bluuebunny/crossref_metadata_2025 huggingface dataset:
Analyses of cost effectiveness in the management of essential hypertension: What they can and what they do not teach us
Authors: Massie Barry M.
Published: February 2009

There are approximately 50 million hypertensive individuals in the United States, and their treatment is often life‐long. Most are asymptomatic, so the goal of treatment is to prevent complications, which often occur decades after the condition is detected. Although the management of hypertension is potentially very costly, it is now clear that antihyperten‐sive therapy can substantially reduce cardiovascular mortality and morbidity. This constellation of an asymptomatic process with a very high prevalence capable of producing severe and potentially costly complications is precisely the circumstance under which cost effectiveness of therapy becomes an important consideration. Several such analyses have been performed, examining the question of which patients should be treated, what procedures should be used in their evaluation, and which therapeutic agents should be used. These studies highlight important issues, but also illustrate the potential pitfalls and fallacies of such analyses, particularly when outcome data are unavailable or inadequate. This article reviews the literature concerning cost‐effectiveness analyses in the management of hypertension and discusses the value of this approach.
Coronary artery and saphenous vein graft remodeling: A review of histologic findings after various interventional procedures—Part II
Authors: Waller Bruce F. , Orr Charles M. , Vantassel James , Peters Thomas , Fry Edward , Hermiller James , Grider Larry D.
Published: February 2009

Catheter balloon angioplasty is a well accepted form of nonsurgical treatment of acutely and chronically obstructed coronary artery vessels. It is also the centerpiece for various new intervention techniques. Their morphologic effects on the site of obstruction has been termed “remodeling.” Part II of this six‐part series focuses on morphologic causes of acute closure after remodeling and discusses findings late after successful balloon angioplasty remodeling.
Cardiac aspergillosis presenting as myocardial infarction
Authors: Cishek Mary Beth , Schaefer Saul , Yost Barbara
Published: February 2009

Immunosuppression can allow organisms which are not usually pathogenetic to cause disease. Invasive fungal disease is becoming increasingly prevalent because of the growing numbers of patients who are immunosuppressed. Aspergillus species frequently form large masses of fungal elements, thrombin, and fibrin, within the vasculature. These masses can then embolize, leading to organ infarction. Reported herein is a case of aspergillosis invading the myocardium and causing widespread necrosis and infarction. Although the epicardial coronary arteries were free of disease, the patient ultimately died in cardiogenic shock.
Abrupt (<1 day), acute (<1 week), and early (<1 month) vessel closure at the angioplasty site. Morphologic observations and causes of closure in 130 necropsy patients undergoing coronary angioplasty
Authors: Waller Bruce F. , Fry Edward T.A. , Peters Thomas F. , Hermiller James B. , Orr Charles M. , Vantassel James , Pinkerton Cass A.
Published: February 2009

While abundant clinical and angiographic data are available regarding features of acute or abrupt closure at the site of balloon angioplasty, little morphologic information is available. This study discusses morphologic‐histologic causes for acute closure after angioplasty in 130 necropsy patients. Intimal‐medial flaps, elastic recoil, and primary thrombosis were the three leading morphologic causes for closure. Data were subdivided into time categories: abrupt (<1 day), acute (<1 week), and early (<1 month). Intimal‐medial flaps remained the most common cause for angioplasty closure despite time from angioplasty to documented occlusion. Morphologic recognition of types and frequencies of angioplasty closure are discussed, and specific mechanical, phar‐macologic, or combined treatments are reviewed.
Transcatheter closure of the patent ductus arteriosus in adults using the gianturco coil
Authors: Ing Frank F. , Muluns Charles E. , Rose Marion , Shapir Yehuda , Bierman Fredrick Z.
Published: February 2009

Background and hypothesis: Although results of surgical ligation of the patent ductus arteriosus (PDA) in the pediatric age group are excellent, surgical management of the adult with a PDA may be more problematic. The PDA that presents in adulthood may be calcified and friable, rendering simple ligation via a thoracotomy difficult, inadequate, and hazardous. Patch closure of the ductus arteriosus from either the aortic or pulmonary artery orifice using cardiopulmonary bypass or transient aortic cross‐clamping is necessary but increases surgical risks. Furthermore, older patients with diseases unrelated to their PDA and patients with Down's syndrome may have higher risks with intubation, general anesthesia, and surgery. Early results of percutaneous transcatheter occlusion of the PDA with Gianturco coils performed under sedation and local anesthesia are promising.

Methods: Six adults with mean age of 39.1 years (range 23.1–62.0 years) were found to have an isolated PDA with mean minimum diameter of 2.7 mm (range 1.0–5.0 mm) at cardiac catheterization. All underwent percutaneous transcatheter occulsion of the PDA using Gianturco coils.

Results: Coil implantation was successful in all patients. There were no complications and all were discharged home within 24 hours. Complete ductal occlusion was seen immediately in 4 of 6 patients (67%) while 2 of 6 (33%) had small residual leaks. However, complete occlusion was achieved in all patients by 6 months following the procedure.

