bluuebunny/crossref_metadata_2025 huggingface dataset:
Preoperative strategies to assess cardiac risk before noncardiac surgery
Authors: Younis Liwa T. , Douglas Miller D. , Chaitman Bernard R.
Published: February 2009

The strategies recommended in the preoperative cardiac risk assessment prior to major vascular and nonvascular surgery are reviewed. The role of clinical evaluation, noninvasive stress testing (exercise test, stress myocardial perfusion imaging, stress echocardiography), and Holter monitoring during the preoperative evaluation are outlined and the value of intervention based on the use of each test is discussed. Recommended strategies to evaluate patients based on their clinical risk markers in addition to the results of the noninvasive risk assessment are presented.
Coronary angioplasty for the control of intractable ventricular arrhythmia
Authors: Bhaskaran Ambika , Seth Ashok , Kumar Anil , Pande Abhay , Kler Tarlochan , Bhandari Suman , Bhatia Madan Lal
Published: February 2009

Ventricular arrhythmias (VAs) that occur following an acute extensive anterior myocardial infarction (MI) usually respond to conventional antiarrhythmic regimes of treatment. Rarely, the VA may prove intractable to therapy. This report is of three patients who presented at varying time frames (3 h to 10 weeks) following an anterior MI. They exhibited sustained monomorphic ventricular tachycardia and hemodynamic instability despite multiple antiarrhythmic drug therapy, intravenous magnesium, direct‐current cardioversion (DCCV), overdrive pacing (in one case), and intra‐aortic balloon counterpulsation (IABP). Although there was no clinical evidence of continuing ischemia and although coronary angiography that was done in each case showed the infarct‐related artery (IRA) to subtend akinetic areas on left ventricular (LV) angiogram, percutaneous transluminal coronary angioplasty (PTCA) of the IRA was done in all three cases. Reestablishing patency of the IRA helped in controlling the VA dramatically with average therapeutic doses of antiarrhythmic drugs. All three patients showed this control to have been maintained over a follow‐up period of more than 1 year, with partial improvement in LV function and signal‐averaged electrocardiogram negative for late potentials. Thus, in patients with extensive infarction and intractable VA, PTCA of the IRA may provide control of VA even in the absence of clinical signs of active ischemia or viable muscle mass.
Electrocardiographic interpretation (1995): Can we do better?—Part II
Authors: Willis Hurst J.
Published: February 2009

An explanation of the Grant method and six steps the author of this paper considers essential to electrocardiographic interpretation are presented in Part I of the paper (Clin. Cardiol. 18, 433–439, 1995).
Postinfarction ventricular aneurysms
Authors: Friedman Brian M. , Dunn Marvin I.
Published: February 2009

Ventricular aneurysms are circumscribed, thinwalled fibrous, noncontractile outpouchings of the ventricle. The majority are apically located, true aneurysms of the left ventricle (LV) that occur as a consequence of transmural myocardial infarction (MI). The precursor of aneurysm formation appears to be infarct expansion early after acute MI and occurrence generally relates to infarct size. The presence of underlying hypertension and the use of steroids and nonsteroidal anti‐inflammatory agents may promote aneurysm formation. The clinical sequelae include congestive heart failure (CHF), thromboembolism, angina pectoris, and ventricular tachy‐arrhythmias. Late rupture is a particular complication of false aneurysms in which the pericardium is the aneurysm wall. The diagnosis may be suspected by the clinical finding of a diffuse, pansystolic apical thrust, persistent ST‐segment elevation on the electrocardiogram, and distortion of the cardiac silhouette on chest x‐ray. This can be confirmed using echocardiography, radionuclide ventriculography, and cardiac catheterization. The latter has the additional advantage of being able to delineate the coronary anatomy. Management involves prevention, specific therapy for the various clinical manifestations, and surgery. Therapeutic interventions with thrombolytic agents, aspirin, heparin, and beta blockers that are applied early in the evolution of an MI may limit infarction size, thereby reducing the tendency toward infarct expansion and aneurysm formation. Patients with mild CHF can usually be controlled with the standard combination of angiotensin‐converting enzyme inhibitors, diuretics, and digoxin. Thromboembolism is best prevented by anticoagulation with warfarin for at least 3 months after the acute MI. The choice of pharmacotherapy for ventricular tachyarrhythmias should be guided by electrophysiologic studies. The treatment of patients with angina pectoris utilizes conventional therapeutic modalities. Refractory angina and high‐risk coronary anatomic subsets have replaced CHF as the commonest indications for surgical intervention in recent studies. In these patients, aneurysmectomy is often performed as an aside to the primary revascularization procedure. Although aneurysmectomy may improve the functional status and ejection fraction of some patients with CHF, its effect on prognosis is less certain. The prognostic advantage of surgery appears to be related more to coronary revascularization than to the aneurysm resection per se.
Left atrial size—A risk factor for left atrial thrombi in mitral stenosis
Authors: Conradie C. , Marx J.D. , Schall R.
Published: February 2009

