bluuebunny/crossref_metadata_2025 huggingface dataset:
The influence of angiographically demonstrated coronary collaterals on the results of stress echocardiography
Authors: Stone David A. , Corretti Mary C. , Hawke Mary W. , Herzog William , Rodriguez Samuel , Plotnick Gary D.
Published: February 2009

Previous studies using thallium‐201 scintigraphy have suggested that angiographic coronary collaterals can protect against the development of stress‐induced perfusion abnormalities, but the effect of collaterals on stress echocardiography (SECHO) has not been determined. In this study, 21 consecutive patients referred for cardiac catheterization underwent SECHO and coronary angiography. Of the 21 study patients, there was a total of 16 significantly obstructed coronary arteries (≥ 70% stenosis) in 14 patients. SECHO revealed stress‐induced wall motion abnormalities in the distribution of seven of nine obstructed coronary vessels without angiographic collaterals, but in only one of seven vessels with collaterals (p ≤ 0.05). Six of eight obstructed vessels not associated with a stress‐induced wall motion abnormality had collaterals, whereas only one of eight obstructed vessels associated with a stress‐induced wall motion abnormality had collaterals. We conclude that (1) angiographically demonstrated coronary collaterals can protect against the development of stress‐induced wall motion abnormalities despite the presence of a high‐grade coronary artery obstruction, and (2) the lack of a stress‐induced wall motion abnormality on SECHO in the perfusion territory of an obstructed vessel may suggest the presence of adequate collateral perfusion.
Effect of precordial electrocardiographic electrode placement on st‐segment measurement during exercise
Authors: Bertolet Barry D. , Boyette Alice F. , Mardis Michele , Hill James A.
Published: February 2009

Research protocols often utilize serial exercise testing to examine the efficacy of anti‐ischemic therapies. These tests, however, are prone to multiple sources of bias. This investigation sought to determine the influence of varying precordial electrocardiographic (ECG) electrode placement on the detection of exercise‐induced ST‐segment shifts. Fifteen coronary artery disease patients with abnormal exercise tests were studied. Based on the previous exercise test, the precordial electrode position exhibiting the greatest ST‐segment shift was selected as the reference electrode. Four additional electrodes were placed around this reference electrode and exercise testing was performed. ECG strips were recorded every minute. The time‐to‐onset and ‐offset of ischemic‐type ST‐segment depression was recorded. ST‐segment depression was recorded during exercise from the reference electrode in 12 of 15 patients. Ischemic‐type ST‐depression was also recorded in each of these 12 patients with the surrounding electrodes; however, the time‐to‐onset detected by all four surrounding electrodes concurred in only 5 of 12 (42%) patients. The time‐to‐offset of the ST‐segment depression concurred in 9 of 12 (75%) patients. Serial ECGs recorded from similar but not exactly the same precordial ECG electrode position should yield similar results for the detection of ischemia, but time‐to‐onset or ‐offset of ischemia may differ by 60 s or more. Small changes in the time‐to‐onset and ‐offset of ischemia should not be considered reliable indicators of anti‐ischemia efficacy.
Pulmonary venous flow in constrictive pericarditis
Authors: Shapira Oz M. , Aldea Gabriel S. , Shemin Richard J. , Connelley Gilbert P.
Published: February 2009

A 35‐year‐old white female patient presented with radiation‐induced constrictive pericarditis. Intraoperative transesophageal echocardiography revealed a uniphasic diastolic flow pattern. This pulmonary flow pattern reverted to a normal biphasic systolic/diastolic profile immediately following radical pericardiectomy. This abnormal flow pattern was previously described as typical for restrictive cardiomyopathy. However, in this case it is most likely due to a marked decrease in left atrial compliance induced by the thick fibrous scar encasing the atria.
Clinical applications of body surface potential mapping
Authors: Green Larry S. , Abildskov J. A.
Published: February 2009

Accumulated evidence suggests that the electrocardiographic information provided by the standard 12‐lead electrocardiogram can be improved by use of multilead electrocardiograms. The clinical utility of body surface potential mapping is related to the selective regional information provided by the increased number of leads. That clinical utility includes such things as improved localization of accessory pathways in preexcitation syndromes, improved localization of pacing sites within the ventricles, localization of late potentials, and improved recognition of acute myocardial ischemia. Recording equipment and interpretation schemes are available to make possible more widespread application of potential mapping.
Cardiac consequences of diabetes mellitus
Authors: Shehadeh Abbas , Regan Timothy J.
Published: February 2009

A variety of disciplines including noninvasive and invasive cardiac methodologies, as well as epidemiologic studies, have provided information that has altered our view on the relation of diabetes to cardiac disease. Instead of an exclusive focus on coronary artery disease, it is now recognized that heart muscle can be independently involved in diabetic patients. In diabetics without known cardiac disease, abnormalities of left ventricular mechanical function have been demonstrated in 40 to 50% of subjects, and it is primarily a diastolic phenomenon. Left ventricular hypertrophy may eventually appear in the absence of hypertension. The diastolic dysfunction appears related to interstitial collagen deposition, largely attributable to diminished degradation. The presence of even moderate obesity intensifies the abnormality. Reversibility of this process is not readily achieved with chronic insulin therapy. Experimental studies have indicated normalization of the collagen alteration by endurance training, begun relatively early in the disease process. General measures of management include the control of other cardiac risk factors and a reasonable program of physical activity. The high mortality during an initial acute myocardial infarction has been attributed to heart failure, which is managed as in nondiabetic patients. Recently, the early introduction of aspirin, thrombolysis, and beta‐adrenergic blockade has reduced mortality during the initial infarction. Chronic use of the latter agent over the subsequent years has also proven to be more beneficial in diabetic patients with acute myocardial infarction compared with nondiabetic patients.
Myocardial damage after successful thrombolysis is associated with the duration of ST re‐elevation at reperfusion
Authors: Ochiai Masahiko , Isshiki Takaaki , Hirose Yoshihiro , Toyoizumi Hideki , Oshma Akio , Kondo Kiyoyuki , Sato Tomohide , Miyashita Hideo , Tamura Tsutomu
Published: February 2009

