bluuebunny/crossref_metadata_2025 huggingface dataset:
A comparison of the effects of adenosine and verapamil on the conduction and pacemaker system of isolated guinea pig hearts
Authors: Stark Gerhard , Stark Ulrike , Bachernegg Maria , Kasper Karin , Kickenweiz Elisabeth , Decrinis Martin
Published: February 2009

Adenosine and verapamil are effective in the treatment of supraventricular arrhythmias. Also, both substances can provoke sinus node arrest or a third‐degree atrioventricular (AV) block with a ventricular escape rhythm. The aim of this study was to compare the effects of adenosine and verapamil on sinus rate and on the rate of the ventricular escape rhythm while a third‐degree AV block was induced by both drugs. Experiments were performed on isolated spontaneously beating guinea pig hearts perfused by the method of Langendorff. A third‐degree AV block was induced by adenosine at a concentration of 30 μm and by verapamil at a concentration of 1 m̈m. Adenosine (30μm) reduced sinus rate only moderately whereas it nearly halved the rate of the ventricular escape rhythm compared with that produced by cutting the AV node. In contrast, verapamil left the rate of the ventricular escape rhythm unchanged but nearly halved the spontaneous sinus rate compared with control conditions. In conclusion, adenosine and verapamil given at dosages with comparable effect on the AV node have markedly different effects on different pacemakers in the same heart. In the treatment of supraventricular arrhythmias, adenosine probably should be used with great caution since it can cause a very slow ventricular escape rhythm.
Long‐Term prognosis after myocardial infarction: Univariate and multivariate analysis of clinical characteristics in 1,000 patients
Authors: Kambara Hirofumi , Nakagawa Masao , Kinoshita Masahiko , Kawai Chuichi
Published: February 2009

To examine the clinical outcome for patients with myocardial infarction and to analyze clinical predictors for long‐term prognosis, 1,000 patients were studied retrospectively. Between January 1983 and December 1987, 1,002 consecutive patients with myocardial infarction, who resided in the Kyoto and Shiga districts, were reviewed after coronary arteriography, but in two patients medical records were not located. During 3.3 ±2.0 years, 75 patients died of cardiac causes and 301 experienced cardiac events (death, reinfarction, and revascularization). Overall 5‐year cardiac mortality was 8% and cardiac event rate was 35%. Among determinants of age, smoking, hypertension, diabetes mellitus, heart failure, postinfarction angina, serious arrhythmia, mitral regurgitation, digitalis and diuretics administration, ejection fraction (EF), left main trunk disease, and number of diseased coronary arteries selected by univariate analysis, multivariate analysis revealed that heart failure, EF, number of coronary vessel disease, diabetes, and mitral regurgitation were the important predictors of cardiac death. For cardiac events, multivariate analysis demonstrated that the number of diseased coronaries, postinfarction angina, and left main trunk disease were significant predictors. Therefore, impaired left ventricular function and myocardial ischemia appear to be important markers for cardiac death, but impaired left ventricular function does not appear to be a predictor for cardiac events. The data obtained in this study will be useful in the assessment of patients with myocardial infarction and will be of clinical significance in predicting mortality and cardiac events.
Minimal residual coronary obstructions in patients who suffered a first myocardial infarction. A prospective study comparing coronary angiography and exercise thallium scintigraphy
Authors: Macieira‐Coelho Eduardo , Cantinho Guilhermina , Da Costa Brás B. , Garcia‐Alves Mário , Lacerda António P. , Dionisio Isabel , Carvalho Madalena , De Pádua Fernando
Published: February 2009

The purpose of the present study was to correlate the presence of minimal coronary obstruction (≤ 50%) assessed by coronary angiography with the presence of myocardial scar and ischemia detected by thallium‐201 myocardial perfusion imaging. The study included 83 consecutive patients (74 men and 9 women) with a mean age 55.4±8.5 years who suffered a first myocardial infarction and did not undergo thrombolytic therapy. In all patients, coronary angiography, left ventriculography, and exercise thallium‐201 tomographic scintigraphy were performed within 3 to 5 months of the myocardial infarction. Coronary arteriograms showed minimal residual obstructions in 37 (45%) patients. Of a total of 54 patients with ≤ 50% obstruction, 18 showed persistent defects and 22 reversible defects on thallium scintigrams. The present study showing estimated angiographic stenosis of ≤ 50% as being responsible either for myocardial scar or myocardial ischemia on postexercise thallium scintigrams leads us to conclude that percent value of stenosis does not accurately predict the pathophysiologic significance of coronary atherosclerotic lesions in patients who suffer a myocardial infarction. After a first myocardial infarction, coronary angiographies and thallium‐201 scintigrams are complementary for an optimal treatment strategy for selected subsets of patients.
Atrioventricular nodal reentry tachycardia: Electrophysiologic comparisons in patients with and without 2:1 infra‐his block
Authors: Willems Stephan , Shenasa Mohammad , Borggrefe Martin , Hindricks Gerhard , Chen Xu , Rotman Brigitte , Kottkamp Hans , Haverkamp Wilhelm , Breithardt GÜNter
Published: February 2009

