bluuebunny/crossref_metadata_2025 huggingface dataset:
Patterns of angiotensin‐converting enzyme inhibitor prescriptions, educational interventions, and outcomes among hospitalized patients with heart failure
Authors: Mcdermott Mary Mcgrae , Lee Peter , Mehta Shruti , Gheorghiade Mihai
Published: February 2009

Background: Among hospitalized patients with heart failure, we describe characteristics associated with prescription of angiotensin‐converting enzyme (ACE) inhibitors in the doses recommended by clinical practice guidelines. We also describe the impact of ACE inhibitor prescriptions, increases in ACE inhibitor dose, and nonpharmacologic educational interventions on readmission‐free survival rates.

Hypothesis: We hypothesize that care by a cardiologist physician and higher mean arterial blood pressure on admission are associated with receipt of optimal ACE inhibitor doses. We hypothesize that receipt of an ACE inhibitor at discharge and an increase in ACE inhibitor dose during hospitalization are associated with superior readmission‐free survival.

Methods: Between January 1, 1992, and December 31, 1993, medical records were reviewed for consecutively hospitalized patients with a principal diagnosis of heart failure at an academic medical center. Documented instructions and medications prescribed at discharge were abstracted. Deaths and readmissions through December 31, 1994, were identified with the National Death Index and the study institution's administrative data base, respectively.

Results: During 1992 and 1993, 387 patients were discharged alive from hospitalization for heart failure. Among patients discharged on enalapril or captopril, 18% received doses recommended by heart failure clinical practice guidelines. Patients discharged on a recommended ACE inhibitor dose were more likely to be African‐American and had lower sodium levels and higher mean arterial pressures than patients discharged on lower ACE inhibitor doses. In survival analyses, an increase in ACE inhibitor dose was associated with improved readmission‐free survival, independent of left ventricular systolic function type. Receipt of an ACE inhibitor at discharge was also associated with superior readmission‐free survival, while nonpharmacologic educational instructions were not associated with improved outcomes.

Conclusion: Interventions are needed to improve the frequency with which ACE inhibitors are prescribed at recommended doses to hospitalized patients with heart failure. We conclude that among these patients, receipt of an ACE inhibitor at discharge and an increase in ACE inhibitor dose during hospitalization are each associated with measurable effects on readmission‐free survival, while provision of educational instructions as currently practiced is not associated with better outcomes.
Comments about the electrocardiographic signs of right ventricular infarction
Authors: Hurst J. Willis
Published: February 2009

This manuscript was written in an effort to emphasize the points made by Porter et al. (Clin Cardiol 1997; 20:971‐973). Right ventricular infarction may be erroneously interpreted as an anteroseptal infarction because of elevation of the S‐T segments in leads V1‐V4. The two can be separated when, using the Grant method of analysis, the S‐T segments are represented as vectors: the mean S‐T vector is directed inferiorly, to the right, and anteriorly when there is an inferior‐right ventricular infarct, and superiorly, to the left, and anteriorly when there is an anteroseptal infarction. Other aspects of right ventricular infarction are also discussed.
Management Strategies for a Better Outcome in Unstable Coronary Artery Disease
Authors: Campbell R. W. F. , Wallentin L. , Verheugt F. W. A. , Turpie A. G. G. , Maseri A. , Klein W. , Cleland J. G. F. , Bode C. , Becker R. , Anderson J. , Bertrand M. E. , Conti C. R.
Published: February 2009

Unstable coronary artery disease is a term encompassing both unstable angina and non‐Q‐wave (non‐ST‐segment elevation) myocardial infarction. Patients with these conditions are at risk of early progression to acute myocardial infarction and death. Thus, management of these conditions must aim to reduce long‐term mortality and morbidity. Risk stratification is crucial for the identification of patients whose risk of early progression is high; they may require coronary angiography and (if suitable) either percutaneous transluminal coronary angioplasty or coronary artery bypass surgery. No single variable can accurately predict risk, but considerable data are emerging to show that biochemical markers of myocardial injury, such as troponin‐T and troponin‐I, are valuable in combination with electrocardiographic findings and clinical features. Routine early invasive procedures (coronary angiography with or without revascularization) have not yet been shown to have any significant advantage over conservative regimens for the majority of patients. Antiplatelet, anticoagulant, and anti‐ischemic agents remain the mainstay of treatment in the acute phase. New agents, such as glycoprotein IIb/IIIa receptor inhibitors and low‐molecular‐weight heparins, as well as antithrombins and Factor Xa inhibitors add to the treatments currently available. Thrombolytic agents are contraindicated in the absence of ST‐segment elevation. After clinical stabilization, ongoing assessment should include exercise testing for all patients who are able; other imaging techniques should be used for patients unable to exercise. A profile indicating a high risk of future events is an indication for elective angiography and consideration for revascularization.
Importance of α1‐sympathetic activity for diurnal change in ischemic threshold in patients with stable angina
Authors: Fujita Masatoshi , Sasayama Shigetake , Tanaka Terumitsu , Nakae Izuru , Tamaki Shun‐Ichi , Kihara Yasuki , Nohara Ryuji
Published: February 2009

Background: Although ischemic threshold reportedly is lower in the early morning than in the afternoon, the mechanisms that account for the diurnal change in minimal coronary vascular resistance in the potentially ischemic area are unknown.