The purpose of this study was to investigate the significance of ST re‐elevation at reperfusion using strict criteria for patient inclusion and exclusion. Twenty‐nine patients who had a first anterior infarction with single‐vessel disease, successful recanalization by intracoronary thrombolysis (ICT) with urokinase, and an angiographically confirmed patent infarct‐related artery after 4 weeks, were divided into three groups according to the deviation of the ST segment at reperfusion: Group A, 10 patients with sustained ST re‐elevation; Group B, 10 patients with transient ST re‐elevation; and Group C, 9 patients with ST reduction. Left ventricular (LV) function was evaluated from cineventriculograms performed in the 30° right anterior projection 4 weeks after ICT. LV ejection fraction and regional wall motion of the infarct area, evaluated by the centerline method (SD/chords), were significantly lower in Group A (44 ± 10%, ‐3.2 ± 0.4) than in Group B (61 ± 9%, ‐1.9 ± 0.7) and Group C (60 ± 5%, ‐2.0 ± 0.4) (p < 0.01). Peak creatine kinase (CK) activity was significantly higher in Group A (5848 ± 2112 IU) than in Group B (2485 ± 1254 IU) and Group C (1889 ± 1525 IU) (p < 0.05). These data suggest that a sustained ST re‐elevation at reperfusion was strongly associated with marked LV dysfunction and higher peak CK activity. It was concluded that sustained, not transient, ST re‐elevation associated with successful reperfusion indicates extensive myocardial damage.
Rapid reversal of digitalis delirium using digoxin immune fab therapy
Authors: Varriale Philip , Mossavi Ahmad
Published: February 2009

A fulminant psychiatric disturbance, as the sole noncardiac manifestation of digitalis toxicity, emerged in a 85‐year‐old woman during treatment for congestive heart failure. Described more than a century ago as ‘digitalis delirium,’ the disorder is characterized by severe agitation, delusional thinking, assaultive behavior, and even death. Digoxin immune Fab therapy was begun because of the fulminant psychiatric manifestations of this toxic state and the clear danger of self‐inflicted physical harm. Within 3 h of therapy, a complete and spectacular resolution of all mental symptoms was observed.
Ventricular tachyarrhythmias, myocardial ischemia, and sudden cardiac death in patients with hypertensive heart disease
Authors: Zehender Manfred , Faber Thomas , Koscheck Ursula , Just Hanjörg , Meinertz Thomas
Published: February 2009

Hypertensive heart disease is increasingly considered to be a strong and independent risk factor for sudden cardiac death. Ventricular tachyarrhythmias in these patients are common and mainly the result of electrophysiologic abnormalities and increased electrical vulnerability of the hypertrophic myocardium. However, proarrhythmia in the hypertrophic heart often is facilitated and aggravated by electrolyte disturbances, the sympathoadrenergic tone, transient blood pressure crisis, and especially by the occurrence of myocardial ischemia. Myocardial ischemia in the setting of hypertensive heart disease may result from stenotic lesions in large and/or small coronary artery vessels and, in the absence of both, will result from the altered cellular oxygen supply and consumption in the hypertrophic myocardium. Recent studies have shown that acute and transient myocardial ischemia are common in many hypertensives, often fail to be symptomatic, and that the dynamic interaction of left ventricular hypertrophy, transient myocardial ischemia, and ventricular tachyarrhythmias may provide a crucial link for the high incidence of sudden cardiac death in patients with hypertensive heart disease.
Evaluation of antihypertensive effects of once‐a‐day isradipine and fosinopril: A double‐blind crossover study by means of ambulatory blood pressure monitoring
Authors: Perticone Francesco , Pugliese Fabiola , Marcantonio Anna Maria , Cloro Cosima , Maio Raffaele , Mattioli Pier Luigi
Published: February 2009

We compared the efficacy and tolerability of is‐radipine (ISR) and fosinopril (FOS) once‐a‐day administration in 17 outpatients, 9 men and 8 women, aged 35–65 years (mean ± SD= 58 ± 10 years), affected by mild to moderate primary systemic hypertension. The patients were given single‐blind placebo for 2 weeks and thereafter, in double‐blind, randomized, crossover sequence, ISR (5 mg) and FOS (20 mg), both for 4 weeks. At the end of each period, patients underwent 24‐h noninvasive blood pressure (BP) monitoring by means of an A&D TM 2420 Monitor Model 7, with readings taken every 10 min during the day (from 7 A.M. to 11 P.M.), and every 20 min during the night (from 11 P.M. to 7 A.M.). Similarly, BP load (BPL) as percentage of systolic and diastolic BP reading > 140 and > 90 mmHg was investigated. Both ISR and FOS induced a highly significant (p<0.0001) decrease in BP from 158/96 ± 7/6 mmHg to 133/86 ± 6/6 and to 132/83 ± 10/7 mmHg, respectively. Mean BP decreased from 117 ± 6 mmHg to 102 ± 6 mmHg (ISR) (p<0.0001) and to 99 ± 8 mmHg (FOS) (p<0.0001). Both ISR and FOS significantly (p<0.0001) reduced systolic BPL from 78 ± 16% to 44 ± 13% and 28 ± 12%, respectively, and diastolic BPL from 70 ± 15% to 40 ± 13% (p<0.0001) and 35 ± 13% (p<0.0001), respectively. A significant difference between the two drugs in systolic (p<0.0002) BPL was observed. No significant differences in heart rate were noted. No unexpected adverse effects were observed in any patient under either therapy. Both ISR and FOS resulted in very effective decrease in BP; however, FOS proved to be significantly more effective than ISR.
Treatment of acute myocardial infarction with streptokinase does not appear to modulate circulating neutrophil function
Authors: Adams Susan A. , Froese Steven P. , Kirsch Ralph E. , Shephard Enid G. , Robson Simon C. , Green Belinda K. W. , Commerford Patrick J.
Published: February 2009