Conclusion: Transcatheter occlusion of the PDA using coils is safe and efficacious in adults.
The medial precordial leads: Overburdened and underinvestigated
Authors: Spodick David H. , Bishop Richard L.
Published: February 2009

Leads V1, V2, and sometimes V3 are omnibus leads that are “overburdened” because they monitor the left ventricular anterior wall, the left ventricular posterior wall, and the right ventricle because they are the only leads normally expressing the ventricular gradient (QRS —T discordance);and because they consequently reflect numerous anatomic and electrical abnormalities and apparently normal variants. These require familiarity with and differentiation among a variety of pathologic and normal conditions.
Coronary artery and saphenous vein graft remodeling: A review of histologic findings after various interventional procedures‐Part III
Authors: Waller Bruce F. , Orr Charles M. , Vantassel James , Peters Thomas , Fry Edward , Hermiller James , Grider Larry D.
Published: February 2009

Catheter balloon angioplasty is a well accepted form of nonsurgical treatment of acutely and chronically obstructed coronary artery vessels. It is also the centerpiece for various new intervention techniques. Their morphologic effects on the site of obstruction has been termed “remodeling.” Part III of this six‐part series focuses on intimal proliferation and chronic recoil in patients undergoing previous remodeling techniques by balloon angioplasty.
Atheroembolic disease following administration of tissue plasminogen activator (TPA)
Authors: Aggarwal Kul , Tjahja Imam E.
Published: February 2009

Atheroembolic disease is an uncommon condition with many interesting manifestations and has been reported following various procedures. Its occurrence following thrombolytic therapy is extremely rare, with only a few case reports in the literature. However, with the widespread application of thrombolysis in patients with acute myocardial infarction, its incidence is likely to increase and therefore this entity needs to be recognized. Early recognition of the illness may help avoid further expensive and unnecessary investigations. We report two cases of atheroembolic disease following the administration of human recombinant tissue plasminogen activator (TPA).
Uniquely abnormal intracavitary row during late systole and relaxation in hypertrophic obstructive cardiomyopathy with midventricular obstruction
Authors: Yamanari Hiroshi , Morita Hiroshi , Mouta Satoshi , Sakuragi Satoru , Ohe Tohru
Published: February 2009

We describe a patient with hypertrophic cardiomyopathy who had a uniquely abnormal jet from the base to the apex during late systole and the relaxation period. This 48‐year‐old woman was admitted with exertional dyspnea and palpitations. Two‐dimensional echocardiography revealed asymmetric septal hypertrophy and a left midventricular obstruction at the level of the papillary muscles. A high‐ velocity ejectional jet (peak velocity 4.8 m/s) directed toward the base during systole and an abnormal jet (peak velocity 2.2 m/s) directed toward the apex during late systole and the relaxation period were demonstrated through the midventricular obstruction site using Doppler echocardiography. The peak systolic pressure gradient between the apical and the basal chamber was 91 mmHg, and the peak systolic pressure was higher in the apical chamber than in the basal chamber. However, a reverse pressure gradient was revealed between the two chambers during late systole and the relaxation period when the abnormal jet was demonstrated.
Correlative studies of heart rate and heart rate variability indices from five consecutive ambulatory electrocardiogram recordings in patients with coronary artery disease
Authors: Madias John E. , Wijetilaka Rohan , Erteza Sayed , Easow Mathai , Mahjoub Mazen , Khan Mujtaba , Sbahi Subhi , Gujral Interpal , Manyam Bose
Published: February 2009

Background: Reproducibility of heart rate (HR) and heart rate variability (HRV) indices from ambulatory electrocardiograms (AECGs) is a prerequisite for their use as predictors or monitors of disease progression, or response to therapeutic interventions.

Hypothesis: This study sought to determine the stability over time of HR and HRV indices in patients with coronary artery disease.

Methods: Five AECGs, recorded at 1‐week intervals in 21 clinically stable patients, were used to calculate minimum, average, and maximum HR, and three commonly used HRV indices in data samples of 15,30,60,120, daytime and nighttime intervals (complete data were available on 17 patients).

Results: All parameters studied were stable over time (p = NS). Diurnal variation was found only for the average and maximum HR, with values being higher for daytime than for nighttime. Intercorrelations of the HR and HRV indices were poor and varied among the five AECGs, suggesting that these parameters reflect different aspects of HRV. The HR and HRV variables calculated from short‐time intervals correlated poorly with the corresponding information from 24‐h recordings, and such relationships varied among the five AECGs.

Conclusions: Thus, HR and HRV indices from five consecutive AECGs recorded at 1‐Week intervals are reproducible. The poor intercorrelations between pairs of the studied indices suggest that none of these parameters can be used as surrogate of the others. Finally, the poor performance of HR and HRV indices, deriving from short‐time intervals, indicate that they cannot be employed in lieu of parameters calculated from 24‐h AECGs.
Atrial flutter with 1: 1 conduction after administration of the antimalarial drug mefloquine
Authors: Fonteyne Winoc , Bauwens Anja , Jordaens Luc
Published: February 2009

Antimalarial drugs are well known for their cardiovascular toxicity. Quinine, the most famous antimalarial agent, mostly causes bradycardia. Quinidine, its dextrorotatory isomer, may cause 1: 1 atrioventricular (AV) conduction during atrial flutter. The newly developed drug mefloquine was reported to have fewer cardiac side effects. We describe a 63‐year‐old male patient with atrial flutter in whom mefloquine use was associated with 1: 1 AV conduction, and who then responded to therapy with digoxin and sotalol. The patient had a history of palpitations. This case report emphasizes that mefloquine should be used with caution in patients with a history of palpitations or underlying heart disease.
Angiotensin‐II receptors: new targets for antihypertensive therapy
Authors: Oliverio Michael I. , Coffman Thomas M.
Published: February 2009