In a follow‐up study, 77 patients with predominant mitral stenosis were examined to investigate the role of left atrial (LA) enlargement in LA thrombi. Fifteen (19.4%) patients had LA thrombi. Of these, 2 (13.3%) were in sinus rhythm and 13 (86.7%) in atrial fibrillation. Fourteen (93.3%) of the patients with LA thrombi had an LA size≥4.8 cm. Only one (6.7%) patient had an LA size of 4.4 cm and was in atrial fibrillation. The median LA size in patients with LA thrombi was 5.2 cm compared with 4.75 cm in patients without LA thrombi (p<0.01). The relative risk for LA thrombi in patients with an LA size≥4.8 cm compared with patients with an LA size<4.8 cm was 10.0 (95% confidence interval 1.4 to 71.4). It was thus confirmed that LA enlargement≥4.8 cm is an in dependent risk factor for LA thrombi in patients with mitral stenosis.
Tilt table evaluation for control pediatric patients: Comparison with symptomatic patients
Authors: Berkowitz Jeffrey B. , Auld Debbie , Hulse J. Edward , Campbell Robert M.
Published: February 2009

This study was designed to evaluate pediatric control patients during head‐up tilt in comparison with symptomatic neurocardiogenic syncope patient head‐up tilt responses. Twenty‐three pediatric control (c) patients (13 females, 10 males; 11.9 ± 3.1 years) were tested with head‐up tilt (HUT) and compared with 66 symptomatic (s) patients. Baseline drug‐free HUT (cHUT‐1), a second drug‐free HUT (cHUT‐2), and a final HUT with isoproterenol infusion (cHUT‐3) were each performed at 80° tilt angle for 30 min or until positive. For comparison, 66 symptomatic patients (41 females, 25 males; 13.6 ± 2.5 years) underwent drug‐free HUT (sHUT‐1); negative responders during sHUT‐1 underwent follow‐up HUT with isoproterenol (sHUT‐2). HUT data were compared for both groups at both 30 and 20 min tilt duration. Twelve control patients (52%) had a symptomatic response during cHUT‐1 at 18±8 min. During cHUT‐2, 5 of 23 patients were positive at 13±5 min; each had previously tested positive during cHUT‐1. Two patients, each positive in cHUT‐1 and cHUT‐2, refused cHUT‐3. The only patient testing positive during cHUT‐3 was test positive in cHUT‐1 but negative for cHUT‐2. In comparison, 43 of 66 (65%) symptomatic patients tested positive during drug‐free sHUT‐1 at 11±6 min. Subsequently, 20 of the 23 negative patients underwent HUT with isoproterenol (sHUT‐2), with 8 of 20 testing positive. Thus, 51 of 66 symptomatic patients (77%) were called “true positives.” Chi‐square analysis for comparison of 30 min cHUT‐1 (12/23 positive patients) versus sHUT‐1 (43/66 positive patients) yielded no statistical difference. However, analysis of data limited to 20 min tilt duration showed 7 of 23 positive cHUT‐1 versus 38 of 66 positive sHUT‐1 patient responses (p = 0.025). It is concluded that (1) pediatric HUT is relatively nonspecific in a control population (52% false positive), (2) concordance for consecutive positive control tilts is low, (3) isoproterenol does not increase overall predisposition to positive pediatric control patient response, and (4) an 80° tilt protocol limited to 20 min duration may help differentiate between false and true positive responses.
Intracardiac thrombi: Frequency, location, etiology, and complications: A morphologic review—Part II
Authors: Waller Bruce F. , Rohr Todd M. , Mclaughlin Todd , Grider Larry , Taliercio Charles P. , Fetters Julie
Published: February 2009

Intracardiac thrombus is a frequent finding at necropsy. Various cardiac disorders have been associated with its presence. Part II of this 5‐part article focuses on atherosclerotic coronary heart disease (myocardial infarction) as an etiology for intracardiac thrombus.
Myocardial infarction with an initially normal electrocardiogram—Angiographic findings
Authors: Caceres Luis , Cooke David , Zalenski Robert , Rydman Robert , Lakier Jeffrey B.
Published: February 2009

To analyze the paradox of acute myocardial infarction (AMI) with an initially normal electrocardiogram (ECG), we reviewed the records of 732 patients discharged with a final diagnosis of AMI over a 2‐year period. Twenty‐one patient were identified whose initial ECG was normal and who underwent coronary arteriography during the index hospitalization. According to the ECG evolution, three distinct groups were identified: Group 1: those who subsequently developed ST elevation or Q waves (n = 7), Group 2: those who developed ST depression or T‐wave inversion (n = 8), and Group 3: those whose ECG remained normal (n = 6). Peak creatine kinase (CK), timing of the first ECG change, life‐threatening complications, and location of the infarct‐related coronary lesion were recorded. Infarct‐related coronary lesions were also classified into those in a major coronary trunk versus those in secondary branches. The incidence of AMI with a normal ECG was 3.7%. There was no difference in the frequency of coronary artery involvement in the groups studied: left anterior descending (33%), right coronary artery (38%), and circumflex (28%). All ECG changes developed within the first 48 h of hospitalization; 17 ± 15 in Group 1, and 24 ± 12 h in Group 2. All six patients who had a persistently normal ECG (Group 3) had lesions in branch vessels (p < 0.05 when compared with Group 1 plus Group 2). Patients who developed ST elevation or Q waves (Group 1) always had a major artery trunk involved (p < 0.05 when compared with Group 2 plus Group 3). Patients in Group 3 had less myocardial damage and fewer complications compared with the other two groups. Myocardial infarction with an initial normal ECG is uncommon and may result from involvement of any of the three coronary arteries. Electrocardiographic evolution usually occurs within the first 48 h of hospitalization. Patients whose ECGs remain normal appear to have culprit lesions in coronary branches, smaller infarctions, and fewer in‐hospital complications.
Is the time domain signal‐averaged electrocardiogram helpful in patients with ventricular tachycardia without apparent structural heart disease?
Authors: Orlov Yelena S. K. , Brodsky Michael A. , Orlov Michael V. , Allen Byron J. , Winters Rex J.
Published: February 2009

