bluuebunny/crossref_metadata_2025 huggingface dataset:
Prevention of coronary restenosis with radiation therapy: A review
Authors: Hafeez Nabeel
Published: June 2007

The problem of restenosis after percutaneous transluminal coronary angioplasty remains the major limiting factor of the procedure. Over the last 10 years, investigators have been studying the use of radiation therapy for preventing restenosis after angioplasty or stent placement. Since radiotherapy has been proven in other cases to be effective in disrupting the cell cycle regulatory proteins and thereby slowing or stopping growth, it was decided to apply the same principle to neointimal hyperplasia. To review the data that have emerged regarding vascular radiation with an emphasis on irradiated stents, 65 articles were reviewed and both pre‐clinical and clinical experiments were included. Overall, studies with gamma and beta radiation show promising results. Endovascular gamma radiation has been shown effective in randomized trials, even at 3‐year follow‐up. Beta radiation is preferred because of greater safety and localization, and because it has also shown encouraging results in initial clinical trials, as well as in larger randomized studies. Consequently, the Federal Drug Administration has approved the use of both. In both types of endovascular brachytherapy, it seems the greater the dose, the better the initial response. Safety concerns include an increased incidence of late thrombosis and greater restenosis at margins. With irradiated stents, however, the situation is not as clear. At times, animal models have presented confusing results. These have ranged from significant suppression of hyperplasia to outright adverse effects of radiation on the vessel wall. While some clinical trials have been encouraging, others have not. Follow‐up of up to 1 year has been disappointing so far. Many issues, such as the “candy wrapper” effect and rebound hyperplasia, must be dealt with before this becomes a viable form of therapy. It has become clear that radiation therapy in this setting, while having potentially great benefits, can cause deleterious effects as well. However, the mixed bag of positive and negative results seen so far, and the attractiveness of stents or percutaneous transluminal coronary angioplasty being “restenosis‐proofed,” eventually is cause for cautious optimism.
Low‐molecular‐weight heparin for the treatment of patients with mechanical heart valves
Authors: Shapira Yaron , Sagie Alex , Battler Alexander
Published: June 2007

Background: The interruption of oral anticoagulant (OAC) administration is sometimes indicated in patients with mechanical heart valves, mainly before noncardiac surgery, non‐surgical interventions, and pregnancy. Unfractionated heparin (UH) is currently the substitute for selected patients. Low‐molecular‐weight heparin (LMWH) offers theoretical advantages over UH, but is not currently considered in clinical guidelines as an alternative to UH in patients with prosthetic valves.

Hypothesis: The aim of the present study was to review the data accumulated so far on the use of LMWH in this patient population and to discuss its applicability in common practice.

Methods: For this paper, the current medical literature on LMWH in patients with mechanical heart valves was extensively reviewed.

Results: There were eight series and six case reports. None of the studies was randomized, and only one was prospective. Data to establish the thromboembolic risk were incomplete. After excluding case reports, the following groups were constructed: (a) short‐term administration, after valve insertion (n = 212);(b) short‐term, perioperative (noncardiac)/periprocedural (n = 114);(c) long‐term, due to intolerance to OAC (n = 16);(d) long‐term, in pregnancy (n = 10). The incidence rate of thromboembolism was 0.9% for all the studies and 0.5, 0, 20, and 0% in groups a, b, c, and d, respectively; for hemorrhage, the overall rate was 3.4% (3.8, 2.6, 10, and 0% for the respective groups).

Conclusions: In patients with mechanical heart valves, short‐term LMWH therapy compares favorably with UH. Data on mid‐ and long‐term LMWH administration in these patients are sparse. Further randomized studies are needed to confirm the safety and precise indications for the use of LMWH in patients with mechanical heart valves.
Tricyclic antidepressants and the brugada syndrome: An example of brugada waves appearing after the administration of desipramine
Authors: Babliaros Vasilis C , Hurst J. Willis
Published: June 2007

Since its initial description in the early 1990s, the Brugada syndrome has become increasingly familiar to active researchers and practicing clinicians. The Brugada wave, a characteristic electrocardiographic abnormality of downsloping ST‐segment elevation in leads V1‐V3 and right bundle‐branch block morphology, has Now been associated with an increased risk of sudden death. Currently, very little is known about the relationship between the Brugada syndrome and tricyclic antidepressants. Accordingly, we report the case of a patient who developed prominent Brugada waves with the administration of increasing doses of desipramine. We believe the mechanism of Brugada wave augmentation or production secondary to tricyclic antidepressants is consistent with the current model of early repolarization. We also speculate that the increased risk of sudden death that may occur with tricyclic antidepressants could be related to the development of the Brugada syndrome. We advocate the judicious use of tricyclic antidepressants in cardiac and elderly patients, with careful monitoring of the electrocardiogram for the development Brugada waves.
Electrocardiogram abnormalities predict angiographic coronary artery disease in women with chest pain: Results from the nhlbi wise study
Authors: Holubkov Richard , Pepine Carl J. , Rickens Cheryl R. , Reichek Nathaniel , Rogers William J. , Sharaf Barry L. , Sopko George , Noel Merz C. Bairey , Kelsey Sheryl F. , Olson Marian , Smith Karen M. , Reis Steven E.
Published: June 2007

Background and hypothesis: Noninvasive risk stratification for coronary artery disease (CAD) is less accurate in women than in men. Based on recent reports that gender‐specific exercise electrocardiogram (ECG) parameters predict CAD, we evaluated the independent predictive value of the resting ECG for angiographic CAD in women with chest pain.

