bluuebunny/crossref_metadata_2025 huggingface dataset:
Coronary arteriovenous fistulas: Collective review and management of six new cases—changing etiology, presentation, and treatment strategy
Authors: Said S. A. M. , El Gamal M. I. H. , Van Werf T. Der
Published: February 2009

We considered it worthwhile to review the literature of the last decade (1985–1995) to answer the question whether the etiology and the clinical picture of coronary arteriovenous fistulas (CAVFs) have changed. Furthermore, new therapeutic modalities such as percutaneous transcatheter embolization have been developed. We tried to define the place of these techniques in the therapeutic arena. Clinical presentation and management of six patients with eight congenital CAVFs and 76 subjects with 96 congenital and acquired CAVFs taken from a review of the recent literature are presented. Sixty‐three review subjects (78%) were treated medically, with one fatal case. Ligation of the fistula was achieved by surgical techniques in 10% of review subjects, while percutaneous transcatheter embolization (PTE) was performed in nine patients (12%). Percutaneous transcatheter embolization techniques are being increasingly used in the treatment of CAVFs. The etiology of CAVFs has a tendency to show alterations toward the acquired pathogenesis. In 64% of the review subjects the fistula was congenital in origin, and in 36% it had an acquired cause. Among the patients of the current review, the clinical presentations were 55% asymptomatic, 34% chest pain (anginal or atypical), and 13% congestive heart failure. The CAVFs of our six patients are all congenital in origin. In the current review, the clinical presentation showed a trend toward increasing chest complaints (34%) compared with the review (10%) published in the mid 1970s. This may be due to a higher mean age, and hence increased concurrent coronary artery disease due to aging compared with the review population of two decades ago.
The risk of coronary artery disease after heart transplantation is increased in patients receiving low‐dose cyclosporine, regardless of blood cyclosporine levels
Authors: Gamba Amando , Mamprin Filippo , Fiocchi Roberto , Senni Michele , Troise Gianni , Ferrazzi Paolo , Ferrara Roberto , Corbetta Giuseppe
Published: February 2009

Background: Coronary artery disease (CAD) of allografted hearts is the main cause of late mortality after cardiac transplant, but its etiology is still undetermined.

Hypothesis: This study was undertaken to evaluate the relevance of several risk factors, including cyclosporine (CsA) dose and blood CsA levels, to the incidence of CAD.

Methods: In 163 heart transplants performed between November 1985 and August 1994 at our Institution, CAD was diagnosed by coronary angiography or at postmortem examination. Patients in whom postmortem examination or coronary angiography was not performed, as well as those < 15 years of age and those who died within 1 month of surgery, were excluded from the study. The following risk factors were analyzed: recipient age, gender, pretransplant diagnosis, donor age, number of human leukocyte antigen (HLA)‐AB mismatches, cytomegalovirus serology, mean serum cholesterol and triglyceride levels, the number of treated acute rejections, mean weighted CsA dose (CsA dosew) and weighted blood CsA levels (blood CsA levelw).

Results:Coronary artery disease was diagnosed in 32 patients (19.6%). A low mean CsA dosew was the only significant predictor for CAD at multivariate analysis (p<0.01); there was no correlation with blood CsA levelw. In the patients receiving a CsA dosew > 4 mg/kg/day, the 8.9 year probability of their remaining CAD free was 69% [confidence interval (CI) 50–87%] in comparison with 31% (CI0–65%) in patients receiving a CsA dosew < 4 mg/kg/day.

Conclusion:In our experience, a low CsA maintenance dose is the main risk factor for CAD, irrespective of blood CsA levels.
Exercise technetium 99m sestamibi single‐photon emission computed tomography late after coronary artery bypass surgery: Long‐term follow‐up
Authors: Desideri Alessandro , Candelpergher Giovanni , Suzzi Gianleone , Terlizzi Raffaele , Colangeli Giovanna , Daskalakis Cosmas , Celegon Leopoldo , Zanco Pierluigi , Borsato Nicoletta , Chierichetti Franca
Published: February 2009

Background and hypothesis: The prognostic value of exercise technetium 99m sestamibi single‐photon emission computed tomography (SPECT) imaging in patients with previous bypass surgery is unknown. The aim of our study was to assess the prognostic information obtained with exercise scintigraphy performed for routine follow‐up or reappearance of symptoms.

Methods: We studied 75 patients referred to our Center at a mean of 38 ± 53 months from the revascularization procedure and prospectively followed them for 38 ± 24 months.

Results: Fifteen patients (20%) had events at follow‐up: there were 4 cardiac deaths, 3 nonfatal acute myocardial infarctions, 8 late revascularization procedures (4 percutaneous transluminal angioplasty and 4 repeat bypass surgery). Univariate analysis identified a history of typical angina (p = 0.001), a clinically positive ergometric test (p = 0.009), peak exercise heart rate (p = 0.0003), percentage of maximal predicted heart rate (p = 0.0001), peak exercise double product (p = 0.048), therapy during exercise (p = 0.003), scintigraphic summed reversibility score (i.e., the summation of the segmental differences between stress and rest) (p = 0.014), as significant predictors of events. Three multivariate models were built, with clinical variables (Model 1, chi square 15.97), ergometric variables (Model 2, chi square 19.66), and with scintigraphic variables added to clinical/ergometric variables (Model 3, chi square 31.13). The scintigraphic variable selected in the model as significant predictor of events was the summed reversibility score (p = 0.008).

