bluuebunny/crossref_metadata_2025 huggingface dataset:
Assessment of abnormal left atrial relaxation by transesophageal pulsed doppler echocardiography of pulmonary venous flow velocity
Authors: Oki Takashi , Tabata Tomotsugu , Yamada Hirotsugu , Fukuda Kazuyo , Abe Miho , Onose Yukiko , Wakatsuki Tetsuzo , Iuchi Arata , Ito Susumu
Published: February 2009

Background: Several studies on left ventricular relaxation have been undertaken in the past: however, left atrial (LA) relaxation has not been fully evaluated.

Hypothesis: The purpose of this study was to assess abnormalities in LA relaxation by evaluating pulmonary venous flow velocity and interatrial septal motion using transesophageal echocardiography.

Methods: The subjects were 56 untreated patients in sinus rhythm, including 25 with previous myocardial infarction, 9 with hypertrophic cardiomyopathy, 11 with dilated cardiomyopathy, as well as 11 with chest pain syndrome as controls. Peak first systolic velocity (PVS1), peak atrial systolic velocity (PVA), and their time‐velocity integrals (PVS1‐I and PVA‐I, respectively) were calculated from the pulmonary venous flow velocity.

Results: The PVS1 and PVS1‐I correlated negatively with the maximum LA dimension and mean pulmonary capillary wedge pressure, and correlated positively with the amplitude of the interatrial septal motion during LA relaxation and percent fractional LA relaxation. The PVA and PVA‐I did not correlate with the mean pulmonary capillary wedge pressure. There was a weak positive correlation between PVA and PVS1, and a close positive correlation between the ratio of PVA to PVS1 and mean pulmonary capillary wedge pressure. Multiple regression analysis indicated that the PVS1 was most closely related to percent fractional LA relaxation, followed by mean pulmonary capillary wedge pressure.

Conclusion: The PVS1 determined from the pulmonary venous flow velocity is closely related to parameters of LA relaxation which may be determined by transesophageal M‐mode echocardiography, and the ratio of PVA to PVS1 is useful for noninvasive evaluation of LA pressure..
Effect of aminophylline in patients with atropine‐resistant late advanced atrioventricular block during acute inferior myocardial infarction
Authors: Alton Armaǧan , Kirdar Celal , ÖZBAY GÜLTAÇ
Published: February 2009

Background: Advanced atrioventricular (AV) block is a frequent complication in patients with acute inferior myocardial infarction (AIMI). This conduction abnormality is associated with narrow QRS complex in conducted or junctional escape beats, suggesting that the site of block is the AV node; however, its pathophysiology has not been properly established.

Hypothesis: This study investigated the effect of aminophylline in eight patients (5 men, 3 women, age range 51 to 78 years, mean 67.5 ± 8.8 years) with atropine‐resistant late advanced AV block during AIMI.

Methods: Advanced AV block was late in appearance in all patients, starting 2 to 5 days after AIMI, and consisted of second‐degree Mobitz II type in two patients and of complete AV block in six patients; all patients had narrow QRS complexes. Before aminophylline administration, all patients had a temporary pacemaker installed which was switched off throughout the study. They were given intravenous atropine (1 mg) that was found to be ineffective. One‐half h after atropine, the first aminophylline injection (240 mg) was given intravenously over 10 min. One h following the first injection, a second aminophylline dose (240 mg) was administered. Electrocardiographic rhythm strips were obtained before and after drug administration, and the type of AV block and atrial and ventricular rate were noted.

Results: Aminophylline restored 1:1 conduction with first‐degree AV block in six patients, Mobitz I AV block in one patient, and normal sinus rhythm in one patient. Mean atrial and ventricular rates before aminophylline were 104 ± 16 beats/min and 57 ± 9 beats/min. respectively, and after drug administration 95 ± 25 beats/min and 89 ± 17 beats/min, respectively, (p = 0.012).

Conclusion: These results indicate that aminophylline improves AV conduction in atropine‐resistant late advanced AV block complicating AIMI.
Propafenone versus procainamide for conversion of atrial fibrillation to sinus rhythm
Authors: Mattioli Anna Vittoria , Lucchi Giulia Ricci , Vivoli Daniela , Mattioli Giorgio
Published: February 2009

Background and hypothesis: Antiarrhythmic drugs are widely used for treatment of atrial fibrillation (AF) and restoration off sinus rhythm. This prospective, randomized, and controlled study compared the efficiency and safety of propafenone versus procainamide for the treatment of acute AF.

Methods: In all, 117 patients (55 women, 62 men, mean age 64.2 ± 13 years, median 63 years) who presented with AF were included in the study. Exclusion criteria were signs or symptoms of heart failure on physical examination, recent myocardial infarction or cardiac surgery, cardiogenic shock, or hypotension. Forty‐one patients spontaneously recovered sinus rhythm; the remaining 76 patients were randomized to receive propafenone or procainamide. Propafenone was given at a dose of 2 mg/kg body weight intravenously (IV) over 30 min. Patients randomized to receive procainamide received a bolus of 100 mg IV administered every 5 min up to a maximum dose of 1 g. The clinical characteristics of the two groups were comparable.

Results: The number of patients who recovered sinus rhythm after the treatment was larger in the procainamide‐treated group (Group 1) (69.5%) than in the propafenone‐treated group (Group 2) (48.7%); p < 0.05. The time required for cardioversion was significantly lower in Group 1 (mean 4.1 ± 1.3 h). than in Group 2 patients (mean 7.3 ± 2.6 h) (p<0.01).