Methods: Women (n = 850, mean age 58 years) with chest pain in the NHLBI Women's Ischemia Syndrome Evaluation (WISE) underwent 12‐lead ECG testing and quantitative coronary angiography.

Results: Significant angiographic CAD (≥ 50% stenosis in ≥1 coronary) was present in 39% of women. Q waves in ≥2 contiguous ECG leads were present in 107 women (13%), including 49 of 657 (7%) without history of infarction. Among 585 women without prior infarction or revascularization, 48% of those with Q waves in contiguous leads versus 26% of others, had significant CAD (p = 0.003; odds ratio [OR] = 2.5, 95% confidence interval [CI] = 1.3‐4.8). Women with Q waves in ≥2 inferior ECG leads were particularly likely to have CAD (63 vs. 26% of others, p < 0.001; OR = 4.6, 95% CI = 2.0‐10.8). Other ECG findings predictive of CAD were any ST‐T abnormality (OR = 1.9, 95% CI = 1.3‐2.8) and T‐wave inversion (OR = 2.4, 95% CI = 1.3‐4.2). In risk‐adjusted analysis, inferior Q waves and T‐wave inversion independently predicted significant CAD. When considered together with radionuclide perfusion test results, T‐wave inversion on resting ECG added significant independent predictive value (OR = 2.8, 95% CI = 1.1‐7.2, p = 0.03).

Conclusions: Selected resting ECG parameters independently predict angiographic CAD in women with chest pain, including women who have also undergone radionuclide stress testing. Prospective studies should consider resting ECG parameters in diagnostic algorithms for CAD in women.
Dobutamine stress echocardiography in the diagnosis of coronary artery disease in women with chest pain: Comparison with different noninvasive tests
Authors: Rollán María Jesús , Román José Alberto San , Vilacosta Isidre , Ortega José Ramón , Bratos José Luis
Published: June 2007

Background: Diagnosis of coronary artery disease (CAD) in women remains elusive. The classical diagnostic armamentarium has been found to be very limited. Dobutamine stress echocardiography has emerged as a powerful test in assessing CAD in the general population, but most studies failed to include women.

Hypothesis: The accuracy of dobutamine stress echocardiography in the diagnosis of CAD in women with chest pain is high and superior to dipyridamole echocardiography, exercise electrocardiography, and sestamibi single‐photon emission tomography (MIBI‐SPECT) scintigraphy.

Methods: We studied 99 consecutive women with chest pain and no previous history of CAD who underwent dobutamine echocardiography and coronary angiography. We also compared these results with those of dipyridamole echocardiography in 63 patients, exercise stress testing in 83 (48 conclusive), and MIBI‐SPECT scintigraphy during dobutamine infusion in 54.

Results: Significant CAD was found in 42 women. Sensitivity and specificity of dobutamine stress echocardiography were 69 and 89%, respectively. Dipyridamole echocardiography showed similar accuracy (sensitivity 72% and specificity 94%). Finally, sensitivity of exercise test and MIBI‐SPECT was similar (76 and 88%, respectively) and specificity was lower (53 and 57%, respectively). After excluding patients known to have a high incidence of false positive results, MIBI‐SPECT specificity rose up to 80%.

Conclusion: Dobutamine stress echocardiography and dipyridamole echocardiography bear a high diagnostic accuracy in women with chest pain. MIBI‐SPECT is also a useful tool after excluding subgroups with a high incidence of false positive results.
Cholesterol absorption inhibitors: Defining new options in lipid management
Authors: Brown W. Virgil
Published: June 2007

Although many studies have documented that reduction of plasma cholesterol levels decreases the risk of coronary artery disease, it remains the most common cause of death in the Western world. Current therapeutic options are effective in lowering cholesterol, especially in clinical trials, but clinical application is not optimized for many reasons. Dietary restriction for long‐term management of hypercholesterolemia is helpful but usually insufficient to reduce low‐density lipoprotein cholesterol (LDL‐C) to goal levels. Powerful drugs are available, but these are often insufficient to meet the clinical demands for cholesterol‐lowering therapy. Phytosterols and phytostanols have been partially effective by providing some inhibition of absorption of cholesterol. Compounds that specifically and more effectively block intestinal absorption of dietary and biliary cholesterol should provide a significant new agent for altering lipoprotein concentrations favorably. Ezetimibe is the first of this class of compounds that act at the gut epithelium to reduce cholesterol absorption in the milligram dose range markedly. Clinical studies indicate that ezetimibe effectively decreases LDL‐C by 15 to 20% as monotherapy, with a favorable safety profile. Moreover, results from preliminary clinical trials indicate that ezetimibe given concomitantly with a statin provides additive efficacy. The combination represents a new approach to lipid management, achieving greater LDL‐C and triglyceride reductions and greater improvements in HDL‐C than statin monotherapy. This could offer another important option in clinical practice for management of hypercholesterolemic patients.
The bezold‐jarisch reflex in acute inferior myocardial infarction: Clinical and sympathovagal spectral correlates
Authors: Chiladakis John A. , Patsouras Nikolaos , Manolis Antonis S.
Published: June 2007

Background: The cardiodepressor Bezold‐Jarisch reflex (BJR) in acute inferior myocardial infarction (AMI) is traditionally considered as an indicator of successful thrombolysis.

Hypothesis: The study aim was to elucidate the role of the autonomic nervous system in the pathogenesis of a BJR response in patients with AMI by tracing spectral profiles of heart rate variability (HRV).

