bluuebunny/crossref_metadata_2025 huggingface dataset:
The appearance of L‐selectinlow polymorphonuclear leukocytes in the circulating pool of peripheral blood during myocardial infarction correlates with neutrophilia and with the size of the infarct
Authors: Roth Arie , Keren Gad , Shapira Itzhak , Arber Nadir , Kassirer Michael , Zeltser David , Rotstein Rivka , Gluzman Boris , Leibovitz Eyal , Goldberg Yifaat
Published: February 2009

Background: It is assumed that not only leukocytosis, but also the activation of white blood cells (WBC) may play a role in the pathogenesis and prognosis of patients with myocardial infarction (MI). Activation of WBC includes upregulation of CD11b∖CD18 and downregulation of CD62L (L‐selectin) antigens.

Hypothesis: The activation of WBC is associated with the appearance of a larger MI.

Methods: CD11b∖CD18 and CD62L were measured on the surface of WBC on Day 1 and Day 3 from the onset of MI. The size of the infarct was estimated by calculating the area under the curve of the creatine kinase enzyme, which was measured every 6 h.

Results: A negative correlation was noted between the absolute polymorphonuclear count and the availability of the CD62L on these cells during Day 1 (r = ‐0.46, p = 0.003) and Day 3 (r = ‐0.35, p = 0.05). There was a positive correlation between the size of MI and the WBC count (r = 0.46, p = 0.004) and a negative correlation with CD62L on polymorphonuclears (r = ‐0.35, p = 0.03). During Day 3, the CD11b∖CD18 on the polymorphonuclears increased despite a decrement in the absolute number of these cells.

Conclusion: The neutrophilia during the early phases of acute MI correspond to the appearance of the L‐selectinlow population of polymorphonuclear leukocytes. There is a correlation between the appearance of this population and the size of the infarct.
The effect of specific inspiratory muscle training on the sensation of dyspnea and exercise tolerance in patients with congestive heart failure
Authors: Weiner Paltiel , Magadle Rasmi , Berar‐Yanay Noa , Pelled Benny
Published: February 2009

Background:It has been previously shown that the inspiratory muscles of patients with congestive heart failure (CHF) are weaker than those of normal persons. This weakness may contribute to the dyspnea and limit exercise capacity in these patients. The respiratory muscles can be trained for both strength and endurance.

Hypothesis:The present study was designed to evaluate the effect of specific inspiratory muscle training (SIMT) on inspiratory muscle performance, lung function, dyspnea, and exercise capacity in patients with moderate heart failure.

Methods:Twenty patients with CHF (NYHA functional class II‐III) were recruited for the study. The subjects were randomized into two groups: 10 patients were included in the study group and received SIMT and 10 patients were assigned to the control group and received sham training. Subjects in both groups trained daily, 6 times/week, for one‐half h, for 3 months. The subjects started breathing at a resistance equal to 15% of their PImax for 1 week and the resistance was then increased incrementally to 60%. Spirometry, inspiratory muscle strength (assessed by measuring the PImax at residual volume), and endurance (expressed by the relationship between PmPeak and PImax), the 12‐min walk test, and peak VO2 were performed before the beginning and at the end of the training period.

Results:All patients in the training group showed an increase in the inspiratory muscle strength [mean (± standard error of the mean) PImax increased from 46.5 ± 4.7 to 63.6 ± 4.0 cm H2O, p < 0.005], and endurance (mean PmPeak/PImax from 47.8 ± 3.6 to 67.7 ± 1.7%, p < 0.05), while they remained unchanged in the control group. This was associated in the training group with a small but significant increase in forced vital capacity, a significant increase in the distance walked (458 ± 29 to 562 ± 32 m, p < 0.01), and an improvement in the dyspnea index score. No statistically significant change in the mean peak VO2 was noted in either group.

Conclusions:Specific inspiratory muscle training resulted in increased inspiratory muscle strength and endurance. This increase was associated with decreased dyspnea, increase in submaximal exercise capacity, and no change in maximal exercise capacity. This training may prove to be a complementary therapy in patients with congestive heart failure.
Myocardial ischemia due to vasospasm of small coronary arteries detected by methylergometrine maleate stress myocardial scintigraphy
Authors: Shimada Toshio , Ishibashi Yutaka , Murakami Yo , Sano Kazuya , Tsukihashi Hironori , Okada Seiji , Kawakami Koichi , Murakami Rinji
Published: February 2009

Background: Recently, several case reports have implicated vasospasm of small coronary arteries in vasospastic angina pectoris. Vasospasm of small coronary arteries was also considered from angiographic findings in patients with atypical chest pain. In Syrian hamster, vasospasm in small coronary arteries was considered to be the cause of dilated cardiomyopathy.

Hypothesis: This study was undertaken to determine whether vasospasm in small coronary arteries can be induced by methylergometrine maleate stress thallium‐201 (201T1) myocardial scintigraphy.

Methods: Twenty‐five patients with chest pain, all of whom had intact coronary arteries, were studied. After intracoronary methylergometrine maleate injection, coronary arteriograms also looked normal in all cases. Thallium‐201 myocardial scintigraphy was carried out immediately after intracoronary methylergometrine maleate injection in four patients with chest pain. In the remaining 21 patients with chest pain, methylergometrine maleate was given intravenously within up to 2 weeks before 201T1 myocardial scintigraphy.

Results: In the intracoronary injection study, one patient had chest discomfort after methylergometrine maleate injection, and ST‐segment elevation was observed on electrocardiogram (ECG). Of the 21 patients with chest pain, 11 patients felt angina‐like chest pain after intravenous injection of methylergometrine maleate, but their ECGs showed no ischemic changes. Stress 201T1 myocardial scintigrams showed methylergometrine maleate‐induced perfusion defects with complete redistribution in 3 of 4 patients in the intracoronary injection study and in 12 of 21 patients in the intravenous injection study. These findings suggest that vasospasm in small coronary arteries caused myocardial ischemia in 15 of 25 patients (60%) with chest pain.