Hypothesis: We hypothesized that calcium‐channel blockers and α1 blockers may affect the ischemic threshold in the early morning and afternoon in patients with stable angina.

Methods: Before and after the administration of the calcium antagonist amlodipine (5 mg) alone and combined with the α1 blocker prazosin (1 mg), a treadmill exercise test using the Balke‐Ware protocol was undertaken in the morning (8:00 A.M.) and repeated in the afternoon (1:00 P.M.) with 15 stable angina patients. The ischemic threshold was defined as a reciprocal of minimal coronary vascular resistance in the presence of comparable levels of myocardial ischemia indicated by 0.1 mV ST depression. Minimal coronary vascular resistance was calculated as mean blood pressure divided by coronary blood flow. Since the coronary blood flow is closely related to myocardial oxygen consumption, which can be replaced by the double product of heart rate and systolic blood pressure, minimal coronary vascular resistance was approximated to 1/heart rate.

Results: At baseline, minimal coronary vascular resistance was significantly higher in the early morning than in the afternoon (8.5 ± 0.3×10−3 min/beats vs. 7.8 ± 0.4×10−3 min/beats, p<0.01). Although treatment with amlodipine alone did not abolish the circadian pattern of minimal coronary vascular resistance (8.0 ± 0.6×10−3 min/beats vs. 7.7 ± 0.6×10−3 min/beats, p<0.05), the addition of prazosin virtually eliminated the diurnal difference in minimal coronary vascular resistance (7.4 ± 0.5×10−3 min/beats vs. 7.5 ± 0.5×10−3 min/beats, p = NS).

Conclusions: These findings indicate that α1‐sympathetic activity may play a role in the pathogenesis of the diurnal change of ischemic threshold in patients with stable angina.
Reversal of dilated to hypertrophic cardiomyopathy after alcohol abstinence
Authors: Stöllberger Claudia , Finsterer Josef
Published: February 2009

Left ventricular dilatation and systolic dysfunction develop in 14‐16% of patients with hypertrophic cardiomyopathy. Such findings may easily be misdiagnosed as dilated cardiomyopathy. It is unknown whether left ventricular dilatation and systolic dysfunction in patients with hypertrophic cardiomyopathy are reversible. A 35‐year‐old man had been a heavy drinker for 13 years and was abstinent for 1 year. Five years previously he suffered cardiac arrest and, based on echocardiographic, radionuclide, and cardiac catheterization findings, the diagnosis of alcohol‐induced dilated cardiomyopathy was established. At presentation the heart was of normal size, with concentric left ventricular hypertrophy and only slightly reduced systolic function. Hypertrophic cardiomyopathy was diagnosed since no other cause for left ventricular hypertrophy could be detected. In hypertrophic cardiomyopathy, alcohol may induce reversible systolic dysfunction and left ventricular dilatation.
Successful conserative treatment of nontyphoid salmonella endocarditis involving a bioprosthetic valve
Authors: Goerre Stefan , Aeschbacher Beat C. , Malinverni Raffaele
Published: February 2009

We report a first case of Salmonella enteritidis endocarditis involving a bioprosthetic aortic valve. Despite additional native tricuspid valve involvement, the clinical course was favorable using an antibiotic regimen of ciprofloxacin and netilmicin. Although Salmonella prosthetic valve endocarditis is considered an indication for surgical replacement of the prosthesis, this case indicates that prolonged treatment with fluoroquinolones may be an alternative provided that the hemodynamic situation is stable.
Comparison of the diagnostic performance of two rapid bedside biochemical assays in the early detection of acute myocardial infarction
Authors: Panteghini M. , Pagani F. , Cuccia C. , Turla C.
Published: February 2009

Background: New biochemical markers have been recently proposed as potential aids in the diagnosis of myocardial infarction. Assessment of these markers in real time by near‐patient testing would allow more rapid decisions regarding critical therapeutic interventions.

Hypothesis: The diagnostic performance of two qualitative, whole blood assays for measurement of myoglobin/creatine kinase (CK)‐MB mass (CARDIAC STATusTM) and cardiac troponin T (TropT$$) was compared. Their potential in optimizing the rule‐in of patients with infarction in order to initiate revascularization therapies was also evaluated.

Methods: A group of 101 patients admitted to the hospital within 12 h from onset of symptoms suggestive of myocardial infarction was studied. A first blood sample was drawn in all patients immediately after admission. In patients not receiving reperfusion therapy (n = 61), three additional samples were also obtained 2,4, and 6 h later.

Results: CARDIAC STATus showed good performance in patients with an admission time > 2 h from onset of pain (diagnostic efficiency, 71‐100%). Conversely, TropT was not sensitive enough for acceptable efficiency. In a subset of 39 patients admitted within 6 h who did not meet standard enrollment criteria for thrombolysis, CARDIAC STATus allowed early detection of almost 50% of infarcts, enabling a significant implementation of alternative revascularization therapies.

