bluuebunny/crossref_metadata_2025 huggingface dataset:
Heparin dosing for percutaneous coronary angioplasty: Use of body surface area to improve initial activated clotting time values
Authors: Pesola Gene R. , Pesola David A.
Published: February 2009

Background: Activated clotting time (ACT) values during percutaneous transluminal coronary angioplasty (PTCA) after the initial 10,000 U heparin bolus are often below target values of 350 or 400 s (Hemochron) and have to be supplemented with additional heparin. This study evaluated the initial 10 min post‐heparin bolus clotting time value using a body surface area (BSA)‐adjusted heparin bolus versus the traditional 10,000 U heparin bolus.

Hypothesis: Body surface area adjustment of initial heparin dosing prior to PTCA will be more effective in reaching target ACT values compared with the 10,000 U heparin bolus method.

Methods: Twenty‐seven patients receiving the BSA‐adjusted heparin bolus were compared with 27 age‐ and gender‐matched controls who had received the traditional heparin bolus. The adjusted heparin bolus formula used was [BSA(m2)/1.3m2] X 10,000 U of heparin.

Results: The success rate at reaching the target value of 400 s was 13 of 27 (48.1%) and 2 of 27 (7.4%) for the BSA‐guided and 10,000 U heparin‐guided groups, respectively (p < 0.01). The success rate at reaching the 350 s target value was 25 of 27 (92.6%) and 6 of 27 (22.2%) for the BSA‐guided and 10,000 U heparin‐guided groups, respectively (p < 0.01). The 95% confidence intervals for the difference in success between the BSA‐guided and 10,000 U heparin‐guided groups were 0.19–0.62 and 0.52–0.89 for the 400 s and 350 s ACT targets, respectively.

Conclusion: Body surface area adjustment of initial heparin dosing is a more effective method of reaching the initial ACT target values of 350 and 400 s compared with the traditional method prior to PTCA. This conclusion applies to the Hemochron ACT device and arterial samples, and adjustments may need to be made for other devices and/or venous samples.
Feasibility of intravascular ultrasound studies: Predictors of imaging success before coronary interventions
Authors: Alfonso Fesc Fernando , , Goncalves Manuel , Goicolea Fesc Javier , , Hernandez Rosana , Segovia Javier , Rodriguez Pedro , Fernandez‐Ortiz Antonio , Najar Sergio , Bañuelos Camino , Macaya Carlos
Published: February 2009

Background: Intravascular ultrasound (IVUS) is currently used to study lesions during transcatheter coronary therapy. However, before dilation some lesions cannot be reached or crossed with the imaging catheter.

Hypothesis: This study seeks to elucidate which factors determine the feasibility of IVUS examination before coronary interventions.

Methods: Accordingly, 100 consecutive patients undergoing IVUS examination before coronary angioplasty were prospectively studied. The clinical and angiographic characteristics of 77 patients with a successful IVUS study (Group A) were compared with those of 23 patients in whom IVUS was attempted but the target lesion could not be interrogated (Group B). The echogenic characteristics of the target lesion [before (n = 77) or after intervention (in 18 patients in Group B)] were also studied.

Results: Patients in Group B were significantly older (62 ± 7 vs. 57 ± 10 years, p < 0.05) and more frequently had stable angina [8 (35%) vs. 9 (11%), p < 0.05]. The distribution of lesions within the coronary tree and angiographic lesion characteristics including length, eccentricity, calcification, bend location, and the American College of Cardiology/American Heart Association classification were similar in both groups. However, proximal tortuosities (>45° at end diastole) were more frequently found in Group B [20 (87%) vs. 47 (61%), p < 0.05]. In addition, by quantitative angiography, patients in Group B had smaller arteries (reference diameter 2.8 ± 0.4 vs. 3.1 ± 0.4 mm, p < 0.05) and more severe lesions (minimal lumen diameter 0.46 ± 0.24 vs. 0.65 ± 0.34 mm, p < 0.05). On IVUS, calcified lesions were more frequently visualized in Group B (61 vs. 38%, p < 0.05). On multivariate analysis, catheter size, baseline minimal lumen diameter, angiographic proximal tortuosities, and lesion calcification on imaging were independent predictors of the feasibility of IVUS studies.

Conclusions: Unsuccessful IVUS studies before intervention occur more frequently (1) in vessels with proximal tortuosities or severe lumen narrowing, (2) in lesions that are calcified on IVUS, and (3) when large imaging catheters are used.
Continuing medical education
Authors: Defeyter P.J. , Abrams Jonathan
Published: February 2009

Handbook of Cardiovascular Interventions Edited by Ulrich Sigwart, Michel Bertrand, and Patrick W. Serruys Churchill Livingstone, New York (1996) 950 pages, illustrated, $225.00 ISBN: 0‐443‐979706

Prevention of Myocardial Infarction Edited by JoAnn E. Manson, Paul M. Ridker, J. Michael Gaziano, and Charles H. Hennekens Oxford University Press, New York (1996) 564 pages, illustrated, $65.00 ISBN: 0‐19‐508582‐5
Cardiogenic shock: Therapy and prevention
Authors: Barry William L. , Sarembock Ian J.
Published: February 2009

