bluuebunny/crossref_metadata_2025 huggingface dataset:
Elevated homocysteine levels might be associated with coronary artery remodeling in patients with stable angina: An intravascular ultrasound study
Authors: Hong Myeong‐Ki , Park Seong‐Wook , Lee Cheol Whan , Choi Si‐Wan , Song Jong‐Min , Kang Duk‐Hyun , Song Jae‐Kwan , Kim Jae‐Joong , Park Seung‐Jung
Published: June 2007

Background: The relationship between plasma biologic markers and coronary artery remodeling is unknown.

Hypothesis: Plasma biologic markers are associated with coronary artery remodeling.

Methods: Preintervention intravascular ultrasound images were obtained in 44 patients with chronic stable angina. Plasma samples were collected 24 h before coronary intervention. The biologic markers included total cholesterol, low‐density lipoprotein (LDL) cholesterol, triglyceride, high‐density lipoprotein (HDL) cholesterol, lipoprotein(a) [LP(a)], C‐reactive protein (CRP), and homocysteine. The remodeling index (RI) was defined as a ratio of the (lesion/ proximal reference) external elastic membrane cross‐sectional area. Positive remodeling was defined as an RI > 1.05, negative remodeling as an RI < 0.95, and intermediate remodeling as an RI between 0.95 and 1.05.

Results: Total cholesterol level (r = 0.092, p = 0.557), LDL cholesterol level (r = 0.123, p = 0.426), triglyceride level (r = 0.020, p = 0.901), HDL cholesterol level (r = 0.042, p = 0.789), LP(a) level (r = 0.062, p = 0.729), and CRP level (r = 0.266, p = 0.089) did not significantly correlate with the RI. However, the plasma homocysteine level positively correlated with the RI (r = 0.398, p = 0.008). The plasma homocysteine level was significantly lower in the lesions with negative remodeling and higher in the lesions with positive remodeling (10.8 ± 0.7 μmol/l in negative remodeling, 13.1 ± 0.6 μmol/l in intermediate remodeling, and 18.1 ± 2.8 μmol/l in positive remodeling, p = 0.021).

Conclusions: Elevated homocysteine levels might be associated with coronary artery remodeling in patients with stable angina.
Comparison between ventricular gradient and a new descriptor of the wavefront direction of ventricular activation and recovery
Authors: Batchvarov Velislav , Kaski Juan Carlos , Parchure Nikhil , Dilaveris Polychronis , Brown Sue , Ghuran Azad , Färbom Patrik , Hnatkova Katerina , Camm A. John , Malik Marek
Published: June 2007

Background: Total R T cosine (TCRT) is a new descriptor of repolarization heterogeneity that quantifies the deviation between the directions of ventricular depolarization and repolarization. It revives the old concept of ventricular gradient (VG).

Hypothesis: Our goal was to examine whether TCRT and VG contain nonredundant information by comparing their reaction to autonomic tests, namely, postural changes and Valsalva maneuver.

Methods: Digital 12‐lead electrocardiograms were recorded in 16 patients with cardiovascular syndrome X (SX, chest pain, exercise‐induced ST‐depression, normal coronary arteries, 3 men, age 60 ± 9 years) and 40 healthy volunteers (31 men, age 33 ± 7 years) during postural changes and Valsalva maneuver. The angle (VGA) [°] and magnitude (VGM) [ms.mV] of VG in reconstructed XYZ leads and TCRT (average cosine of the angles between the QRS and T vectors in mathematically reconstructed three‐dimensional space) were calculated.

Results: (mean ± standard of the mean): In healthy subjects, VGM and TCRT decreased, whereas VGA increased in the sitting and standing compared with supine position (TCRT: 0.61 ± 0.05, 0.47 ± 0.06, 0.29 ± 0.08, supine, sitting, and standing, p < 0.05) and during phase II Valsalva (TCRT: 0.47 ± 0.06 vs. 0.61 ± 0.05, p < 0.01 in supine, 0.24 ± 0.08 vs. 0.37 ± 0.07, p < 0.01 in standing). In patients with SX, VGM decreased in the standing position, VGA did not change significantly, while TCRT decreased only in patients without T‐wave abnormalities (n = 9) (TCRT in standing and supine: 0.55 ± 0.09 vs. 0.68 ± 0.08, p < 0.05). VGM increased during Valsalva in patients with SX. Total R T cosine correlated strongly with VGA (r = –0.84, p< 0.00001) and, unlike VGM, did not correlate with heart rate.

Conclusions: Ventricular gradient and TCRT contain non‐redundant information. In healthy subjects, they react sensitively to autonomic provocation. In patients with SX, their reaction is attenuated, which suggests disturbance of the autonomic control of repolarization.
Primary percutaneous interventions for acute myocardial infarction in octogenarians: A single‐center experience
Authors: Skelding Kimberly A. , Mehta Laxmi S. , Pica Mark C , Finta Bohuslav , Shoukfeh Mazen , Grines Cindy L. , O'Neill William W. , Kahn Joel K.
Published: June 2007

Background: The majority of cardiovascular deaths occur in the elderly. The safety and results of primary infarct intervention in octogenarians is Not well characterized.

Hypothesis: The purpose of this study was to compare the results of primary infarct intervention in octogenarians with those in younger patients during 1997‐1998 and to compare these results to those obtained in octogenarians treated in 1991‐1994.

Methods: During 1997‐1998, 40 octogenarians were treated with primary infarct intervention and were compared with 60 randomly selected patients aged < 80 years treated during the same time period. The results in octogenarians were compared with the results in a group of 37 patients of similar age treated in 1991‐1994. The baseline characteristics, procedural results, and hospital outcome were obtained from a prospectively designed interventional database at a busy single‐center program.