Conclusions: In patients admitted to the coronary care unit on the basis of case history and clinical examination, CARDIAC STATus assay is more effective than TropT in the early diagnosis of infarction, providing a valuable aid to cardiologists for confirming a suspected infarction rapidly, thus allowing, if indicated, recourse to revascularization therapy in clinically uncertain cases.
Occurrence, characteristics, and outcome of patients hospitalized with a diagnosis of acute myocardial infarction who do not fulfill traditional criteria
Authors: Herlitz Johan , Karlsson Thomas , Karlson Bjöurn , Engdahl Johan , Sandén Wanja , Dellboirg Mikael
Published: February 2009

Background: The diagnosis of acute myocardial infarction (AMI) is traditionally based on clinical history, elevation of serum enzyme activity, and typical changes in the electrocardiogram (ECG); however, not all patients who develop AMI fulfill these criteria on discharge from hospital.

Hypothesis: The aim of the study was to evaluate (1) the frequency with which the traditional criteria for AMI are not fulfilled among patients diagnosed with AMI on discharge, and (2) whether patients with and without these criteria differ in terms of characteristics, treatment, and outcome.

Methods: All patients aged < 75 years and hospitalized in the municipality of Göteborg with a discharge diagnosis of AMI were included. Fulfillment criteria for AMI were two of the following three points: (1) chest pain, (2) increase in cardiac enzymes, and (3) development of Q waves.

Results: In all, 1,188 admitted patients, 27% of whom were women, were included in the analysis. Of these, 193 (16%) did not fulfill the traditional criteria for AMI. These patients had an in‐hospital mortality rate of 48%; of these, 59% died a sudden death, and of those who were autopsied (62%), 96% showed signs of a fresh AMI. The most common symptom on admission to hospital in patients who did not fulfill the traditional criteria was chest pain (34%), followed by dyspnea (27%) and fatigue (14%). Of those who died suddenly, fewer than half had been admitted to the coronary care unit.

Conclusion: Patients diagnosed with AMI who do not fulfill the traditional diagnosis criteria have high mortality. On admission to hospital, the initial suspicion of AMI is often vague. Measures for earlier detection of life‐threatening coronary artery disease among these patients are warranted.
Streptococcal mural endocarditis and myocardial abscess occurring in a left ventricular aneurysm—case report and review
Authors: Lo S.S.S. , Sheppard M.N. , Frcpath J.G. , Bennett M.J. , Poole Wilson R.A. , Weinbren M.J , Ong Y.E.
Published: February 2009

Infection of the mural endocardium within a left ventricular aneurysm without valvular involvement is exceedingly rare. The presenting clinical features can be non‐specific, and a high index of suspicion is required for its diagnosis. Delay in diagnosis invariably leads to a fatal out‐come. Although no controlled studies are available to guide therapy and management of these patients, appropriate antibiotic therapy and early surgical resection of the infected ventricular aneurysm remain the cornerstone of therapy.
Additional antianginal and anti‐ischemic efficacy of mibefradil in patients concomitantly treated with long‐acting nitrates for chronic stable angina pectoris
Authors: Frishman William H. , Bittar Neville , Glasser Stephen , Habib Gabriel , Smith William , Pordy Robert
Published: February 2009

Background: Mibefradil, a newly approved antihypertensive and antianginal drug, is the first member of a new class of calcium antagonists (CAs), the tetralol derivatives, that selectively blocks T‐type Ca2+ channels in contrast to classical CAs which, at therapeutic concentrations, block only L‐type Ca2+ channels. Since patients with chronic stable angina pectoris typically may be treated with the combination of a long‐acting nitrate and a CA, the additive efficacy and safety of mibefradil in combination with nitrate therapy needs to be determined.

Hypothesis: This study was designed to assess the efficacy, tolerability, and safety of mibefradil when added to longacting nitrate therapy in patients with chronic stable angina pectoris.

Methods: Following a 1 ‐week placebo run‐in period, patients were randomized to receive either mibefradil 50 mg (n = 96) or placebo (n = 93) once daily in addition to their nitrate therapy. After 2 weeks of active treatment, patients receiving the mibefradil were force titrated to 150 mg once daily for an additional 2 weeks. Exercise tolerance tests (ETTs) were per formed at the end of Weeks 2 and 4; patients also maintained an anginal diary during the 4‐week treatment period.

Results: After 2 weeks of treatment with 50 mg mibefradil (within the current recommended dose range), a statistically significant but modest increase in total exercise duration was observed (treatment effect 16.4 s, p = 0.04). Similarly, there was a significant increase in time to onset of ischemia (treatment effect 26 s, p = 0.008). The adverse event profile of the 50 mg dose was indistinguishable from placebo, indicating that this dose was extremely well tolerated. At Week 4, the mibefradil‐treated patients were taking 150 mg, which is above the current recommended dose range. The increase in total exercise duration was larger for the mibefradil 150 mg group than for the placebo group. For the intent‐to‐treat population, this difference did not reach statistical significance, whereas in the standard population it did (treatment effect 21 s, p = 0.05). The other two ETT variables, time to onset of angina and time to onset of 1 mm ST‐segment depression, demonstrated significantly greater effect with mibefradil 150 mg (treatment effects 40 s, p = 0.002, and 55 s, p < 0.001, respectively, for the intent‐to‐treat population). Mibefradil 150 mg was associated with more adverse events than placebo, specifically, dizziness, leg edema, and postural hypotension.