The administration of thrombolytic therapy is the most common method of achieving patency of the occluded coronary artery in patients with acute myocardial infarction (AMI). However, thrombolytic agents and the byproducts of fibrinolysis have the potential to affect neutrophil activation and thus function, thereby augmenting myocardial damage further. This study assessed the effect of streptokinase administration on the function of circulating neutrophils in patients with AMI. For this neutrophil adherence to human umbilical vein endothelial cells, homotypic neutrophil aggregation, and CDII b and L‐selectin expression on the neutrophil membrane prior to and I h and 6 h after thrombolytic therapy was monitored. The study population included patients with AMI who received aspirin and streptokinase, and healthy laboratory workers who received aspirin only; all subjects acted as their own controls. Circulating fibrin degradation products and white cells were markedly raised following administration of streptokinase. No significant differences in neutrophil adherence to endothelium, homotypic neutrophil interactions, and CDI Ib or L‐selectin expression were demonstrated between neutrophils, either pre‐ or post‐thrombolytic therapy in the infarct group, or between neutrophils from the infarct group and from the control group. It was concluded that streptokinase produces an abrupt neutrophil leukocytosis together with a marked increase in circulating levels of fibrin degradation products. The assay systems used were unable to show significant sequential changes in circulating neutrophil adhesion and L‐selectin or CD I l b expression in patients with AM1 following thrombolytic therapy or when these patients were compared with controls.
Captopril in acute myocardial infarction: Beneficial effects on infarct size and arrhythmias
Authors: Bussmann Wulf‐Dirk , Micke Guido , Hildenbrand Ralf , Klepzig Harald
Published: February 2009

It is known from experiments that angiotensin‐converting enzyme inhibitors can limit infarct size. In a prospective, randomized, placebo‐controlled double‐blind study, 22 patients were given 1.5–2.0 mg captopril/h I.V., while 24 patients were given placebo. Medication was started between 2 and 18 h from the onset of infarction. The two groups were matched for age, infarct location, and time of intervention. With the exception of one patient in either group, all were concurrently given nitroglycerin. The necrosis parameters were provided by the quantitative measurement of the QRS complex. The Q wave decreased with captopril treatment (—0.003 mV), but increased with placebo (+0.14 mV, p < 0.05). The number of ventricular premature beats at 24 h from the start of treatment was 25/h with placebo, and 9/h with captopril (p < 0.02). Ventricular fibrillation occurred seven times in the placebo group, but did not occur in the captopril group. The creatine kinase infarct weight was 59 gram‐equivalents (gEq) with placebo, and 45 gEq with captopril (p = NS). Mean arterial pressure was reduced by 12 mmHg with captopril treatment. The results show a beneficial effect of captopril on infarct size and electrical instability, over and above the effect of standard management with nitroglycerin and thrombolysis.
The effects of age and gender on brachial artery endothelium‐dependent vasoactivity are stimulus‐dependent
Authors: Corretti Mary C. , Plotnick Gary D. , Vogel Robert A.
Published: February 2009

Impaired endothelium‐dependent vasomotion in response to flow‐mediated, cholinergic, and cold pressor stimulation has been demonstrated in the presence of both atherosclerosis and cardiac risk factors. This study investigated the effects of different vasoactive stimuli on brachial artery vasomotion with respect to age and gender. Forty healthy subjects (20 men and 20 women), ages 23 to 52 years, were studied. Using 7.5 MHz ultrasound, brachial artery diameter and Doppler flow velocity at baseline, following 5 min of ipsilateral blood pressure cuff occlusion (flow‐mediated), during contralateral hand immersion in ice (cold pressor) and after sublingual nitroglycerin administration, were measured in older subjects (> 40 yrs) and younger subjects (< 40 yrs). Among normal subjects, % diameter change in response to the flowmediated stimulus was less in older men than in younger men (6.8 ± 3.2% vs. 11.5 ± 7.4%, p < 0.05); older and younger women had comparable responses (10.0 ± 5.3% vs. 11.6 ± 4.3%, p = NS). With cold pressor, normal older men and older women vasoconstricted (–1.2 ± 0.9%, –2.2 ± 4.7%) compared with younger subjects who vasodilated (1.4 ± 2.5%, 0.6 ± 2.3%, p<0.02). The cold pressor test elicited comparable responses among older normal subjects. Nitroglycerin, a nonendothelium‐mediated stimulus, induced significant vasodilatation in all the groups. In conclusion, endothelium‐mediated responses in subjects of varying age and gender are stimulus‐dependent. Flow‐mediated vasodilatation could not differentiate older premenopausal women from younger women; cold pressor stimulus could.
Intracardiac thrombi: Frequency, location, etiology, and complications: A morphologic review—Part I
Authors: Waller Bruce F. , Grider Larry , Rohr Todd M. , Mclaughlin Todd , Taliercio Charles P. , Fetters Julie
Published: February 2009