Results: There was No significant difference in hospital survival between the two groups of patients treated in 1997‐1998 although there was a trend toward higher mortality in the octogenarian group. Length of stay and use of intra‐aortic balloon pumps were greater in the octogenarian group. When the results in octogenarians treated in 1997‐1998 were compared with the group of 37 patients treated in 1991‐1994, the hospital mortality declined from 27 to 10% (p = 0.05).

Conclusions: There has been improvement in hospital mortality over the past decade for patients aged ≥ 80 years treated with primary infarct intervention. Hospital resources and length of stay are greater for the octogenarian group. Ongoing research studies are comparing the results of thrombolytic therapy and primary intervention in aged patients.
Characteristics of cardiac myxoma with constitutional signs: A multicenter study in Japan
Authors: Endo Akihiro , Ohtahara Akira , Kinugawa Toru , Ogino Kazuhide , Hisatome Ichiro , Shigemasa Chiaki
Published: June 2007

Background: A relationship between constitutional signs in patients with cardiac myxoma and interleukin‐6 has been Noted. However, there is little information about characteristics of cardiac myxomas associated with constitutional signs.

Hypothesis: The objective of this study was to clarify the characteristics of myxoma patients who had constitutional signs.

Methods: Questionnaires were sent to cardiology or cardiovascular surgery divisions at university hospitals throughout Japan. Constitutional signs were considered present when a patient had fever, weight loss, or elevations of C‐reactive protein or gammaglobulin. In addition, interleukin‐6 concentrations were evaluated in some patients.

Results: Data were obtained in 249 patients with primary cardiac tumors (204 myxomas, 15 other primary benign tumors, and 30 primary malignant tumors), confirmed histologically between 1993 and 1996. Fever and weight loss were observed in 15 and 6% of patients with myxoma, respectively, while C‐reactive protein and gammaglobulin were increased in 39 and 21%, respectively. This amounted to a prevalence of constitutional signs in 49%. All constitutional signs disappeared after tumor resection. Age, gender, tumor site, and frequency of thrombosis did Not differ between patients with and without constitutional signs. Tumors associated with constitutional signs were significantly more likely to be large, multiple, or recurrent than those unassociated with constitutional signs.

Conclusions: Constitutional signs are present in about half of patients with myxoma. Large or multicentric tumors are likely to induce constitutional signs, which are reversible upon resection. These might suggest that constitutional signs result when interleukin‐6 concentrations exceed a certain threshold.
Limitation of infarct size and ventricular remodeling in patients with completely reperfused anterior acute myocardial infarction—the potential role of ischemia time
Authors: Miura Hiroshi , Kiuchi Kaname , Nejima Jun , Takano Teruo
Published: June 2007

Background: Experimental studies suggest that coronary reperfusion does not result in appreciable myocardial salvage beyond 3 to 4 h.

Hypothesis: The present study was undertaken to examine the potential role of ischemia time as a determinant of infarct size and cardiac function in humans.

Methods: Ninety patients (69 men, 21 women, aged 61 ± 1 years) presented within 24 h of onset of a first anterior infarct had ST‐segment elevation on electrocardiogram. All patients underwent coronary intervention within 24 h of onset of symptoms and obtained complete reperfusion of the infarct‐related artery.

Results: Infarct size expressed as a percentage of the area at risk (IS/RA) and left ventricular end‐diastolic volume (LVEDV) were significantly (p < 0.017) smaller and left ventricular ejection fraction (LVEF) assessed by left ventriculography (35 ± 4 days) was significantly higher in patients treated within 4 h after onset (IS/RA:55 ± 4%, LVEDV: 127 ± 7 ml, LVEF: 62 ± 2%) than in those treated 4 to 12 h (97 ± 2%, 140 ± 13 ml, 52 ± 3%) and 12 to 24 h (93 ± 2%, 163 ± 14 ml, 49 ± 5%) after symptom onset. Left ventricular end‐diastolic volume was significantly smaller in patients treated 4 to 12 h after onset than in those treated 12 to 24 h after onset.

Conclusions: Patients with < 4 h of myocardial ischemia exhibited significant myocardial salvage and better left ventricular function and patients with 4 to 12 h of myocardial ischemia exhibited significantly smaller LVEDV than those with more prolonged ischemia, although there was no difference in final infarct size.
Exercise capability and myocardial perfusion in chronic angina patients treated with enhanced external counterpulsation
Authors: Tartaglia J. , Stenerson J. , Charney R. , Ramasamy S. , Fleishman B. L. , Gerardi P. , Hui J. C. K.
Published: June 2007

Background: Enhanced external counterpulsation (EECP) has been shown to improve treadmill times and myocardial perfusion. However, improvement in perfusion defects has been demonstrated only in patients exercised to the same cardiac workload on the post‐EECP as the pre‐EECP stress test.

Hypothesis: This study was to determine the effect of EECP on exercise capacity and myocardial perfusion by comparing results of maximal exercise radionuclide testing pre‐ and post‐EECP treatment.

Methods: This prospective study included 25 patients with angina who had performed maximal symptom‐limited exercise tolerance tests (ETT) with Bruce protocol and radionuclide perfusion single‐photon emission computed tomography (SPECT) study prior to and at completion of EECP treatment.

Results: After 35 h of EECP, 23 patients (93%) improved by at least one functional angina class. There is a significant improvement in their total treadmill times (357 ± 93 to 449 ± 97 s, p < 0.001). There was a significant change in their peak double products, from 18,891 ± 3,939 pre‐EECP to 20,464 ± 4,305 post‐EECP ETT (p < 0.03). Pre EECP, 16 patients had ST‐segment depression on their initial ETT. After EECP, 13 of these patients (80%) either no longer had ST depression or had a significant increase in their time to ST depression (229 ± 52 to 315 ± 60 s, p < 0.001). The radionuclide perfusion scores also showed a significant reduction in ischemic segments (16.36 ± 10.52 to 14 ± 10.9, p < 0.05).