Methods: We studied 32 patients who presented with BJR after starting intravenous thrombolysis for an inferior AMI. Spectral components of HRV were analyzed over the three specific 5‐min periods preceding and following reflex activation. Clinically, the occurrence of BJR was correlated with the outcome of thrombolysis to achieve timely reperfusion and sustained coronary artery patency.

Results: The BJR was associated with early reperfusion in 94% of the patients, and with benign transient bradyarrhythmias and patent Thrombolysis in Myocardial Infarction (TIMI) grade 3 flow right coronary arteries in 89% of the patients. Spectral analysis revealed a characteristic pattern of a sympathetic predominance with an impending gradual vagal withdrawal up to the onset of BJR, as reflected by progressive increases in low‐frequency and reciprocal changes in high‐frequency powers.

Conclusions: The BJR in inferior AMI represents a reliable prognosticator of timely reperfusion and sustained coronary patency. Stimulation of vagal afferents in response to sympathetic overactivity may be the underlying pathogenetic mechanism promoting a BJR response.
Tryptase levels in patients after acute coronary syndromes: The potential new marker of an unstable plaque?
Authors: Filipiak Krzysztof J. , Tarchalska‐Krynska Bozena , Opolski Grzegorz , Rdzanek Adam , Kochman Janusz , Kosior Dariusz A. , Czlonkowski Andrzej
Published: June 2007

Background: Mast cells (MCs) are multifunctional immune cells that produce a number of vasoactive or thromboactive mediators. Elevated numbers of human heart MCs are observed in the shoulder regions of coronary atherosclerotic plaques, suggesting that they play a role in plaque rupture. Cardiac MC degranulation after myocardial ischemia has been documented in animal models. Cardiac MCs are highly profibrinolytic cells and release tryptase, their specific protease, after ischemic events.

Hypothesis: Mast cell activation and release of tryptase may differentiate among patients with acute coronary syndromes (ACS), potentially determining the clinical course of ACS. Tryptase levels may indirectly reflect the fibrinolytic status of patients.

Methods: Mast cell activation after ACS was estimated in 10 controls and 52 patients by measuring the serum levels of tryptase in the acute phase, at 2 weeks, and at 3 months after the ACS episode. Total tryptase levels were determined by using the UniCAP® system and analyzed with respect to the patients' clinical types of ACS on admission (ACS with persistent ST‐segment elevation on electrocardiogram or with ST‐segment depression).

Results: Significant differences in serum tryptase levels between the groups were found, with higher serum tryptase concentrations in the ST‐segment depression group in the acute phase, and at follow‐up.

Conclusions: Serum tryptase concentration differences among patients with distinct types of ACS may indicate a more important role of human heart MCs in ACS with ST‐segment depression pathogenesis. To our knowledge, this is the first report indicating that serum tryptase levels may differentiate patients with distinct types of ACS.
Residual flow to the infarct zone against lethal ventricular tachyarrhythmias during the acute phase of myocardial infarction
Authors: Yang Hyun Suk , Lee Cheol Whan , Hong Myeong‐Ki , Lee Jae‐Hwan , Nam Gi‐Byoung , Choi Kee‐Joon , Kim Jae‐Joong , Park Seong‐Wook , Kim You‐Ho , Park Seung‐Jung
Published: June 2007

Background: The benefits of residual flow to the infarct zone have been demonstrated in acute myocardial infarction (AMI), but its relation to ventricular tachyarrhythmias remains uncertain.

Hypothesis: This study was undertaken to test the hypothesis that residual flow is an important determinant of lethal ventricular tachyarrhythmias (sustained ventricular tachycardia or ventricular fibrillation) during the acute phase of AMI.

Methods: We investigated the determinants of lethal ventricular tachyarrhythmias within 24 h after the onset of symptoms in 310 consecutive patients (256 men; age 57.4 ± 11.5 years) with AMI undergoing primary angioplasty. Patients were divided into two groups: those with (Group 1, n = 40) and those without (Group 2, n = 270) lethal ventricular tachyarrhythmias. Residual flow was defined as the presence of anterograde flow (≤ Thrombolysis in Myocardial Infarction [TIMI] 2 flow) or good angiographic collaterals (≤ grade 2) on a preintervention angiogram.

Results: Univariate determinants of lethal ventricular tachyarrhythmias were cardiogenic shock, systolic blood pressure, peak level of creatine kinase, culprit artery, spontaneous reperfusion, and residual flow. In multivariate analysis, however, cardiogenic shock (odds ratio [OR] = 4.79, 95% confidence interval [CI] 1.63–14.11, p = 0.004), residual flow (OR = 0.34, 95% CI 0.14–0.81, p = 0.015), and the right coronary artery as the culprit artery (OR = 2.09, 95% CI 1.03–4.22, p = 0.040) were independent determinants of these arrhythmias. In‐hospital death occurred in 10 patients and was more common in Group 1 than in Group 2 (12.5% vs. 1.9%, respectively, p < 0.001).

