bluuebunny/crossref_metadata_2025 huggingface dataset:
Early and late potentials in postinfarction patients
Authors: Walczak F. , Kepski R. , Hoffman M.
Published: February 2009

Injury within the myocardium may cause disturbances of the intraventricular conduction and may be manifested by altered spectrum of the QRS complex. The purpose of this report is to indicate the existence of microvolt early waves appearing at the beginning of the QRS complex in some postinfarction patients with low ejection fraction. The method used incorporated the high resolution ECG recording, where the “pyramid” electrode location was applied. Results indicated a relationship between high frequency potentials, QRS duration time, and ejection fraction, as well as dependence between ventricular tachycardia/fibrillation (VT/VF) occurrence and early and/or late ventricular activity. In patients with secondary VT/VF where early and late potentials were found, the ejection fraction (EF) was the lowest (26 ±15%). Early waves appeared more often in patients with secondary VT/VF (30%) compared with those with primary VT/VF (8%). In patients without VT/VF and without myocardial infarction (MI) early potentials were not remarked. In those patients late potentials also appeared less often. It could be concluded that existence of early potentials, late activity, and significant prolonged total ventricular activation time is associated with wide dispersion and nonuniform delay of the electrical activity within the myocardium as well as with serious lowering of the ejection fraction. Therefore, existence of early waves seems to be a significant diagnostic factor for the poor hemodynamic condition as well as a serious warning for the recurrent late ventricular tachycardia/fibrillation.
Influence of atenolol on the relationship between heart rate and qt interval in patients with exercise‐induced myocardial ischemia
Authors: Ferraro Sergio , Maddalena Giovanni , D'Agosto Vicente , D'Alto Michele , Chiariello Massimo , Santomauro Maurizio , Romano Massimo , Fazio Serafino
Published: February 2009

The aim of this study was to analyze the relationship between heart rate and QT interval (HR‐QT) during exercise in control subjects (Group A) and in patients with coronary artery disease (CAD) with effort angina and without previous myocardial infarction (MI) (Group B). The diagnosis of CAD was confirmed by coronarographic examination. The correlation HR‐QT was significant (p <0.001) in both groups on effort and at recovery. The analysis of the regression HR‐QT was carried out separately, both on effort in upright position and at rest in supine position, to avoid the influence of posture on QT length. During effort, the regression line showed lower slope and intercept values in Group B (p<0.001) than those for Group A. A similar behavior was also observed at rest. Thus, at the highest heart rate, where ECG signs of ischemia (ST depression >1 mm) frequently occurred, a longer QT interval was present in Group B. Moreover, in Group B, the QT interval in the presence of ECG signs of ischemia was significantly longer (p<0.01) than in Group A at comparable heart rates both on effort and at rest, thereby confirming the result obtained by comparing both regression lines. The same effort protocol was repeated in Group B patients after acute administration of atenolol 100 mg per os. After atenolol administration, the analysis of the regression HR–QT in Group B clearly showed a shorter QT interval than that obtained in washout period during the baseline test at the highest heart rates where the ECG frequently showed signs of ischemia. This was proven by the presence of a higher slope (p < 0.05) of the regression line HR‐ QT during treatment compared with that obtained in the same group without therapy. In conclusion, transient myocardial ischemia provokes a longer QT interval in patients with CAD in comparison with normal subjects. Atenolol affected the HR–QT relationship showing a shorter QT interval at the highest heart rates, particularly when ECG showed signs of ischemia, compared with that achieved in the same patients in washout.
Evaluation of myocardial perfusion defects by means of “bull's eye” images
Authors: Minoves M. , Garcia A. , Pavia J. , Herranz R. , Setoain J. , Magriña J.
Published: February 2009

The purpose of this study was to evaluate the usefulness of so‐called “bull's eye” imaging as a simplified display of tomographic slices in the detection of coronary artery disease (CAD). A total of 64 patients were studied at stress and at rest, by single photon emission computed tomography (SPECT), either with thallium‐201 (201T1) or with technetium‐99m methoxy‐isobutyl‐isonitril (Tc‐MIBI). The myocardial perfusion defects detected by bull's eye image alone and in combination with visual analysis of tomographic images were evaluated in all cases, taking coronary arteriographic results as a gold standard. The overall sensitivity and specificity for detection of CAD were as follows: bull's eye imaging, 100% and 70.8%; tomographic imaging (SPECT), 90% and 91.6%. The results of bull's eye imaging and SPECT interpreted together were 96.6% and 83.3%. The regional sensitivity and specificity of bull's eye for individual coronary arteries were: right coronary artery (RCA), 100% and 73.7%; left anterior descending (LAD), 100% and 87.2%; left circumflex (LCx), 100% and 97.3%. For SPECT they were: RCA, 93.7% and 89.5%; LAD, 86.6% and 92.3%; LCx, 73.3% and 97.4%. For bull's eye with SPECT they were: RCA, 94.4% and 86.1%; LAD, 87.5% and 92.1%; LCx, 82.3% and 97.2%. We conclude that the bull's eye image display allows an easier and more objective assessment of myocardial perfusion defects and shows higher sensitivity. However, it has a relatively low specificity which can cause an over‐estimation of perfusion defects. Thus, visual analysis of bull's eye imaging is a useful diagnostic tool but must be evaluated in conjunction with tomographic imaging.
Duplex sonographic detection of internal jugular venous thrombosis after removal of central venous catheters
Authors: Karnik Ronald , Valentin Andreas , Winkler Walther‐Benedikt , Donath Peter , Slany Jörg
Published: February 2009