Cardiogenic shock is defined as profound circulatory failure resulting in insufficient tissue perfusion to meet resting metabolic demands. It occurs in approximately 7.5% of patients with acute myocardial infarction. Treatment strategies include inotropic agents, use of intra‐aortic balloon counterpulsation, and revascularization. Current evidence supports the use of primary angioplasty. Surgery should be considered in patients with triple‐vessel disease. If early catheterization is not available, thrombolytic therapy should be given to eligible patients and transfer to an interventional facility should be considered. Effective therapy for shock must also include a prevention strategy. This requires identification of patients at high risk for shock development and selection of patients who are candidates for aggressive intervention.
Clinical and detailed angiographic findings in patients with ambulatory electrocardiographic ischemia without critical coronary narrowing: Results from the asymptomatic cardiac ischemia pilot (ACIP) study
Authors: Sharaf Barry L. , Mcmahon Robert P. , Pepine Carl J. , Chaitman Bernard R. , Williams David O. , Daves Richard F. , Proschan Michael , Richard Conti C. , Bourassa Martial G. ,   For the ACIP investigators
Published: February 2009

Background: Patients with ambulatory electrocardiographic (AECG) ST‐segment depression and critical coronary narrowing are known to be at increased risk for adverse outcome, but little is known about patients with AECG ST‐segment depression without critical coronary narrowing.

Hypothesis: The objectives of this study were to characterize the coronary angiographic pathology in patients with AECG ST‐segment depression but without critical (< 50% di‐ameter stenosis) coronary narrowing and to compare demographic and clinical findings in these patients with those enrolled in the Asymptomatic Cardiac Ischemia Pilot Study with AECG ST‐segment depression and critical (≥50% diameter stenosis) coronary narrowing.

Methods: Coronary angiograms from patients with AECG ST‐segment depression were reviewed in a central laboratory and quantitative measurement of percent stenosis was performed. Clinical and angiographic comparisons were made between patients with and without critical coronary narrowing.

Results: Patients without critical coronary narrowing (n = 64) were younger (p = 0.02), less likely to be male (p < 0.001) or to have risk factors for coronary atherosclerosis or a history of myocardial infarction (p < 0.001), and had fewer ischemic episodes per 24 h on the screening AECG (p = 0.02) than patients with critical coronary narrowing (n = 441). Of patients without critical narrowing, one half had angiographic evidence for coronary artery disease (≥ 20% stenosis) and 60% had an ejection fraction > 70%.

Conculsions: Patients with AECG ST‐segment depression without critical coronary narrowing are heterogeneous, with half having measurable coronary artery disease. Demographically and clinically, they appear to be different than patients with AECG ST‐segment depression with critical coronary narrowing.
Association of ventricular ectopy with nuclear scintigraphic perfusion defects during dipyridamole stress testing
Authors: Rabin David L. , Ali Amjad , Barron John T.
Published: February 2009

Background and hypothesis: No information is available regarding the significance of ventricular ectopic activity induced during dipyridamole nuclear scintigraphic stress testing. This study tested the hypothesis that dipyridamole‐induced ventricular ectopy predicts a thallium‐201 or technetium‐99m sestamibi perfusion defect.

Methods: A group of 186 consecutive patients with premature ventricular contractions and/or couplets occurring during dipyridamole stress testing (ventricular tachycardia did not occur) was compared with a control group of 194 patients without ventricular ectopy during dipyridamole stress testing.

Results: The results indicated that ventricular ectopy induced during dipyridamole infusion occurred more frequently in patients demonstrating either a fixed or reversible perfusion defect on scintigraphic imaging (p <0.01). The higher frequency of perfusion defects in this group of patients was attributable to a higher frequency of “fixed” compared with “reversible” defects (p<0.05). This finding is consistent with the additional observation that ventricular ectopy induced by dipyridamole was associated with the presence of Q waves on the resting ECG (p<0.05). The positive and negative predictive values of the presence of ventricular ectopy in predicting a fixed myocardial perfusion defect were 59 and 54%, respectively.

Conclusions: Ventricular ectopy induced during dipyridamole infusion suggests the presence of a fixed myocardial perfusion defect.
Factors determining angiotensin‐converting enzyme inhibitor underutilization in heart failure in a community setting
Authors: Philbin Edward F.
Published: February 2009

Background: Angiotensin‐converting enzyme (ACE) inhibitors were underprescribed for patients with congestive heart failure (CHF) treated in the community setting in the early 1990s despite convincing evidence of benefit.

Hypothesis: We postulated that (1) the prevalence of ACE inhibitor use has increased, and (2) prescribing biases have narrowed, as community physicians have gained additional clinical experience with these drugs for treatment of CHF.

Methods: We examined rates of ACE inhibitor use among 1, 150 patients with CHF hospitalized at 10 community hospitals in 1995, evaluated determinants of ACE inhibitor prescription, and compared the results with survey data gathered among similar patients during 1992.

Results: Compared with 1992, ACE inhibitor use prior to hospital admission was increased among all patients (42 vs. 33%, p < 0.001) and the subset with a history of CHF (53 vs. 39%, p< 0.0005). Angiotensin‐converting enzyme inhibitor prescription at hospital discharge also increased among all survivors (64 vs. 51%, p < 0.00005) and the subset eligible for ACE inhibitor treatment based on clinical trial criteria (77 vs. 66%, p = 0.04). Multivariate analysis suggested no change in the prescribing biases previously observed; ACE inhibitor use was related to lower ejection fraction, lower serum creatinine, documentation of left ventricular systolic function, younger patient age, prescription of any diuretic drug, and nonprescription of alternate vasodilators and calcium blockers. In multivariate analyses, physician specialty did not predict ACE inhibitor use.

