bluuebunny/crossref_metadata_2025 huggingface dataset:
Prognostic implications of ventricular ectopy one week, one month, and sixteen months after an acute myocardial infarction
Authors: Vaage‐Nilsen Merrete , Rasmussen Verner , Hansen JøRgen Fischer , Hagerup Leif , Borring Sørensen Margit , Pedersen‐Bjergaard Ole , Mellemgaard Kresten , Holländer Niels H. , Nielsen Ingolf , Sigurd Bjarne M.
Published: February 2009

Background: Ventricular ectopy early after an acute myocardial infarction (AMI) has previously been demonstrated to predict mortality. Less information is available about the prognostic implications of ventricular ectopy occurring late after an AMI, and no information is available about the prognostic implication of the development of ventricular ectopy during the first year after an AMI.

Hypothesis: The purpose of the present prospectively conducted trial, a part of the Danish Verapamil Infarction Trial II (DAVIT II), was to evaluate the prognostic implication of (1) ventricular premature complexes (VPCs) recorded by 24‐h Holter monitoring 1 week, 1 month, and 16 months after an AMI; and (2) development of > 10 VPCs/h or of any complex ventricular ectopy, that is, pairs, more than two types of VPCs, ventricular tachycardia, or > 10 VPCs/h during follow‐up after an AMI.

Methods: Patients were monitored 1 week (n = 250), 1 month (n = 210), and 16 months (n = 201) after AMI.

Results: Multivariate analyses based on history, clinical findings, and ventricular ectopy showed the following results: After 1 week, > 10 VPCs/h (p = 0.0006) and heart failure (p< 0.007); after 1 month, >10 VPCs/h (p = 0.003) and resting heart rate (p < 0.02); and after 16 months, ventricular tachycardia (p = 0.002) independently predicted long‐term mortality. Mortality was significantly predicted by the development of > 10 VPCs/h from 1 week to 1 month (p = 0.003) and 16 months (p = 0.03), and from 1 to 16 months (p = 0.007) after AMI, as well as by the development of any complex ventricular ectopy from 1 week to 1 month (p = 0.02) and 16 months (p = 0.01), and from 1 to 16 months (p = 0.04) after AMI.

Conclusion: The present study demonstrated that 1 week and 1 month after an AMI the quantity of VPCs, that is, >10 VPCs/h, predicted mortality, whereas 16 months after an AMI the quality of VPCs, that is, ventricular tachycardia, predicted mortality.
Endovascular stenting of an unprotected left main coronary artery stenosis in a heart transplant patient
Authors: Weston Mark W. , Spoto Edward , Aranda Juan , Sears Nicholas
Published: February 2009

Endoluminal revascularization of left main coronary artery vessels is considered to be relatively contraindicated because of a high procedural mortality and restenosis rate. This report describes the first successful case of endovascular stenting in an unprotected left main coronary artery stenosis in a heart transplant patient.
The importance of randomized clinical trials and evidence‐based medicine: A clinician's perspective
Authors: Kennedy Harold L.
Published: February 2009

Clinical evaluation of therapies for patient care has evolved during the twentieth century from a variety of scientific methods. As a result of medical, political, and economic changes that occurred in the 1990s, randomized clinical trials and evidence‐based methods are presently in the forefront of the physician's thinking in the decision‐making process for therapeutic interventions. A new standard of patient care has emerged during this process. This report provides a clinician's viewpoint of the importance and interpretation of evidence‐based methods and suggests a strategy when such evidence does not exist.
Effect of balloon inflation‐induced acute ischemia on QT dispersion during percutaneous transluminal coronary angioplasty
Authors: Aytemir Kudret , Bavafa Veli , Ozer Necla , Aksoyek Serdar , Oto Ali , Ozmen Ferhan
Published: February 2009

Background: QT dispersion (QTd = QTmax ‐ QTmin) measured as interlead variability of QT interval reflects the spatial inhomogeneity of ventricular repolarization times, and increased QTd may provide a substrate for malignant ventricular arrhythmias. Ischemia is associated with regional abnormalities of conduction and repolarization.

Hypothesis: This study aimed to investigate the effect of acute ischemia on QTd during successful percutaneous transluminal coronary angioplasty (PTCA).

Methods: Forty‐three patients (10 women, 33 men, mean age 56 years) were enrolled in the study. Electrocardiogram (ECG) recordings were taken before PTCA and during balloon inflation period. QT maximum (QTmax), QT minimum (QTmin), and QTd (QTmax ‐ QTmin) values were calculated from the surface ECG.

Results: There was no difference among QTmax values (p = 0.6). Mean QTmin during balloon inflation was lower than before PTCA (368 ± 45 vs. 380 ± 41 ms, p = 0.002). The difference between QTd values before and during balloon inflation was statistically important (65 ± 9 vs. 76 ± 10 ms, p = 0.001). This difference is caused by a decrease in QTmin during balloon inflation.

Conclusion: Acute reversible myocardial ischemia induced by balloon inflation causes an increase in QTd value, and this increment is the result of a decrease in QTmin interval. Therefore, QTd may be a marker of reversible myocardial ischemia.
Long‐Term safety of pravastatin‐gemfibrozil therapy in mixed hyperlipidemia
Authors: Iliadis Elias A. , Rosenson Robert S.
Published: February 2009

Background: Combined HMG‐CoA reductase inhibitor and fibric acid derivative therapy is often necessary for the effective reduction of concentrations of low‐density lipoprotein (LDL) cholesterol and triglycerides in patients with mixed hyperlipidemia; however, the potential risk of myopathy has limited the use of these agents.

