bluuebunny/crossref_metadata_2025 huggingface dataset:
Resolution of late potentials with improvement in left ventricular systolic function in patients with first acute myocardial infarction
Authors: Masui Akira , Tamura Koji , Tarumi Noritaka , Kamihata Hiroshi , Karakawa Masahiro , Takehana Kazuya , Sugiura Tetsuro , Iwasaka Toshui , Inada Mitsuo
Published: February 2009

Background: Ventricular late potentials predict subsequent arrhythmic events and sudden death in postinfarction patients. Late potentials are recorded in the infarcted area, but it should be pointed out that they probably represent micropotentials in the area of delayed conduction found among isolated areas of scar tissue and normal myocardium.

Hypothesis: The study was undertaken to investigate the relationship between chronic reversible myocardial ischemia, such as stunned or hibernating myocardium, and late potentials in 38 patients with a first myocardial infarction.

Methods: The patients were divided into two groups, one with (Group 1) and one without (Group 2) resolution of late potentials recorded by signal‐averaged electrocardiogram at 6 months after onset of myocardial infarction. We investigated the clinical, echocardiographic, and signal‐averaged electrocardiographic characteristics of Groups 1 and 2.

Results: In the chronic phase of myocardial infarction, a higher incidence of patency of the infarct‐related artery and an improvement of wall motion score were found in Group 1, and left ventricular ejection fraction was better preserved in Group 1 than in Group 2.

Conclusions: These results suggest that the resolution of late potentials was influenced by the improvement of left ventricular systolic function and patency of the infarct‐related artery. We concluded that chronic reversible myocardial ischemia, such as stunned or hibernating myocardium, might be the substrate that generated late potentials.
Contraction‐excitation feedback in human atrial fibrillation
Authors: Antoniou Anna , Milonas Dimitris , Kanakakis John , Rokas Stelios , Sideris Dmitris A.
Published: February 2009

Background: Contraction‐excitation feedback, that is, electrophysiologic changes that are caused or preceded by mechanical changes of the myocardium, has been extensively studied in the ventricles. The role of contraction‐excitation feedback in the atria, and more particularly in the genesis and maintenance of atrial fibrillation, has been less adequately investigated.

Hypothesis: The aim of the present study was to determine whether increased right atrial pressure (RAP) facilitates the induction of atrial fibrillation (AF) in patients with a history of lone AF.

Methods: Sixteen patients with a history of paroxysmal AF but without structural heart disease were included in the study. All patients underwent electrophysiologic study at both a lower (3.1 ± 2.0 mmHg) and (in 13 cases) a higher (6.4 ± 2.5 mmHg) RAP. “Higher” was considered the pressure following rapid (in about 30 min) intravenous administration of normal saline or before the administration of a diuretic.

Results: Rapid atrial pacing induced AF in 19 of 29 attempts. At a lower pressure, rapid pacing induced brief (3 s to 3 min) AF in 3 of 16 patients, long‐lasting (>3 min) AF in 3 of 16 patients, and no AF in 10 of 16 patients. At a higher pressure, brief AF was induced in 3 of 10 patients in whom no AF could be induced at a lower pressure, and long‐lasting AF in 10 patients in whom either brief AF (3 cases) or no AF (7 cases) was induced at a lower pressure. In 11 patients, in whom Wenckebach periodicity was determined at both higher and lower pressure, the critical cycle length at which atrioventricular block appeared was significantly (p<0.001, paired t‐est) longer(349.1 ± 44.4 ms, i.e.,+15.5 ± 11.3 ms)at higher than at lower atrial pressure (333.6 ±41.0 ms). In nine patients, in whom Wenckebach periodicity was determined and two rhythms occurred at different pressures, the critical cycle length was 332.2 ± 45.8 ms when associated with sinus rhythm, and significantly (p<0.01) longer (344.4 ± 48.0 ms, i.e., +12.2 ± 8.3 ms) when associated with induction of AF.

Conclusion: In patients with lone atrial fibrillation, modest increases in atrial pressure may facilitate the induction of atrial fibrillation.
Abnormalities of the S‐T segment—Part I
Authors: Willis Hurst J.
Published: February 2009

The usual normal S‐T segment of the surface electrocardiogram (ECG) contributes little to the diagnostic procedure. When the S‐T segment is too long or too short, or when it is displaced upward or downward, it is commonly abnormal. Under such circumstances, an S‐T segment abnormality usually contributes considerable diagnostic information. When the Grant method of ECG interpretation is used, it is possible to perceive abnormalities of the S‐T segment that may otherwise be ignored or misinterpreted. This paper describes the method of identification and the significance of primary and secondary S‐T segment abnormalities. When a mean vector constructed for the S‐T segment displacement seen in 12 ECG leads is relatively parallel with a mean vector representing the T wave, it is, with a few exceptions, part of the repolarization process and is therefore part of the T wave. This may be called a secondary S‐T segment abnormality. When a mean vector constructed for the S‐T segment displacement seen in 12 ECG leads is not relatively parallel with a mean vector representing the T wave, it is, with a few exceptions, not part of the repolarization process and is therefore not part of the T wave. This may be called a primary S‐T segment abnormality.
Isolated and preclinical impairment of left ventricular filling in insulin‐dependent and non‐insulin‐dependent diabetic patients
Authors: Astorri Ettore , Fiorina Paolo , Astorri Annalisa , Contini Giovanni Andrea , Albertini Daniela , Magnati Giuseppe , Lanfredini Mario
Published: February 2009

Background: Diabetes mellitus can induce a pattern of myocardial pathology known as specific diabetic cardiomyopathy, even if this is not clearly specified.