Conclusion: Vasospasm in small coronary arteries may be involved in the myocardial ischemia of some patients with chest pain who do not show any large coronary artery vasospasm.
Anomalies in the dosing of diltiazem
Authors: Pool Peter E.
Published: February 2009

From early research, investigators understood that the dose of diltiazem required for the treatment of hypertension (commonly 360 mg/day) was greater than that required for the treatment of angina (commonly 240 mg/day). Nonetheless, studies of recent prescribing practices show that the 240 and 180 mg capsule strengths constitute more than 70% of the diltiazem prescriptions for hypertension. Physicians became accustomed to the lower antianginal doses of diltiazem for 7 years before a hypertension indication was approved. Subsequently, these dosing levels were reinforced by the production of once‐a‐day formulations with highest capsule strengths of 240 mg and 300 mg. These strengths were dictated by the sheer bulk of the formulations, which limited how much diltiazem could be inserted into the #00 capsule, the largest capsule that can be comfortably administered. An examination of the combined data from the six randomized, blinded, and placebo‐controlled trials submitted to the FDA for the original new drug applications of the three formulations of diltiazem available in the United States shows a clear linear dose‐response relationship between diltiazem dose and blood pressure lowering through the 480‐‐540 mg/day range. It also demonstrates that the 90‐‐120 mg/day range is the “no‐effect dose.” These conclusions are supported by a MEDLINE review of all other studies of multilevel dosing of higher dose levels of diltiazem. The data support the conclusion that diltiazem is generally underdosed, but when properly dosed may be the single most potent antihypertensive overall.
Incomplete ventricular septal rupture following blunt chest trauma
Authors: Tsikaderis D. , Dardas P. , Hristoforidis H.
Published: February 2009

Nonpenetrating cardiac trauma should be considered in the diagnosis of electrocardiographic changes after road traffic accidents. Transesophageal echocardiography is the most useful noninvasive technique for the diagnosis of cardiac trauma. This paper reports the case of a patient with traumatic contusion of the ventricular septum following a fall from a 20 m height onto the roof of a car.
Brain natriuretic peptide increases acutely and much more prominently than atrial natriuretic peptide during coronary angioplasty
Authors: Kyriakides Zenon S. , Michalis Lambros , Antoniadis Aias , Nikolaou Nikolaos I. , Kremastinos Dimitrios T. , Markianos Manolis
Published: February 2009

Background: Increased levels of plasma brain natriuretic peptide (BNP) are observed in patients with congestive heart failure, hypertension, left ventricular hypertrophy, and acute myocardial infarction. However, there are no data on serial changes in plasma levels of BNP in patients undergoing coronary angioplasty.

Hypothesis: The study was undertaken to examine plasma concentrations of BNP together with those of atrial natriuretic peptide (ANP) in patients undergoing percutaneous transluminal coronary angioplasty (PTCA).

Methods: Plasma concentrations of BNP and ANP were examined in 13 patients with stable angina pectoris and good left ventricular function undergoing PTCA. Blood samples were taken from the femoral vein at baseline, after the first balloon inflation, after the end of the procedure, and 4 h thereafter.

Results: Plasma BNP levels were 14 ± 4 at baseline, 22 ± 10 after the first balloon inflation, 28 ± 12 at the end of the procedure, and 15 ± 4 pgr/ml 4 h thereafter (F = 13.05, p < 0.00001). Plasma ANP levels were 80 ± 15, 86 ± 14, 90 ± 24, and 75 ± 6 fmol/l (F = 5.95, p = 0.002), respectively. The increase of BNP at the end of the procedure was related to the increase of ANP (r = 0.78, p = 0.002).

Conclusion: Plasma BNP levels increase acutely and much more prominently than those of plasma ANP during coronary angioplasty; however, plasma BNP levels return to baseline values shortly after the end of the procedure.
Ortnery's syndrome in association with mitral valve prolapse
Authors: Kishan C. V. , Wongpraparut N. , Adeleke K. , Frechie P. , Kotler M. N.
Published: February 2009

The case of an 83‐year‐old woman with a history of hypertension, valvular heart disease, atrial fibrillation, and cardiomegaly is presented. The patient also had progressive hoarseness of her voice and intermittent dysphagia. Ear, nose, and throat examination revealed left vocal cord paralysis. Echocardiography revealed severely dilated left (LA) and right atria (RA), moderate mitral regurgitation, severe tricuspid regurgitation, and prolapse of both these valves. A review of literature of Ortner's or cardiovocal syndrome is presented. Ortner's syndrome due to mitral valve prolapse has not been reported previously.
Correlation of coronary angiography with “tombstoning” electrocardiographic pattern in patients after acute myocardial infarction
Authors: Guo Xiao Hua , Guan Yee , Chen Li Jia , Huang Jian , John Camm A.
Published: February 2009

Background: It has been suggested that a specific pattern of electrocardiographic (ECG) changes following acute myocardial infarction (AMI), the so‐called “tombstoning,” predicts a poorer outcome, although the cause and associations of such changes are not known. To address the possible cause and implications, we correlated angiographic findings with tombstoning in patients following AMI.

Methods: The study investigated 124 patients with AMI, whose ECGs were taken within 24 h of onset of symptoms and who subsequently underwent angiography. In this population, 24 (19%) patients had a definite tombstoning pattern on their admission ECG.