Patients with atrioventricular nodal reentry tachycardia (AVNRT) occasionally may demonstrate a 2:1 infra‐His block during tachycardia. However, the electrophysiologic background of this phenomenon has not been established so far. In the present study we compared the electrophysiologic parameters of 10 consecutive patients with a transient 2:1 infra‐His block during AVNRT of the common type (Group A) with those of 17 consecutive patients without this phenomenon during tachycardia (Group B). Transient 2:1 infra‐His block occurred without termination of the tachycardia in all 10 patients of Group A. The tachycardia sustained despite intermittent or permanent conduction disturbance of the infrahisian tissue in 8 of these 10 patients. In comparison, the electrophysiologic parameters of 17 patients without 2:1 block during AVNRT of the common type (Group B) were analyzed. A significantly longer antegrade (318±58 ms vs. 259±50 ms) and retrograde (308±59 ms vs. 239±20 ms) AV conduction capacity could be demonstrated in these patients. The tachycardia cycle length did not differ significantly between the two groups, although the mean tachycardia cycle length was 48 ms longer in patients of Group B. These observations demonstrate an advanced conduction capacity in patients with a transient infra‐His block during AVRNT of the common type. This study underlines that the reentry circuit in AVNRT is not necessarily dependent on infrahisian tissue.
Atrioventricular junctional reentrant tachycardia utilizing multiple retrograde fibers during ablation of the slow pathway
Authors: Katritsis Demosthenes , Slade Alistair , John Camm A. , Rowland Edward
Published: February 2009

This report deals with a patient with atrioventricular (AV) reentrant junctional tachycardia who, during radiofrequency ablation of her slow pathway, developed both anterior and posterior type of slow‐fast atrioventricular nodal reentry; in both tachycardias different fibers were alternately utilized for retrograde conduction, thus resulting in alternating tachycardia cycle lengths. This observation provides further evidence in favor of the multifiber structure of the AV node in patients with AV reentrant junctional tachycardia.
Bundle‐Branch reentry tachycardia
Authors: Kusniec Jairo , Strasberg Boris , Birnbaum Yochai , Sclarovsky Samuel
Published: February 2009

A 21‐year‐old man with aborted sudden death developed bundle‐branch reentry tachycardia at electrophysiologic study. Ablation of the right bundle branch was performed in an attempt to eliminate the recurrence of ventricular arrhythmia. The clinical arrhythmia was no longer inducible; however, a second type of ventricular tachycardia of a different mechanism and origin was induced. Following a new clinical episode of ventricular tachycardia with hemodynamic deterioration, an automatic implantable cardioverter and defibrillator was implanted.
Prognosis during one year of follow‐up after acute myocardial infarction with emphasis on morbidity
Authors: Herlitz Johan , Karlson BJörn W. , Sjölin M. , Ekvall Hans‐Eric , Hjalmarson Årke
Published: February 2009

Previous descriptions of the prognosis after acute myocardial infarction (AMI) have mainly included patients admitted to coronary care units, often with an upper age limit. This study describes the prognosis, with emphasis on morbidity, during 1 year in 921 patients admitted to one single hospital with AMI regardless of age and regardless of whether or not they were admitted to the coronary care unit. During the first year, 29% of the patients died and 16% developed a reinfarction. Fifty‐four percent required rehospitalization for various reasons, mainly for AMI, chest pain of other origins, and congestive heart failure. After 1 year, 52% of the surviving patients had symptoms of angina pectoris. Among patients younger than 65 years, only 37% were back to work full time after 1 year. Of patients alive after 1 year, 25% fulfilled the following criteria: no reinfarction, no rehospitalization, and no angina pectoris. Of patients aged less than 65 years at follow‐up, 12% fulfilled the same criteria and were back to work full time after 1 year. in this unselected, consecutive series of patients with AMI, mortality and morbidity were high during the first year. Only a small percentage of patients were free of events or symptoms of angina pectoris.
Influence of glyceryl trinitrate on venous and arterial effects of chronic, asymmetric isosorbide dinitrate treatment in patients with ischemic heart disease
Authors: Jørgensen LARS H. , Refsum Harald E. , Thaulow Erik
Published: February 2009

Asymmetric dosage regimes have been introduced to circumvent development of nitrate tolerance. This study assessed invasively the hemodynamics during supine rest and exercise before and after 4 weeks treatment with 30 mg isosorbide dinitrate (ISDN) or placebo asymmetrically b.i.d. in 14 randomized patients with stable ischemic heart disease in a double‐blinded study. An intravenous infusion of glyceryl trinitrate (GTN) was used to assess possible nitrate tolerance. During the initial, medication‐free exercise all patients had increased pulmonary arterial wedge pressure (PAWP) 31.4 ± 5.56 mmHg (mean ± SD), showing impaired left ventricular function, while mean arterial pressures (MAP) rose from 112 ± 16.3 mmHg at rest to 141 ± 15.9 mmHg during exercise. After 4 weeks ISDN treatment, mean exercise PAWP and MAP, 3 h after morning dose, were reduced to 22.4 ± 7.09 mmHg and 127 ± 18.2 mmHg, respectively. Before the ISDN treatment, GTN reduced exercise PAWP to 13.9 ± 5.27 mmHg and MAP to 119 ± 11.2 mmHg, whereas after 4 weeks ISDN treatment, the addition of GTN did not reduce exercise PAWP and MAP to the same low levels. Thus, the applied ISDN regimen improved the hemodynamics, but induced a definite, partial nitrate tolerance.
Decreased adrenergic response in hypertensive patients without left ventricular hypertrophy
Authors: Sugishita Yasuro , Iida Keiji , Fujieda Kazushi , Yukisada Kimihiko
Published: February 2009