Hypothesis: The aim of our study was to evaluate the presence of preclinical myocardial damage in insulin‐ and non‐insulin‐dependent diabetic patients and controls by assessment with Doppler echocardiography.

Methods: Twenty insulin‐dependent diabetic (IDDM) patients, 10 non‐insulin‐dependent diabetic (NIDDM) patients, and 12 healthy individuals (C) as controls, matched for age, gender, and without overt cardiovascular disease, were assessed in this study.

Results: Systolic function parameters presented normal values in the three groups, with the exception of a slight reduction in ventricular volume indices in the NIDDM group. Diastolic function was clearly impaired in both groups of patients versus that in healthy controls. In particular, ventricular filling was impaired in the NIDDM compared with the IDDM patients, especially the peak early filling rate E (p<0.001). Moreover, in the IDDM group, the duration of diabetes (p<0.01) and glycosilated hemoglobin value (HbA1C, p<0.02) were higher than in the NIDDM group. Multiple regression analysis showed a significant inverse correlation between HbA1C and peak late filling rate A (R2 = 0.28) in both groups of patients and a direct correlation between velocity time integral E and age, duration of diabetes, and HbA1C (R2 = 0.46). The two groups presented a small, homogeneous number of cases with initial microangiopathy and borderline autonomic neuropathy, associated with microalbuminuria. Doppler echocardiography showed an early impairment of left ventricular filling, as well as an early preclinical alteration of myocardial function in diabetic patients, especially in the NIDDM group.

Conclusion: These early signs of cardiomyopathy could constitute a predisposing condition toward the high cardiac morbidity and mortality rate in diabetic patients.
Routine arterial oxygen saturation monitoring is not necessary during transesophageal echocardiography
Authors: Kassimatis Antonis , Tsoukas Athanasios , Ikonomidis Ignatios , Joshi Jayshree , Nihoyannopoulos Petros
Published: February 2009

Background: Transesophageal echocardiography (TEE) is now an established adjunct to routine echocardiography, its diagnostic impact making it an invaluable first‐line diagnostic procedure in many cardiac conditions. However, there is no unanimity in the way the transesophageal procedure is carried out, especially with regard to the need for antibiotic prophylaxis, sedation, and the monitoring of oxygen saturation.

Hypothesis: This study was prospectively undertaken (1) to determine the presence and magnitude of oxygen desaturation and (2) the changes in heart rate and blood pressure following sedation for routine TEE in an unselected and consecutive group of patients to identify those at high risk.

Methods: Arterial oxygen saturation, heart rate, and systolic, diastolic, and mean blood pressure were monitored in 106 consecutive patients undergoing routine transesophageal echocardiography. Ninety‐four (89%) patients received intravenous sedation with midazolam.

Results: Three min after midazolam administration there was a drop in oxygen saturation from 97 ± 2.5 to 95 ± 2.9 (p<0.001), in systolic blood pressure from 139 ± 19.5 to 124.8 ± 22.2 mmHg (p<0.001), in diastolic blood pressure from 86.6 ± 19.9 to 77.5 ± 17.7 mmHg (p<0.001), and in mean blood pressure from 108.3 ± 18 to 95.6 ± 28.8 mmHg (p<0.001). After introduction of the transesophageal probe and during the examination, there was a further drop in oxygen saturation with a maximum drop at the 15th min of the examination (93.7 ± 3.7 vs. 97 ± 2.5, p<0.001). The maximum blood pressure drop occurred at the 12th min into recovery: systolic blood pressure dropped from 139 ± 19.5 to 118 ± 20.8 mmHg (p<0.001), diastolic blood pressure from 86.6 ± 16.9 to 75.8 ± 17.9 mmHg (p<0.005), and mean blood pressure from 108.3 ± 18 to 92.5 ± 19.4 mmHg (p<0.01). Patients with congestive heart failure had a greater drop in oxygen saturation compared with patients who were not in heart failure (p<0.01). Twelve patients did not receive any sedation; however, they all showed a drop in oxygen saturation from 97.8 ± 2.3 to 94.6 ± 3.4 (p<0.001), with a maximum drop at the 15th min during the transesophageal examination.

Conclusion: In patients with no chronic obstructive airway disease who are not in congestive heart failure, routine oxygen saturation monitoring is not deemed necessary during transesophageal examination. The cause of hypoxemia during the procedure is not only related to sedation but also to esophageal intubation.
Detection of significant residual stenosis of the infarct‐related artery after thrombolysis by high‐dose dipyridamole echocardiography test: Is it detected often enough?
Authors: Nešković Aleksandar N. , Bojić Milovan , Popović Aleksandar D.
Published: February 2009

Background and hypothesis: It has been reported that high‐dose dipyridamole echocardiography test (DET) can be successfully used for the detection of critical residual stenosis of the infarct‐related artery (IRA). However, we have recently noticed low sensitivity of DET for the detection of residual IRA stenosis in patients with single‐vessel disease. This study sought to determine the value of DET for the detection of significant residual stenosis of the IRA after thrombolysis.

Methods: Dipyridamole echocardiography test was performed in 55 consecutive patients after a first acute myocardial infarction before hospital discharge. All patients underwent coronary angiography 23 ± 6 days after infarction.