The signal‐averaged electrocardiogram (SAECG) has been a screening method for identifying patients at risk for ventricular tachycardia (VT) in the setting of coronary artery disease (CAD). Its significance in patients with VT unrelated to CAD or left ventricular dysfunction is undetermined. In order to define the value of SAECG in this patient population further, we compared the time domain SAECG at 25,40, and 80 Hz filters in 35 patients with clinically symptomatic VT in the absence of structural heart disease was compared with 10 normal controls and 10 patients with CAD and inducible VT. SAECG data in patients without structural heart disease were intermediate between normal controls and patients with CAD. No single or combined SAECG criterion helped to differentiate between patients with inducible and noninducible VT. There was no concordance to other arrhythmia testing. It was concluded that signal‐averaged electrocardiography may have little screening value in VT unrelated to CAD or left ventricular dysfunction.
Silent cortical strokes associated with atrial fibrillation
Authors: Hara Masahide , Ooie Tatsuhiko , Yufu Kunio , Tsunematsu Yoshihiro , Kusakabe Takanori , Ooga Masatoshi , Saikawa Tetsunori , Sakata Toshiie
Published: February 2009

To clarify whether silent cortical strokes (SCS) could be a predictor of symptomatic stroke in patients with atrial fibrillation (AF), 72 patients with AF (50 with chronic AF, 22 with paroxysmal AF) were studied. Patients with mitral stenosis, history of myocardial infarction, or dilated cardiomyopathy were excluded from this study. Using cranial magnetic resonance imaging (MRI), the patients were divided into those with SCS (23 patients, Group 1) and those without SCS (49 patients, Group 2). The incidence of symptomatic stroke was then compared between the two groups. Three patients (13%) in Group 1 developed symptomatic brain infarction; this is statistically significant (p < 0.05), compared with the patients in Group 2, none of whom experienced symptomatic stroke. We suggest that SCS is a predictor of symptomatic cerebral infarct in patients with AF. Therefore, it is thought to be important to diagnose SCS using cranial MRI or computed tomography and to keep patients with SCS under close surveillance.
Effectiveness of intravenous propafenone for conversion of recent‐onset atrial fibrillation: A placebo‐controlled study
Authors: Bellandi Francesco , Cantini Fabrizio , Pedone Tiziana , Palchetti Roberto , Bamoshmoosh Mohamed , Dabizzi Roberto Piero
Published: February 2009

To evaluate the efficacy of propafenone in converting recent‐onset atrial fibrillation (AF) lasting <7 days, 182 patients were treated intravenously with propafenone (Group 1, n = 98) and with placebo 0.9% saline solution (Group 2, n = 84) in a double blind study. The treatment was continued until sinus rhythm (SR) was restored, but for no more than 24 h. Eighty‐nine patients treated with propafenone (90.8%) and 27 patients treated with placebo (32.1%) responded to the treatment and SR was restored (p < 0.0005). The mean time for SR restoration was 2.51± 2.77 h in Group 1, and 17.15± 7.8 h in Group 2 (p < 0.0005). In both groups the patients in whom SR was not restored (nonresponders) had larger left atrial size and longer duration of AF than responders at the onset of the arrhythmia. Nonresponders in Group 1 showed a decrease in mean ventricular rate (MVR) from 143± 16 to 101± 18 (p < 0.0005), while in the nonresponders in Group 2 no reduction of MVR was observed. Two patients whose SR was restored with propafenone had sinus standstill lasting 3.4 and 3.8 s, respectively. Propafenone used intravenously is an effective, quick, and safe drug for treating AF. Moreover, it significantly reduces MVR in nonresponders.
Functional explanation for increased atrial natriuretic peptide in systemic sclerosis
Authors: Kazzam Elsadig , Caidahl Kenneth , Hedner Thomas , Waldenström Anders
Published: February 2009

We related atrial natriuretic peptide (ANP) among 30 consecutive patients with systemic sclerosis (SScl) and 48 gender‐ and age‐matched controls to the measurements of left ventricular (LV) function as evaluated by echocardiography and external pulse curves to determine possible causative factors for an increased level of plasma ANP. The patients had a markedly elevated plasma ANP level (239.4± 59 vs. 178.2± 36 pmol/1, p < 0.0005), which was not related to LV systolic function, heart rate, or blood pressure. Patients had LV hypertrophy and plasma ANP correlated directly to interventricular septal thickness (r = 0.41, p < 0.005), LV posterior wall thickness (r = 0.32, p < 0.01), and wall thickness to cavity dimension (r = 0.44, p < 0.0005), LV mass index (r = 0.40, p < 0.005). LV early filling properties were impaired, with reduction of atrial emptying index (p < 0.0005) and increased contribution of atrial contraction to LV filling. Plasma ANP correlated to atrial emptying index (r = 0.41, p < 0.0005) and to apex‐car‐diographic a wave (r = 0.28, p <0.05). Plasma ANP was also related to left atrial dimension index (r = 0.27, p < 0.05), and was still related to atrial emptying index, but not to left atrial dimension, when considering the degree of LV hypertrophy in multivariate analysis. We conclude that ANP is elevated in patients with SScl. Reduced LV compliance, probably due to increased fibrosis, may cause changes in atrial pressure sufficient to stimulate ANP production without systolic dysfunction as a prerequisite.
Familial endocrine myxolentiginosis
Authors: Panossian David H. , Marais Gary E. , John Marais H.
Published: February 2009