Intracardiac thrombus is a frequent finding at necropsy. Various cardiac disorders have been associated with its presence. Part I of this 5‐part article focuses on classification by location and etiology and reviews primary cardiomyopathy as a specific condition associated with intracardiac thrombus.
Thymoma with pericardial tamponade
Authors: Woldow Andrew , Kotler Morris , Goldstein Steven , Milcu Maria
Published: February 2009

Thymomas are tumors of the anterior mediastinum. They are most often seen in adults aged 45 to 50 years. These tumors are routinely asymptomatic for prolonged periods of time. The most common presentation is discovery on routine chest x‐ray. We therefore present a case report of an elderly woman who presented with symptoms of dyspnea caused by a malignant thymoma. To our knowledge, symptomatic pericardial tamponade due to a thymoma with a massive pericardial effusion has not been described previously.
Quantification of mitral regurgitation—Comparison of the proximal flow convergence method and the jet area method
Authors: Grossmann Georg , Giesler Martin , Schmidt Arnold , Kochs Matthias , Wieshammer Siegfried , Felder Carmen , Höher Martin , Hombach Vinzenz
Published: February 2009

A total of 92 patients with mitral regurgitation (age 63 ± 13 years, 51 men, 41 women), quantified by angiography, were studied using color‐flow Doppler imaging of isovelocity surface areas in the flow convergence region proximal to the regurgitant orifice (PISAs) and of the regurgitant jet in the left atrium. The PISA radii for the flow velocities (aliasing borders) of 28 and 41 cm/s, jet area, jet length, and relation of jet area to left atrial area were measured. A proximal flow convergence region was imaged in 98% (85%) of all patients for a flow velocity of 28 (41) cm/s. A regurgitant jet could be visualized in all patients. The PISA radii for both flow velocities correlated more closely with the angiographic grade (rsp = 0.79 for both flow velocities) than the jet area (rsp = 0.43), jet length (rsp = 0.39), and relation of jet area to left atrial area (rsp = 0.37). A correct differentiation of grade I‐II from grade III‐IV mitral regurgitation was provided in 95% of the patients by the proximal flow convergence method for both flow velocities and in up to 78% of the patients by the jet area method using the uncorrected jet area. The PISA radii correlated weakly with the parameters from the regurgitant jet (r = 0.5–0.58). It can be concluded that the proximal flow convergence method and the jet area method reach comparable sensitivity for the detection of mitral regurgitation. The proximal flow convergence method is more suitable than the jet area method to determine the severity of mitral regurgitation and only it provides a reliable method to differentiate between grade I–II and grade III–IV mitral regurgitation.
Lipoprotein (a) is increased in acute coronary syndromes (unstable angina pectoris and myocardial infarction), but it is not predictive of the severity of coronary lesions
Authors: Brunelli Claudio , Spallarossa Paolo , Balbi Manrico , Barbara Cristina , Pastorini Carlo , Caponnetto Salvatore , Bertolini Stefano , Masturzo Paola , Lantieri Pasquale B.
Published: February 2009

Lipoprotein (a) [Lp(a)] concentrations were determined in 365 patients undergoing coronary angiography for stable angina (n = 159), unstable angina (n = 99), recent myocardial infarction (n = 45), and nonischemic heart disease (cardiomyopathy or valvular disease, n = 62, non‐IHD). Mean ± SD and median Lp(a) concentrations in stable angina (29.9 ± 29.2; 22 mg/dl) did not differ from those in non‐IHD (26.9 ± 26.3; 17), but were significantly lower than in patients with unstable angina (52.7 ± 36.6; 58) and myocardial infarction (44.8 ± 36.4; 34) (p < 0.01). Coronary angiography revealed that 261 patients, including 4 patients in the non‐IHD group, had significant (≥ 50%) coronary lesions. Lp(a) was higher in patients with (41 ± 35; 32) than in those without (28 ± 27; 19) angiographic evidence of significant coronary stenosis (p < 0.05) and showed a weak univariate correlation with the angiographic index (Total Score) of the severity of the disease (r = 0.106; p < 0.05). However, in the subgroup of 303 patients with stable/unstable angina or myocardial infarction, Lp(a) was predictive neither of angiographic presence nor of severity of coronary disease. Patients were then ranked according to the Total Score values. Among patients with comparable angiographic severity of coronary artery disease, Lp(a) appeared to be remarkably higher in patients with acute ischemic syndromes (unstable angina, myocardial infarction) than in patients with stable angina. In conclusion, Lp(a) was roughly twice as high in acute (unstable angina, myocardial infarction) than in chronic (stable angina) ischemic syndromes, but there was no difference between chronic stable angina and non‐IHD. Serum level determination of Lp(a) made a poor contribution in predicting the extent of coronary artery disease.
The effect of body position on a free‐floating ball thrombus as observed by transesophageal echocardiography
Authors: Miyamoto Shinii , Hadama Tetsuo , Mori Yoshiaki , Shigemitsu Osamu , Sako Hidenori , Soeda Tohru , Yoshimatsu Toshihide , Uchida Yuzo
Published: February 2009

Two cases of free‐floating left atrial ball thrombi (FLABT) in association with mitral stenosis were observed by transesophageal echocardiography (TEE). Our report describes the relation between body position and thrombi kinetics. Both cases demonstrated similar kinetics. In the supine and right lateral decubitus positions, the thrombi recoiled from and sometimes became entrapped within the mitral valve. In the sitting and left lateral decubitus positions, the thrombi appeared to be nearly fixed and did not contact with the mitral valve. Our results indicate that the latter two positions prevent thrombi disintegration and incarceration into the mitral valve. Finally, TEE is an extremely useful tool for assessing the safest position for individuals with FLABT.
Assessment of cardiac risk in noncardiac surgery
Authors: Forgosh Les B. , Movahed Assad
Published: February 2009

