bluuebunny/crossref_metadata_2025 huggingface dataset:
Implications of the absence of st‐segment elevation in lead V4R in patients who have inferior wall acute myocardial infarction with right ventricular involvement
Authors: Kosuge Masami , Kimura Kazuo , Ishikawa Toshiyuki , Hongo Yoichiro , Shigemasa, Tomohiko , Sugiyama Mitsugi , Tochikubo Osamu , Umemura Satoshi
Published: February 2009

Background: ST‐segment elevation of ± 1.0 mm in lead V4R has been shown to be a reliable marker of right ventricular involvement (RVI), a strong predictor of a poor outcome in patients with inferior acute myocardial infarction (IMI). However, patients with no ST‐segment elevation in lead V4R despite the presence of RVI have received little attention.

Hypothesis: The study was undertaken to study the clinical features of patients with no ST‐segment elevation in lead V4R despite the presence of RVI, which means false negative, as such patients have received little attention in the past.

Methods: We studied 62 patients with a first IMI. who had total occlusion of the right coronary artery (RCA) proximal to the first right ventricular branch and successful reperfusion within 6 h from symptom onset, to examine the implications of the absence of ST‐segment elevation in lead V4R despite the presence of RVI.

Results: A standard 12‐lead electrocardiogram (ECG) and right precordial ECG (lead V4R) were recorded on admission, and three posterior chest ECGs (leads V7 to V9) were additionally recorded in 34 patients. Patients were classified according to the absence (Group 1, n = 18) or presence (Group 2, n = 44) of ST‐segment elevation of ± 1.0 mm in lead V4R on admission. Patients in Group 1 had a greater ST‐segment elevation in leads V7 to V9 (2.9 ± 2.4 vs. 1.4 ± 3.0 mm, p < 0.05), a higher frequency of a dominant RCA (defined as the distribution score ≥ 0.7) (72 vs. 11%, p < 0.001), and a higher peak creatine kinase level (3760 ±; 1548 vs. 2809 ± 1824 mU/ml, p < 0.05) than those in Group 2.

Conclusions: In patients with IMI caused by the occlusion of the RCA proximal to the first right ventricular branch, no ST‐segment elevation in lead V4R can occur because of concomitant posterior involvement. In such patients, the incidence of RVI may be underestimated on the basis of ST‐segment elevation in lead V4R.
histamine—can it cause an acute coronary event?
Authors: Gupta Mahendra Kumar , Gupta Parul , Rezai Feridoun
Published: February 2009

Myocardial infarction (MI) occurring during the course of an allergic urticarial reaction in the absence of systemic hypotension has been rarely reported. This paper reports the case of a 28‐year‐old woman with no significant risk factors for coronary artery disease who presented with generalized urticaria associated with chest pain and had electrocardiographic and enzymatic evidence of an acute MI. Review of the literature suggests that local histamine release may induce spasm of the coronary vasculature, thus leading to myocardial ischemia and infarction.
Transluminal endovascular stent grafting of aortic dissections and aneurysms: A concise review of the major trials
Authors: Dieter Robert S.
Published: February 2009

Transluminal endovascular repair of the vascular system is rapidly emerging as a leading therapeutic modality for aortic dissections and aneurysms. The use of transluminal endovascular stent grafting has been used to intervene successfully on the aorta and its major branch vessels. There have been several studies examining transluminal endovascular stent grafting of thoracic aortic aneurysms, dissections, and abdominal aortic aneurysms. This paper reviews some of the major trials of transluminal endovascular stent grafting as well as its major limitation, endoleak.
Preinfarction angina prevents left ventricular remodeling in patients treated with thrombolysis for myocardial infarction
Authors: NeŠKOVIÉ Aleksandar N. , Pavlovski KoČO , Bojić Dragana , Popović Zoran , Ota ević Petar , Vlahovićca Alja , Obradovićca Velibor , Putnikovićca Biljana , Vasiljevićca‐Pokraj Zorana , Bojićca Milovan , Popovićca Aleksandar D.
Published: February 2009

Background: It has been shown that preinfarction angina may have beneficial effects on infarct size and mortality. However, there are no studies that have serially assessed the impact of preinfarction angina on left ventricular (LV) function in a large series of patients.

Hypothesis: The study was undertaken to determine whether preinfarction angina (within 7 days before infarction) influences LV remodeling.

Methods: In all, 119 consecutive patients with acute myocardial infarction were serially evaluated by 2‐dimensional echocardiography (on Days 1, 2, 3, and 7; at 3 and 6 weeks; and at 3, 6, and 12 months following infarction). Left ventricular volumes were determined using Simpson's biplane formula and normalized for body surface area. Wall motion score index and sphericity index were calculated for each study. Coronary angiography was performed before discharge.

Results: Preinfarction angina was detected in 39 of 119 patients. Initial echocardiographic and clinical data as well as the incidence of patent infarct‐related artery and collaterals were similar for patients with and without preinfarction angina. In the subset of thrombolysed patients, patients with preinfarction angina showed decrease of LV end‐diastolic and end‐systolic volumes during the follow‐up period (p = 0.033 and p = 0.001, respectively), and improvement of wall motion score index (p < 0.001) and ejection fraction occurred (p = 0.001), without changing of LV shape (p > 0.05); in addition, patients with preinfarction angina had smaller LV volumes and higher ejection fraction than did those without angina, from 3 weeks onward. These favorable effects were not detected in patients not treated with thrombolysis.