Venous thrombosis is a very common complication of central venous catheters inserted via the jugular or subclavian vein. The aim of this prospective study is to test the suitability of duplex sonography in detecting thrombi in the internal jugular vein after catheter removal and to analyze the number and extent of such thrombus formations. The study group comprised 64 consecutive patients with an average age of 59 ± 16 years admitted to an internal intensive care unit. In 54 cases the catheters were removed under sonographic control. In 10 cases duplex sonography was carried out within 24 h after removal of the catheters. The data of 63 patients were evaluated. In 40 patients (63.5%), thrombi of varying extent were present in the jugular vein. No significant correlations were found between thrombus formation and the basic disease, duration of cannulation, the type of catheters used, and the mode of heparinization (therapeutic vs. low‐dose). Local inflammation signs and local hematoma showed a significantly higher incidence (p < 0.01) in patients with thrombus formation. Duplex sonography lends itself as a valuable diagnostic tool in the diagnosis of thrombus formation in the internal jugular vein after removal of central venous catheters. Sonographic examinations should be carried out in all long‐stay patients at an intensive care unit, in whom central venous catheters are inserted repeatedly via the internal jugular vein.
Mitral regurgitation following first‐time acute myocardial infarction— early and late findings by doppler echocardiography
Authors: Alam Mahbubul , Thorstrand Curt , Rosenhamer Gunnar
Published: February 2009

A total of 61 patients with first‐time mild to moderate acute myocardial infarction and no reinfarction within the following 2 months were studied prospectively by Doppler echocardiography before hospital discharge and after 2 months to evaluate the prevalence of mitral regurgitation. Twenty‐one age‐matched healthy subjects served as controls. At baseline, the prevalence of Doppler‐recorded mitral regurgitation was 74% and 29% in patients and controls, respectively. In the patients, the regurgitant flow measured by color flow Doppler was 1.04 cm2 (range 0.2–8 cm2) and occupied 7.5% (range 2–45%) of the left atrial area. Corresponding figures for controls were 0.35 cm2 (0.1–0.6) and 2.4% (0.7–4.5), respectively. On continuous wave Doppler, most patients (33/45) had Doppler signals similar to those of healthy controls. The prevalence of mitral regurgitation was about the same in anterior and inferior infarction (75 and 72% respectively). In the patients, the prevalence was similar after 2 months (79%) with minor changes in the Doppler characteristics of the regurgitation (regurgitant flow 1.12 cm2 and occupying 8.1% of left atrial area). The study demonstrates that in a group of patients with first‐time mild to moderate myocardial infarction the prevalence of Doppler‐recorded mitral regurgitation is high and mild in severity in the majority of the cases. The changes remain almost similar even after 2 months.
Abnormal qt intervals associated with negative t waves induced by antiarrhythmic drugs are rapidly reduced using magnesium sulfate as an antidote
Authors: Gurfinkel Enrique , Mautner Branco , Pazos Angel Alvarez
Published: February 2009

This study was undertaken to determine whether prolonged QTc interval as a consequence of abnormal repolarization induced by coronary disease or antiarrhythmic drugs could be shortened by intravenous administration of magnesium sulfate. A total of 21 patients with basal prolonged QTc intervals (QTc > 500 ms) were divided in two groups: 7 with ischemic coronary disease and negative T waves (Group A), and 14 treated with antiarrhythmic drugs (Group B). Nine of the latter had negative T waves (Subgroup B‐1) and five had positive T waves (Subgroup B‐2) recorded in precordial leads. Nine patients were taking amiodarone and six quinidine. Magnesium sulfate was given intravenously in a bolus of 3.75 g (25% solution) over 3 min. Patients had normal electrolyte serum levels. The prolonged QTc and JTc intervals were shortened after magnesium sulfate in patients of Subgroup B‐1 from the basal values [QTc 20.7% and JTc 25.4%, (p = < 0.0001 and 0.02, respectively)]. None of the patients in Group A or Subgroup B‐2 experienced altered QTc or JTc intervals. While some antiarrhythmic drugs are capable of altering the refractoriness of ventricular cells, probably by causing changes in the intracellular metabolic pathways, in patients with coronary disease gaps in the membrane induced by ischemic injury let calcium enter the cells parallel with dispersion of ventricular repolarization. When secondary negative T waves are present, magnesium sulfate as an antidote probably acts as a blocking agent at the sarcoplasmic reticulum, thus reducing both QTc and JTc intervals.
Acute myocardial infarction with papillary muscle rupture
Authors: Hackel Donald B. , Wagner Galen S.
Published: February 2009

The subject of this report is a 57‐year‐old obese, hypertensive woman who had been well until the onset of severe chest pain and hypotension. She had to be defibrillated four times on her way to the hospital. The diagnosis of acute inferior‐posterior infarction was made by electrocardiogram (ECG) and there was a markedly elevated serum creatine kinase (CK) (including the MB fraction). The patient had a very low cardiac output and ejection fraction. A lung scan revealed possible pulmonary embolism for which she was anticoagulated. She remained hypotensive and hypoxemic and, on Day 17 of her hospital stay, she had a bout of severe dyspnea. A new systolic murmur was heard and the clinical diagnosis of ruptured papillary muscle was made and confirmed by echocardiography, and later at autopsy. All three coronary arteries were severely atherosclerotic and, in addition, the right coronary artery was completely closed by a thrombus. This case clearly illustrates the major pathological changes in the heart that correlate with the clinical findings in patients with a myocardial infarct that is complicated by left ventricular papillary muscle rupture. The pathophysiological effects of this condition, as illustrated in this case report, include the following:

1. The posterior papillary muscle was almost completely separated from its base, with only a thin strip of muscle intact. The mitral valve thus was insufficient (a “flail valve“); this markedly reduced the ejection fraction of the left ventricle, increased its end‐diastolic volume and pressure, produced a damming of blood in the pulmonary circulation, and this resulted in the pulmonary edema seen on the chest x‐ray.