Conclusion: In the present study, procainamide was more effective than propafenone for the treatment of AF of short duration.
Impairment of left atrial appendage function after spontaneous conversion of atrial flutter
Authors: Kontos Michael C. , Paulsen Walter H.J.
Published: February 2009

This paper reports a patient in atrial flutter who spontaneously converted to sinus rhythm while undergoing a transesophageal echocardiogram. Atrial appendage flow velocities were noted to be significantly decreased after conversion to sinus rhythm. Spontaneous contrast also developed in the left atrium shortly after conversion. Spontaneous cardioversion may be associated with decreased mechanical activity of the left atrium and appendage, resulting in “stunning.” This provides a possible explanation for the occurrence of thromboembolic events in patients without apparent thrombus before cardioversion.
Anomalous origin of the right coronary artery from the main pulmonary artery: Diagnosis and management
Authors: Hekmat Vahid , Rao Sudha M. , Chhabra Manoj , Chiavarelli Mario , Anderson John E. , Nudel Dov B.
Published: February 2009

Anomalous origin of the right coronary artery (ARCA) from the main pulmonary artery (MPA) is a rare congenital anomaly, with only 18 reported cases in the pediatric age group. More than half of these had associated cardiac anomalies that masked the presence of ARCA. Conversely, in many patients with ARCA as an isolated anomaly, the diagnosis has been missed during lifetime. The only patient with an isolated ARCA who was diagnosed in infancy presented with congestive heart failure. Asymptomatic infants with ARCA from the MPA have not been previously reported. Three additional cases, two infants and a child with ARCA from the MPA, are reported in this paper. The diagnostic dilemmas and the prognosis are discussed and management is recommended.
Relationship between joint national committee‐VI classification of hypertension and ambulatory blood pressure in patients with hypertension diagnosed by casual blood pressure
Authors: Inden Yasuya , Tsuda Makoto , Mayashi Hiroshi , Takezawa Hiroto , Iino Shigeo , Kondo Takahisa , Yoshida Yukihiko , Akahoshi Makoto , Terasawa Masayuki , Itoh Teruo , Saito Hdehiko , Hirai Makoto
Published: February 2009

Background: White‐coat hypertension has been diagnosed arbitrarily based on different criteria. In 1997, the Joint National Committee‐VI (JNC‐VI) reported a new classification of hypertension and strongly emphasized the importance of ambulatory blood pressure (ABP) monitoring. The report pronounced normal ABP values for the first time.

Hypothesis: The study's aim was to clarify the relationship between casual blood pressure (BP) and ABP of patients with essential hypertension in each stage of JNC‐VI classification, and the prevalence of white‐coat hypertension diagnosed by using JNC‐VI normal ABP criteria.

Methods: Ambulatory blood pressure was monitored noninvasively in 232 patients with essential hypertension whose casual BP was ≥ 140/90 mmHg. The patients were classified according to JNC‐VI classification, and their casual BP was compared with ABP. The criterion of white‐coat hypertension was defined as casual BP ≥ 140/90 mmHg with normal ABP according to JNC‐VI criteria (< 135/85 during daytime and < 120/75 during nighttime).

Results: Mean ABP increased as the stage advanced, and the differences between casual BP and ABP also increased.

There were considerable overlaps in the distribution of ABP among stages. The prevalence of white‐coat hypertension was 13% overall: 30% of the patients with isolated systolic hypertension, 19% of those in stage 1,10% in stage 2, and 4% in stage 3.

Conclusions: Classification of hypertension based on casual BP may not always correspond in severity to that based on ABP. Ambulatory blood pressure monitoring recommended by JNC‐VI is very useful for the evaluation of hypertension to differentiate white‐coat hypertension from true hypertension.
Clinical characteristics of ruptured chordae tendineae in hospitalized patients: Primary tear versus infective endocarditis
Authors: Portugese Shirley , Amital Howard , Tenenbaum Alexander , Bar‐Dayan Yaron , Levy Yair , Afek Arnon , Shemesh Joseph , Shoenfeld Yehuda
Published: February 2009

Background: Several etiologies have been associated with the rupture of chordae tendineae. The leading causes are infective endocarditis, primary rupture, and the association with various connective tissue disorders.

Hypothesis: In order to define the attributes of these patients, a retrospective study was conducted that investigated the medical files of hospitalized patients in the Sheba Medical Center, Tel‐Hashomer, Israel.

Methods: Twenty patients (17 men, 3 women) with ruptured chordae were detected. Primary rupture of the chordae tendineae had been diagnosed in 11 patients, while infectious endocarditis was the cause for the tear of the chordae tendineae in 9 patients. The patients who had primary rupture of the chordae were older than the patients with endocarditis (67.4 ±11.3 vs. 57 ± 9.3 years, respectively, p < 0.05).

Results: The posterior mitral valve cusp was more commonly involved (15 patients). Six of the patients with posterior mitral valve cusp involvement manifested atrial fibrillation. Mitral valve prolapse (MVP) was detected among seven patients, six of whom belonged to the group with infective endocarditis.

Conclusion: Primary tear and infective endocarditis are leading etiologies of ruptured chordae tendineae in hospitalized patients. Particularly among the patients with infective endocarditis, concomitant MVP was frequently detected. It is the authors' opinion that this coexistence implies that MVP may predispose to the rupture of chordae tendineae.
Association of genetic polymorphisms in the ace, apoe, and tgfβ genes with early onset ischemic heart disease
Authors: Biggart S. , Chin Mrcp, D. , Fauchon M. , Cardew G. , Du Fou L. , Harker N. , Quinn E. , Keller C. , Vincent R. , Mayne L.
Published: February 2009

Background: The genetic factors that contribute to ischemic heart disease (IHD) are poorly understood, and it is likely that multiple genes acting independently or synergistically contribute to the risk of IHD and outcome. The genes for angiotensin‐converting enzyme (ACE) and apolipoprotein E (ApoE) have been implicated independently in the risk of IHD.

