bluuebunny/crossref_metadata_2025 huggingface dataset:
Early postexercise thallium‐201 reinjection after sublingual nitroglycerin augmentation: Effects on detection of myocardial ischemia and/or viability
Authors: Antonopoulos Athanassios , Georgiou Evangelos , Kyriakidis Michael , Nikolopoulos Dimitrios , Toutouzas Pavlos , Proukakis Charalambos
Published: February 2009

Background: Thallium‐201 (201Tl) reinjection after conventional redistribution imaging is a standard procedure, resulting in enhanced 201 Tl redistribution which is compatible with viable myocardium. Although this method significantly improves identification of viable myocardium, it increases the investigation time by approximately 1 h. Thus, this technique is suboptimal from the standpoint of patient convenience, since its routine performance may be impractical in a high‐volume nuclear medicine laboratory.

Hypothesis: This study was undertaken to evaluate the efficacy of an early 201Tl reinjection and imaging protocol in combination with sublingual nitroglycerin, to detect myocardial ischemia and/or viability, and to reduce the need for conventional (4 h) redistribution imaging.

Materials and Methods: In this study, 62 consecutive coronary patients, referred for the detection of possible myocardial ischemia and/or viability, were involved (mean age 55 years, range 41‐70). Of those, 50 had previous angina attacks, with 42 having a history of previous myocardial infarction; 10 patients had coronary artery bypass grafting; and the remaining 2 had atypical chest pain. Immediately after the completion of the initial postexer‐cise imaging, 0.3 mg sublingual nitroglycerin followed by the reinjection of 1 m Ci of 201Tl were administered, and two further sets of images were acquired 1 h and 4h later.

Results: In each set of i mages, a total of496 segments were analyzed. On postexercise imaging, 305 (61%) segments demonstrated defects of which 198 (65%) showed enhanced thallium uptake, 97 (32%) did not change, and 10(3%) showed reverse redistribution on 1 h reinjection imaging (IRI). Of the 97 persistent defects, only 17 (6%) showed fill‐in of 201 Tl on 4 h redistribution imaging (CRI), while 12 (4%) segments showed reverse redistribution. On the other hand, after analyzing the 62 patients of the 1 h IRI, 17 (27%) remained unchanged while in only 1 patient (6%) of 17 the diagnosis changed from myocardial necrosis to ischemia after analysis ofthe 4h CRI.

Conclusion: These results indicate that early postexercise reinjection of 201Tl in combination with sublingual nitroglycerin followed by l h image acquisition may prove useful for a comprehensive and convenient assessment of myocardial ischemia and/or viability.
Transient cerebral ischemic attack and left atrial free‐floating thrombus: A case report
Authors: Abaci Adnan , Kabakci Giray , Tokgöuzoglu Lale , Kes Sirri , Ersoy $Uunsal
Published: February 2009

A patient with rheumatic mitral stenosis was found to have a free‐floating thrombus in the left atrium during echocardiography. Subsequently, the patient underwent surgical treatment. At surgery, a free thrombus was found within the left atrium. The postoperative course of the patient was satisfactory.
Ascending aortic aneurysm and dissection in young adults with bicuspid aortic valve: Implications for echocardiographic surveillance
Authors: Burks John M. , Illes Richard W. , Keating Edward C. , Lubbe Willem J.
Published: February 2009

Bicuspid aortic valve (BAV) is an independent risk factor for aneurysm and dissection of the ascending aorta. Despite this association, routine imaging of the aorta has not been recommended for patients with BAV. We describe two young men who developed life‐threatening aneurysm or dissection of the ascending aorta; one had a normally functioning BAV and the other was 10 years after valve replacement. The pathology of this condition is very similar to that found in the Marfan syndrome. We recommend echocardiographic surveillance of the ascending aorta at regular intervals, and consideration of beta‐adrenergic blockade among patients with significant dilation.
Alternate Patterns of Ventricular Activation during Supraventricular Bigeminy
Authors: Littmann Laszlo
Published: February 2009

Several investigators have previously noted that in the presence of bigeminal atrial extrasystoles, the premature beats may exhibit an alternate pattern of ventricular excitation either in the form of alternating left and right bundlebranch block, or alternating right bundle‐branch block and normal intraventricular conduction. However, the association of alternating intraventricular conduction with other types of supraventricular bigeminy has rarely been documented. In this report we present five diverse forms of supraventricular bigeminy exhibiting the phenomenon of alternating ventricular excitation on the early beats. Our findings suggest that the exact mechanism of supraventricular bigeminy is irrelevant in terms of subsequent ventricular events. Practically any type of supraventricular bigeminy may result in an alternate pattern of ventricular activation.
Successful management of myocardial infarction during pregnancy in a renal transplant recipient
Authors: Bhaktaram Vivi K.J. , Asirvatham Sam , Sebastian Cherian , Sivaram Chittur A. , Pederson James A. , Stanley John R. , Pennington Larry R.
Published: February 2009

Myocardial infarction (MI) complicating pregnancy in a renal transplant recipient is described. Management challenges of MI in pregnancy and the possible predisposing roles of renal transplantation and erythropoietin (EPO) use are discussed.
Cardiac involvement in acquired immunodeficiency syndrome—a review to push action
Authors: Mllei JosÉ , Grana Daniel , Alonso Graciela Fernández , Matturri Luigi
Published: February 2009