To analyze the adrenergic responses and to compare them between hypertensive patients with and without left ventricular hypertrophy (LVH), left ventricular (LV) fractional shortening (FS) and end‐systolic wall stress (ESS) were measured by echocardiography and the inotropic response to the infusion of isoproterenol (0.02 μg/kg/min for 5 min) was studied in 25 hypertensive patients without LVH [H(‐)] and 30 hypertensive patients with LVH [H(+)]. LVH was determined by echocardiography. Age, gender, heart rate, systolic and diastolic blood pressures, LV end‐systolic and end‐diastolic diameters, and FS were matched between the groups. The tests were performed before introduction of antihypertensi ve treatment or 4 weeks after its discontinuation. ESS showed a significant inverse linear relation with FS in all the subjects before isoproterenol infusion. The inotropic response to isoproterenol was measured as the increase of FS corrected for the decrease of ESS (ΔFS/‐ΔESS), that is, the slope of the change of the relation between FS and ESS. The change in ΔFS/‐ΔESS was significantly smaller (0.49 ± 0.15 cm2/g, mean ± SD) in H(−) than in H(+) patients (1.01 ± 0.57 cm2/g) (p < 0.001). It is concluded that, compared with the H(+) group, adrenergic response is depressed in H (−) patients. This depression might be etioloically related to the phenomenon that LVH did not develop in the H(−) group in spite of the same level of pressure load as in the H(+) group.
Pathology of aortic valve stenosis and pure aortic regurgitation a clinical morphologic assessment—part I
Authors: Waller Bruce , Howard Jane , Fess Stephen
Published: February 2009

This two‐part article examines the histologic and morphologic basis for stenotic and purely regurgitant aortic valves. Part I discusses stenotic aortic valves and Part II will discuss causes of purely regurgitant aortic valves. In over 95% of stenotic aortic valves, the etiology is one of three types: congenital (primarily bicuspid), degenerative, or rheumatic. Other rare causes of stenotic aortic valves include active infective endocarditis, homozygous type II hyperlipoproteinemia, and systemic lupus erythematosis. The causes of pure aortic regurgitation are multiple but can be separated into diseases affecting the valve (normal aorta) (infective endocarditis, congenital bicuspid, rheumatic, floppy), diseases affecting the walls of aorta (normal valve) (syphilis, Marfan's, dissection), disease affecting both aorta and valve (abnormal aorta, abnormal valve) (ankylosing spondylitis), and diseases affecting neither aorta nor valve (normal aorta, normal valve) (ventricular septal detect, systemic hypertension). Diseases affecting the aortic valve alone are the most common subgroup of conditions producing pure aortic valve regurgitation.
Coronary artery‐pulmonary artery fistula associated with hypertrophic cardiomyopathy
Authors: Geist Michael , Rozenman Yoseph , Hasin Yonathan , Gotsman Mervyn S.
Published: February 2009

This report describes two patients with the combination of a coronary artery fistula from the left anterior descending artery (LAD) to the pulmonary artery together with hypertrophic cardioinyopathy.
Beta‐adrenergic blockade following thrombolytic therapy: Is it helpful or harmful?
Authors: Becker Richard C.
Published: February 2009

Beta‐adrenergic blockade has been a mainstay in the treatment of patients with acute myocardial infarction for nearly two decades. Clearly, it has withstood the test of time. The emergence of thrombolytic therapy, however, has shifted the medical community's focus, raising questions as to the benefit of beta‐adrenergic blockade. Although further investigation is warranted, the available evidence suggests that beta blockers can be given safely to selected patients following coronary thrombolysis, particularly in the absence of moderate to severe left ventricular dysfunction.
Quantification of infarct size by thallium‐201 single‐photon emission computed tomography using the unfolded map method. Comparison with QRS score and angiographic infarct size at 4 weeks after infarction
Authors: Shimada Tomoyoshi , Tsuda Nobuyuki , Kamihata Hiroshi , Suga Yutaka , Kurimoto Tohru , Iwasaka Toshiji , Inada Mltsuo
Published: February 2009

A new technique of data processing, the unfolded map method, was used with thallium‐201 single‐photon emission computed tomography to quantify infarct size in 35 patients with single‐vessel disease at 4 weeks after their first myocardial infarction (24 anterior and 11 inferior infarcts), and the results were compared with those obtained by electrocardiography and contrast left ventriculography. The myocardial borders and the infarcted region were defined using the threshold technique and a cutoff value of 55%. Count profile data for each short‐axis slice were unfolded zonally into single planes with the same ratio, and their areas were calculated from the slice thickness and radius. Thus, the size of the unfolded map represented the actual left ventricular myocardial area Infarct size was quantitated from the ratio of pixels in the infarcted region to those in the whole map, and the ratio itself was used as the percent infarct size. Although a defect 1 cm in diameter (0.8 cm2) could not be detected in a phantom study, defects ≥ 2 cm in diameter (≥3.1 cm2) could be measured satisfactorily. The infarct size and percent infarct size determined by the unfolded map method correlated well with the QRS score (r = 0.841 and r = 0.838), the percentage of abnormally contracting segments on left ventriculography (r = 0.835 and r = 0.87 7), and the ejection traction (r = ‐0.835 andr = ‐0.856). These data indicate that the unfolded map method provides adequate quantification of infarct size, even in the chronic phase, without complicated data processing.
Direct recording of sinus node potentials using electrode catheter techniques
Authors: Lévy Samuel , Lekieffre Jean
Published: February 2009

Direct recording of sinus node (SN) potentials using electrode catheter techniques is feasible and may be achieved in 50‐86% of patients, ft takes 15‐30 min using commercially available catheters. However, obtaining stable recordings is often difficult, necessitating direct contact of the distal electrode with the endocardial area underlying the sinus node. There is a wide range in sinoatrial (SA) intervals (30‐150 ms) obtained, and an overlap exists between patients with normal and abnormal SN function. Consequently, measurement of the SA interval alone may not be a reliable tool for diagnosing SN dysfunction. However, direct SN recordings have a theoretic value, allowing differentiation of disorders of SA conduction from disorders of the impulse generation.
Unstable angina: Prognosis, noninvasive risk assessment, and strategies for management
Authors: Mcclellan Joseph R.
Published: February 2009