Conclusions: These data indicate that preinfarction angina has an inhibiting effect on long‐term LV remodeling in patients who underwent thrombolysis for first acute myocardial infarction. It appears that preinfarction angina has no impact on infarct size and early postinfarction LV function.
Increased levels of plasma thrombomodulin in patients with acute myocardial infarction who had thrombolytic therapy and achieved successful reperfusion
Authors: Ileri Mehmet , Hisar Ismet , Yetkin Ertan , KoŞar Feridun , Cehreli Sengül , Korkmaz Sule , Demirkan Deniz
Published: February 2009

Background: There is a growing body of evidence from animal and in vitro studies for the existence of reperfusion injury after thrombolytic therapy for acute myocardial infarction (AMI), but the patient data are limited.

Hypothesis: We aimed to examine the plasma thrombomodulin (TM) levels as a marker of endothelial injury and to investigate the effect of successful reperfusion on these levels.

Methods: The study included 32 patients who had a first episode of acute myocardial infarction (AMI) and received intravenous streptokinase therapy.

Results: Thrombomodulin levels increased significantly at 60 min after thrombolysis compared with the levels before thrombolytic therapy (0 min) in 21 (66%) patients who had successful reperfusion (49.09 ± 10.51 vs. 25.76 ± 5.55 ng/ml, p < 0.001). There was no difference between the TM levels at 0 and at 60 min of thrombolysis in the remaining 11 (34%) patients who could not achieve reperfusion (27.81 ± 6.32 vs. 28.72 ± 7.28 ng/ml, p = 0.35).

Conclusion: There was a significant increase in TM levels at 60 min after thrombolysis in a group of patients with AMI who achieved successful reperfusion; this increase may have been caused by the activation/injury of endothelial cells. Data also suggest that the increment in TM levels may be predictive of the potential success of thrombolytic therapy.
Adequacy of anticoagulation in patients with atrial fibrillation: Effect of various parameters
Authors: Cohen Natan , Almoznino‐Sarafian Dorit , Alon Irena , Gorelik Oleg , Koopfer Margarita , Chachashvily Shulamit , Shteinshnaider Miriam , Litvinjuk Vladimir , Modai David
Published: February 2009

Background: Despite reported evidence of the vital importance of appropriate anticoagulation in patients with chronic atrial fibrillation for stroke prevention, this treatment modality still lags behind optimal requirements.

Hypothesis: Our objectives were to evaluate various doctor‐or patient‐related factors that influence quality of control and to assess the adequacy of anticoagulation provided by physicians in the community.

Methods: In a retrospective study, International Normalized Ratio (INR) values obtained immediately on admission to hospital were considered representative of previous long‐term control.

Results: Only 42% of the relevant 385 patient population fell within the protective anticoagulation range of INR 1.91‐4.1. The respective figures for patients with poor (INR < 1.5) or suboptimal (INR 1.51‐1.9) control, as well as those whose INR values risked bleeding (INR > 4.1), were 28.3, 14.1, and 15.6%. Patient involvement in treatment positively influenced quality of control. By contrast, age 70–80 years or absence of congestive heart failure negatively affected quality of anticoagulation [p = 0.07, odds ratio (OR), 1.7 (95% confidence interval, 0.94–3.08), p = 0.014, OR, 2.06 (95% confidence interval, 1.15–3.7) respectively]. The percentage of patients admitted with stroke who had been adequately anticoagulated was significantly lower than that of patients who had no stroke (21 vs. 44.4%). Adequacy of anticoagulation in patients with cardiac prosthetic valves was superior compared with the rest of the patient population (56.7 vs. 42% with optimal, and only 14.5 vs. 28.3% with poor anticoagulation, respectively), indicating that under the same conditions a better quality of treatment could be achieved.

Conclusions: Adequacy of anticoagulation in patients with atrial fibrillation lags behind actual recommendations. Better control is required and achievable.
Staged revascularization in critically ill patients with coronary artery disease
Authors: Hayat Nasser Jowhar , Varghese Kiron , Thomas Christus Singh , Khan Nazir Ali
Published: February 2009

Background: Critically ill patients undergoing bypass surgery experience a higher mortality and morbidity.

Hypothesis: The study was undertaken to evaluate the efficacy and value of percutaneous transluminal coronary angioplasty (PTCA) as a bridge to coronary artery bypass graft surgery (CABG) in high‐risk patients with refractory unstable angina or cardiogenic shock.

Methods: We present 11 seriously unstable patients with severe multivessel coronary artery disease undergoing culprit vessel PTCA. Angioplasty was performed not as a definitive procedure but rather as a bridge to surgical revascularization. All the patients had sustained at least one myocardial infarction prior to catheterization, all had refractory unstable angina, eight patients had only a single patent coronary artery, and five patients were in cardiogenic shock.

Results: Following PTCA, all patients enjoyed a stable in‐hospital period. One patient died 12 weeks after successful PTCA while awaiting second CABG. Seven patients subsequently underwent CABG and are doing well. The remaining three patients were also advised to undergo CABG, but elected to continue medical management.

Conclusions: Coronary angioplasty of the culprit vessel may play a role as a bridge to surgery in critically ill patients.
Cardiac troponin T Arg92Trp mutation and progression from hypertrophic to dilated cardiomyopathy
Authors: Fujino Noboru , Shimizu Masami , Ino Hidekazu , Okeie Kazuyasu , Yamaguchi Masato , Yasuda Toshihiko , Kokado Hiromasa , Mabuchi Hiroshi
Published: February 2009

Background: Mutations in the cardiac troponin T gene causing familial hypertrophic cardiomyopathy (HCM) are associated with a very poor prognosis but only mild hypertrophy. To date, the serial morphologic changes in patients with HCM linked to cardiac troponin T gene mutations have not been reported.