Conclusions: Angiotensin‐converting enzyme inhibitor use among patients with CHF is increasing but remains below the 80‐90% rates of drug tolerance documented in randomized clinical trials. This discrepancy is partially explained by the prevalence of renal impairment and “diastolic” heart failure in the community setting. However, age bias, use of alternative vasodilators, and substandard quality of care may also play a role.
Left atrial abnormality by electrocardiogram predicts left ventricular hypertrophy by echocardiography in the presence of right bundle‐branch block
Authors: Mehta Anurag , Jain Abnash C. , Morise Anthony P. , Mehta Mahaveer C. , Billie Mike
Published: February 2009

Background: Left ventricular hypertrophy (LVH) on the electrocardiogram (ECG) may be masked in the presence of complete right bundle‐branch block (RBBB). Left bundle‐branch block on the ECG is associated with LVH at autopsy in 93% of hearts studied. However, RBBB does not predict LVH and the usual ECG criteria applied for LVH may not be reliable in the presence of RBBB.

Hypothesis: The study was undertaken to evaluate left atrial (LA) abnormality as a criterion for the diagnosis of LVH in the presence of RBBB.

Methods: Left atrial abnormality in the ECG was assessed by two independent observers as a criterion of LVH in the presence of RBBB in 100 patients, and data were compared with those of 50 patients without LA abnormality.

Results: Left ventricular hypertrophy was confirmed by echocardiographic determination of left ventricular (LV) mass in both groups. Observers reliably differentiated between hy‐pertrophied and normal‐sized LV in the presence of RBBB by using LA abnormality as an ECG criterion when correlated with LV mass determined by echocardiography. Observer 1 correctly detected LVH in 88% and Observer 2 in 82% of patients. False positive diagnosis was made in 12 and 18% of patients by Observers 1 and 2, respectively. Observers' performance of recognition of LA abnormality in the present study was 94%. Results showed sensitivity of 76 and 70% and specificity of 84 and 92% for Observers 1 and 2, respectively. Left ventricular mass increased significantly and was diagnostic of LVH in 92% of patients with LA abnormality. Left ventricular mass was high in 84% of patients when corrected by body surface area. LVH in the presence of RBBB by the ECG was found in only seven patients (5%) when six commonly used conventional criteria of diagnosis of LVH by ECG were employed. Regression analysis found LA abnormality to be a strong independent predictor of increased LV mass. Multiple regression analysis revealed that age, body mass index, body surface area, and frontal axis are also significant predictors of LV mass.

Conclusion: The results obtained by the correlation of LA abnormality by ECG and LVH by echocardiography conclude that LA abnormality by ECG was significantly diagnostic of LV hypertrophy in the presence of RBBB.
Prevalence of atrial fibrillation and stroke in paced patients without prior atrial fibrillation: A prospective study
Authors: Mattioli Anna Vittoria , Castellani Emma Tarabini , Vivoli Daniela , Sgura Fabio Alfredo , Mattioli Giorgio
Published: February 2009

Background: Several reports suggest that the incidence of stroke and atrial fibrillation is reduced in patients receiving physiologic pacemakers, compared with patients receiving a ventricular pacemaker.

Hypothesis: The study was undertaken to address the impact of different pacing modalities on the incidence of stroke and atrial fibrillation.

Methods: We prospectively analyzed 210 consecutive patients. Those with previous episodes of cerebral ischemia and/ or atrial fibrillation were excluded from the study. The study population included 100 patients paced for total atrioventricular (AV) block or second‐degree AV block (type II Mobitz) and 110 patients paced for sick sinus syndrome (SSS). The pacing mode was randomized. All patients underwent a brain computed tomography (CT) scan at the date of enrollment and after 1 and 2 years. Patients were followed for 2 years, and the incidence of atrial fibrillation and stroke was evaluated.

Results: The incidence of atrial fibrillation was 10% at 1 year and 11% at 2 years. Comparing the different pacing modalities, we reported an increase in the incidence of atrial fibrillation in patients receiving ventricular pacing (p<0.05). On the other hand, no difference was found between patients paced for AV block and those paced for SSS. At the end of follow‐up, we reported 29 cases of cerebral ischemia: 9 patients had AV block while 20 had SSS (p<0.05). Comparing the different pacing modalities, there was an increase in the incidence of stroke in patients receiving ventricular pacing (p< 0.05).

Conclusion: There was an increase in the incidence of stroke and atrial fibrillation in patients with ventricular pacing.
A novel source of enterococcal endocarditis
Authors: Milbrandt Eric
Published: February 2009

An important element of the evaluation of patients with infective endocarditis is the determination of an infectious source. In approximately 20‐45% of cases, no source is identified. Often the specific organism involved implicates the source, as is classically described by the association of S. bovis with colonic neoplasia. Other gut organisms have been reported to infect heart valves when colorectal pathology is present, but at far less frequency than S. bovis. This report deals with the case of a 75‐year‐old man with Enterococcus faecalis endocarditis of an unusual source‐a cecal carcinoma that was causing intermittent appendiceal obstruction and infection. This case adds to previous case reports which suggest that the occurrence of enterococcal endocarditis in the absence of a classic infectious source should lead to a search for occult colorectal pathology.
Acute myocardial infarction with simultaneous occlusions of two major coronary arteries in a young man
Authors: Yoshitomi Yuji , Kuramochi Morio , Kojima Shunichi
Published: February 2009