The renin–angiotensin system regulates blood pressure and sodium homeostasis through a series of coordinated substrate–enzyme interactions. These interactions result in the production of angiotensin II (AII), which exerts a number of diverse biologic effects mediated through AII cell‐surface receptors. Dysregulation of this system is implicated in the pathogenesis of various forms of hypertension. Traditional therapy for hypertension has included angiotensin‐converting enzyme inhibitors, which block the production of AII. However, a new class of drugs, AT1‐receptor blockers, now offers a number of benefits by specifically blocking the effects of AII at its physiologically relevant receptor.
Variability in the measurement of intracoronary ultrasound images: implicatioNs for the identification of atherosclerotic plaque regression
Authors: Foster Gary P. , Mittleman Murray A. , Koch Michael , Abela George , Zarich Stuart W.
Published: February 2009

Background and hypothesis: Serial coronary angiography cannot reliably detect the small changes in arterial dimensions. Measurement of arterial dimensions by intracoronary ultrasound (ICUS) may be a superior method to determine the extent of atherosclerotic burden since it directly images the diseased portion of the vessel.

Methods: To quantify inter‐ and intraobserver variability of ICUS measurements, 27 images of atherosclerotic coronary lesions were measured by two study physicians and repeated 14 days later.

Results: Interobserver correlation coefficients for external elastic lamina, lumen, and effective plaque area were 0.96, 0.99, and 0.91, respectively. Intraobserver correlation coefficients for external elastic lamina, lumen, and effective plaque area were 0.99, 0.99, and 0.97, respectively. To determine progression or regression in effective plaque area, a minimal difference of 2.77 mm2 (which represents a 23% change in plaque area) is needed.

Conclusions: Direct visualization of the extent of atherosclerosis by ICUS can be accomplished with a low degree of inter‐ and intraobserver variability. ICUS may be a preferable alternative to angiography in atherosclerosis regression trials.
Early predictors of late dilation and remodeling after thrombolized anterior transmural myocardial infarction
Authors: Modena Maria Grazia , Rossi Rosario , Sgura Fabio Alfredo , Muia Nicola , Molinari Rosella , Mattioli Giorgio
Published: February 2009

Background and hypothesis: Dilation of the left ventricle after myocardial infarction is associated with an adverse prognosis. There are no clinical studies on the role viable myocardium in the infarcted area assumes in relation to the development of late ventricular remodeling. The hypothesis of this study was to define the relation between remodeling and the presence of viable but akinetic myocardium in the infarct area and to identify early predictors of left ventricular (LV) dilation at 1 year.

Methods: In all, 92 consecutive patients with myocardial infarction were divided into two groups according to their ventricular volumes. Group I included 57 patients with normal volumes at discharge (9 ± 3 days after acute infarction) and after 12 months or with LV dilation at discharge who had a normalization of their volumes over a 12‐month period. Group II included 35 patients who, independent of their initial volumes, developed LV dilation during follow‐up. Low‐dose dobutamine infusion was utilized at discharge for echocardiographic evaluation of contractile recovery of viable myocardial segments.

Results: At the first control, patients in Group I presented an end‐diastolic volume index (EDVI) of 100 ± 7 ml/m2 which decreased to 68.8 ± 6.5 ml/m2 12 months later (p < 0.0001), and an end‐systolic volume index (ESVI) of 47.6 ± 6.7 ml/m2 at the first control and 30.5 ± 8.8 ml/m2 after 12 months (p< 0.001). Patients in Group II presented a mean EDVI of 116.2 ± 8.1 ml/m2 at the first control and 138.8 ± 8 ml/m2 12 months later (p < 0.001), and a mean ESVI of 68.8 ± 6.5 ml/m2 at the first control and 79.5 ± 5.4 after 12 months (p < 0.01). Ventricular mass index (VMI) in Group I increased from 106.4 ± 11 to 122.3 ± 15 g/m2 (p<0.01), while in Group II it decreased from 101.1 ± 10 to 98.7 ± 8 g/m2 (p = NS). In Group I, mass‐to‐volume ratio was 1.15 ± 0.1 g/ml at the first control and 1.67 ± 0.1 12 g/ml 12 months later (p < 0.001), while in Group II it declined from 0.88 ± 0.1 to 0.69 ± 0.1 g/ml (p<0.01). The multivariate analysis revealed that ejection fraction ≤ 40%, restrictive filling pattern, wall motion score index >2.5 in response to dobutamine infusion, and mass‐to‐volume ratio ≤ 1 g/ml, all at discharge, as well as an occluded left anterior descending artery discriminate in favor of late LV dilation and remodeling.

Conclusions: Correct use of noninvasive strategies should result in early identification of postinfarct patients who are at risk of developing LV remodeling.
Retrograde atrial kick in acute aortic regurgitation. study of mitral and pulmonary venous flow velocities by transthoracic and transesophageal echocardiography
Authors: Vilacosta Isidre , Castillo Juan Antonio , Arganda Lourdes , Rollán María Jesús , Peral Vicente , Sánchez‐Harguindey Luis , Román José Alberto San , Zarco Pedro
Published: February 2009

Background and hypothesis: The purpose of this study was the comprehensive evaluation of the changes in pulmonary venous and mitral flow velocities of patients with acute and chronic severe aortic regurgitation. Transmitral flow velocities obtained with pulsed‐wave Doppler echocardiography have been used to provide information on left ventricular (LV) filling and diastolic function. Pulmonary venous flow tracings are an important adjunct to LV inflow pattern in assessing LV diastolic function.