Hypothesis: This study examined whether genetic polymorphisms in the ACE and ApoE genes are associated with early onset IHD. Polymorphisms in a third gene, transforming growth factor β2 (TGF β2), with a known role in wound repair and cardiac development, are also examined with respect to early onset IHD.

Methods: In all, 101 patients with IHD and onset of disease before 55 years for men and 60 years for women, and 100 controls with angiographically confirmed normal coronary arteries were recruited for this study. The ACE, ApoE, and TGF β2 genotypes were determined by polymerase chain reaction amplification or Southern blotting and were compared with the patient's clinical and family histories.

Results and Conclusion: The frequency of the ACE D allele was significantly lower in the patient group (0.475) than in the control group (0.59, p = 0.03), which was attributed to a reduction in the number of patients with the DD genotype (patients: 24% DD, controls: 33% DD). Sudden cardiac death was also associated with the DD genotype. These data are consistent with the ACE D allele contributing to a fatal outcome. No association between the DD genotype and risk of myocardial infarction, presenting age, extent of vessel disease, family history, hypertension, or hypercholesterolemia was seen. Analysis of the ApoE genotype showed no association with early onset IHD. There was no evidence for a synergistic effect between the ACE and ApoE genotypes on the risk of early onset IHD. A polymorphism in the TGF (32 gene was rare and not associated with early onset IHD.
Uncommon electrocardiographic changes corresponding to symptoms during recurrent pulmonary embolism as documented by computed tomography scans
Authors: Watanabe Takuya , Kikushima Shuji , Tanno Kaoru , Geshi Eiichi , Kobayashi Youichi , Takeyama Youichi , Katagiri Takashi
Published: February 2009

Electocardiographic (ECG) findings of pulmonary embolism (PE) include S1Q3T3 pattern, right bundlebranch block, right‐axis deviation, and T‐wave inversion in medial precordial leads. We report other uncommon ECG changes associated with various symptoms during recurrent PE as documented by computed tomography (CT) scans in a single patient. An 83‐year‐old woman was admitted with PE secondary to deep venous thrombosis in the left leg. During episodes of chest pain, ECG showed QTc prolongation (480 ms) with new T‐wave inversion in leads III, aVF, and V1‐V3, and ST‐segment depression in leads V5‐V6. Despite adequate anticoagulant therapy, recurrent episodes of PE occurred in the hospital. When the patient experienced sudden chest tightness, ECG showed a new S‐wave notch in lead V1 and clockwise rotation with sinus tachycardia. She also experienced transient syncope with hypotension. At this time, ECG showed transient atrioventricular junctional rhythm followed by sinus arrest, and CT scan showed a new massive embolus in the main pulmonary trunk with right ventricular dilatation, as demonstrated by echocardiography. The mechanism responsible for QTc prolongation with ST‐T changes, the S‐wave notch in lead V1 with clockwise rotation, or atrioventricular junctional rhythm with sinus arrest during PE may be associated with myocardial ischemia, acute right ventricular overload, or vagal reflex, respectively.
Complicated pericardial cyst: Atypical anatomy and clinical course
Authors: Bava Gian Lauro , Magliani Lucia , Bertoli Daniele , Gorrieri Pier Francesco , Rimini Alessandro , Zaccagnini Gianfranco , Bertolini Alberto
Published: February 2009

Pericardial cysts are usually detected by chance and are clinically silent in most cases. Nevertheless, symptoms and serious complications may occur. We describe a case of pericardial cyst diagnosed in an 8‐year‐old boy who was admitted with chest pain. Echocardiography revealed a mild to moderate pericardial effusion and a 7.5 × 5.5 cm intrapericardial echo‐free lesion consistent with a pericardial cyst. Surgery was carried out 3 days afterward because of the patient's worsening condition, the progressive increase of pericardial effusion, and the onset of initial signs of cardiac tamponade. The cyst showed a long and easily movable vascular pedicle and inflammatory areas involving the pericardial surface. Like the pericardial effusion, the contents of the mass appeared as serosanguineous fluid on aspiration. Histologic examination confirmed the diagnosis of pericardial cyst and showed findings according to ischemia‐related lesions of the cyst. The coexistence of pericardial cyst and cardiac tamponade is very unusual. The atypical anatomy and clinical course suggest a distinct and so far undescribed pathogenetic mechanism for this association: the torsion of a vascular pedicle and the subsequent development of ischemia‐related lesions of the cyst.
Effects of dichloroacetate in patients with congestive heart failure
Authors: Lewis Jannet F. , Dacosta Michelle , Wargowich Thomas , Stacpoole Peter
Published: February 2009

Background: Conventional approaches to management of congestive heart failure (CHF) rely on drugs that increase myocardial contractility or reduce ventricular afterload. These approaches often improve cardiac symptoms and survival, but may be associated with significant deleterious effects. An alternative approach is to enhance myocardial energy production. Dichloroacetate (DCA) stimulates pyruvate dehydrogenase activity and accelerates aerobic glucose, pyruvate, and lactate metabolism in myocardial cells. These alterations would be expected to improve myocardial function.

Hypothesis: The purpose of the investigation was to assess the efficacy of DCA in patients with left ventricular systolic dysfunction and to examine the mechanism by which improvement occurs.