Conclusions: Exercise sestamibi SPECT scintigraphy provides optimal prognostic information after clinical and ergometric parameters in patients with previous bypass surgery.
Nonneoplastic diseases of aorta and pulmonary trunk—Part II
Authors: Waller Bruce F. , Clary James D. , Rohr Todd
Published: February 2009

This five‐part review focuses on selected nonneoplastic diseases of the aorta and pulmonary trunk. Because many more diseases affect the aorta compared with the pulmonary trunk and right and left main pulmonary arteries, most of this review will be devoted to disorders of the aorta. Part II of this five‐part series discusses complications of aortic dissection and aortic aneurysm.
Calculating vascular resistances
Authors: Skimming Jeffrey W. , Cassin Sidney , Nichols Wilmer W.
Published: February 2009

Vascular resistance calculations often affect decisions regarding therapeutic options encountered by physicians and their patients. However, many of the terms, units, and methods used when calculating vascular resistances are ambiguous. This report attempts to clarify some of these ambiguities and suggests methods for predicting normal vascular resistances.
Transesophageal echocardiographic evaluation of aortitis
Authors: Harris Kevin M. , Malenka David J. , Plehn Jonathan F.
Published: February 2009

Aortitis is an uncommon infection which may occur in patients with preexisting atherosclerotic disease of the aorta. The clinical features in two patients presenting with fever and nonspecific symptoms are reviewed. In these patients, transesophageal echocardiographic features of wall thickening and false aneurysm formation were suggestive of the diagnosis of aortitis. Both patients were taken for surgical excision of the descending aorta and subsequently improved.
Right ventricular involvement in hypertrophic cardiomyopathy: A case report and literature review
Authors: Mozaffarian Dariush , Caldwell James H.
Published: February 2009

Although hypertrophic cardiomyopathy (HCM) is classically considered a disease of the left ventricle, right ventricular (RV) abnormalities have also been reported. However, involvement of the right ventricle in HCM has not been extensively characterized. The literature regarding prevalence, genetics, patterns of involvement, histologic findings, symptoms, diagnosis, and treatment of RV abnormalities in HCM is reviewed. To highlight the salient points, a case is presented of apical HCM with significant RV involvement, with an RV outflow tract gradient and near obliteration of the RV cavity, in the absence of a left intraventricular gradient. Right ventricular involvement in HCM appears to be as heterogeneous as that of the left ventricle. The spectrum extends from mild concentric hypertrophy to more unusual severe, obstructive disease. While in some cases the extent of RV involvement correlates with left ventricular (LV) involvement, predominant RV disease can be seen as well. While the genetics of RV involvement have not been well characterized, histologic findings appear to be similar to those in the left ventricle, suggesting similar pathogenesis. Significant RV involvement may result in RV outflow obstruction and/or reduced RV diastolic filling, with potentially increased incidence of severe dyspnea, supraventricular arrhythmias, and pulmonary thromboembolism. The optimal treatment for patients with significant RV disease is unknown. Medical and surgical therapies have been attempted with variable success; experience with newer techniques such as percutaneous catheter ablation has not been reported. Further characterization of RV involvement in HCM is necessary to elucidate more clearly the clinical features and optimal treatments of this manifestation of HCM.
Association between calcific aortic stenosis and hypercholesterolemia: Is there a need for a randomized controlled trial of cholesterol‐lowering therapy?
Authors: Chui Michele C. K. , Newby David E. , Panarelli Mauritzio , Bloomfield Peter , Boon Nicholas A.
Published: February 2009

Background: Calcific aortic stenosis may have common etiological factors with atherosclerosis.

Hypothesis: In this retrospective, case‐control study, we aimed to determine whether there is an association between hypercholesterolemia and calcific aortic valve stenosis.

Methods: Consecutive patients undergoing single aortic or mitral valve replacement in a regional cardiothoracic surgical center were reviewed and preoperative patient characteristics were recorded: demographics, comorbidity (including coronary artery disease and associated risk factors), serum total cholesterol, lipid‐lowering therapy, and serum creatinine.

Results: Serum total cholesterol concentrations were significantly higher in patients with calcific aortic stenosis than in controls (6.2 ± 1.1 vs. 5.3 ± 1.1 mmol/l;p< 0.001). The significant difference in serum cholesterol concentrations remained following correction for gender and body mass index (p = 0.02) and when patients with coronary artery disease were excluded (6.3 ± 1.1 vs. 5.3 ± 1.4 mmol/l; p < 0.001). Subgroup analysis demonstrated that the association between elevated serum cholesterol concentrations and calcific aortic stenosis was particularly strong in patients with tricuspid aortic valves (6.4 ± 1.2 vs. 5.3 ± 1.1 mmol/l; p < 0.001) compared with those with bicuspid valves (5.9 ± 1.1 vs. 5.3 ± 1.1 mmol/l; p = 0.06).

Conclusions: We conclude that hypercholesterolemia is associated with calcific aortic stenosis and may be implicated in its pathogenesis and progression. We believe that there is now a need for a randomized, controlled trial of cholesterol‐lowering therapy in patients with calcific aortic stenosis.
Detection of the “midband” lipoprotein in patients with coronary artery spasm
Authors: Miwa Kunihisa , Nakagawa Keiko , Suzuki Kayo , Inoue Hiroshi
Published: February 2009

Background: Dyslipidemia in patients with coronary vasospasm has been characterized by a low level of high‐density lipoprotein (HDL) cholesterol without elevation of low‐density lipoprotein (LDL) cholesterol, distinct from patients with organic coronary artery disease.