Methods: Fourteen patients with severe aortic regurgitation (8 chronic and 6 acute) and in sinus rhythm were examined by transthoracic and transesophageal pulsed Doppler echocardiography. Mitral and pulmonary flow velocities were recorded and compared. All patients had ejection fractions > 40%.

Results: Early mitral flow peak velocity was higher in patients with acute regurgitation (p<0.001). The mitral A wave was absent in five patients with acute regurgitation. In contrast, a prominent reverse atrial pulmonary systolic wave AR was demonstrated in these patients. Peak diastolic velocity of the pulmonary venous flow was greater in patients with acute aortic regurgitation (0.76 ± 0.13) than in patients with chronic aortic regurgitation (0.40 ± 0.09) (p<0.001). Peak systolic velocity did not differ significantly between the two groups. The systolic fraction of pulmonary venous flow in patients with acute aortic regurgitation was lower (0.43 ± 0.05) than that of patients with chronic regurgitation (0.63 ± 0.1) (p<0.01). All patients with acute aortic regurgitation had an S/D ratio < 1, while those with chronic regurgitation had an S/D >1 (p< 0.001) and an E/A<1.

Conclusion: Patients with severe acute aortic regurgitation showed a retrograde atrial kick (absence of transmitral A wave with prominent pulmonary AR wave). These patients had an S/D ratio < 1 (restrictive Doppler pattern). Patients with chronic aortic regurgitation exhibited a Doppler pattern of abnormal LV relaxation (E/A <1, S/D > 1).
High‐rate cardiac pacing increases blood pressure and decreases right atrial pressure in patients with hemodynamic significant acute right ventricular myocardial infarction and bradyarrhythmia
Authors: Vrouchos G. T. , Kiulpalis A. , Trullakis G. A. , Stasinos P. G. , Ellinkakis S. G. , Koumatzias N. C. , Chatzakis G. K.
Published: February 2009

Background: In an 84‐year‐old patient with acute right ventricular myocardial infarction (RVI), complete heart block, and low cardiac output, a significant increase in blood pressure (BP) and decrease in right atrial pressure (RAP) were accidentally observed during the performance of high‐rate ventricular pacing.

Methods: Based on that observation, the acute effects of high‐rate cardiac pacing (VVI or AAI) on BP and RAP were studied in 15 consecutive patients (67.4 ± 7.7 years), with hemodynamically significant RVI. Ten had advanced heart block and five had sinus bradycardia. Cardiac pacing with simultaneous recording of BP and RAP at intrinsic rhythm and at heart rates of 70,90,110,130 beats/min was performed.

Results: Systolic BP (SBP) increased significantly from 94.6 ± 15 mmHg during intrinsic rhythm to 101.9 ± 13.8 mmHg‐127 ± 12.2 mmHg at heart rates 70–130 beats/min (p<0.0001). Diastolic BP (DBP) also increased from 48.2 ± 8.7 to 53.9 ± 3.7–69.1 ± 3 mmHg at heart rates 70–130 beats/min, (p<0.014–0.0001). Mean RAP decreased from 14.5 ± 5 to 14.1 ± 5 mmHg‐11.1 ± 4.1 mmHg at heart rates 70–130 beats/min (p = 0.16–0.0001). Significant elevation of SBP (p<0.007), DBP (p<0.0075), and decrease of RAP (p<0.038) were also detected by comparing the usual pacing rate at 70 beats/min with pacing rates at 90–130 beats/min.

Conclusions: These findings, if demonstrated over a prolonged period during the acute state of RVI, may influence the management of patients with RVI to include high‐rate cardiac pacing, probably in the range of 80–110 beats/min.
Unmasking of fast and slow atrioventricular nodal pathways by successful radiofrequency ablation of two accessory atrioventricular connections
Authors: Centurión Osmar Antonio , Kaibara Muneshige , Isomoto Shojiro , Konoe Atsushi , Yano Katsusuke
Published: February 2009

Electrophysiologic findings suggesting the coexistence of dual atrioventricular (AV) nodal pathways and accessory AV connections have been previously described. Anterograde conduction through the accessory pathway (AP) may preclude the diagnosis of AV nodal dual pathway physiology during atrial stimulation. This study reports on a patient with manifest Wolff‐Parkinson‐White syndrome with clinically documented paroxysmal atrial fibrillation, in whom dual AV nodal pathways were unmasked after successful radiofrequency ablation of two accessory AV connections. In spite of detailed investigation, fast and slow AV nodal pathways were not detected in the first electrophysiologic study 8 years before ablation, nor were they detected during preablation study because of exclusive anomalous anterograde conduction. The anterograde AP effective refractory period was shorter than that of the fast and slow AV nodal pathways, and was limited by atrial refractoriness at 190 ms. The present findings strongly suggest the necessity for a careful postablation electrophysiologic study before and after isoproterenol administration with specific evaluation of AV nodal conduction. This is the first documented report on the finding of AV nodal dual pathway physiology and reentry after successful radiofrequency ablation of two APs. This finding may be of great therapeutic significance in light of the feasibility of slow pathway ablation also during a single session, had AV nodal reentry been induced in a sustained manner after ablation of the AP to prevent late recurrence of tachycardia.
Paracardiac masses caused by a right coronary artery aneurysm and a saphenous vein graft aneurysm
Authors: Chalasani Prasad , Konlian Donna , Clements Stephen
Published: February 2009