Hypothesis: This study evaluated long‐term safety and efficacy of combined pravastatin and gemfibrozil therapy.

Methods: Eighty‐three patients with hyperlipidemia were treated with combined pravastatin and gemfibrozil therapy for a median of 44 months (range 9–78 months). Plasma lipids, serum liver function tests, creatinine, and creatinine kinase (CK) levels were measured every 3 to 4 months.

Results: One patient developed myalgia with a normal CK level after 4 months of combination therapy. Three patients had transient elevations in CK levels that ranged from 3 to 5 times the upper limits of “normal” and that returned to normal upon repeat testing. Liver function tests did not change significantly from baseline. in a subset of 26 previously untreated patients, combined pravastatin (mean daily dose 22 mg) and gemfibrozil (mean daily dose 1,154 mg) therapy lowered total cholesterol by 25% (p<0.001), triglycerides by 53% (p = 0.0001), LDL cholesterol by 14% (p = 0.24), and increased high‐density lipoprotein (HDL) cholesterol by 20% (p = 0.012).

Conclusion: Pravastatin and gemfibrozil therapy is safe and efficacious in patients with mixed hyperlipidemia. The long‐term safety results are consistent with other reports on follow‐up of shorter duration.
Assessing the appropriateness of coronary revascularization: The university of maryland revascularization appropriateness score (ras) and its comparison to rand expert panel ratings and american college of cardiology/american heart association guidelines with regard to assigned appropriateness rating and ability to predict outcome
Authors: Ziskind Andrew A. , Vogel Robert A. , Lauer Michael A. , Bishop Gregory
Published: February 2009

Background:Significant regional variation in procedural frequencies has led to the development of the RAND and American College of Cardiology/American Heart Association (ACC/AHA) guidelines; however, they may be difficult to apply in clinical practice. The University of Maryland Revascularization Appropriateness Score (RAS) was created to address the need for a simplified point scoring system.

Hypothesis:The study was undertaken to compare revascularization appropriateness ratings yielded by the RAND Expert Panel Ratings, ACC/AHA guidelines, and the University of Maryland RAS.

Methods:We applied these three revascularization appropriateness scoring systems to 153 catheterization laboratory patients with a variety of cardiac diagnoses and treatments. For each patient, appropriateness scores assigned by each of the three systems were compared with each other and with the actual treatment delivered. Concordance of care with appropriateness score was then correlated with outcome.

Results:There were significant differences among all three scoring systems in their ratings and in the concordance of treatment with appropriateness rating. When treatment provided was concordant with RAND rating, there was a lower occurrence of subsequent coronary artery bypass grafting (CABG), the composite end point of either CABG or percutaneous transluminal coronary angioplasty (PTCA), and the composite end point of death, myocardial infarction (MI), or revascularization. When treatment was concordant with the ACC/AHA guidelines, there was lower occurrence of all‐cause mortality, PTCA, the composite end point of either CABG or PTCA, and the composite end point of death, MI, or revascularization. When treatment provided was concordant with the RAS, there was lower occurrence of cardiac death, all‐cause death, CABG, the composite end point of either CABG or PTCA, and the composite end point of death, MI, or revascularization.

Conclusions:The RAS is a simple scoring system to assess revascularization appropriateness. When the RAND, ACC/AHA, and RAS systems are compared in a catheterization laboratory population, they rate the same patient differently and vary in their correlation of appropriateness rating with outcome.
An Electrocardiographic Algorithm for the Prediction of the Culprit Lesion Site in Acute Anterior Myocardial Infarction
Authors: Kim Thomas Y. , Alturk Najib , Shaikh Nasir , Kelen George , Salazar Manny , Grodman Richard
Published: February 2009

Background:Although the 12‐lead electrocardiogram (ECG) has been found useful in identifying the left anterior descending (LAD) coronary artery as the infarct‐related artery in acute myocardial infarction (MI), it has traditionally been felt to be incapable of localizing the culprit lesion within the LAD itself. Such a capability would be important, because anterior MI due to proximal LAD lesions carry a much worse prognosis than those due to more distal or branch vessel lesions.

Hypothesis:This study investigated whether certain ECG variables—especially an ST‐segment injury pattern in leads aVL and/or V1—would correlate with culprit lesion site, and an ECG algorithm was developed to predict culprit lesion site.

Methods:The initial ECGs of 55 patients who had undergone cardiac catheterization after an anterior or lateral MI were reviewed to identify the leads with an ST‐segment injury pattern; the corresponding catheterization films were then reviewed to identify the location of the culprit lesion; and these separate findings were then compared.

Results:The sensitivity and specificity of an ST‐injury pattern in a VL in predicting a culprit lesion before the first diagonal branch were 91 and 90%, respectively; the same values in predicting a lesion prior to the first septal branch were 85 and 78%. ST‐segment elevation in V1, on the other hand, was a much less sensitive and specific predictor of a preseptal lesion. Overall, our algorithm correctly identified the culprit lesion location in 82% of our patients.

Conclusion:Based on our findings, we conclude that an ST‐segment injury pattern in a VL during an anterior myocardial infarction predominantly reflects a proximal LAD lesion and therefore constitutes a high‐risk finding.
Lack of association between prior infection with chlamydia pneumoniaeand acute or chronic coronary artery disease
Authors: Altman Raul , Rouvier Jorge , Scazziota Alejandra , Gonzalez Claudio , Absi Ruben S.
Published: February 2009

Hypothesis: The study was designed to establish a lack of relationship between chronic C. pneumoniae infection and CHD.