Simultaneous formation of the thrombi in two different coronary arteries is a very rare event. We present a 34‐year‐old man with acute myocardial infarction due to simultaneous occlusion of the two major coronary arteries. His only risk factor was smoking 40 cigarettes daily. Emergency arteriography revealed a total occlusion of the proximal left anterior descending artery (LAD) and the left circumflex coronary artery (LCx). We performed primary angioplasty to the LAD and instituted thrombolytic therapy to the LCx. During intra‐aortic balloon pumping and medical treatment, the patient had no symptoms of angina. He underwent a second catheterization 4 weeks after primary angioplasty. After intravenous ergonovine provocation, coronary arteriography revealed diffuse vasospasm of the LAD and the LCx. These data suggest that habitual heavy smoking and coronary spasm may have been causatory factors for myocardial infarction in this case.
Pathophysiologic bases for adjunctive therapies in the treatment and secondary prevention of acute myocardial infarction
Authors: Gutstein David E. , Fuster Valentin
Published: February 2009

Postmyocardial infarction (MI) survival has been steadily improving. This improvement has been due, in part, to the actions of the adjunctive medical therapies for the treatment of MI. Aspirin, beta blockers, angiotensin‐converting enzyme (ACE) inhibitors, and lipid‐lowering agents have been shown to improve survival in the treatment and secondary prevention of MI. Nitrates have beneficial effects as well. These medications complement the reperfusion strategies through different mechanisms. Other adjunctive medical therapies, namely magnesium, antiarrhythmic agents, and calcium‐channel blockers, have not been shown to improve mortality with routine post‐MI use despite their theoretical benefits.
Differences between male and female patients with regard to baseline demographics and clinical outcomes in the asymptomatic cardiac ischemia pilot (acip) trial
Authors: Frishman William H. , Catanese James , Furia‐Palazzo Suzanne , Mueller Hiltrud , Gomberg‐Maitland Mardi , Hirsch Herbert , Steingart Richard , Forman Sandra ,   For the Asymptomatic Cardiac Ischemia Pilot (ACIP) Investigators
Published: February 2009

Background: Coronary artery disease (CAD) is a common problem in men and women; however, men and women with similar clinical presentations of myocardial ischemia may receive different revascularization treatments.

Hypothesis: Using the data base of the Asymptomatic Cardiac Ischemia Pilot (ACIP) trial, this study was undertaken to compare by gender the baseline demographic data and the clinical outcome results in patients randomized to various treatments in the ACIP study.

Methods: This randomized trial compared three treatment regimens [pharmacologic management of angina, pharmacologic management of angina and ambulatory electrocardiographic (ECG) evidence of ischemia, and revascularization—that is, angioplasty and coronary artery bypass surgery], in patients with known CAD, positive stress ECG tests, and ECG evidence of ischemia during 48 h ambulatory monitoring. In all, 558 patients were randomized, 79 of whom were women (mean age:men 61.6 years, women 60.6 years). Ambulatory ECG evidence of ischemia, clinical events, that is, death, myocardial infarction, hospital admission for coronary events, and exercise performance were monitored.

Results: Although of the same age as men at baseline, women had a higher prevalence of hypertension and diabetes. Women had less severe CAD by angiography and higher left ventricular ejection fractions. Men had longer exercise tolerance times on the treadmill. However, men and women had similar numbers and duration of ambulatory ECG ischemic abnormalities. Regarding revascularization, men more commonly underwent coronary artery bypass surgery (p = 0.025) while women underwent percutaneous transluminal coronary angioplasty more frequently (p = 0.10). Clinical outcomes were comparable in men and women, although the numbers of events were relatively small.

Conclusion: Men and women of comparable age manifest CAD with similar ischemic ECG abnormalities seen on both exercise tolerance and ambulatory ECG examinations. In ACIP, women tended to have more risk factors for CAD and less severity in anatomical disease, which may explain why women are less likely than men to have coronary bypass surgery.
The clinical implications (or lack thereof) of vegetations detected by echocardiography in patients not thought to have endocarditis
Authors: Ali Abbas S. , Rosman Howard , Alam Mohsin , Singireddy Sukhendar , Craven Betty , Lesch Michael
Published: February 2009

Background: The clinical impact of echocardiographic demonstration of a vegetation (Veg) in patients in whom infective endocarditis (IE) is not suspected has not previously been analyzed.

Hypothesis: In this study, an echocardiographic database was interrogated to test whether discovery of a vegetation by echocardiography should result in treatment for endocarditis if IE is not suspected.

Methods: In all, 2,750 serial transthoracic echocardiograms (TTE) were reviewed to generate a list of reports containing the word Veg or thickening (Thk). A chart review of cases identified the impact the report had on patient management. To analyze reader bias due to echocardiographic requests, stating “rule out Veg or IE” as the reason for the study, an additional 1,000 serial TTE requests were segregated into two groups with and without this term. The incidence of the terms Veg or Thk in TTE reports of these groups was tabulated.