Conclusion: The absence of residual flow was associated with greater risk of lethal ventricular tachyarrhythmias during the acute phase of AMI, suggesting a protective role of residual flow against these arrhythmias in AMI.
Plasma C‐reactive protein predicts left ventricular remodeling and function after a first acute anterior wall myocardial infarction treated with coronary angioplasty: Comparison with brain natriuretic peptide
Authors: Morishima Itsuro , Sone Takahito , Tsuboi Hideyuki , Kondo Junichiro , Mukawa Hiroaki , Kamiya Hiroki , Hieda Nobuyuki , Okumura Kenji
Published: June 2007

Background: C‐reactive protein (CRP) directly participates in the myocardial injury of acute myocardial infarction (MI). Although high plasma CRP levels in the acute phase strongly indicate a poor early clinical outcome of patients with MI, the impact of CRP levels on late left ventricular (LV) function and remodeling, which are closely associated with long‐term prognosis, remains unknown.

Hypothesis: Acute plasma CRP levels may predict late LV function and remodeling after MI.

Methods: We prospectively studied 12 consecutive patients with a first acute anterior MI recanalized by angioplasty. We measured plasma CRP levels on Days 0, 1, 2, 3, 4, and 7, and calculated the area under the curve (AUC). We also measured plasma brain natriuretic peptide (BNP) levels on Day 3 as the referential indicator of LV dysfunction and late LV remodeling. Late LV indices were independently assessed on a left ventriculogram obtained at 5.3 months to estimate the extent of LV remodeling.

Results: Plasma CRP reached its peak at Day 2.8 (8.68 ± 4.57 mg/dl). On linear regression analysis, the AUC of CRP (35.21 ± 19.33 mg/dl X day) correlated positively with BNP (316.5 ±418.6 pg/ml) (r = 0.646, p = 0.023). The AUC of CRP, peak CRP, and BNP correlated significantly with late LV indices. Among these, the AUC of CRP showed the best correlation with end‐diastolic volume index (r = 0.765, p = 0.004), end‐systolic volume index (r = 0.907, p < 0.001), and ejection fraction (r = −0.862, p<0.001).

Conclusions: Patients with high plasma CRP levels may be at risk for late LV dysfunction and remodeling; theoretically, their longterm prognosis may be poor. Measuring plasma CRP levels may provide valuable information for long‐term risk stratification after MI.
Monocyte chemoattractant protein‐1 and coronary artery disease
Authors: Ikeda Uichi , Matsui Keiji , Murakami Yoshiaki , Shimada Kazuyuki
Published: June 2007

The designation of atherosclerosis as a chronic inflammatory process represents an exciting and logical paradigm shift for cardiologists. Monocyte chemoattractant protein‐1 (MCP‐1) plays an important role in the recruitment and activation of monocytes and thus in the development of atherosclerosis. Enhanced MCP‐1 expression has been detected in macrophages, endothelial cells, and vascular smooth muscle cells in the atheromatous plaque. Activation of macrophages by MCP‐1 also appears to be involved in the vulnerability of the plaque. Indeed, circulating MCP‐1 levels are elevated in patients with acute myocardial infarction and in those with unstable angina, but not in patients with stable angina. Production of MCP‐1 and macrophage accumulation are also observed after coronary angioplasty or grafting, indicating that MCP‐1 expression may be related not only to instability of atheromatous plaques, but also to the formation of restenotic lesions. The development of therapeutic drugs for atherosclerosis targeted specially against MCP‐1 may be useful in the prevention of plaque formation and future myocardial infarction.
Use of adenosine as a diagnostic tool for dual atrioventricular nodal pathways: Response of control patients to incremental doses of adenosine
Authors: Burkart Thomas A. , Scozzaro Matthew J. , Angella Farahnaz R. , Jayaram Kiran N. , Gonzalez Mario D. , Conti Jamie B. , Curtis Anne B.
Published: June 2007

Background: Adenosine at low doses preferentially blocks fast over slow pathway conduction in patients with dual atrioventricular (AV) nodal physiology and typical AV nodal reentrant tachycardia (AVNRT). During atrial pacing, this effect is manifested as an abrupt increase in the AH interval with low doses of adenosine. This demonstration of dual AV nodal physiology may be useful as a diagnostic tool during electro‐physiologic studies in patients with supraventricular tachycardia who are not easily inducible, as clear demonstration of dual AV nodal pathways may indicate that AVNRT is a likely diagnosis and that further attempts at arrhythmia induction should be tailored in that direction. However, to be a useful test, adenosine should not cause an abrupt increase in AH interval in patients without dual AV nodal physiology.

Hypothesis: This study was designed to investigate the prevalence of dual AV nodal pathways with administration of adenosine in patients with no history suggestive of AVNRT.

Methods: Thirty‐seven patients who had no prior history of AVNRT and were undergoing electrophysiologic study for standard indications were enrolled. Baseline Wenckebach cycle length (WCL) and AV nodal effective refractory periods were measured at atrial pacing cycle lengths of 400 and 600 ms. The atrium was then paced at WCL + 50 ms, and WCL + 100 ms, while incrementally larger doses of intravenous adenosine were administered until AV nodal block occurred.

Results: The mean (± standard deviation) doses of adenosine required to cause AV nodal block while pacing at WCL + 50 ms and WCL + 100 ms were 7.1 ±3.9 and 7.4±4.5 mg, respectively. In 1 of 37 patients (2.7%, 95% confidence interval 0–8%), an abrupt prolongation of the AH interval was seen with the administration of adenosine during atrial pacing as well as during the atrial refractory period determination. In all other patients, no dual AV nodal physiology was demonstrated during the refractory period determination, and there were only gradual changes in the AH interval with atrial pacing during administration of adenosine.