Two unusual cases of large aneurysms, one located in the native right coronary artery and the other in a saphenous vein graft, are reported. Their size and mode of presentation as asymptomatic paracardiac masses on chest x‐ray films make them unique. It is proposed that these entities be considered as part of the differential diagnosis of paracardiac masses.
Unsuspected vasculitis and intracranial hemorrhage following thrombolysis
Authors: Srinivasan Gopalakrishnan , Boschman Cynthia , Roth Sanford I. , Hendel Robert C.
Published: February 2009

Treatment with thrombolytic agents such as streptokinase or tissue plasminogen activator (TPA) is an accepted standard for the treatment of patients with acute myocardial infarction (MI)1–2 A devastating sequel of thrombolytic therapy may be the development of a hemorrhagic complication, particularly intracranial bleeding, which, although rare, is usually associated with significant neurologic sequelae or death.1–2 While various risk factors have been correlated with the development of intracranial hemorrhage following thrombolysis, a possible relationship between bleeding and a clinically unsuspected underlying vasculitis has not been previously reported. This report deals with the case of a 49‐year‐old man who died of multiple intracranial hemorrhages after thrombolytic therapy for acute MI and who was found at autopsy to have had polyarteritis nodosa of the coronary arteries and vasculitis of the meningeal vessels.
Surgery in patients with coronary artery disease—silent ischaemia during transurethral resection of tumors of prostate or bladder
Authors: Wacker Petra , Saborowski Friedhelm , Assenmacher Martin , Dieterich Hans Armin
Published: February 2009

Background: Asymptomatic episodes of myocardial ischemia in clinically stable patients seem to occur frequently and may hint at a worse prognosis.

Hypothesis: This study was undertaken to determine whether surgical patients with coronary artery disease (CAD) have a higher risk of cardiac ischemia during the perioperative period compared with the late postoperative period and compared with patients without CAD.

Methods: In all, 14 patients with and 14 patients without CAD were examined by Holter monitoring during the perioperative and three days later during the postoperative periods for the presence of ST‐segment depression as a marker of silent myocardial ischemia.

Results: While patients without CAD did not show ST‐segment depression, patients with CAD were found to have had 143 episodes of ST‐segment depression, 49% in the perioperative and 51% in postoperative recordings.

Conclusion: Though patients were asymptomatic with antianginal therapy, there were episodes of ST‐segment depression indicating silent myocardial ischemia in patients with CAD. Surgical interventions such as transurethral resection of tumors of prostate or bladder did not produce an increase of ischemic burden registered by Holter monitoring.
Effect of antibiotic treatment on vegetation size and complication rate in infective endocarditis
Authors: Rohmann Sven , Erbel Raimund , Darius Harald , Makowski Thomas , Meyer JÜRgen
Published: February 2009

Background: Infective endocarditis is associated with significant morbidity and mortality, with valvular destruction, and with congestive heart failure. Embolic events are more common in patients with echocardiographically discernible vegetations, especially when vegetations are >10 mm in diameter.

Hypothesis: The objective of the study was to follow vegetation morphology during native valve endocarditis, to compare it with the clinical course and antibiotic treatment chosen, and to evaluate whether the impact on vegetation size and complication rate of antibiotic regimens differed in patients with positive and negative blood cultures.

Methods: The effect of different antibiotic regimes on vegetation size monitored by using transesophageal echocardiography was evaluated in 183 patients with echocardiographic evidence of infective endocarditis. A total of 223 vegetations attached to the aortic or mitral valves were detected using the transesophageal approach. The patients were followed for a mean of 76 weeks and underwent a minimum of two consecutive transesophageal echocardiographic examinations.

Results: Treatment with different kinds of antibiotics corresponded with significant differences in vegetation size; vancomycin‐associated treatment was related to a 45% reduction, ampicillin to a 19% reduction, penicillin to a 5% reduction, penicillase‐resistant drugs to a 15% increase, and cephalosporin to a 40% increase in vegetation size. Multivariate analysis showed that penicillin, cephalosporin, and penicillase‐resistant drug treatments were associated with an increased embolic risk, vancomycin treatment with abscess formation, and cephalosporin medication with increased mortality. Plotting changes in vegetation size against the incidence of embolism and mortality, linear regression analysis suggested a 40–50% reduction in vegetation size, thereby greatly reducing the risk of embolism and mortality.

Conclusion: Our study shows that different antibiotics have different effects on vegetation size. The highest complication rate was observed when vegetations significantly increased in size during antibiotic treatment. Especially in culture‐negati ve patients, monitoring vegetation size by means of transesophageal echocardiography may prove to be useful for estimating the efficacy of antibiotic treatment.
May age onset be relevant in the occurrence of left ventricular hypertrophy in Friedreich's ataxia?
Authors: Maione Stefania , Giunta Anna , Spinelli Letizia , Liucci Giovanni Antonio , Condorelli Mario , Filla Alessandro , De Michele Giuseppe , Campanella Giuseppe
Published: February 2009

Background: Although heart involvement has been widely reported in Friedreich's ataxia (FA), which is the most prevalent of the spino‐cerebellar degenerative diseases, the reason that cardiac abnormalities develop has not been yet established.

Hypothesis: The investigation was undertaken to study the prevalence and characteristics of cardiac abnormalities in patients with FA and to evaluate whether the presence of left ventricular hypertrophy could be predicted.

Methods: In all, 75 patients with FA and 16 patients with late onset FA (LOFA) disease were investigated for cardiac abnormalities using noninvasive methods.