Hypothesis: The aim of this study was to determine the long‐term course of patients with familial HCM caused by the cardiac troponin T gene mutation, Arg92Trp.

Results: The Arg92Trp missense mutation was present in 10 individuals from two unrelated pedigrees. They exhibited different cardiac morphologies: three had dilated cardiomyopathy‐like features, five had asymmetric septal hypertrophy with normal left ventricular systolic function, one had electrocardiographic abnormalities without hypertrophy, and one had the disease‐causing mutation but did not fulfill the clinical criteria for the disease. The mean maximum wall thickness was 14.1 ± 6.0 mm. The three patients with dilated cardiomyopathy‐like features had progressive left ventricular dilation. Three individuals underwent right ventricular endomyocardial biopsy. There was a modest degree of myocardial hypertrophy (myocyte diameter: 18.9 ± 5.2 m̈m), and minimal myocardial disarray and mild fibrosis were noted.

Conclusion: The Arg92Trp substitution in the cardiac troponin T gene shows a high degree of penetrance, moderate hypertrophy, and early progression to dilated cardiomyopathy in Japanese patients. Early identification of individuals with this mutation may provide the opportunity to evaluate the efficacy of early therapeutic interventions.
Thrombopoietin and mean platelet volume in coronary artery disease
Authors: ŞENARAN HANDAN , Ileri Mehmet , AltinbaŞ Ahmet , KoŞar Ali , Yetkin Ertan , ÖZTÜRK Mustafa , Karaaslan YaŞar , Kirazli Şerafettin
Published: February 2009

Background: Large platelets are shown to be hemostatically more active. It has been suggested that mean platelet volume (MPV) is increased during acute myocardial infarction (AMI) and unstable angina pectoris (USAP). However, the underlying mechanism of the phenomenon remains unclear.

Methods: Twenty patients with AMI and 20 patients with USAP were included in this study. Seventeen healthy adult subjects served as controls. Venous blood samples of the subjects were drawn within 12 h after admission. Thrombopoietin levels were measured by ELISA and platelet counts and MPV were assayed by autoanalyzer.

Results: Patients with AMI and USAP had higher platelet counts than those in the control group. Although the platelet counts were slightly higher in AMI than in USAP, this did not reach statistical significance. Mean platelet volume and levels of TP were found to be elevated in patients with AMI and USAP compared with control subjects (p < 0.001). Thrombopoietin levels were higher in AMI than USAP, but this was not statistically significant. There was a positive correlation between TP levels and MPV values (p < 0.05).

Conclusion: Increased TP levels may increase both platelet counts and platelet size, resulting in hemostatically more active platelets, which may contribute to the development and progression of CAD.
Effect of acute exercise on the raised plasma fibrinogen, soluble P‐Selectin and von willebrand factor levels in chronic atrial fibrillation
Authors: Li‐Saw‐Hee Foo Leong , Blann Andrew D. , Edmunds Eiry , Gibbs Christopher R. , Lip GREGORY Y. H.
Published: February 2009

Background: There is increasing evidence that chronic atrial fibrillation (AF) is associated with a prothrombotic or hypercoagulable state.

Hypothesis: This study was undertaken to determine whether short‐term exercise in patients with chronic AF would shift the overall hemostatic balance toward a more prothrombotic state with a reduction in fibrinolytic potential.

Methods: We recruited 20 patients (13 men;mean age 65 years ± 11 standard deviation [SD]) with chronic AF who were not treated with antithrombotic therapy and exercised them to exhaustion using a multistage treadmill exercise (standard Bruce) protocol. Blood samples were taken pre exercise, immediately after cessation of exercise, and at 20 min post exercise. The prothrombotic state was quantified by fibrinogen (an index of hemorheology and a coagulation factor), soluble P‐selectin (sP‐sel, marking platelet activation), von Willebrand factor (vWF, an index of endothelial dysfunction), and plasminogen activator inhibitor‐1 (PAI‐1, a regulator of fibrinolytic activity) levels. There were two groups of age‐ and gender‐matched controls in sinus rhythm: (1) healthy controls, and (2) “hospital controls” who were patients with vascular disease.

Results: Baseline levels of vWf (p = 0.034) and fibrinogen (p < 0.0001), but not sP‐sel (p = 0.075) were significantly elevated in patients with AF compared with both control groups in sinus rhythm. The PAI‐1 levels were highest in the hospital control patients, but not in chronic AF (p = 0.041). Following treadmill exercise, achieving a mean metabolic equivalent of 4.9 METS (± 1.75 SD) and total exercise duration of 4.9 min (± 2 SD), there was a significant rise in plasma fibrinogen (repeated measures analysis of variance [ANOVA] p = 0.047) and a reduction in PAI‐1 levels (p = 0.025) in patients with AF. There were no significant changes seen in vWf (p = 0.308) or sP‐sel (p = 0.071) levels. No significant changes in these indices were seen in hospital controls (all p = not significant), despite a much longer duration of exercise with greater workload.