Conclusions: Patients treated with EECP demonstrated a reduction in angina symptoms, improvement in exercise capacity, increase in time to ST‐segment depression, and decrease in perfusion defects despite performing at a higher workload.
Modulating atherosclerosis through inhibition or blockade of angiotensin
Authors: Rosenson Robert S.
Published: June 2007

Angiotensin‐converting enzyme (ACE) inhibitors are well recognized for their benefits in treating hypertension and congestive heart failure and preventing postmyocardial infarction heart failure or left ventricular (LV) dysfunction. Recently, blockade of the angiotensin II type 1 (AT1) receptor was shown to reduce cardiovascular events in hypertensive subjects with LV hypertrophy. Several lines of evidence are now converging to show that ACE inhibitors may affect the atherosclerotic process itself. Emerging clinical data indicate that angiotensin‐receptor blockers (ARBs) may possibly modulate atherosclerosis as well. The antiatherogenic properties of ACE inhibitors and ARBs may derive from inhibition or blockade of angiotensin II, now recognized as an agent that increases oxidative stress. Angiotensin‐converting enzyme inhibition and angiotensin‐receptor blockade also increase endothelial nitric oxide formation, which improves endothelial function. In contrast to the effects of ARBs, the vascular effects of ACE inhibitors may, in part, be mediated by an increase in bradykinin. This article reviews some of the biologic mechanisms whereby ACE inhibitors and ARBs may modulate atherosclerosis.
Increased TIMI frame counts in cocaine users: A case for increased microvascular resistance in the absence of epicardial coronary disease or spasm
Authors: Kelly Russell F. , Sompalli Vineel , Sattar Payman , Khankari Kishore
Published: June 2007

Background: Cocaine produces adverse cardiovascular effects, some of which cannot be explained by epicardial coronary artery disease (CAD) or spasm.

Hypothesis: The hypothesis of this study was that cocaine users would have increased coronary microvascular resistance, even in the absence of recent myocardial infarction (MI), CAD, or spasm.

Methods: Microvascular resistance was assessed by the corrected Thrombolysis in Myocardial Infarction (TIMI) frame count (cTFC) method in a consecutive series of 59 cocaine users without acute or recent MI or angiographically significant epicardial stenosis (> 50%) or spasm. The cTFCs in these patients were compared with 21 normal controls and with published normal cTFC values.

Results: The cTFC was significantly elevated (by 26‐54%) in cocaine users. The cTFCs in the left anterior descending (LAD), circumflex (LCx), and right coronary (RCA) arteries in cocaine users were 30.0 ± 10.9, 34.1 ± 11.5, and 28.6 ± 11.8, respectively, compared with values in normal controls of 21.3 ± 4.3 (p = 0.001), 24.4 ± 7.2 (p = 0.001), and 22.7 ± 5.1 (p = 0.04), respectively, and published normal cTFC values (all p < 0.01). An abnormally high cTFC was present in 61% of patients in the LAD, 69% in the LCx, and 47% in the RCA.

Conclusions: Markedly decreased coronary blood flow velocity, indicating increased microvascular resistance, is present in cocaine users, even in the absence of acute or recent MI, or significant epicardial CAD or spasm. Increased microvascular resistance may explain many important cardiovascular manifestations of cocaine use and has therapeutic implications. Slow coronary filling may also suggest the possibility of cocaine use in patients in whom it was not otherwise suspected.
Association of cholesterol levels and occurrence of angiographically detectable endothelial disruption during coronary angioplasty
Authors: Rubboli Andrea , Euler David E. , Sangiorgio Pietro , Casella Gianni , La Vecchia Luigi , Fontanelli Alessandro , Bracchetti Daniele
Published: June 2007

Background: Disruption of the atherosclerotic plaque is a common feature of both acute coronary syndromes and balloon dilatation of coronary artery stenoses.

Hypothesis: The study was undertaken to evaluate whether the known association of cholesterol levels and acute coronary syndromes also exists for the occurrence of angiographically detectable endothelial disruption (ED) following coronary angioplasty.

Methods: For this purpose, we examined 79 consecutive patients (men/women 58/21; mean age: 62 ± 11 years), with a noncalcified, de novo, significant stenosis in a single native coronary artery, undergoing elective coronary intervention because of stable effort angina. Coronary angioplasty was performed using regular balloon catheters, aiming for a balloon/ artery ratio of 1, with stent implantation allowed only provisionally. Following balloon dilatation, patients were divided into two groups according to the presence or absence of angio‐graphically detectable ED.

Results: Endothelial disruption occurred in 28 patients (35%). The two groups with and without ED were comparable with respect to clinical, angiographic, and procedural parameters. A history of hypercholesterolemia was significantly more frequent in patients with ED (93 vs. 2%; p < 0.001). Total and low‐density lipoprotein (LDL) cholesterol levels were significantly higher in the group with ED (230.1 ± 46.5 vs. 204.4 ± 30.2 mg/dl, p < 0.05; and 150.6 ± 39.2 vs. 125.8 ± 26 mg/dl, p < 0.03, respectively). A cut‐off value of LDL cholesterol ≥135 mg/dl identified patients at higher risk of developing ED.