Methods: Chlamydia‐specific IgG‐antibody was assayed using an indirect immunofluorescence test in the serum of 159 patients with severe arterial disease and 203 patients with a heart valve prostheses and no demonstrable CHD. Fatal and nonfatal vascular events and systemic thromboembolism were recorded over a 2‐year period.

Results: In the arterial group 107 patients (67.3%) and in the valvular group 120/203 (59.1%) were positive for C. pneumoniae antibody. The number of patients with fatal or nonfatal vascular events (double end point) in the arterial and valvular groups was 23 and 2, respectively (p<.0001). Triple end points (fatal plus nonfatal vascular events plus thromboembolism) were also more frequent in the arterial group (p< 0.002). The prevalence of chlamydia antibody positivity was the same in the arterial and valvular groups, and the occurrence of clinical events was also the same for chlamydia‐positive (227 patients) as for chlamydia‐negative (135 patients). After adjustment for confounding variables, only arterial disease was a predictive factor for double (OR 17.0; 95% CI 3.94–73.3) or triple (OR 3.12; 95% CI 1.56–6.25) end points.

Conclusion: We find C. pneumoniae chronic infection not to be an independent risk factor for acute or chronic arterial disease.
Effect of aprindine on heart rate variability indices in patients with ischemic heart disease
Authors: Takase Bonpei , Arakawa Koh , Satomura Kimio , Ohsuzu Fumitaka , Uehata Akimi , Nishioka Toshihiko , Kurita Akira
Published: February 2009

Background: Decreased heart rate variability indices (HRV) are associated with untoward outcome of patients with ischemic heart disease (IHD). Most class I antiarrhythmic agents decrease HRV, but aprindine (a new class I antiarrhythmic agent) is reported to increase HRV in patients without ischemia.

Hypothesis: The study was undertaken to determine whether aprindine might increase HRV in patients with IHD.

Methods: To investigate the effect of aprindine on HRV in patients with IHD, we performed 24‐h ambulatory electrocardiogram (ECG) at the end of placebo and aprindine (60 mg daily) treatment phases on 38 patients with IHD and at least isolated premature ventricular contractions (PVC). The study protocol utilized a single blind, 4‐week, placebo‐controlled design. Heart rate variability from ambulatory ECG included SDNN (ms), SDANN (ms), SD (ms), rMSSD (ms), pNN50 (%); frequency analysis of HRV consisting of total (ms, 0.01–1.00 Hz), low (ms, 0.04–0.15 Hz), and high (ms, 0.15–0.40 Hz) components.

Results: Study patients were divided into three groups according to the severity of IHD and antiarrhythmic efficacy of aprindine. Group 1 consisted of 15 patients with angina with single‐vessel disease, and Group 2 was composed of 10 patients with either multivessel disease or post myocardial infarction; PVCs decreased in both groups as a result of aprindine treatment. Group 3 consisted of 13 patients who showed no decreased PVC after aprindine treatment. RMSSD increased, and pNN50 and high‐frequency spectra tended to increase in Group 1, while SD, rMSSD, pNN50, and total and low‐frequency spectra decreased in Group 3; no significant changes were observed in Group 2. Aprindine significantly augments vagal activity, as reflected by the increase of rMSSD, pNN50, and high‐frequency spectra in mild IHD.

Conclusion: These salutary effects are less in more severe IHD, but aprindine does not aggravate HRV. Thus, if there are salutary effects on arrhythmias and no proarrhythmic effects, aprindine could be prescribed to patients with IHD without concern about decreasing HRV.
Differential hormonal profiles of adrenomedullin and proadrenomedullin n‐terminal 20 peptide in patients with heart failure and effect of treatment on their plasma levels
Authors: Etoh Takuma , Kato Johji , Takenaga Makoto , Imamura Takuroh , Kitamura Kazuo , Koiwaya Yasushi , Eto Tanenao
Published: February 2009

Background: Adrenomedullin (AM) is a potent vasodilatory peptide discovered in human pheochromocytoma tissue. Proadrenomedullin N‐terminal 20 peptide (PAMP) processed from an AM precursor is also a novel hypotensive peptide which inhibits catecholamine secretion from sympathetic nerve endings.

Hypothesis: The present study sought to examine the relationships between the two peptides and other clinical parameters by measuring the plasma AM and PAMP concentrations in 98 patients with heart failure.

Methods: In all, 98 patients [65 men and 33 women, aged 58.2 ± 11.0 years, mean ± standard deviation (SD)] with heart failure and 26 healthy volunteers (12 men and 14 women, aged 54.1 ± 8.6 years) were examined in this study. Heart failure was secondary to previous myocardial infarction in 58 patients, valvular disease in 28, cardiomyopathy in 9, and congenital heart disease in 3. All patients were classified into two groups of class I or II (Group 1) and class III or IV (Group 2) according to the New York Heart Association (NYHA) functional classification.

Results: Both plasma AM and PAMP concentrations in the patients were significantly higher than those in healthy volunteers. In addition, plasma AM and PAMP concentrations in patients in class III or IV of New York Heart Association (NYHA) classification were significantly higher than those in NYHA class I or II. The elevated plasma concentrations of these peptides in patients in NYHA class III or IV significantly decreased in response to the treatment for 7 days. There was a significant correlation between plasma AM and PAMP, though the plasma concentration of PAMP was one‐fifth to one‐seventh of that of AM in patients and controls. The plasma AM concentration correlated significantly with the plasma concentrations of atrial and brain natriuretic peptides, epinephrine, and right atrial pressure, whereas such a relationship was not noted for the plasma PAMP concentration.