As more effective therapies have produced longer survival times for human immunodeficiency virus (HIV)‐infected patients, new complications of late‐stage HIV infection including HIV‐related heart disease have emerged. Almost any agent that can cause disseminated infection in patients with acquired immunodeficiency syndrome (AIDS) may involve myocardium, but clinical evidence of cardiac disease is usually overshadowed by manifestations in other organs, primarily the brain and lungs. Cardiac abnormalities are found at autopsy in two‐thirds of patients with AIDS, and more than 150 reports of cardiac complications have been published. Cardiac involvement in HIV disease includes pericardial effusion, myocarditis, dilated cardiomyopathy, and/or endocardial involvement at any stage of the disease. This review deals with all the cardiac manifestations of AIDS and serves to highlight two problems and one indication. First of all, there are very few clinical studies. Current knowledge is based almost exclusively on echocardiography and autopsy studies. Observational or clinical trials would be useful. Second, there exists very poor information on the impact of treatment; and epidemiologic and clinicopathologic studies are mandatory for obtaining detailed data concerning the mechanisms of myocardial damage in AIDS. Finally, because cardiac complications are often clinically inapparent or subtle in the initial stages, periodic screening of HIV‐positive patients by electrocardiogram and echocardiogram is probably indicated. in addition, AIDS may also provide the opportunity to gain insights into the pathogenesis of little understood cardiac diseases such as lymphocytic myocarditis and dilated cardiomyopathy.
“Nonspecific” chest pain associated with high long‐term mortality: Results from the primary prevention study in göteborg, sweden
Authors: Wilhelmsen Lars , Rosengren Annika , Hagman Marianne , Lappas Georg
Published: February 2009

Background: The syndrome angina pectoris with effort‐related chest pain or discomfort is usually easy to recognize. However, vague and nonspecific symptoms may cause little reason for extensive evaluation. The prognosis of such patients in the general population has so far not been well described.

Hypothesis:The study was undertaken to investigate longterm prognosis in men with chest pain considered to be non‐specific in comparison with men with typical angina pectoris (AP) or prior myocardial infarction (MI), and men without chest pain.

Methods: At the second screening of the Göteborg Primary Prevention Study in 1974‐1977, 6,488 men aged 51 to 59 years at baseline were available for the present analysis. Men who had responded positively to a postal questionnaire about chest pain during exercise or at rest were interviewed by a physician according to a Rose questionnaire at the screening examination. Those with typical or probable AP were further examined by a single experienced physician. The following four groups were formed: Group 1: men who did not complain of chest pain (n = 5,545). Group 2: men who had not consulted any doctor because of chest pain, but who had chest pain according to a questionnaire (n = 441);these men were not considered to have AP according to a three‐step examination by experienced physicians. Group 3: typical AP (n = 232). Group 4: men who had suffered an MI (n = 134).

Results:During 16 years of follow‐up, coronary heart disease (CHD) mortality forGroups 1 4 was 8.0,19.5,24.8, and 48.5%, respectively. Mortality from all cardiovascular diseases was 1 1.5,24.5,3 1.2, and 59.0% respectively. Noncardiovasculardisease mortality was 14.1,17.7,14.3, and 8.7%, respectively. Thus, the relative risk (RR) for CHD mortality among men with nonspecific chest pain (Group 2) was 2.77 95% confidence interval (CI) 2.20,3.50, for all cardiovascular disease mortality 2.46 (95% CI 2.00,3.02), and for non‐cardiovascular disease mortality I .60 (95% CI 1.28, 2.00). Total mortality in this group was as high )44%) as among those with typical AP (45%), but the highest mortality was found among men with a previous MI (68%). in men without chest pain it was 26%. Patients of Groups 2 4 had higher levels of cardiovascular risk factors than those in Group 1. Neither any specific questions in the Rose questionnaire, nor electrocardiographic changes at rest (uncommon) were of prognostic significance. Serum cholesterol, systolic blood pressure, diabetes, and smoking were significant predictors of outcome, both with respect to fatal CHD and to total mortality during the 16‐year follow‐up.
Twenty‐four‐hour ambulatory oxygen desaturation and electrocardiographic recording in obstructive sleep apnea syndrome
Authors: Noda Akiko , To Riekol , Ashima Nobuonak, , Yokota Mitsuhiro , Okada Tamotsu , Yasuma Fumihiko
Published: February 2009

Background: Although nocturnal pulseoximetry is routinely performed in obstructive sleep apnea syndrome (OSAS), pulseoximetry over a 24‐h period has not been studied.

Hypothesis: The purpose of the study was to determine whether simultaneous 24‐h oxygen desaturation and electrocardiographic (ECG) recording might be used to screen for daytime sleep sequelae in patients with OSAS.

Methods: Simultaneous recording of arterial oxygen saturation (SpO2) and ECG was conducted over a 24‐h period in 18 male patients with OSAS (mean age 51.3 years) who were diagnosed by standard polysomnography (PSG), and in 15 agematched healthy subjects (mean age 52.7 years) as controls to evaluate circadian variation of these parameters. The measures of heart rate variability (HRV) were calculated from 24‐h ambulatory ECGs. Seventeen patients with OSAS showed excessive daytime sleepiness (EDS). We calculated the duration in which SpO2 decreased to <90% (duration of SpO2 > 90%). The number of apnea/hypopneas per hour (AHI) during sleep was investigated with Apnomonitors (Chest MI, Co., Tokyo) on the same day as the SpO2 recordings.