Conclusion: High cholesterol levels appear to favor the occurrence of ED during coronary angioplasty. Aggressive lipid‐lowering therapy and a more careful procedural approach may be warranted in patients with hypercholesterolemia undergoing coronary interventions in order to decrease the occurrence of ED and the associated clinical (acute ischemia) and procedural (stent implantation) consequences.
Measuring treatment effects of Cilostazol on clinical trial endpoints in patients with intermittent claudication
Authors: Smith James A. M.
Published: June 2007

Intermittent claudication (IC) comprises the most common presenting symptoms of peripheral arterial disease (PAD), which itself is a manifestation of systemic atherosclerosis. Typical symptoms of IC are aching pain, numbness, and fatigue in the lower extremities. Symptoms are induced by walking or exercise and usually resolve with rest. The cornerstone of treating IC is risk‐factor reduction and a supervised exercise regimen. Pharmacotherapy specifically indicated for the treatment of IC includes a new drug, cilostazol, and the traditional drug, pentoxifylline. Cilostazol also has antiplatelet, antithrombotic, and vasodilatory activity, as well as a positive effect on serum lipids. Eight multicenter clinical trials, seven in the U.S. and one in the U.K., used objective and subjective clinical endpoints to assess the treatment efficacy of cilostazol. Objective endpoints included maximal and pain‐free walking distance (MWD and PFWD, respectively), the ankle‐brachial index, peripheral hemodynamic measurements, and serum lipid levels. Subjective endpoints, assessed by patient questionnaires, included perceived functional status and health‐related quality of life. Cilostazol treatment showed statistically significant increases in MWD and PFWD within 4 weeks, as well as improvements in physical functional status at 24 weeks, compared with placebo and pentoxifylline. Increases in high‐density lipoprotein cholesterol and decreases in plasma triglycerides were also noted. Subjective assessments appeared to match objective parameters.
A comparison of treadmill scores to diagnose coronary artery disease
Authors: Fearon William F. , Gauri Andre J. , Myers Jonathan , Raxwal Vinod K. , Atwood J. Edwin , Froelicher Victor F.
Published: June 2007

Background: Recently, several treadmill scores have been proposed as means for improving the diagnostic accuracy of the exercise treadmill test (ETT). Questions remain regarding the diagnostic accuracy of treadmill scores when applied to a different patient population than that from which they were derived; furthermore, many treadmill scores have not been compared with one another in the same population.

Hypothesis: The diagnostic accuracy of treadmill scores may not be the same.

Methods: A retrospective analysis of data collected prospectively was performed on consecutive patients referred for evaluation of chest pain. All patients underwent a standard ETT followed by coronary angiography. Using angiographic evidence of coronary artery disease (CAD) as a reference, the area under the curve (AUC) of receiver operator characteristic (ROC) plots of the ST response alone, the Duke Treadmill Score (DTS), the Morise score, the Detrano score, the VA score, and a Consensus score consisting of the Morise, Detrano, and VA scores together were calculated and compared. The predictive accuracies of the DTS and the Consensus score to stratify patients for the likelihood of CAD were calculated and compared.

Results: In all, 1,282 patients without a prior myocardial infarction had an ETT and coronary angiography. The AUC (± standard error) was 0.67 ± 0.01 for the ST response, 0.73 ± 0.01 for DTS, 0.76 ± 0.01 for Detrano score, 0.77 ± 0.01 for Morise score, 0.78 ± 0.01 for VA score, and 0.78 ± 0.01 for Consensus score. The AUC for each treadmill score was significantly higher (z‐score > 1.96) than for the ST response alone. The AUC of DTS was significantly lower than all other treadmill scores (z‐score > 1.96). The predictive accuracy (± 95% confidence interval) of the DTS to risk stratify patients into high and low likelihood for CAD was 71 (65‐77)%, versus 80 (74‐86)% for the Consensus score (p < 0.0001).

Conclusion: In this population, the DTS remains useful for diagnosing CAD and stratifying for the likelihood of CAD, although it is less accurate than other treadmill scores.
Exaggerated carotid sinus massage responses are related to severe coronary artery disease in patients being evaluated for chest pain
Authors: Tsioufis Costas P. , Kallikazaros Ioannis E. , Toutouzas Konstantinos P. , Stefanadis Christodoulos I. , Toutouzas Pavlos K.
Published: June 2007

Background: Previous studies have reported that carotid sinus massage responses are associated with advancing age and carotid or coronary artery disease.

Hypothesis: This study was undertaken to investigate the potential role of carotid sinus hypersensitivity as a marker for the presence of coronary artery disease, and especially left main stem disease, in patients who were referred for evaluation of chest pain.

Methods: Toward this end, carotid sinus stimulation with simultaneous recordings of the electrocardiogram and aortic pressure was performed before coronary arteriography in 150 selected consecutive patients (mean age 59.4 ± 9 years) who were referred for evaluation of chest pain.

Results: Coronary artery disease was present in 118 patients (78.7%); of these, 35 had single‐vessel disease, 35 had double‐vessel disease, 33 had triple‐vessel disease, and 15 had left main stem with or without such vessel disease. Carotid sinus hypersensitivity was found in 40 patients (26.6%). The incidence of hypersensitivity in patients with single‐, double‐, or triple‐vessel disease and left main stem disease was 8.5, 14.2, 57.5, and 73.3%, respectively. Stepwise multiple logistic regression analysis revealed that left main stem disease was significantly and independently related to the presence of carotid sinus hypersensitivity (p < 0.05). In addition, the presence of hypersensitivity had 73.3% sensitivity, 86.2% specificity, and 96.3% negative predictive value for the presence of left main stem disease.

Conclusion: In patients being evaluated for suspected ischemic heart disease, carotid sinus massage responses are related to severe coronary disease. The absence of hypersensitivity may reflect absence of left main stem disease.
Conjugated estrogen administration improves common carotid artery elastic properties in normotensive postmenopausal women
Authors: Kallikazaros Ioannis , Tsioufis Costas , Zambaras Panagiotis , Stefanadis Christodoulos , Toutouzas Pavlos
Published: June 2007

Background: Various vascular effects of estrogens have been proposed to explain further the beneficial effect of replacement therapy in cardiovascular events.