Hypothesis: Disordered triglyceride‐rich lipoprotein metabolism may be linked to the genesis of coronary artery spasm.

Methods: The incidence of the “midband” lipoprotein observed between very low‐density lipoprotein (VLDL) and LDL bands in the polyacrylamide disc gel electrophoretic analysis was determined in 48 patients with coronary spastic angina (CSA), in 50 patients with stable effort angina and a significant fixed coronary stenosis (SEA), and in 40 control subjects without coronary artery disease (Control).

Results: The incidence was significantly (p<0.05) higher in CSA (71%) than in SEA (50%) and Control (25%). Smoking was significantly (p<0.05) more prevalent in CSA (77%) than in SEA (50%) and Control (50%). In SEA, serum levels of triglyceride and apoproteins C‐II, C‐III, and E were all significantly higher, and the serum level of HDL cholesterol was significantly lower in the midband‐positive than in the midband‐negative subgroup. In CSA, no significant differences were found in these serum levels between the midband‐positive and ‐negative subgroups, except for a significantly (p<0.05) lower level of HDL cholesterol in the former. However, a significantly (p<0.05) higher incidence of diabetes mellitus or impaired glucose tolerance was noted in the midband‐positive (41%) than in the midband‐negative subgroup (7%) in CSA. The incidence of the detected midband lipoprotein was significantly decreased in the blood samples obtained from 20 of CSA after a>6‐month angina‐free period (70 → 25%, p<0.05).

Conclusions: The midband lipoprotein was frequently detected in patients with coronary vasospasm, suggesting that dyslipidemia with disordered triglyceride‐rich lipoprotein metabolism may be linked to the genesis of coronary artery spasm.
Dobutamine as bridge to angiotensin‐converting enzyme inhibitor‐nitrate therapy in endstage heart failure
Authors: Levine T. Barry , Levine Arlene B. , Elliott William G. , Narins Barbara , Stomel Robert J.
Published: February 2009

Background: Intravenous inotropic intervention in congestive heart failure is generally associated with a poor prognosis and is largely used as a “bridge” to mechanical support or heart transplantation.

Hypothesis: We hypothesized that the inotropic support afforded by dobutamine may serve as a bridge to the introduction and intensification of angiotensin‐converting enzyme (ACE) inhibitor‐nitrate therapy.

Methods: We studied the efficacy of transitioning inotrope‐dependent patients in endstage heart failure from intravenous dobutamine to high‐dose ACE inhibitor‐nitrates, with 1‐year follow‐up. Forty‐nine sequential dobutamine‐dependent patients with left ventricular ejection fraction (LVEF) 17 ± 17% were treated with increasing lisinopril (1.9 ± 1.5 to 46 ± 28 mg/day) and isosorbide dinitrate (7 ± 6 to 229 ± 161 mg/day). Outpatient dobutamine was continued or repeat infusions pursued, as indicated, and dobutamine was tapered when feasible.

Results: During the following year, 14 of 49 patients required repeat dobutamine, with home treatment with dobutamine for 6.3 ± 3.7 months (n = 5). At 1 year, New York Heart Association (NYHA) classification improved from 3.6 ± 0.5 to 1.9 ± 1.0, p < 0.0001; yearly hospitalizations fell from 2.7 ± 2.3 to 1.2 ± 3.0, p = 0.02; and LVEF rose from 17 ± 7% to 24 ± 11%, p < 0.0001. At 1 year, 14 patients who remained dobutamine dependent had significantly more severe symptoms than dobutamine‐independent patients (n = 35). Transplant or death occurred in 7 of 14 patients with follow‐up dobutamine, and in 5 of 35 patients free of subsequent dobutamine, p = 0.03. Patients with poor outcome (transplant n = 10, death n = 12) continued to be more limited (NYHA 2.7 ± 0.9 vs. 1.7 ± 0.9, p = 0.0002), with more follow‐up hospitalizations (3.6 ± 5.4 vs. 0.6 ± 0.8, p = 0.0004), and no improvement in LVEF (17 ± 8 vs. 28 ± 11%, p = 0.003).

Conclusions: Of the patients on dobutamine inotropic support, 70% were successfully transitioned to ACE inhibitor‐nitrate therapy, with improved symptoms and LVEF, and with reduced hospitalizations and follow‐up dobutamine or transplant. Thirty percent of patients with continued need for dobutamine had a significantly poorer 1‐year clinical outcome.
Elevated plasma levels of interleukin‐2 and soluble il‐2 receptor in ischemic heart disease
Authors: Simon Alan D. , Yazdani Shahram , Wang Weizheng , Schwartz Allan , Rabbani LeRoy E.
Published: February 2009

Background: T‐lymphocytes are present in significant numbers in the atherosclerotic plaque, but their role in the progression and pathogenesis of coronary syndromes remains poorly understood.

Hypothesis: We sought to determine the relationship between T‐lymphocyte activation and ischemic heart disease by measuring plasma levels of cytokines related to T‐lymphocyte function in patients with stable and unstable angina.

Methods: Plasma levels of interleukin‐2 (IL‐2) and soluble IL‐2 receptor (sIL‐2R) were measured in 105 patients: 66 with stable angina, 24 with unstable angina, and 15 healthy controls. Patients who presented to the cardiac catheterization laboratory with unstable or stable anginal syndromes for coronary angiography or percutaneous coronary intervention enrolled in the study.