Conclusions: Judging from the difference in not only the biological actions but also the hormonal profiles between AM and PAMP, they may differentially modulate the cardiovascular system in patients with heart failure, although they are processed from the same precursor.
Isolated left ventricular abnormal trabeculation in adults is associated with neuromuscular disorders
Authors: Finsterer Josef , Blazer Gerhard , Stöllberger Claudia , Valentin Andreas , Tscholakoff Dimiter
Published: February 2009

Background: Isolated left ventricular abnormal trabeculation (ILVAT) is defined as < 3 coarse trabeculations of the left ventricular wall, apically to the papillary muscles, in hearts without congenital malformations.

Hypothesis: The aims of the study were to assess by echocardiography the prevalence of ILVAT, to confirm the diagnosis by cardiac magnetic resonance imaging (CMRI), to look for cardiac findings in ILVAT, and to determine whether ILVAT is familial and associated with neurological disorders.

Methods: During a 1‐year period (July 1995 to July 1996) all patients in whom transthoracic echocardiography visualized ILVAT, were included in the study. The examination and measurements were performed according to established guidelines.

Results: During 1 year, ILVAT was found in 6 of 3,397 patients (0.2%). When applied, CMRI confirmed ILVAT. Four patients had heart failure, all had electrocardiographic (ECG) abnormalities. None of the investigated relatives showed ILVAT. One patient had Becker's muscular dystrophy, three had mitochondrial myopathy, one had polyneuropathy, and one had muscle wasting of unknown origin.

Conclusions: Isolated left ventricular abnormal trabeculation is rare, visible on echocardiography and CMRI, associated with ECG abnormalities, sometimes with heart failure, and always with neuromuscular disorders. Thus, when ILVAT is found, the cardiologist should consider a neurology referral.
Multiple coronary occlusions associated with ST‐segment elevation
Authors: Dhond Milind R. , Kang June , Wentzien Thomas , Amsterdam Ezra A.
Published: February 2009

We describe the case of a patient with rapid sequential ST‐segment elevation in different areas on the electrocardiogram (ECG) associated with lesions of differing etiologies in the corresponding coronary arteries. Prior reports of ST‐segment elevations in multiple areas on the ECG have been from obstructions of single coronary vessels whose distribution overlapped separate areas on the ECG or spasm of multiple coronary arteries. We could find no prior reports of such rapid sequential ST‐elevation in different areas on the ECG caused by two differing etiologies.
Potential proarrhythmic effects of implantable cardioverter‐defibrillators
Authors: Duru Firat , Candinas Reto
Published: February 2009

Implantable cardioverter‐defibrillator (ICD) interventions have the potential to be proarrhythmogenic. New arrhythmias can occur in the setting of clinically appropriate therapies, as well as during a cardiac rhythm for which therapy is not intended. Cardioversion/defibrillation therapies, antitachycardia pacing, and antibradycardia pacing are potential triggers for the development of new arrhythmias. Newer ICDs allow better recognition and interpretation of the arrhythmias that are induced by delivered therapies. Two cases of ICD‐induced proarrhythmias are described. Based on the course of these patients and review of previous reports, proarrhythmic effects of ICD interventions along with prevention and management strategies are discussed.
NC100100, a new echo contrast agent for the assessment of myocardial perfusion—safety and comparison with technetium‐99m sestamibi single‐photon emission computed tomography in a randomized multicenter study
Authors: Binder Thomas , Assayag Patrick , Baer Frank , Flachskampf Frank , Kamp Otto , Nienaber Christoph , Nihoyannopoulos Petros , Pi érard Luc , Steg Gabriel , Vanoverschelde Jean‐Louis , Wouw Poll Van Der , Meland Nils , Marelli Claudio , Lindvall Kaj
Published: February 2009

Background and hypothesis: Myocardial contrast echocardiography using second‐generation agents has been proposed to study myocardial perfusion. A placebo‐controlled, multi‐center trial was conducted to evaluate the safety, optimal dose, and imaging mode for NC100100, a novel intravenous second‐generation echo contrast agent, and to compare this technique with technetium ‐ 99m sestamibi (MIBI) single‐photon emission computed tomography (SPECT).

Methods: In a placebo‐controlled, multicenter trial, 203 patients with myocardial infarction > 5 days and < 1 year previously underwent rest SPECT and MCE. Fundamental and harmonic imaging modes combined with continuous and electrocardiogram‐ (ECG) triggered intermittent imaging were used. Six dose groups (0.030, 0.100, and 0.300 μl particles/kg body weight for fundamental imaging; and 0.006, 0.030, and 0.150 μl particles/kg body weight for harmonic imaging) were tested. A saline group was also included. Safety was followed for 72 h after contrast injection. Myocardial perfusion by MCE was compared with myocardial rest perfusion imaging using MIBI as a tracer.

Results: NC100100 was well tolerated. No serious adverse events or deaths occurred. No clinically relevant changes in vital signs, laboratory parameters, and ECG recordings were noted. There was no significant difference between adverse events in the NC100100 (25.7%) and in the placebo group (17.9%, p=0.3). Intermittent harmonic imaging using the intermediate dose was superior to all other modalities, allowing the assessment of perfusion in 76% of all segments. Eighty segments (96%) with normal perfusion by SPECT imaging also showed myocardial perfusion with MCE. However, a substantial percentage of segments (61–80%) with perfusion defects by SPECT imaging also showed opacification by MCE. This resulted in an overall agreement of 66–81% and a high specificity (80–96%), but in low sensitivity (20–39%) of MCE for the detection of perfusion defects.