Methods: A total of 25 patients (16 men, 9 women; age range 31‐72 years, mean 59) with CHF and ejection fraction ≤40% received an intravenous infusion of 50 mg/kg DCA over 15 min. Indices of systolic and diastolic function were obtained by two‐dimensional and Doppler echocardiography performed at baseline, 30 min, and 60 min following completion of DCA infusion.

Results: Baseline ventricular ejection fraction was 27.3 ± 9.1%; 17 patients (68%) had nonischemic cardiomyopathy. Heart rate increased after DCA infusion from 73.9 ± 14.5 to 79.2 ± 14.9 beats/min at 60 min; p = 0.02. Left ventricular diastolic and systolic volumes increased at 30 min compared with baseline (248.7 ± 98.1 vs. 259.6 ± 99.6; p = 0.04, and 180.1 ± 80.4 vs. 192.2 ± 84.9; p = 0.002, respectively), but stroke volume (49.2 ± 19.1 vs. 48.9 ± 18.1; p = 0.9) and ejection fraction (27.3 ± 9.1 vs. 25.7 ± 9.8; p = 0.2) were un changed. Indices of diastolic function were also unchanged.

Conclusion: Dichloroacetate infusion in patients with CHF is not associated with improvement in noninvasively assesse left ventricular function.
The impact of beta‐receptor blocker addition to high‐dose angiotensin‐converting enzyme inhibitor‐nitrate therapy in heart failure
Authors: Barry Levine T. , Levine Arlene B. , Keteyian Steven J. , Narins Barbara
Published: February 2009

Background: The natural history of heart failure is one of continued worsening of cardiac function. Beta‐receptor blocker therapy has been effective in improving clinical status and left ventricular function in patients with heart failure. Similarly, high doses of angiotensin‐converting enzyme (ACE) inhibitors with nitrates partially reverse the ventricular remodeling of heart failure.

Hypothesis: We tested the hypothesis that beta‐blocker therapy added to high‐dose ACE inhibitor‐nitrates would potentiate the reversal of heart failure.

Methods: Thirteen patients, aged 52 ± 8 years, with moderate to severe heart failure, 12 of whom were referred for transplant consideration, with heart failure duration of 4.8 ± 2.2 years, were prospectively followed for 12 months. Baseline echocardiographic ejection fraction was 19 ± 8%, and presenting New York Heart Association class was 2.9 ± 0.7. Angiotensin‐converting enzyme inhibitors and nitrates were uptitrated over 6 months to a final dose of lisinopril 53 ± 31 mg/day, and isosorbide dinitrate 217 ± 213 mg/day. At 6 months, beta‐blocker therapy with atenolol was initiated and titrated to a final dose of 46 ± 23 mg/day. Two‐dimensional Doppler echocardiography and metabolic stress testing were performed at baseline, at 6 months on lisinopril‐nitrates only, and at 12 months on combined ACE inhibitor‐nitrate and beta‐blocker therapy.

Results: New York Heart Association classification improved from 2.9 ± 0.7 to 1.8 ± 0.8 on lisinopril‐nitrates (p< 0.05), and to 1.5 ± 0.5 with the addition of beta blockade (p = NS). On follow‐up, peak oxygen consumption rose from 17 ± 7 ml O2/kg/min at baseline to 21 ± 5 ml O2/kg/min at 6 months on lisinopril‐nitrates (p = 0.06) without further change on beta blockade. Ejection fraction rose from 19 ± 8 to 33 ± 14% on lisinopril‐nitrates at 6 months (p = 0.005) and to 36 ± 18% on beta blockade at 12 months (p = NS).

Conclusion: High‐dose ACE inhibitor‐nitrate therapy significantly improved patient clinical status and left ventricular systolic function in heart failure. The addition of beta‐receptor blockade over and above high‐dose ACE inhibitor‐nitrates was well tolerated but had no further impact on symptomatic status, exercise tolerance, or left ventricular systolic function. The potential for pharmacologic reversal of heart failure remodeling may be finite despite the use of complementary therapies. Larger placebo‐controlled and randomized trials of beta‐receptor blockade added to high‐dose ACE inhibitor‐nitrate therapy are needed to confirm these observations.
Characteristics of patients less than 45 years of age compared with older patients undergoing coronary artery bypass grafting
Authors: Nguyen Trung Duc , Virgilio Christian De , Kakuda James , Omari Bassam O. , Milliken Jeffrey C. , Robertson John R. , Baumgartner Fritz J.
Published: February 2009

Background: Coronary artery disease (CAD) was not recognized as common among young patients until the study by Yater in 1948. Subsequent studies further elucidated the nature of the disease, which had become more apparent in the younger groups.

Hypothesis: The study was undertaken to determine the prevalence of risk factors and severity of coronary disease among young patients aged ≤ 45 years undergoing coronary artery bypass grafting (CABG) compared with older patients.

Methods: in all, 112 young patients aged ≥ 45 years (Group 1) and 798 older patients aged > 45 years (Group 2) were analyzed for trends to hypertension, smoking, diabetes, family history of heart disease, hypercholesterolemia, obesity, and history of previous myocardial infarction (MI). The severity of disease was examined in terms of number of diseased vessels, vessel size, number of grafts performed, performance of endarterectomies, and left ventricular function.