We present an unusual case of a left atrial myxoma as a feature of a familial mesoectodermal disorder and review the literature. The new term ‘familial endocrine myxolentiginosis’ is proposed, which is descriptive of the major clinical components of the syndrome. Myriad features of this disorder include (1) cardiac myxomas; (2) cutaneous myxomas; (3) multiple lentigines or blue nevi, particularly of the head and neck; (4) bilateral primary pigmented nodular adrenocortical hyperplasia; (5) unusual testicular tumors; (6) pituitary tumors; (7) myxoid fibroadenomas of the breast; (8) myxomatous disorder of the stroma of the breast; (9) ductal adenoma of the breast; and (10) psammomatous melanotic schwannoma. A tentative diagnosis is suggested by identifying two features and a definitive diagnosis is made by three or more features. The clinical and pathologic features of cardiac myxoma in familial endocrine myxolentiginosis are identical to those of familial cardiac myxoma: age < 40 years, atypical locations, multicentric origins, and recurrent presentations. A Venn diagram classification for cardiac myxomas is proposed. We include photographic, echocardiographic, biopsy, and adrenal computerized tomography documentation in our patient. Recognition of this disorder is important because of its clinical, surgical, and genetic implications. The availability of transesophageal echocardiographic technology should allow early diagnosis of this underdiagnosed entity. Clinicians should consider this entity in the differential diagnosis of their patients with any one of these manifestations.
Restenosis following coronary angioplasty: Clinical presentations and therapeutic options
Authors: Levine Glenn N. , Chodos Andrew P. , Loscalzo Joseph
Published: February 2009

Restenosis following angioplasty is an iatrogenic disease of increasing frequency. Restenosis may be defined in terms of either angiographic or clinical criteria. Definitions of angiographic restenosis have varied in different studies, accounting in part for the differences in reported restenosis rates. Most studies now define angiographic restenosis as either a >50% loss of initial gain or an absolute lesion stenosis of ≥50% at follow‐up angiogram. Common clinical end points used in defining restenosis include recurrent angina, need for repeat revascularization, or myocardial infarction. Despite technical advances and multiple pharmacologic interventions, most studies have found that the incidence of angiographic restenosis remains in the range of 40%; in none of these studies, however, was complete angiographic follow‐up obtained, and thus actual restenosis rates may be somewhat higher. In several studies, clinical restenosis has been found to occur in approximately 36–40% of patients. Thus, a minority of patients with angiographic restenosis have no clinical manifestations. Most patients who develop symptoms of restenosis develop these symptoms within the first 3 months after angioplasty. The presenting symptom in the majority of these patients is progressive exertional angina. Patients occasionally will present with unstable angina and only rarely with acute myocardial infarction. In patients who present with recurrent chest pain, several features have been found to be helpful in predicting whether they will have angiographic restenosis at follow‐up angiography. Patients who present 1–6 months after angioplasty with typical anginal symptoms have a high likelihood of having angiographic restenosis. By contrast, patients who present more than 6 months after percutaneous transluminal coronary angioplasty with recurrent chest pain are more likely to have new, significant coronary lesions to account for their symptoms. Noninvasive testing in patients with clinical presentations suggestive of restenosis can, in general, add only modest information in predicting whether restenosis is indeed present. A negative exercise thallium test appears to have a high specificity in ruling out restenosis and may be helpful in patients who present with more atypical symptoms. Repeat angioplasty is the therapy most frequently utilized to treat restenosis, although coronary artery bypass surgery or medical therapy may be reasonable alternative therapies. Clinical success rates with repeat angioplasty are >90%, and major complications are rare; however, restenosis will recur in a significant percentage of these patients. Some patients who develop such recurrent restenoses will ultimately benefit from a strategy of repeat angioplasties, although many will require surgical revascularization.
The effect of beta‐blockade therapy on the response to exercise training in postmyocardial infarction patients
Authors: Pavia Leandro , Orlando Gaspare , Myers Jonathan , Maestri Maurizia
Published: February 2009

Cardiac rehabilitation after a myocardial infarction has been shown to improve exercise capacity. Beta blockade has been shown to be effective in treating angina and reducing mortality, but studies are controversial as to whether beta‐blockade therapy attenuates the effects of training. We attempted to study the effects of beta blockade (metoprolol) on the response to training in patients enrolled in a cardiac rehabilitation program after an uncomplicated myocardial infarction. We studied 27 patients with a recent uncomplicated myocardial infarction who were subdivided in two groups: Group 1 (13 patients) not taking a beta blocker, and Group 2 (14 patients) taking metoprolol (mean 142 ± 57 mg daily). All patients underwent a maximal cardiopulmonary exercise test before and after a 3‐month training program. The training intensity was designed to approximate the ventilatory threshold. Results showed an increase in peak VO2 in both Group 1 (27%, p<0.01) and Group 2 (33%, p<0.001), and an increase in VO2 at the ventilatory threshold (39% in Group 1 and 28% in Group 2, p<0.01). The mean changes in exercise capacity were not different between groups. It was concluded that metoprolol did not influence the beneficial effects of a cardiac rehabilitation program in postmyocardial infarction patients.
Pulmonary artery aneurysm: Review and case report
Authors: Lopez‐Candales Angel , Kleiger Robert E. , Aleman‐Gomez Jose , Kouchoukos Nicholas T. , Botney Mitchell D.
Published: February 2009