Surgical techniques have been refined so that complications directly resulting from surgical procedures are relatively small. However, with the high prevalence of coronary artery disease in the United States, many surgical patients have concomitant coronary artery disease. Anesthesia as well as the surgical procedure induce stresses on the heart and circulatory system which could result in perioperative cardiac morbidity and mortality. Assessing patients prior to surgical procedures by history, physical examination, laboratory data, and newer cardiovascular diagnostic procedures can stratify the cardiac risk and help to predict the incidence of perioperative cardiac morbidity and mortality. If great risk exists, an alternative therapy or cancellation of the surgical procedure may be considered. In certain subgroups of patients, coronary artery revascularization, valvular heart surgery, or beginning medical therapy of the underlying cardiac pathology could be performed prior to the surgical procedure. If this cannot be arranged for the high‐risk patients, more intensive and invasive hemodynamic monitoring and optimal medical management perioperatively might reduce cardiac complications.
Intracardiac thrombi: Frequency, location, etiology, and complications: A morphologic review—Part III
Authors: Waller Bruce F. , Mclaughlin Todd , Grider Larry , Rohr Todd M. , Taliercio Charles P. , Fetters Julie
Published: February 2009

Intracardiac thrombus may develop as a consequence of multiple underlying cardiac disorders. Left ventricular (LV) aneurysm following acute myocardial infarction has been associated with intra‐aneurysmal thrombus and emboli. Part III of this 5‐part article on intracardiac thrombus focuses on the frequency and consequence of thrombus associated with LV aneurysm.
Pitfalls in the diagnosis and management of papillary muscle rupture: A study of four cases and review of the literature
Authors: Samman Bashar , Korr Kenneth S. , Katz Alan S. , Parisi Alfred F.
Published: February 2009

Four cases of papillary muscle rupture occurring in the setting of acute myocardial infarction are presented, which illustrate the following points: the diagnosis may not be apparent at presentation, a mitral regurgitant murmur may be absent, transesophageal echocardiography may establish the diagnosis when transthoracic echocardiography does not, and appropriate surgical correction can lead to excellent functional recovery.
Non‐visualized left anterior descending artery revealed on selective conus artery catheterization
Authors: Feld Steven , Epstein Menashe , Ayzenberg Oded , Caspi Avi
Published: February 2009

Cardiac catheterization of a man with severe angina and anterior ischemia on exercise testing with perfusion imaging demonstrated normal anterior wall motion on resting left ventriculography, but failed to visualize the left anterior descending (LAD) or conus artery on left and right coronary angiography. Selective contrast injection of a large conus artery originating from a separate ostium in the right aortic sinus demonstrated extensive collateral circulation to an LAD occluded at its origin from the left main coronary artery, thus providing essential information for subsequent patient management.
Transesophageal echocardiography in diagnosing cardioembolic stroke
Authors: Husain Aatif M. , Alter Milton
Published: February 2009

Stroke is a disease with high morbidity and mortality that afflicts older people. The most common type of stroke is ischemic, and 15–20% of these strokes are cardioembolic. Because clinical features are not very specific for the type of stroke, diagnostic aides are needed to identify the mechanism of stroke so that appropriate therapy can be initiated. Numerous studies have shown that transesophageal echocardiography (TEE) is a more sensitive tool for diagnosing cardioembolic stroke than transthoracic echocardiography (TTE). However TTE and TEE are still considered complementary as they both provide unique information. The many abnormalities that can be identified by TEE and their therapy are discussed in this review, along with indications and complications of TEE. TEE has demonstrated that cardioembolic causes of stroke are much more common than previously thought. With a more precise diagnosis, appropriate therapy can be provided to help prevent cardiogenic stroke.
Vascular dynamics in isolated systolic arterial hypertension
Authors: Meaney Eduardo , Soltero Enrique , Samaniego Virginia , Alva Felix , Moguel Rafael , Vela Agestin , Gonzalez Vidal
Published: February 2009

With a growing elderly population, the incidence of isolated systolic hypertension (ISH) has increased. This study characterizes dynamic vascular changes that occur with advanced age and with ISH. Fifty‐five healthy individuals and seven with ISH were distributed in seven age groups from the second to the seventh decade. An index of aortic stiffness (ΔP/ΔV) was derived using a mercury sphygmomanometer to obtain pulse pressure, and ultrasonographic measurements were used to estimate aortic volumes applying the “cylinder formula.” The mathematic derivation of this formula is explained in detail. Pulse pressure showed no significant change with age, but showed a significant increase with ISH. A decrease in volume change from systole to diastole was found with advanced age. Normotensive subjects aged 65 ± 2 years had a 2.6‐fold increase in aortic stiffness compared with young individuals. Elderly patients with ISH had a 7‐fold increase in aortic stiffness compared with Group 1 (15 ± 2 years) (p<0.001) and a 2.7‐fold increase compared with Group 6 (normotensive subjects aged 65 ± 2 years). A strong correlation between systolic pressure and arterial stiffness was observed (r = 0.953) (p<0.001). The proposed stiffness index was compared with the one described by Hirai, obtaining a high correlation, that is, r = 0.989 (p<0.001). When compared with Stefanadis's index of distensibility, our index showed a correlation of r = 0.932 (p<0.003). It is concluded that while systolic pressure is a main determinant of arterial stiffness, the ΔP/ΔV is a more sensitive method to estimate dynamic changes in elastic arteries such as the aorta.
Visual estimation of ejection fraction by two‐dimensional echocardiography: The learning curve
Authors: Akinboboye Olakunle , Sumner John , Gopal Aasha , King Donald , Shen Zhanging , Bardfeld Philip , Blanz Lisa , Brown Edward J.
Published: February 2009