Results: Controls showed no episodes of oxygen desaturation. in patients with OSAS, driving (33.3% of patients with OSAS) was the most common activity in which SpO2 decreased to <90%, followed by daytime napping (27.8%) and resting after meals (22.2%). The duration of SpO2 < 90% over a 24‐h period correlated significantly with the duration levels recorded during sleep (r = 0.99, p < 0.05) and in the afternoon (r = 0.62, p <0.05), and with the AHI (r = 0.55, p>0.05), but not with the duration of SpO2> 90% in the morning. The number of ventricular premature beats correlated significantly with the duration of SpO2>90% for a 24‐h period, but not with measures of HRV. Ventricular tachycardia was found in two (11.1 %) and ST‐T depression in three patients (16.6%) with underlying cardiac diseases.

Conclusion: Our results suggest that daytime sleep attacks accompanied by oxygen desaturation in patients with moderate to severe OSAS may contribute to the occurrence of traffic or cardiovascular accidents. We conclude that 24‐h ambulatory recordings of SpO2 and ECG are useful for screening for daytime sleep sequelae associated with the potential risk of this pathology in OSAS during social activities.
A case of atypical aortic coarctation with refractory congestive heart failure‐treatment with axillo‐iliac artery bypass
Authors: Nakao Kazuhisa , Shibata Junichi , Kikutake Shuuhei , Nagata Tsuyoshi , Uraguchi Kenichirou , Hidaka Yoshio , Imaeumi Tsutomu
Published: February 2009

Coarctation of the aorta is rare. We present a case of atypical coarctation due to aortitis syndrome with congestive heart failure refractory to conventional medical treatment. Although indications for surgical treatment are not well established and, in general, treatment of choice is an aorto‐aortic bypass, we selected axillo‐iliac bypass with subcutaneous tunnel because of severe heart failure. Postoperatively, the pressure gradient disappeared and heart failure was improved.
A review of the amyloidoses that infiltrate the heart
Authors: MCCARTHY, III ROBERT E. , Kasper EDWARD K.
Published: February 2009

Primary amyloidosis, systemic senile amyloidosis, isolated atrial amyloidosis, and transthyretin isoleucine 122 amyloidosis frequently involve the heart. Amyloid fibrils infiltrate the myocardium, impairing ventricular contraction and relaxation. The clinical manifestations of cardiac infiltration in these disorders are protean, though congestive heart failure and arrhythmias are most common. Treatment of cardiac amyloidosis is directed at the underlying cause and at relief of symptoms. Heart transplantation is not a viable treatment option for patients with primary amyloidosis; its role in the other amyloidoses has not been established. The prognosis of patients with cardiac amyloidosis varies and is largely determined by the underlying disorder responsible for amyloid infiltration.
Value of t‐wave direction with lead iii st‐segment depression in acute anterior wall myocardial infarction: Electrocardiographic prediction of a “wrapped” left anterior descending artery
Authors: Porter Avital , Sclarovsky Samuel , Ben‐Gal Tuvia , Herz Itzhak , Solodky Alejandro , Sagie Alex
Published: February 2009

Background: Lead III ST‐segment depression during acute anterior wall myocardial infarction (AMI) has been attributed to reciprocal changes. However, the value of the T‐wave direction (positive or negative) in predicting the site of obstruction and type of the left anterior descending (LAD) artery is not clear and has not been studied before.

Hypothesis: The aim of the study was to assess retrospectively the correlation between two patterns of lead III ST‐segment depression, and type of LAD artery and its level of obstruction during first AMI.

Methods: The study group consisted of 48 consecutive patients, admitted to the coronary care unit for first AMI, who showed ST‐segment elevation in lead aVL and ST‐segment depression in lead III on admission 12‐lead electrocardiogram. The patients were divided by T‐wave direction into Group 1 (n = 31), negative T wave, and Group 2 (n = 17), positive T wave. The coronary angiogram was evaluated for type of LAD (“wrapped”, i.e., surrounding the apex or not), site of obstruction (pre‐ or postdiagonal branch), and other significant coronary artery obstructions.

Results: Mean lead III ST‐segment depression was 1.99 ± 1.32 mm in Group 1 and 1.13 ± 0.74 mm in Group 2 (p = 0.004); mean ST‐segment elevation in aVL was 1.35 ± 0.84 mm and 1.23 ± 0.5 mm, respectively (p = 0.5). A wrapped LAD was found in 12 patients (38.7%) in Group 1 and in 13 in Group 2 (76.4%) (p = 0.02). The sensitivity of lead III ST‐segment depression with positive T wave to predict a wrapped LAD was 52%, and the specificity was 82% with a positive predictive value of 76%. On angiography, 25 patients (80%) in Group 1 and 13 (76%) in Group 2 had prediagonal occlusion of the LAD (p = 0.77 ). No significant difference between groups was found for right and circumflex coronary artery involvement or incidence of multivessel disease.

Conclusions: The presence of lead III ST‐segment depression with positive T wave associated with ST‐segment elevation in aVL in the early course of AMI can serve as an early electrocardiographic marker of prediagonal occlusion of a “wrapped” LAD.
Electrophysiologic significance of leftward qrs axis deviation in bifascicular and trifascicular blocks
Authors: Ducceschi Valentino , Sarubbi Berardo , D'Andrea Antonello , Liccardo Biagio , Lucca Pasqualina , Mayer Maria Serena , Scialdone Antonino , Santangelo Lucio , Iacono Aldo
Published: February 2009

Background: Intraventricular conduction disturbances determine complete impairment of impulse propagation along the right or left bundle branch or the two left fascicles.