Conclusion: Among patients with no history suggestive of AV nodal reentrant tachycardia, only 2.7% have clinically silent dual AV nodal pathways using this method. Incremental adenosine infusion during electrophysiologic study can be used as a highly specific diagnostic tool for patients with dual AV nodal pathways.
Rescue percutaneous coronary intervention following coronary artery bypass graft—A descriptive analysis of the changing interface between interventional cardiologist and cardiac surgeon
Authors: Adams Mark R. , Orford James L. , Blake Gavin J. , Wainstein Marco V. , Byrne John G. , Selwyn Andrew P.
Published: June 2007

Background: Despite decreasing rates of acute and suba‐cute complications of percutaneous coronary intervention (PCI), these procedures are generally only performed in centers where it is possible for failed PCI to be treated by rescue coronary artery bypass graft (CABG). Case reports and case series have documented successful PCI following failed CABG. We sought to confirm this decrease in the needforres‐cue CABG following failed PCI and to examine trends in the utilization of rescue PCI following failed CABG.

Hypothesis: The interface between interventional cardiologist and cardiac surgeon is characterized by changing practice patterns and resource utilization.

Methods: We examined the medical records of all patients admitted to the Brigham and Women's Hospital over a 7‐year period and identified 169 patients who required both PCI and CABG during the same hospital admission. We describe and compare three predetermined groups of patients defined by the sequence of, and indication for, the relevant myocardial revascularization procedures.

Results: In all, 100 patients required CABG for failed PCI, 46 patients had planned hybrid procedures involving both CABG and PCI, and 23 patients required PCI following failed CABG. There was a decrease in the need for rescue CABG following failed PCI, both in total numbers and as a percentage of total cases (2.5% in 1994 and 0.22% in 1999). There was a simultaneous increase in the utilization of rescue PCI following failed CABG (0% in 1994 and 1.6% in 2000). Hybrid procedures were identified as a source of innovative solutions to a variety of challenging clinical problems.

Conclusions: Changing patterns of resource utilization shouldbe considered whenplanning hospital facilities and patient triage, and these patients undergoing percutaneous or surgical revascularization may benefit from close cooperationbe‐tween the cardiac surgeon and the interventional cardiologist.
Timing of coronary artery bypass graft surgery following acute myocardial infarction: A critical literature review
Authors: Crossman Arthur W. , D'Agostino Harry J. , Geraci Stephen A.
Published: June 2007

Despite more than 30 years' experience with coronary artery bypass surgery, controversy still exists about the optimal timing of surgical revascularization following acute myocardial infarction. To review the published information on this topic, a Medline search of the literature published between 1984 and October 2000 was performed. After reviews and individual case reports were excluded, 11 retrospective and prospective studies remained for analysis. Pervasive heterogeneity with respect to inclusion criteria, outcome measurement, definitions, variance among studies of measured time between myocardial infarction (MI) and coronary artery bypass graft (CABG), differences in study endpoints, and evolution of surgical techniques and medical regimens over this time precluded formal meta‐analysis. Although prospective randomized trials are lacking, the preponderance of data from the 11 retrospective and prospective observational studies suggests that timing of bypass surgery after infarction is not an independent predictor of outcome and that delaying coronary bypass surgery for an arbitrary period of time following acute MI is unwarranted. Rather, ventricular function, post‐infarction ischemia, noncardiac comorbid conditions, and the urgency of the surgery itself constitute the important predictors of perioperative mortality, and these clinical factors should be used to estimate perioperative risk and decide upon the risk:benefit relationship for CABG in this patient population.
Angiotensin receptor antagonist losartan improves endothelial function of epicardial coronary arteries in patients with essential hypertension
Authors: Deng You‐Bin , Yang Hao‐Yi , Li Chun‐Lei , Chang Qing
Published: June 2007

Background: Angiotensin II can impair endothelial function, which is mediated by the angiotensin II type 1 receptor subtype.

Hypothesis: The study sought to determine whether treatment with the angiotensin II type 1 receptor antagonist losartan would restore the normal dilation of the left main coronary artery (LMCA) by cold pressor test in patients with essential hypertension, as shown by echocardiography.

Methods: The study population included 30 patients with mild to moderate essential hypertension and 30 matched healthy subjects. Measurements of the cold pressor test‐induced and nitroglycerin‐induced changes in LMCA diameter by echocardiography were performed at the end of the washout period and after 12 weeks of losartan administration.

Results: The percent change in LMCA diameter induced by the cold pressor test in hypertensive patients (‐3.5 ± 8.8%) was significantly lower than that in control subjects (10.2 ± 3.7%, p< 0.0001). After losartan treatment, the percent change (13.9 ± 8.4%) was significantly higher than that before losartan treatment (‐3.5 ± 8.8%, p < 0.0001), but not significantly different between the 17 hypertensive patients with satisfactory control of blood pressure (13.8 ± 9.1%) and the 13 hypertensive patients without satisfactory control of blood pressure (14.0 ± 7.7%, p = 0.9). Losartan treatment in patients with essential hypertension did not modify the percent change in LMCA diameter caused by sublingual administration of ni‐troglycerin (23.2 ± 14.0% vs. 27.3 ± 13.7%, p = 0.2).

Conclusions: This study demonstrates that treatment with losartan normalized response of the LMCA to the cold pressor test in patients with mild to moderate essential hypertension and that this effect is not dependent on the reduction of blood pressure.
C‐reactive protein as a marker for active coronary artery disease in patients with chest pain in the emergency room
Authors: Magadle Rasmi , Weiner Paltiel , Beckerman Marinella , Berar‐Yanay Noa
Published: June 2007

Background: Markers of inflammation, such as C‐reactive protein (CRP), were found to be related to risk for cardiovascular disease (CVD) events in patients with angina pectoris. In addition, recent studies have shown that, in the case of atherosclerosis, increased CRP concentration reflects the inflammatory condition of the vascular wall.