Conclusion: Patients with chronic AF have increased vWf and fibrinogen levels compared with sinus rhythm. Exercise to exhaustion influences the hypercoagulable state in chronic AF, with a rise in plasma fibrinogen and possible increase in fibrinolytic activity. Nevertheless, acute exercise does not appear to have a significant influence on endothelial dysfunction or platelet activation in patients with AF.
Clinical benefit of noninvasive viability studies of patients with severe ischemic left ventricular dysfunction
Authors: Soto Juan R. , Beller George A.
Published: February 2009

The population of patients who have congestive heart failure of ischemic origin is large and growing. It imposes a heavy burden on human suffering and economic costs such as the chronic use of costly medications, recurrent hospital admissions, and, eventually, death or the necessity of heart transplantation. Therefore, the development of methods for detecting viable myocardium may allow the accurate selection of those patients with coronary artery disease with severe left ventricular dysfunction who are most likely to benefit from revascularization, but also excludes patients who are unlikely to obtain any improvement with revascularization techniques. The presence of reversible dysfunctional myocardium that may improve after revascularization implies the concepts of stunned and hibernating myocardium. Recent evidence suggests that hibernation may not be a stable condition since it might evolve toward an irreversible dysfunction if it is not revascularized at the right moment. The techniques available for viability studies are single‐photon emission computed tomography using thallium‐201 or compounds labeled with technetium‐99m, positron emission tomography, and dobutamine stress echocardiography. Newer and promising techniques are magnetic resonance imaging and contrast echocardiography, whose definitive roles are not clear yet. There is abundant evidence from several important studies showing that patients with a significant amount of viable myocardium have a poor outcome if they are treated medically. Conversely, if these patients are revascularized, their outcomes improve and their symptoms significantly decrease, with less necessity of medication, fewer admissions to the hospital, and even in some cases avoiding heart transplantation. On the other hand, patients with poor or no viability who are revascularized do not obtain significant benefit.
The international EECP patient registry (IEPR): Design, methods, baseline characteristics, and acute results
Authors: Barsness Gregory , Holmes David R. , Feldman Arthur M. , Holubkov Richard , Kelsey Sheryl F. , Kennard Elizabeth D.
Published: February 2009

Background: In 1998, the International EECP Patient Registry (IEPR) was organized to document patient characteristics, safety, and efficacy during the treatment period, and long‐term outcomes. All centers with EECP facilities were invited to join the voluntary Registry. The Registry population comprises all patients starting EECP therapy for treatment of angina pectoris in participating centers.

Hypothesis: The study was undertaken to determine whether EECP is a safe and effective treatment for patients with angina pectoris regardless of their suitability for revascularization by more conventional techniques.

Methods: After 18 months of operation, 43 clinical centers representing over half of clinical sites using the EECP system contributed cases. The data reported here were collected before the first EECP treatment and upon completion of final treatment. EECP can be used for patients ineligible for either coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI), as well as for those who prefer noninvasive treatment to avoid or delay revascularization. in this report, patients considered to be candidates for revascularization are compared with those not considered suitable.

Results: Of the 978 patients analyzed, 70% had Canadian Cardiovascular Society Classification class III or IV angina before starting treatment, and 62% used nitroglycerin. Most (81%) had been previously revascularized, and 69% were considered unsuited for either PCI or CABG at the time of starting EECP. A full treatment course (usually 35 h) was completed in 86%, of whom 81% reported improvement of at least one angina class immediately after the last treatment.

Conclusion: In a broad patient population, EECP has been shown to be a safe and effective treatment.
Effect of coronary risk factors on arterial compensatory enlargement in japanese middle‐aged patients with de novo single‐vessel disease—An intravascular ultrasound study
Authors: Isoda Kikuo , Arakawa Koh , Kamezawa Yashuhiro , Nishizawa Ken‐Ya , Nishikawa Ken‐Ichirou , Shibuya Toshio , Ohsuzu Fumitaka , Nakamura Haruo
Published: February 2009

Background: Compensatory enlargement (CE) of atherosclerotic human arteries has been reported; however, the pattern of arterial remodeling in response to plaque formation is not unique.

Hypothesis: The study was undertaken to determine the extent of coronary artery compensatory enlargement at stenotic lesions and to correlate the arterial compensatory enlargement with risk factors.

Methods: We studied 62 patients with stable angina and de novo single‐vessel disease using intravascular ultrasound and obtained good images in 42 patients (68%). The vessel cross‐sectional area (VA), lumen cross‐sectional area (LA), and plaque cross‐sectional area (PA) were measured at the lesion site and at proximal and distal reference sites. Positive CE was defined as increase in VA of lesion site > 10% compared with that of proximal reference site (CE group, n = 15); shrinkage was defined as reduction in VA of lesion site > 10% compared with that of proximal reference site (S group, n = 14); inadequate CE was defined as intermediate between CE and S (IE group, n = 13). All subjects had coronary risk factors measured before this study.

Results: There was no difference in VA, LA, or PA among the three groups at the proximal and distal reference sites, nor in LA at the lesion site; however, VA and PA were significantly smaller in the S group than in the other groups (p < 0.01). Of coronary risk factors, increased systolic blood pressure (SBP), increased diastolic blood pressure (DBP), and decreased high‐density lipoprotein cholesterol (HDL‐c) levels had the strongest association with shrinkage (p < 0.05).

Conclusion: Hypertension and decreased HDL level may contribute to the shrinkage response in middle‐aged patients with stable angina.
Homocysteine levels in patients with risk factors for atherosclerosis
Authors: Blum Arnon , Khazim Khaled , Gumanovsky Marina , Yeganeh Shay , Jawabreh Subchi , Lupovitch Sacha , Peleg Aviva
Published: February 2009

Background: Abundant epidemiological evidence has demonstrated that the presence of mild to moderate hyperhomocysteinemia is an independent risk factor for atherosclerosis in the coronary, cerebral, and peripheral vasculature, and for vascular disease, including coronary disease. It has been demonstrated that plasma total homocysteine level is a strong predictor of mortality in patients with angiographically confirmed coronary artery disease.