Hypothesis: This study was undertaken to investigate the electrophysiologic significance of QRS axis (QRSA) orientation in bifascicular and trifascicular blocks.

Methods: A group of 76 subjects, 43 with right bundle‐branch block (RBBB) and left anterior hemiblock (LAH) (Group A), and 33 with left bundle‐branch block (LBBB) (Group B) was submitted to electrophysiologic evaluation.

Results: In Group A, QRSA was inversely related only to intraventricular conduction, while in Group B, QRSA inversely related to infrahisal conduction times. A value of <60° was considered the cut‐off point for determin‐ing subjects with a considerable leftward QRSA deviation. Of the 27 Group A patients with a QRSA <‐60°, 38.5% developed an infrahisal second‐degree atrioventricular (AV) block during incremental atrial stimulation (IAS) in comparison with 11.1 % of those with QRSA >‐60°. Of the 9 Group B patients with a QRSA <‐60°, 44.4% exhibited severe impairment of infrahisal conduction at baseline and 66.6% developed an infrahisal second‐degree AV block during IAS, whereas among the remaining 24 with a QRSA >60°, in only 8.3% were both infrahisal (HV1 and HV2) intervals dangerously prolonged, and 23.8% encountered an infrahisal second‐degree AV block during IAS. In Group A, atrioventricular conduction time >200 ms exhibited a better predictive accuracy than QRSA <60° for the development of an infrahisal second‐degree AV block during IAS, whereas the latter appeared the best noninvasive predictor in Group B with a slightly lesser predictive accuracy than HV >80 ms.

Conclusion: The degree of leftward QRSA deviation seems to reflect the entity of intraventricular conduction delay in patients with RBBB + LAH, while it appears to be directly related to infrahisal conduction prolongation in those with LBBB.
Myocardial dna strand breaks are detected in biopsy tissues from patients with dilated cardiomyopathy
Authors: Seki Yukihiko , Kai Hisashi , Kai Mamiko , Muraishi Akihiko , Adachi Kyo , Imaizumi Tsutomu
Published: February 2009

Background: Progressive damage of cardiomyocytes with interstitial and replacement fibrosis accompanied by less inflammatory cell infiltration is observed in patients with dilated cardiomyopathy (DCM), suggesting some other mechanisms rather than necrotic cell death.

Hypothesis: The aim of this study was to assess the possible involvement of apoptotic process in the pathogenesis of DCM and myocarditis.

Methods: Endomyocardial biopsy was performed in patients with DCM (n = 9). myocarditis (n = 4), or atypical chest pain syndrome (as controls; n = 5). The TUNEL method was used for in situ detection of oligonucleosomal DNA strand breaks.

Results: The TUNEL‐positive cells were observed in three of nine patients with DCM and in all four with myocarditis, but in none of the controls. The TUNEL‐positive nuclei were observed exclusively in cardiomyocytes in DCM, whereas in myocarditis they were detected mainly in interstitial cells and in a few myocytes. In DCM, interstitial fibrosis was greater in the TUNEL‐positive than in TUNEL‐negative patients (p<0.05). In either DCM or myocarditis, electron microscopic examination could not reveal morphologic features of apoptosis of cardiomyocytes.

Conclusion: The DNA strand breaks were detected in cardiomyocytes in patients with DCM and mainly in interstitial cells in myocarditis. It is possible that the DNA strand breaks can be involved in mechanisms of progressive loss of functional cardiac units in these myocardial diseases.
Unrecognized major bleeding following thrombolysis for acute myocardial infarction presenting with syncope
Authors: Cohen Natan , Zaidenstein Ronit , Blatt Alex , Sarafian Dorit Almoznino , Litinsky Irena , Modai David
Published: February 2009

Complete atrioventricular block and syncope sometimes are the presenting signs of acute myocardial infarction. In a presyncopal attempt to assume sitting position, the patient may fall and suffer consequent trauma. Once in hospital, this sequence of events may be overlooked by both the patient and admitting physicians. Moreover, physical examination initially may not be revealing. We report on two such patients who developed massive subcutaneous bleeding following thrombolytic and heparin treatment. We conclude that these patients constitute a specific group with a relatively high risk of trauma and bleeding at the gluteal region following thrombolytic therapy. Special attention must be given to these patients.
Mitral valve replacement in sickle cell disease
Authors: Sgambati Maria T. , Kon Neal D. , Cruz Julia M.
Published: February 2009

Cardiac dysfunction, including mitral valve regurgitation and congestive heart failure, can occur in patients with sickle cell disease. However, major surgery poses a greater risk in this population. This paper reports on the management of a patient with sickle cell disease who underwent successful replacement of the mitral valve.
Treatment of severe mitral stenosis with percutaneous balloon valvotomy in pregnant patients
Authors: Martínez‐Reding Jesus , Cordero Alejandro , Kuri Jorge , Martínez‐Ríos Marco A. , Salazar Eduardo
Published: February 2009

Background: Pregnancy can cause life‐threatening complications in women with mitral stenosis. Frequently, there is an urgent need to increase the mitral valve area mechanically. In selected cases, percutaneous mitral balloon valvotomy (PMBV) has emerged as a safe and effective alternative to surgical commissurotomy.

Hypothesis: The study evaluates the effects of PMBV by the Inoue technique in nine pregnant patients with severe symptomatic mitral stenosis.

