hemodynamic, echocardiographic, and electrocardiographic abnormalities within 14 days. This case emphasizes the importance of aggressive and appropriate medical therapy in pheochromocytoma heart disease.
Mitral valve prolapse causing severe mitral regurgitation in a patient with absent right pulmonary artery
Authors: Yip Alex S. B. , Chow Wing Hing , Lee Denise F. M. , Cheung King Loong
Published: February 2009

A 33‐year‐old man was investigated for dyspnea on exertion and the presence of a pansystolic murmur. Physical examination revealed dextrocardia confirmed by chest radiograph, which also showed oligemic right lung field. Subsequent cardiac catheterization revealed secundum atrial septal defect, persistent left sided superior vena cava, and severe mitral valve prolapse causing severe mitral regurgitation with pulmonary hypertension. The right pulmonary artery was absent. It is the first report of the association between severe mitral valve prolapse and absent right pulmonary artery.