Results: Compared with non‐tombstoning ECGs, the significant differences in the tombstoning group are as follows: (1) All patients, including those with inferior infarction, had either total or partial occlusion of the left anterior descending (LAD) artery (100 vs. 44%, p < 0.0001); (2) LAD occlusions were significantly more severe and mostly proximal (100% occlusion: 50 vs. 20.5%, p = 0.02; <50% occlusion: 0 vs. 15.9% p = 0.039; proximal occlusion: 92 vs. 65%, p = 0.017); (3) patients with tombstoning ECGs had a significantly greater incidence of occlusion of all three coronary arteries (54.1 vs. 22%, p = 0.001); (4) tombstoning ECGs were more strongly associated with anterior than with inferior infarction (83.3 vs. 33%, p < 0.0001).

Conclusions: The patients with a tombstoning pattern on the admission ECG, who underwent angiography, were associated with occlusion of a high‐grade stenosis of the proximal LAD artery (usually with involvement of more than one artery) and were predominantly seen in association with anterior infarction.
Angina induced by excessive bradycardia
Authors: Shaheen Joseph , Wanderman Aryeh , Tzivoni Dan
Published: February 2009

Angina pectoris usually occurs in patients with significant coronary artery disease during periods of increased coronary demand such as increased heart rate. Bradycardia is a rare and unusal cause of angina pectoris that should be considered during the evaluation of patients with agnia. This paper reports three cases of bradycardia‐induced angina.
The incidence and consequences of mental disturbances in elderly patients post cardiac surgery—a comparison with younger patients
Authors: Heijmeriks J. A. , Dassen W. , Prenger K. , Wellens H. J. J.
Published: February 2009

Background: Limited data exist about the incidence and consequences of mental confusion following open heart surgery in different age groups. Likewise, little is known about preoperative predictors of mental confusion.

Methods: Two‐hundred consecutive patients, aged şş75 years (Group 1), and 400 procedure‐ and gender‐matched younger patients (Group 2) who underwent coronary or valvular surgery were included in a prospective study. The relation between postoperative mental confusion, mortality, morbidity, and quality of life was studied.

Results: Mental confusion was present in 11.8% Group 2 and 22.6% Group 1 patients. The incidence was higher after valvular surgery. Preoperative risk factors in Group 1 patients were diabetes mellitus, a history of heart failure, weak carotid pulsations, and repeat surgery. Late mortality, after a median follow‐up duration of 31 months, was significantly worse in patients who were confused, which was related to the underlying disease. Recovery of quality of life was clearly diminished in elderly patients with confusion in contrast to younger patients.

Conclusion: Postoperative mental confusion has a high incidence in the elderly population and is associated with a diminished quality of life.
Endothelial dysfunction, subangiographic atheroma, and unstable symptoms in patients with chest pain and normal coronary arteriograms
Authors: Clague Jonathan R. , Bagger Jens‐Peder , Ward David E. , Cox Ian D. , Kaski Juan‐Carlos
Published: February 2009

Background: Patients with chest pain and normal coronary arteriograms (CPNA) may present with unstable symptoms and other evidence of ischemia during clinical follow‐up. Although repeat angiography usually proves negative, functional assessment of coronary vasomotor abnormalities may provide additional pathophysiologic information.

Hypothesis: The study was undertaken to evaluate the relationship between endothelial dysfunction and subangiographic atheroma in patients with CPNA undergoing repeat angiography because of unstable symptoms.

Methods: We investigated nine patients with CPNA (8 women, mean age 57 ± 9 years) undergoing repeat angiography because of unstable anginal symptoms. After normal angiography, simultaneous coronary epicardial and microvascular vasomotor responses to intracoronary vasodilators [acetylcholine (10−6 M), adenosine (18 μg) and nitroglycerin (300 μg)] were investigated in the left anterior descending artery using quantitative angiography and Doppler flow measurements. The presence of subangiographic atheroma was assessed by intravascular ultrasound.

Results: Three patients demonstrated proximal and distal epicardial vasoconstriction and a reduction in coronary flow in response to acetylcholine, indicating concordant epicardial and microvascular endothelial dysfunction. These changes were associated with chest pain and ischemic electrocardio‐graphic changes in two patients. None of the remaining patients suffered chest pain in response to intracoronary acetylcholine. Six patients had significant subangiographic disease (intimal thickness >0.3 mm) on intravascular ultrasound imaging, and multivariate analysis indicated a significant relationship (R2 = 0.89, overall p = 0.001) between the extent of subangiographic disease and both plasma cholesterol concentration and hypertensive history. No significant relationship was demonstrated between endothelial dysfunction and the extent of subangiographic disease.

Conclusion: Concordant epicardial and microvascular endothelial dysfunction may be pathophysiologically and clinically significant in unstable patients with CPNA but does not appear to be directly related to the extent of subangiographic atheroma.
New and emerging pharmacologic strategies in the management of chronic heart failure
Authors: Krum Henry
Published: February 2009