Methods: The patients were in New York Heart Association (NYHA) functional class II to IV and had echocardiographic scores of ≤ 8. The mean gestational age was 24.8 ± 6.1 weeks. The patient's pelvic and abdominal regions were covered with a lead apron to protect the fetus from radiation. A stepwise dilatation technique was used. Fluoroscopy time was kept to 10 to 15 min.

Results: One patient developed severe mitral regurgitation requiring emergency valve replacement. The remaining eight patients showed marked immediate symptomatic and hemodynamic improvement. After dilatation, the transmittal pressure gradient decreased from 20.8 ± 6.5 to 7.3 ± 1.4 mmHg (p = 0.001) and the calculated mitral valve area increased from 0.9 ± 0.1 to 1.8 ± 0.4 (p < 0.001). All patients had uneventful term deliveries of normal babies. On follow‐up they were in NYHA functional class I.

Conclusions: Percutaneous mitral balloon valvotomy is a safe and effective procedure for selected pregnant patients with severe mitral stenosis. The procedure is well tolerated by the fetus. Severe mitral regurgitation requiring immediate surgery may occur occasionally. The possible harmful effects to the fetus from its exposure to radiation during PMBV are unknown.
Constrictive pericarditis after coronary artery bypass surgery as a cause of unexplained dyspnea: A report of five cases
Authors: Dardas Petros , Tsikaderis Dimitris , Ioannides Efstathios , Bisbos Apostolos , Smirlis Dimitris , Arditis Iakovos , Spanos Panagiotis
Published: February 2009

Constrictive pericarditis after coronary artery bypass grafting (CABG) is rare and can present as unexplained dyspnea. We report five consecutive cases of post‐CABG constrictive pericarditis seen within a period of 17 months at our institution. All patients presented with heart failure of unknown etiology within a period of 8‐84 months after surgery. During the initial post‐CABG period, two patients had developed postcardiotomy syndrome that was successfully treated with steroids. They were all assessed noninvasively and invasively. In all patients, the diagnosis of constriction was initially suspected clinically (symptoms, high jugular venous pressure with deep “X” and “Y” descents, pericardial knock). Echocardiography showed transmural flow typical of constriction in all patients and hepatic venous flow in two. Two patients showed rapid left ventricular relaxation. In all patients, hemodynamic assessment showed diastolic equalization of pressures in all chambers, “W” shape waveform in right atrial pressure, and “dip and plateau” configuration in right and left ventricular pressure waveforms. Diagnosis was confirmed surgically in four patients who were subjected to pericardiectomy‐pericardial stripping (three survived, one died). One patient refused surgery. We conclude that constrictive pericarditis, although rare, should be suspected in every case of unexplained dyspnea post CABG. It can appear early or late after surgery, and clinical examination plays an important role in its early recognition. It requires a full noninvasive and invasive assessment in case of clinical suspicion.
Unstable angina: Prognosis of the individual patient
Authors: Bugiardini Rafhaele , Richard CONTI C.
Published: February 2009

Not all patients diagnosed with unstable angina have the same outcome. Thus, it is incumbent on the physician caring for these patients to try to identify factors that will risk‐stratify them. These factors include the degree of coronary angiographic stenosis, the lesion morphology, severity of symptoms, presence or absence of transient myocardial ischemia, and state of left ventricular function. In addition, many other factors including the patient's age, gender, and coexisting medical disorders must be considered when trying to prognosticate an individual patient. Clinical experience indicates that clinical indices that combine information provided by all of the above related variables should have more powerful prognostic significance than any individual variable.
Improved risk stratification in unstable angina: Identification of patients at low risk for in‐hospital cardiac events by admission echocardiography
Authors: Stein James H. , Neumann Alex , Preston Lynn M. , Vandenberg Betsy J. , Parrillo Joseph E. , Calvin James E. , Marcus Richard H.
Published: February 2009

Current protocols for risk stratification of patients with acute chest pain syndromes rely on clinical parameters and are oriented toward identification of patients at high risk for adverse cardiac events; however, this paradigm for risk stratification does not adequately address the observation that adverse cardiac events are relatively uncommon in this population. In an era of cost containment, consideration also should be given to identification of patients at low risk for adverse cardiac events, who may be safely discharged without expensive inpatient hospitalization.
Atrial natriuretic peptide augments coronary collateral blood flow: A study during coronary angioplasty
Authors: Kyriakides Zenon S. , Sbarouni Eftihia , Antoniadis Aias , Iliodromitis Efstathios K. , Mitropoulos Dimitrios , Kremastinos Dimitrios T.
Published: February 2009

Background and hypothesis: In vitro studies have shown that atrial natriuretic peptide (ANP) causes relaxation of pre‐constricted blood vessel strips and inhibits the contraction of isolated vessels in response to norepinephrine and angiotensin II. The present study examined the effects of exogenous ANP on the coronary collateral blood flow during angioplasty.

Methods: We studied 15 patients undergoing elective balloon angioplasty during the second and third balloon inflations. A Doppler flow guidewire was advanced distal to the lesion and used for the estimation of coronary blood flow velocity. After the second balloon inflation, 25 ng/kg/min of ANP were administered intracoronarily for 8 min. Electrocardiogram, pressure, and flow velocity were recorded immediately before each balloon deflation. Fourteen other patients served as controls and received normal saline infusion.

Results: Velocity time integral increased from 65 ± 40 to 79 ± 46 mm (p < 0.05) during the third balloon inflation, whereas ST deviation decreased from 1.3 ± 0.9 to 0.7 ± 1.0 mV (p< 0.05). These variables did not change in the control group during the two tested balloon inflations.