Results: A significant (p< 0.01) difference in the age onset (9.8 ±3.9 years) was found in 31 of the 75 patients with FA (41%) who showed left ventricular hypertrophy (LVH) at echocardiographic examination compared with the remaining 44 patients with FA without LVH (12.6 ± 4.3 years). Moreover, none of the 16 patients with LOFA (age onset 26.5 ± 4.2 years) showed abnormalities at echocardiographic examination. A significant (p<0.01) concordance in the familial distribution of hypertrophy was also found.

Conclusion: These data suggest that the earlier the disease develops the more frequently LVH occurs.
Disparity between serotonin‐ and acetylcholine‐provoked coronary artery Spasm
Authors: Kanazawa Kenji , Suematsu Masakuni , Ishida Tatsuro , Hirata Ken‐Ichi , Kawashima Seinosuke , Akita Hozuka , Yokoyama Mitsuhiro
Published: February 2009

Background and hypothesis: Intrinsic vasoactive substances, such as serotonin and acetylcholine, are known to provoke coronary artery spasm in patients with vasospastic angina. It remains unclear, however, whether these different agents, which activate different receptors, produce spasms at the same sites in these patients. The present study was designed to clarify the disparity of receptor agonist‐induced coronary artery spasms in the same patients.

Methods: We conducted sequential provocative tests of coronary artery spasm by acetylcholine, serotonin, and ergonovine in 20 patients with rest angina examined with quantitative coronary angiography.

Results: Coronary artery spasms were provoked in all patients at 27 spastic sites. In 13 patients, ergonovine provoked spasms and in 10 of 13 patients who were diagnosed with variant angina, both acetylcholine and serotonin provoked spasms at the same sites where ergonovine also did. In 4 of 13 patients, spasms were provoked by serotonin but not by acetylcholine. In the remaining seven patients, whose spasms were induced by ergonovine, spasms were produced by acetylcholine but not by serotonin. On coronary angiography, the spastic sites for both acetylcholine and serotonin, and those for serotonin alone, were located in the proximal segments of coronary arteries, whereas the spastic sites for acetylcholine alone were located in the distal segments.

Conclusions: This study documented the disparity between serotonin‐ and acetylcholine‐induced spasms. Provocative tests using agents that activate different receptors may produce coronary artery spasms at the same and/or different sites, and this disparity may reflect the clinical heterogeneity of vasospastic ischemic syndrome.
Catheter ablation of ventricular tachycardia in chagasic cardiomyopathy
Authors: Rosas Fernando , Velasco Victor , Arboleda Felipe , Santos Hernando , Orjuela Hernando , Sandoval Nestor , Caicedo Victor , Correa Juan , Fontaine Guy
Published: February 2009

There is a limited experience with catheter ablation for treatment of ventricular tachycardia (VT) in Chagasic cardiomyopathy. A 30‐year‐old woman experienced episodes of palpitations and syncope due to attacks of VT. A diagnosis of Chagas disease was established on a biological basis. Two‐dimensional echo and contrast ventriculography showed an apical aneurysm with thrombus. Surgery was indicated to resect the aneurysm and ablate the VT. Ventricular tachycardia recurred 1 month later despite therapy, including amiodarone. Two clinical frequent and well‐tolerated tachycardias were identified. The site of origin was located in the right ventricular apex and in the apical‐lateral wall of the left ventricle, respectively. Catheter ablation was performed at two sites with DC shocks (total energy 600 J) after unsuccessful radiofrequency ablation. Holter recordings performed during the postoperative period showed only infrequent extrasystoles. After follow‐up of 24 months the patient remains asymptomatic. Drug‐refractory VT in Chagasic cardiomyopathy can be ablated by medium‐energy DC shocks after failure of radiofrequency ablation.
Echocardiographic diagnosis of papillary fibroelastoma of the mitral and tricuspid valve apparatus
Authors: Lund Gunnar K. , Koschyk Dietmar H. , Nienaber Christoph A. , öder SÖRen
Published: February 2009

Papillary fibroelastomas are rare and normally benign cardiac tumors typically attached to cardiac valves. This report describes two patients who were evaluated for intermittent dyspnea in one case and for the source of cerebral embolism in the other. In both patients transthoracic echocardiography revealed a pedunculated mobile mass adjacent to an atrioventricular valve, suggestive of papillary fibroelastoma. Postoperative histology was confirmatory of papillary fibroelastoma with a typical hyalinized hypocellular stroma covered by a single layer of endocardial cells.
Predictive value of dobutamine radionuclide ventriculography in detection of functional improvement after acute anterior wall infarction and thrombolytic therapy
Authors: Zafrir Nili , Bassevich Roni , Zlotikamien Bruria , Sulkes Jaqueline , Sclarovsky Shmuel , Lubin Ernesto
Published: February 2009

Background: Prolonged postischemic ventricular dysfunction (stunned myocardium) may prevent the assessment of myocardial salvage early after thrombolysis. Dobutamine in conjunction with radionuclide ventriculography has been proposed for the early assessment of myocardial viability and prediction of functional recovery.

Hypothesis: This study was designed to investigate the effects of low‐dose dobutamine infusion on early global and regional function of reperfused myocardium after acute anterior wall myocardial infarction (MI). In particular, our purpose was to examine whether this response can predict late recovery of left ventricular function and correlate with the reperfused status (patency of infarct‐related artery).