Conclusions: This study demonstrates that mibefradil 50 mg once daily in the setting of the background long‐acting nitrate therapy produces additive antianginal and anti‐ischemic effects and is extremely well tolerated.
Telemetry outside critical care units: Patterns of utilization and influence on management decisions
Authors: Sivaram Chittur A. , Summers John H. , Ahmed Naveed
Published: February 2009

Background: Guidelines for the use of telemetry in hospitalized patients have been proposed by the American College of Cardiology (ACC). However, there have been only a few studies which have investigated the usefulness of these guidelines in clinical practice.

Hypothesis: This study assessed the role of telemetry in the decision making process outside the critical care units.

Methods: The observational study, lasting 4 weeks, was conducted in the telemetry unit of a tertiary care teaching hospital and included 61 male patients (age range 40‐61 years). They had been directly admitted to the telemetry unit or transferred from a critical care unit and were followed for as long as telemetry was active. Indication for telemetry and the contribution of telemetry to management decisions were assessed by a physician not involved in the care of the patient.

Results: Cumulative number of telemetry days was 379 with a mean of 6.2 days per patient. Total number of telemetry events was 297. According to the ACC classification, 14 patients (22.9%) had class I indication, 21 patients (34.4%) had class II indication, and 26 patients (42.6%) had class III indication. Telemetry events were seen in 18.2% of class I patients, in 39.7% of class II patients, and in 42.1% of class III patients. Only 12 telemetry events (4%) resulted in patient management, with none belonging to class III.

Conclusion: Telemetry findings in patients outside the critical care units are not usually responsible for major therapeutic changes. The value of telemetry in such patients may be overrated.
An adult case of kawasaki disease with multiplex coronary aneurysms and0 myocardial infarction: The role of transesophageal echocardiography
Authors: Habon Tamas , Toth Kalman , Keltai Matyas , Lengyel Maria , Palik Imre
Published: February 2009

Kawasaki disease (mucocutaneous lymph node syndrome) is an acute inflammatory disease that primarily affects infants and young children. in spite of proper therapy, coronary aneurysms develop in 10 to 25% of cases. Adult diagnosis of coronary aneurysm, presumably caused by Kawasaki disease, is rare. A 37‐year‐old male patient with previous inferior wall myocardial infarction (MI) was admitted with an acute anterior wall MI. Coronary angiography, performed 2 weeks after successful thrombolytic therapy, showed right coronary artery occlusion and multiplex (left main, left anterior descending, left circumflex, right coronary artery) giant coronary aneurysms. Transthoracic echocardiography was unable to detect the aneurysms. Transesophageal echocardiography (TEE) visualized a large left main coronary aneurysm with an occlusive thrombus and measured low flow velocity (0.2 m/s) in the proximal left anterior descending artery. At 4 weeks control, TEE showed marked regression of the thrombus, and it was not detectable after 6 months of oral anticoagulation with acenocumarol (International Normalized Ratio: 3‐3.5) and standard postinfarction therapy. After 2 years of follow‐up, the patient has no symptoms, and myocardial ischemia could not be provoked by stress tests [treadmill, dipyridamole single‐photon emission computed tomography (SPECT)]. We conclude that, for diagnosis and follow‐up of adult Kawasaki disease, transesophageal echocardiography is indicated. The importance and efficacy of long‐term anticoagulant treatment should be emphasized in this disease.
The molecular genetics of arrhythmias and sudden death
Authors: Brugada Ramon , Roberts Robert
Published: February 2009

The current status of the research in genetics of cardiac diseases causing sudden death is reviewed. Few techniques will impact medicine as will those of molecular biology. The identification of the gene‐causing diseases will allow the use of better preventive, diagnostic, and therapeutic options. From genetic counseling at present to gene therapy in the future, the new challenge for the clinician will be to acquire the new information provided by molecular biology and apply it at the bedside to improve the quality of life for the patient.
Left ventricular function and exercise tolerance in patients with type ii diabetes mellitus
Authors: Irace Luigi , Iarussi Diana , Guadagno Immacolata , De Rimini Maria Luisa , Mansi Luigi , Lucca Pasqualijna , Spadaro Pasquale , Romano Ada , Iacono Aldo
Published: February 2009

Background: Left ventricular (LV) preload changes may alter exercise tolerance (ET), probably lessening activation of the Maestrini‐Starling mechanism. Reduced LV filling (preload) during the diastolic phase, usually impaired in diabetic patients, could affect ventricular function.

Hypothesis: To evaluate the relationship between some echocardiographic LV function indices and ET, 24 patients (age 43‐75 years, mean 54 ± 13 years, Group A) with type II diabetes mellitus (DM), not suffering from other pathologies, and for whom the ergometric stress test (EST) resulted in an early interruption because of muscular fatigue and/or dyspnea, and 14 patients (age 38‐70 years, mean 53 ± 12 years, Group B) with type II DM and maximal ergometric stress test, used as control group, were studied.

Methods: The EST was performed by increasing the load by 25 W every 2 min; its duration was used as an ET index and correlated with clinical parameters of LV function obtained with M‐mode, two‐dimensional, and Doppler echocardiography.

Results: No patient in either Group A or Group B showed a high systolic blood pressure value at rest and/or an LV hypertrophy and/or an alteration of systolic functional indices. In neither group was there significant correlation between ET and duration of DM, basal heart rate, basal and max systolic blood pressure, and EF values. Linear regression analysis showed a significant correlation between Doppler parameters of the diastolic function and ET index in Group A, while there was no significant correlation inGroup B.