Results: Group 1 had a higher incidence of positive family history (68.5 vs. 51.2%, p < 0.05), and lower incidences of hypertension (62.7 vs. 81.5%, p < 0.05), obesity (42.9 vs. 83.9%, p<0.05), and history of previous MI (54.5 vs. 94.6%, p < 0.05). Group 2 had a higher incidence of left main disease (22.6 vs. 11.4%, p < 0.05). The distribution of the affected vessels of the young patients was most commonly the left anterior descending (90.4%) followed by the right coronary (79.8%) and circumflex arteries (69.2%). Group 2 had more grafts per patient (3.82 vs. 3.37, p< 0.05). The size of the diseased vessels measured intraoperatively was similar (1.56 vs. 1.58 mm, p = NS) in both groups. Endarterectomy was performed almost three times more often in Group 1 patients (8.2 vs. 3.0%, p>0.05). Operative mortality was less in Group 1 mean (1.8 vs. 6.3%, p < 0.05). Group 2 had a greater mean left ventricular ejection fraction (53.8 vs. 49.7%, p< 0.05).

Conclusion: Compared with the older population, patients < 45 years of age who underwent CABG had (1) a higher incidence of positive family history of CAD, (2) a higher likelihood of requiring an endarterectomy, and (3) lower operative mortality rate despite a slightly poorer ventricular function.
Emergency department thrombolysis critical pathway reduces door‐to‐drug times in acute myocardial infarction
Authors: Cannon Christopher P. , Blair Johnson E. , Scirica Benjamin M. , Cermignani Monica , Sagarin Mark J. , Walls Ron M.
Published: February 2009

Background: Rapid time to treatment with thrombolytic therapy is an important determinant of survival in acute myocardial infarction (AMI).

Hypothesis: We hypothesized that establishment of an AMI thrombolysis critical pathway in the Emergency Department could successfully reduce the “door‐to‐drug” time, the time between patient arrival and start of thrombolysis.

Methods and results: Before establishment of the AMI critical pathway, median door‐to‐drug time was 73 min, which was reduced to 37 min after critical pathway implementation (p<0.05). The percentage of patients treated within 30 min rose from 0% prior to establishment of the pathway to 43% (p = 0.03). Similarly, the percentage treated in within 45 min rose from 0 to 67% (p = 0.0005). Door‐to‐drug times were longer for women than for men (median 105 min for women vs. 70 min for men before pathway implementation). The pathway reduced door‐to‐drug time for both genders, but the median door‐to‐drug times were higher for women than for men (Mann‐Whitney p = 0.013). The difference between men and women was 35 min before establishment of the pathway to 10 min by the end of the study period.

Conclusions: Our critical pathway was successful in reducing door‐to‐drug times. We observed a “gender gap” in door‐to‐drug times, with longer mean times for women, which was reduced by the AMI critical pathway. Thus, our data provide support for the use of critical pathways to reduce door‐to‐drug times, as recommended by the National Heart Attack Alert Program.
Randomized evaluation of four versus five french catheters for transfemoral coronary angiography
Authors: Metz Damien , Chapoutot Laurent , Brasselet Camille , Jolly Damien
Published: February 2009

Background and hypothesis: in coronary angiography there is a trend toward using smaller catheters to avoid puncture site complications. An increased utilization of outpatient facilities may result. This study was undertaken to determine whether using 4Fr diagnostic catheters in comparison with 5Fr catheters would reduce the vascular complication rate, after patient ambulation following 4 h bedrest, without altered technical performance and or procedural duration.

Methods: The study population comprised 100 consecutive, unselected patients, who were randomly assigned for transfemoral coronary angiography with 4 or 5Fr diagnostic catheters. Procedural characteristics, quality of angiogram, and clinical assessment of puncture site at 4, 12, and 24 h were analyzed.

Results: No significant difference was demonstrated concerning procedural characteristics, ventriculography, coronary contrast quality, or local vascular damage. However, two patients crossed over in the 4Fr group and one in the 5Fr group.

Conclusion: As a consequence, the feasibility, reliability, and utility of catheter size on vascular complication rates must be considered to be similar with either 4Fr or 5Fr diagnostic catheters.
Cardiac and autonomic evaluation in a pediatric population with human immunodeficiency virus
Authors: Plein D. , Van Camp G. , Cosyns B. , Alimenti A. , Levy J. , Vandenbossche J.‐L.
Published: February 2009

Background: Cardiac involvement in children with human immunodeficiency virus (HIV) infection is a well‐known entity and occurs clinically more often in patients with advanced acquired immunodeficiency syndrome (AIDS). Autonomic dysfunction is less known, especially in children.

Hypothesis: The aim of this study was to asses the prevalence of cardiovascular abnormalities in a pediatric population with HIV. We also aimed to evaluate whether autonomic involvement occurs in the same population and is dependent on echocardiographic abnormalities.

Methods: The occurrence of echocardiographic abnormalities was evaluated in 22 children with HIV infection, and five noninvasive tests were performed to evaluate the presence of autonomic dysfunction.

Results: We found cardiac lesions in four children (18%), consisting of pericardial effusion in three children, wall motion abnormalities in three children, and acute aortic endocarditis in one child. All cardiac abnormalities were found at Stage C by Center for Disease Control (CDC) revised classification. We also found left ventricular filling pattern abnormalities consisting of E‐wave maximal velocity decrease and prolonged deceleration time compatible with diastolic dysfunction. One of the five autonomic tests (Valsalva maneuver) was significantly altered, even in patients without abnormal echocardiography, suggesting mild autonomic dysfunction.