2. Cardiac hypertrophy (weight = 561 g) was undoubtedly the result of the increased workload imposed on the left ventricle by the systemic arterial hypertension that this patient had for several years. A high blood pressure that persists after a myocardial infarct predisposes to myocardial rupture, but was probably not a risk factor in her case since it did not persist.

3. The cause of the myocardial infarct was the thrombotic occlusion of the right coronary artery (on top of severe three‐vessel coronary atherosclerosis), which resulted in infarction of the right as well as the posterior left ventricle and can partly explain the mistaken clinical impression that she had pulmonary emboli.
Infective endocarditis due to fusobacterium nucleatum: Case report and review of the literature
Authors: Shammas Nicolas W. , Murphy Gerald W. , Eichelberger James , Klee Daniel , Schwartz Ronald , Bachman William
Published: February 2009

Endocarditis caused by Fusobacterium nucleatum is exceedingly rare. We report a case of F. nucleatum right‐sided endocarditis in a patient with no known intravenous drug abuse. A detailed computer and manual search of the literature using Med‐Line and Index Medicus, respectively, revealed a total of five cases of endocarditis due to this species. The clinical characteristics and the patient's hospital course are summarized and reviewed.
The puzzle of normal coronary arteries in the patient with chest pain: What to do?
Authors: E. Assey Michael
Published: February 2009

Over one million Americans undergo cardiac catheterization each year because of chest pain, with the expectation that coronary artery disease will be found. However, up to 30%—a subgroup that includes patients with both cardiac and noncardiac pathology—will have angiographically normal coronary arteries. While the prognosis of the group as a whole is excellent, successful management requires a clear understanding of the multiple and varied conditions that can cause this syndrome.
Noninvasive detection of coronary artery disease by assessing diastolic abnormalities during low isometric exercise
Authors: Manolas Jan
Published: February 2009

The handgrip‐apexcardiographic test (HAT) is a simple low‐level (40% of maximal voluntary handgrip during 2 min) stress test which can detect left ventricular (LV) diastolic abnormalities. To determine whether it contributes to the diagnosis of coronary artery disease (CAD), HAT was obtained in 68 patients–47 with and 21 without angina pectoris–who prospectively underwent coronary arteriography. According to the highest or lowest individual values of diastolic apexcardiographic indices in 255 healthy volunteers, a pathologic or positive HAT was defined by the presence of at least one of the following new criteria: (1) A wave relative to total height of apexcardiogram during and/or after handgrip>21%, (2) total apexcardiographic relaxation time (TART) during handgrip>TART at rest > 143 ms and/or TART corrected for the duration of diastole (TARTT) during handgrip <0.14, or (3) diastolic amplitude time index (DATI), given by dividing TAR‐TI and A wave relative to total diastolic amplitude of apex tracing during handgrip<0.27. HAT was positive in 20 of 21 patients with single‐vessel disease (sensitivity 95%), 21 of 24 patients with double‐vessel disease (sensitivity 88%), and in 22 of 23 patients with triple‐vessel disease (sensitivity 96%). Furthermore, HAT was positive in 20 of 21 (95%) patients without symptoms. Thus, the overall sensitivity of HAT for detecting CAD was 93%. This study is the first to demonstrate the high sensitivity of HAT in identifying patients with CAD with or without symptoms by assessing diastolic apexcardiographic abnormalities during low‐level isometric stress. Thus, HAT potentially could become an additional simple diagnostic tool for noninvasive detection of patients with CAD.
Anatomy, histology, and pathology of the cardiac conduction system: Part I
Authors: F. Waller Bruce , E. Gering Lawrence , D. Slack John , A. Branyas Nancy
Published: February 2009

Normal anatomic and histologic features of the sinus node, atrial myocardium, and interatrial conduction of the cardiac impulse are reviewed. The controversy surrounding atrial conduction via specialized atrial cells versus specific in‐ternodal tracts (between sinus and atrioventricular nodes) is discussed.
Percutaneous mitral balloon valvotomy in a patient with coexistent mitral stenosis and hypertrophic cardiomyopathy
Authors: Chow Wing‐Hing , Chow Tsun‐Cheung , Wat Ming‐Sun , Cheung King‐Loong
Published: February 2009

A patient with coexistent mitral stenosis and hypertrophic cardiomyopathy is described, in whom symptoms related to impaired left ventricular diastolic filling improved after successful percutaneous mitral balloon valvotomy.
A simultaneous study of doppler‐echo and catheterization in noninvasive assessment of the left ventricular dp/dt
Authors: Ge Zhiming , Duran Carlos , Zhang Yun , Kang Weigiang , Fan Dongsheng
Published: February 2009