Chronic heart failure (CHF) is a complex syndrome involving activation of multiple cellular, metabolic, and neurohumoral pathways following the initial myocardial insult. Recently, there have been considerable advances in the pharmacologic management of CHF. The current approach to treatment recognizes the need to target neurohormonal activation, and the use of angiotensin‐converting enzyme (ACE) inhibitors and beta blockers should now be regarded as part of standard therapy in many patients with CHF. However, because of the complexity of the disease, blockade of additional pathways is likely to be required to maximize the therapeutic benefit of intervention. To this end, there are several agents under active late‐phase clinical evaluation. The most advanced of these new strategies (beyond renin‐angiotensin‐aldosterone blockade) is inhibition of the endothelin system. There is a substantial body of evidence that this system is intimately involved in CHF disease progression. Early‐phase clinical data are very encouraging and support the potential utility of long‐term endothelin inhibition. Other novel approaches involve the use of cytokine antagonists (e.g., agents that block tumor necrosis factor‐α activity) and the augmentation of natriuretic peptides. If all these potential agents prove to be of benefit in CHF, the question of which agent or combination of agents to use in which patients will arise. There is therefore a need to develop scientific approaches in order to be able to identify more accurately patients who will obtain benefit from specific classes or combinations of drugs.
Changes in QT dispersion during adenosine infusion
Authors: Kumar Ananth , Narasimhan Calambur , Sankari Abdul , Ranginani Anil , Lennon Catherine , Bekerman Carlos , Clark William , Denes Pablo
Published: February 2009

Background: QT dispersion (QTd) measurement during treadmill stress testing has been to shown to improve the accuracy of exercise electrocardiogram (ECG) in the detection of significant coronary artery disease (CAD).

Hypothesis: The aim of this study was to determine whether adenosine‐induced changes in QTd could predict significant CAD and to assess its efficacy as a diagnostic index in patients undergoing adenosine stress test.

Methods: QT interval measurements were made in 57 consecutive patients undergoing adenosine sestamibi stress test. Patients with an abnormal stress test underwent coronary angiography. Patients with significant disease by coronary angiography (> 70% stenosis) were classified as having CAD (Group 1), and those with normal stress images and/or normal coronaries by angiography were classified as having no CAD (Group 2).

Results: QT dispersion increased from 28.2 ± 4.5 to 43.8 ± 4.5 ms with a ΔQTd of 15.53 ± 3.68 in Group 1 (p = 0.001) and from 28.4 ± 2.6 to 34.8 ± 2.8 ms with a ΔQTd of 6.58 ± 2.21 ms in Group 2 (p = 0.006). Patients in Group 1 had a significantly higher increase in QTd (ΔQTd) than the patients in Group 2 (p < 0.03). Addition of ΔQTd (> 10 ms) to the ST depression during adenosine infusion would increase the sensitivity of the ECG from 23 to 65% and decrease the specificity from 91 to 70% for diagnosis of significant CAD.

Conclusions: ΔQTd is significantly more prolonged in patients with CAD during adenosine infusion. It increases the sensitivity of the stress ECG in diagnosis of CAD during adenosine infusion when used as an adjuvant index.
Monotherapy with amlodipine or atenolol versus their combination in stable angina pectoris
Authors: Kenneth Pehrsson S. , Ringqvist Ivar , Ekdahl Sten , Karlson BjÖRn W. , Ulvenstam GÖRan , Persson Stig
Published: February 2009

Background: The basic cause of angina pectoris is imbalance between the metabolic needs of the myocardium and the capacity of the coronary circulation to deliver sufficient oxygenated blood to satisfy these needs.

Hypothesis: The study was undertaken to evaluate whether the effect of combined amlodipine and atenolol therapy on patients with stable angina pectoris and with ST‐depression during exercise testing and 48‐h ambulatory electrocardiographic monitoring is superior to that of either agent given alone.

Methods: Patients with stable angina pectoris and ST depression during exercise and ambulatory monitoring were randomized to receive amlodipine (n = 116) or atenolol (n = 116), or both (n = 119). All patients were also treated with short‐ and long‐acting nitrates. The design was a double‐blind, randomized, triple‐arm parallel group study with 10 weeks of administration of the test medication.

Results: In terms of time to onset of ST depression > 1 mm, time to onset of angina, total exercise time, maximum achieved workload, and peak intensity of angina, amlodipine and atenolol alone were as effective as their combination. During ambulatory monitoring, atenolol was more effective than amlodipine regarding total time and number of ST‐depression episodes, and as effective as the combined drugs.

Conclusion: For individual patients with stable angina pectoris, combination of a beta blocker with a calcium antagonist is not necessarily more effective than either drug given alone.
Endothelial function and peripheral vasomotion in the brachial artery in neurally mediated syncope
Authors: Takase Bonpei , Akima Takashi , Uehata Akimi , Katushika Syuichi , Isojima Kazusige , Satomura Kimio , Ohsuzu Fumitaka , Kurita Akira
Published: February 2009

Background: Paradoxical peripheral vasodilation is one of the suspected mechanisms of neurally mediated syncope. Parasympathetic stimulation following sympathetic activation during orthostatic stress mainly contributes to this vasodilation.

Hypothesis: Since endothelial function modulates peripheral vascular tone, this study aimed to determine whether endothelial function and inappropriate peripheral vasomotion has a significant role in the pathogenesis of neurally mediated syncope.

Methods: To investigate whether endothelial function is augmented or whether abnormal peripheral vasomotion exits, flow‐mediated dilation (FMD, endothelium‐dependent vasodilation) and sublingual glyceryl trinitrate‐induced dilation (0.3 mg, GTN‐D, endothelium‐independent vasodilation) were measured in the brachial artery in 16 patients with neurally mediated syncope, aged 33 ± 10 years, by using high‐resolution ultrasound. All patients underwent positive head‐up tilt testing. These measures were compared with those in 16 control subjects matched with the patients by age, gender, and coronary risk factors. For FMD, percent diameter changes were obtained from baseline to hyperemic conditions (1 min after 5 min occlusion of the forearm artery). There were five smokers in both the patient and the control groups, but there was no structural heart disease in either group.