Our purpose was to determine the learning curve of visual estimation of ejection fraction (EF) by echocardiography. Sixty consecutive patients, who had clinically indicated echocardiography and radionuclide ventriculography (RVG) within 1 month were selected. Five standard views were reviewed independently by a first‐year cardiology fellow, a private cardiologist, and an experienced echocardiographer. Observers were given feedback of the RVG EFs immediately after estimating the EF on each study. To assess the effect of learning, the echocardiographic studies were divided into three groups of 20 and were read successively by each observer. A statistical comparison of the two methods was performed for each group. The correlation between the two techniques for the first group of studies was marginal. There was a significant improvement in the correlation with subsequent groups. The correlation did not change significantly with the last group of studies compared with the second group. In conclusion, visual estimation of EF by two‐dimensional echocardiography can be learned, with a learning curve of approximately 20 studies if immediate feed‐back is available.
Echocardiographic diagnosis of partial anomalous pulmonary venous connection from right upper lobe to the coronary sinus
Authors: Otsuji Y. , Kisanuki A. , Arima S. , Shimokawa S. , Taira A. , Tanaka H.
Published: February 2009

A 36‐year‐old woman was admitted because of an enlarged right heart. Echocardiographic examination revealed an abnormal vessel connecting to the dilated coronary sinus. The abnormal vessel traveled in the direction from the right axillary to the left epigastric region. Partial anomalous pulmonary venous connection (PAPVC) from the right upper lobe to the coronary sinus was initially considered as a possible diagnosis by echocardiography. At surgery, diagnosis of an isolated PAPVC of the right upper pulmonary vein to the coronary sinus was confirmed.
Continuing medical education
Authors: Kaplan Samuel , Schlant Robert C.
Published: February 2009

Congenital Heart Disease in Adults: A Practical Guide By Andrew Redington, Darryl Shore, and Paul Oldershaw W. B. Saunders Company, Ltd., London (1994) 270 pages, illustrated, $59.00 ISBN: 0–7020–1913–5

The History of Cardiology By Louis J. Acierno The Parthenon Publishing Group, London (1994) 758 pages, illustrated, 98.00 ISBN: 1–85070–339–6
Functional significance of alterations in cardiac contractile protein isoforms
Authors: Kitsis Richard N. , Scheuer And James
Published: February 2009

Multiple closely related, yet distinct, isoforms exist for each of the cardiac contractile proteins. The isoform composition of the heart changes in response to developmental and physiologic cues. This paper reviews the molecular basis for cardiac contractile protein isoform diversity and the functional consequences of isoform shifts.
This section edited by Marek Malik, M. D. Heart rate variability during repeated incremental head‐up tilt discloses time dependence of individual autonomic dynamics
Authors: Bootsma Marianne , Swenne Cees A. , Bruschke Albert V. G.
Published: February 2009

According to the Rosenblueth‐Simeone model, the heart rate (HR) is proportional to the sympathovagal balance. The individual proportionality constant is the intrinsic HR, which can be determined only invasively. The percentage low‐frequency spectral HR variability power, relative to the low‐ plus high‐frequency spectral power (%LF) has been raised as a noninvasive alternative. We previously studied young healthy male subjects, in whom gradual autonomic changes were induced by incremental head‐up tilt (0–10–20–30–40–45–50–55–60–65–70–75–80° ). At each tilt angle we computed HR and %LF. Linear regressions of %LF on HR, characterizing individual autonomic dynamics, confirmed that, within a subject, changes in %LF were proportional to changes in HR. For the current study, we made repeated measurements in 19 subjects after 1 to 8 months. in six subjects, the session 1 and session 2 regression lines differed significantly (t‐test, p < 0.05), demonstrating the time dependence of the autonomic dynamics. in such cases, similar HR values on different days are to be associated with different %LF values. We also determined the reproducibility of the supine HR and %LF values. For all 19 subjects, the coefficients of variation were 7 and 22%, respectively: HR reproduces better than %LF. Hence, time‐dependent autonomic dynamics contribute systematically to the inferior reproducibility of %LF.
Exercise‐induced syncope and holter‐documented asystole in an endurance runner with moderate aortic stenosis
Authors: Shapira Yaron , Kusniec Jairo , Birnbaum Yochai , Strasberg Boris
Published: February 2009

The case of an endurance runner with moderate aortic stenosis, who had recurrent syncope, is reported. A Holter recording during syncope revealed asystole lasting 57 s. Head‐up tilt table test with isoproterenol was abnormal. No important abnormality was found in sinus or atrioventricular nodal functions. It was postulated that the syncope was due to exaggerated left ventricular baroreflex response, probably aggravated by the increased vagal tone in an endurance runner. The patient was given a beta‐adrenergic blocker, and a pacemaker was implanted because of the profound cardio‐inhibi‐tory response. The arguments for this approach are discussed.
Giant right coronary artery aneurysm with fistulous connection to the coronary sinus: Diagnosis and management
Authors: Shammas Nicolas W. , Murphy Gerald W. , Risher William H. , Shapiro Janine R. , Latouf Sean E. , Pomerantz Richard M,
Published: February 2009