Conclusion: The study demonstrated a high prevalence of cardiac lesions in children with HIV infection and indicated the presence of autonomic dysfunction even when there are no echocardiographically detected abnormalities.
Electrocardiographic patterns in acute inferior myocardial infarction with and without right ventricle involvement: Classification, diagnostic and prognostic value, masking effect
Authors: Willis Hurst J. , Correale Ernesto , Battista Rossano , Martone Angela , Pietropaolo Ferdinando , Ricciardiello Vincenzo , Digirolamo Domenico , Barlera Simona , Maggioni Aldo P.
Published: February 2009

Background: in acute inferior myocardial infarction (AIMI), the ST depression from V1 to V4 has been the subject of many papers, while the ST changes in other leads, their association, and the right ventricular (RV) involvement have been studied less.

Hypothesis: This study was performed to contribute to the meaning of the ST changes and RV involvement in AIMI.

Methods: Seventy‐one patients, admitted within 6 h from symptom onset, all thrombolysed, were enrolled. We classified them according to ST patterns and RV involvement. We divided the right coronary artery into three segments, considering the origin of RV branch and the crux as dividing points. We established a coronary score attributing 2 points to each terminal branch. Comparisons were performed between the electrocardiographic (ECG) findings at onset, the creatine phosphokinase (CPK) peaks, the radionuclide ejection fractions, and the coronary angiographies.

Results: We found that the ST changes give indications regarding the site, extension, and extent of AIMI; RV involvement can mask posterior extension, points to the right coronary as the culprit vessel (100%), and, with high probability, indicates the proximal segment as the site of the lesion; the ECG signs of isolated AIMI indicate a peripheral obstruction; and a collateral circulation may appear relatively early.

Conclusions: Our findings prove the diagnostic and prognostic value of the ST changes and RV involvement at the onset of AIMI and suggest that the higher in‐hospital mortality and complication rates found with RV involvement and reported in the literature are related more to posterior extension, masked by RV involvement than to this involvement per se. Furthermore, these findings prove the clinical value of our classification of the AIMIs and distinction in segments of the right coronary artery.
Angiotensin‐Converting enzyme inhibitor‐induced pancreatitis
Authors: Muchnick J. S. , Mehta J. L.
Published: February 2009

Approximately 2% of pancreatitis in adults is drug induced. Although some angiotensin‐converting enzyme (ACE) inhibitors have been associated with pancreatitis, to the knowledge of the authors this is the first reported case involving benazepril. This case report presents laboratory‐ and image‐proven pancreatitis in a noninsulin dependent 70‐year‐old man. The patient took benazepril at three different times and experienced the same epigastric symptoms 30 min after each dose. Possible mechanisms are reviewed. Clinicians should strongly consider discontinuing ACE inhibitors, including benazepril, in patients with pancreatitis of no identifiable source.
Circadian variations of qtc dispersion: Is it a clue to morning increase of sudden cardiac death?
Authors: Kemal Batur M. , Aksöyek Serdar , Oto Ali , Yildirir Aylin , Özer Necla , Atalar Enver , Aytemir Kudret , Kabakci Giray , Övünç Kenan , Özmen Ferhan , Kes Sirri
Published: February 2009

Background: Several studies related to cardiac events including sudden death have shown a peak incidence in the early morning hours. It has also been known that acute ischemia is a potent stimulus to increased dispersion of repolarization and development of malignant arrhythmias.

Hypothesis: The purpose of the present study was to investigate diurnal variations of corrected QT dispersion (QTcD) in patients with coronary artery disease (CAD) (Group 1) compared with controls with normal coronary angiograms (Group 2).

Methods: We investigated a total of 110 patients who had been referred for coronary angiography, of whom 62 (42 men, 20 women; age 55 ± 7 years) had double‐ or triple‐vessel disease, and of whom 48 (31 men, 17 women; age 54 ± 9 years) had normal coronary angiograms. QTcD measurements were calculated from a 12‐lead resting electrocardiogram (ECG) during sinus rhythm. These ECGs were obtained for each patient in the morning, at noon, in the evening, and at night on the day after performance of coronary angiography. QTcD was significantly greater in patients with abnormal coronary angiograms (Group 1) than in patients with angiographically documented normal coronary arteries (Group 2). This difference appeared to be more prominent in the morning hours (p < 0.001) than at other times. QTcD in the evening and night hours was not statistically different (p >0.05) between both groups. We also compared intragroup QTcD values: QTcD values were significantly increased in the morning hours and were more prominent in Group 1 than in Group 2.

Conclusions: Our data suggest that QTcD has a circadian variation with an increase in the morning hours, especially in patients with coronary artery disease. This finding was thought to be an explanation for the role played by sympathetic nervous system in the occurrence of acute cardiac events and sudden death during these hours.
Deceleration‐dependent shortening of the qt interval: A new electrocardiographic phenomenon?
Authors: Liebl Nancy , Zimmerman Frank , Nouri Soraya , Willis Hurst J. , Gussak Ihor , Bjerregaard Preben , Chaitman B. R.
Published: February 2009

In clinical cardiology, deceleration‐dependent QT interval shortening is considered to be an extraordinary electrocardiographic phenomenon. We present an early premature born 4‐year‐old African‐American girl with complications related to her premature birth, developmental delay, and several episodes of cardiac arrest. An episode of severe transient bradyarrhythmia was documented on Holter monitoring. The unique feature of the rhythm strips was paradoxical gradual shortening of the QT interval to 216 ms with accompanying transient T‐waves abnormalities. The activation of the Ik, ACh due to an unusually high vagal discharge to the heart is proposed as a possible mechanism responsible for both slowing of the heart rate and shortening of the QT interval.
Myotonic dystrophy associated with qt prolongation and torsade de pointes
Authors: Umeda Yuji , Ikeda Uichi , Yamamoto Jun , Fukazawa Hiroshi , Hayashi Yuji , Fujikawa Hideyuki , Shimada Kazuyuki
Published: February 2009