Results: Of 2,750 reports, 20 contained the word Veg. Blood cultures were drawn in 16 of 20, with 7 of 16 being positive. Therapy for IE was initiated in 5 of 7 patients with positive cultures. Of 1,000 requests reviewed in the second phase, 24% of those with rule out Veg as the indication for TTE (n = 29) had Veg and 7% had Thk, while in 971 cases with other indications for TTE 0.2% had Veg and 9.3% had Thk.

Conclusions: Clinicians disregard TTE demonstration of Veg if clinical suspicion for IE is low. It is not clear whether the initial echo request biases the interpretation.
QT‐interval dispersion in malnourished children
Authors: Fuenmayor Abdel J. , Fuenmayor Abdel M. , Mora Rosa E. , Fuenmayor Akbar C.
Published: February 2009

Background: Little is known about the electrocardiographic (ECG) QT interval and its variability in malnourished children.

Hypothesis: The study of the QT interval and its dispersion in malnourished children was undertaken to determine whether the QT interval and its variability are increased in these children.

Methods: In 40 children (20 malnourished and 20 controls) aged 12.2 ± 14.4 months (23 male) a conventional ECG was performed for computing heart rate, heart rate variability, corrected QT interval, and QT‐interval dispersion. A blood sample was obtained for measuring hemoblogin, hematocrit, plasma protein, and plasma electrolytic concentrations.

Results: Corrected heart rate, heart rate variability, and QT interval were similar in both groups. When compared with the control group, the malnourished children had greater corrected QT‐interval dispersion, and that dispersion was more accentuated in the precordial leads. They also had repolarization abnormalities (flattened or inverted T waves and U waves). Hemoglobin, hematocrit, plasma protein, and plasma electrolytic concentrations were lower in the malnourished children. However, the ECG findings showed no statistically significant relationship with either the blood parameters, the severity or type of malnutrition, and the size or the weight of the children.

Conclusions: QT‐interval dispersion is increased in malnourished children and the dispersion is more accentuated in the precordial leads.
Prinzmetal's variant angina
Authors: Mayer Susan , Hillis L. David
Published: February 2009

Although the prevalence of variant angina pectoris is unknown, it appears to be substantially less common than typical, exertional angina and unstable angina at rest. The patient with variant angina typically complains of a pressure‐like, squeezing retrosternal chest discomfort of several minutes duration. The diagnosis is secured by the occurrence of transient ST‐segment elevation in association with chest pain, both of which resolve spontaneously or with nitroglycerin. After the diagnosis is made, the patient usually becomes symptom‐free on calcium‐channel blockers with or without long‐acting nitrates. Although the long‐term survival of these patients is excellent, an occasional individual with variant angina sustains a complication, most often myocardial infarction, a life‐threatening arrhythmia, or sudden cardiac death.
Comparison of transesophageal doppler coronary flow reserve measurements with thallium‐201 single‐photon emission computed tomography imaging in assessment of left anterior descending artery stenoses
Authors: Zehetgruber Manfred , Mörtl Deddo , Porenta Gerold , Mundigler Gerald , Christ Günter , Lengauer Roland , Stix Günter , Probst Peter , Maurer Gerald , Sochor Heinz , Siostrzonek Peter
Published: February 2009

Background and hypothesis: Recent studies demonstrate the feasibility of coronary flow reserve measurements by transesophageal echocardiographic (TEE) Doppler recordings of coronary sinus or left anterior descending (LAD) coronary artery flow velocity for detecting stenoses of the LAD artery. This study compares coronary flow reserve measurements by Doppler TEE with thallium‐201 (201T1) single‐photon emission computed tomography (SPECT) in patients with proximal single‐vessel LAD stenosis.

Methods: Nineteen patients with various degrees of LAD stenosis (mean area stenosis 71 ± 24%; range 24‐96%) were studied. Area stenosis by quantitative coronary angiography was < 75% in 7 patients and > 75% in 12 patients. Transesophageal LAD and coronary sinus Doppler measurements were performed at baseline and after intravenous dipyridamole. Coronary flow reserve was calculated as the ratio of hyperemic to baseline average peak velocities. Predefined coronary flow reserve cut‐off values of 1.8 for the coronary sinus method and of 2.0 for the LAD method were used for diagnosis of significant LAD stenosis. Results were compared with qualitative 201T1 dipyridamole SPECT.

Results: Overall predictive accuracy for diagnosis of > 75% LAD stenosis was 79% for 201T1 SPECT, 77% for the transesophageal LAD and 79% for the transesophageal coronary sinus technique. Concordant results between 201T1 SPECT and the LAD and coronary sinus Doppler methods were observed in 79% and 71% of patients, respectively.

Conclusions: Thallium‐201 SPECT and transesophageal Doppler assessment of coronary flow reserve have similar accuracy for diagnosing significant proximal LAD stenosis. Therefore, both transesophageal Doppler techniques might constitute another widely available, noninvasive method for assessment of left coronary artery disease, if disease location is proximal.
Prognostic value of predischarge radionuclide ventriculography at rest and exercise after acute myocardial infarction treated with thrombolytic therapy or primary coronary angioplasty
Authors: Gosselink A. T. Marcel , Liem Ay Lee , Zulstra Felix , Reiffers Stoffer
Published: February 2009

Background: Previous studies have demonstrated the prognostic value of radionuclide ventriculography at rest and exercise in patients post myocardial infarction (MI). The number of studies in patients treated with modern reperfusion techniques, including thrombolysis or primary angioplasty, however, is limited.