Results: Nine of 19 patients with positive DET revealed new adjacent asynergy and all of the patients had patent and significantly stenotic IRA. Sensitivity and specificity of DET in identifying significant residual stenosis of the IRA were 24 and 100%, respectively. Among 49 patients with significantly stenotic or occluded IRA, 40 patients without adjacent asynergy during DET had higher baseline wall motion score index (WMSI) compared with 9 patients who revealed adjacent asynergy during DET (1.45 ± 0.30 vs. 1.24 ± 0.18; p<0.05). When all patients with positive DET (adjacent or remote asynergy) were compared with those with negative DET, no difference in baseline WMSI was found (1.37 ± 0.24 vs. 1.44 ±0.24;p>0.05).

Conclusions: Our data indicate that sensitivity of DET in detecting significant residual stenosis of the IRA after thrombolysis is low. It seems that the extent of myocardial infarction affects the ability of DET to detect adjacent, but not remote asynergy.
Role of transesophageal echocardiography in the clinical management of a patient with a giant coronary artery aneurysm
Authors: Wolford David C. , Jost Charles M.T. , Madu Ernest C. , Ramanathan K. B. , Walker William
Published: February 2009

Transthoracic echocardiography (TTE) has substantial limitations for the study of abnormalities of the coronary tree. Transesophageal echocardiography (TEE) allows a more complete examination of the coronary arteries, particularly the proximal segments. This report describes the use of TEE after cardiac catheterization in the clinical management of a patient with unstable angina. While angiography first showed the giant aneurysm of the left circumflex coronary artery, TEE, by revealing an active thrombus of the lumen, prompted an immediate surgical resolution.
Eustachian valve endocarditis: Detection with multiplane transesophageal echocardiography
Authors: Palakodeti Vachaspathi , Keen William D. , Rickman Leland S. , Blanchard Daniel G.
Published: February 2009

Right‐sided involvement is fairly common in infective endocarditis, but involvement of the eustachian valve is distinctly rare. We present the case of a 36‐year‐old intravenous drug user with staphylococcal bacteremia and septic pulmonary emboli. Transthoracic echocardiography was normal, but transesophageal echocardiography revealed a large eustachian valve vegetation. This case illustrates the utility of multiplane transesophageal echocardiography in the evaluation of eustachian valve pathology.
Ischemic preconditioning: Clinical relevance and investigative studies
Authors: Schlaifer Jay D. , Kerensky Richard A.
Published: February 2009

Experimental animal studies have shown that repetitive brief coronary occlusions render the heart resistant to myocardial infarction from subsequent, more prolonged, coronary occlusions. This phenomenon in animal models has been called ischemic preconditioning. In a number pf clinical scenarios, the second in a series of ischemic episodes appears to be less severe than the first, suggesting that ischemic preconditioning also occurs in humans. If the mediator of preconditioning could be identified, it is conceivable that this agent could be administered to patients with coronary artery disease as a myocardial protectant. However, the definite clinical relevance of this interesting experimental finding remains unknown. Unlike the case in animal models subjected to an abrupt occlusion, preconditioning is difficult to study in the clinical setting. This article reviews the findings and limitations of the relevant clinical studies looking for ischemic preconditioning in humans.
Comparison of the histopathology of culprit lesions in chronic stable angina, unstable angina, and myocardial infarction
Authors: Haft Jacob I. , Mariano Domenic L. , Goldstein Jonathan , Waller Bruce
Published: February 2009

Background: The etiology of unstable angina (UA) and myocardial infarction (MI) both involve rupture of an atherosclerotic plaque in a coronary artery. It has been suggested that the two syndromes differ because MI results if a red occlusive permanent thrombus occurs and UA occurs only if a nonocclusive platelet (white) thrombus occurs.

Hypothesis: The purpose of this study was to determine the differences between coronary lesion pathology in MI and UA and compare them with lesions of chronic stable angina (CSA).

Methods: We reviewed the pathologic specimens of culprit lesions obtained by directional coronary atherectomy in 27 patients with MI, 29 patients with UA, and 16 patients with CSA.

Results: The incidence of ruptured plaque was high and identical in patients with MI (77.8%), and UA (75.8%), and significantly lower in patients with CSA (25.0%) (p « 0.001). Similarly, the incidence of red thrombus was the same in MI (92.6%) and UA (82.7%), and significantly less in CSA (p “0.001).

Conclusions: The underlying pathophysiology of both UA and MI appears to be the same, with red thrombus playing an important role in both syndromes. The only difference is in the degree of occlusiveness of the red thrombus on the ruptured plaque and whether the occlusion is transient (UA) or persistent (MI). The balance between thrombosis and endogenous clot lysis determines which syndrome occurs. Lytic therapy is not effective in UA, probably because the clot is not occlusive or because endogenous lysis has already achieved the degree of coronary opening that eventuates from tissue plasminogen activator or streptokinase administration. Prompt catheterization and revascularization may be as indicated in patients with MI if there remains viable myocardium as in patients with UA.
Vasospastic angina induced by nonsteroidal anti‐inflammatory drugs
Authors: Mori Etsuo , Ikeda Hisao , Ueno Takafumi , Kai Hisashi , Haramaki Nobuya , Hashing Tatsuya , Ichiki Kazuya , Katoh Atsushi , Eguchi Hiroyuki , Ueyama Takahisa , Imaizumi Tsutomu
Published: February 2009