Hypothesis: The study was undertaken to assess the effect of conjugated estrogen on the elastic properties of the large arteries innormotensive, healthy, postmenopausal women.

Methods: Toward this end, we investigated the acute effect of conjugated estrogen on the elastic properties of the common carotid artery (CCA) in 20 normotensive, healthy, postmenopausal women (age 54 ± 3 years) at baseline and 20 min after the intravenous administration of 1.25 mg conjugated estrogens. The CCA distensibility was derived by a combination of surface ultrasonographic data and simultaneous blood pressure measurements at the brachial artery. The carotid pulsatility index, a measure of brain impedance, was determined electronically by tracing the CCA Doppler waveform.

Results: At baseline, CCA distensibility had a negative correlation with both patients' age and time since menopause (r= −0.57andr= −0.48, p< 0.05 for both cases). After estrogen administration, estradiol and estrone plasma levels were restored to the range of usual premenopausal values. Estrogen induced a significant increase in CCA distensibility by 0.92 ± 0.005 dyne−1 · cm2 · 10−6 (from 2.03 to 2.95 dyne−1 · cm2 · 10−6) and a significant reduction in CCA pulsatility index by 0.24 ± 0.06, (from 2.17 to 1.93) (p<0.001 for both cases). The improvement in CCA distensibility had a negative correlation with both patients' age and time since menopause (r=−0.46 and r=−0.44, respectively, p< 0.05 forboth cases).

Conclusions: Acute conjugated estrogen administration induced an improvement in CCA elasticity and a reduction in brain impedance in normotensive, postmenopausal women. As the age of women and the time since menopause increased, the improvement in carotid distensibility decreased in such selected subjects.
Detection of occult left ventricular dysfunction in patients without prior clinical history of myocardial infarction by technetium‐99m sestamibi myocardial perfusion gated single‐photon emission computed tomography
Authors: Yao Siu‐Sun , Nichols Kenneth , DePuey E. Gordon , Rozanski Alan
Published: June 2007

Background: In the absence of a prior history of myocardial infarction (MI), left ventricular (LV) dysfunction is commonly due to hypertension, valvular heart disease, or hibernating myocardium.

Hypothesis: Since technetium‐99m sestamibi gated single‐photon emission computed tomography (SPECT) may be used to determine both stress/rest myocardial perfusion and resting LV function, we attempted to evaluate the ability of gated SPECT imaging to detect occult LV dysfunction.

Methods: We evaluated the ability of this technique to detect occult LV dysfunction among 179 patients without history MI and angiographically documented coronary artery disease (CAD). All patients underwent both gated SPECT and cardiac catheterization within a 6‐month time period. Left ventricular volume and ejection fraction (EF) values were determined according to a previously validated technique using Simpson's rule. Normal limit values for LV volumes and EF were derived from a control population of 93 patients with normal coronary angiograms.

Results: Based on normal limit‐derived criteria, 15% of the CAD study cohort had occult LV dysfunction (> 2 standard deviations below gender‐specific normal limit means for LVEF). Mean LV end‐diastolic volume index (EDVi) was significantly increased (p < 0.05) and LVEF decreased (p < 0.05) in patients with triple‐vessel CAD. End‐diastolic volume index was also increased in the cohort of patients with both hypertension and LV hypertrophy (LVH) (p < 0.05). However, multivariate logistic regression analysis revealed that only CAD extent, but not hypertension or LVH, was a significant predictor of occult LV dysfunction (p = 0.009).

Conclusion: Occult LV dysfunction can be detected in patients with CAD by gating technetium‐99m sestamibi SPECT studies, and its presence may signify the presence of extensive CAD.
Anticoagulants for atrial fibrillation: Why is the treatment rate so low?
Authors: Buckingham Thomas A. , Hatala Robert
Published: June 2007

The incidence of atrial fibrillation (AF) is increasing in many countries along with aging demographics. Atrial fibrillation is clearly associated with an increased rate of stroke. Numerous large clinical trials have shown that dose‐adjusted warfarin can reduce the stroke rate in these patients, particularly in the elderly, and clear guidelines for the use of anticoagulants in such patients have been published. However, many studies show that treatment rates remain disappointingly low (≤50%). Numerous barriers to the use of dose‐adjusted warfarin exist, including practical, patient‐, physician‐, and healthcare system‐related barriers. These include the complex pharmacokinetics of warfarin, the need for continuous prothrombin time monitoring and dose adjustments, bleeding events, noncompliance, drug interactions, and increased costs of monitoring and therapy. Possible solutions to this problem are discussed and include improved patient and physician education, the use of anticoagulation clinics, new approaches to AF, and potential treatment improvements through use of newer anticoagulants.
A stratified approach to the treatment of a symptomatic myocardial bridge
Authors: Gomberg‐Maitland Mardi , Kim Michael C. , Fuster Valentin
Published: June 2007

A case of symptomatic myocardial bridge requiring intracoronary stent complicated by in‐stent restenosis is reported. A stratified approach for the treatment of a symptomatic myocardial bridge is proposed.
Hemodynamic changes and prognosis in patients with hypertrophic cardiomyopathy and abnormal blood pressure responses during exercise
Authors: Nagata Mitsuru , Shimizu Masami , Ino Hidekazu , Yamaguchi Masato , Hayashi Kenshi , Taki Junichi , Mabuchi Hiroshi
Published: June 2007

Background: An abnormal blood pressure response (BPR) during exercise has been proposed as a risk factor for sudden cardiac death in patients with hypertrophic cardiomyopathy (HCM). Some patients with HCM show systolic dysfunction during exercise.