Conclusion: Exogenous ANP augments coronary collateral blood flow and ameliorates myocardial ischemia during angioplasty.
Comparison of adenosine effects on atrioventricular node reentry and atrioventricular reciprocating tachycardias
Authors: Kevin DONAHUE J. , Orias David , Berger Ronald D. , Tomaselli Gordon F. , Lawrence John H. , Calkins Hugh
Published: February 2009

Background: Adenosine is an established first line therapy for the treatment of narrow complex tachycardias. The two most common etiologies of paroxysmal supraventricular tachycardia (SVT) are atrioventricular node reentry tachycardia (AVNRT) and atrioventricular reciprocating tachycardia (AVRT).

Hypothesis: We postulated that adenosine might have different effects on the termination of AVNRT vs. AVRT, and that these differences might assist in the noninvasive differentiation between these diagnoses.

Methods: Fifty‐nine patients referred for the diagnosis and treatment of SVT were included in the study. All patients had SVT induced during electrophysiology testing, and each patient received adenosine during SVT. The adenosine dose, time to tachycardia termination, and site of tachycardia termination were recorded. Seventeen patients required isoproterenol administration to initiate SVT. This subset of patients was compared with those not requiring isoproterenol.

Results: There was no statistically significant difference in the adenosine dose or time to tachycardia termination when comparing patients with AVNRT with those with AVRT. All patients with AVNRT had termination of tachycardia in the antegrade direction with final activation in the atria. Patients requiring isoproterenol for tachycardia initiation experienced tachycardia termination significantly faster than those not requiring isoproterenol, although there was no difference in the dose of adenosine required for termination.

Conclusion: These data demonstrate that patients with dual AV node physiology and AVNRT do not have altered sensitivity to adenosine compared with patients with AVRT and normal AV nodes. Further investigation will be required to determine the clinical utility of the significantly shorter time to tachycardia termination for patients receiving isoproterenol.
Clinical implications of endothelial dysfunction
Authors: Pepine Carl J.
Published: February 2009

Endothelial dysfunction is increasingly recognized as an early event in the pathogenesis of cardiovascular disease. This observation is consistent with the growing appreciation of the role of endothelium in maintaining cardiovascular health. Endothelial dysfunction and coronary artery disease are both linked to hypertension, hypercholesterolemia, diabetes mellitus, and cigarette smoking. Modification of these conditions improves both endothelial function and coronary artery disease outcomes. Dietary and lifestyle modifications and antioxidant vitamin supplementation have a beneficial effect on endothelial function, as do angiotensin‐converting enzyme inhibitors and lipid‐lowering agents. Future studies will determine whether interventions that specifically target endothelial dysfunction can reduce rates of clinical disease.
Treatment with ramipril improves systolic function even in patients with mild systolic dysfunction and symptoms of heart failure after acute myocardial infarction
Authors: Kongstad‐Rasmussen Ole , Blomstrand Peter , Broqvist Mats , Dahlström Ulf , Wranne Bengt
Published: February 2009

Background: Clinical signs of heart failure such as pulmonary rales and dyspnea, ventricular dysfunction, and ventricular arrhythmia are independent predictors of a poor prognosis after acute myocardial infarction (AMI).

Hypothesis: The study aimed to assess the effect of ramipril treatment on mildly depressed left ventricular (LV) systolic function, assessed by atrioventricular (AV) plane displacement in patients with congestive heart failure after AMI.

Methods:The study was a substudy in the Acute Infarction Ramipril Efficacy Study, a double‐blind, randomized, placebo‐controlled trial of ramipril versus placebo in patients with symptoms of heart failure after AMI. In all, 56 patients were included in the main study, 4 refused to participate in the substudy, and 4 were excluded for logistical reasons. Echocardiography was performed at entry and after 6 months. Patients who underwent coronary artery bypass grafting during the follow‐up period were excluded.

Results: At baseline, the patients had modest LV dysfunction, and mean AV plane displacement of 9.7 mm. During follow‐up, AV plane displacement increased in ramipril‐treated patients from 9.5 to 10.9 mm (p < 0.01). No statistically significant changes were seen in the placebo group.

Conclusions: Ramipril improves LV systolic function in patients with clinical signs of heart failure and only modest systolic dysfunction after AMI. Measurement of AV plane displacement is a simple and reproducible method for detection of small changes in systolic function and may be used instead of ejection fraction in patients with poor image quality.
Aneurysms of the ascending aorta: Diagnostic features and prognosis in patients with marfan's syndrome versus hypertension
Authors: Kodolitsch Yskert V. , Simic Ognjen , Nienaber Christoph A.
Published: February 2009

Background: In Marfan's syndrome progressive dilation of the sinuses of Valsalva, the supra‐aortic ridge and the ascending aorta are well characterized abnormalities likely to set the stage for severe aortic sequelae accounting for 70% of lethal complications. However, the specific anatomical, clinical, and prognostic profiles of aortic pathology are less well characterized in the setting of patients with Marfan's syndrome symptomatic from aortic complications.

Hypothesis: The study was designed to characterize the spectrum of anatomical, clinical, and prognostic profiles of thoracic aortic disease in symptomatic patients with Marfan's syndrome compared with patients with arterial hypertension. Noninvasive imaging techniques were used for comprehensive mapping of aortic pathology associated with Marfan's syndrome.