Aneurysms involving the main pulmonary artery and its branches are rare. Clinical experience is limited and current knowledge is mainly derived from autopsy findings. This case report describes a patient with a pulmonary artery aneurysm associated with a previous, partially corrected stenotic pulmonary valve. The patient presented with symptoms suggestive of aneurysm dissection three decades after commissurotomy. The diagnostic approach and therapeutic intervention are emphasized with a review of the literature.
Cardiovascular effects of commonly used ophthalmic medications
Authors: Shiuey Yichieh , Eisenberg Mark J.
Published: February 2009

Eye disease and cardiovascular disease frequently coexist. As a result, cardiologists and ophthalmologists often treat the same patients. Among ophthalmologists it is well known that topical ophthalmic medications are capable of producing serious cardiovascular effects, including congestive heart failure, arrhythmias, and death. However, cardiologists may not be aware of these potential complications. This article reviews the cardiovascular effects of commonly prescribed topical ocular medications and describes important contraindications to their use in patients with cardiovascular disease. Cardiologists, by making themselves and their patients more aware of the cardiovascular effects of topical ocular medications, may be able to avoid the adverse and potentially fatal complications of these agents.
Comparative efficacy of short‐term intravenous infusions of milrinone and dobutamine in acute congestive heart failure following acute myocardial infarction
Authors: Karlsberg Ronald P. , DeWood Marcus A. , DeMaria Anthony N. , Berk Martin R. , Lasher Keith P. , For The Milrinone‐Dobutamine Study Group
Published: February 2009

The purpose of this study was to compare the hemodynamic and clinical effects of milrinone, a vasodilating and positive inotropic agent, with those of dobutamine in patients with congestive heart failure (CHF) following acute myocardial infarction (AMI). Thirty‐three patients in Killip classification II or III within 12 h to 5 days after AMI were randomized in a multicenter, open‐label clinical trial to receive a 24‐h infusion of milrinone or dobutamine. Drugs were titrated to achieve at least a 30% increase in cardiac index (CI) from mean baseline or at least a 25% decrease in mean pulmonary capillary wedge pressure (MPCWP) from baseline. Both drugs improved CI, MPCWP, and other hemodynamic parameters. Criteria for decrease in MPCWP were met by 94% (15/16) of the milrinone‐treated patients and 57% (8/14) of dobutamine‐treated patients (p = 0.03). Both groups met the minimum efficacy criterion for CI. Maximal reduction in MPCWP over 0–3 h was greater in the milrinone group (‐53.2%) than in the dobutamine group (‐31.0%; p ≤ 0.01); reductions were sustained over 24 h. Both drugs improved echocardiographic global ejection fraction and were generally well tolerated. The short‐term infusion of milrinone may have a role in the management of CHF following AMI, especially when the aim is the rapid reduction of pulmonary congestion.
Prognostic significance of the initial electrocardiographic pattern in patients with inferior wall acute myocardial infarction
Authors: Hasdai David , Sclarovsky Samuel , Solodky Alejandro , Sulkes Jaqueline , Birnbaum Yochai
Published: February 2009

The purpose of the study was to determine whether the initial electrocardiographic pattern is predictive of in‐hospital mortality in inferior wall acute myocardial infarction. It is commonly perceived that patients with acute myocardial infarction presenting with greater ST elevation have a worse prognosis. The initial electrocardiogram of patients (n = 213) with inferior wall myocardial infarction was categorized based on the pattern of ST‐segment elevation in inferior leads: (A) ST< 1 mm with tall T waves, (B) ST ≥ 1 mm with normal terminal QRS, and (C) ST≥ 1 mm with distortion of terminal QRS. ST deviation from baseline was calculated for all leads. Patients with maximal precordial ST depression in V4‐V6 and pattern A had an in‐hospital mortality rate of 68.8% compared with 16.9% for the entire study group. By univariate analysis, only pattern A was significantly predictive of in‐hospital mortality [odds ratio = 2.91,95% confidence interval (CI) 1.22–6.93], but by multivariate analysis adjusted for (1) age, (2) diabetes mellitus, (3) previous myocardial infarction, (4) thrombolytic therapy, (5) precordial ST‐depression pattern, and (6) patterns of ST elevation, maximal ST depression in V4‐V6 was significantly predictive (odds ratio = 4.93, 95% CI 1.79–13.56), whereas pattern A was not (odds ratio = 1.12, 95% CI 0.36–3.52). Contrary to popular perception, patients with inferior wall myocardial infarction presenting with minimal ST‐segment elevation are at highest risk for in‐hospital mortality, especially if accompanied by maximal precordial ST depression in V4‐V6.
Changes in left ventricular inflow and pulmonary venous flow velocities during preload alteration in dilated heart
Authors: Kiyoshige Koichi , Oki Takashi , Fukuda Nobuo , Iuchi Arata , Tabata Tomotsugu , Fujimoto Takashi , Manabe Kazuyo , Kageji Yoshimi , Sasaki Miwa , Ito Susumu
Published: February 2009