A rare case of myotonic dystrophy (MD) with congestive heart failure, associated with QT prolongation and torsade de pointes (TdP) is reported. A 53‐year‐old woman was admitted to the hospital because of congestive heart failure. Electrocardiograph (ECG) showed first‐degree atrioventricular block and QT prolongation. During hospitalization, TdP appeared but returned to sinus rhythm spontaneously. As the patient had quadriplegia, a myopathic face, cataracts, diabetes mellitus, and an increased number of cytosine‐thymineguanine (CTG) repeats (760 repeats), she was diagnosed as having MD. Electrocardiographic analysis of her family also revealed abnormal QT(U) prolongation in her daughter and brother who both had MD, while ECG findings of other family members without MD were normal. Thus, the presence of QT(U) prolongation was associated with MD in this family.
Coronary stent deployment in a young adult with kawasaki disease and recurrent myocardial infarction
Authors: Ueno Takafumi , Kai Hisashi , Ikeda Hisao , Ichiki Kazuya , Hashino Tatsuya , Imaizumi Tsutomu
Published: February 2009

A 19‐year‐old man developed a huge coronary aneurysm and stenosis in the right coronary artery as a sequela of Kawasaki disease (KD) that resulted in recurrent episodes of myocardial infarction. Coronary ischemic events were successfully prevented after balloon angioplasty followed by coronary stent implantation into the stenotic lesion. The stent deployment may have an advantage compared with balloon angioplasty and other new devices for the treatment for patients with KD showing stenotic lesions without dense calcification.
Sudden death in dilated cardiomyopathy
Authors: Wu Audrey H. , Das Sunil K.
Published: February 2009

The purpose of this review is to examine the potential contribution of arrhythmia to the occurrence of sudden death in dilated cardiomyopathy (DCM) and to discuss current treatment options. We performed a search of the MEDLINE database from 1985 to the present and the reference citations of selected articles pertaining to the prognostic significance, management, and pathophysiology of arrhythmias in DCM. A large proportion of patients with DCM die suddenly, most secondary to ventricular arrhythmia and a smaller proportion due to bradyarrhythmia. The presence and severity of ventricular ectopy may predict risk for sudden death, but the role of electrophysiologic study and signal‐averaged electrocardiography in further risk stratifying patients remains uncertain. Abnormalities of the autonomic nervous system and renin‐angiotensin‐aldosterone axis appear to promote the occurrence of ventricular arrhythmias. Angiotensin‐converting enzyme inhibitors improve overall mortality in congestive heart failure, and the use of direct angiotensin‐receptor antagonists is currently being studied. In addition, beta‐receptor antagonists appear to improve morbidity and may prove to improve mortality in heart failure as well. Other interventions still under investigation include amiodarone and the implantable cardioverter‐defibrillator. The underlying pathophysiology of sudden death in DCM involves primarily ventricular tachyarrhythmia. Angiotensin‐converting enzyme inhibitors remain a mainstay of improving overall mortality, while further study on the roles for newer drugs and devices is ongoing.
Attenuated severity of new acute ischemic events in patients with previous coronary heart disease receiving long‐acting nitratesa
Authors: Garc ía‐Dorado David , Permanyer‐Miralda GaietÀ , Brotons Carles , Calvo Francisco , Campreci ós Marta , Oliveras Juan , Teresa Santos M. , Moral Irene , Soler‐Soler J.
Published: February 2009

Background: Platelet aggregation and secondary vasoconstriction are key events in the genesis of acute coronary syndromes.

Hypothesis: Since nitrates have vasodilatory and antiaggregant effects, treatment with long‐acting nitrates at the time of onset of acute coronary syndromes could be associated with attenuation of their severity.

Methods: A consecutive series of 533 patients with acute coronary syndrome and past history of coronary artery disease admitted to the Cardiology Service of a general hospital was studied. A specific questionnaire assessed the use of nitrates and other relevant drugs, as well as other clinical variables. The diagnosis of unstable angina or acute myocardial infarction (MI) was established according to clinical, electrocardiographic, and enzymatic criteria.

Results: In the whole cohort, 169 patients had MI and 364 had unstable angina. Previous use of long‐acting nitrates was significantly more common in patients with unstable angina (56%) than in those with MI (37%) (p<0.0001). Multivariate analysis identified being a nonsmoker [odds ratio: 95%, confidence limits (CL) 0.37, 0.23–0.59], previous unstable angina (CL 0.62, 0.41–0.92), use of aspirin (CL 0.58, 0.41–0.92), and use of long‐acting nitrates (CL 0.61, 0.40–0.93) as the independent predictors of the development of unstable angina rather than MI; of these the combination of nitrates and aspirin was the strongest predictor.