Risk stratification in patients with unstable angina is a major clinical problem with important therapeutic implications. Antiplatelet therapy is clearly effective in reducing the occurrence of myocardial infarction and death in this syndrome. Interventions including coronary bypass surgery and coronary angioplasty are frequently recommended for these patients, but the most appropriate application of these techniques needs to be further defined. After a brief discussion of the value of medical and interventional therapies, this review focuses on the clinical and noninvasive predictors of adverse events in unstable angina. An overall management strategy for these patients, based on current information, will be proposed.
Forearm compartment syndrome following thrombolytic therapy for acute myocardial infarction
Authors: Burnside Joyce , Costello John M. , Angelastro Nicholas J. , Blankenship James
Published: February 2009

Thrombolytic therapy for myocardial infarction may contribute to bleeding complications when central venous or arterial access is required, but peripheral venous access is usually uncomplicated. We report a patient in whom tissue plasminogen activator and subsequent intravenous heparin exacerbated bleeding from a disrupted intravenous access site, leading to acute compartment syndrome requiring surgical decompression. This case emphasizes the risks associated with iatrogenic trauma during thrombolytic therapy.
The use of activated clotting times to monitor heparin therapy during and after interventional procedures
Authors: Bowers John , Ferguson James J.
Published: February 2009

Use of the activated clotting time (ACT) was recommended in the mid 1970s to guide administration and reversal of heparin during cardiopulmonary bypass. As the applications of cardiopulmonary bypass spread, so too did the need for more efficient techniques to assess coagulation status. This led to the development of automated ACT measurements. Today, the importance of coagulation and anticoagulation has been further highlighted by recent advances in the field of interventional cardiology. More and more cardiologists are using in‐laboratory bedside coagulation monitoring to assess heparin requirements during interventional procedures such as percutaneous transluminal coronary angioplasty (PTCA). This review focuses on the development of anticoagulation monitoring and provides historic information on the clinical use of heparin. The application of ACTs in the catheterization laboratory and in other clinical situations is discussed, along with alternative methods for bedside assessment of coagulation status. No definite guidelines have been established for ACT monitoring during invasive intravascular procedures; thus its role continues to be refined. in the meantime, the ACT appears to be an extremely useful method for monitoring heparin therapy and the adequacy of anticoagulation.
Intrapulmonary artery coiling of a permanent pacing lead
Authors: Trigano J. A. , Batsou R. , Lauribe P. , Paganelli F. , Gérard R. , Lévy S.
Published: February 2009

Intrapulmonary artery displacement of a permanent ventricular lead is reported to be a severe form of lead coiling and is attributed to the failure of the fixation procedure. The lead instability indicated a need for surgical correction.
Transient reversal of blood flow in an internal thoracic artery to coronary artery graft during syncope
Authors: Mauric A. , Samani N. J. , De Bono D. P.
Published: February 2009

Transcutaneous duplex ultrasound can be used to image and quantify blood flow in the proximal part of the internal thoracic artery to coronary artery bypass grafts. 1 In addition to providing information about graft patency and blood flow for follow‐up purposes, the technique also provides an opportunity to study the physiology and pharmacology of the coronary circulation. In this paper we describe and attempt to interpret an unusual pattern of internal thoracic artery graft blood flow observed during inadvertent nitrate‐induced syncope.
Dyslipidemia and coronary artery disease
Authors: T.KUO Peter
Published: February 2009

Genetically determined and metabolically induced disturbances in lipid metabolism, as manifested in several types of dyslipidemia, have been shown to be causally related to the development of coronary artery disease (CAD). A diversity of clinical and angiographic studies has been made to evaluate the linkage between plasma lipid‐control therapy in the development of initial and recurrent cardiovascular events. The plan of treatment invariably begins with a low‐fat, low‐cholesterol diet before initiation of drug therapy. However, many patients have difficulty in adhering to the low‐fat diet. Fortunately, metabolic studies show that foods which contain fats rich in stearic (saturated) and oleic (monounsaturated) fatty acids may be given in limited amounts to boost patients' compliance to a low‐fat diet and to prevent their blood lipids from rising to abnormal levels. A bile acid sequestrant (cholestyramine or colestipol) is the first‐line drug for control of hypercholesterolemia. Either gemfibrozil or gemfibrozil plus niacin is prescribed to raise high‐density lipoprotein (HDL) levels of CAD patients. Approval of two HMG CoA reductase inhibitors, pravastatin and simvastatin, by the FDA gives physicians the additional flexibility of employing a single or a combination drug therapy for optimal control of dyslipidemia. The association of low serum cholesterol level (< 160mg/dl) with increase in noncardiac mortality has prompted health professionals to consider modifying the universal screening and treatment of serum cholesterol in children and young women and to use hypolipidemic drugs in patients judiciously.
Long‐term use of K‐strophanthin in advanced congestive heart failure due to dilated cardiomyopathy: A double‐blind crossover evaluation versus digoxin
Authors: Agostoni Pier Giuseppe , Doria Elisabetta , Berti Marco , Guazzi Maurizio D.
Published: February 2009