Conclusion: From these data we can deduce that in absence of left systolic ventricular dysfunction the impairment of LV relaxation in DM can influence exercise tolerance, probably by limiting activation of the contractile reserve.
Right ventricular dysplasia with complete atrioventricular block: Necessity and limitation of left ventricular epicardial pacing
Authors: Akazawa Hiroshi , Ikeda Uichi , Minezaki Kenryo K. , Hayashi Yuji , Kuroki Shigehiro , Shimada Kazuyuki
Published: February 2009

This paper reports a case of right ventricular dysplasia, in which the patient presented with atrioventricular block and was followed for more than 8 years under left ventricular epicardial pacing. Five years after first epicardial pacemaker implantation, loss of capture occurred. Replacement of the epicardial leads was performed.
Acute ischemic syndromes following coronary artery bypass graft surgery
Authors: Hirsch William S. , Ledley Gary S. , Kotler Morris N.
Published: February 2009

Coronary artery bypass graft (CABG) surgery, performed for the control of angina pectoris, leads to postoperative relief from symptoms in most patients. Amelioration of ischemia and improvement in exercise capacity after CABG are well documented. However, patients currently undergoing CABG are more complex than in the past—they are older and are maintained on medical therapy for longer periods. A large number of these patients have had one or more previous myocardial revascularization procedures. The postoperative period would appear to be a time of vulnerability for coronary events. However, previous investigators have focused on the pre‐ and intraoperative aspects of peri‐CABG ischemia. Outcome data suggest that the postoperative interval is at least equally important as a determinant of short‐ and long‐term morbidity and mortality. We discuss the epidemiology, etiology, pathophysiology, and treatment of ischemic syndromes in the postoperative period after CABG. In addition, we review recent data from a series of 14 patients, observed at our institution, who underwent cardiac catheterization and, in some cases, angioplasty of the culprit vessel in the immediate postoperative period.
Verapamil use in patients with cardiovascular disease: An overview of randomized trials
Authors: Pepine Carl J. , Faich Gerald , Makuch Robert
Published: February 2009

Background: Several reports have questioned the lack of safety data on calcium antagonists as a drug class. Because this drug class is heterogeneous, unique features of certain calcium antagonists may set them apart in terms of safety and efficacy.

Hypothesis: With in excess of 7,000 person‐years of observation from randomized clinical trials, verapamil was selected to evaluate whether there was evidence of harm in patients with cardiovascular disease.

Methods: MEDLINE search of English‐language articles, Science Citation Index, Current Contents, manual review of cited references, pharmaceutical files, and investigator correspondence was performed. Independent review of 66 articles identified 14 randomized, parallel‐group studies for inclusion. Independent, duplicate assessments were made of patient outcomes and trial characteristics (including study design, treatment dosage and schedule, duration of treatment, inclusion criteria, and sample size). Standard meta‐analytic techniques were employed for analysis and interpretation of results.

Results: Based on over 4,000 person‐years of observation, patients with acute myocardial infarction (MI) treated with verapamil had a decreased risk of nonfatal reinfarction compared with placebo (relative risk 0.79; 2‐sided 95% confidence interval 0.65, 0.97; p = 0.024). Verapamil had no significant effect on overall mortality compared with placebo (relative risk ranged from 0.93; 2‐sided 95% confidence interval 0.78, 1.10; p = 0.40 to 0.86; 2‐sided 95% confidence interval 0.71, 1.04; p = 0.13) depending on rules used to include or exclude patients from the pooling process. For the combined outcome of death or reinfarction, verapamil use was associated with a decreased risk compared with placebo (relative risk 0.82; 2‐sided 95% confidence interval 0.70, 0.97; p = 0.016).

In patients with angina involving a wide spectrum of disease severity, data were limited to 2,900 person‐years of observation, and verapamil use did not appear to be associated with an apparent effect on mortality or MI. Data available from randomized studies of verapamil in patients with hypertension were too limited to reach conclusions (50 person‐years of observation, with no deaths or MIs reported). Subgroups of hypertensive patients in two of the largest post‐MI studies and the largest angina study, involving over 600 patients, yielded little useful added information.

Conclusions: In patients with MI, the risks of both nonfatal reinfarction and the combined outcome of death or nonfatal MI were reduced over intermediate‐term follow‐up among patients treated with verapamil compared with controls (p = 0.024 and p = 0.016, respectively). In patients with angina, no evidence for harm was noted, but in hypertension the data were too limited to draw conclusions. These findings support the need to distinguish among different calcium antagonist compounds and to emphasize the need for more data in patients with hypertension.
A comparative study of eccentric and concentric coronary stenosis vasomotion in patients with prinzmetal's variant angina and patients with stable angina pectoris
Authors: Tousoulis Dimitris , Daves Graham , Kaski Juan Carlos
Published: February 2009

Background and hypothesis: In patients with stable angina pectoris, eccentric stenoses have a greater potential for dynamic changes of caliber in response to vasoactive stimuli than concentric lesions. It is not known whether in patients with coronary artery spasm the degree of coronary vasoconstriction differs in eccentric versus concentric stenoses. Therefore, we examined the relationship between coronary stenosis morphology and the vasomotor response to vasoactive stimuli in patients with variant angina.