Results: Mean levels of IL‐2 were significantly higher in patients with stable angina than in those with unstable angina. The differences between stable angina and control groups, or between unstable angina and control groups, were not statistically significant. Mean levels of sIL‐2R were significantly higher in patients with stable angina than in either patients with unstable angina or control patients.

Conclusions: Levels of IL‐2 and sIL‐2 receptor are significantly elevated in patients with stable angina, but not in patients with unstable angina. The contribution of T‐lymphocytes to the development of both stable and unstable angina requires further investigation.
Prognostic significance of bundle‐branch block in acute myocardial infarction: The importance of location and time of appearance
Authors: Melgarejo‐Moreno Antonio , Galcerá‐Tomás Josa , Garcia‐Alberolam Arcadio
Published: February 2009

Background: The presence of bundle‐branch block (BBB) is associated with high mortality rates and is considered an important predictor of poor outcome in patients with acute myocardial infarction (AMI).

Hypothesis: The objective of this study was to assess the prognostic significance of BBB in patients with AMI depending on its form of presentation.

Methods: A multicenter prospective 1‐year follow‐up study involving 1,239 consecutive patients diagnosed with AMI was performed.

Results: Bundle‐branch block was present in 177 cases (14.2%), associated with worse clinical characteristics, lower rate of thrombolytic therapy, and higher mortality: in‐hospital (23.8 vs. 9.7%, p < 0.01) and 1‐year (40.9 vs. 16.9%, p < 0.01). Compared with right BBB (n = 135), left BBB (n = 42) was more often associated with female gender and higher prevalence of cardiovascular diseases, but had a similar 1 ‐year mortality. In the absence of heart failure or complete atrioventricular (AV) block, there was no difference in in‐hospital mortality of patients with BBB (n = 76) and without BBB (n = 786) (2.6 vs. 3.9%). Compared with existing BBB (n = 113), BBB of new appearance (n = 64) was more often accompanied by complete AV block and heart failure and higher in‐hospital and 1‐year mortality rates. Only BBB of new appearance was an independent predictor of mortality: in‐hospital (odds ratio [OR] 2.3, 95% confidence interval [CI] 1.1–4.7) and 1‐year mortality (OR 3.2, 95% CI, 1.7–9.1).

Conclusions: In patients with AMI, the classification of BBB according not only to location but also to time of appearance is of practical interest. New BBB is an independent predictor of short‐ and long‐term mortality.
Relief of symptoms and improvement of health‐related quality of life five years after coronary artery bypass graft in women and men
Authors: Herlitz Johan , Wiklund Ingela , Sjöland Helén , Karlson Björn W. , Karlsson Thomas , Haglid Maria , Hartford Marianne , Caidahl Kenneth
Published: February 2009

Background: Severe coronary artery disease can be successfully treated with coronary artery bypass graft (CABG), with considerable improvement in the symptoms of angina pectoris. Approximately three of four patients are free of ischemic events for 5 years; however, increased survival is demonstrated only in selected subgroups with advanced coronary artery disease, and this effect has not been established in elderly patients.

Hypothesis: The study was undertaken to determine the relief of symptoms and improvement in other aspects of health‐related quality of life (QoL) during 5 years after CABG in women and men.

Methods: Patients who underwent CABG in western Sweden were approached prior to and 5 years after surgery. Health‐related QoL was estimated with Physical Activity Score (PAS), Nottingham Health Profile, and Psychological General Well‐Being Index.

Results: Women (n = 381) had a 5‐year mortality of 17% compared with 13% for men (n = 1,619; NS). After 5 years, 1,719 patients (survivors) were available for the survey; of these, 876 (51%) answered the inquiry both prior to and after 5 years. Both women and men improved markedly and highly significantly, both with respect to symptoms and other aspects of health‐related QoL. Women suffered more than men in terms of limitation of physical activity, dyspnea, chest pain, and others aspects of health‐related QoL. There was a significant interaction between time and gender, with more improvement in men with regard to chest pain when walking uphill or quickly on level ground, when walking on level ground at the speed of other persons their own age, when under stress, and in windy and cold weather. For those parameters as well as for PAS, improvement was more marked in men than in women. In the other aspects of health‐related QoL, there was no interaction between time and gender.

Conclusion: Five years after CABG, limitation of physical activity, symptoms of dyspnea, and chest pain were reduced, and various aspects of health‐related QoL had improved in both women and men. In general, women suffered more than men both prior to and after CABG; however, in some aspects the improvement was more pronounced in men. Because of the limited response rate, the results may not be applicable to a nonselected population who had undergone CABG.
Low clinical utility of routine angiographic surveillance in the detection and management of cardiac allograft vasculopathy in transplant recipients
Authors: Clague Jonathan R. , Cox Ian D. , Murday Andrew J. , Charokopos Nick , Madden Brendan P.
Published: February 2009

Background: Cardiac allograft vasculopathy (CAV), a form of accelerated atherosclerosis, is the major cause of late death in heart transplant recipients. Routine annual coronary angiography has been used as the standard surveillance technique for CAV in most transplant centers.

Hypothesis: The aim of this study was to investigate the clinical utility of routine angiographic surveillance in the detection and management of CAV in transplant recipients.

Methods: We reviewed the case notes and angiograms of 230 patients who underwent cardiac transplantation in our unit between January 1986 and January 1996 and survived beyond the first year post transplantation.