Hypothesis: The aim of this study was to clarify the hemo‐dynamic response during exercise and prognosis in patients with HCM and abnormal BPR.

Methods: Sixty‐five patients with HCM underwent radionuclide monitoring of left ventricular function and measurement of blood pressure during supine ergometer exercise. Thereafter, cardiac events were recorded for an average period of 76 months.

Results: Seven of 65 patients had abnormal BPR, while the others had normal BPR. Changes of heart rate and systemic vascular resistance during exercise did not differ between the two groups. Stroke volume did not increase in the abnormal BPR group but did in the normal BPR group. During a mean follow‐up period of 76 months, three of the seven patients (43%) with abnormal but only one patient (2%) with normal BPR suffered a malignant arrhythmia.

Conclusions: Abnormal BPR occurred in about 11% of patients with nonobstructive HCM and was associated with a high prevalence of cardiac events. The predictor of abnormal BPR during exercise may not be an abnormal response of systemic vascular resistance and heart rate, but the lack of an appropriate increase in stroke volume.
Systolic, diastolic, and pulse pressures as coronary risk factors in a population with low cholesterol levels: A prospective 10‐year evaluation
Authors: Onat Altan , Ceyhan Käksal , Erer Burak , Basar Ämer , Uysal Ämer , Sansoy Vedat
Published: June 2007

Background: Pulse pressure (PP) has recently been found to be predictive of subsequent cardiovascular, particularly coronary, events in some middle‐aged and elderly populations.

Hypothesis: The aim of this prospective population‐based study was to evaluate the roles of systolic (SBP), diastolic blood pressure (DBP), and PP in predicting coronary heart disease (CHD) morbidity and mortality in both genders in a population of a wide age span and a setting of low levels of low‐density lipoprotein (LDL) and high‐density lipoprotein (HDL) cholesterol.

Methods: Of participants in the Turkish Adult Risk Factor Study aged ⩾ 20 years, those free of CHD at baseline examination in 1990 were followed up for a mean of 9.3 years. Coronary heart disease was diagnosed based on clinical findings and Minnesota coding of resting electrocardiograms (ECGs). In 2,601 men and women (mean age at baseline 41.4 ± 15 years), deaths from CHD developed in 80 and nonfatal CHD in 158 patients.

Results: In a logistic regression analysis for predictors of composite endpoint of coronary mortality and morbidity, individually, DBP was not significantly and independently associated, while SBP was an independent risk predictor in both genders (relative risk [RR] 1.016). When two of three blood pressure components were entered jointly into the multivariable model, PP had a value inferior to that of SBP among men and women, but was of greater value than DBP in men in predicting both the composite endpoint and death from CHD. Among women, the predictive values of PP and DBP were similar. Within the categories of SBP ⩾ 120 mmHg in men, PP contributed significantly to the predictive power of SBP in overall CHD risk over and above that supplied by SBP, whereas DBP remained noncontributory.

Conclusion: Although inferior to the predictive power of SBP, PP was an important determinant of CHD risk in a population of a diverse age span and a better predictor than DBP in men.
Pulsus paradoxus in cardiac tamponade: A pathophysiologic continuum
Authors: Swami Ashwin , Spodick David H.
Published: June 2007

Pulsus paradoxus has interested physicians for more than a century. Since McGregor's comprehensive New England Journal of Medicine article in 1979,1 there have been no updated reviews; accordingly, we review pulsus paradoxus based on the clinical and physiologic literature and personal experience.2
Bone marrow stimulation and left ventricular function in acute myocardial infarction
Authors: Tomoda Haruo , Aoki Naoto
Published: June 2007

Background: Experimental studies have demonstrated that bone marrow stem cells can migrate into peripheral blood and regenerate damaged myocardium.

Hypothesis: Bone marrow stimulation might improve myocardial functional recovery after acute myocardial infarction (AMI).

Methods: In all, 104 consecutive patients with anterior wall AMI treated by primary coronary angioplasty and stenting within 12 h after onset, and who underwent left ventriculography on admission and 6 months after discharge, were studied. Among these, 23 patients (Group 1) demonstrated transient appearance of immature blood cells including myelocytes, promyelocytes, and myeloblasts during hospital stay. Thirty‐eight matched patients in whom no immature blood cells were detected were studied as a control group (Group 2).

Results: There was no significant difference in baseline characteristics between the two groups. There was no significant difference in left ventricular ejection fraction (EF) on admission between Group 1 (33 ± 12%) and Group 2 (34 ± 8%). In contrast, EF was significantly better in Group 1 (47 ± 12%) than in Group 2 (40 ± 10%, p = 0.016) 6 months after discharge.

Conclusion: The study suggests significantly greater improvement in left ventricular function in patients with AMI with sign of bone marrow stimulation than in matched patients with no sign of bone marrow stimulation.
Thyroid function is associated with presence and severity of coronary atherosclerosis
Authors: Auer J. , Berent R. , Weber T. , Lassnig E. , Eber B.
Published: June 2007

Background: Overt hypothyroidism has been found to be associated with cardiovascular disease. Moreover, subclinical hypothyroidism is a strong indicator of risk for aortic atherosclerosis and myocardial infarction.

Hypothesis: We hypothesized that variation of thyroid function within the normal range may influence the presence and severity of coronary atherosclerosis.