Hypothesis: The aim of this study was to evaluate the prognostic significance of predischarge radionuclide ventriculography at rest and exercise in patients with acute MI treated with thrombolysis or primary angioplasty.

Methods: A total of 272 consecutive patients with acute MI who were randomized to thrombolysis or primary coronary angioplasty underwent predischarge resting and exercise radionuclide ventriculography. Left ventricular ejection fraction at rest, decrease in ejection fraction during exercise >5 units below the resting value, angina pectoris, ST‐segment depression, and exercise test ineligibility were related to subsequent cardiac events (cardiac death, nonfatal reinfarction) during follow‐up.

Results: During a mean follow‐up of 30 ± 10 months, cardiac death occurred in 11 (4%) patients and nonfatal reinfarction in 14 (5%) patients. Resting left ventricular ejection fraction was the major risk factor for cardiac death. In patients with an ejection fraction <40%, cardiac death occurred in 16% compared with 2% in those with an ejection fraction ≥ 40% (p = 0.0004). In addition, cardiac death tended to be higher in patients ineligible than in those eligible for exercise testing (11 vs. 3%, p = 0.08). None of the other exercise variables (decrease in ejection fraction during exercise >5 units below the resting value, angina pectoris or ST‐segment depression) were predictive for cardiac death. When all exercise test variables in each patient were combined and expressed as a risk score, a low risk (n = 185) and a higher risk (n = 87) group of patients could be identified, with cardiac death occurring in 1 and 10%, respectively. As the predictive accuracy of a negative test was high, radionuclide ventriculography was of particular value in identifying patients at low risk for cardiac death. Radionuclide ventriculography was not able to predict recurrent nonfatal MI.

Conclusion: In patients with MI treated with thrombolysis or primary angioplasty, radionuclide ventriculography may be helpful in identifying patients at low risk for subsequent cardiac death. In this respect, left ventricular ejection fraction at rest was the major determinant. Variables reflecting residual myocardial ischemia were of limited prognostic value. Identification of a large number of patients at low risk allows selective use of medical resources during follow‐up in this subgroup and has significant implications for the cost effectiveness of reperfusion therapies.
Long‐term outcome of spinal cord electrical stimulation in patients with refractory chest pain
Authors: Bagger Jens Peder , Jensen Bent Skov , Johannsen Gunnar
Published: February 2009

Background and hypothesis: Treatment of patients with refractory chest pain remains a challenge. In this study, the long‐term clinical effects of spinal cord electrical stimulation were evaluated in 10 consecutive male patients (mean age 53.7 years) with chronic chest pain in a prospective observational study.

Methods: After placement of the electrode in an epidural position and before implantation of the device, patients were subjected to clinical evaluation, including atrial pacing, in order to document significant antianginal effects.

Results: Spinal cord electrical stimulation abolished or improved pacing time to angina by more than 50% in seven of the patients who subsequently had the device implanted. In three of these patients, the system was ineffective after a period of 3‐9 months despite paresthesia in the area of anginal pain with electrical stimulation. The effects of treatment remained satisfactory in the remaining patients (40%) after a mean follow‐up of 60 (45‐72) months. Thus, a long‐lasting clinical response was able to be predicted in 57% of the patients.

Conclusion: Spinal cord electrical stimulation is one of the few therapeutic options in inoperable patients with refractory chest pain.
Severe transmural myocardial ischemia after dipyridamole administration implicating coronary steal
Authors: Hansen Christopher L. , Williams Eric
Published: February 2009

Myocardial perfusion imaging with coronary vasodilators is routinely used for patients with suspected coronary disease who are unable to exercise. Since these agents work by increasing blood flow without significantly changing myocardial oxygen demand, they generally do not produce ischemia. A minority of patients show evidence of ischemia which some investigators suggest is due to a coronary steal phenomenon, but this has been challenged by several investigators. We present the case of a patient who developed severe transmural myocardial ischemia manifested by ST‐segment elevation and severe perfusion defects which occurred after dipyridamole administration and which were reversed with aminophylline and nitroglycerin. This case supports the notion that coronary vasodilation with dipyridamole can induce a coronary steal.
Cerebral infarction in a patient with congenital complete heart block
Authors: Hayabuchi Yasunobu , Matsuoka Suguru , Nii Masaki , Suzuya Hiroko , Kuroda Yasuhiro
Published: February 2009

Stokes‐Adams attacks are fairly common in children with congenital complete heart block, but the occurrence of cerebral infarction is quite unusual. We present the case of a 13‐year‐old boy with congenital heart block and an embolic stroke involving the cerebral artery. Echocardiography revealed no valvular regurgitation, hypokinetic segments, mural thrombus, or myxoma. Electrocardiographic monitoring demonstrated good response of ventricular rate to exercise and no episodes of atrial or ventricular dysrhythmia. It is assumed that embolism occurred due to bradycardia.
Ticlopidine‐induced neutropenia mimicking sepsis early after intracoronary stent placement
Authors: Ochoa Anthony B. , Wolfe Mark , Lewis Peter , Lenihan Daniel J.
Published: February 2009

We report a case of ticlopidine‐induced profound neutropenia early in the course of therapy, which was manifest as a febrile systemic illness mimicking sepsis. This clinical presentation was potentially indicative of a contaminated intracoronary stent. The patient's signs and symptoms of illness promptly resolved with removal of ticlopidine, and no infection was documented. Review of indications for ticlopidine use, potential adverse effects, and monitoring recommendations are discussed.
Significance of prominent atrial‐wave and diastasis deflection in radionuclide diastolic volume curve during exercise in detection of coronary artery disease
Authors: Klainman E. , Lebzelter J. , Weisenberg D. , Fink G.
Published: February 2009

Background: Exercise testing with multigated acquisition technetium radionuclide cineangiography (MUGA) is a useful modality that can discriminate systolic and diastolic performance in patients with ischemic heart disease. However, some patients may have abnormal left ventricular filling dynamics with normal regional and global systolic function.