Results: Baseline brachial artery diameters were comparable (3.8 ± 0.6 vs. 3.8 ± 0.7 mm, NS). Flow‐mediated dilation in patients with neurally mediated syncope had a normal value of 9.8 ± 5.0% despite the inclusion of five smokers. Flow‐mediated dilation and GTN‐D in patients with neurally mediated syncope were significantly greater than those in controls (9.0 ± 5.0 vs. 3.0 ± 3.5%, p<0.05; 18.4 ± 5.5 vs. 14.1 ± 4.4%, p<0.05).

Conclusions: Augmented endothelial function and/or abnormal peripheral vasomotion in peripheral arteries are important in patients with neurally mediated syncope in selected populations.
Chagas' Heart Disease
Authors: Jr Anis Rassi , Rassi Anis , Little William C.
Published: February 2009

Chagas' disease is caused by a protozoan parasite, Trypanosoma cruzi, that is transmitted to humans through the feces of infected bloodsucking insects in endemic areas of Latin America, or occasionally by nonvectorial mechanisms, such as blood transfusion. Cardiac involvement, which typically appears decades after the initial infection, may result in cardiac arrhythmias, ventricular aneurysm, congestive heart failure, thromboembolism, and sudden cardiac death. Between 16 and 18 million persons are infected in Latin America. The migration of infected Latin Americans to the United States or other countries where the disease is uncommon poses two problems: the misdiagnosis or undiagnosis of Chagas' heart disease in these immigrants and the possibility of transmission of Chagas' disease through blood transfusions. Diagnosis is based on positive serologic tests and the clinical features. The antiparasitic drug, benznidazole, is effective when given for the initial infection and may also be beneficial for the chronic phase. The use of amiodarone, angiotensin‐converting enzyme inhibitors, and pacemaker implantation may contribute to a better survival in selected patients with cardiac involvement of chronic Chagas' disease.
Restenosis and Progression of Coronary Disease after Balloon Angioplasty in Patients with Diabetes Mellitus
Authors: Rozenman Yoseph , Sapoznikov Dan , Gotsman Mervyn S.
Published: February 2009

Background: Patients with diabetes mellitus (D) (both insulin‐requiring D [IRD] and non‐IRD) who undergo angioplasty have worse long‐term outcome than do non‐D patients. Few data are available in the literature that explain these findings.

Hypothesis: The study was undertaken to compare restenosis and progression of coronary disease after angioplasty in IRD patients, in non‐IRD patients, and in non‐D patients.

Methods: Diabetic patients who underwent coronary angioplasty were separated into two subgroups: IRD and non‐IRD patients. Their angiographic outcome was compared with non‐D patients. We examined retrospectively 353 coronary angiograms of patients who were referred for diagnostic angiography > 1 month after successful angioplasty. Quantitative angiography was used to determine the outcome in dilated narrowings (restenosis) and in nondilated narrowings (disease progression).

Results: Baseline clinical and angiographic characteristics were similar in all groups. Restenosis rate was higher in IRD (61 %) than in non‐IRD (36%) and non‐D (35%) patients (p = 0.04). Late luminal loss after angioplasty was two times greater in IRD patients than in the other two groups (p=0.01). Disease progression of nondilated narrowings was significantly more prominent in non‐IRD than in non‐D patients: Diameter stenoses were similar in the initial angiogram, but narrowings were significantly more severe (p=0.02) in the final angiogram (70 ± 27% and 60 ± 33%, respectively). New narrowings were more common in non‐IRD than in non‐D patients: there was a 23% increase in the number of narrowings in the follow‐up angiogram in non‐IRD patients compared with only 12% in non‐D patients (p < 0.003). These new narrowings were more common (p=0.01) in angioplasty arteries (57 narrowings on 420 arteries—13.6%) than in nonangioplasty arteries (54 narrowings on 639 arteries—8.5%).

Conclusion: Restenosis is more common in IRD patients and explains the high rate of adverse cardiac events within the first year after coronary intervention in these patients (mainly target lesion revascularization). Disease progression (including new narrowings) is the main determinant of patient outcome > 1 year after coronary intervention and is accelerated in non‐IRD compared with non‐D patients.
Myocardial viability in patients with thrombolyzed myocardial infarction: Is it assessable by predischarge exercise electrocardiography test?
Authors: Samad Bassem A. , Hulting Johan , Ruiz Hernan , Höjer Jonas , Jensen‐Urstad Mats , Jensen‐Urstad Kerstin , Bouvier Fredric
Published: February 2009

Background: Most studies concerning exercise electrocardiography (ECG) testing after acute myocardial infarction (AMI) were carried out in the prethrombolytic era. ST‐segment elevation in the infarction area during exercise has usually been interpreted as indicating the presence of dyskinesia as a result of extensive left ventricle damage.

Hypothesis: This study was undertaken to evaluate the contributions of exercise‐induced ST‐segment elevation and T‐wave pseudonormalization to the assessment of myocardial viability in patients with thrombolyzed myocardial infarction (MI), compared with low‐dose dobutamine echocardiography.

Methods: The study comprised 52 consecutive patients with AMI treated with thrombolysis. All patients underwent low‐dose dobutamine echocardiography and symptom‐limited exercise testing before discharge.

Nineteen patients showed ST‐segment elevation (Group 1), 9 showed isolated T‐wave pseudonormalization (Group 2), and 24 patients did not exhibit either of these ST‐T segment changes (Group 3). Low‐dose dobutamine echocardiography revealed evidence of viability in 16 patients (84%) in Group 1 (p=0.01), 5 (56%) in Group 2 (p=NS), and 11 patients (46%) in Group 3 (p = NS).