K‐strophanthin or digoxin were added to diuretics (all cases) and vasodilators (most cases) for treating advanced congestive heart failure in 22 patients with dilated cardiomyopathy and sinus rhythm. K‐strophanthin (0.125 mg intravenously) or digoxin (0.25 mg orally) were administered daily in two 3‐month periods, during which vasodilators and diuretics were kept constant and patients received one of the two digitalis preparations in a double‐blind fashion, crossing over to, the alternative preparation in the next period. Blindness was assured throughout the trial with a daily intravenous injection of 10 ml normal saline solution either containing K‐strophanthin or not, and with daily oral administration of either placebo or active digoxin. At the end of the run‐in period, 15 days after starting active preparations, and thereafter every month for the next 6 months, we evaluated left ventricular pump function at rest and patients' functional performance by a cardiopulmonary exercise test. At Day 15, cardiac index and ejection fraction at rest, compared with run‐in, were significantly raised with both glycosides; during exercise while on K‐strophanthin, peak oxygen consumption was augmented by 1.4 ml/min/kg (p < 0.01) and oxygen consumption at anaerobic threshold by 2.2 ml/ min/kg (p < 0.01); corresponding variations on digoxin (0.1 and +0.3, respectively) were not significant versus run‐in. These patterns were duplicated at repeated tests during follow‐up. In the entire population Means for oxygen consumption at peak exercise and at anaerobic threshold were raised from run‐in values by 1.4 (p < 0.01) and 2.2 ml/min/kg (p < 0.01), respectively, after 3 months of K‐strophanthin treatment, and by 0.0 and 0.1 ml/min/kg, respectively, after treatment with digoxin for the same period of time. Results were similar in nine patients when they were given digoxin intravenously (0.25 mg/day) for 1 week after having completed the trial with the oral digoxin preparation. These results indicate that K‐strophanthin improved functional performance in patients with severe cardiac decompensation due to dilated cardiomyopathy; digoxin failed to provide the same results, independent of the drug sequence or the route of administration. The reasons for these differences are basically unknown and do not seem to be related only to changes in cardiac performance at rest, because both K‐strophanthin and digoxin significantly and persistently raised cardiac output and ejection fraction at rest.
A multinational study of the effects of low‐dose pravastatin in patients with non‐insulin‐dependent diabetes mellitus and hypercholesterolemia
Authors: Behounek Bruce D. , Mcgovern Mark E. , Kassler‐Taub Kenneth B. , Markowitz S. Jeffrey , Bergman Michael ,   THE PRAVASTATIN MULTINATIONAL STUDY GROUP FOR DIABETES
Published: February 2009

This multinational, 16‐week, randomized, doubleblind, placebo‐controlled study evaluated the efficacy and safety of low‐dose pravastatin in 325 patients with non‐insulindependent diabetes mellitus (NIDDM) and hypercholesterolemia [serum total cholesterol concentrations of 5.2‐7.8 mmol/1 (200 to 300 mg/dl)]. Patients were randomized to receive pravastatin 10 mg or matching placebo with doubling of the dose after 8 weeks if predefined target levels for total cholesterol [(i.e., < 5.2 mmol/1 (200 mg/dl) or > 15% decrease from baseline] had not been achieved. At Week 16, pravastatin‐treated patients showed a 21.4% decrease in serum low‐density lipoprotein cholesterol (LDL‐C) and a 13.5% reduction in serum total cholesterol (TC) concentrations (p < 0.001 compared with placebo). Levels of triglycerides (TG) were reduced 9.6% during pravastatin treatment (p < 0.05 compared with placebo) while high‐density lipoprotein cholesterol (HDL‐C) levels were increased 4.4% (p =NS). Adverse events and laboratory test abnormalities were similar among patients treated with pravastatin or placebo. Glycosylated hemoglobin (HbA1C) levels remained unchanged. The results of this study demonstrate that low‐dose pravastatin is effective and well tolerated for lowering elevated cholesterol concentrations during short‐term treatment of patients with NIDDM and hypercholesterolemia.
Enterovirus‐induced myocarditis: Hemodynamic deterioration with immunosuppressive therapy and successful application of interferon‐α
Authors: Heim Albert , Stille‐Siegener Michael , Kreuzer Heinrich , Figulla Hans R. , Kandolf Reinhard
Published: February 2009

In 1985Myocarditis was diagnosed by endomyocardial biopsy in a 53‐year‐old woman who was free of symptoms of heart insufficiency. Immunosuppressive therapy with azathioprine and prednisolone was prescribed as the patient had deteriorated to NYHA II heart insufficiency in March 1986. When application of immunosuppressive agents was terminated in 1987, serial endomyocardial biopsies revealed no signs of myocarditis, thus indicating effectiveness of immuno uppression. Nevertheless, the patient had worsened clinically and hemodynamically. At follow‐up in 1991, the patient had progressed to dilated cardiomyopathy resulting in NYHA III heart insufficiency. Enterovirus infection of the heart was detected by in situ nucleic acid hybridization. In addition, retrospective serology indicated a significant increase of coxsackievirus B2 antibodies between 1985 and 1991. Investigational antiviral therapy with recombinant interferon a‐2a was tolerated well and a favorable clinical, hemodynamic, and virologic response was observed. Thus, progression of biopsy‐proven myocarditis to dilated cardiomyopathy may have been facilitated by immunosuppressive therapy in enterovirus infection. Antiviral therapy might be advantageous in patients with enterovirus myocarditis and dilated cardiomyopathy.
Post‐traumatic pseudoaneurysm of the ascending aorta—an incidental finding two decades later
Authors: Prater Stephen P. , Mckiernan Thomas L. , Leya Ferdinand S.
Published: February 2009