Results: Significant complications secondary to angiography arose in 19 patients (8.2%). Cardiac allograft vasculopathy was present on none of angiograms performed 3 weeks post transplantation, but was identified in 9 patients (4%) at the first annual angiogram and an additional 25 patients by the fifth annual angiogram. A target lesion suitable for angioplasty was only identified in two patients, and only limited procedural success was achieved in both cases. Twenty‐five patients (11%) died during the study period, and the most common cause of late death was graft failure which occurred in 10 patients. All patients who died from graft failure had significant CAV at autopsy, but the most recent coronary angiogram had been normal in eight of these patients.

Conclusions: These data clearly illustrate the limited clinical utility of routine angiographic surveillance for CAV in heart transplant recipients and prompted us to abandon this method of surveillance in our unit.
Cardiac tamponade masking pulmonary embolism
Authors: Jairath Umesh C. , Benotti Joseph R. , Spodick David H.
Published: February 2009

This report describes a patient admitted with shortness of breath due to cardiac tamponade, which masked concomitant pulmonary embolism that was diagnosed only after right heart pressures failed to decrease after successful pericardiocentesis. The patient was found to have widely metastatic adenocarcinoma of colon (with metastases to pericardium) and a paraneoplastic syndrome of deep vein thrombosis.
A double‐blind, multicentered study comparing the accuracy of diagnostic markers to predict short‐ and long‐term clinical events and their utility in patients presenting with chest pain
Authors: Fromm Robert , Meyer Denise , Habib Gabriel , Roberts Robert , Zimmerman Janice , Boudreaux Ann , Smalling Richard , Wun Chuan‐Chuan C. , Davis Barry
Published: February 2009

Background: Millions of patients present annually with chest pain, but only 10% have myocardial infarction (MI). We recently reported comparative sensitivity and specificity of available markers in the diagnosis of MI; however, optimum interpretation of marker results requires prognostic follow‐up data.

Hypothesis: The study was undertaken to study the accuracy of CK‐MB subforms, troponin I and T, myoglobin, and CK‐MB in predicting clinical events at 30 days and 6 months.

Methods: in all, 955 consecutive patients with chest pain were enrolled in a prospective, multicenter, double‐blind study to test the prognostic accuracy of these markers.

Results: Myocardial infarction was diagnosed in 119 by CK‐MB mass criteria and unstable angina (UA) in 203 patients by clinical criteria. Follow‐up at 30 days and 6 months was available in 824 and 724 patients, respectively, with mortalities of 2.8 and 4.14%, respectively. Cumulative 6‐month mortality was 5.6% in MI, 4.4% in UA, and 3.0% in others. Revascularization was reported in 9.3% of patients by 6 months. A positive test on each of the markers except myoglobin was predictive of revascularization. The composite endpoint of death or revascularization occurred in 107 patients by 6 months and a positive result on each of the markers was predictive of this composite endpoint (p < 0.05). The relative risk of death or revascularization for patients who did not have MI but tested positive on each of the markers was > 1.0 but did not reach statistical significance.

Conclusions: With the possible exception of myoglobin, each of the diagnostic markers displayed similar prognostic performance in patients with chest pain presenting to emergency departments. The most appropriate markers to triage patients with chest pain, which has both adequate early diagnostic sensitivity and prognostic accuracy, are the CK‐MB subforms.
Ibutilide: Efficacy and safety in atrial fibrillation and atrial flutter in a general cardiology practice
Authors: Eversole Amy , Hancock William , Johns Thomas , Lopez Larry M. , Richard Conti C.
Published: February 2009

Background: Published experience with ibutilide (IB) in randomized clinical trials reveals that conversion to sinus rhythm (SR) occurs in 31% of patients with atrial fibrillation (AF) and in 63% of patients with atrial flutter.

Hypothesis: The study was undertaken to test the efficacy and safety of IB in patients with AF and with atrial flutter and to compare them with those reported in previous studies.

Methods: in a general cardiology practice, 54 consecutive patients with AF or atrial flutter, no contraindication to IB, and a normal QTc interval, were treated with intravenous IB (0.4–2.0 mg). Duration of arrhythmia, left atrial (LA) size, ejection fraction (EF), time to conversion, QTc interval, and adverse drug events were determined. Patients were observed for a minimum of 6 h. Successful cardioversion was defined as arrhythmia termination within 6 h.

Results: Twenty‐four of 34 (70.6%) patients with AF and 15 of 20 (75%) patients with atrial flutter converted to SR. Conversion of AF to SR was more likely to occur if duration of AF was ˜ 96 h compared with > 96 h (81 vs. 17%, respectively; p = 0.006). The mean time to arrhythmia termination was 68.8 min. Left atrial size, determined by echocardiogram, was 44 ± 13 mm in 43 patients. Patients with LA size > 45 mm had a conversion rate of 55% in both AF and flutter, compared with a conversion rate of 72% in patients with LA size < 45 mm. Ejection fraction was not a predictor of drug success. The QTc intervals were significantly prolonged after IB administration, with a mean change of 47.1 ms for successfully treated patients. Sustained polymorphic ventricular tachycardia occurred in one patient within 1 min of IB infusion, requiring electrical cardioversion to SR. This patient's serum electrolytes and QTc interval were normal prior to IB infusion; however, the QTc increased by 160 ms (from 387 to 547 ms) during drug infusion. No systemic or pulmonary emboli occurred.