This report describes the case of a giant aneurysmal right coronary artery connecting to the coronary sinus near its opening into the right atrium in a 70‐year‐old woman who presented with a recent onset of congestive heart failure. By coincidence, a secundum atrial septal defect was also present. The diagnosis and surgical management of this uncommon pathology are described.
Infarct size limitation: Acute N‐acetylcysteine defense (ISLAND trial): Preliminary analysis and report after the first 30 patients
Authors: Šochman Jan , Vrbská Jana , Musilová Blanka , Roček Miroslav
Published: February 2009

Our previous experimental research and initial clinical observations regarding the use of N‐acetylcysteine in the treatment of ischemic and reperfusion injury in acute myocardial infarction gave rise to a study entitled the Infarct Size Limitation: Acute N‐acetylcysteine Defense (ISLAND) trial. Today, this randomized, echocardiographically and angio‐graphically controlled study includes the first 30 patients with a first anterior wall myocardial infarction: Group A (n = 10) consisting of patients with successful recanalization of the in‐farct‐related left anterior descending artery by streptokinase without any further treatment, Group B (n = 10) consisting of patients with failed infarct‐related artery recanalization, and Group C (n = 10) comprising patients who had successful streptokinase‐induced recanalization of the left anterior descending artery plus N‐acetylcysteine administration at a dose of 100 mg/kg body weight. The parameters monitored in our study include changes in global and regional left ventricular ejection fraction of the infarct‐related segment using echocar‐diography and, using electrocardiograms and the Wagner QRS scoring system, the amounts of acutely jeopardized and finally infarcted myocardium. In Group A, global left ventricular ejection fraction rose nonsignificantly within 2 weeks from 37.5 ± 9.6% to 38.5 ± 13.8%; it declined significantly in Group B from 36.2 ± 6.1% to 30.1 ±6.7% (p < 0.05), while it considerably improved in Group C from 41.7 ± 4.1 % to 59.6 ±8.1 % (p < 0.001). Regional left ventricular ejection fraction changed significantly only in Group C: from — 4.5 ± 27.3 to 45.6 ± 16.3 (p < 0.001). In Group A, in which the amount of acutely jeopardized myocardium was 21.7 ± 7.2, infarction actually occurred in 20.4 ± 9.7% (practically no myocardial salvage). In Group B, risk area was 18.1 ± 4.3%, but infarct size rose to a resulting 29.1 ±6.0%. Significant myocardial salvage was accomplished only in Group C: of 26.2 ±8.1% of jeopardized myocardium, infarct size was reduced to 10.8 ± 7.1% (salvage by 58.8%). Also, basic division of patients by therapy showed that, although those with nonidentical findings on their coronary arteries were included into the same groups, patients treated with streptokinase plus N‐acetylcysteine had significantly more favorable values of the monitored parameters than those treated with streptokinase alone. We conclude our interim analysis suggests that N‐acetylcysteine has a beneficial effect, reducing the functional and structural impacts of myocardial infarction.
Chronic‐intermittent urokinase therapy in patients with end‐stage coronary artery disease and refractory angina pectoris—A pilot study
Authors: Schoebel F. C. , Leschke M. , Jax T. W. , Stein D. , Strauer B. E.
Published: February 2009

Patients with coronary artery disease and severe angina pectoris refractory to conventional medical treatment (beta Mockers, nitrates, calcium antagonists) and without the option for invasive revascularization procedures represent an increasing clinical problem. For these patients, chronic‐intermittent urokinase therapy has been developed. Twenty patients received 500,000 IU urokinase as intravenous bolus injection 3 times a week over a period of 12 weeks. The average reduction in anginal symptoms in 19 patients was 74%, from 23.5 ± 10.8 to 5.2 ±4.8 events/week (p< 0.001); 1 patient was excluded from further treatment because of an increase of > 66 % in anginal events. Fibrinogen decreased by 34% from 370 ± 57 to 244 ± 44 mg/dl (p< 0.001), the rheological parameters plasma viscosity by 6.1 % from 1.39 ± 0.04 to 1.31 ± 0.03 mPas (< 0.001), and red blood cell aggregation by 18% from 13.9±2.4 to 11.2±2.2 (p<0.001). Exercise tolerance increased by 51%. Average ST‐segment depression decreased from 0.16 ±0.10 to 0.12 ± 0.09 (p<0.01). After 12 weeks of follow‐up, angina pectoris and fibrinogen levels were still significantly reduced compared with baseline values. Chronic‐intermittent urokinase therapy represents an effective anti‐ischemie and antianginal approach in patients with refractory angina pectoris and end‐stage coronary artery disease. Improvement of rheological blood properties and thrombolytic effects are likely therapeutic mechanisms.
Excessive myocardial contraction in vasovagal syncope demonstrated by echocardiography during head‐up tilt test
Authors: Lee Tsung‐Ming , Chen Ming‐Fong , Chao Chia‐Lun , Liau Chiau‐Suong , Lee Yuan‐Teh , Su Sheng‐Fang
Published: February 2009