Traumatic rupture of the aorta following blunt trauma is a wel 1 described entity. Rupture of the ascending aorta is frequently associated with concomitant cardiac damage and immediate death with few long‐term survivors described in the literature. A case of traumatic pseudoaneurysm of the ascending aorta discovered two decades after the initial injury is reported.
Directional coronary atherectomy in women compared with men
Authors: Movsowitz Herman D. , Emmi Ronald P. , Manginas Athanassios , Wells Elizabeth , Ledley Gary S. , Kotler Morris N. , Nakhjavan Fred K. , Yazdanfar Shahriar
Published: February 2009

The influence of gender on the procedural outcome of directional coronary atherectomy (DCA) is controversial. This study of 373 consecutive patients (418 lesions) undergoing DCA demonstrates that the procedural success rate of DCA is significantly lower in women compared with men (72.7 vs. 82.9%, p = 0.011). Women have significantly smaller coronary arteries than men (2.5 mm vs. 2.7 mm, p = 0.028) and were older than men (66 vs. 61 years, p = 0.0001). Multivariate analysis identifies small coronary vessel size rather than female gender per se as an independent predictor of poor procedural outcome. Procedural success rates in women with coronary vessel size ≥ 2.5 mm is significantly higher (92.2%) than in women with coronary vessel size < 2.5 mm (73.1%), and parallels that in men with vessel size ≥ 2.5 mm (89.3%). Inability to engage the ostium of the coronary artery adequately with the guiding catheter and to cross the lesion with the atherectomy device is significantly more common in women compared with men. Major ischemic complication rates are similar in women and men (8.5 vs. 8.7%). Groin complications are significantly more common in women compared with men (13.5 vs. 2.9%). We conclude that procedural success rates in women may be improved by careful patient selection, with particular attention to small vessel size. DCA is best performed in vessels > 2.5 mm in diameter.
Is there a role for positive inotropic agents in congestive heart failure: Focus on mortality
Authors: Amidon Thomas M. , Parmley William W.
Published: February 2009

Congestive heart failure (CHF) is a common clinical syndrome that may result from a variety of etiologies. Impaired contractility can lead to pump failure and a number of hemodynamic and neurohormonal alterations. Vasodilator therapy improves symptoms and survival in patients with CHF due to systolic dysfunction. Inotropic therapy, on the other hand, has not been shown to improve survival and may even worsen survival. This article reviews the mechanism of action and clinical trials of inotropic therapy in patients with CHF.
Cardiocirculatory and metabolic strain during rowing ergometry in coronary patients
Authors: Urhausen A. , Spieldenner J. , Gabriel H. , Schwarz L. , Schwarz M. , Kindermann W.
Published: February 2009

To investigate the suitability of rowing for cardiac rehabilitation, the Cardiocirculatory and metabolic reactions during rowing (RE) and cycle (CE) ergometry were compared. Ten male normotensive subjects of an outpatient heart group (age 56 ± 7 years, maximum performance on CE 2.0 ± 0.4 W‐kg ‐1) carried out a stepwise increasing test on an isokinetic rowing ergometer and a CE (increasing by 25 W every 3 min).In a 1‐min break after each step, heart rate and blood pressure, blood concentrations of lactate, and the free catecholamines adrenaline and noradrenaline were measured. Four patients showed signs of myocardial ischemia occurring almost one step earlier on RE than on CE. In RE, the endurance and maximum performance were about 20 W lower than on CE. At similar workloads, heart rate, blood pressure, and concentrations of lactate and catecholamines measured significantly higher on RE than on CE. At workloads above the individual anaerobic threshold, the increase in adrenaline and noradrenaline was significantly higher on RE than on CE. The results can be explained by the lower work efficiency, the higher isometric demands with increased cardiac pressure load, and the higher mental stress in RE. Rowing is only suitable in cardiac rehabilitation when well‐defined prerequisites have been considered.
Effects of atenolol and diltiazem‐SR on exercise and pressure load in hypertensive patients
Authors: Chrysant Steven G. , Miller Elinor
Published: February 2009

The effects of monotherapy with atenolol or diltiazem‐SR on blood pressure, 24‐h blood pressure (BP) load, and exercise capacity were tested in patients with mild to moderate (stages I and II) essential hypertension. After 3‐week single blind placebo therapy, patients with sitting diastolic blood pressure (SDBP) of 94‐114 mmHg were randomized to atenolol 50 mg/day (62 patients) or diltiazem‐SR 90 mg b.i.d. (60 patients) in a double‐blind parallel study. Depending on SDBP response, the dose was increased to 100 mg/day for atenolol and 180 mg b.i.d. for diltiazem‐SR. Twenty‐four‐hour ambulatory blood pressure measurements and exercise tolerance lest by the Bruce protocol were done at the end of placebo and active treatment. Compared with placebo, both atenolol and diltiazem‐SR significantly decreased heart rate (HR), sitting systolic blood pressure (SSBP), SDBP, ambulatory BP, BP load for waking and sleeping hours, area under the BP curve, rate‐pressure product (p < 0.001), and exercise time (NS). Atenolol exerted a greater effect on ambulatory BP, HR, rate‐pressure product, waking diastolic BP load, and area under the 24‐h BP curve. The drugs were well tolerated and caused no serious side effects necessitating discontinuation of treatment. These findings indicate that (1) monotherapy for hypertension with atenolol or diltiazem SR is effective and well tolerated, (2) it decreases the 24‐h BP load, (3) it does not interfere with exercise capacity.
Hereditary dilated cardiomyopathy
Authors: Mcminn Thomas R. , Ross John
Published: February 2009