Methods: In all, 29 consecutive patients with first uncomplicated anterior wall MI, and who had received thrombolytic therapy, underwent radionuclide ventriculography at rest and 2 min after each dose increment of dobutamine infusion (5–15 m̈g/kg/min) on the third day after the infarction, at discharge, and at 3 months' follow‐up. Global and regional ejection fraction were calculated at each stage. Four patients with complications were dropped from the study. A significant response to dobutamine was defined as an increase of at least ≥7% in global or regional ejection fraction at the infarct zones.

Results: Of the 25 patients, 18 (72%) fulfilled these criteria. Of these, 10 patients (56%) had a significant improvement in global or regional ejection fraction at discharge and 13 patients (72%) at 3‐month follow‐up. The overall sensitivity of the dobutamine test in predicting left ventricular improvement was 100% at discharge and 93% at 3‐month follow‐up. However, the positive and negative predictive values were 56 and 100% at discharge and 72 and 86%, respectively, at 3‐month follow‐up.

Conclusion: Low‐dose dobutamine radionuclide ventriculography is a safe and useful test for assessing myocardial viability and may predict late functional improvement in patients with anterior wall MI.
Comparison of transesophageal coronary sinus and left anterior descending coronary artery doppler measurements for the assessment of coronary row reserve
Authors: Mundigler Gerald , Zehetgruber Manfred , Christ Günter , Siostrzonek Peter
Published: February 2009

Background: Currently used methods for assessment of coronary flow reserve are invasive and require extensive laboratory equipment. Recently, noninvasive assessment of coronary flow reserve by transesophageal Doppler evaluation of coronary sinus (CS) or left anterior descending coronary artery (LAD) flow has been proposed. Direct comparison between these two techniques is lacking.

Methods: Doppler recordings of CS and LAD flow velocity were obtained before and after 0.6 mg/kg/5 min dipyridamole in 16 patients with significant stenosis of the LAD (Group A) and in 14 control patients (Group B). Flow recordings and all measurements were performed in a blinded manner. For assessment of coronary flow reserve, Doppler measurements after dipyridamole were divided by the respective baseline values.

Results: Doppler studies of the CS and LAD were feasible in 30 of 30 (100%) and 23 of 30 (71%) patients, respectively. Analyzing the maximum flow velocities, coronary flow reserve in Groups A and B was 1.18 ± 0.28 and 1.68 ± 0.53 with CS recordings and 1.78 ± 0.83 and 2.51 ± 0.76 with LAD recordings, respectively. Analyzing the velocity time integrals, coronary flow reserve in Groups A and B was 1.53 ± 0.68 and 2.59 ± 0.74 with CS recordings and 1.77 ± 0.38 and 2.68 ± 0.93 with LAD recordings, respectively. Correlation between LAD and CS recordings was 0.69 (p<0.001), when coronary flow reserve was calculated from the velocity time integral and 0.68 (p<0.001) when the maximum flow velocities were used.

Conclusion: Both transesophageal Doppler techniques might be useful for noninvasive assessment of coronary flow reserve.
Autonomic responses to orthostatic stress in head‐up tilt testing: Relationship to test‐induced prolonged asystole
Authors: Takase Bonpei , Nagai Tomoo , Uehata Akimi , Katushika Syuichi , Isojima Kazushige , Hakamata Naohiro , Ohtomi Shingo , Ota Satoshi , Kurita Akira , Nakamura Haruo
Published: February 2009

Background: Prolonged asystole is sometimes an extreme manifestation of neurally mediated syncope.

Hypothesis: To investigate the mechanism of head‐up tilt testing‐induced prolonged (life‐threatening) cardiac asystole, we measured temporal changes in frequency domain heart rate variability indices in 25 patients with syncope of undetermined etiology.

Methods: Head‐up tilt testing (80°) was performed in 25 patients for up to 40 min or until asystole or syncope occurred. Three patients (Group 1; 37 ±13 years, 1 man, 2 women) had an episode of prolonged cardiac asystole (≥ 10 s) during testing, necessitating cardiopulmonary resuscitation. Syncope, but no asystole, was induced in 10 patients (Group 2; 48 ± 31 years, 6 men, 4 women), and 12 patients (Group 3; 55 ± 20 years, 5 men, 7 women) failed to show asystole or syncope during testing. Power spectra of low (0.04–0.15 Hz) and high (0.15–0.40 Hz) frequency, and total (0.01–1.00 Hz) frequency spectra were measured in consecutive 2 min segments throughout the test.

Results: Maximally changed values in heart rate, systolic blood pressure, and heart rate variability indices during testing were compared among the three groups (maximally changed values did not include the values during tilt‐induced symptoms). High frequency spectra in Groups 2 and 3, but not in Group 1, decreased during the test. High frequency spectra, low frequency spectra, and total spectra in Group 1 were significantly higher than those in Groups 2 and 3 during testing. In Group 1 patients, findings at test‐induced asystole were consistent with exaggerated sympathetic and concurrent persistent parasympathetic activity.

Conclusion: Unusual autonomic responses to orthostatic stress can cause prolonged asystole, and this autonomic nerve dysregulation may relate to asystolic episodes associated with cardiovascular collapse.
Estimation of left ventricular systolic function by nonvolumetric echocardiographic analysis in subjects with poor left ventricular visualization: A pilot study
Authors: Cosme Octavio , Grodman Richard S.
Published: February 2009

Background: Accurate assessment of left ventricular (LV) systolic function is an essential requirement in clinical cardiology. Several echocardiographic methods provide quantitative analysis of LV volumes and ejection fraction (EF) based on the precise tracing of endocardial borders. Often, however, technically limited studies prohibit such direct analysis, and alternative techniques must be applied.