Conclusion: NC100100 is safe in patients with myocardial infarction. Intermittent harmonic imaging with a dose of 0.03 μl particles/kg body weight can be proposed as the best imaging protocol. Myocardial contrast echocardiography with NC 100100 provides perfusion information in approximately 76% of segments and results in myocardial opacification in the vast majority of segments with normal perfusion as assessed by SPECT. Although the discrepancies between MCE and SPECT with regard to the definition of perfusion defects requires further investigation, MCE with NC 100100 is a promising technique for the noninvasive assessment of myocardial perfusion.
Assessment of quality of life in patients with chest pain and normal coronary arteriogram (syndrome x) using a specific questionnaire
Authors: Atienza Felipe , Velasco José A. , Ridocci Francisco , Brown Sue , Kaski Juan Carlos
Published: February 2009

Background: Prognosis in patients with syndrome X (chest pain and normal coronary arteriograms) is good; however, persistent chest pain and functional disability are common in these patients. Accurate assessment of quality of life may be useful for patient management.

Aim: The quality of life status in patients with syndrome X was assessed using a specific questionnaire. This questionnaire was developed and validated for the assessment of quality of life in patients with typical chest pain despite normal coronary arteriograms.

Methods: Ninety consecutive patients were invited to complete both the questionnaire (on two occasions within 2 weeks) and a standardized angina diary. Fully completed questionnaires were received from 66 (73%) patients (mean age 58±8 years, 55 women).

Results: Answers were scored according to a grading system where higher scores indicate worse quality of life. We observed that total scores increased with severity of angina (Canadian Class I, 38±16, II: 93±29, III–IV, 119±23; p<0.001) and correlated with both the number and the severity of chest pain episodes (r=0.50–0.66: p<0.001). In patients who remained clinically stable (n=37) during the 2‐week assessment, test‐retest analysis showed no score differences (87±30 vs. 81±30; p=0.1), while total score increased in patients (n=24) whose symptoms worsened (108±31 vs. 116±31; p < 0.02) and was reduced in those (n=5) whose symptoms improved (55±37 vs. 39±28; p<0.04).

Conclusion: Our study shows that quality of life is significantly impaired in patients with syndrome X and that the specific questionnaire used for assessment is a reliable and sensitive tool for the evaluation of quality of life in patients with chest pain and normal coronary arteriograms.
Antigens of the major histocompatibility system in ischemic heart disease and idiopathic dilated cardiomyopathy
Authors: Osa Ana , Almenar Luis , Palencia Miguel , Puig Nieves , Montoro Jose , Chirivella Melitina
Published: February 2009

Background: Although dilated cardiomyopathy (DCM) is a disease of unknown and probably multifactorial etiology, a change in immune mechanisms is presumably significant, with many abnormalities in humoral and cellular responses having been reported. The heart thus becomes the target organ for an initial episode of myocardial damage that triggers an autoimmune response.

Hypothesis: The purpose of this study was to analyze the frequency of different human leukocyte antigens in patients with a diagnosis of well‐advanced DCM and ischemic heart failure, comparing them with a control group of presumably healthy subjects.

Methods: The group with dilated cardiomyopathy consisted of 50 patients (7 women and 43 men), aged from 14 to 64 years. The group with ischemic heart disease included 76 patients (4 women and 72 men), with ages ranging from 34 to 64. The control group, consisting of 1,337 presumably healthy subjects from the Spanish Mediterranean area, was recruited based on paternity studies.

Results: Compared with the control group, we found in DCM a greater incidence of B15 (20 vs. 6%) and DQ 3 (83 vs. 50%) antigens. In ischemic heart disease we found a lower incidence of A1 (3 vs. 22%), B8 (5 vs. 12%), and DQ2 (16 vs. 50%) in comparison with the control group.

Conclusions: In the Spanish Mediterranean area, the presence of antigens B‐15 and DQ3 would be associated with advanced DCM. The absence of antigens A1, B8, and DQ2 would be associated with the occurrence of severe ischemic heart disease.
Acquired coronary cameral fistulas: Are these collaterals losing their destination?
Authors: Said SalahA. M. , Werf Tjeerd Van Der
Published: February 2009

Background: The majority of coronary cameral fistulas (CCFs) are congenital in origin. On the other hand, acquired coronary cameral fistulas, having various etiopathogenic origins, are increasingly recognized.

Hypothesis: The aim of this study was to assess the possible involvement of coronary atherosclerosis in the pathogenesis of acquired coronary cameral fistulas.

Methods: Between 1993 and 1996 coronary cameral fistulas were detected in seven adults patients with coronary atherosclerosis (n = 4) and following myocardial infarction (n = 3) with a mean age of 59.3 years (range 40–77). They were analyzed at our hospital.

Results: Myocardial infarction (MI) was documented in six patients and was localized at the same territory of the fistula‐related artery in three of them. All patients remained asymptomatic after the detection of the fistula. Five patients had associated cardiac disorders. Two patients were treated conservatively with medical therapy. Coronary artery bypass grafting (CABG) was performed in three patients. One patient died while awaiting CABG. Thirty‐four adult cases with acquired CCFs were collected from the current literature. The right coronary artery was the origin of the fistula in 37% and they terminated into the right heart‐side in 72% of cases. They remained asymptomatic in 62% of cases.