Dilated cardiomyopathy (DCM) is a common and important cause of morbidity and mortality. Many factors can contribute to the development of this disorder, although most commonly the etiology is unexplained. However, recent studies in individuals with idiopathic DCM now reveal a heritable cause in 20–30% of individuals. Diverse modes of inheritance have been demonstrated, encompassing an autosomal dominant type (by far the most common), together with recessive and X‐linked forms, and maternal inheritance through mitochondrial DNA. The hereditary forms of DCM (HDCM) predominantly affect the left ventricle, although inherited abnormalities affecting primarily the right ventricle also are described. HDCM may occur as a primary cardiomyopathy, or secondary to inherited systemic metabolic or neuromuscular disorders. The causative genes for primary HDCM of the autosomal dominant and recessive types have not yet been discovered, but the combination of family pedigree analysis and phenotyping by echocardiography, together with new genetic techniques, should now allow their identification. Knowledge of the gene or genes responsible for HDCM would improve diagnostic accuracy, facilitate genetic counseling, advance understanding of pathogenesis, and provide the starting point for new methods of treatment. Because of the frequently heritable nature of DCM, it is of great importance that a diligent search for all potentially affected family members be undertaken.
Effect of hydration on cavity obliteration during dobutamine stress echocardiography
Authors: Weissman Neil J. , Nidorf Stefan M. , Weyman Arthur E. , Picard Michael H.
Published: February 2009

The purpose of this study was to determine whether it is possible to prevent or delay the onset of midventricular cavity obliteration during a dobutamine stress test with standard hydration. Left ventricular (LV) intracavitary obstruction has been reported as the mechanism for hypotension seen in approximately 20% of patients undergoing dobutamine stress echocardiography. In addition, it has been proposed that administration of a normal saline bolus prior to dobutamine infusion may avert the dynamic ventricular obstruction. We performed a standard graded dobutamine stress echocardiogram before and after fluid loading with 10 ml/kg of normal saline in 10 mongrel dogs. Measurements were made of left atrial pressure, aortic pressure, and the area of the LV cavity at the papillary muscle level throughout each infusion. Although hydration produced an increase in baseline left atrial pressure (5.7 ± 3.2 to 8.1 ± 2.7 mmHg, p < 0.01) and systolic blood pressure (128 ± 18 to 139 ± 22 mmHg, p=0.03), there was no significant change in pre‐dobutamine heart rate or systolic area. With dobutamine infusion, there was a similar change in heart rate, systolic blood pressure, diastolic area, and systolic area (SA) at each dose of dobutamine regardless of hydration status. In addition, the dose at which cavity obliteration occurred was not altered by hydration (p = NS). Although all dogs developed cavity obliteration (SA<1.0 cm2) with dobutamine infusion, none experienced hypotension. In this canine model, cavity obliteration does not lead to systemic hypotension and cannot be prevented or delayed by volume loading.
Pathology of pulmonic valve stenosis and pure regurgitation
Authors: Waller Bruce F. , Howard Jane , Fess Stephen
Published: February 2009

Little morphologic information is available on operatively excised pulmonic valves. The causes of pulmonic stenosis are limited to a few conditions: (1) rheumatic and (2) non‐rheunatic (congenital, carcinoid, infective endocarditis). Congenital causes of pulmonic stenosis constitute well over 95% of these conditions. Congenital types of pulmonic stenosis include acommissural dome‐shaped, dysplastic, and bicuspid. Rare acquired causes of pulmonic stenosis include carcinoid, rheumatic, and infective endocarditis. Of the acquired causes of pulmonic stenosis, carcinoid is the most common condition. In contrast, causes of pure pulmonic regurgitation are multiple. Two major categories of pure pulmonic regurgitation include (1) conditions associated with anatomically abnormal valve cusps (congenital, rheumatic, carcinoid, trauma, and infective endocarditis) and (2) conditions associated with anatomically normal cusps (elevated pulmonary artery systolic pressures, idiopathic dilated pulmonary trunk, and Marfan's syndrome).
Cardiac complications of cocaine abuse
Authors: Chakko Simon , Myerburg Robert J.
Published: February 2009

Cardiac complications of cocaine abuse and a rational approach to evaluating and managing them are described. Cardiac abnormalities reported among asymptomatic cocaine abusers include echocardiographic left ventricular hypertrophy and segmental wall motion abnormalities. Electrocardiogram may reveal increased QRS voltage, ST‐T changes, and pathologic Q waves. Episodes of ST elevation may be seen during Holter monitoring. The management of cocaine‐abusing patients who present to an emergency room with acute chest pain is controversial because the two reported studies yielded conflicting results regarding the incidence of myocardial infarction (MI). Even in the absence of infarction, electrocardiographic abnormalities are common among these patients, which complicates the decision‐making regarding hospitalization. Pathophysiology of cocaine‐related MI is discussed. Distinct clinical features of cocaine‐related MI make it clear that the association between the two is not just temporal. However, considering the number of persons abusing cocaine, it is a rarity. Beta‐adrenergic blockers should be avoided in the treatment of cocaine‐induced myocardial ischemia which is best treated with nitrates and calcium‐channel blockers. Reports of cocaine‐induced myocarditis and cardiomyopathy are reviewed. Experimental studies and clinical case reports suggest that cocaine may cause lethal arrhythmias. Cocaine prolongs repolarization by a depressant effect on potassium current and may generate early afterdepolarizations. It is possible that cocaine‐associated arrhythmias are secondary to vasospasm‐related ischemia and reperfusion as well.
The effects of intracoronary adenosine on preconditioning during coronary angioplasty
Authors: Kerensky Richard A. , Kutcher Michael A. , Braden Gregory A. , Applegate Robert J. , Solis Gustavo A. , Little William C.
Published: February 2009