Conclusion: The efficacy of IB for conversion of AF to SR in this prospective observational study was considerably better than previously reported. Duration of AF remains an important predictor of conversion to SR. Complications are rare and without long‐term adverse effects.
C‐Reactive protein is a marker for a complex culprit lesion anatomy in unstable angina
Authors: Moukarbel George V. , Arnaout M. Samir A. , Alam Samir E.
Published: February 2009

Backgrvund: The putative theory is that the clinical syndrome of unstable angina is caused by rupture of the atherosclerotic plaque with superimposed thrombus formation. It is characterized by angiographically complex coronary lesions in the majority of patients.

Hypothesis: This study aimed at assessing the correlation between C‐reactive protein (CRP) and the complexity of culprit coronary lesions in unstable angina.

Methods: We identified culprit lesion complexity in 96 patients with unstable angina and normal creatine kinase (CK) and CK‐MB mass. Serum concentrations of CRP (N < 5.0 mg/1) and cardiac troponin T (cTnT; N < 0.1 ng/ml) were measured on admission.

Results: There was a trend toward a higher grade of anatomical complexity of the culprit lesion in patients with elevated CRP (p=0.007) and cTnT levels (p=0.027). Patients who had intermediate‐ or high‐grade lesion severity had a higher level of CRP (8.5 ±5.7 mg/1) and cTnT (0.118 ± 0.205 ng/ml) on admission than those who had normal or low‐grade lesions (5.7 ± 4.0 mg/1,0.017 ±0.021 ng/ml, respectively); Mann‐Whitney U, p=0.002 and p < 0.001, respectively. Furthermore, the likelihood of having intermediate‐ or high‐grade complexity of the culprit lesion was higher when CRP levels were elevated in all patients (p = 0.007, odds ratio [OR] = 4.286; 95% confidence interval [CI] 1.492–12.310) and in those with normal cTnT levels (p = 0.025, OR = 3.876; 95% CI 1.185–12.678). Also, higher CRP levels strongly correlated with the need for revascularization interventions (p < 0.0005).

Conclusion: Elevated CRP level on admission is a marker for anatomic complexity of culprit lesions and need for revascularization interventions in unstable angina.
Event‐free survival in patients after an acute coronary event with exercise‐induced normalization of the T‐wave
Authors: Bednarz Bronislaw , Wolk Robert , Mazurek Tomasz , Stec Sebastian , Chamiec Tomasz
Published: February 2009

Background: Risk stratification of patients with unstable angina or non‐Q‐wave myocardial infarction (MI) is an unresolved clinical problem. The prognostic value of T‐wave normalization (TWN) during exercise has not been studied in this group of patients.

Hypothesis: Event‐free survival in clinically stable patients after an acute coronary event without ST‐segment elevation can be predicted by the presence of exercise‐induced TWN.

Methods: Sixty‐five patients (43 men and 22 women, mean age 62 ± 10 years) entered the study. The diagnosis of unstable angina and non‐Q‐wave MI was made in 40 and 25 patients, respectively. A treadmill exercise test was performed in all patients after clinical stabilization. The patients were divided into three groups: those with negative baseline T waves and exercise‐induced TWN (Group 1); those with negative baseline T waves, but without TWN (Group 2); and those with positive baseline T waves (Group 3). The patients were followed up for 6 months.

Results: During follow‐up, serious cardiovascular complications occurred in 15 (23%) patients. These included exacerbation of ischemic heart disease (14 patients) and acute MI (1 patient). Event‐free survival was greater in patients in Group 1 (95%) than in those in Group 2 (68%, p < 0.034) or Group 3 (71%, NS). Among all patients studied, exercise‐induced TWN was predictive of event‐free survival with a sensitivity of 38% and a specificity of 93%.

Conclusions: In clinically stable patients after an acute coronary event without ST‐segment elevation, exercise‐induced TWN is a specific but not sensitive predictor of event‐free survival after 6 months.
Issues in the assessment of the safety and efficacy of tenecteplase (TNK‐tPA)
Authors: Gibson C. Michael , Marble Susan J.
Published: February 2009

While thrombolytic agents have demonstrated improved mortality over the use of placebo, this has come at the expense of bleeding complications such as intracranial hemorrhage (ICH). Tenecteplase (TNK‐tPA) is a novel thrombolytic agent engineered to improve upon the ease of use and safety of alteplase (t‐PA). Given its longer half‐life, TNK‐tPA can be administered as a single bolus. The dosing of TNK‐tPA has been weight optimized to enhance both safety and efficacy outcomes. Weight‐optimized TNK‐tPA dosing requires body weight estimation, which may introduce the potential for medication error. However, data from TNK‐tPA clinical trials suggest that body weight estimates can err by up to 20 kg (44 lb) without an increased risk of ICH or death. Furthermore, the results of TNK‐tPA clinical trials showed that even at the highest weight‐optimized dosage of 50 mg, ICH rates were among the lowest reported in clinical trials of thrombolytics for acute myocardial infarction. in elderly female patients of low body weight, the use of weight‐optimized TNK‐tPA lowered the risk of ICH compared with the use of t‐PA, expanding the potential use of thrombolytics to this high‐risk patient population. Tenecteplase has demonstrated clinical equivalence to t‐PA, but with a wider therapeutic margin of safety.
Safety and potential cost savings of same‐setting electrophysiologic testing and placement of transvenous implantable cardioverter‐defibrillators
Authors: Pires Luis A. , May Lynette M. , Ravi Srihari , Lal Vinit R. , Kahlon Jaskamal P. S.
Published: February 2009

Background: Separately, electrophysiologic study (EPS) and placement of a transvenous implantable cardioverter‐defibrillator (ICD) can be performed safely in the majority of patients. The safety and potential cost savings of same‐setting procedures have not been evaluated.