We report two cases of vasospastic angina associated with anaphylactic reaction caused by nonsteroidal antiinflammatory drugs (NSAIDs). Both patients exhibited anaphylactic manifestations, such as general rash and urticaria, along with angina pectoris with electrocardiographic ST‐segment elevations after suppository administration of diclofenac sodium or indomethacin, the most commonly used NSAIDs. Although these patients had normal coronary arteriograms, intracoronary administration of ergonovine or acetylcholine provoked diffuse coronary artery spasms accompanied by chest pain and ischemic ST‐segment changes. It is therefore suggested that an allergic mechanism may be involved as a causative factor of the coronary artery spasm induced by NSAIDs.
Propafenone‐induced drug fever in the absence of agranulocytosis
Authors: O' Rourke Daniel J. , Palac Robert T. , Holzberger Peter T. , Gerling Barbara R. , Greenberg Mark L.
Published: February 2009

Propafenone is an antiarrhythmic drug used in the treatment of life‐threatening ventricular tachyarrhythmias. Adverse reactions necessitating discontinuation of the medication are common. Propafenone‐induced drug fever has not been definitively proven. We present a case report of drug fever secondary to propafenone, confirmed with rechallenge.
Safety and efficacy of angiography‐guided stent placement in small native coronary arteries of < 3.0 mm in diameter
Authors: Lau Kean‐Wah , He Qing , Ding Zee‐Pin , Johan Abdullah
Published: February 2009

Background and hypothesis: Increased operator experience, greater insight in stent deployment techniques, and improved poststent medication regimen have significantly reduced the risk of thrombotic stent closure following stent placement in large coronary arteries ( 3.0 mm in diameter). Whether equally favorable results are afforded by stent placement in small vessels (> 3.0 mm), however, remains unclear. Accordingly, the aim of this study was the specific examination of the risk of stent placement in small native coronary vessels, using stent deployment technique consisting of supplementary dilatations with larger balloons or high‐pressure inflations, and aggressive aspirin‐ticlopidine and short‐term oral anticoagulation poststent therapy.

Methods: Forty‐seven balloon‐expandable stents (20 Gianturco‐Roubin, 21 NIR, 6 Palmaz‐Schatz) were successfully implanted without intravascular guidance in 45 native coronary arteries (mean reference diameter of 2.5 mm) in 44 consecutive patients (31 men, 13 women), the majority of whom (87%) were stented for the treatment of failed or suboptimal balloon angioplasty outcome.

Results: Successful stent placement reduced the lesion diameter stenosis from 91 ± 9% to 3 ± 7% (p = 0.0001). There were no early stent thrombosis or major cardiovascular events prior to hospital discharge. During a 12‐month follow‐up period, most patients remained symptomatically improved and no myocardial infarction, stroke, or death was observed. Five‐month angiographic reassessment revealed an in‐stent restenosis rate of 41%, which was higher in vessels 2.5 mm in size (47 vs. 33% for vessels > 2.5 mm, p = 0.2747).

Conclusions: In selected patients with small native coronary vessels < 3.0 mm in diameter, angiography‐guided optimal stent placement is associated with a low risk of stent thrombosis and bleeding complications. However, the in‐stent restenosis rate is high with the stents used in this study.
Atrial natriuretic peptide levels after different types of inferior wall myocardial infarction
Authors: Assali Abid , Gilad Irit , Herz Itzhak , Solodky Alejandro , Sulkes Jaqueline , Strasberg Boris , Sclarovsky Samuel
Published: February 2009

Background: Atrial natriuretic peptide (ANP) is released from cardiac atrium secondary to increased atrial pressure. The plasma levels of ANP have been found to be related to short‐and long‐term prognosis after acute myocardial infarction (MI). The purpose of the present study was to investigate the plasma levels of ANP in three groups of patients with inferior wall acute MI classified according to ST‐segment depression in the precordial leads.

Methods: The study population consisted of 18 patients with inferior wall acute MI classified into three types: Type 1 = no precordial ST‐segment depression (7 patients), Type 2 = sum of ST‐segment depression in leads V1 to V3 equal to or more than the sum of ST‐segment depression in leads V4 to V6 (4 patients), and Type 3 = maximal precordial ST‐segment depression in leads V4 to V6 (7 patients).

Results: Radioimmunoassay showed that plasma ANP levels were significantly higher in patients with Type 3 acute inferior wall myocardial infarction compared with those with Types 1 and 2 (313.1 ± 233, 73.0 ± 27.5), and 84 ± 32.7 pg/ml, respectively, p = 0.018).

Conclusions: Plasma ANP levels are higher in patients with Type 3 acute inferior wall MI compared with patients with Types 1 and 2. These findings, together with earlier ones, may contribute to our understanding of the pathophysiology of the presence of ST‐segment depression in the precordial leads in inferior wall acute MI.
Chronic infection in the etiology of atherosclerosis‐the case for chlamydia pneumoniae
Authors: Gupta Sandeep , Camm A. John
Published: February 2009

Established cardiovascular risk factors do not fully explain the variations in the prevalence and severity of coronary heart disease. Recent evidence suggests that common chronic infections may contribute, either by direct or indirect mechanisms, to the etiology and/or progression of coronary atherosclerosis. Of the candidate infectious agents implicated, Chlamydia pneumoniae has emerged as the most likely pathogen to have a causal role. Evidence for this is based on seroepidemiologic, pathologic, and laboratory‐based evidence, in addition to recent small‐scale antibiotic intervention studies. Concerted efforts are now focused on the design of large prospective trials with antibiotics active against C. pneumoniae in the secondary prevention of coronary heart disease.
Lack of association between the insertion/deletion polymorphism of the angiotensin‐converting enzyme gene and vasospastic angina
Authors: Kuroki Shigehiro , Ikeda Uichi , Maeda Yoshikazu , Sekiguchi Hiromichi , Shimada Kazuyuki
Published: February 2009

Background and hypothesis: It has been suggested that the insertion/deletion (I/D) polymorphism of the angiotensin‐converting enzyme (ACE) gene is an independent risk factor for coronary atherosclerosis and myocardial infarction, but its relation to vasospastic angina has not been fully proven. In the present study, we investigated the possible relationship between the ACE I/D genotype and vasospastic angina.