Hypothesis: The purpose of the study was to assess exercise‐induced diastolic dysfunction as expressed by a prominent atrial (A) wave or diastasis deflection at the left ventricular volume curve, in patients with different degrees of ischemic heart disease.

Methods: In all, 32 men and 7 women aged 35‐70 years (mean 54 ± 8.6 years) underwent MUGA at rest and during exercise for analysis of the radionuclide volume curve. Within 6 weeks, thallium‐201 scintigraphy and coronary angiography were performed and the patients were categorized into three groups: (1) disease‐free (n = 10), (2) single‐vessel disease (> 50% stenosis) (n = 19), and (3) double‐vessel disease or more (n = 10). A waves or diastasis deflections were compared among the groups.

Results: Significant differences (p<0.01) were noted in A‐wave deflection relative to peak diastolic volume curve during exercise (Aexe/T) between Group 1 and Groups 2 and 3. Group 1 manifested only a mild rise in A‐wave deflection from rest (20.20 ± 8.49%) to exercise (25.85 ± 8.49%), whereas Groups 2 and 3 exhibited a significant increase from 25.89 ± 9.55% and 28.40 ± 12.6%, respectively, to 60.21 ± 22.5% and 63.0 ± 22.86%, respectively. Group 2 had a significantly (p<0.05) higher maximal heart rate than Group 3.

Conclusions: The addition of prominent A‐wave or diastasis deflection to a normal systolic response during exercise testing with multigated radionuclide cineangiography might be a sensitive marker of coronary artery disease. The A wave represents diastolic dysfunction of the left ventricle, considered an early event in the ischemic cascade.
Sensitivity and long‐term prognostic value of cardiac troponin‐i increase shortly after percutaneous transluminal coronary angioplasty
Authors: Attali P. , Aleil B. , Depoli F. , Mossard J. M. , Wiesel M. L. , Petitpas G. , Wuillermin A. , Cazenave J. P.
Published: February 2009

Background: After successful coronary interventions, minor elevations of creatine kinase MB (CK‐MB) identified a population with a worse long‐term prognosis than that in patients without enzyme elevations. In that setting, cardiac troponin‐I (cTn‐I), a highly specific marker for myocardial injury, was considered for a small study; the results did not support the view that significant myocardial damage occurred during successful percutaneous transluminal coronary angioplasty (PTCA).

Hypothesis: The present study was designed to assess the rate of elevated values of cTn‐I after successful PTCA and to determine its prognostic value.

Methods: CTn‐I and CK‐MB were measured in 44 patients before and daily for 3 days after PTCA. Two groups of patients were considered according to the presence or absence of elevated levels of cTn‐I. The rate of free‐event survival was estimated for the two groups using the Kaplan‐Meier method and was compared with the log rank test.

Results: Globally, 36% of patients had an increase in cTn‐I (normal values 0.35 ng/ml) and 9% had an increase in CK‐MB, p = 0.002. The mean time to maximal enzyme level was 1.8 days for cTn‐I and 2.2 days for CK‐MB. Over a follow‐up of 1375 ± 416 days, 18% of patients experienced adverse events, and cTn‐I did not identify a population of worse longterm prognosis.

Conclusion: These results suggest that cTn‐I is more sensitive than CK‐MB in identifying minor myocardial damage after PTCA, but these elevated concentrations of cTn‐I in the short‐term aftermath of angioplasty do not seem to be a marker of worse long‐term prognosis.
Acute anterior wall myocardial infarction entailing st‐segment elevation in lead v1: Electrocardiographic and angiographic correlations
Authors: Bengal Tuvia , Herz Itzhak , Solodky Alejandro , Birnbaum Yochai , Sclarovsky Samuel , Sagie Alex
Published: February 2009

Background: The correlation between ST elevation in lead V1 during anterior wall acute myocardial infaction (AMI) and the culprit lesion site in the left anterior descending (LAD) coronary artery is poor.

Hypothesis: The study was undertaken to assess the electrocardiographic (ECG) characteristics and angiographic significance of ST‐segment elevation in lead V1 during anterior wall acute myocardial infarction (AMI).

Methods: Data from 115 patients with anterior wall AMI, who underwent coronary angiography within 14 days of hospitalization, were studied. The admission 12‐lead ECG was examined and the coronary angiogram was evaluated for the nature of the conal branch of the right coronary artery (RCA) and for the culprit lesion site in the left anterior descending (LAD) coronary artery.