Hypothesis: The study was undertaken to determine the extent of homocysteine levels in patients without documented coronary artery disease, but with at least one risk factor for atherosclerosis.

Methods: Fasting blood samples were collected prospectively from 160 consecutive patients (50 women and 110 men, mean age 65 ± 7 years) who had at least one risk factor for atherosclerosis, but had no documented coronary artery disease. Homocysteine levels were measured by an immunoassay method.

Results: Of the patients studied, 78 (48.75%) with at least one risk factor for atherosclerosis had high homocysteine levels; 62 patients had mild hyperhomocysteinemia (15–30 μmol/l); and 16 patients had moderate hyperhomocysteinemia (30–100 μmol/l).

Conclusions: Our data suggest that hyperhomocysteinemia is highly prevalent in patients with risk factors for atherosclerosis. Homocysteine level (an independent convertible risk factor to atherosclerosis) should be measured routinely in patients with risk factors for atherosclerosis and treated appropriately.
Low‐dose combination therapy with colesevelam hydrochloride and lovastatin effectively decreases low‐density lipoprotein cholesterol in patients with primary hypercholesterolemia
Authors: Davidson Michael H. , Toth Phillip , Weiss Stuart , Mckenney James , Hunninghake Donald , Isaacsohn Jonathan , Donovan Joanne M. , Burke Steven K.
Published: February 2009

Background: Colesevelam hydrochloride is a novel, lipid‐lowering agent that binds bile acids with high affinity. A multicenter, randomized, double‐blind, placebo‐controlled, parallel‐design study was conducted to assess the efficacy and tolerability of combination low‐dose colesevelam and lovastatin treatment in patients with primary hypercholesterolemia.

Hypothesis: Combination therapy with low doses of colesevelam and lovastatin decreases low density (LDL) cholesterol with minimal adverse events.

Methods: Following a 4‐ to 6‐week dietary lead in, 135 patients were randomized into five groups for a 4‐week treatment period: placebo, colesevelam 2.3 g at dinner, lovastatin 10 mg at dinner, the combination of colesevelam and lovastatin given at dinner (dosed together), and combination treatment with colesevelam given at dinner and lovastatin administered at bedtime (dosed apart).

Results: Combination colesevelam and lovastatin treatment decreased LDL cholesterol by 34% (60 mg/dl, p < 0.0001) and 32% (53 mg/dl, p < 0.0001) when colesevelam and lovastatin were dosed together or dosed apart, respectively. Both combination therapies were superior to either agent alone (p < 0.05). Decreases in LDL cholesterol exceeded the combined decreases observed for colesevelam alone (13 mg/dl, 7%) and lovastatin alone (39 mg/dl, 22%). Both combination treatments reduced total cholesterol by 21% (p < 0.0001) and apolipoprotein B by 24% (p < 0.0001). Neither combination treatment significantly altered high‐density lipoprotein cholesterol or triglycerides. Adverse side effects were not significantly different among randomized groups.

Conclusions: Combination colesevelam and lovastatin was efficacious and well tolerated, resulting in additive decreases in LDL cholesterol levels whether or not both agents were administered simultaneously.
Successful external cardioversion of atrial fibrillation in patients referred to an electrophysiologist for internal cardioversion
Authors: Verdino Ralph J. , Teuteberg Jeffrey J. , Burke Martin C. , Kopp Douglas E. , Timothy Johnson C. , Lin Albert C. , Alberts Michael , Kall John G. , Wilber David J.
Published: February 2009

Background: Internal cardioversion of atrial fibrillation with direct current energy has become an increasingly employed technique for patients who fail external cardioversion.

Hypothesis: The purpose of this study was to determine whether internal cardioversion could be avoided by careful attention to cardioversion technique in a group of patients referred specifically for internal cardioversion after failed external cardioversion by community cardiologists.

Methods: We performed external cardioversion utilizing two operators applying significant pressure to the thorax with up to 360 J prior to the planned internal cardioversion in 20 patients referred for internal cardioversion after failed attempts at external cardioversion.

Results: Sixteen patients (80%) were successfully cardioverted and avoided the risk, inconvenience, and cost of internal cardioversion.

Conclusion: External cardioversion with significant anterior paddle pressure by two operators can decrease the need for internal cardioversion in a significant portion of patients referred to electrophysiologists for internal cardioversion and should be considered prior to an invasive procedure.
Effect of verapamil on prevention of atrial fibrillation in patients implanted with an implantable atrial defibrillator
Authors: Tse Hung‐Fat , Wang Qlong , Yu Cheuk‐Man , Ayers Gregory M. , Pak Chu‐
Published: February 2009

Background: The role of verapamil in the prevention of atrial fibrillation (AF) in patients with recurrent AF is unknown.

Hypothesis: The aim of this study was to evaluate the effect of verapamil on the prevention of AF in patients implanted with an implantable atrial defibrillator (IAD).

Methods: The effects of verapamil (240 mg/day) on the total duration of AF, number of AF recurrences, and number of cardioversions were prospectively evaluated in a randomized, crossover fashion over an 8‐week period in 11 patients (9 men, 2 women; mean age: 60 ± 6 years) implanted with an IAD.

Results: Implantable atrial defibrillators successfully converted 13 of 14 (93%) spontaneous episodes of AF. There was no significant difference in the efficacy of cardioversion (86 vs. 100%, p = 0.8), the total duration of AF (173 ± 198 vs. 270 ± 241 h, p = 0.5), the number of AF episodes (8.5 ± 9.0 vs. 9.3 ± 10.2, p = 0.3), and the number of cardioversions (1.7 ± 2.4 vs. 1.8 ± 2.1, p = 0.7) with or without treatment with verapamil.