Methods: We explored the distribution of the ACE genotype in 20 patients with vasospastic angina without fixed coronary artery stenosis, 55 angina patients with fixed coronary artery stenosis, and 30 control subjects without coronary artery disease.

Results: The frequency of the DD genotype in patients with vasospastic angina (DD: 30.0%, ID: 20.0%, II: 50.0%) did not differ from that in the control subjects (DD: 23.3%, ID: 26.7%, II: 50.0%), while the frequency in patients with coronary artery stenosis (DD: 43.7%, ID: 21.8%, II: 34.5%) was significantly higher than that in the control subjects. The frequency of the D allele also did not differ between patients with vasospastic angina (0.40) and control subjects (0.37), while the frequency was significantly higher in patients with coronary artery stenosis (0.55).

Conclusions: These findings suggest that the ACE DD genotype is a potent genetic risk factor for organic coronary artery disease, while it confers no appreciable increase in risk of vasospastic angina. These results also suggest the diversity of the pathogenesis of vascular lesions in these two types of coronary artery disease.
Termination and suppression of idiopathic left ventricular tachycardia by diltiazem
Authors: Lin Lang , Conti Jamie Beth , Curtis Anne B.
Published: February 2009

Idiopathic left ventricular tachycardia is known to be responsive to verapamil in many cases. However, the role of other calcium‐channel blockers, such as diltiazem, in treating this specific type of ventricular tachycardia is unknown. We report a case of idiopathic left ventricular tachycardia in a patient with a structurally normal heart, which was terminated and suppressed in the electrophysiology laboratory by a single dose of diltiazem intravenously, and was subsequently suppressed long‐term with sustained‐release diltiazem. Our finding suggests that idiopathic left ventricular tachycardia may be managed effectively with diltiazem in both the acute and chronic settings.
Venous thrombosis causing arterial embolization to the same limb through a patent foramen ovale
Authors: Herity N. A. , Dalzell G. W. N.
Published: February 2009

We describe a patient who presented with acute ischemia affecting the left lower limb. Because a transthoracic echocardiogram was abnormal, a transesophageal study was arranged. This demonstrated an atrial septal aneurysm and right‐to‐left shunting of contrast, raising the possibility of paradoxical embolism. The diagnosis was confirmed by contrast venography, which showed extensive thrombosis in the deep veins of the left thigh, and a ventilation‐perfusion scan which was consistent with multiple pulmonary emboli. Among the lessons from this case was the finding that in patients with arterial embolism the likely origin of the embolus should be considered and, in the absence of common risk factors (atrial fibrillation, rheumatic heart disease, left ventricular dilatation, widespread atheroma), occult venous thrombosis and a right‐to‐left shunt should be sought. In this select group of patients, transesophageal echocardiography is significantly more sensitive than transthoracic study and should be the investigation of choice. Second, in the patient described in this report the clinical signs of deep venous thrombosis (DVT) were masked by the more prominent features of acute arterial ischemia. Without the incidental echocardiographic abnormality, it is likely that the important diagnoses of DVT, pulmonary embolism, and paradoxical embolism would not have been made.
Postinfarction Left Ventricular Pseudoaneurysm
Authors: Csapo Kalman , Voith Laszlo , Szuk Tibor , Edes Istvan , Kereiakes Dean J.
Published: February 2009

Left ventricular wall rupture after myocardial infarction is a mechanical complication that may result in a pseudoaneurysm. Between January 1994 and October 1996, false or pseudoaneurysms were detected in 6 (0.0026%) of 2,600 consecutive patients (4 women, 2 men; mean age 59.4 years) undergoing cardiac catheterization at University Medical School, Debrecen, Hungary. All patients had a history of cardiovascular disease, with diagnosis of pseudoaneurysm confirmed by echocardiography. The average time from the occurrence of acute infarction to diagnosis was 37.0 days (range 3–80 days). All patients were in New York Heart Association functional class IV congestive heart failure; in four patients cardiogenic shock was present. Five patients underwent coronary angiography, which demonstrated multivessel disease and occlusion of the infarct–related artery (TIMI 0) without adequate collateral circulation (grade 0–1). Five patients had surgical repair of the false aneurysm, and, in three patients, concomitant coronary bypass grafting was performed. The 2‐year mortality rate for all patients was 50%. Early diagnosis of false aneurysm is facilitated by echocardiography, and coronary angiography is required before surgery. Early surgical correction with coronary revascularization is advised.
Detection of left ventricular systolic and diastolic abnormalities in patients with coronary artery disease by color kinesis
Authors: Vitarelli Antonio , Sciomer Susanna , Schina Mauro , Luzzi Marco Ferro , Dagianti Armando
Published: February 2009

Background: Color kinesis (CK) is a recently developed echocardiographic technique based on acoustic quantification that automatically tracks and displays endocardial motion in real time and has been used in initial studies to improve the evaluation of global and regional wall motion.