Hypothesis: Electrophysiologic study and placement of transvenous ICDs can be performed safely in the same setting at reduced cost.

Methods: in all, 160 (mean age 65 ± 10 years, 75% men) and 41 (mean age 66 ± 11 years, 73% men) consecutive patients who underwent same‐ versus separate‐setting procedures, respectively, were prospectively evaluated.

Results: The two groups had similar clinical characteristics and indications for EPS and ICD therapy. Complications occurred in eight patients (5.0%, 95% confidence interval [CI] 2.3–10.3) who had same‐setting procedures (one hypotension during ICD testing, one pocket hematoma, two lead dislodgments, two pneumothoraces, one stroke, and one infection) and in two (4.9%, CI 0.60–16.5) who had separate‐setting procedures (one pocket hematoma and one infection). There were no procedure‐related deaths or long‐term ICD‐related complications in either group. The mean time from ICD implantation to hospital discharge was similar in the two groups (2.5 ± 2.4 vs. 2.7 ± 2.2 days, p = NS). The combined procedure cost was higher in patients who had separate‐setting procedures ($12,403 ± 1,386 vs. $10,242 ± 2,256, p = < 0.001), who incurred an additional hospital cost of $2,121 ± $2,125 for the waiting period (1.7 ± 1.6 days) between EPS and ICD implantation.

Conclusions: in patients deemed candidates for ICD therapy based on EPS results, placement of transvenous defibrillators in the same setting as EPS is as safe as separate‐setting procedures and, if adopted, could further reduce the cost of providing ICD therapy.
Continuous long‐term dosing with oral slow‐release isosorbide dinitrate does not reduce incidence of cardiac events in patients with healed myocardial infarction
Authors: Kanamasa Ken , Hayashi Takahiro , Takenaka Toshihiko , Kimura Akio , Ikeda Akiko , Ishikawa Kinji
Published: February 2009

Background: in the short term, isosorbide dinitrate (ISDN) is considered to be therapeutically effective. The long‐term effects of treatment with slow‐release ISDN are less clear.

Hypothesis: The study was undertaken to investigate the effects of continuous, long‐term dosing with oral slow‐release ISDN on the incidence of cardiac events in patients with healed myocardial infarction (MI). The study was carried out in accordance with the intention‐to‐treat principle.

Methods: in all, 1,102 in‐ and outpatients, of either gender, with healed MI were randomly divided into groups treated with ISDN (n = 470) and not treated with ISDN (n = 632). Patients in the ISDN group received a continuous regimen of 20 mg of oral, long‐acting ISDN three times a day, after meals. The mean observation period was 15.0 ± 18.5 months. The primary endpoints were nonfatal and fatal recurrent MI, death from congestive heart failure, and sudden death.

Results: There were no significant differences in the baseline characteristics of the patients in the ISDN and no‐treatment groups; nevertheless, significantly more patients in the ISDN group experienced cardiac events. in the ISDN group, 35 patients (7.4%) experienced cardiac events during the observation period, versus only 28 patients (4.4%) in the no‐treatment group (p<0.05; odds ratio 1.74; 95% confidence interval 1.04–2.90).

Conclusion: Continuous long‐term dosing with oral, slow‐release ISDN does not reduce and probably increases the incidence of cardiac events among patients with healed MI.
The effect of thrombolytic therapy on left ventricular aneurysm formation in acute myocardial infarction: Relationship to successful reperfusion and vessel patency
Authors: Tikz H. , Balbay Y. , Atak R. , Terzi T. , Gençl Y. , Utüuk E. Kü
Published: February 2009

Background: Although there is increasing evidence for the beneficial effect of thrombolytic therapy on global left ventricular (LV) function in acute myocardial infarction (AMI), the data concerning the early effect of thrombolytic therapy on the incidence of left ventricular aneurysm (LVA) formation and its relationship to clinical and angiographic determinants are limited.

Hypothesis: The study aimed to determine the independent factors involved in the development of LVA and to evaluate whether thrombolytic therapy has any preventive effect on the development of LVA in AMI.

Methods: In all, 350 consecutive patients suffering from a first attack of AMI were included. Of these, 205 who arrived within 12 h of onset of symptoms received thrombolytic therapy (thrombolytic group) and the remaining 145 patients served as control group. All patients received aspirin and maximal‐dose anticoagulation with intravenous heparin therapy. Early successful reperfusion was assessed by enzymatic and electrocardiographic evidence, and late vessel patency was evaluated according to Thrombolysis in Myocardial Infarction (TIMI) classification. Patients with TTMI grade 2 or 3 flow were considered to have vessel patency.

Results: The overall incidence of LVA was 11.7% (41/350), and no statistical difference was found between the incidence of LVA between the two groups (11.7 vs. 11.7%, p>0.05). However, the patients receiving thrombolytic therapy and exhibiting a patent infarct‐related artery (PIRA) (n = 125, 61%), had a significantly reduced incidence of LVA compared with those who did not (7.2 vs. 18.8%, p=0.015). In univariate analysis, vessel patency, proximal left anterior descending artery (LAD) stenosis, total LAD occlusion, multivessel disease, and hypertension were found to be important factors in LVA formation after AMI. After adjustment for other clinical and angiographic variables, total LAD occlusion (odds ratio [OR] 3.62,95% confidence interval [CI] 2.45–8.42, p = 0.0014), absence of PIRA (OR 2.92, 95% CI 1.41–09, p = 0.0037) and proximal LAD stenosis (OR 2.11, 95% CI 1.05–4.71, p = 0.045) remained the independent determinants of LVA formation after AMI.