Methods: Computerized quantitative angiography was used to measure minimum luminal diameter of eccentric and concentric stenoses before and after the administration of ergonovine and isosorbide dinitrate in 22 patients with Prinzmetal's variant angina and in 20 patients with chronic stable angina.

Results: In patients with variant angina, mean stenosis diameter reduction with ergonovine was ‐0.85 ± 0.38 and ‐1.12 ±0.69 mm in eccentric and concentric stenoses, respectively (p = NS). Isosorbide dinitrate promptly relieved spasm in all patients and increased the diameter of eccentric stenoses by 0.26 ± 0.34 mm and that of concentric stenoses by 0.24 ± 0.32 mm (p = NS). In patients with chronic stable angina, mean diameter reduction with ergonovine was ‐0.23 ±0.12 and ‐0.12 ± 0.10 mm for eccentric and concentric stenoses, respectively (p < 0.05). Isosorbide dinitrate increased coronary diameter by 10% from baseline in 70% of eccentric and 38% of concentric stenoses (p < 0.01).

Conclusion: In patients with variant angina pectoris, eccentric and concentric spastic stenoses react similarly in response to vasoactive stimuli. In patients with chronic stable angina, eccentric stenoses are more likely to show vasomotor responses than concentric stenoses.
Maximizing the hemodynamic benefit of enhanced external counterpulsation
Authors: Suresh Krishnamurthy , Simandl Susan , Lawson Wiliiam E. , Hui JOHN C.K. , Lillis Oneida , Burger Lynn , Guo Tong , Cohn Peter F.
Published: February 2009

Background: Enhanced external counterpulsation (EECP) has been demonstrated to be an effective treatment for angina and exertional ischemia in patients with coronary disease.

Hypothesis: It is hypothesized that the ability of EECP to enhance the recruitment or development of coronary collaterals in coronary artery disease may be determined by the relative magnitude of diastolic augmentation (DA) and systolic unloading (SU). This study examines the relation between the proposed EECP effectiveness ratio (DA/SU), as assessed by finger plethysmography, and changes in descending aortic flow as assessed by Doppler echocardiography in 15 patients during EECP.

Methods: Varying external cuff pressures (0‐275 mmHg) were used to generate a range of DA/SU ratios. The effect on aortic antegrade systolic and retrograde diastolic flow was assessed by Doppler echocardiography to determine whether there was an optimal EECP effectiveness ratio that maximizes the hemodynamic effects of EECP. With increasing DA/SU there was an initial positive linear increase in both systolic and diastolic flow volume. Systolic flow maximized at an effectiveness ratio of 1.5 and diastolic flow at a ratio of 2.0.

Result: Therefore, effectiveness ratios (DA/SU) in the range of 1.5‐2.0 are optimal for maximizing the hemodynamic effects of EECP.
Serum amyloid type a may be a predictor of restenosis
Authors: Blum Arnon , Laniado Shlomo , Miller Hylton , Kaplan Giora , Vardinon Nurit , Yust Israel , Burke Michael
Published: February 2009

Background: Elevation of acute phase proteins [C‐reactive protein (CRP) and serum amyloid type A (SAA)] has been demonstrated in unstable angina with an adverse clinical prognosis.

Hypothesis: The study was undertaken to determine the effect of angioplasty on the levels of SAA and the correlation with postangioplasty restenosis.

Methods: In a university‐affiliated tertiary medical center, a prospective case study was undertaken in 55 patients who underwent successful percutaneous transluminal coronary angioplasty (PTCA) of a single coronary lesion for angina pectoris. Three groups of patients were clinically characterized according to Braunwald's classification of anginal syndrome: Group A: class III; Group B: class I; Group C: stable angina. Serum amyloid type A was measured by an ELISA method before PICA and after 24 h, 1, and 3 months. Patients were followed clinically for 12 months. A thallium stress perfusion scan was performed 3 months after PTCA and coronary angiography was repeated in patients with an abnormal thallium perfusion scan.

Results: Serum amyloid type A levels >100 m̈/ml could identify Group A patients with a high sensitivity and specificity (r = 0.85 and 0.86, respectively). Of the patients studied. 75% increased their SAA level 24 h after angioplasty. An increase of SAA by >100% was associated with an increased risk of restenosis, with a relative risk of 6.4 (p < 0.05).

Conclusion: Increased levels of SAA characterize patients with unstable angina pectoris with a high specificity and sensitivity. Levels of SAA that increase > 100% 24 h after angioplasty may serve as a marker of restenosis.
Symmetric and asymmetric left ventricular hypertrophy in patients with end‐stage renal failure on long‐term hemodialysis
Authors: Straumann Edwin , Meyer Beat , Misteli Max , Blumberg Alfred , Jenzer Hansrudolf , Bertel Osmund , Weiss Philip
Published: February 2009

Background: Patients with end‐stage renal disease on regular hemodialysis have an increased prevalence of left ventricular (LV) hypertrophy that is associated with morbidity and mortality. Asymmetric septal hypertrophy and impairment of LV outflow can occur in these patients and may contribute to adverse outcomes. More insight into the prevalence, extent, geometry, and promoting factors of LV hypertrophy is important.