Hypothesis: For further validation of the use of CK for analysis of segmental ventricular dysfunction, we assessed its sensitivity and specificity for detection of regional systolic and diastolic wall motion abnormalities in patients with coronary artery disease (CAD).

Methods: Two‐dimensional (2‐D) echocardiography and CK were used to study 15 normal subjects and 63 patients with technically good quality echocardiographic tracings, who underwent coronary arteriography within 1 month of echocardiography. Significant (>70% luminal diameter stenosis) CAD was present in 50 patients (79%).

Results: Color kinesis tracked endocardial motion accurately in 93% of left ventricular segments. Wall motion score, systolic segmental endocardial motion (SEM), and the time of systolic SEM (tSEM) and diastolic (tDEM) segmental endocardial motion were calculated. Intra‐ and interobserver variability were within narrow limits. SEM and tSEM were significantly lower and tDEM was significantly higher in the patient population than in the control group (p< 0.001). Comparison between CK and 2‐D echocardiography showed a correlation coefficient of 0.81 between the two techniques. The score was identically graded in 74% of segments, with concordance of 82% in diagnosing segments as abnormal. Interobserver concordance was 86% for CK (r=0.85) and 81% for 2‐D echocardiography (r=0.80). The sensitivity and specificity of systolic and diastolic CK parameters for the detection of CAD were 88 and 92% and 77 and 85%, respectively. The positive predictive values were 93 and 96%, respectively, the negative predictive values were 63 and 73%, respectively, and the overall accuracy was 86 and 91%, respectively.

Conclusions: Our data suggest that CK is a feasible and sensitive technique for identifying regional systolic as well as diastolic wall motion abnormalities in patients with CAD.
The role of cardiac troponin t and other new biochemical markers in evaluation and risk stratification of patients with acute chest pain syndromes
Authors: Solymoss B. Charles , Bourassa Martial G. , Wesolowska Ewa , Dryda Ihor , Th$Earoux Pierre , Mondor Louise , Perrault Danielle , Gilfix Brian Mark
Published: February 2009

Background and hypothesis: Increased serum creatinine kinase (CK) and CK‐MB enzyme levels have been used for years to detect myocardial infarction (MI). However, serum myoglobin and CK‐MB mass or protein levels may indicate MI earlier; cardiac troponin T is the most specific marker of myocardial injury and it can detect even minor myocardial necrosis. The diagnostic and prognostic utility of the traditional and new markers of cardiac injury in the emergency evaluation of patients with acute chest pain syndromes were therefore compared.

Methods: One hundred and fifteen consecutive patients with an acute coronary syndrome, and 64 controls recruited during the same period, were examined. The time elapsed from onset of symptoms to blood collection was recorded. Cardiac markers were measured in specimens collected upon arrival (0 h), and 2 and 5–9 h, and later in cases of longer observation. The major cardiac events occurring up to 40 months after the index examination were recorded.

Results: cTnT levels provided unique information: they were the most specific indicators of myocardial damage and identified unstable angina patients at high risk of future major events. Up to 6 h after the onset of chest pain, the new markers were elevated more frequently than the traditional ones and permitted earlier MI recognition. The worst prognosis (nonfatal myocardial infarction or death) was noted in subjects with chest pain at rest within 48 h before the index examination and elevated cTnT levels.

Conclusions: The new markers, particularly cardiac troponin T, offer considerable advantages and they should be more widely used in the diagnosis and risk stratification of acute coronary syndromes.
Left ventricular mass assessed by three‐dimensional echocardiography using rotational acquisition
Authors: Rodevand Olaf , Bjornerheim Reidar , Kolbjornsen Odd , Ihlen Halfdan , Kjekshus John
Published: February 2009

Background: The reproducibility of left ventricular (LV) mass measurement by two‐dimensional (2‐D) echocardiography is inadequate for individual assessments.

Hypothesis: This study was undertaken to evaluate the potential of LV mass determination with a new three‐dimensional (3‐D) echocardiographic method compared with 2‐D measurement.

Methods: Porcine agarose‐filled left ventricles (n = 15, true mass 61–511 g) of different shapes were measured by a multiplane 3‐D method based on 90 images acquired by probe rotation axis (1) perpendicular and (2) parallel to the ventricular long axis [“parasternal” (the left sternal border was not present as a reference point in this study) and apical views]. Mass was also obtained using (3) the biplane truncated ellipsoid and (4) area‐length methods, as well as (5) the modified cube formula. Five hearts were not analyzed with the apical 3‐D technique because of insufficient image quality.

Results: Systematic deviation from true mass was small with all methods (< 5.3%). Accuracy, expressed as 1 standard deviation of individual estimates around this systematic bias, was 7.7, 13.6, 8.2, 11.9, and 11.9% of true mass for the methods 1–5, respectively. Interobserver reproducibility, expressed as the coefficient of variation, was 4.7, 8.8, 8.1, 8.9, and 9.4% for the same methods.

Conclusion: Limits for individual accuracy and reproducibility of LV mass estimates are nearly doubled using apical compared with “parasternal” 3‐D echocardiography in vitro. A main advantage of “parasternal” 3‐D compared with 2‐D LV mass estimates is better reproducibility, but at the expense of greater time consumption. Apical 3‐D technique is not superior to simpler 2‐D methods based on “parasternal” short axis imaging.
Results of electrophysiologic studies in patients with acute chagasic myocarditis
Authors: Fuenmayor Abde I. J. , Fuenmayor Abdel M. , Carrasco Hugo , Parada Henry , Fuenmayor Carmen , Jugo Diego
Published: February 2009

Background: As the acute stage of Chagas' myocarditis is rarely detected, little is known about the electrophysiologic characteristics of that stage.