Conclusions: Long‐acting nitrates as well as aspirin are suggested to have a protective or modifying effect on the development of acute coronary syndromes, favoring unstable angina rather than acute MI.
Transesophageal echocardiography for the evaluation and management of patients with cerebral ischemia
Authors: Rahmatullah Amin F. , Rahko Peter S. , Stein James H.
Published: February 2009

To prevent recurrent strokes and transient ischemic attacks, considerable attention is devoted to investigating the etiology of acute cerebral ischemia in the large subpopulation of patients without an easily identifiable cause. In general, transthoracic echocardiography is an insensitive tool for the evaluation of patients with cerebral ischemia, unless clinical signs and/or symptoms of cardiac disease are present. Transesophageal echocardiography (TEE), because of its increased sensitivity for aortic arch atheromata, atrial septal pathology, left atrial thrombi, and valvular abnormalities, is the preferred cardiac imaging modality, especially in young patients, older patients with hypertension or systemic atherosclerosis, and patients with prosthetic heart valves. This paper reviews the prognostic and therapeutic impact of TEE in patients with cerebral ischemia, specifically focusing on the ability of information obtained by this technique to alter patient management and improve risk stratification.
The effects of metoprolol and captopril on heart rate variability in patients with idiopathic dilated cardiomyopathy
Authors: Jansson Kjell , Östlund Rolf , Nylander Eva , Dahlström Ulf , Hagerman Inger , Karlberg Karl‐Erik , Nyquist Olof
Published: February 2009

Background: The effects of treatment with captopril or metoprolol on heart rate variability (HRV) were investigated in 38 patients (29 men and 9 women) with mild to moderate symptoms of heart failure due to idiopathic dilated cardiomyopathy (DCM).

Hypothesis: The aim of the study was to investigate and compare the effects of the angiotensin‐converting enzyme inhibitor captopril with those of the selective beta‐adrenergic receptor blocker metoprolol on HRV in patients with idiopathic DCM.

Methods: Heart rate variability was analyzed in the time and frequency domains from 18 h of Holter monitoring before randomized treatment was started, after 6 months of therapy, and 1 month after therapy was stopped.

Results: Captopril treatment increased HRV expressed as total power and low‐frequency power in the frequency domain. There was no change in the time domain. In the metoprolol group, there was a pronounced increase in both time‐and frequency‐domain indices of HRV. The increase in total power was partly maintained 1 month after therapy was stopped in both treatment groups.

Conclusion: Treatment with captopril and metoprolol increases HRV in patients with DCM. This effect seems to be maintained for at least 1 month after therapy is stopped. The increase in HRV seems to be more pronounced with metoprolol, and the two different pharmacologic approaches may have additive effects that are of prognostic importance in patients with heart failure.
Paradoxical behavior of the QT interval during exercise and recovery and its relationship with cardiac memory
Authors: Moleiro Federico , Misticchio Francesca , Torres Jose M. , Pulido Moises , Luque Milagros , Rodriguez Ana , Mendoza Ivan , Guerrero Julio , Ruesta Victor , Castellanos Agustin , Myerburg Robert J.
Published: February 2009

Background: Few studies have dealt with the behavior of the corrected (QTc) and uncorrected QT intervals during exercise and recovery.

Hypothesis: Based on previously published dynamics of the QT interval during treadmill testing, this study attempted to reevaluate the computer‐proposed underlying mechanisms of these dynamics and to determine whether the so‐called memory phenomenon could be operative in some subjects without evidence of structural heart disease.

Methods: This study included 42 unmedicated healthcare volunteers, 23 men and 19 women aged between 20 and 42 (mean 31.7) years. All had normal physical examinations, x‐rays, and transthoracic echocardiograms. The electrocardiograms were also normal with 12‐lead QT interval dispersions of <90ms.

Results: During exercise and recovery, the behavior of the QT intervals permitted the categorization into two groups. In Group 1 (31/42; 73.8% of subjects) the uncorrected QT interval showed a biphasic pattern consisting of a gradual decrease during incremental exercise followed by a gradual increase during recovery. In contrast, the QTc interval had a triphasic pattern resulting from a slight increase during the early phase of exercise, a gradual decrease at the highest rates, and a final increase during recovery as the rate slowed to control values. In Group 2 (11/42; 36.2% of subjects) the behavior was considered as paradoxical since the uncorrected QT interval displayed in a triphasic pattern whereas the QTc interval yielded a tetraphasic pattern due to the fact that both showed a second decrease during recovery while the rate was decreasing.

Conclusions: Analysis of dynamics behavior of the QTc and the uncorrected QT intervals during exercise showed that some normal subjects had a paradoxical behavior which, because of its temporal relation to the phases of exercise, could be an expression of the so‐called memory phenomenon.
Morning attenuation of endothelium‐dependent, flow‐mediated dilation in healthy young men: Possible connection to morning peak of cardiac events?
Authors: Etsuda Hirokuni , Takase Bonpei , Kusano Hiroyuki , Hamabe Akira , Kuhara Ryoji , Akima Takashi , Matsushima Yoshihiro , Arakawa Koh , Satomura Kimio , Ohsuzu Fumitaka , Kurita Akira , Uehata Akimi
Published: February 2009

Background and hypothesis: Brachial artery flow‐mediated dilation (FMD), a noninvasive, widely used clinical index of endothelial function and magnitude of FMD, has been reported to be closely related to many coronary risk factors and coronary atherosclerosis. However, there has been no study that examines the diurnal change of FMD. We designed this study to reveal the diurnal variation of FMD in healthy volunteers.

Methods: We examined FMD in response to reactive hyperemia by high resolution ultrasound in 13 healthy young men (age 25–32) at four different times over the course of a day.

Results: Mean measures of brachial artery FMD was 4.0% at 8:00, 5.3% at 12:00, 9.7% at 17:00, and 6.9% at 21:00 hours. Flow‐mediated dilation at 8:00 and at 12:00 hours was significantly lower than that at 17:00 (p <0.05).

Conclusions: These results show that endothelial function has diurnal variation and is significantly attenuated in the morning. Morning attenuation of endothelial function should be recognized in clinical research and may play an important role in the circadian variation of the occurrence of acute cardiovascular events.