Conclusions: It could be concluded that acquired CCFs may complicate the course of severe atherosclerosis or myocardial infarction in certain adult patients. The symptomatology and treatment strategy is comparable in the congenital and acquired types. The distribution of involvement of the right or left coronary arteries is equally divided in both the acquired and congenital types. Further studies are needed to investigate the precipitating factors for the occurrence of and incidence of acquired CCFs in patients with severe atherosclerosis or post‐MI subjects.
Digital assessment of the epicardial electrocardiogram: Novel methodology for a core laboratory for clinical studies
Authors: Willis Hurst J. , Bertolet Barry E. , Boyette Alice F. , Handberg‐Thurmond Eileen M. , Wolf Robert A. , Deitchman David , Blumenthal Mel , Pepine Carl J.
Published: February 2009

Background: The epicardial electrocardiogram (ECG) is a sensitive marker for cardiac ischemia and has been used as a measure of ischemia in clinical trials. We sought to examine the utility of a central ECG laboratory for determining ischemic‐type ST‐segment shifts from epicardial ECG recordings obtained from multiple clinical sites.

Hypothesis: We speculated that an operator‐assisted digital ECG core laboratory is feasible, reliable, and efficient, with the ability for rapid and accurate interpretation of the epicardial ECG.

Methods: The epicardial ECG was recorded via an angioplasty guidewire placed in a coronary artery of a patient undergoing angioplasty. Site investigators visually determined the time‐to‐onset of 0.1 and 0.3 mm ST‐segment elevation, and the maximal ST‐segment elevation during balloon inflation, and then compared the measurements with those made at an operator‐assisted digital ECG core laboratory.

Results: Agreement between the two methods occurred in 78% of the time‐to‐onset measurements, but in only 39% of the maximal ST‐segment measurements. Overall, the visual measurements of the clinical investigators of time‐to‐onset differed from the digital core laboratory by 11.8 ± 11.6 s for 0.1 mV, and 15.8 ± 20.6 s for 0.3 mV. Recorded maximal ST‐segment shifts differed by a mean of 0.47 ± 0.69 mV.

Conclusion: The magnitude of inconsistency between the ECG core laboratory results using an operator‐assisted digital method and the interpretations of clinical investigators using manual caliper‐type analysis was surprisingly large. These results support the need for an ECG core laboratory in clinical trials where ECG ST‐segment shifts are used as a response variable.
Transient effusive‐constrictive pericarditis due to chemotherapy
Authors: Woods Timothy , Vidarsson Brynjar , Mosher Deane , Stein James H.
Published: February 2009

Commonly used chemotherapeutic agents, specifically cytarabine and daunorubicin, can cause effusive‐constrictive pericarditis. We describe a case of transient effusive‐constrictive pericarditis in a patient with acute myelogenous leukemia. This is the first case report of a patient with transient effusive‐constrictive pericarditis due to chemotherapy.
ILEAD‐ischemia of the lower extremities due to aortic dissection: The isolated presentation
Authors: Spodick David
Published: February 2009

Background and hypothesis: Lower extremity symptoms accompanying dissecting hematomas of the aorta are well described. Isolated lower extremity ischemia as the presenting syndrome of aortic dissection is rare and frequently misinterpreted so that the diagnosis of aortic dissection is delayed or missed, often with catastrophic results. This study was undertaken to determine its common characteristics and to reinforce recognition of this life‐threatening phenomenon.

Methods: After the first patient in our series presented with isolated lower extremity ischemia due to aortic dissection, a prospective search for similar presentations was undertaken over 2 years. We also conducted a retrospective search for all aortic dissections at our hospital for the past 10 years and a MEDLINE search for all reported aortic dissections in the literature of the past 20 years, as well as for all reports of isolated ischemia of the lower extremities due to aortic dissection.

Results: Three patients with isolated ischemia of the lower extremities due to aortic dissection were found prospectively after the index case. Over 10 years, 40 patients with acute aortic dissection were diagnosed at our hospital. The MEDLINE search revealed 1,751 aortic dissections of which 10% had lower extremity symptoms. Only 10 cases of aortic dissection were reported as lower extremity ischemia with symptoms isolated to one or both lower extremities. Smoking, hypertension, male gender, hypercholesterolemia, and recent history of coronary artery bypass grafting were common predisposing risk factors for this rare presentation.

Conclusion: Symptomatic isolated ischemia of the lower extremities due to aortic dissection is rare and often missed. Awareness of its characteristics, aided by the acronym ILEAD, made it possible to suspect the true origin of this misleading syndrome.
Antianginal and anti‐ischemic effects of nisoldipine and ramipril in patients with syndrome X
Authors: Özçelik Fatih , Altun Armaǧan , Özbay Gultaç
Published: February 2009

Background: Syndrome X is defined as typical angina pectoris, positive treadmill exercise test, negative intravenous ergonovine test, and angiographically normal coronary arteries.

Hypothesis: in the present study, we investigated the anti‐ischemic and antianginal effects of nisoldipine and ramipril in patients with syndrome X.

Methods: After 2 weeks of the first wash‐out period, 18 patients (7 men, 11 women, age 46 ± 10 years) were given nisoldipine (NIS) 5 mg twice daily for 4 weeks, and after 2 weeks of the second wash‐out period, the same patients were given ramipril (RAM) 2.5 mg once daily for 4 weeks. A treadmill exercise test with modified Bruce protocol was performed at the end of each period.

Results: The time to angina in exercise (607 ± 115 s‐650 ± 117 s, p = 0.006, vs. 630 ± 114 s‐660 ± 123 s, p = 0.02), total exercise time (612 ± 110 s‐656 ± 114 s, p = 0.0008, vs. 630 ± 114 s‐660 ± 123 s, p = 0.02), and maximum MET value (11.09 ± 2.08–11.86 ± 2.04, p = 0.0016, vs. 11.42 ± 2.09–12.2 ± 2.26, p = 0.01) were increased significantly with both therapy modalities. The time to 1 mm ST‐segment depression (123 ± 93 s ‐ 220 ± 172 s, p = 0.002) was increased significantly with NIS therapy. The time to ST‐segment recovery (434 ± 268 s‐330 ± 233 s, p = 0.016 vs. 443 ± 289 s‐370 ± 278 s, p = 0.012), the frequency of anginal attacks per week (1.27 ± 1.4–0 ± 0.38, p = 0.005, vs. 1 ± 1.32–0.33 ± 0.59, p = 0.028), and the need for sublingual nitroglycerin (1.16 ± 1.29–0.11 ± 0.32, p = 0.005, vs. 0.94 ± 1.16–0.27 ± 0.57, p = 0.012) were decreased significantly with both drugs.