The aim of the present study was to assess the changes of left ventricular inflow (LVIF) and pulmonary venous flow (PVF) velocities during preload alteration in 30 patients with dilated heart (LV end‐diastolic dimension ≥ 6.0 cm) and impaired LV systolic function (% fractional shortening of the LV ≤ 25%). We performed transesophageal pulsed Doppler echocardiography during lower body negative (LBNP, ‐40 mmHg) and positive pressure (LBPP, +40 mmHg) in 10 patients with dilated cardiomyopathy, in 20 with old myocardial infarction, and in 22 healthy controls. Eight of the patients showed a pseudonormalization (compliance failure) pattern, and 22 showed a decreased early diastolic wave and compensatorily increased atrial systolic wave (relaxation failure) pattern of LVIF in the control state. Mean pulmonary capillary wedge pressure (PCWP) was greater in the compliance failure group than in the relaxation failure group in the control state. LVIF in 6 of the 22 patients with the relaxation failure pattern changed to the compliance failure pattern during LBPP, and that in 3 of 8 patients in the compliance failure group changed to the relaxation failure pattern during LBNP. The 6 patients with a change from the relaxation failure to the compliance failure pattern showed significantly higher peak diastolic and atrial systolic PVFs during LBPP than in the control state, and significantly higher PCWPs in the control state than the 16 patients with no change in LVIF. These find ings suggest that the compliance failure and relaxation failure patterns of LVIF are readily interchangeable in various hemo‐dynamic conditions, and that pattern analysis of LVIF and PVF during preload alteration is useful for understanding the hemodynamic severity and for evaluating preload reduction therapy in the dilated heart.
Prediction of recovery after abstinence in alcoholic cardiomyopathy: Role of hemodynamic and morphometric parameters
Authors: Vecchia Luigi La , Bedogni Francesco , Bozzola Loredana , Bevilacqua Pierantonio , Ometto Renato , Vincenzi Mario
Published: February 2009

The aim of the study is to describe the hemodynamic and morphometric characteristics of patients with alcoholic cardiomyopathy (ACM) and to evaluate whether these parameters can identify the subgroup of patients in whom recovery of cardiac function after abstinence will occur. Nineteen male patients (mean age 52.4 years, range 39–64 years) with symptomatic left ventricular dysfunction (LVD) [ejection fraction (EF) < 50%] and a history of chronic heavy alcohol intake were submitted to a full invasive work‐up including right ventricular endomyocardial biopsy (EMB). Counseling aimed at obtaining abstention and clinical follow‐up were regularly performed in all patients. The two requisites necessary to define recovery were (1) an increase in left ventricular EF, and (2) improvement of symptoms. The former was defined as a gain in left ventricular EF > 15% from baseline; the latter, as a gain of at least one New York Heart Association (NYHA) functional class. Using these criteria, 9 alcoholic patients (48%) (Group A) improved significantly, while 10 (52%) (Group B) either stabilized or deteriorated at 2 years' follow‐up. Group A patients had significantly lower pulmonary artery mean pressure (27.8 mmHg ± 13.3 vs. 40.3 mmHg ± 12.4; p < 0.05) and pulmonary capillary wedge pressure (18.4 mmHg ±8.9 vs. 26.5 mmHg ± 7.7; p < 0.05) compared with Group B. All other hemodynamic data did not show statistically significant differences in the two groups. Quantitative evaluation of myocardial hypertrophy and interstitial fibrosis performed on EMB tissue samples using the morphometric approach was not predictive of recovery. Improvement in cardiac performance and functional class was detected in about one‐half of patients with ACM who abstained from alcohol, and occurred even in cases presenting with severe LVD. Recovery is associated with significantly lower pulmonary artery and pulmonary wedge pressures. The morphometric evaluation of EMB does not provide adjunctive prognostic information in these patients.
QT interval in cardiac amyloidosis
Authors: Parthenakis Frangiskos I. , Vardas Panos E. , Ralidis Loukianos , Dritsas Athanasios , Nihoyannopoulos Petros
Published: February 2009

The aim of the study was to investigate whether cardiac amyloidosis is associated with QT interval abnormalities and ventricular arrhythmias. A controlled study of 30 patients was undertaken at a university cardiology department in a large referral hospital. Thirty patients (18 men, 12 women, mean age 56 ± 12 years) with systemic amyloidosis verified by biopsy and strong indications of cardiac amyloidosis comprised the study group, with 30 healthy age‐ and sex‐matched individuals serving as controls. Complete M‐mode and two‐dimensional echocardiographic study was undertaken and QT interval and QTc were calculated. All patients and controls underwent 24‐h Holter monitoring for arrhythmias. Left ventricular (LV) wall thickening was found in all patients with cardiac amyloidosis. The LV mass in the patients with cardiac amyloidosis was significantly greater than that of the control group, as was the ratio LVmass/body surface area (p < 0.001). There was no significant difference in the max QT interval or in QTc dispersion between the two groups, although the max QTc was greater in the patients with cardiac amyloidosis. Patients with cardiac amyloidosis did not have a higher incidence of arrhythmias than the controls. Although patients with thickened cardiac walls due to cardiac amyloidosis have a prolonged QTc in comparison with controls, they do not show an increase in interlead QTc dispersion which might suggest the possibility of regional disturbances of the uniformity of repolarization. Patients with cardiac amyloidosis do not have a higher incidence of arrhythmias than controls.
Mechanisms of cardiopulmonary resuscitation in a patient with right ventricular dilatation—an echocardiographic contribution
Authors: Gilon Dan , Geist Michael , Rein Azaria J.J.T. , Gotsman Mervyn S. , Hasin Yonathan
Published: February 2009

The mechanism of cardiopulmonary resuscitation is still debated. Two different theories have been proposed: direct cardiac compression versus intrathoracic pressure. A patient with dilated right cardiac chambers, who underwent a transesophageal echocardiography study during cardiopulmonary resuscitation, is reported. The direct compression mechanism was clearly demonstrated.
Left Ventricular Mural Thrombus after Acute Myocardial Infarction
Authors: Keeley Ellen C. , David Hillis L.
Published: February 2009