Methods: We studied a total of 100 consecutive men and women (59 men, 41 women, age 63.7 ± 11.0 years) who underwent coronary angiography. Blood was tested for serum thyrotropin concentrations and for free tri‐iodothyronine and free thyroxine concentrations. In addition to the assessment of thyroid function, conventional risk factors for coronary artery disease (CAD), clinical characteristics, serum lipid levels, fasting total homocysteine, and angiographic results of coronary artery assessment were obtained. Two experienced cardiologists blinded to clinical and laboratory data reviewed the cine‐films. The severity of CAD was scored as 0 for those with smooth normal epicardial coronary arteries, 0.5 for plaquing (< 50% diameter stenosis), and 1,2, or 3 for those with single‐, double‐, or triple‐vessel epicardial coronary artery stenosis of > 50%, respectively.

Results: The severity of CAD was scored as 0,0.5,1,2, and 3 in 14,26,25,22, and 13 patients, respectively. Higher levels of serum‐free thyroid hormone concentrations were associated with decreased severity of coronary atherosclerosis. Serum‐free tri‐iodothyronine was 2.99 ±0.33 pg/ml in patients with a CAD severity score of 0 to 1 and 2.74 ± 0.49 pg/ml in patients with CAD severity scores of 2 and 3 (p <0.01). Moreover, serum‐free thyroxine concentrations showed a trend toward higher levels in patients with CAD severity score 0 to 1 compared with patients with CAD severity scores 2 and 3 (11.65 ± 1.87 pg/ml vs. 10.9 ± 2.3 pg/ml; p = 0.09). Higher levels of serum thyrotropin concentrations were associated with increased severity of coronary atherosclerosis (1.37 ± 1.02 mU/l vs. 1.98 ± 2.13 mU/l in patients with CAD severity score 0 to 1 versus CAD severity scores 2 and 3; p=0.049). When grouped into three subsets according to their serum free tri‐iodothyronine levels (<2.79, 2.8 to 3.09, and ± 3.1 pg/ml), the prevalence of CAD scores 2 and 3 was significantly higher in the subset of patients with low serum free tri‐iodothyronine levels (48.5%) than in the subsets of patients with medium or high tri‐iodothyronine concentrations (32.25 and 25%, respectively, p for trend < 0.05).

Conclusion: These data in patients referred for coronary angiography suggest that variation of thyroid function within the statistical normal range may influence the presence and severity of coronary atherosclerosis.
Mortality and rate of stroke or embolism in atrial fibrillation during long‐term follow‐up in the embolism in left atrial thrombi (ELAT) study
Authors: Stöllberger Claudia , Chnupa Pavel , Abzieher Christine , Länger Thomas , Finsterer Josef , Klem Igor , Hartl Elisabeth , Wehinger Cornelius , Schneider Barbara
Published: June 2007

Background: Patients with atrial fibrillation (AF) have a higher mortality and risk of stroke/embolism than patients with sinus rhythm.

Hypothesis: The aim of the study was to assess the association of clinical and echocardiographic characteristics with mortality and stroke/embolism and the use of antithrombotic medicationin the year 2000 in patients who participated 1990‐1995 in the Embolism in Left Atrial Thrombi (ELAT) study.

Methods: The study included 409 outpatients with non‐rheumatic AF (62 ± 12 years, 36% women, 39% intermittent AF). Patients with thrombi received anticoagulation, patients without thrombi aspirin until follow‐up in 1995; thereafter, anticoagulation according to clinical risk factors was recommended. Primary events were death and secondary events were stroke/embolism. All patients were contacted during the year 2000.

Results: Mean follow‐up was 102 months. Mortality was 4%/year; the cause of death was cardiac (n=84), fatal stroke (n = 26), malignancy (n = 23), sepsis (n = 5), and unknown (n = 24). Multivariate analysis identified age (p < 0.0001), heart failure (p = 0.0013), and reduced left ventricular systolic function (p = 0.0353) as predictors of mortality. Stroke/embolism occurred in 83 patients, with a rate of 3%/year. Multivariate analysis identified age (p = 0.0006) and previous stroke (p = 0.0454) as predictors of stroke/embolism. In the year 2000, 51 (21%) of the 247 surviving patients received no antithrombotic medication, 88 received (36%) oral anticoagulants, 102 (41%) acetylsalicylic acid, and 6 (2%) low‐molecular heparin.

Conclusions: Therapy for heart failure and oral anticoagulation in AF should be seriously considered, especially in elderly patients and in those with previous stroke.
Patients with uncontrolled hypertension or concomitant hypertension and benign prostatic hyperplasia
Authors: Zusman Randall
Published: June 2007

At optimal doses, individual antihypertensive agents lower blood pressure (BP) by an average of 10 mmHg. Many patients with hypertension, including those with stage 3 hypertension, target organ damage, or those at high risk for cardiovascular events and/or adverse effects of high‐dose monotherapy, are likely to require combination antihypertensive drug treatment to achieve the recommended systolic/diastolic BP (< 140/90 mmHg). Two studies, a placebo‐controlled, double‐blind trial (n = 70) and a community‐based, open‐label trial (n = 491) investigated the antihypertensive efficacy of doxazosin, a long‐acting selective α1‐adrenoceptor blocker, as add‐on therapy for uncontrolled hypertension with other antihypertensive medications and in patients with concomitant benign prostatic hyperplasia (BPH) and treated but inadequately controlled hypertension, respectively. The addition of doxazosin to baseline antihypertensive medication(s) significantly lowered BP and had a significantly positive effect on the serum lipid profile. In patients with concomitant BPH, doxazosin significantly improved all BPH symptom scores, regardless of initial symptom severity. Add‐on doxazosin sufficiently reduced systolic/diastolic BP such that many patients whose hypertension was previously uncontrolled by other antihypertensive medications were able to reach goal BP (< 140/90 mmHg). Doxazosin as add‐on therapy was well tolerated. In conclusion, doxazosin as add‐on therapy improves BP control in hypertensive patients not at goal BP and improves lower urinary tract symptoms in patients with concomitant BPH.
The accuracy of electrocardiographic Q waves for the detection of prior myocardial infarction as assessed by a novel standard of reference
Authors: Hurst Willis , Sandler Leonard L. , Pinnow Ellen E. , Lindsay Joseph
Published: June 2007

Background: The electrocardiogram (ECG) is valuable for the identification of prior myocardial infarction (MI) in individuals participating in epidemiologic studies or undergoing screening examinations. Although the Minnesota Code, a set of criteria for the interpretation of ECGs in such situations, is commonly used to identify MI in these settings, its accuracy is incompletely understood.