Hypothesis: The study was undertaken to determine whether CRP levels in individuals with chest pain attending the emergency room (ER) may be used as a marker of active CVD.

Methods: Serum CRP level was measured in 226 of 326 consecutive patients (128 men, 98 women; mean age 61.3 ± 5.9 years; range 19–87 years) referred to the ER with chest pain. The decision whether to admit or release the subjects was determined without taking the CRP level into account. Follow‐up was then performed for 1 year.

Results: Eighty‐four patients were admitted to the hospital. Of these, 9 with acute coronary syndrome (ACS) had very high levels of CRP (25–40 mg/l), 35 had had an acute coronary event within the preceding 3 months, with levels of CRP 14–20 mg/l. Only eight patients with nonsignificant CVD had elevated CRP levels. Twenty‐eight subjects who were released from the ER had elevated CRP levels (7–14 mg/l); 8 of these, in addition to 4 subjects with normal CRP levels, had a late coronary event.

Conclusion: This study indicates that in patients referred to the ER with chest pain and no other indication for hospitalization, a normal level of CRP suggests safe release. Most hospitalized patients with normal CRP will not have acute coronary syndrome. Patients who will develop early coronary events have very high CRP levels. High serum CRP level, after excluding other inflammatory sources, was proven to be a sensitive diagnostic and prognostic marker for significant coronary disease.
Effects of distension of urinary bladder on coronary conduit and resistance vessels in hyperlipidemic patients
Authors: Lee Tsung‐Ming , Su Sheng‐Fang , Tsai Chang‐Her
Published: June 2007

Background: Distension of the urinary bladder reflexly causes a change of coronary vasomotor response. The effect of such distension on the coronary circulation in hyperlipidemic patients, a condition with impaired endothelial function, remains unknown.

Hypothesis: We tested the hypothesis whether urinary bladder distension caused an exaggerated vasomotor response of epicardial and resistance vasoconstriction in hyperlipidemic patients.

Methods: Thirty patients with early atherosclerosis (< 50% diameter stenosis) were divided into three groups: Group 1 (n = 10): hyperlipidemia without doxazosin administration; Group 2 (n = 10): hyperlipidemia with pretreatment of a1‐adrenergic receptor blocker (oral doxazosin 2 mg); and Group 3 (n = 10): normolipidemia. A prospective analysis of the results of quantitative angiograms, intracoronary Doppler flow, and lactate concentrations from aortic root and coronary sinus was performed during distension of urinary bladder.

Results: Bladder distension significantly decreased coronary diameter at the stenotic segments (p = 0.004), coronary blood flow (p = 0.05), and increased coronary resistance (p = 0.006) compared with baseline values, in Group 1 patients. In Group 2 patients during bladder distension, coronary diameter, coronary blood flow, and coronary resistance showed no significant changes compared with baseline values. There were significant differences of stenotic coronary diameter (p = 0.01) between Groups 1 and 3 during bladder distension despite similar changes in rate‐pressure product. No significant differences were noted among the groups in the responses of coronary diameter, coronary blood flow, and coronary resistance after nitroglycerin administration.

Conclusions: The present study showed that urinary bladder distension caused an abnormal vasomotor response of epicardial vasoconstriction and that a concomitant increased coronary resistance involved mechanisms related to ct1‐adrenoceptors. Hyperlipidemia may further impair the response. Pretreated administration of doxazosin had reversed the changes toward baseline. Vasoconstriction during bladder distension can be relieved after nitroglycerin administration, suggesting an unchanged responsiveness of vascular smooth muscle cells to such distension.
Comparison of left ventriculography and coronary arteriography with positron emission tomography in assessment of myocardial viability
Authors: Bourdillon Patrick D. V. , Von Der Lohe Elisabeth , Lewis Stephen J. , Sharifi Mohsen , Burt Robert W , Sawada Stephen G.
Published: June 2007

Background: Assessment of viability of myocardium after an ischemic insult is an important clinical question that affects decisions pertaining to potential revascularization. The results of contrast left ventriculograms and coronary angiography were compared to positron emission tomography (PET) in 64 patients with coronary artery disease and reduced left ventricular function.

Hypothesis: The study was undertaken to determine the relative utility of the invasive studies in the assessment of viability.

Methods: Right anterior oblique ventriculograms were assessed for hypokinesis, akinesis, or dyskinesis in six segments. The PET scans were assessed for viability by visual estimation of flourodeoxyglucose (FDG) uptake in six segments that corresponded to the segments analyzed on the ventriculograms.

Results: Of a total of 373 segments successfully analyzed by PET, 272 were judged to be viable (normal or hypokinetic) by contrast ventriculography. Of these, 253 (93%) were considered viable by PET. Of 177 segments deemed either normal or mild‐to‐moderately hypokinetic by ventriculography, 170 (94%) were viable by PET. Of 95 severely hypokinetic segments, 83 (84%) were viable by PET. Of 79 akinetic segments, 44 (56%) were considered viable by PET. For segments that were dyskinetic and thought to be nonviable by ventriculography, 19 of 22 (86%) were also considered nonviable by PET. For 294 segments for which a determination on viability was made based on the presence of wall motion on the ventriculogram (normal, hypokinetic, or dyskinetic; not akinetic), there was excellent agreement with PET (93%; p < 0.001). In 49 patients there was akinesis in no more than one segment in either the anterior or inferior territories, indicating the potential for assessment of viability by ventriculography in at least two of three segments in each territory. Coronary anatomy was analyzed to assess whether coronary patency could help in assessing viability. Segments supplied by patent arteries were more likely to be viable by PET than segments supplied by occluded arteries (p < 0.001). Akinetic segments were more likely to be supplied by occluded arteries (56 vs. 23, 72%). Dyskinetic segments were predominantly nonviable by PET (86%) and were usually supplied by occluded arteries (77%).