Conclusion: We observed that 10 mg daily NIS and 2.5 mg daily RAM have similar anti‐ischemic and antianginal effects in patients with syndrome X.
Physician risk assessment and apache scores in cardiac care units
Authors: Pierpont Gordon L. , Parenti Connie M.
Published: February 2009

Background: The need to correct outcome data for case mix is well recognized, but risk assessment for coronary care unit (CCU) patients remains problematic.

Hypothesis: This study determined the feasibility of using physicians' opinions to predict mortality for CCU patients and compared their results to Acute Physiology and Chronic Health Evaluation II (APACHE II) scores.

Methods: A prospective observational study was performed on consecutive patients admitted to a university‐affiliated Veterans Affairs Medical Center CCU over a 2‐month period. Physician assessment of likely mortality during hospitalization, obtained using an MD Prognosis Score ranging from 1 (best) to 7 (worst), was compared with APACHE II scores.

Results: MD Prognosis Scores were obtained on 122 of the 237 eligible patients (51% response rate) and averaged 2.3 ± 1.4 (mean ± standard deviation). APACHE II scores on these patients averaged 9.9 ± 4.8 (range 2‐29) with very poor correlation between the two methods (r = 0.3). Of the four patients who died, three had MD prognosis scores of 7. None of the survivors had scores of 7 and only three had scores of 6. APACHE II did not predict a high likelihood that any of the patients would die (none with > 90% likelihood of mortality).

Conclusions: APACHE scores are inadequate for cardiac patients. Although physicians can identify CCU patients most likely to die, reliance on physicians scoring systems is limited by difficulties in obtaining their opinion. A new method of risk assessment for acutely ill cardiac patients is needed if CCU outcomes are to be compared across institutions.
The use of the New york heart association's classification of cardiovascular disease as part of the patient's complete problem list
Authors: Hurst J. Willis , Morris Douglas C. , Alexander R. Wayne
Published: February 2009

This paper extols the value of combining two systems in order to improve learning, teaching, communication, patient care, and clinical research in patients with heart disease. This is accomplished by using Weed's recommendation regarding the creation of a complete Problem List and, within this context, characterizing the cardiac or vascular problem according to the recommendations of the New York Heart Association.
QRS prolongation on the signal‐averaged electrocardiogram versus st‐segment changes on the 12‐lead electrocardiogram: Which is the most sensitive electrocardiographic marker of myocardial ischemia?
Authors: Michaelides Andreas P. , Dilaveris Polychronis E. , Psomadaki Zoi D. , Richter Dimitris J. , Andrikopoulos George K. , Pitsilides Nikolaos , Stefanadis Christodoulos , Toutouzas Pavlos K. , Dounis Vasilios
Published: February 2009

Background: ST‐segment changes and QRS prolongation are electrocardiographic (ECG) markers of myocardial ischemia.

Hypothesis: This study was undertaken to investigate the appearance of QRS duration changes with or without concomitant ST‐segment changes during a typical anginal episode.

Methods: For this purpose, 126 patients underwent 12‐lead surface ECG and signal‐averaged electrocardiogram (SAECG) during typical anginal pain as well as at the time the patient was asymptomatic. In both periods, QRS duration and ST‐segment changes were evaluated. All patients underwent cardiac catheterization.

Results: Of the 126 patients, 108 (86%) had coronary artery disease (CAD), whereas the remaining 18 (14%) patients had normal coronary arteriograms. During typical anginal pain, 75 of the 108 (70%) patients with CAD and 2 of the 18 (11%) patients with normal coronary arteriograms developed QRS prolongation, whereas 60 of the 108 (56%) patients with CAD and 2 of the 18 (11%) patients with normal coronary vessels developed ST‐segment changes. Thus, the sensitivities of QRS prolongation measured by SAECG and of ST‐segment changes on the surface ECG for the detection of myocardial ischemia were found to be 70 and 56%, respectively, (p <0.01), whereas the specificities were both found to be 89% (p=NS).

Conclusions: During typical anginal pain, QRS prolongation on the SAECG is more sensitive than are ST‐segment changes on the ECG for the detection of myocardial ischemia.
QT dispersion plus st‐segment depression: A new predictor of restenosis after successful percutaneous transluminal coronary angioplasty
Authors: Aytemir Kudret , Özer Necla , Aksöyek Serdar , Özkutlu Hilmi , Oto Ali , Özmen Ferhan
Published: February 2009

Background: ST‐segment depression during exercise testing is frequently observed in the absence of restenosis after percutaneous transluminal coronary angioplasty (PTCA).

Hypothesis: With the goal of improving the prediction of restenosis after PTCA, we evaluated the usefulness of ST‐segment depression plus QT dispersion (QTd = QT max ‐ QTmin) during treadmill stress test.