Methods: An unselected group of 62 patients (31 women), aged 55 ± 14 years, on maintenance hemodialysis was investigated by Doppler echocardiography. Eight patients with valvular heart disease were excluded from further analysis. We assessed prevalence of LV hypertrophy and asymmetric septal hypertrophy, as well as parameters of LV geometry and LV filling and outflow dynamics.

Results: Prevalence of LV hypertrophy was 65%. Patients were analyzed according to LV mass and geometry. Mean LV mass index was normal (105 ± 17 g/m2) in Group 1 without LV hypertrophy (n = 19); it was markedly elevated in Group 2 (symmetric hypertrophy, n = 22) and Group 3 (asymmetric hypertrophy with systolic anterior movement of mitral valve, n = 7), and highest (191 ± 54 g/m2) in Group 4 (asymmetric hypertrophy without systolic anterior movement of mitral valve, n = 6, p < 0.001). Age, body mass index, and duration of hypertension were associated with LV hypertrophy and asymmetric septal hypertrophy (p = 0.01). Group 3 with systolic anterior motion of mitral valve had the smallest end‐diastolic LV diameters (p = 0.02); increased heart rates, and increased ejection velocities in the LV outflow tract (p = 0.03, and p = 0.005, respectively, vs. Groups 1,2, and 4) which pointed to an impairment of LV outflow.

Conclusions: Symmetric LV hypertrophy and asymmetric septal hypertrophy are frequent in patients on maintenance hemodialysis. Predictors for LV hypertrophy were age and body mass index, and, particularly for asymmetric septal hypertrophy, age and hypertension duration. Volume withdrawal during hemodialysis may lead to symptomatic hypotension due to dynamic obstruction in some patients with severe asymmetric septal hypertrophy.
Incidence and prognostic value of electrocardiographic abnormalities after heart transplantation
Authors: Golshayan Dela , Seydoux Charles , Berguer Danièle Gillard , Von Segesser Ludwig , Goy Jean‐Jacques , Stumpe Frank , Hurni Michel , Ruchat Patrick , Fischer Adam , Mueller Xavier , Sadeghi Hussein
Published: February 2009

Background: The improvement of surgical techniques and the use of immunosuppressive drugs within the past 15 years has made heart transplantation an increasingly performed procedure and an accepted treatment for end‐stage cardiac failure.

Hypothesis: The aim of this study was to describe the changes of the 12‐lead electrocardiogram (ECG) after heart transplantation and to determine their prognostic value on complications such as rejection or graft coronary artery disease during follow‐up.

Methods: The ECGs of 62 consecutive patients were analyzed for 5 years at follow‐up periods of 1,2,3,6 months and yearly after transplantation.

Results: The most prevalent abnormality was the presence of complete or incomplete right bundle‐branch block (RBBB). New RBBB appeared in 69% (43/62) of the patients, mainly during the first month (21/43). There was no left bundle‐branch block. We detected nine episodes of supraventricular arrhythmias: one atrial fibrillation, six atrial flutter, one junctional tachycardia, one orthodromic tachycardia on a Wolff‐Parkinson‐White syndrome; all appearing during the first 3 months. Three of the six episodes of atrial flutter occurred during an episode of acute rejection. There was no relation between RBBB and the gender and age of recipients and donors, nor with the graft ischemic time and the pre‐transplantation hemodynamic values. Right bundle‐branch block was not associated with acute rejection nor with graft coronary artery disease.

Conclusion: The ECG abnormalities after heart transplantation have no predictive value on the long‐term evolution. Right bundle‐branch block is very frequent and is not associated with adverse prognosis.
Unexpected instant death following successful coronary artery bypass graft surgery (and other clinical settings): Atrial fibrillation, quinidine, procainamide, et cetera, and instant death
Authors: O'Neal HUMPHRIES J.
Published: February 2009

Primum non nocere. Atrial fibrillation (AF) occurs commonly following coronary artery bypass graft surgery, although new onset atrial fibrillation in this setting is usually transient. When AF reverts or is converted to sinus rhythm it is unlikely to recur, whether or not the patient takes preventive medication. As no benefit (and sometimes increased risk) associated with reduced mortality or morbidity in this setting has been reported for antiarrhythmic agents, standard treatment should consist of observation or control of ventricular response with an appropriate agent until AF relapses to sinus rhythm. If an antiarrhythmic agent, especially a class I agent, is used because of persistent or recurrent AF in the early postoperative period, heart rhythm should be monitored as long as the class I agent is administered and treatment initiated if an un‐dersirable rhythm develops. Atrial fibrillation in other clinical settings in patients with structural heart disease presents a more difficult management problem. Class I agents are reported to be associated with an increased risk of death, despite an efficacious effect of maintaining sinus rhythm. Amiodarone is reported to be well tolerated with respect to the cardiovascular system, but unacceptable noncardiac effects are reported. A safe amiodarone‐like agent is greatly needed. Atrial fibrillation in patients with no structural heart disease is not discussed in this presentation.
Current clinical applications of heart rate variability
Authors: Stys A. , Stys T.
Published: February 2009