Conclusion: Exercise‐induced ST‐segment elevation may contribute to the evaluation of myocardial viability in patients with AMI treated with thrombolysis. However, in the absence of exercise‐induced ST‐segment elevation, further noninvasive studies might be indicated to assess myocardial viability.
Influence of age on left atrial appendage function in patients with nonvalvular atrial fibrillation
Authors: Ilercil Arzu , Kondapaneni Jyothi , Hla Aung , Shirani Jamshid
Published: February 2009

Background: Age is an independent risk factor for thromboembolism in nonvalvular atrial fibrillation (NVAF). An association between low left atrial appendage (LAA) Doppler velocities and thromboembolic risk in NVAF has been reported.

Methods: Forty‐two consecutive patients (age 69 ± 2 years [range 42–92], 24 [57%] men) with NVAF underwent transthoracic and transesophageal echocardiography. The following were compared in 22 patients younger and 20 older than 70 years: left ventricular (LV) diameter, mass and ejection fraction, left atrial (LA) diameter and volume, LAA area and volume, LAA peak emptying (PE) and peak filling (PF) velocities, presence and severity of spontaneous echo contrast (SEC) and mitral regurgitation (MR).

Results: Left atrial diameter (4.6 ± 0.1 vs. 4.5 ± 0.2 cm), LA volume (105 ± 10 vs. 92 ± 8 ml), LAA area (6.8 ± 0.6 vs. 5.2 ± 0.8 cm), and LAA volume (5.6 ± 0.9 vs. 3.9 ± 1.0 ml) were similar (p>0.05) in both groups. Older patients had lower LAA PE (26 ± 2 vs. 34 ± 3 cm/s, p = 0.02) and PF (32 ± 2 vs. 41 ± 4 cm/s, p = 0.04) velocities, lower LV mass (175 ± 13 vs. 234 ± 21 gm, p = 0.02), higher relative wall thickness (0.52 ± 0.02 vs. 0.43 ± 0.03, p = 0.02), smaller LV diastolic diameter (4.3 ± 0.1 vs. 5.2 ± 0.2 cm, p <0.001), and higher LV ejection fraction (62 ± 2 vs. 55 ± 2%, p = 0.025). Frequency and severity of SEC and MR were similar in both groups. Multivariate analysis identified older age as the only significant predictor of reduced LAA velocities.

Conclusion: Compared with younger patients, older patients with NVAF have lower LAA velocities despite higher LV ejection fraction, smaller LV size, and similar LA and LAA volumes. These findings may explain the higher thromboembolic rates in older patients with NVAF.
Combination treatment with telmisartan and hydrochlorothiazide in black patients with mild to moderate hypertension
Authors: Mcgill Janet B. , Reilly Paul A.
Published: February 2009

Background: Hydrochlorothiazide (HCTZ) is commonly used to treat black patients with hypertension. To avoid the metabolic disturbances associated with high‐dose HCTZ, blood pressure control may be achieved by combining low doses with another antihypertensive.

Hypothesis: The study was undertaken to assess the tolerability and antihypertensive dose‐response efficacy of telmisartan and HCTZ and their combination in black patients with mild to moderate hypertension (mean supine blood pressure 140/95‐200/114 mmHg).

Methods: Following a 4–week, single‐blind, placebo run‐in period, 222 black patients were randomized to once‐daily treatment with one of 20 different double‐blind combinations of telmisartan (0, 20, 40, 80, 160 mg) and HCTZ (0, 6.25, 12.5, 25 mg) for 8 weeks. Blood pressure was measured at baseline and after 2, 4, and 8 weeks.

Results: Telmisartan 80 mg/HCTZ 12.5 mg reduced supine trough diastolic blood pressure (DBP)—primary efficacy parameter—by 13.3 mmHg, and supine trough systolic blood pressure (SBP) by 21.5 mmHg. These reductions represented benefits of 13.7/8.7 mmHg over telmisartan 80 mg and 12.3/8.1 mmHg over HCTZ 12.5 mg(p<0.01). Telmisartan 40 mg/HCTZ 12.5 mg reduced supine trough SBP/DBP by 14.3/10.0 mmHg, amounting to 12.3/3.3 mmHg more than telmisartan 40 mg and 5.1/4.8 mmHg more than HCTZ 12.5 mg, This reached significance for the comparisons with telmisartan 40 mg for SBP and HCTZ 12.5 mg for DBP (p≤0.05). A response surface analysis and therapeutic response rates confirmed the additive antihypertensive effects of telmisartan and HCTZ. All treatments were well tolerated, with side‐effect profiles comparable with placebo. Adverse events were mainly transient and of mild to moderate severity.

Conclusions: Telmisartan 80 mg combined with HCTZ 12.5 mg is effective and well tolerated in black patients with mild to moderate hypertension, providing greater antihypertensive activity than the corresponding monotherapies.
Homocysteine: A new cardiac risk factor?
Authors: Chai Andrew U. , Abrams Jonathan
Published: February 2009

Elevated plasma homocysteine levels have recently been implicated as a new risk factor for coronary artery disease. In this Article, homocysteine metabolism, secondary causes of elevated plasma homocysteine, and the potential mechanism of vascular damage in hyperhomocysteinemia are briefly reviewed. The current clinical evidence implicating hyperhomocysteinemia as a risk factor for coronary artery disease, as well as the data regarding the effects of B vitamin supplementation on homocysteine concentrations, are also reviewed. The current recommendation of the authors is to treat patients with known coronary artery disease or those who are considered to be at high risk for coronary artery disease with 400 μg of folate supplementation. Until prospective clinical trial data become available, this approach appears to be a safe and effective way to approach this patient population.
Single left coronary artery with origin of the right coronary artery from distal circumflex
Authors: Shammas Ronny L. , Miller Michael J. , Babb Joseph D.
Published: February 2009