To confirm the feasibility and accuracy of the method for the noninvasive measurement of the left ventricular dp/dt, 53 patients with mitral regurgitation underwent simultaneous determination of left ventricular dp/dt by continuous‐wave Doppler echocardiography and cardiac catheterization. Doppler‐determined left ventricular dp/dt is derived from the Doppler mitral regurgitant spectrum by dividing the magnitude of the left ventricular‐atrial pressure gradient rise between 1 and 3 m/s of the mitral regurgitant velocity signal by the time taken for this change. Left ventricular dp/dt by Doppler ranged from 629 to 3494 mmHg/s (x̄ ± SD, 1971 ± 785 mmHg/s), and that by catheterization varied between 716 and 3650 mmHg/s (x̄ ± SD, 1974 ± 727 mmHg/s). There was a high correlation (r = 0.93, y = 0.862 × + 274.77, SEE = 271 mmHg/s, p < 0.001) of left ventricular dp/dt between the two techniques. It is concluded that left ventricular dp/dt is one of the most commonly used parameters for the evaluation of left ventricular systolic function and that Doppler echocardiography provides a new, accurate and noninvasive method of evaluation.
Stent wire cutting during coronary directional atherectomy
Authors: Meyer T. , Schmidt T. , Buchwald A. , Wiegand V.
Published: February 2009

Directional atherectomy represents one potential approach for the treatment of restenosis in stented coronary arteries. In this case report we demonstrate an important pitfall of this angioplasty technique for stent restenosis—inadvertent entanglement of the stent wire in the device. While cutting and removal of part of the wire was achieved in the case presented, this potential adverse event limits the applicability of directional atherectomy for restenosis in coronary stents.
Low‐dose dobutamine stress test for the evaluation of cardiac function using ultrafast computed tomography
Authors: Yamaoka Osamu , Fujioka Hideyuki , Haque Tuhn , Nakamura Yasuyuki , Mitsunami Kenichi , Kinoshita Masahiko , Morita Rikushi , Murata Kiyoshi
Published: February 2009

High dose‐dobutamine (DOB) has been previously used as a pharmacological stress test to evaluate wall motion abnormalities. As a result, recent stress echocardiography with low‐dose DOB has been reported to be valuable for investigating stunned myocardium after thrombolysis. However, echocardiography requires an operator's skill and experience to evaluate wall motion abnormalities which are subjectively determined by the observer. In contrast, ultrafast computed tomography (UFCT) does not necessarily require extreme technical skill and experience. To evaluate the feasibility of stress UFCT with low‐dose DOB, we scanned 10 normal subjects along the short‐axis by 8‐slice‐multicine mode. After scanning at rest for baseline, we scanned during the administration of 4 and 8 m̈g/kg/min of DOB, respectively, for 5 min. Ejection fraction, contraction, and thickening were higher during 8 m̈g/kg/min of DOB than during 4 m̈g/kg/min of DOB and baseline, while the above values were higher during 4 m̈g/kg/min of DOB than during baseline (p < 0.01). It was possible to detect changes of cardiac function and wall motion due to low‐dose DOB by UFCT. We therefore conclude that UFCT is a reliable modality for evaluating cardiac function and wall motion for low‐dose DOB stress test because of its excellent spatial and contrast resolution.
Exertional hemodynamics in women with chest pain—an aortic doppler ultrasound study–B. Janerot Sjoberg et al.: Women during exercise
Authors: Sjoberg Birgitta Janerot , Wranne Bengt , Swahn Eva
Published: February 2009

Aortic ultrasound Doppler recordings of stroke volume, maxima] flow velocity, and acceleration can be used to assess central hemodynamic effects of exercise in coronary artery disease (CAD) and left ventricular dysfunction. We wanted to evaluate the time course and amplitude of changes in aortic Doppler ultrasound parameters in women during supine exercise and the potential diagnostic value of a submaximal supine exercise test. For this purpose, 18 women who had undergone coronary angiography because of incapacitating chest pain (10 with significant coronary stenoses and previous myocardial infarction, 8 without stenoses or infarction) were compared with 10 healthy controls. Pathological electrocardiographic (ECG) ST‐segment depression during supine exercise was common in all groups. In the control group, a significant increase of stroke volume (10%), maximal aortic flow velocity (27%), and acceleration (43%) occurred at low load during exercise. Women with CAD showed no increase and a lower cardiac output during exercise, indicating left ventricular dysfunction. Women with syndrome X resembled the controls but had a higher maximal flow velocity at rest, which may indicate hyperdynamic circulation. We conclude that a test up to 40% of seated maximal load is valuable and often sufficient when assessing the hemodynamic effects of supine exercise by Doppler ultrasound in terms of stroke volume, maximal flow velocity, and acceleration. By characterizing left ventricular function in groups of female patients where false‐positive stress ECG reactions are common, Doppler ultrasound may contribute to the understanding and clinical management of women with chest pain.
Safety of transvenous right ventricular endomyocardial biopsy guided by two‐dimensional echocardiography
Authors: Blomström‐Lundqvist Carina , Noor Anne‐Marie , Eskilsson Jan , Persson Stig
Published: February 2009

A total of 231 endomyocardial biopsy procedures performed in 74 consecutive patients were evaluated to compare the incidence and nature of complications in procedures guided by fluoroscopy versus those guided by echocardiography. Sixty biopsy procedures were guided by fluoroscopy and 171 by two‐dimensional echocardiography. The right interventricular septum was the target site for biopsy sampling in all patients. Clinical signs of myocardial perforation occurred during one (1.7%) procedure guided by fluoroscopy versus two (1.2%) procedures guided by echocardiography. Two cases of interventricular septal perforation were visualized during the echo‐guided procedures. The biopsy specimens were judged to be inadequate for diagnosis in 2.2% of the biopsy procedures, all of which were guided by fluoroscopy. The number of samples obtained during a procedure guided by fluoroscopy was lower (mean 2.3 ± 1.6) (mean ± 1 SD) than that taken during a procedure guided by echocardiography (mean 4.0 ± 1.2). Epicardial or pericardial tissue was present in 5.8% of the samples obtained under fluoroscopic guidance, versus 0.7% of the samples obtained using echocardiography (p = 0.0003). It is concluded that although echocardiography seems to provide more accurate and safer guidance for the positioning of the bioptome toward the septum, the presence of epicardium or pericardium in 0.7% of the samples indicates that inadvertent sampling from the right ventricular free wall cannot be avoided.
The noninvasive assessment of myocardial viability
Authors: Ragosta Michael , Beller George A.
Published: February 2009