Conclusions: The results of the present study suggest that treatment with verapamil has no significant effect on the prevention of AF in patients treated with an IAD.
Spinal cord stimulation for chronic intractable angina pectoris: A unified theory on its mechanism
Authors: Latif Osman A. , Nedeukovic Srdjan S. , Stevenson Lynne Warner
Published: February 2009

The use of spinal cord stimulation (SCS) for chronic intractable anginal pain was first described in 1987. Numerous studies have demonstrated its efficacy in improving exercise tolerance, decreasing frequency of anginal episodes, and prolonging time to electrocardiographic signs of ischemia. This review will examine the potential mechanisms of this antianginal effect and propose a unified hypothesis explaining it. The effect of SCS involves a mutual interaction of decreased pain, decreased sympathetic tone, and a likely redistribution of myocardial blood flow to ischemic regions. Spinal cord stimulation reduces the transmission of nociceptive impulse via the spinothalamic tract due to an enhanced release of gamma aminobutyric acid (GABA) from dorsal horn interneurons. Improvement of myocardial blood flow at the microvascular level has been demonstrated by positron emission tomography (PET). A decreased sympathetic tone has been shown by norepinephrine kinetics, tests of sympathetic reflexes, and the use of ganglionic blockers. We hypothesize that SCS exerts its beneficial effects by decreasing pain and decreasing sympathetic tone, the result of which is decreased myocardial oxygen consumption along with an improved myocardial microcirculatory blood flow.
Obesity is associated with premature occurrence of acute myocardial infarction
Authors: Suwaidi Jassim Al , Scott WRIGHT R. , Grill Joseph P. , Hensrud Donald D. , Murphy Joseph G. , Squires Ray W. , Kopecky Stephen L.
Published: February 2009

Background: The American Heart Association has classified obesity as a major modifiable risk factor for coronary artery disease, but its relationship with age at presentation with acute myocardial infarction (AMI) is poorly documented.

Hypothesis: The study was undertaken to evaluate the impact of obesity on age at presentation, and on in‐hospital morbidity and mortality in patients with AMI.

Methods: Our analysis includes a consecutive series of 906 Olmsted County patients (mean age 67.7 years, 51% male) admitted with AMI to the Mayo Clinic Coronary Care Unit (CCU). The patients were entered into the Mayo CCU Database, a prospective registry of data pertaining to patients admitted to the Mayo Clinic CCU with AMI. Age at AMI occurrence and in‐hospital morbidity and mortality were noted.

Results: Obese patients (body mass index [BMI] >30) with AMI were significantly younger than patients with AMI in the overweight (BMI 25–30) and normal‐weight (BMI <30) groups (62.3 ± 13.1 vs. 66.9 ± 13.2 and 72.9 ± 13.4, respectively, p < 0.001). Obesity and overweight status were associated with male gender, diabetes mellitus, hypercholesterolemia, and smoking history; however, after multivariate adjustment for these risk factors, excess weight and premature AMI remained significantly associated. Compared with normal‐weight patients, overweight patients presenting with AMI were 3.6 years younger (p < 0.001, confidence interval [CI] 1.9–5.4) and obese patients 8.2 years younger (p < 0.001, CI 6.2–10.1). No significant increase in in‐hospital morbidity and mortality was seen.

Conclusion: In this population‐based study, overweight and obese status are independently associated with the premature occurrence of AMI, but not with an increased incidence of in‐hospital complications.
Exceptional prevalence of interatrial block in a general hospital population
Authors: Jairath Umesh C. , Spodick David H.
Published: February 2009

Background: Interatrial block (IAB: P wave ≥ 110 ms) is a strong correlate of left atrial (LA) enlargement and an important predictor of supraventricular tachyarrhythmias, notably atrial fibrillation and flutter. It is surprising that, despite its association with arrhythmias and its effects on the electromechanical properties of the left atrium, there is widespread neglect of this common abnormality.

Hypothesis: The study was undertaken to investigate the prevalence of IAB in a general hospital population.

Methods: We prospectively evaluated the electrocardiograms of 1,000 consecutive adult patients, analyzed for P‐wave duration.

Results: Our results showed a very high prevalence of IAB (41.1% of patients in sinus rhythm and 32.8% of all patients). As expected, it was more common in patients aged > 60 years.

Conclusions: Given this unusually high prevalence of IAB in hospital patients and its ominous portents (LA enlargement, thrombosis and embolism, arrhythmias), physicians should be aware of its frequency and computer software should be programmed to recognize it.
Long‐term follow‐up after deferring angioplasty in asymptomatic patients with moderate noncritical in‐stent restenosis
Authors: Lee Jae‐Hwan , Lee Cheol Whan , Park Seong‐Wook , Hong Myeong‐Ki , Kim Jae‐Joong , Rhee Kyoung Suk , Park Seung‐Jung
Published: February 2009

Background: Many patients with in‐stent restenosis (ISR) are angina‐free, but the optimal treatment for these patients remains uncertain.

Hypothesis: In cases with asymptomatic moderate noncritical ISR, deferral of the intervention may be safe and associated with favorable clinical outcome.

Methods: We evaluated the long‐term clinical outcome of asymptomatic patients (Group 1, n = 98) with moderate non‐critical ISR (< 70% diameter stenosis) after intervention was deferred, and compared it with that of patients (Group 2, n = 655) without restenosis. After repeat angioplasty was deferred, all patients were treated medically and later underwent angioplasty only in the case of clinical recurrence.