Methods and results: Fifty‐six patients (37 men, 19 women, mean age 51 ± 14 years) were evaluated with treadmill exercise testing and coronary angiography 7 ± 5 months after PTCA. Treadmill test was positive in 30 patients and negative in 26 patients. At coronary angiography, restenosis was present in 16 patients with positive exercise electrocardiogram (ECG) and in 6 patients with negative exercise ECG. Fourteen patients with a positive stress test did not have restenosis. There was no difference in QTd values between groups at baseline (p> 0.05). Exercise QTd was 63 ± 9 ms in patients with positive exercise test, 54 ± 18 ms in patients with negative exercise test (p=0.003), 71 ± 13 ms in patients with restenosis, and 53 ± 17 ms in patients without restenosis (p=0.001). ST‐segment depression during the stress test determined restenosis with a sensitivity of 80% and a specificity of 58%. Sensitivity and specificity of QTd of ≥60 ms for prediction of restenosis were 83 and 61%, respectively. When QTd of ≥60 ms was added to ST‐segment depression as a condition for positive test, the sensitivity and specificity increased to 91 and 78%, respectively. QT dispersion plus ST‐segment depression had higher sensitivity and specificity than either QTd or ST‐segment depression alone (p <0.05).

Conclusion: The addition of QTd to ST‐segment depression during exercise test improves the diagnostic value and can be used as a noninvasive tool in the diagnosis of restenosis after PTCA.
Coronary dissection and thrombosis associated with exercise testing three months after successful coronary stenting
Authors: Maraj Rajiv , Fraifeld Moises , Owen Alyson N. , Kotler Morris N. , Yazdanfar Shahriar
Published: February 2009

Exercise testing is commonly performed to assess the functional result of coronary revascularization procedures and is usually not associated with any complications. However, this report documents a rare case of coronary dissection and thrombosis, which resulted in an acute myocardial infarction, in a patient who underwent stress testing 3 months following successful coronary stent implantation.
Metastatic germ cell tumor to the heart presenting with syncope
Authors: Vohra Ameet , Saiz Enma , Davila Enrique , Burkle Jaime
Published: February 2009

Malignant nonseminomatous germ cell tumors (NSGCT) rarely metastasize to the heart. The first such case presenting with syncope is described. Eight previously described cases of NSGCT with intracaval metastasis to the heart are reviewed and the literature to date is discussed. Transesophageal echocardiography is the diagnostic study of choice and treatment consists primarily of platinum‐based chemotherapy followed by surgical resection of residual deposits.
Predicting mitral regurgitation following percutaneous mitral valvotomy with the inoue balloon: Comparison of two echocardiographic scoring systems
Authors: Mezilis Nick E. , Salame Mohamed Y. , Oakley G. David G.
Published: February 2009

Background: Percutaneous balloon mitral valvotomy (PBMV) has become the procedure of choice for many patients with symptomatic mitral stenosis. However, the development of significant mitral regurgitation (MR) remains an infrequent but very important complication. The echocardiographic scoring system described by Padial et al. has been successful in predicting the development of severe MR following PBMV using the double balloon technique.

Hypothesis: We aimed to assess the applicability of this new scoring system in predicting a significant increase in MR with the Inoue balloon and to compare it with the established Wilkins score.

Methods: The echocardiograms of 23 patients who had undergone PBMV for symptomatic mitral stenosis were analyzed retrospectively using both scoring systems, and the severity of MR was determined from pre‐ and postprocedure studies.

Results: Post PBMV, significant MR occurred in four patients (17%) while severe MR occurred in two patients (9%). Padial scores [mean (standard error of the mean)] in the group of patients with and without significant MR were [9.1 (0.8)] and [6.0 (0.3)], respectively (p = 0.002), while the Wilkins score was [7.5 (1.0)] and [6.4 (0.5)], respectively (p = 0.3). Using 8 as a cutoff point, the sensitivity and specificity of the newer scoring system was 83 and 100%, respectively, while the sensitivity and specificity of the Wilkins score was 50 and 50%, respectively. The positive predictive value >8 was 100% (4/4) for the Padial and 25% (1/4) for the Wilkins system. Accordingly, the negative predictive value <8 was 89% (17/19) for the Padial and 73% (14/19) for the Wilkins system.

Conclusion: The newer scoring system is better at reliably identifying patients at risk of developing significant MR from PBMV with the Inoue balloon.
Left ventricular filling in the hypertensive patient: Long‐Term course and influence of treatment
Authors: Gosse Philippe , Jullien Veronique , Jarnier Philippe , Lemetayer Philippe , Clementy Jacques
Published: February 2009

Background: Hypertension is accompanied by abnormalities in left ventricular filling; however, there is a lack of agreement on the extent of the influence of antihypertensive treatment on them.

Hypothesis: The present study was designed to evaluate the long‐term course of these abnormalities in both treated and untreated hypertensive patients.

Methods: Left ventricular filling assessed by pulsed Doppler echocardiography of mitral flow was studied over a long follow‐up period in both untreated and treated hypertensive patients. This retrospective study included 73 hypertensive patients who had not received any treatment. They had been followed up for at least 3 years and were divided a posteriori into two groups: Group 1 comprised the untreated patients, while Group 2 included the patients who had received antihypertensive treatment throughout the follow‐up period.

Results: in the overall population, age and heart rate measured during the Doppler examination were the only parameters that correlated significantly with mitral flow. No significant changes in blood pressure or left ventricular mass were observed in Group 1 (14 patients) over the study period. There was a slight but nonsignificant decrease in E/A ratio of mitral flow. in the treated patients, there was a drop in heart rate‐adjusted E/A ratio, despite a reduction in blood pressure and left ventricular mass, at mean follow‐up of 5 years.

Conclusion: Antihypertensive therapy did not arrest the long‐term reduction in E/A ratio in hypertensive patients despite reduction in blood pressure and left ventricular mass.