Conclusion: In patients in whom the assessment of viability is clinically relevant, the presence of systolic inward motion on the contrast left ventriculogram correlates well with segment viability by PET, while outward or dyskinetic movement correlates well with nonviability. Thus, the use of PET to assess viability in many patients may be unnecessary.
Characteristics and outcome of patients with ST‐elevation infarction in relation to whether they received thrombolysis or underwent acute coronary angiography: Are we selecting the right patients for coronary angiography?
Authors: Herlitz Johan , Ekström Lars , Hartford Marianne , Karlson Björn W. , Karlsson Thomas , Grip Lars
Published: June 2007

Background: During the last decade, there has been an ongoing debate with regard to whether percutaneous coronary intervention (PCI) or thrombolysis should be preferred in patients with ST‐elevation acute myocardial infarction (AMI). Some studies clearly advocate PCI, while others do not.

Hypothesis: The study aimed to describe the characteristics and to evaluate outcome of patients with suspected ST‐elevation or left bundle‐branch block infarction in relation to whether they received thrombolysis or had an acute coronary angiography aiming at angioplasty.

Methods: The study included all patients admitted to Sahlgrenska University Hospital in Göteborg, Sweden, with suspected acute myocardial infarction who, during 1995‐1999, had ST‐elevation or left bundle‐branch block on admission electrocardiogram (ECG) requiring either thrombolysis or acute coronary angiography. A retrospective evaluation with a follow‐up of 1 year after the intervention was made.

Results: In all, 413 patients had thrombolytic treatment and 400 had acute coronary angiography. The patients who received thrombolysis were older (mean age 70.3 vs. 64.1 years). Mortality during 1 year of follow‐up was 20.9% in the thrombolysis group and 16.6% in the angiography group (p = 0.12). Among patients in whom acute coronary angiography was performed, only 85% underwent acute percutaneous coronary intervention (PCI). There was a mortality of 12.1 vs. 41.7% among those who did not undergo acute PCI. Development of reinfarction, stroke, and requirement of rehospitalization was similar regardless of type of initial intervention. The thrombolysis group more frequently required new coronary angiography (36.9 vs. 20.6%; p < 0.0001) and new PCI (17.8 vs. 11.9%; p = 0.01). Despite this, after 1 year symptoms of angina pectoris were observed in 27% of patients in the thrombolysis group and in only 14% of those in the angiography group (p = 0.0002).

Conclusion: In a Swedish university hospital with a high volume of coronary angioplasty procedures, we found no significant difference in mortality between patients who had thrombolysis and those who underwent acute coronary angiography. However, requirement of revascularization and symptoms of angina pectoris 1 year later was considerably less frequent in those who had undergone acute coronary angiography. However, distribution of baseline characteristics was skewed and efforts should be focused on the selection of patients for the different reperfusion strategies.
The relative utility of cardiac troponin i, creatine kinase‐mbmass, and myosin light chain‐1 in the long‐term risk stratification of patients with chest pain
Authors: Hillis Graham S. , Taggart Pamela , Wardlaw Delana , Hillis Lorraine , Zhao Ning , Dalsey William C. , Mangione Antoinette
Published: June 2007

Background: Sensitive and specific cardiac markers convey important short‐term prognostic information about patients with an acute coronary syndrome. There are, however, few data assessing their value as long‐term predictors.

Hypothesis: The aim of the current study was to assess the relative value of three such markers and clinical characteristics in determining the long‐term prognosis of patients with chest pain.

Methods: Cardiac troponin I (cTnI), myosin light chain‐1 (MLC‐1), and creatine kinase‐MBmass levels were obtained on admission (0 h) and at 4, 8, 16, and 24 h in 208 patients with chest pain. Eligible subjects were determined, at the time of hospital admission, to be at > 7% risk of acute myocardial infarction (MI), but without new ST‐segment elevation on their presenting electrocardiogram. Follow‐up was performed a median of 28 (range 1‐46) months later. The primary study endpoint was death or nonfatal MI, subsequent to the index admission.

Results: Cardiac TnI levels ≥ 0.2 ng/ml (odds ratio [OR] 1.93, 95% confidence interval [CI] 1.09‐3.40) and MLC‐1 levels ≥ 1 ng/ml (OR 3.24, 95% CI 1.83‐5.73) were both significant predictors of death or MI during long‐term follow‐up; MLC‐1 was, however, the only independent biochemical predictor (OR 2.11, 95% CI 1.14‐3.93).

Conclusions: Both cTnI and MLC‐1 predict the long‐term outcome of patients with chest pain, but, in this cohort, MLC‐1 proved to be a better predictor of mortality and nonfatal acute MI.
Evaluation of serial QT dispersion in patients with first non‐Q‐wave myocardial infarction: Relation to the severity of underlying coronary artery disease
Authors: Lyras T. G. , Papapanagiotou V. A. , Foukarakis M. G. , Panou F. K. , Skampas N. D. , Lakoumentas J. A. , Priftis C. V. , Zacharoulis A. A.
Published: June 2007

Background: Increased QT dispersion (QTD) has been correlated with ventricular arrhythmias. Recent reports suggest that it may serve as a marker of the severity of underlying coronary artery disease (CAD).