Results: Baseline characteristics were similar between the two groups. Clinical follow‐up was available in all patients at 26.3 ± 15.9 months. Twenty patients died during the follow‐up: 1 in Group 1 and 19 in Group 2. Target lesion revascularization was performed in 3 patients in Group 1 and 11 patients in Group 2 during follow‐up (p = NS), and new lesion revascularization in 2 patients in Group 1 and 27 patients in Group 2 (p = NS). Event‐free survival rate (cardiac death, nonfatal myocardial infarction, repeat revascularization) was 86.7 ± 6.1% in Group 1 and 84.8 ± 2.2% in Group 2 at the end of follow‐up (p = NS). Major adverse cardiac events were only associated with the presence of diabetic mellitus (hazards ratio 2.65,95% confidence interval [CI] 1.48–4.73, p < 0.01). The percentage of patients receiving antianginal medication was similar between the two groups at the end of the study (p = NS).

Conclusions: Asymptomatic patients with moderate non‐critical ISR have a good prognosis and similar clinical outcome as those without ISR, suggesting that it may be safe to defer repeat angioplasty in these patients until angina recurrence.
Development and validation of the ITG health‐related quality‐of‐life short‐form measure for use in patients with coronary artery disease
Authors: Buchner Deborah A. , Graboys Thomas B. , Pharm Kiel Johnson, , Mordin Margaret Mcgrath , Goodman Linda , Partsch Deborah S. , Goss Thomas F.
Published: February 2009

Background: Available coronary artery disease (C AD)‐specific health‐related quality‐of‐life (HRQL) measures are not ideally suited for routine clinical practice. We report development of a valid and reliable CAD‐specific short‐form measure.

Hypothesis: The Integrated Therapeutics Group (ITG) CAD‐specific short‐form HRQL measure is reliable and valid for assessing the health status of patients with CAD.

Methods: In all, 409 patients (mean age 62.4 years) completed the 24–item CAD‐specific HRQL questionnaire. Factor analysis was used to identify the scaling of the 24 CAD‐specific items. Analysis of variance was used to reduce the number of items within each scale, and reliability (Cronbach's a), discriminant validity, and ceiling and floor effects of short‐form scales were evaluated. Short‐form scales were compared with the longer scales using relative validity coefficients. The CAD severity was assessed using New York Heart Association criteria, physician assessment, electrocardiogram results, the number of myocardial infarctions, and the number of CAD‐specific medications. Clinical validity of short‐form scales was then assessed based on their ability to discriminate across severity levels of these clinical criteria.

Results: Four scales were identified: Extent of Chest Pain, Functioning and Weil‐Being, Activities Level‐Physical, and Activities Level‐Social. The 24‐item questionnaire was reduced to a 13‐item short form, with reliability exceeding 0.70 for all four scales. Relative validity estimates comparing short‐form to original scales ranged from 0.68 to 2.58. Mean scores varied significantly (p < 0.05) by clinical severity, supporting the discriminant validity of the ITG CAD short‐form scales.

Conclusions: The ITG CAD short form (used alone or with a general HRQL measure) is valid and practical for assessing patients with CAD.
Left atrial size in 164 hypertensive patients: An echocardiographic and ambulatory blood pressure study
Authors: Tedesco Michele A. , Salvo Giovanni Di , Ratti Gennaro , Natale Francesco , Iarussi Diana , Iacono Aldo
Published: February 2009

Background: Left atrial enlargement (LAE) is associated with an increased risk of death and cardiovascular (CV) hospitalization. Whether or not LAE reflects early structural change from hypertension is unclear.

Hypothesis: The aim of this study was to evaluate the relationship between LA size, 24‐h blood pressure measurements, age, body mass index (BMI), and left ventricular mass index (LVMI) in hypertensive patients.

Methods: We studied 164 outpatients (age range 30–76 years, 73 men and 91 women) with mild to moderate hypertension. Physical examination, electrocardiogram, noninvasive blood pressure monitoring (ABPM), Doppler echocardiogram were performed. Left ventricular mass index and LA dimensions were calculated. The sample was divided by age (< 60 and ≥ 60 years).

Results: Left ventricular hypertrophy (LVH) was present in 45% of patients aged < 60 years and in 70% of patients aged ≥60 years (p = 0.002). Left atrial enlargement (>4 cm) was present in 35% of elderly and in 24% of young patients (p = 0.31), and in 36% of patients with and 21 % of patients without LVH (p = 0.0057). There was no significant difference in the younger patients with and without LVH. The incidence of obesity was low (31 %) in the whole sample. The percentage of overweight in the elderly patients with LVH and higher LA size was equally low. Multivariate analysis showed age (p = 0.044) and LVMI (p = 0.002) as the only significant predictors of LA enlargement.

Conclusion: Since LAE is associated with a high risk of death and CV hospitalization, we emphasize the importance of development and use of drugs that inhibit LVH.
Psychological distress across the course of care: A case study from implantable cardioverter defibrillator to cardiac transplantation evaluation
Authors: Eads Angela S. , Sears Samuel F. , Marhefka Stephanie , Aranda Juan , Schofield Richard , Conti Jamie B.
Published: February 2009

The psychological distress of cardiac patients can complicate treatment or the recovery process. This case study presents a 47‐year‐old male recipient of an implantable cardioverter defibrillator who experienced multiple, consecutive shocks and subsequently developed anxiety and depressive difficulties. Psychological treatment to diminish these symptoms was employed. Despite declining cardiac function, the patient made significant progress in managing this negative affect. Subsequently, he was evaluated for cardiac transplant, and this treatment progress became critical evidence of his psychosocial suitability for transplant.
An iatrogenic coronary arteriovenous fistula causing a steal phenomenon: An intracoronary doppler study
Authors: Wexberg Paul , Gottsauner‐Wolf Michael , Kiss Katharina , Steurer Günter , Glogar Dietmar
Published: February 2009