There is evidence that the first balloon inflation during coronary angioplasty provides a preconditioning stimulus leading to decreased ischemia during subsequent balloon inflations. Endogenous adenosine release may play a role in ischemic preconditioning. Therefore, intracoronary adenosine administration prior to the first balloon inflation during percutaneous transluminal coronary angioplasty (PTCA) might modify the preconditioning response to the first balloon inflation. Forty‐one patients underwent double‐blind randomization to treatment with 100 mcg of intracoronary adenosine or placebo prior to coronary angioplasty. Twenty patients (11 adenosine, 9 placebo) had complete resolution of ischemia between inflations allowing comparison between the first and second inflation. An angioplasty guidewire was used to obtain an intracoronary electrocardiogram. The mean reduction in ST elevation during the second inflation compared with the first was 4.8 mm in the placebo group and ‐0.8 in the adenosine group (p<0.05 placebo vs. adenosine). Seven of 9 placebo patients had a decrease in ischemia during the second inflation compared with the first, while only 2 of 11 adenosine patients showed a reduction. It was concluded that (1) the first inflation during PTCA is a preconditioning stimulus leading to a decrease in ischemia during later inflations, and (2) intracoronary adenosine administration prior to PTCA modifies the preconditioning effect of the first inflation. These data suggest that adenosine plays a role in ischemic preconditioning in humans.
Hydrochlorothiazide‐induced pulmonary edema with severe acute myocardial dysfunction
Authors: Frierson John H. , Marvel Steven L. , Thomas Gregory M.
Published: February 2009

A 73‐year‐old woman presented with acute pulmonary edema and hypotension less than 1 h after taking hydrochlorothiazide 50 mg, a reaction which has been reported as a rare but classic adverse drug response. Though prior cases have supported a noncardiogenic pulmonary edema syndrome, hemodynamic monitoring in this patient demonstrated a refractory low cardiac output state for more than 24 h. In the absence of other etiologies, this represents a new finding.
Heart failure: Lessons learned over the past 25 years
Authors: Weber Karl T,
Published: February 2009

Over the past 25 years, a great deal has been learned about the pathophysiology and management of heart failure—a major health problem whose prevalence and incidence have not declined, unlike other cardiovascular disorders. Several of these lessons are reviewed herein. However, despite these advances, important issues remain to challenge both the practicing physician and the research scientist.
Pregnancy‐induced increase of supraventricular arrhythmias in wolff‐parkinson‐white syndrome
Authors: Kounis Nicholas G. , Zavras George M. , Papadaki P.J. , Soufras G.D. , Kitrou M.P. , Poulos E.A.
Published: February 2009

Six women suffering from Wolff‐Parkinson‐White syndrome and who were previously asymptomatic or nearly asymptomatic, were followed prospectively during and after their subsequent pregnancies. Three women experienced several attacks of supraventricular tachycardia (SVT) for the first time and the rest experienced an increase in their attacks. It seems that there is an increased tendency for SVT in pregnancy. Increased adrenergic sensitivity by estrogens, increased plasma volume, stress, and anxiety during pregnancy may be some of the causative factors.
Are there gender differences in patients with coronary artery disease presenting with spontaneous sustained ventricular tachycardia and ventricular fibrillation?
Authors: Martinez‐Rubio Antoni , Borggrefe Martin , Shenasa Mohammad , Chen Xu , Wichter Thomas , Fetsch Thomas , Reinhardt Lurz , Breithardt Günter
Published: February 2009

The incidence of coronary artery disease (CAD) is greater in men than in women. The aim of the study was to analyze whether any gender‐related differences in patients with CAD and documented spontaneous sustained ventricular tachyarrhythmias exist, and which parameters influence the induction of sustained ventricular tachyarrhythmias. The data of 250 patients [43 women (17.2%) and 207 men (82.8%)] with spontaneous sustained ventricular tachycardia [n = 190 (76%)] and fibrillation [n = 60 (24%)] who underwent coronary and left ventricular angiography, electrophysiological study, and signal‐averaging electrocardiogram (ECG) form the basis of this analysis. No gender‐related differences could be observed in age, number of diseased coronary arteries, history, location and number of myocardial infarctions, presence of left ventricular aneurysm, ejection fraction, type of spontaneous or induced arrhythmias, right ventricular effective refractory period, and signal‐averaged ECG parameters. Age, presence of previous myocardial infarction, and ejection fraction were significant predictors (p<0.001) of inducibility of sustained ventricular tachyarrhythmias. Once CAD has begun, female and male patients present similar clinical and electrophysiologic characteristics. Thus, both genders should benefit similarly from diagnostic and therapeutic approaches if they are referred to the hospital or to invasive interventions at similar intervals in the course of their illness.
Pathology of tricuspid valve stenosis and pure tricuspid regurgitation—Part II
Authors: Waller Bruce E. , Howard Jane , Fess Stephen
Published: February 2009

This three‐part article examines the histologic and morphologic basis for stenotic and purely regurgitant tricuspid valves. In Part I, conditions producing tricuspid valve stenosis were reviewed. In Part II, conditions producing pure tricuspid regurgitation are discussed. In contrast to the relatively few causes of tricuspid stenosis, the causes of pure (no element of stenosis) tricuspid regurgitation are multiple. Some of the conditions producing pure regurgitation include floppy tricuspid valves, infective endocarditis, papillary muscle dysfunction, rheumatic disease, and Ebstein's anomaly.