We report two very unusual cases of agenesis of the right coronary ostium with continuation of the left circumflex artery as the right coronary artery. The recognition of the anomaly in the first case lead to a better understanding of this finding in the second case, which translated into shorter procedure time, less contrast volume, and fewer catheter manipulations.
Angiotensin receptor blockers: Evidence for preserving target organs
Authors: Carson Peter , Giles Thomas , Higginbotham Michael , Hollenberg Norman , Kannel William , Siragy Helmy M.
Published: February 2009

Hypertension is a major problem throughout the developed world. Although current antihypertensive treatment regimens reduce morbidity and mortality, patients are often noncompliant, and medications may not completely normalize blood pressure. As a result, current therapy frequently does not prevent or reverse the cardiovascular remodeling that often occurs when blood pressure is chronically elevated. Blockade of the renin‐angiotensin system (RAS) is effective in controlling hypertension and treating congestive heart failure. Both angiotensin‐converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) inhibit the activity of the RAS, but these two classes of antihypertensive medications have different mechanisms of action and different pharmacologic profiles. Angiotensin‐converting enzyme inhibitors block a single pathway in the production of angiotensin II (Ang II). In addition, angiotensin I is not the only substrate for ACE. The ACE inhibitors also block the degradation of bradykinin that may have potential benefits in cardiovascular disease. Bradykinin is, however, the presumed cause of cough associated with ACE inhibitor therapy. Data from clinical trials on ACE inhibitors serve to support the involvement of the RAS in the development of cardiovascular disease. Angiotensin receptor blockers act distally in the RAS to block the Ang II type 1 (AT1) receptor selectively. Thus, ARBs are more specific agents and avoid many side effects. Experimental and clinical trials have documented the efficacy of ARBs in preserving target‐organ function and reversing cardiovascular remodeling. In some instances, maximal benefit may be obtained with Ang II blockade using both ARBs and ACE inhibitors. This review describes clinical trials that document the efficacy of ARBs in protecting the myocardium, blood vessels, and renal vasculature.
Clinical characteristics of patients with increased urinary excretion of adrenaline in mild to moderate heart failure
Authors: Grochowicz Urszula , Wolk Robert , Bednarz Bronislaw , Budaj Andrzej , Ceremuzynski Leszek
Published: February 2009

Background: We have previously demonstrated that adrenaline (AD) is released into the circulation during acute myocardial infarction and is associated with a more severe clinical course. The role of elevated AD levels in congestive heart failure is not known.

Hypothesis: The study aimed to determine whether increased daily AD excretion is associated with more severe clinical symptoms and a more complicated clinical course in patients with exacerbation of congestive heart failure (CHF).

Methods: Urinary excretion of AD, noradrenaline, magnesium (Mg), and potassium (K), serum levels of aldosterone, K, and Mg, as well as the incidence of arrhythmias (24‐h Holter) were assessed in 49 patients with CHF New York Heart Association (NYHA) class II‐III. The patients were allocated to two groups, with normal (Group 1) and increased (Group 2) excretion of AD.

Results: Groups 1 and 2 did not differ in respect of age, etiology of CHF, or the medication used. Also, left ventricular ejection fraction was similar in the two groups. However, left ventricular end‐diastolic dimension was greater in Group 2 (61 ± 9 vs. 55 ± 11 mm, p < 0.05), as was the proportion of patients in NYHA class III (74 vs. 40%). Group 2 was also characterized by increased urinary excretion of Mg (60 ± 24 vs. 43 ± 16 mg/24 h, p < 0.007) and the presence of more complex and numerous ventricular arrhythmias (74 vs. 37% and 68 vs. 33% of patients, respectively).

Conclusions: Urinary excretion of AD is increased only in a subgroup of patients with CHF. These patients are characterized by a more advanced NYHA class, increased end‐diastolic left ventricular diameter, and increased urinary excretion of magnesium. It is likely that all these factors contribute to the presence of more complex and numerous ventricular arrhythmias in this subgroup of patients.
factors predicting success rate and recurrence of atrial fibrillation after first electrical cardioversion in patients with persistent atrial fibrillation
Authors: Frick Mats , Frykman Viveka , Jensen‐Urstad Mats , Östergren Jan
Published: February 2009

Background: The recurrence rate of atrial fibrillation (AF) after elective cardioversion is high.

Hypothesis: The study aimed to identify clinical predictors for successful electrical cardioversion and maintenance of sinus rhythm after a first electrical cardioversion in patients with persistent AF without concomitant antiarrhythmic drugs of class I and III.

Methods: Consecutive outpatients (n = 166) with persistent AF for > 1 month, scheduled for elective cardioversion, were prospectively included in the study. A clinical investigation, echocardiographic assay, and Holter electrocardiogram (ECG) before and ECG 4 weeks after cardioversion, were performed in all patients.

Results: The mean age of the patients was 68 years (range 45–83) and duration of AF was 5 (1–48) months. Sinus rhythm was established in 124 (75%) patients. In multivariate analysis, only duration of AF < 6 months (p < 0.04, odds ratio [OR] 2.2, 95% confidence interval [CI] 1.1 to 4.7) and patients weight (p < 0.03, OR 2.3, 95% CI 1.1 to 4.8 for weight < 80 kg) were identified as independent predictors of successful cardioversion. At 4 weeks after cardioversion, only 46 (37%) of 124 patients maintained sinus rhythm. Independent factors for maintenance of sinus rhythm, in multivariate analysis, were AF < 3 months (p < 0.04, OR 2.5, 95% CI 1.1 to 5.6), treatment with beta blockers (p < 0.00001, OR 7.0, 95% CI 3.0 to 16.3) or verapamil/diltiazem (p < 0.04, OR 3.6, 95% CI 1.0 to 12.1), and right atrial dimension < 37 mm (p < 0.02, OR 5.9, 95% CI 1.4 to 25.4).