We present the case of a 67‐year‐old man in whom a guidewire broke at rotablation of the right coronary artery, creating an iatrogenic aneurysmal arteriovenous fistula to the coronary sinus. Successful Doppler wire‐guided fistula occlusion by percutaneous coil embolization lead to normalization of coronary blood flow and relief of the patient's symptoms. Myocardial ischemia in this patient may have been due to a steal phenomenon caused by coronary artery fistulae, as suggested by blood flow velocity data obtained before and after fistula occlusion.
Assessment of subclinical atherosclerosis and cardiovascular risk
Authors: Michael BENITEZ R. , Vogel Robert A.
Published: February 2009

Conventional cardiac risk factors do not fully explain the incidence of coronary artery disease and coronary events. Risk stratification and therapy based solely on these conventional risk factors may exclude a population who would otherwise benefit from lifestyle and risk factor modification. Recent efforts to improve our ability to recognize individuals and populations at increased risk of coronary events have focused on the noninvasive imaging of atherosclerosis, both in coronary and extracoronary arterial beds, or the identification of “non‐traditional” serum markers. We review the complimentary role of these newer methods of risk stratification in the context of conventional risk factor evaluation.
A Critique of the new ST‐segment criteria for the diagnosis of acute myocardial infarction in patients with left bundle‐branch block
Authors: Madias John E. , Sinha Anjan , Ashtiani Ramin , Agarwal Himanshu , Win Moethu , Narayan Virenjan K.
Published: February 2009

Background: Recently, electrocardiogram (ECG) criteria have been proposed for the diagnosis of acute myocardial infarction (AMI) in the presence of left bundle‐branch block (LBBB). However, clinical experience indicates that such ECG changes indicative of AMI are occasionally noted in clinically stable patients with LBBB, raising concerns about the specificity of the proposed criteria.

Hypothesis: The aim of this study was to evaluate the frequency of ST‐segment abnormalities suggestive of AMI in ambulatory patients with cardiovascular disease and chronic LBBB, who did not have an AMI. In addition, the ECG determinants of such ST‐segment abnormalities were sought.

Methods: The files of all (4,193) patients followed in the outpatient cardiology clinic were reviewed to identify patients with LBBB. Electrocardiograms of these patients were evaluated as to the duration of the QRS complex, frontal QRS axis, amplitude of QRS in leads V1‐V3, and the presence and magnitude of ST‐segment depression (‐ST) in leads V1‐V3, and ST‐segment elevation (+ST) in leads with predominantly positive or negative QRS complexes. Correlations of these ECG variables were carried out.

Results: In 124 patients with LBBB only 1 patient with — ST of 1 mm in leads V1‐V3, and 1 patient with +ST of 1 mm in a predominantly positive ECG lead were found; the latter patient also had +ST of 6 mm in V3. Nine patients were detected with > 5 mm +ST in at least one ECG lead with predominantly negative QRS complex. Regression analysis of amplitude of +STS on corresponding QRS amplitudes in leads V1‐V3 yielded Rs of 0.69, 0.68, and 0.69, all with a p value of 0.00005. A similar analysis of the amplitudes of+STs > 5 mm with the corresponding QRSs yielded an R=0.76 and a p value of 0.0018.

Conclusions: Thus, recently proposed ST‐segment criteria for the diagnosis of AMI in patients with LBBB are appropriate. However, stable > 5 mm +STs are occasionally found in leads with predominantly negative QRS complexes, particularly of large amplitude (mean value 46.0, range [28.0–71.0] mm) in the absence of AMI. In such patients presenting with symptoms suggestive of AMI, further non‐ECG confirmation of probable underlying AMI should be sought.
Power motion imaging can improve image quality in stress conditions with tachycardia
Authors: Nishino Masami , Youn Ho‐Joong , Gheorghevici Dorina , Zellner Christian , Chou Tony M. , Sudhir Krishnankutty , Redberg Rita F.
Published: February 2009

Backgrvund: Stress echocardiographic studies are useful, but the evaluation of wall motion is sometimes suboptimal. The recently developed technique of power motion imaging can enhance mobile tissue definition.

Hypothesis: The study was undertaken to determine whether power motion imaging improves endocardial definition during tachycardia compared with conventional two‐dimensional (2‐D) imaging.

Methods: Twenty pigs were studied during pacing rates of 100, 120, and 150 beats/min. We compared power motion imaging with standard 2‐D imaging using systolic thickening visualization (STV) scores (3 = excellent definition of systolic thickening ˜ 0 = total lack of visualization of systolic thickening) at each heart rate. We calculated the sum of the scores of 22 left ventricular segments as the overall STV score, and also calculated the sum of the scores in 10 parasternal segments and 12 apical segments separately.

Results: The overall STV scores in both imaging methods were similar at 100 beats/min, but scores for power motion imaging were significantly higher than those of usual 2‐D imaging at 120 and 150 beats/min. Using power motion imaging, the overall STV scores were similar as heart rate was increased; however, while using standard 2‐D imaging, STV scores were significantly decreased as heart rate was increased. Findings were analyzed separately by parasternal and apical images. Especially in the parasternal images, the scores were significantly increased as heart rate was increased using power motion imaging.

Conclusions: We conclude that power motion imaging improves the detection of endocardial border in stress condition with tachycardia, and thus this modality is useful for stress echocardiography.