The purpose of this study was to gain insight into the mechanism of vasovagal syncope and to test the efficacy of theophylline to prevent syncope. Twenty‐six patients with vasovagal syncope underwent two‐dimensional echocardiography and theophylline test during head‐up tilt test. A standard parastemal short‐axis view of echocardiography at the level of the papillary muscle was recorded to measure fraction shorting of the left ventricle, and left ventricular end‐diastolic and end‐systolic dimensions. Heart rate, blood pressure, and symptoms were recorded. There were three groups; Group 1: no syncope with and without isoproterenol (n = 5); Group 2: syncope only after the infusion of isoproterenol (n = 16); Group 3: syncope without isoproterenol (n = 5). Groups 2 and 3 proceeded to theophylline injection (250 mg). The study showed that the 80° tilt induced an increase in heart rate of 6.6 ± 4.0,12.4 ± 6.6, and 25.4 ± 4.5 beats/min in Groups 1,2, and 3, respectively (p < 0.05 in Groups 1 and 2, p < 0.05 in Groups 1 and 3). The addition of isoproterenol during posture change from supine to an 80° tilt made the significant change of fractional shortening from 0.4 ± 5% to 6 ± 13% in Group 2 (p = 0.05), compared with no significant change in Group 1. There were no significant differences in left ventricular end‐diastolic dimension and end‐systolic dimension in each group between baseline and isoproterenol infusion during posture change. Vasovagal syncope was associated with vigorous myocardial contraction, rather than with contraction against an empty left ventricle. The acute loading of theophylline was not effective in preventing vasovagal syncope.
Assessing the Physiologic Significance of Coronary Artery Disease: Role of Doppler Methodology
Authors: Schlaifer Jay D. , Hill James A.
Published: February 2009

It is important to define both anatomic and functional significance of coronary artery stenoses. Quantitative angiography has decreased the inter‐ and intraobserver variability in interpreting the coronary angiogram, but it is less clinically applicable in assessing functional significance. The coronary Doppler catheter and guidewire can provide considerable information regarding the functional effects and patho‐physiology of coronary stenosis in humans at the time of cardiac catheterization. Clinically, it is a simple and safe technique which makes it feasible in a clinical setting to use it as a tool to assess the physiologic significance of an intermediate stenosis or the functional result of an interventional procedure. Other uses for the intravascular Doppler method, such as the evaluation of cardiac transplant vasculopathy and rejection and evaluation of patients with chest pain syndromes and normal coronary angiograms, are being studied. However, the usefulness of this technique in decision‐making has yet to be fully clarified. Future clinical studies should be directed toward comparing this method with noninvasive methods, that is, exercise treadmill test and thallium studies, and attempt to answer questions regarding its prognostic value.
Atrial fibrillation in acute myocardial infarction: A prospective study based on data from a consecutive series of patients admitted to the coronary care unit
Authors: Madias John E. , Patel Dilip C. , Singh Deovrat
Published: February 2009

Atrial fibrillation (AF) is a common and much‐studied arrhythmia in patients with acute myocardial infarction (MI). However, documentation of its occurrence in temporal association with MI has been often neglected in the literature; also, its frequent occurrence with mere advanced age, or in the setting of various cardiac conditions or complications, has prevented the definition of an exact role for AF as a marker or determinant of outcome in patients with ML The purpose of this study was to evaluate prospectively the frequency of AF (present or occurring subsequently) in a consecutive series of patients with MI admitted to the Coronary Care Unit, and to explore for variables associated with this arrhythmia; the role of AF in determining major clinical outcomes of the patients was also examined. A large data base of baseline, clinical, laboratory, and patient outcome variables was generated and continuously updated to examine correlates of AF and its possible role in determining prognosis. AF was found in 72 of 517 patients, of whom 58 experienced this arrhythmia anew. Univariate analyses detected a positive association of AF with age, pulmonary congestion, left ventricular hypertrophy, high admission Killip class, and a large array of complications including in‐hospital mortality. Multivariate analyses showed, however, that AF correlated weakly with age and strongly with left ventricular hypertrophy and occurrence of ventricular tachycardia, but that it was not a determinant of ventricular fibrillation or in‐hospital mortality.
Change of plasma leukotriene c4 during myocardial ischemia in humans
Authors: Takase Bonpei , Kurita Akira , Maruyama Toshiharu , Uehata Akimi , Nishioka Toshihiko , Mizuno Kyoichi , Nakamura Haruo , Katsura Kenichiro , Kanda Yoshikazu
Published: February 2009

Changes in leukotriene C4 levels during different degrees of myocardial ischemia in humans were examined by comparing radioimmunoassay measures of leukotriene C4 plasma levels obtained during transient and prolonged myocardial ischemia. Leukotriene C4 levels in systemic arterial and coronary sinus blood were determined in patients with chronic stable angina before and after myocardial ischemia induced either by exercise (supine bicycle ergometer exercise stress testing; n = 14; age, 52 ± 8 years) or by coronary occlusion during angioplasty (n = 14; age 53 ± 7 years). Temporal changes of leukotriene C4 were also followed in arterial and pulmonary artery blood within 24 h after the onset of chest pain (acute phase), and 1 day, 1 week, and 1 month later in 22 patients with acute myocardial infarction (AMI) (12 patients with thrombolytic therapy, age 61 ± 10 years; 10 patients without thrombolytic therapy, age 60 ± 11 years). Clinical characteristics, including coronary risk factors and the severity of coronary artery disease, were not significantly different among the groups. Exercise‐induced myocardial ischemia and coronary occlusion did not induce any significant leukotriene C4 changes in the chronic stable angina patients, whereas AMI patients had significantly higher plasma leukotriene C4 levels in both arterial and pulmonary artery blood in the acute phase compared with those of chronic stable angina patients (arterial blood, 471 ± 164 pg/ml and 477 ±235 pg/ml vs. 275 ± 254 pg/ml or 240 ± 66 pg/ml, p< 0.05; pulmonary artery blood in AMI, 543 ± 162 pg/ml vs. 234 ± 125 pg/ml or 225 ±64 pg/ml, coronary sinus blood in chronic stable angina, p < 0.05). These results suggest that leukotriene C4 is involved more in prolonged myocardial ischemia than in transient myocardial is chemia, and that leukocyte function might play a significant role in the pathogenesis of patients with AMI.