The major objective of noninvasive imaging for detection of myocardial viability is to assist in the improved selection of patients with coronary artery disease and severe left ventricular dysfunction who would benefit most from revascularization. The techniques most commonly used to identify viable myocardium are thallium‐201 (TI) scintigraphy, positron emission tomography (PET) using a flow tracer in combination with a metabolic tracer, technetium‐99m (Tc) sestamibi imaging, and dobutamine echocardiography. On stress TI scintigraphy, asynergic regions showing normal thallium uptake, an initial defect with delayed redistribution at 3–4 h, late redistribution at 24 h, or defect reversibility after reinjection of a second dose of TI at rest all suggest preserved viability. The greater the final uptake of TI in areas of regional myocardial dysfunction preoperatively, the greater the improvement in ejection fraction after coronary revascularization. Demonstration of uptake of fluoro‐18 deoxyglucose (FDG) in regions of diminished blood flow on PET imaging also correlates well with improved systolic function after revascularization. Tc sestamibi may also be useful for assessment of myocardial viability, particularly after thrombolytic therapy for acute myocardial infarction. Dobutamine echocardiography has good positive predictive value for viability determination, but absence of systolic thickening in an akinetic zone in response to intravenous infusion of the drug may still be associated with viable myocardium in 25–50% of segments. Of all the techniques cited above, quantitative resting TI scintigraphy may be the best approach for distinguishing between viable and irreversibly injured myocardium.
Plasma brain natriuretic peptide and atrial natriuretic peptide concentrations correlate with left ventricular end‐diastolic pressure
Authors: Haug C. , Grünert A. , Metzele A. , Kochs M. , Hombach V.
Published: February 2009

The present study was designed to investigate whether brain natriuretic peptide (BNP) and atrial natriuretic peptide (ANP) plasma concentrations correlate with left ventricular end‐diastolic pressure (LVEDP), pulmonary capillary wedge pressure (PCWP), diastolic pulmonary arterial pressure (DPAP), right atrial pressure (RAP), or ejection fraction (EF). Plasma BNP and ANP levels were determined by commercial radioimmunoassays (Peninsula) after Sep Pak C18 extraction in blood samples withdrawn from the pulmonary artery and the left ventricle or from the left ventricle and the femoral vein in 85 patients undergoing diagnostic cardiac catheterization. Linear and nonlinear regression analysis and the paired sample f‐test were applied to the data. Pulmonary arterial plasma BNP and ANP levels showed a close nonlinear correlation with LVEDP (BNP: r=0.94, p < 0.001; ANP: r=0.81, p < 0.001), a significant linear correlation with PCWP, DPAP, and RAP, and a significant negative correlation with EE ANP concentrations decreased significantly from the pulmonary artery to the left ventricle and from the left ventricle to the femoral vein (p < 0.001). BNP levels also decreased significantly between the left ventricle and the femoral vein (p < 0.001), but there was no significant difference between pulmonary arterial and left ventricular BNP concentrations. BNP and ANP concentrations correlated significantly between pulmonary arterial and left ventricular blood samples (BNP: r = 0.99, ANP: r = 0.93, p < 0.001) and between left ventricular and peripheral blood samples (BNP: r=0.99, ANP: r=0.94, p<0.001). The present data suggest that peripheral plasma BNP and ANP levels are useful noninvasive indices of cardiac performance.
Prognosis in diabetics in whom the initial suspicion of acute myocardial infarction was not confirmed
Authors: Karlson Björn W. , Strömbom Ulf , Ekvall Hans‐Erik , Herlitz Johan
Published: February 2009

For 2,058 consecutive patients hospitalized for suspected acute myocardial infarction (AMI) but in whom AMI was later ruled out, we describe the prognosis with particular emphasis on diabetics. In all, a previous history of diabetes mellitus occurred in 290 (14%) of the patients. Compared with nondiabetics, they had a longer delay time between onset of symptoms and arrival in hospital. During 1 year of follow‐up, their mortality rate was 28% compared with 14% for nondiabetics (p < 0.001), and their reinfarction rate was 20% compared with 10% for nondiabetics. More diabetics died in association with a fatal myocardial infarction and more frequently had ventricular fibrillation preceding death. With the exception of re‐infarction, no clear difference in terms of morbidity was observed between the two groups. We conclude that the prognosis in diabetics in whom AMI is ruled out is poor, with between one‐quarter and one‐third not surviving 1 year.
Anatomy, histology, and pathology of the cardiac conduction system—part V
Authors: Waller Bruce F. , Gering Lawrence E. , Branyas Nancy A. , Slack John D.
Published: February 2009

Although morphologic findings in many of the cardiac arrhythmias of acute and chronic disease have been elusive, the correlates of heart block (particularly atrioventricular block) are abundant. Pathologic features of sinoatrial, atrioventricular, and bundle‐branch block are reviewed. Lev and Lenegre diseases (idiopathic bilateral bundle‐branch fibrosis) are also reviewed.
Amlodipine once a day in stable angina: Double‐blind crossover comparison with placebo
Authors: Deedwania Prakash C. , Cheitlin Melvin D. , Das Sunil K. , Pool Peter E. , Singh Jang B. , Pasternak Richard C.
Published: February 2009