Hypothesis: We sought to test the accuracy of the Minnesota Code Q and QS criteria for MI against a new standard of reference, the presence of a perfusion defect on a resting myocardial scintigraphic image.

Methods: The resting myocardial scintigrams of all patients studied in our nuclear cardiology laboratory during 7 consecutive months were screened for the presence of perfusion defects. For each patient with such a defect, two individuals examined on the same day, who had no perfusion defect, were selected as controls. Electrocardiograms recorded within 30 days of the scintigraphy were read blindly by two of the authors using the Minnesota Code criteria for Q or QS waves indicative of MI.

Results: For 214 patients selected on the basis of their scintigraphic findings, a satisfactory ECG recorded within a month of the scintigraphy was also available. The overall sensitivity of the Q or QS criteria was 0.58 and the specificity was 0.75. As might be expected when only the most stringent criteria were applied, sensitivity was least and the specificity best.

Conclusions: As in previous studies, in which necropsy material served as the standard of reference, sensitivity of the Q and QS criteria contained in the Minnesota Code is relatively modest and specificity is reasonable but not outstanding.
Relation of lateral ST‐segment elevation pattern to myocardial salvage in patients with recanalized anterolateral acute myocardial infarction
Authors: Kosuge Masami , Kimura Kazuo , Ishikawa Toshiyuki , Endo Tsutomu , Sugano Teruyasu , Nakagawa Takeshi , Hibi Kiyoshi , Nakatogawa Tomoyori , Okuda Jyunn , Toda Noritaka , Tsukahara Kengo , Takamura Takeshi , Tahara Yoshio , Umemura Satoshi
Published: June 2007

Background: Although anterior acute myocardial infarction (AMI) with ST‐segment elevation in lateral leads is associated with a poor prognosis, the significance of the pattern of lateral ST‐segment elevation has not been examined.

Hypothesis: The aim of the study was to examine the relation of the pattern of lateral ST‐segment elevation to myocardial reperfusion and infarct size in patients with AMI.

Methods: We studied 111 patients who had a first AMI presenting with anterolateral ST‐segment elevation and Thrombolysis in Myocardial Infarction (TIMI) grade 3 flow of the left anterior descending coronary artery within 6 h from symptom onset. Patients were classified into two groups according to the pattern of lateral ST‐segment elevation on the admission electrocardiogram: Group 1, 42 patients with equivalent or greater ST‐segment elevation in lead I than in lead aVL, and Group 2, 69 patients with lesser ST‐segment elevation in lead I in than in lead aVL. Left ventricular ejection fraction (LVEF) was measured by predischarge left ventriculography.

Results: There were no differences between the two groups in age, gender, time from onset to recanalization, culprit lesion, or collateral development. Group 1 patients had a higher probability of impaired myocardial reperfusion as indicated by a myocardial blush grade of 0 or 1 after recanalization, a higher peak creatine kinase level, and a lower LVEF than Group 2 patients (p = 0.0001, respectively).

Conclusions: We conclude that equivalent or greater ST‐segment elevation in lead I than in lead aVL is associated with impaired myocardial reperfusion and less myocardial salvage in patients with recanalized AMI who present with anterolateral ST‐segment elevation on the admission electrocardiogram.
Ethnic differences in utilization of invasive cardiac procedures and in long‐term survival following acute myocardial infarction
Authors: Mak Koon‐Hou , Kark Jeremy D. , Chia Kee‐Seng , Tan Caren , Foong Bok‐Huay , Chew Suok‐Kai
Published: June 2007

Background: Ethnic differences in coronary mortality have been documented, and South Asians from the Indian subcontinent are particularly vulnerable.

Hypothesis: This study sought to determine whether there was a difference in the utilization of invasive cardiac procedures and long‐term mortality in survivors of myocardial infarction (MI) among Chinese, Malays, and South Asians in Singapore.

Methods: All MI events in the country were identified and defined by the Singapore Myocardial Infarction Register, which uses modified procedures of the World Health Organization MONICA Project. Information on utilization of coronary angiography, coronary angioplasty, coronary artery bypass graft, and survival was obtained by data linkage with national billing and death registries. Hazard ratios (HR) were calculated using the Cox proportional hazards model with adjustment for baseline characteristics.

Results: From 1991 to 1999, there were 10,294 patients who survived ≥3 days of MI. Of these, 40.6% underwent coronary angiography and 16.5% a revascularization procedure ≤28 days. Malays received substantially less angiography (34.0%) and revascularization (11.4%) than Chinese (41.9%, 17.9%) and South Asians (40.0%, 16.3%). The ethnic disparity increased during the 1990s, particularly in the performance of coronary angiography (p = 0.038). While fatality declined during the study period for Chinese and South Asians, the rate remained stable for Malays. After a median follow‐up period of 4.1 years, survival was lowest among Malays (adjusted HR, 1.28; 95% confidence interval, 1.15‐‐1.42, compared with Chinese).

Conclusion: Ethnic inequalities in invasive cardiac procedures exist in Singapore and were exacerbated in the 1990s. Inequalities in medical care may contribute to the poorer long‐term survival among Malays.