Methods: Thirty‐five consecutive patients with Marfan's syndrome (16 women, 19 men; mean age 35± 12 years) were imaged by transthoracic (TTE; n = 26) and transesophageal echocardiography (TEE; n = 11), contrast enhanced computed tomography (XCT; n = 16), or magnetic resonance techniques (MRI; n = 14). Diagnostic results were compared with both in‐traoperati ve or angiographic findings and also with a group of 85 consecutive patients with aortic pathology associated with arterial hypertension.

Results: Aortic pathology was more frequently confined to the ascending aorta (p<0.05) and aortic regurgitation was more prevalent in Marfan's syndrome than in arterial hypertension (p < 0.05). In 23 cases (66%) of dissection and 12 cases (34%) of nondissecting aneurysms, no Marfan‐specific aortic macropathology was identified when compared with arterial hypertension. Diagnostic results of TEE, XCT, and MRI were all excellent; however, in contrast to the transesophageal ultrasound approach, transthoracic ultrasound was not useful in the detection of aortic dissection and intramural hemorrhage. Both 30‐day (100 vs. 70%; p<0.05) and 5‐year survival rates (91 vs. 57%; NS) were higher in patients with Marfan's syndrome than in those with arterial hypertension. Repeat surgery, however, was more frequently required in patients with Marfan's syndrome (25% vs. none in aortic aneurysm; p < 0.05).

Conclusions: There are no macropathologic findings of the aorta specific for Marfan's syndrome. In patients with Marfan's syndrome with an inherently high rate of aortic complications, serial noninvasive imaging should be encouraged, preferably utilizing TEE or MRI.
Modulation of ventricular rate in permanent atrial fibrillation: Randomized, crossover study of the effects of slow‐release formulations of gallopamil, diltiazem, or verapamil
Authors: Bottoe Giovanni L. , Bonini Walter , Broffoni Tiziana
Published: February 2009

Background: The management of permanent atrial fibrillation (PAF) consists primarily of long‐term anticoagulation with either aspirin or warfarin to prevent systemic embolization, and modulation of ventricular rate (VR) to improve cardiac function by prolonging the ventricular diastolic filling time.

Hypothesis: The effects of slow‐release formulations of gallopamil (100 mg b.i.d.), diltiazem (120 mg bid.), or verapamil (120 mg b.i.d.) on VR were evaluated in 18 patients with PAF without organic heart disease.

Methods: In all patients, each treatment was administered randomly, was compared with oral digoxin, and was assessed by 24‐h Holter monitoring during daily life and by a 6‐min walk ing test.

Results: There were no significant differences in mean and minimum VR recorded during 24‐h Holter monitoring among the four treatments. Peak heart rates recorded during the 6‐min walking test with digoxin treatment was 167 ± 12 beats/min. This was significantly reduced by gallopamil (149 ± 23 beats/ min, p = 0.01), diltiazem (142 ± 4 beats/min, p< 0.001), and verapamil (137 ± 30 beats/min, p < 0.001). There were no significant differences in peak VR during the walking test among the three calcium antagonists. Pauses of ≥ 3 s were observed in 3 of 18 (17%) patients who received digoxin (max 3.4 s) and in 5 of 18 (28%) patients who received diltiazem (max 3.4 s); p = NS. Periods of bradycardia < 30 beats/min were observed in 5 of 18 (28%) patients during digoxin treatment, and in 3 of 18(17%) patients during treatment with gallopamil, diltiazem, and verapamil; p = NS.

Conclusion: Gallopamil, diltiazem, or verapamil are superior to digoxin in controlling VR during mild exercise in patients with PAF without organic heart disease. The reduction of peak VR is obtainable without further slowing of resting VR. However, gallopamil appears to be the least effective calcium blocker at controlling resting and exercise VR; thus, there are no advantages over the other calcium blockers in its use in the clinical setting.
Prior revascularization increases the effectiveness of enhanced external counterpulsation
Authors: Lawson William E. , Hui John C.K. , Guo Tong , Burger Lynn , Cohn Peter F.
Published: February 2009

Background and hypothesis: Enhanced external counterpulsation (EECP) is an effective noninvasive treatment for chronic angina. However, its usefulness has been felt to be limited in patients with angiographically demonstrated triplevessel coronary artery disease (CAD), in accord with the hypothesis that a patent vessel is necessary for transmission of the EECP‐augmented coronary artery pressure and volume to the distal coronary vasculature.

Methods: The effect of revascularization [coronary artery bypass grafting (CABG)] prior to EECP was examined in 60 patients with CAD and chronic angina (35 without and 25 with prior CABG). Patients were grouped by the extent of CAD (single‐, double‐, triple‐vessel disease in the unrevascularized group) and by the extent of residual disease (number of stenotic native vessels unbypassed or supplied by a stenotic graft in the CABG group). Significant CAD or graft stenoses were defined as stenoses demonstrating ≥ 70% luminal diameter narrowing. Benefit was assessed by improvement in postEECP treatment over pretreatment radionuclide stress testing.

Results: Radionuclide stress testing demonstrated a comparable favorable response (80 vs. 71 %; p = NS) in patients with prior CABG versus unrevascularized patients. Enhanced external counterpulsation was highly and comparably effective in patients with unrevascularized native single‐ and double‐vessel CAD and in patients with CABG with residual single‐and double‐vessel CAD (88 vs. 80%; p = NS). Most notably, CABG significantly increased the beneficial response to EECP in those patients with triple‐vessel CAD and stenotic grafts compared with unrevascularized patients with triplevessel CAD (80 vs. 22%; p < 0.05 by chi‐square test).