Although calcium antagonists form a mainstay of therapy in patients with angina pectoris, the currently available agents have significant limitations. Nifedipine, diltiazem, and verapamil are all high‐clearance agents with significant hepatic extraction and rapid clearance, leading to limited and shortlived bioavailability necessitating frequent daily administration. In contrast, amlodipine, a dihydropyridine calcium antagonist, has a long half‐life of 35–50 h (compared with 3 to 4 h elimination half‐life of diltiazem, verapamil, and nifedipine).1 After oral doses, the relative bioavailability of amlodipine is high (64%) and absorption is smooth, with peak plasma levels being achieved 6–12 h postdose.1 Bioavailability is not affected by the consumption of food.2 In common with other dihydropyridine calcium antagonists, amlodipine is eliminated mainly by metabolism.3 None of the metabolites of amlodipine has significant calcium antagonist effects in humans.3 In contrast to verapamil or diltiazem, amlodipine has no effect on sinus or atrioventricular node4 and little or no effect on the resting heart rate.5 Amlodipine does not have any appreciable negative inotropic effect with the relevant clinical dose.6 Other clinical studies have shown amlodipine to be effective when used once‐daily in chronic stable angina and vasospastic angina.7 Comparative studies indicate that the antianginal efficacy of amlodipine is comparable to the beta blocker nadolol8 and the benzothiazepine calcium antagonist diltiazem.9 Amlodipine has also been found to provide improved antianginal effects when combined to treatment with beta blockers and/or long‐acting nitrates.10, 11 Treatment with amlodipine either as monotherapy or combined with other antianginal therapy for up to 26 weeks shows that efficacy is maintained, with no evidence of tolerance.11

We evaluated the antianginal efficacy and safety of amlodipine in a placebo‐controlled multicenter randomized crossover study in patients with chronic stable angina.
Thrombolytic therapy for unstable angina
Authors: Borzak Steven , Bajwa Harpaul S. , Lesch Michael , Verier Joel
Published: February 2009

Thrombolytic therapy for unsTable angina has not gained acceptance as a primary treatment for unsTable angina (UA) despite the evidence showing a reduction in mortality when these agents are given for myocardial infarction. The purpose of this review is to examine the clinical value of thrombolytic therapy for UA. The multiple lines of evidence supporting intracoronary thrombus formation as a key mechanism in the pathogenesis of UA are reviewed. Studies examining the effect of thrombolytic therapy on angiographic endpoints have shown little effect on the extent of luminal narrowing, but do reveal a decrease in angiographically detected thrombus. Twelve randomized, controlled trials of thrombolytic agents in 611 UA patients with predefined clinical endpoints have been published. These trials varied widely in design and adjunctive therapy both in treated and control groups. Review of these trials shows a tendency to fewer clinical events such as death, infarction, and need for revascularization in treated patients, with a corresponding increase in bleeding complications. Clinical efficacy of thrombolytic therapy cannot be excluded by the available data, perhaps in part because of insufficient numbers of patients treated. Determination of the net clinical value of thrombolytic therapy must await larger and more definitive trials.
Silent ischemia and loss of reversible myocardial dysfunction following myocardial infarction
Authors: Scognamiglio Roldano , Fasoli Giuseppe , Nlstrl Stefano , Mlorelu Manuela , Frigato Nlcoletta , Pausi Monica , Miraglia Giuseppe , Dalla‐Volta Sergio
Published: February 2009

Sixty‐seven asymptomatic patients were enrolled after a first uncomplicated myocardial infarction (MI) so as to study the relevance of reversible myocardial dysfunction in determining left ventricular function soon after the acute episodes and 12 months later. Moreover, the potential role of silent ischemia in conditioning the evolutive aspects of contractile dysfunction has been investigated. Postextrasystolic potentiation during two‐dimensional echocardiographic (2‐D echo) monitoring has been used to detect the presence of viable myocardium in asynergic myocardial segments. Results of electrocardiographic (ECG) ambulatory monitoring at predischarge determined patient groups: Group A included 49 patients without ST changes during monitoring, while Group B included 18 patients with silent ischemia. Incidence of reversible myocardial dysfunction was similar in the two study groups (82 vs. 86%, p = NS). Group B patients were older (59.6 ± 6.7 vs. 50.6 ± 10.6 years, p < 0.015) and had lower ejection fractions (EFs, 43.4 ± 6.4% vs. 51.2 ± 8.3%, p = 0.026) and higher at‐rest wall‐motion scores (WMSs, 11.4 ± 5.9 vs. 7.2 ± 3.8, p = 0.019). Left ventricular end‐diastolic volume (LVEDV) and potentiated WMS did not differ. At 1‐year examination, Group B patients exhibited a greater LVEDV index (96 ± 6.5 vs. 70.7 ± 14 ml/m2, p < 0.002) with a worsening both in rest and in potentiated wall‐motion score index (12.8 ± 4.6 vs. 5.3 ± 1.8, p < 0.001; 9.2 ± 3.6 vs. 4.8 ± 2.2, p < 0.001, respectively). Left ventricular EF remained significantly depressed in Group B patients (42 ± 8.7% vs. 55.5 ± 8.1%, p < 0.002). Over the first year, spontaneous functional recovery of asynergic segments occurred in 60% of Group A patients with reversible myocardial dysfunction at early study. In Group B patients, only three (20%) showed functional recovery, and a small number (24%) maintained reversible contractile dysfunction. Thus, reversible contractile dysfunction is a common finding in asymptomatic patients without clinical ischemia soon after a first MI. The presence of silent ischemia during ambulatory ECG monitoring identifies a group of patients at high risk of further loss of myocardial viability and progressive left ventricular dilation over the first year.
Cutting balloon coronary angioplasty—initial clinical experience
Authors: Unterberg C. , Buchwald A. B. , Schmidt T. , Kreuzer H. , Wlegand V. , Barath P.
Published: February 2009