Heart rate variability (HRV) has become a popular method for the studies of physiologic mechanisms responsible for the control of heart rate fluctuations, in which the autonomic nervous system appears to play a primary role. Depression of HRV has been observed in many clinical scenarios, including autonomic neuropathy, heart transplantation, congestive heart failure, myocardial infarction (MI), and other cardiac and noncardiac diseases. However, it is important to realize that clinical implication of HRV analysis has been clearly recognized in only two clinical conditions: (1) as a predictor of risk of arrhythmic events or sudden cardiac death after acute MI, and (2) as a clinical marker of evolving diabetic neuropathy. Recently, its role in evaluation and management of heart failure has also been recognized. It is pertinent to recognize the limitations of HRV as far as its clinical utility at present is concerned. The methodology of HRV had remained poorly standardized until the recent publication of the Special Report of the Task Force of ESC/NASPE, and thus has been presenting difficulty in comparing earlier existing data. Also, determination of the exact sensitivity, specificity, and predictive value of HRV, as well as the normal values of standard measures in the general population, still require further investigation before better standards can be set for existing and future clinical applications. This article reviews the major concepts of HRV measurements, their clinical relevance, and the recent advances in this field.
Arrhythmic profile, ventricular function, and histomorphometric findings in patients with idiopathic ventricular tachycardia and mitral valve prolapse: Clinical and prognostic evaluation
Authors: Vecchia Luigi La , Ometto Renato , Centofante Paolo , Varotto Leonardo , Bonanno Carlo , Bozzola Loredana , Bevilacqua Pierantonio , Vincenzi Mario , Cardiologia Divisione Di
Published: February 2009

Background: In patients with ventricular tachycardia (VT) and apparently normal hearts, mitral valve prolapse (MVP) is discovered fairly often, raising the question of whether or not it is an occasional finding.

Hypothesis: This issue was analyzed in a series of patients with VT and apparently normal hearts in order to define the prevalence of MVP in this condition, the existence of specific diagnostic features suggesting a nonrandom association between idiopathic VT and MVP, and the prognostic implications of this finding.

Methods: We studied 28 consecutive patients with documented VT and no history of heart disease. Two‐dimensional (2‐D) echocardiogram, cardiac catheterization, morphometric examination of endomyocardial biopsy and arrhythmologic evaluation (24‐h Holter monitoring, electrophysiologic study, and signal‐averaged electrocardiogram) were performed. Inclusion criteria for all patients were angiographically normal coronary arteries, normal biventricular function, and absence of histologic evidence of myocarditis. Data obtained in patients found to have MVP at 2‐D echo were compared with those of the remaining patients. Long‐term follow‐up data were also collected.

Results: The prevalence of MVP in our study group was 25% (7 patients). It was not associated with leaflet dysplasia or significant regurgitation. Biventricular function (ventricular volumes and ejection fraction) was comparable in patients with and without MVP. Patients with MVP had a significantly higher prevalence of ventricular late potentials at signal‐averaged electrocardiogram (86 vs. 29%, p = 0.027), more interstitial fibrosis at morphometry (8.5 ± 3.7 vs. 5.4 ± 2.7% p = 0.028), and VT of right bundle‐branch block morphology (100 vs. 48%; p = 0.044). Other arrhythmologic findings were similar in the two groups. After a mean follow‐up of >5 years, no patient in either group died, and none developed heart failure or severe mitral regurgitation.

Conclusions: Mitral valve prolapse is frequently detected in idiopathic VT. The distinguishing features of this association are (1) VT of right bundle‐branch block morphology, (2) high prevalence of ventricular late potentials, and (3) increased fibrosis on endomyocardial biopsy. Ventricular function and other arrhythmologic findings are not specific of this association. Prognosis remains substantially benign, as is true for most cases of idiopathic VT.
Hypotensive response during dobutamine stress echocardiography in coronary patients: A common event of well‐functioning left ventricle
Authors: Rallidis Loukianos S. , Moyssakis Ioannis E. , Nihoyannopoulos Petros
Published: February 2009

Background: Hypotensive response during dobutamine stress echocardiography (DSE) is a common complication, lacking the prognostic significance of hypotension during exercise treadmill test.

Hypothesis: The present study aimed to assess the possible mechanisms of hypotensive response during DSE and to compare it with exercise treadmill test.

Methods: In all, 91 patients with known coronary artery disease (CAD) underwent both DSE and exercise treadmill test. Dobutamine‐induced hypotension was defined as a systolic blood pressure drop ≥20 mmHg from baseline or from the previous level of infusion.

Results: Twenty‐one (23%) patients, 10 of whom also had bradycardia, developed hypotension during dobutamine infusion. Five (5.5%) patients were severely symptomatic and the infusion was stopped prematurely, while in the remaining 16 the addition of atropine allowed the continuation of the test. Patients prone to hypotension were predominantly female (p = 0.0004). had smaller (p = 0.01) and better functioning left ventricles (p = 0.0004), were unlikely to have rest wall motion abnormalities (p = 0.0008) or multivessel CAD (p = 0.02), and had less ischemia (wall motion score difference) (p = 0.03). Hypotension during exercise treadmill test was observed in only one (1%) patient with left main disease.

Conclusions: Hypotension during DSE is unrelated to the anatomical or functional extent of CAD and is frequent in the setting of a well‐functioning left ventricle. We suppose that vigorous contraction of a small chamber during dobutamine infusion results in an excessive stimulation of cardiac mechanoreceptors that mediate reflex hypotension and bradycardia.