Conclusion: The results suggest a new role for EECP as an effective treatment for post CABG ischemia, despite extensive CAD and even in the presence of stenotic grafts.
Pregnancy‐induced severe left ventricular systolic dysfunction in a patient with hypertrophic cardiomyopathy
Authors: Kazimuddin Mohammed , Vashist Aseem , Basher Abul W. , Brown Edward J. , Alhaddad Imad A.
Published: February 2009

This paper reports the first case of hypertrophic cardiomyopathy (HCM) that developed postpartum congestive heart failure (CHF) and severe left ventricular (LV) systolic dysfunction. Review of the literature and clinical implications are discussed.
Early deaths with thrombolytic therapy for acute myocardial infarction in corticosteroid‐dependent rheumatoid arthritis
Authors: Kotha Purushotham , Joseph Mcgreevy M. , Kotha Akther , Look Michelle , Weisman Michel H.
Published: February 2009

Intravenous thrombolytic therapy has become standard treatment for acute myocardial infarction (AMI). We describe three patients with long‐standing seropositive rheumatoid arthritis (RA) on chronic corticosteroid therapy who experienced very early (1‐6 h) mortality after the use of intravenous thrombolytic therapy for the treatment of AMI. All three patients likely experienced electromechanical dissociation (EMD). Their charts were evaluated in depth, and the literature was reviewed in regard to possible etiopathologic mechanisms. Within 1‐6 h of apparently successful thrombolytic therapy for AMI, these three patients experienced sudden and profound bradycardia and hypotension and could not be resuscitated. The potential occurrence of EMD in all three patients raises the possibility of accelerated myocardial rupture, as EMD is one of the clinical hallmarks of this condition. As suggested by the three clustered cases, this heretofore undescribed association between sudden unexpected cardiac death and thrombolytic therapy for AMI in patients with seropositive, corticosteroid‐dependent RA suggests that further study and observation are needed. This deleterious association, if verified, has important implications for the treatment of AMI in patients who have RA and are corticosteroid dependent.
Salutary effects of aspirin in coronary artery disease are not limited to its platelet inhibitory effects
Authors: Mehta J. L.
Published: February 2009

Aspirin is widely used in the treatment and prevention of coronary artery disease (CAD). However, other platelet inhibitory agents, which inhibit platelet activation, have not been found to be effective or as effective as aspirin. The discrepancy between the efficacy of these compounds and aspirin suggests that the therapeutic efficacy of aspirin may not be limited to its platelet inhibitory effect. in this review, the basis for a unique place for aspirin in the therapy of patients with CAD is discussed. The author believes that the nonplatelet‐mediated effects of aspirin could be more important than the platelet inhibitory effect, or at least may complement the platelet inhibitory effects of aspirin in patients with acute myocardial ischemia and in others undergoing intra‐coronary procedures.
The effects of an angiotensin‐converting inhibitor (enalapril) on patients with mild cardiac failure—evaluating cardiac function based on the relationship between daily walking pace and heart rate
Authors: Ino‐Oka Eji , Umeda Showko , Kutsuwa Yoshiharu , Takahashi Takashi , Sagawa Kouichi , Takahashi Takayuki , Inooka Hikaru
Published: February 2009

Background: Heart failure has been evaluated by several methods, the New York Heart Association (NYHA) classification of heart failure based on symptoms being used most frequently. However, the degree of heart failure assessed by these criteria does not always correlate with cardiac function in daily life.

Hypothesis: The aim of the study was to evaluate cardiac function based on the walking pace/heart rate (HR) relationship to assess the effects of enalapril, an angiotensin‐converting enzyme inhibitor, in patients with mild to moderate cardiac function.

Methods: To evaluate cardiac function objectively, we developed a method using a pedometer to count the steps walked while simultaneously recording HR using a Holter electrocardiograph (ECG). Step‐count walk rate (WR) was recorded on the magnetic tape of the Holter apparatus, and both HR and walking pace were calculated automatically by the Holter ECG analysis system. Data were determined every hour, and mean pace and HR were plotted along the x and y axes, respectively. The slope of HR X WR was calculated using the least squares method. The slope and the total number of steps were regarded as indicators of cardiac function and quality of life, respectively. We analyzed 36 subjects, consisting of 8 normal volunteers, 8 patients in New York Heart Association (NYHA) class 1,11 in class II, and 9 in class III chronic mild heart failure, during maximal exercise work load by bicycle ergometer; furthermore, fractional shortening of the left ventricle on echocardiogram was determined in 14 patients with chronic mild heart failure and was compared with the slope of HR X WR. Enalapril was administered at a daily dose of 2.5‐10 mg for 1‐24 months (mean 6 months) in 60 patients to evaluate the effects of this drug on these parameters.

Results: There was a significant inverse relationship between maximal work load and the HR X WR slope, and also between the fractional shortening and the slope, suggesting that the slope may reflect the severity of cardiac dysfunction. Furthermore, the slope decreased significantly from 1.8 ± 1.26 before enalapril to 1.0 ± 0.94 (mean ± standard deviation) after drug administration, while the total number of steps increased significantly from 4842 ± 3581 to 7804 ± 4793.

Conclusion: The slope of the graph relating step count and HR proved to be a good, objective indicator of cardiac function, and enalapril therapy improved this parameter.