Hypothesis: Nonvolumetric echocardiographic methods which do not require endocardial edge definition and tracing may accurately provide quantitative LV systolic function data.

Methods: A pilot study was conducted to validate and compare two recently described indirect echocardiographic methods of LV systolic function analysis, with LVEF by radionu‐clear cardiac angiography (RNCA). Thirty‐two consecutive patients undergoing RNCA for clinical indications also underwent echocardiography within 24 h, with LV analysis performed by the techniques of (1) atrioventricular plane displacement (AVPD) and (2) mitral valve leaflet coaptation point to interventricular septum distance at end‐systole (MVC‐IVS).

Results: Thirteen patients had an echocardiogram with poor two‐dimensional visualization of LV endocardial borders. One patient could not be evaluated by the MVC‐IVS method and two others by the AVPD method because of technical limitations. Chi‐square analysis to compare how each method could discriminate between an RNCA LVEF of < or ≥ 50% demonstrated high correlations for the AVPD method (r = 0.6530, p < 0.0005) and the MVC‐IVS method (r = –0.7029, p < 0.0001). Sensitivity, specificity, positive and negative predictive values, and test accuracy for the AVPD and MVC‐IVS methods were 85 and 80%, 88 and 94%, 85 and 92%, 82 and 83%, and 83 and 87%, respectively.

Conclusion: This pilot study demonstrates that both alternative echocardiographic methods may be useful in the assessment of LV systolic performance, even in the setting of poor LV endocardial border visualization. A larger study is warranted to apply and contrast these methods in different patient subsets.
Circadian patterns in the onset of cardiogenic acute pulmonary edema
Authors: Buff Daniel D. , Calikyan Raffi , Neches Richard B. , Bavli Samuel Z.
Published: February 2009

Background: Circadian patterns of onset favoring the morning hours have been demonstrated for many cardiovascular disorders. Although much is known about cardiogenic acute pulmonary edema (CAPE), the relationship between time of day and CAPE episode onset has not been previously studied.

Methods: We examined 154 consecutive episodes of CAPE treated at an urban community hospital to determine whether circadian patterns existed in the time these episodes began.

Results: For all episodes, a significant circadian pattern existed, with peak onset between 6:00 and 11:59 A.M. (p<0.01). When CAPE episodes were analyzed by the most probable precipitant of pulmonary edema, only the pattern for patients with progressive symptoms, showing a peak in the 6:00 and 11:59 A.M. interval, was statistically significant (p<0.01). Although a similar trend existed for CAPE occurring in association with acute myocardial infarction, the pattern fell short of statistical significance (p=0.09).

Conclusions: These data suggest that circadian patterns favoring the morning hours exist for episodes of CAPE, and that patterns may vary depending on the precipitant of the episode.
Comparative analysis of cardiac troponin i and creatine kinase‐MB as markers of acute myocardial infarction
Authors: Pervaiz Shazib , Waskiewicz Dave , Anderson F. Philip , Lawson Charlotte J. , Lohmann Thomas P. , Feng Yue‐Jin , Contois John H. , Wu Alan H.B.
Published: February 2009

Background: The World Health Organization (WHO) criteria for the diagnosis of acute myocardial infarction (AMI) includes presentation of chest pain over 20 min, evolutionary changes on the electrocardiogram (ECG), and abnormal levels of cardiac enzymes.

Hypothesis: A multicenter study was conducted to evaluate the efficacy of cardiac troponin I (cTnI) in detecting and ruling out AMI.

Methods: The normal range for cTnI in 149 apparently healthy subjects without known history of cardiac or other diseases was 0 to 0.5 ng/ml. Cutoffs of 2.5 ng/ml for cTnI and 5.0 ng/ml for creatine kinase‐MB (CK‐MB) were used.

Results: The diagnostic sensitivity of blood collected from 291 consecutive patients with suspicion of AMI was 95.0 and 96.4%, respectively, for samples obtained at 4–48 h after AMI onset. CK‐MB was more sensitive during the early 4–8 h interval (84 vs. 74%); both had 100% sensitivity from 12–36 h. CTnI remained at 100% for 72 h, while CK‐MB declined to 57%. The clinical specificity was 97.4 vs. 85.8%, respectively, on non‐AMI patients with cardiac and noncardiac diseases, and those with renal disease.

Conclusion: cTnI is an excellent marker for detecting and ruling out AMI, because it has better specificity and a wider diagnostic window than the accepted standard, CK‐MB.
Patient datasheets and generic evaluation sheets: Tools for improving patient care, patient satisfaction, and chart documentation while decreasing physician frustrations
Authors: Ewy Gordon A.
Published: February 2009

A medical record system that utilizes a patient datasheet and pretyped generic patient evaluation sheets is described. When completed, the patient datasheet facilitates quick access to all of the pertinent patient medical information, improves transmission of instructions to the patient, simplifies record‐keeping of patient visits, prevents the rewriting of repetitive information (such as a long list of medications and dosages and instructions after each visit), facilitates the tracing of the patient medication history, and improves communication with the patient and with other physicians. The “generic evaluation sheets” have a near‐complete medical history and physical examination already typed with areas where information can be easily added or deleted and provides a place for the patient assessment and medical treatment plan. This approach to outpatient medical record‐keeping not only results in the ready availability of patient medical information, thus decreasing some of the frustrations of patient care, but also markedly improves patient care documentation while facilitating referral letters and in‐hospital patient records.