Methods: We studied eight patients who had positive xenodiagnosis, positive mice culture, and positive complement fixation test for Chagas' disease.

Results: Trypanosoma cruzi were identified in all of the patients' stained blood samples. Right ventricular endomyocardial biopsies were obtained, evidencing a distinct infiltrate of lymphocytes that confirmed the diagnosis of acute myocarditis. The cardiac dimensions and the ventricular systolic and diastolic function were preserved in all patients. The electrocardiogram evidenced conduction defects in two patients. The signal‐averaged electrocardiogram displayed late potentials in three patients. In the electrophysiologic study, atrial fibrillation or flutter was induced in four patients. When compared with control patients, Chagasic patients were found to have greater values of atrial threshold, A‐H interval, and atrioventricular (AV) nodal effective refractory period. The H‐V interval was mildly prolonged in two patients, but the dynamic AV nodal conduction was preserved (1:1 conduction during right atrial stimulation at a cycle length of 400 ms) in all the Chagasic patients. The ventricular parameters were within normal limits, and no sustained ventricular arrhythmia could be induced.

Conclusions: Patients with mild acute Chagasic myocarditis may suffer from electrical abnormalities and arrhythmias that are more evident at the supraventricular level and the AV junction.

Hypothesis: This investigation was undertaken to conduct an electrophysiologic study of the properties of the heart during the acute phase of Chagasic myocarditis.
Thrombolytic therapy guided by a decision analysis model: Are there potential benefits for patient management?
Authors: Kellett John , Ryan Breda
Published: February 2009

Background: Although thrombolytic therapy improves the outcome of myocardial infarction, it is associated with increased risks of stroke and bleeding; these risks may outweigh the benefits of therapy. The risks and benefits of thrombolysis, for any individual clinical situation, can be explicitly estimated by means of decision analysis.

Hypothesis: The aim of this study was to compare the actual use of thrombolytic agents for suspected acute myocardial infarction (AMI) with the management preferred by a decision analysis model.

Methods: Admission data prospectively obtained in 262 consecutive patients admitted to a rural community hospital's coronary care unit with suspected AMI, as well as clinical decisions and outcomes, were reviewed and analyzed.

Results: Seventeen deaths from AMI and no major strokes were observed, compared with 18.30 deaths and 0.85 major strokes predicted by a decision analysis model. Forty‐seven of 84 patients with confirmed AMI and 3 of 178 without AMI were given a thrombolytic agent, compared with 65 patients with and 7 without AMI who had decision analysis‐guided therapy. Decision analysis‐guided therapy could have saved 3.7 additional lives and gained 29.6 life years, but produced 0.4 extra strokes. Changing the quality adjustment for stroke or heart failure would not have altered the treatment preferred by decision analysis in any of the 262 cases studied. Some patients were predicted to benefit considerably from thrombolysis with little extra risk of stroke and vice versa: all cases must, therefore, be assessed individually.

Conclusions A decision analysis model can guide thrombolytic therapy by promptly defining its risks and benefits.
Echocardiographic detection of kaposi's sarcoma causing cardiac tamponade in a patient with acquired immunodeficiency syndrome
Authors: Chyu Kuang‐Yuh , Birnbaum Yochai , Naqvi Tasneem , Siegel Robert J. , Fishbein Michael C.
Published: February 2009

Pericardial effusions are common in patients with acquired immunodeficiency syndrome (AIDS). The differential diagnosis is diverse, and in most cases the etiology cannot be established. A cardiac tamponade was diagnosed in a 32‐year‐old male with AIDS and systemic Kaposi's sarcoma. Transthoracic echocardiography revealed a large pericardial effusion with right atrial collapse and a mobile multilobular mass at the apex protruding into pericardial space. Autopsy showed that this mass was Kaposi's sarcoma confined to the epicardial fat. This is the first case of cardiac Kaposi's sarcoma detected premortem by echocardiography.
Multivessel coronary thrombosis treated with abciximab (reopro®) in a patient with essential thrombocythemia
Authors: Michaels Andrew D. , Whisenant Brian , Macgregor John S.
Published: February 2009

A 50‐year‐old man was admitted with acute inferior and anterior myocardial infarction. The patient was diagnosed with essential thrombocythemia (ET) based on the findings of marked thrombocytosis of 1,113 × 103/mm3, splenomegaly, and numerous clumping megakaryocytes on bone marrow biopsy. Emergent coronary angiography revealed extensive multivessel thrombosis involving the left main coronary artery and completely occluding the proximal right coronary artery. In addition to standard therapy with aspirin, heparin, and primary angioplasty of the right coronary artery, the patient received additional antiplatelet therapy with ticlopidine, hydroxyurea, and the platelet glycoprotein IIb/IIIa receptor‐inhibiting monoclonal antibody drug abciximab (ReoPro®). Serial coronary angiograms 1 and 5 days following the infarction showed progressive thrombus resolution. The pathophysiologic mechanisms and therapeutic challenges of ET‐associated coronary thrombosis are discussed in this report.
Current knowledge and significance of coronary artery ectasia: A chronologic review of the literature, recommendations for treatment, possible etiologies, and future considerations
Authors: Sorrell Vincent L. , Davis Michael J. , Bove Alfred A.
Published: February 2009