The success of percutaneous transluminal coronary angioplasty is limited by acute occlusion and late restenosis. In 25 patients (20 men, 5 women, age range 36–81 years) coronary angioplasty was performed using a new cutting balloon into which 3–4 longitudinally orientated blades are incorporated so as to reduce the rate of severe dissections. In 12 patients stenoses were reduced from 83.9 ± 7.8% to 28.4 ± 10.7% (mean ± SD) by the cutting balloon alone, using predilatation with a small conventional balloon in two cases. Thirteen other patients were additionally dilated with a conventional balloon because of a residual stenosis > 50% after cutting balloon angioplasty. Here the stenoses could be reduced from 78.1 ± 8.7% to 29.1 ± 11.3%. Six months follow‐up angiography in 14 patients showed > 50% restenosis in two of seven patients dilated with a conventional balloon in addition to the cutting balloon, and in one of seven patients dilated with the cutting balloon alone but predilated with a small conventional balloon. These results show that coronary angioplasty by the new cutting balloon results in a stenosis reduction comparable with conventional balloons at a low complication rate. Available 6 months follow‐up data show three restenoses in patients either pre‐ or postulated by a conventional balloon and none in stand‐alone cutting balloon cases.
Electrocardiogram signal variance analysis in the diagnosis of coronary artery disease—A comparison with exercise stress test in an angiographically documented high prevalence population
Authors: Nowak Jacek , Yléan Marco , Hagerman Inger , Nyquist Olof , Sylven Christer
Published: February 2009

Variance electrocardiography (variance ECG) is a new resting procedure for detection of coronary artery disease (CAD). The method measures variability in the electrical expression of the depolarization phase induced by this disease. The time‐domain analysis is performed on 220 cardiac cycles using high‐fidelity ECG signals from 24 leads, and the phase‐locked temporal electrical heterogeneity is expressed as a nondimensional CAD index (CAD‐I) with the values of 0–150. This study compares the diagnostic efficiency of variance ECG and exercise stress test in a high prevalence population. A total of 199 symptomatic patients evaluated with coronary angiography was subjected to variance ECG and exercise test on a bicycle ergometer as a continuous ramp. The discriminant accuracy of the two methods was assessed employing the receiver operating characteristic curves constructed by successive consideration of several CAD‐I cutpoint values and various threshold criteria based on ST‐segment depression exclusively or in combination with exertional chest pain. Of these patients, 175 with CAD (≥ 50% luminal stenosis in 1 + major epicardial arteries) presented a mean CAD‐I of 88 ± 22, compared with 70 ± 21 in 24 nonaffected patients (p < 0.01). Variance ECG provided a stochastically significant discrimination (p < 0.01) which was matched by exercise test only when chest pain variable was added to ST‐segment depression as a discriminating criterion. Even then, the exercise test diagnosed single‐vessel disease with a significantly lower sensitivity. At a cutpoint of CAD‐I ≥ 70, compared with ST‐segment depression ≥ 1 mm combined with exertional chest pain, the overall sensitivity of variance ECG was significantly higher (p < 0.01) than that of exercise test (79 vs. 48 %). When combined, the two methods identified 93% of coronary angiography positive cases. Variance ECG is an efficient diagnostic method which compares favorably with exercise test for detection of CAD in high prevalence population.
Antiplatelet therapy in the treatment of cerebrovascular disease
Authors: Couch James R.
Published: February 2009

Aspirin and the new agent ticlopidine have been the most thoroughly evaluated of the platelet‐antiaggregating drugs used for the prevention of stroke and other vascular events. Numerous trials have shown aspirin to be effective in reducing the risk of myocardial infarction (MI), recurrent transient ischemic attacks, stroke, and vascular death in men at high risk for these events. Primary prevention trials have shown that aspirin reduces the risk of MI in healthy men over 50 years of age but does not reduce the risk of stroke. Two large, multicenter trials have shown that ticlopidine is effective in reducing the risk of fatal and nonfatal stroke in both men and women. Ticlopidine may also be effective in reducing the risk of recurrent stroke in patients who have had a completed thromboembolic stroke.
Use of a latex cover sheath for transesophageal echocardiography (TEE) instead of regular disinfection of the echoscope?
Authors: Fritz Stephan , Hust Martin H. , Ochs Christel , Gratwohl Isolde , Staiger Mathias , Braun Bernd
Published: February 2009