Results: Mean ST‐segment deviation and the frequency of patients with ST‐segment elevation > 0.1 mV were significantly lower in lead V i than in lead V2 (0.136 $$ 0.111 mV vs. 0.421 $$ 0.260 mV, and 37 vs. 96%, for leads Vi and Vi, respectively). A small conal branch not reaching the interventricular septum (IVS) was more prevalent among patients with ST‐segnicni elevation >0.1 mV in lead Vi (67%), whereas a large conal branch was more prevalent in patients with ST‐segment deviation (1 mV in that lead (83%, p<0.001). No relation was found between ST‐segment deviation in lead V i during anterior wall AMI and the culprit lesion site in the LAD.

Conclusion: ST‐segment elevation in lead V1 during first anterior wall AMI was found in one third of the patients, and its magnitude was lower than that in the other precordial leads. ST‐segment elevation in lead V1 favors the presence of a small conal branch of the RCA that does not reach the IVS.
Plasma kinetics of chylomicron‐like emulsion in renal transplant patients receiving cyclosporin‐based immunosuppression
Authors: De Lima JosÉ Jayme Galvão , Da Maria , Krieger Eduardo M. , Latrilha Conceição M. , Toftoletto Odaly , Ianhez Luis Estevan , Maranhã Raul C.
Published: February 2009

Background: Atherosclerotic cardiovascular disease is prevalent among renal transplant patients. Increase in serum total cholesterol, low‐density lipoprotein, and very low‐density lipoprotein is common in those patients. Alterations in chylomicron metabolism, however, are also related to atherogenesis and were not studied in renal transplant.

Hypothesis: The aim of this study was to evaluate chylomicron metabolism in renal transplant recipients receiving cyclosporin‐based immunosuppression. We determined the plasma kinetics of triglyceride‐rich emulsions labeled with pHjtriolein and [l4C]cholesteryl oleate that are known to mimic the chylomicron metabolism when injected into the blood stream.

Methods: Fourteen renal transplant recipients with normal renal function (10 men, 4 women, aged 40 $pL 6.1 years) and 17 age‐ and gender‐matched healthy controls received bolus injections of the chylomicron‐like emulsion. Plasma samples were then taken at regular intervals during 60 min. Disappearance curves of the labels and the respective fractional clearance rates (FCR) were calculated in order to measure lipolysis and chylomicron remnant removal from the plasma.

Results: Fasting serum lipid levels did not differ in the two groups. The difference between Median FCR of [3H]triolein
emulsion in renal transplant patients and that obtained in the controls (0.07 vs. 0.11 min‐1, NS) was not statistically significant. Median FCR of [14C]cholesteryl oleate also did not differ between the groups (patients: 0.044 controls: 0.046, NS).

Conclusion: These results indicate that neither chylomicron lipolysis nor remnant removal are affected in stable renal transplant patients treated with cyclosporin‐based immunosuppression.
Assessment of mitral valve volume by quantitative three‐dimensional echocardiography in patients with rheumatic mitral valve stenosis
Authors: Limbu Yuba Raj , Chen Haozhu , Shen Xuedong , Pan Cuizhen , Shi YuefanG.
Published: February 2009

Background: Thickening of mitral leaflets in rheumatic mitral valve stenosis is well described in necropsy studies; however, volume computation of the thickening mitral leaflets has not been attempted. Atrial fibrillation is one of the complications of rheumatic mitral stenosis. Quantitative assessment of thickened mitral valve and its relation to clinical complications is clinically desirable.

Hypothesis: The study was undertaken to compare measurement of mitral valve volume in normal subjects and in patients with rheumatic mitral valve stenosis.

Methods: An HP Sonos 2500 echocardiography system with 5 MHz multiplane transesophageal transducer was used for data acquisition, and TomTec Echoscan computer setup was used to off‐line volume computation. Study subjects included 10 normal subjects (mean age 44.8 years) and 36 patients with rheumatic mitral valve stenosis (22 female, 14 male) with an age range of 25 to 69 years (mean age 47 $pL 9.6 years). Mitral valve volumes were compared between the normal subjects and patients with mitral valve stenosis, and further comparison was made between the sinus rhythm (SR) and atrial fibrillation (AF) groups in patients with mitral valve stenosis. In all study subjects, the mitral valve area (MVA) was determined by two‐dimensional echocardiography.

Results: Quantitative three‐dimensional (3‐D) echocardiography showed that mitral valve volume was significantly larger in patients with mitral valve stenosis than in normal subjects (9.0 $pL 2.2 and 4.5 $pL 0.7 ml, respectively, p<0.001). When patients with mitral valve stenosis were divided into the SR and AF groups, mitral valve volume was found to be significantly larger in the AF group than in the SR group (9.76 $pL 2.2 ml.and 7.72 $pL 1.5 ml, respectively, p < 0.01) and patients in the AF group tended to be older (p < 0.05) with larger left atrial diameter (LAD) (p<0.01). However, MVA between the two groups showed no statistical significance (1.1 $pL 0.43 and 1.0 $pL 0.34 cm2, respectively, p >0.2). When the study subjects were divided into two groups (< 50 and > 50 years) according to age, the comparison of mitral valve volume between these two groups (9.37 $pL 2.18 and 8.56 $pL 2.14 ml, p >0.2) showed no statistical significance.

Conclusions: Quantitative 3‐D echocardiography can be applied for the measurement of mitral valve volume in vivo. Patients with rheumatic mitral valve stenosis with atrial fibril lation have a propensity to have a larger mitral valve volume and are older than the patients with sinus rhythm; however, the age per se does not seem to be a cause for larger mitral valve volume.