Conclusion: Our data indicate that not all patients who received thrombolytic therapy, but only those with PIRA had evidently reduced the incidence of LVA. Patients with total LAD occlusion, with proximal LAD stenosis, and without PIRA were found to have increased risk for formation of LVA after AMI. These findings indicate that the presence of vessel patency has a preventive effect on LVA formation in AMI.
Left ventricular systolic and diastolic function after anthracycline chemotherapy in childhood
Authors: Iarussi Diana , Galderisi Maurizio , Ratti Gennaro , Tedesco Michele Adolfo , Indolfi Paolo , Casale Fiorina , Tullio Maria Teresa Di , De Divitiis Oreste , Iacono Aldo
Published: February 2009

Background: In childhood, late cardiotoxicity is characterized by inappropriately thin wall and consequent increased end‐systolic wall stress, but the associations of impaired left ventricular geometry and function occurring under these circumstances need further investigation.

Hypothesis: The purpose of this study was to assess anthracycline late effects on the relationships occurring between increased end‐systolic stress (ESS) and changes in both M‐mode systolic measurements (i.e., endocardial and midwall fractional shortening) and Doppler diastolic indices in the pediatric age.

Methods: The population consisted of 101 children treated with anthracyclines for at least 12 months and 91 healthy children. Using M‐mode echocardiography, end‐systolic wall stress was calculated as index of afterload, and endocardial and midwall fractional shortening as systolic indices. Doppler transmitral measurements were made as diastolic indices.

Results: Patients treated with anthracyclines showed significantly lower relative wall thickness and left ventricular mass index, greater end‐systolic wall stress, reduced endocardial and midwall fractional shortening and peak E/A ratio, prolonged deceleration, and isovolumic relaxation times. Direct relationships were found between end‐systolic wall stress and both endocardial and midwall shortening. The use of midwall shortening in the relation showed a greater, but not significant increase (from 3 to 6%) in the proportion of patients with depressed systolic function than did endocardial shortening. In the anthracycline group, end‐systolic wall stress was also inversely related to relative wall thickness and directly to isovolumic relaxation time.

Conclusions: In childhood, reduced myocardial thickness and increased afterload explain much of systolic and diastolic dysfunction of late anthracycline toxicity. Midwall fractional shortening does not seem to add useful information for identifying subsets of children more prone to the development of heart failure.
Magnetocardiographic mapping of QRS fragmentation in patients with a history of malignant tachyarrhythmias
Authors: Göudde P. , Agrawal R. , Müuller H.‐P. , Czerski K. , Endt P. , Steinhoff U. , Oeff M. , Schultheiss H.‐P. , Behrens S.
Published: February 2009

Background: The identification of patients at increased risk for ventricular tachycardia or ventricular fibrillation (VT/VF) and sudden cardiac death has consequences for therapeutic options and thus may reduce mortality in patients with coronary artery disease (CAD).

Hypothesis: We hypothesized that the intra‐QRS fragmentation in magnetocardiographic recordings is increased in patients with CAD and with a history of VT/VF.

Methods: Multichannel magnetocardiography (MCG) was carried out in 34 healthy controls, 42 patients with CAD without a history of VT/VF, and 43 patients with CAD and with a history of VT/VF. The intra‐QRS fragmentation was quantified by a new fragmentation score. Its spatial distribution was investigated using two‐dimensional (2‐D) contour maps according to the sensor position of the 49‐channel magnetogradiometer.

Results: Patients with CAD and with a history of VT/VF had significantly increased QRS fragmentation compared with patients with CAD without VT/VF or controls (72.9 ± 37.5,48.5 ± 14.3, and 42.5 ± 7.8, respectively; p< 0.05). The area of high fragmentation in 2‐D contour maps was twice as large in patients with than in those without a history of VT/VF (represented by the number of MCG channels with high fragmentation: 26.3 ± 15.5 vs. 12.4 ± 9.9, p<0.0001). Patients prone to VT/VF could be identified with a sensitivity of 64% and a specificity of 90%.

Conclusion: In patients with CAD and with a history of VT/VF, intra‐QRS fragmentation is increased and the area of high fragmentation in 2‐D contour maps is enlarged. These findings may be helpful in identifying patients with CAD at risk for malignant tachyarrhythmias.
Interleukin‐6 and acute coronary syndrome
Authors: Ikeda Uichi , Ito Takayuki , Shimada Kazuyuki
Published: February 2009

The designation of atherosclerosis as a chronic inflammatory process represents an exciting and logical paradigm shift for cardiologists. Plasma concentrations of interleukin‐6 (IL‐6) and its hepatic by‐product C‐reactive protein (CRP) appear to reflect the intensity of occult plaque inflammation and by inference may determine vulnerability to rupture. Indeed, circulating IL‐6 levels are elevated in patients with acute myocardial infarction (AMI), and also in patients with unstable, but not with stable angina. Coronary sinus IL‐6 concentrations are also increased after percutaneous coronary intervention (PCI), and late restenosis correlates with an increase in IL‐6 concentration after the procedure, indicating that IL‐6 expression may be not only related to instability of atheromatous plaques, but also to the formation of restenotic lesions after PCI. These observations suggest the advantage of screening for circulating IL‐6 concentration and the use of anti‐inflammatory treatment for those thought be at high risk to reduce the risk of future AMI.