Left ventricular mural thrombus is a well‐recognized complication of acute myocardial infarction. In survivors of infarction, the incidence with which mural thrombus occurs is influenced by the location and magnitude of infarction, so that it occurs commonly in those with large anterior Q‐wave infarctions, particularly in the presence of a left ventricular aneurysm. Echocardiography, radionuclide imaging with indium‐111 labeled platelets, computerized tomography, and magnetic resonance imaging may be used to identify a left ventricular mural thrombus. Acute and chronic anticoagulation with heparin and warfarin, respectively, is given to prevent further thrombus formation and to reduce the incidence of systemic embolization.
Intracoronary ultrasound: Insights into mechanisms and results of coronary interventions
Authors: Schreiter Steven W. , Tenaglia Alan N. , Buda Andrew J.
Published: February 2009

Intracoronary ultrasound imaging is a modality which allows in vivo cross‐sectional visualization of coronary arteries similar to that obtained by pathology. Compared with coronary angiography, intracoronary ultrasound provides more detail on plaque morphology and topography and more accurate quantification of lumen and plaque area. Thus, it has evolved into a valuable research tool. For example, intracoronary ultrasound imaging has increased understanding of the mechanisms of action of balloon angioplasty and new interventions such as atherectomy and laser treatment. It may prove to have clinical utility by helping to individualize device selection and sizing and by assessing treatment results more accurately. Coronary imaging may be performed at low risk. Future developments will include smaller catheters, combined ultrasound and therapeutic catheters, and three‐dimensional reconstruction of images.
Increased adhesiveness of peripheral blood leukocytes corresponds to the appearance of expansion following anterior wall myocardial infarction
Authors: Solodky A. , Zafrir N. , Kuzniec J. , Lifshitz A. , Sclarovsky S. , Berliner S. , Winder A. , Arber N.
Published: February 2009

The appearance of increased leukocyte adhesiveness/aggregation as an inflammatory marker in the peripheral blood of patients with anterior wall myocardial infarction was monitored. Of the 26 patients included in the study, 7 had infarct expansion as shown by an enlargement of left ventricular end‐diastolic volume. The percent of aggregated leukocytes in the peripheral blood of patients with expansion (29.7 ± 15.5%) was significantly higher (p = 0.01) than that obtained from patients with no expansion (18.5 ± 6.8%). The lack of significant differences in peak creatine kinase concentrations between patients with and without expansion suggests that infarct size is not necessarily the main determinant for the appearance of expansion; an increased inflammatory reaction could be a contributory factor.
Reduction of left ventricular spontaneous echo contrast in cardiomyopathy by acute inotropic intervention or aggressive therapy
Authors: Patel Vijay G. , Weisse Allen B. , Feuerman Martin
Published: February 2009

The purpose of this study was to determine whether improvement of left ventricular (LV) systolic function could reduce the severity or eliminate LV spontaneous echo contrast found with transthoracic echocardiography in a group of patients with advanced cardiomyopathy. A successful reduction of this by hemodynamic means might indicate an additional beneficial method of helping prevent thromboembolism in advanced cardiomyopathy. Six patients with advanced cardiomyopathy and demonstrating spontaneous echo contrast on transthoracic echocardiography were treated with acute inotropic drug infusions or aggressive medical therapy to improve LV systolic function to determine whether reduction in spontaneous contrast could be achieved by such means. A spontaneous echo contrast scoring system was devised: 0 to 4, indicating absent to severe. Six observers, unacquainted with the study plan, were blinded as to the source of the 12 pre‐and post‐ therapy two‐dimensional echocardiograms obtained and re‐recorded in a random sequence, and were asked to grade the degree of spontaneous echo contrast. In all six patients. LV spontaneous echo contrast was reduced by improvement in LV systolic function (average score lowered from 2.94 to 1.25, p<0.005). Among patients with cardiomyopathy at high risk for LV thromboembolism, as indicated by the presence of LV spontaneous echo contrast, improvement in LV systolic function may serve as an adjunct to anticoagulation or, in some cases, as a substitute when the latter is contraindicated in the prevention of thromboembolism. The results obtained suggest merit in prospective, long‐term studies of a larger group of such patients.
Clinical significance of the apical late systolic ejection murmur: A new phonocardiographic sign indicating dynamic mid‐left ventricular obstruction
Authors: Fukuda Nobuo , Oki Takashi , Iuchi Arata , Tabata Tomotsugu , Manabe Kazuyo , Kageji Yoshimi , Sasaki Miwa , Yamada Hirotsugu , Ito Susumu
Published: February 2009

Systolic ejection murmurs of the left heart usually have their peak during early to mid‐systole. Few reports have addressed ejection murmurs with their peak at late systole. We evaluated the clinical significance of an apical systolic ejection murmur with a peak intensity during late systole using Doppler and two‐dimensional (2‐D) echocardiography and phonocardiography. The apical late systolic ejection murmur was observed in 9 of 13 consecutive patients with mid‐left ventricular obstruction. We investigated the ejection flow velocity and the timing of maximum velocity at the three different sites of the left ventricle, the left ventricular cavity shape, and the timing of the peak murmur intensity in these nine patients (late‐murmur group). The same parameters were also examined in 8 consecutive patients with mid‐systolic ejection murmurs (mid‐murmur group), 10 with early systolic ejection murmurs (early‐murmur group), and 7 controls without murmurs. Patients with aortic stenosis were excluded. The mid‐ventricular ejection flow velocity was significantly higher in the late‐murmur group than in the other three groups; that of the outflow tract was markedly higher in the mid‐murmur group. The ejection flow velocity at the aortic orifice of patients in the early‐murmur group was significantly high compared with that of the controls. The timing of the peak murmur intensity in each group correlated with that of the peak flow signal at the corresponding site with maximum velocity. In all patients in the late‐murmur group, 2‐D echocardiography revealed a systolic narrowing of the cavity at the mid‐ventricle. Amyl nitrite inhalation induced a marked increase in the intensity of the murmur without evidence of appearing or increasing mitral regurgitation. It was concluded that the apical ejection murmur with a late systolic peak intensity is a new phonocardiographic sign indicative of dynamic, mid‐left ventricular obstruction. This murmur should be differentiated from the mitral regurgitant murmur.
Usefulness of the 12‐lead electrocardiogram in detection of myocardial infarction: Electrocardiographic‐anatomic correlations—Part II
Authors: Parker Alton B. , Waller Bruce F. , Gering Lawrence E.
Published: February 2009