Conclusions: In patients with persistent AF, the patient's weight and the duration of AF are independent predictors for a successful cardioversion. Short duration of AF, treatment with beta blockers or verapamil/diltiazem, and right atrial area/dimension are independent predictors for maintenance of sinus rhythm.
Magnetic resonance imaging of old myocardial infarction in young patients with a history of Kawasaki disease
Authors: Fujiwara Motoki , Yamada Naoaki , Ono Yasuo , Yoshibayashi Muneo , Kamiya Tetsuro , Furukawa Susumu
Published: February 2009

Background: On magnetic resonance imaging (MRI) using gadolinium diethylenetriamine pentaacetic acid (Gd‐DTPA) as contrast medium, images of infarct regions are enhanced in acute myocardial infarction (AMI). In old myocardial infarction (OMI), thinning of the myocardial walls is present, but images are no longer enhanced by Gd‐DTPA. On the other hand, MI in children with a history of Kawasaki disease (KD), several differences from adult MI are observed.

Hypothesis: The aim of this study was to evaluate the lesions that result from OMI in children with a history of KD using MRI with Gd‐DTPA as a contrast medium.

Methods: The subjects were 16 young patients with a history of KD who were diagnosed as having OMI. Of these, both thinning of the myocardial wall and MRI enhancement by Gd‐DTPA were observed in 4 cases, thinning alone was observed in 6 cases, Gd‐DTPA image enhancement alone was observed in 3 cases, and neither thinning nor Gd‐DTPA image enhancement was observed in 3 cases.

Results: The Gd‐DTPA‐image‐enhanced, OMI‐induced lesions observed in patients with KD were different from those observed in adults; this might be attributable to histologic differences.

Conclusion: Magnetic resonance imaging using Gd‐DTPA can evaluate myocardial thinning and presence of circulation noninvasively at the same time and is considered to be useful for long‐term follow up of the patients with KD and OMI.
Assessment of coronary morphology and flow in a patient with guillain‐barré syndrome and st‐segment elevation
Authors: Dagres Nikolaos , Haude Michael , Baumgart Dietrich , Sack Stefan , Erbel Raimund
Published: February 2009

Patients with Guillain‐Barré syndrome often have cardiac disturbances as a manifestation of autonomic dysfunction. Such abnormalities consist of arrhythmias and disturbances of heart rate and blood pressure. We report a case of a patient with Guillain‐Barré syndrome who developed ST‐segment elevation in the inferolateral leads, suggestive of an acute coronary syndrome. Cardiac catheterization revealed angiographically normal coronary arteries. Intracoronary ultrasound was also normal. Intracoronary Doppler flow measurements revealed an elevated baseline coronary flow velocity of up to 41 cm/s and decreased coronary flow reserve, particularly in the left circumflex artery. Myopericarditis as cause of the electrocardiographic changes could be ruled out by echocardiography and endomyocardial biopsy. We postulate that the intracoronary Doppler findings are caused by autonomic dysfunction with decrease of coronary resistance and redistribution of the transmural myocardial blood flow.
Diagnostic superiority of continuous‐loop electrocardiographic recording over other testing in a patient with recurrent syncope and underlying coronary artery disease with severe left ventricular dysfunction
Authors: Chiladakis John A. , Davlouros Periklis , Simeonidou Eftihia , Manolis Antonis S.
Published: February 2009

Dysrhythmic causes of syncope may elude diagnosis in postinfarction patients despite elaborate testing, including electrophysiologic study. For a correct diagnosis, capture of cardiac rhythm during patient's typical symptoms is crucial. This report describes a patient with coronary artery disease and decreased left ventricular ejection fraction who experienced recurrent syncopal episodes without obvious precipitating factors. The 12‐lead electrocardiogram showed left bundle‐branch block indicating a possible conduction abnormality as the underlying cause of syncope. Twenty‐four‐h Holter monitoring exhibited no sinus rhythm or conduction disturbances but revealed a nonsustained run of ventricular tachycardia. Findings at electrophysiologic testing led to a presumptive diagnosis of tachyarrhythmic cause of syncope; however, the correct diagnosis was only made with use of a loop monitor which documented a 15‐s sinus pause during a syncopal episode.
Women with high exercise tolerance and the role of myocardial perfusion imaging
Authors: Chatziioannou Sofia N. , Moore Warren H. , Dhekne Ramesh D. , Ford Patrick V.
Published: February 2009

Background: Myocardial perfusion imaging (MPI) provides incremental diagnostic and prognostic information, even in patients with high exercise tolerance.

Hypothesis: Myocardial perfusion imaging provides significant diagnostic value, specifically in women with high exercise tolerance.

Methods: Our study population consisted of all women who underwent exercise MPI in our Department from January 1992 to June 1996 and reached at least Stage IV in the Bruce protocol. Patients were divided into those with known and those with possible coronary artery disease (CAD). All patients were followed for 3 years from the performance of MPI.

Results: Of 4,803 women who underwent myocardial perfusion imaging, 3,183 had exercise stressing, and of those, 311 reached at least Stage IV in the Bruce protocol. Of these 311 MPI scans, only 23 (7.4%) were abnormal (reversible, fixed, or mixed) and the remaining 288 (92.6%) were normal. Of the 82 patients with known CAD, 13 (15.8%) had an abnormal MPI, while only 10 (4.4%) of the 229 patients with possible CAD. No myocardial infarction or cardiac death occurred within 3 years; one patient with normal MPI needed revascularization.

Conclusion: in women with high exercise tolerance, especially in those without already known CAD, the yield of MPI is very low. Women with high exercise tolerance have an excellent prognosis.