Coronary artery ectasia is the abnormal enlargement of the coronary artery. The prognosis, treatment, and etiology of this disease remain an enigma. There is some evidence to suggest that the incidence of ectasia is increasing, and therefore understanding of this entity needs to improve. This article reviews the current literature on coronary artery ectasia and summarizes the findings. A treatment plan that targets each of the suggested clinical complications is provided. Using multiple indirect observations and current understanding of endothelium‐derived relaxation factor, a possible etiology that implicates overstimulation of endogenous nitric oxide is provided. Current literature suggests that ectatic coronary arteries, even without the presence of coronary stenosis, are subject to thrombus formation, vasospasm, and spontaneous dissection. Newer subgroups of ectasia are arising with the use of multiple interventional devices to dilate coronary artery stenosis. By design, these destroy the media of the coronary artery, and it is not clear whether these “iatrogenic” ectatic arteries are subject to the same complications as “idiopathic” coronary artery ectasia. Further investigation is necessary to help define the benefit of the proposed treatment regimen, to clarify the prognosis of these newer groups of “iatrogenic” ectasia, and to confirm or disprove the hypothesis targeting nitric oxide as an etiologic factor.
Validation of a decision support tool for the evaluation of cardiac arrest victims
Authors: Mccullough Peter A. , Thompson Richard J. , Tobin Kenneth J. , Kahn Joel K. , O'Neill William W.
Published: February 2009

Background: There is currently no well‐accepted model for early and accurate prediction of neurologic and vital outcomes after cardiac arrest. Recent studies indicate that individuals with acute myocardial ischemia as the etiology for the arrest may benefit from early revascularization.

Hypothesis: This study was undertaken to examine whether the cardiac arrest score is valid for predicting outcomes upon arrival at the emergency department.

Methods: We previously developed a cardiac arrest score based on time to return of spontaneous circulation, initial systolic blood pressure, and level of neurologic alertness in 127 patients (derivation set). This score was prospectively applied to 62 patients with similar clinical profiles (validation set). Utility of the score was evaluated by the area under the receiver operator characteristic curves (C) for both sets. Consistency was measured by using the alpha statistic applied to the cumulative survival at each ascending level of the score.

Results: The derivation and validation sets were similar with respect to baseline characteristics and proportions at each level of score. The survival to discharge was 41.7 and 53.2% for the two sets, respectively. The value of C was 0.89 ± 0.03 and 0.93 ± 0.03 for neurologic recovery and 0.81 ± 0.04 and 0.92 ± 0.04 for survival to discharge in the two sets, respectively. The level of agreement between the sets across the levels of the score was 0.98 and 0.99 (both p<0.0001) for the two outcomes.

Conclusions: The cardiac arrest score is a valid decision support tool in the evaluation of cardiac arrest victims. Patients with the most favorable scores may be considered for early angiography and revascularization if myocardial ischemia is the etiology of the arrest.
Unstable angina: Specialty‐related disparities in implementation of practice guidelines
Authors: Reis Steven E. , Zell Kathleen A. , Edmundowicz Daniel , Shapiro Alan H. , Feldman Arthur M. , Holubkov Richard
Published: February 2009

Background: The Agency for Health Care Policy and Research (AHCPR) has published practice guidelines to improve the quality of care of patients with unstable angina. Prior to publication, studies demonstrated that when compared with cardiologists, internists were less likely to use effective pharmacologic therapies or revascularization in patients with unstable angina.

Hypothesis: The study was undertaken to determine whether the AHCPR guideline publication abolished specialty‐related disparities in care.

Methods: We performed a chart review of consecutive patients hospitalized at a university‐affiliated institution with an admission diagnosis of chest pain in the absence of myocardial infarction and a noncardiac etiology. Treatment and diagnostic cardiac testing were compared between risk‐stratified patients cared for by a generalist (n = 125) and those whose care was guided by a cardiologist (n = 211).

Results: In those with low‐risk unstable angina, generalists were less likely to prescribe recommended aspirin (71 vs. 88%, p<0.01) and beta blockers (9 vs. 37%, p<0.001), and heparin (20 vs. 49%, p<0.001), and to perform a recommended diagnostic stress test or cardiac catheterization (28 vs. 60%, p<0.001). In those with at least intermediate risk, generalists were less likely to prescribe beta blockers (19 vs. 52%, p<0.001), heparin (19 vs. 66%, p<0.001), and nitrates (77 vs. 96%, p<0.001), and to refer for diagnostic testing (19 vs. 65%, p<0.001). Generalists' care was associated with significantly lower hospital charges.

Conclusions: AHCPR guidelines for the evaluation and treatment of unstable angina are implemented more effectively, but not uniformly, by cardiologists at our institution. Further studies are necessary to evaluate the barriers to implementation of the AHCPR guidelines.
Hormones and the cardiologist
Authors: Abrams Jonathan
Published: February 2009

Cardiologists must become more involved in discussing and recommending hormone replacement in postmenopausal women with established coronary artery disease, and those individuals at high risk of coronary events. A large amount of epidemiologic and observational data, as well as new research in vascular biology, strongly support the benefits of estrogen on the development and progression of coronary atherosclerosis. While breast and uterine cancer are valid concerns, selected high‐risk women with and without established coronary disease should be counseled by an informed cardiologist to consider hormone replacement therapy.