Hypothesis: The aim of this study was to examine in‐hospital changes of QTD and their possible correlation with the severity of underlying CAD in patients with first non‐Q‐wave myocardial infarction.

Methods: In 62 patients we estimated QTD, precordial QTD, as well as their values corrected for heart rate on Days 3 and 7 after admission. The severity of underlying ischemic burden was estimated by means of the number of diseased vessels as well as by the jeopardy score.

Results: On Day 3, patients with jeopardy score ≥ 6 exhibited greater QTD, corrected QTD, precordial QTD, and corrected precordial QTD (p = 0.001, p = 0.003, p = 0.02, p = 0.036, respectively); patients with multivessel disease had greater QTD (p = 0.007). On Day 7, patients with jeopardy score ≥6 and multivessel disease exhibited greater QTD, corrected QTD, precordial QTD, and corrected precordial QTD (p < 0.001 for all). Multiple regression analysis revealed a jeopardy score of ≥ 6 as the most significant independent predictor for QTD variables. From Days 3 to 7, only patients with none or one diseased vessel or jeopardy score < 6 had shortened QTD (p = 0.01 and p = 0.015, respectively) and corrected QTD (p < 0.001 for both).

Conclusions: In patients with first non‐Q‐wave myocardial infarction, QTD variables and their in‐hospital changes reflect the severity of underlying CAD.
Sustained use of nesiritide to aid in bridging to heart transplant
Authors: Hill James A. , Hsu Kevin , Pauly Daniel F , Schofield Richard , Aranda Juan M.
Published: June 2007

Patients with end‐stage heart failure awaiting heart transplant are often maintained on continuous intravenous inotropic therapy. However, this therapy alone is often inadequate for maintenance of appropriate pulmonary artery pressure and stable clinical course. Nesiritide, B‐type natriuretic peptide, is a recently released intravenous vasodilator for short‐term use in patients with decompensated heart failure. This report details experience in four patients in whom this agent was used to bridge to transplant for prolonged periods (11–35 days) with added clinical benefit and without obvious tolerance. This suggests that new strategies for pretransplant management may be needed.
Oral platelet glycoprotein IIb/IIIa receptor inhibitors—part II
Authors: Cannon Christopher P.
Published: June 2007

Although the hypothesis of benefit from prolonged oral IIb/IIIa inhibition was appealing, the large Phase III trials have uniformly shown there was no improvement in outcome. In addition, there was an increased mortality seen in patients treated with the oral IIb/IIIa inhibitor. This latter finding is not adequately explained, but is likely a multifactorial problem of this strategy of platelet inhibition. The trials found that, even with no improvement in efficacy, there was increased bleeding, meaning that for chronic therapy with IIb/IIIa inhibition there does not appear to be a therapeutic window. Accordingly, chronic oral IIb/IIIa inhibition appears to have been well tested but has not worked. Fortunately, there are several other oral antiplatelet agents available that have shown beneficial results, including clopidogrel. In addition, other newer classes of antiplatelet agents are in earlier stages of development. Thus, agents targeted more “upstream” in platelet activation pathways may offer a more tolerable and efficacious approach to long‐term antiplatelet therapy.
Reversal of heart failure remodeling: Is it maintained?
Authors: Levine T. Barry , Levine Arlene B. , Bolenbaugh Janet , Green Pamela R.
Published: June 2007

Background: Reversal of heart failure remodeling has been observed with intensive heart failure therapy.

Hypothesis: We hypothesized that reversal of heart failure remodeling may not be sustained in long‐term follow‐up.

Methods: Sixty‐one sequential patients with heart failure and left ventricular ejection fraction ≤ 35%, who improved their ejection fraction by ≥ 10% over baseline at follow‐up, were prospectively followed and retrospectively analyzed. Each patient underwent echocardiography at baseline and biannually thereafter.

Results: In all patients, left ventricular ejection fraction increased from 18±7% to 42 ± 12% on uptitrated medical therapy. At follow‐up over 20 ± 8 (± standard deviation) months, this improvement was sustained in 38 patients (“Improved”). A relapse in remodeling occurred in the remaining 23 patients (“Relapsed”), with ejection fraction falling to 24 ± 7%.

For Improved and Relapsed patients, baseline echocardiographic and clinical parameters were equivalent. However, Improved patients tended to be younger, with shorter heart failure duration. Improved patients had more effective improvement inejection fraction than Relapsed patients (45 ± 13% vs. 36 ± 8%, p = 0.005), with greater reductions in chamber size and mitral regurgitation.

Conclusion: Reversal of heart failure remodeling may be sustained in only two‐thirds of patients at long‐term follow‐up. In contrast to Relapsed patients, Improved patients tended to be younger, with shorter heart failure duration and a more complete recovery of left ventricular systolic function.
Right atrial sensing for VDD pacing through a persistent left superior Vena Cava
Authors: Trigano J.‐A. , Caucino K. , Sbragia P. , Paganelli F. , Levy S.
Published: June 2007

This report describes a pacing lead insertion through a persistent left superior vena cava in the VDD pacing mode, with a large retrograde lead course allowing the optimal positioning of the sensing electrodes in the right atrium.