Better visualization of cardiac structures is an advantage of transesophageal echocardiography (TEE). Because of this, the transesophageal approach is an essential window in the assessment of various cardiovascular disorders. Quick consecutive access to this instrument should not be delayed by time‐consuming cleansing procedures of the probe. In this study we used a sterile latex condom in routine TEE examinations as a barrier to contamination of the echoscope, observing practical use and the incidence of perforations. Defects were detected after the procedure by visual inspection and by an airtightness test. Maneuvers or situations associated with an increased likelihood of injury were checked for. In 180 studies a total of 168 patients were consecutively examined; insertion was feasible in all but one case (99.5%). We found 8 of 181 (4.4%) sheaths defective following the procedure. Visual inspection was less sensitive (only 3 of 8) for finding defects than an airtight‐ness test (8 times). Teeth in situ and/or a bite guard are the only sharp edges during insertion and removing the probe; these seem to be the main risk factors in latex perforation. Application of a cover sheath for each examination saves approximately two‐thirds of the time otherwise necessary for a cleansing bath, and easy handling of cover sheaths for TEE make them an alternative to regular disinfection in general. For reasons of safety we recommend checking each used cover sheath after examination for holes so as not to jeopardize the following patient by the possible spread of germs from contaminated probes. Not only visual inspection but also a second method, for example, an airtightness test, is mandatory.
Head‐upright tilt table testing for recurrent, unexplained syncope
Authors: Samoil Daniela , Grubb Blair P.
Published: February 2009

Recurrent episodes of unexplained syncope are a common and often frustrating problem for the practicing physician. Although vasovagally mediated episodes of hypotension and bradycardia have been felt to be a common cause of these idiopathic events, traditionally this was a diagnosis of exclusion. Recently, head‐upright tilt table testing has emerged as a method both for confirming the diagnosis of vasovagal syncope and for better understanding the mechanisms by which these events occur. This paper reviews current understanding of the pathophysiology of vasovagal syncope, the development and role of head‐upright tilt table testing in its evaluation, and potential therapeutic modalities that can be helpful for the prevention of recurrent episodes.
Assessment of right ventricular diastolic filling in patients with coronary artery disease
Authors: Yamagishi Takashi , Matsuda Yasuo , Nakatsuka Masami , Maeda Junya , Matsuda Masako
Published: February 2009

To assess right ventricular (RV) diastolic filling in coronary artery disease (CAD), with special reference to the involved lesions of the coronary arteries and left ventricular (LV) systolic function, gated radionuclide ventriculography was performed at rest in 106 patients with single‐vessel CAD. Based on the site of coronary arterial involvement, patients were classified into three groups: left anterior descending CAD, right CAD, and left circumflex CAD. Patients in each group were further subdivided according to normal or decreased LV ejection fraction, resulting in six groups. Seventeen normal subjects were examined as a control group. Tune‐activity and its first‐derivative curves were computed for the right and left ventricles. RV systolic function was normally preserved in all six groups, even when LV systolic function was damaged severely. The ratio of peak RV filling rate to peak RV ejection rate was significantly decreased in all six groups compared with that in control subjects, indicating that RV filling was impaired in patients with CAD. The ratio was below the lower limit of normal in 14 (23%) of 62 patients with normal LV systolic function and in 13 (30%) of 44 patients with impaired LV systolic function. None of the control subjects showed a decreased ratio of peak RV filling rate to peak RV ejection rate. Thus, in patients with CAD, RV filling is impaired, which may be independent of the site of coronary arterial involvement and of the LV or RV systolic function.
A case of tachycardia‐induced cardiomyopathy due to chronic ectopic atrial tachycardia
Authors: Hayano Motonobu , Kawasaki Tomomro , Egucm Yoshiki , Tsuji Shinsuke , Tokushima Takasw , Ogata Tohru , Eguchi Swnji , Matsunaga Moronari , Matsunaga Kazuyo , Matsuo Shuzo
Published: February 2009

Only a few reports exist that chronic supraventricular tachycardia causes ventricular dilation and poor left ventricular contraction—so‐called “tachycardia‐induced cardiomyopathy.”1‐4 Clinical and electrophysiologic features of chronic supraventricular tachycardia including chronic persistent ectopic atrial tachycardia (EAT)5‐7 in adults have also been described by a few investigators.5‐9 We report a rare case of long follow‐up of chronic EAT‐induced severe cardiomyopathy and mitral regurgitation that was well controlled after medical treatment.
Diastolic heart function—pathophysiology, characterization, and therapeutic approaches
Authors: Modersohn Diethelm , Walde Torsten , Bruch Leonhard
Published: February 2009

In recent years diastolic cardiac function has attracted increasing attention since parameters of diastolic function were found to be altered earlier or more specifically than parameters of systolic function. Diastolic cardiac function is determined by both active (muscular relaxation, redistribution of calcium, synchronization, etc.) and passive (myocardial structure, fibrosis, etc.) factors. As a consequence, a comprehensive assessment of diastolic cardiac function cannot be based on one single parameter. For a complete analysis of diastolic function it is necessary to perform invasive diagnostic procedures involving the measurement of atrial and ventricular pressures, as well as the registration of volume changes with a high time resolution. In addition, it is necessary to measure wall thickness and ventricular configuration, so that apart from filling parameters the stress‐strain relationship can be obtained. Noninvasive techniques (Doppler echocardiography, radionuclear ventriculography, apexcardiography) may suggest alterations in diastolic function as well. They ought to be complemented by additional diagnostic procedures (pulmonary pressure, stress testing, etc.). Therapy must consider potentially harmful effects on diastolic function parameters, particularly if changes in myocardial oxygen consumption may result (heart rate, parietal wall stress). Calcium antagonists (verapamil, diltiazem, nifedipine), phosphodiesterase inhibitors (milrinone), beta‐adrenergic agonists and antagonists with vasodilating effects (e. g., celiprolol) all have beneficial effects on diastolic myocardial function.

A range of diastolic function parameters is being reviewed in the following paper. Their role in the estimation of cardiac function and their responsiveness to therapy in hypertrophy, cardiomyopathy, and coronary heart disease is being discussed.