Part II of this two‐part series on electrocardiographic‐necropsy correlation of infarct location focuses on lateral and posterior (“inferior”) infarctions. The value of infarct location regarding complications and prognosis is also discussed.
Vascular reactivity of arterial coronary artery bypass grafts—implications for their performance
Authors: Dzimiri Nduna , Duran Carlos , Chester Adrian H. , Allen Sean P. , Yacoub Magdi H.
Published: February 2009

Specific properties of the vessel wall of arteries employed as coronary bypass grafts are thought to play an important role in the short‐ and long‐term performance of these conduits. Heterogeneity in the endothelial and smooth muscle cell function between different arteries may provide particular vessels with properties which will favor them for use as bypass conduits. The aim of this review is to provide an insight into how the vascular reactivity of presently used arterial conduits varies and to discuss the clinical implications of these findings both in terms of flow modulation in response to physiologic and exogenous vasoactive mediators and long‐term patency.
Prediction of in‐hospital cardiac events using dipyridamole‐thallium scintigraphy performed very early after acute myocardial infarction
Authors: Bosch Xavier , Magriñá Jordi , March Remei , Sanz GinéS , García Alicia , Betriu Amadeo , Navarro‐López Francisco
Published: February 2009

Background and Hypothesis: Ischemic complications occur frequently during hospitalization after acute myocardial infarction. Dipyridamole‐thallium scintigraphy performed early after admission can detect residual ischemia, may have additional prognostic value and be useful in the management of these patients.

Methods: Dipyridamole infusion and 201thallium imaging were performed on the third day of infarction in 114 consecutive patients. Coronary angiography was performed before hospital discharge in 90% of patients and exercise testing was performed at the time of discharge in patients without contraindications.

Results: Side effects occurred in 28 patients, but they were mild and transient or rapidly reversed with intravenous aminophylline. During hospitalization, three patients died and four had a nonfatal reinfarction. Patients with these major cardiac events had previously shown a higher prevalence of reversible perfusion defects during testing (71 vs. 31 %, p < 0.05). In addition, 19 patients had early recurrent ischemia requiring early in‐hospital revascularization. Overall, cardiac events defined as death, reinfarction, or early myocardial revascularization occurred in 22 patients. Of the patients with these events, 68% had thallium redistribution on initial myocardial scanning compared with 25% of patients without events (p = 0.0001). Patients with cardiac events also showed a higher number of myocardial segments with reversible perfusion defects (1.8 ± 2.2 vs. 0.6 ± 1.3, p = 0.001). Logistic regression analysis revealed that among all the other clinical, scintigraphic, and an‐giographic variables, the presence of thallium redistribution on the dipyridamole‐thallium scan was the only independent predictor of cardiac events, increasing the risk by sixfold. Furthermore, during a 1‐year follow‐up, 14 other patients had ischemic events. Of these, 64% had previously shown thallium redistribution during early dipyridamole testing compared with 19% of patients without cardiac events (p < 0.001).

Conclusions: Intravenous dipyridamole‐thallium‐scintigraphy performed very early after myocardial infarction is safe and useful to predict in‐hospital ischemic events.
Assessment of posterior aortic wall motion using echocardiogram in patients with atrial fibrillation
Authors: Nobuoka Sachihiko , Hatano Seiji , Yoshida Akihiro , Nagashima Junzo , Noda Kiyohito , Takada Hideomi , Miyake Fumihiko , Murayama Masahiro
Published: February 2009

Background and hypothesis: Noninvasive evaluation of left ventricular (LV) diastolic function was performed on 12 patients with atrial fibrillation (AF) using posterior aortic wall echocardiogram and a parameter for determining the optimal heart rate in patients with chronic atrial fibrillation was considered.

Methods: Subjects were divided into two groups; one with no underlying cardiac disease (AF only group; n = 7) and the other with dilated cardiomyopathy (DCM group; n = 5). Left atrial emptying index (LAEI) obtained from the posterior aortic wall echocardiogram was used as the parameter of LV diastolic function, and R‐R interval‐LAEI relation and minimum R‐R interval showing LAEI = 1.0 were investigated and compared between the two groups.

Results: There was a good correlation between R‐R interval and LAEI until LAEI of 1.0 was obtained in all patients. Slope of the regression line was significantly steeper in the AF only group than in the DCM group, and minimum R‐R interval showing LAEI = 1.0 was significantly shorter in the AF only group.

Conclusion: Assessment of R‐R interval‐LAEI relation was useful for the noninvasive evaluation of LV diastolic function, and this parameter could be used for clinical application to determine the optimal heart rate in atrial fibrillation.