International Journal of Cardiology

Editorial Board

2012-05-31

The use of coercive trial acronyms should be discouraged

Tsung O. Cheng — 2012-03-26

Physicians, especially cardiologists, like to use or invent acronyms . All the current medical journals, especially cardiological journals, continue to be filled with acronyms. New acronyms are being invented every day, especially for cardiological trials. The use of acronyms is sometimes necessary to simplify and facilitate modern communication in our highly technical world, especially to avoid repetition of long, unwieldy, breath-catching and space-occupying trial names in a scientific publication . A trial acronym is particularly advantageous to the participating investigators of the trial who, by merely mentioning the acronym, can be instantly referred to the appropriate staff to answer any questions when they call a trial center to register a potential patient .

Circulating biomarkers with preventive, diagnostic and prognostic implications in cardiovascular diseases

Allegra Battistoni, Speranza Rubattu, Massimo Volpe — 2011-07-15

Abstract: The search for molecules that may contribute to better identify patients at risk for cardiovascular diseases (CVD) represents today an active field in clinical research. Few biomarkers have already been identified as reliable and useful tools in medical decision making, such as cardiac troponin (cTn) and NT-proBNP. At the same time, evidence regarding the possible role of other molecules is piling up. Every new putative biomarker has demonstrated effectiveness in at least one clinical application: cardiovascular risk assessment, diagnosis or outcome prediction. On the other hand, combination of preventive, diagnostic and prognostic implications for the same molecule is expected to improve enormously the usefulness of a biomarker in medicine. We performed a search of the literature looking for circulating molecules found to exert discriminating abilities in all three mentioned clinical applications. The purpose of the present review is to bring to the attention of medical and research communities those biomarkers for which a relevant amount of evidence has been accumulated regarding their potential application in all clinical steps of the cardiovascular continuum.Furthermore, since simultaneous testing of different plasmatic molecules has been proposed as a suitable tool to improve medical decision making, we also discuss feasible associations of biomarkers that promise to be the most effective for cardiovascular risk assessment in the general population and for outcome prediction in patients affected by acute coronary syndrome (ACS) and by heart failure (HF).

Non-red blood cell transfusion as a risk factor for mortality following percutaneous coronary intervention

2011-01-10

Abstract: Background: Bleeding following percutaneous coronary intervention (PCI) is common and may lead to transfusion and death. Although previous work has examined the effect of red blood cell (RBC) transfusion in patients with coronary disease, no study had investigated whether transfusion of non-RBC components was associated with mortality following PCI.Methods: All subjects transfused in the 10days following PCI were identified using the British Columbia Cardiac and Central Transfusion Registries. Patients undergoing cardiac surgery following PCI were excluded as transfusion was assumed to be due to surgical related bleeding. Transfusion products were categorised as RBC and non-RBC comprising platelets, plasma and cryoprecipitate. Blood product use was compared according to thirty day mortality using multivariate regression and propensity adjustment for confounding variables.Results: From a total of 32,580 patients who underwent PCI, 952 patients received at least 1 blood product within 10days of PCI. Non-RBC transfusion occurred more commonly in the cohort of transfused patients dying within 30days (p<0.001). After adjustment for baseline risk, transfusion of plasma/cryoprecipitate (HR 5.17; 95% C.I. 2.87–9.32, p<0.001) and platelets (HR 2.13; 95% C.I. 1.10–4.13, p=0.03) was associated with increased 30day mortality. In a propensity risk adjusted model, transfusion of plasma/cryoprecipitate and RBC transfusion volume remained as significant predictors of 30-day mortality (p<0.001).Conclusions: Transfusion following PCI appears to be associated with an increased risk of death within 30days. We now report that transfusion with plasma rich non-RBC products may confer an additional mortality risk to patients undergoing PCI.

Tanshinone IIA prevents doxorubicin-induced cardiomyocyte apoptosis through Akt-dependent pathway

2010-12-30

Abstract: Background: Doxorubicin, one of the original anthracyclines, remains among the most effective anticancer drugs ever developed. Clinical use of doxorubicin is, however, greatly limited by its serious adverse cardiac effects that may ultimately lead to cardiomyopathy and heart failure. Tanshinone IIA is the main effective component of Salvia miltiorrhiza known as ‘Danshen’ in traditional Chinese medicine for treating cardiovascular disorders. The objective of this study was set to evaluate the protective effect of tanshinone IIA on doxorubicin-induced cardiomyocyte apoptosis, and to explore its intracellular mechanism(s).Methods: Primary cultured neonatal rat cardiomyocytes were treated with the vehicle, doxorubicin (1μM), tanshinone IIA (0.1, 0.3, 1 and 3μM), or tanshinone IIA plus doxorubicin.Results: We found that tanshinone IIA (1 and 3μM) inhibited doxorubicin-induced reactive oxygen species generation, reduced the quantity of cleaved caspase-3 and cytosol cytochrome c, and increased BcL-xL expression, resulting in protecting cardiomyocytes from doxorubicin-induced apoptosis. In addition, Akt phosphorylation was enhanced by tanshinone IIA treatment in cardiomyocytes. The wortmannin (100nM), LY294002 (10nM), and siRNA transfection for Akt significantly reduced tanshinone IIA-induced protective effect.Conclusions: These findings suggest that tanshinone IIA protects cardiomyocytes from doxorubicin-induced apoptosis in part through Akt-signaling pathways, which may potentially protect the heart from the severe toxicity of doxorubicin.

Duration of preceding hypertension is associated with prolonged length of ICU stay

2011-01-03

Abstract: Background: A substantial proportion of patients suffer prolonged length of intensive care unit stay (PLOS) or prolonged mechanical ventilation (PMV) following coronary artery bypass grafting (CABG). Identifying factors associated with PLOS and PMV would aid in patient risk stratification. We sought to identify the factors associated with PLOS and PMV following CABG.Methods: Participants were patients undergoing first-time elective CABG. All were observed until discharge and clinical data were collected on a standardized proforma. PLOS and PMV were defined a priori as >2days and >12h respectively, based on centre norms.Results: Of the 439 patients in the study, 105 (23.9%) had PLOS and 111 (25.2%) had PMV. Independent predictors of PMV were age, diabetes, previous myocardial infarction (MI), New York Heart Association (NYHA) class and statin use. The only independent predictor of PLOS was the duration of preceding hypertension.Conclusion: The factors associated with PMV and PLOS in our study are easily attainable, routine clinical details and may be built into bed management algorithms. Confirmation of the association of preceding hypertension and subsequent investigation of the possible mechanism mediating this association, is suggested.

Duty-cycled unipolar/bipolar versus conventional radiofrequency ablation in paroxysmal and persistent atrial fibrillation

2011-01-03

Abstract: Background: Duty-cycled (DC) radiofrequency ablation (RFA) for atrial fibrillation (AF) has been introduced, however, data on large patient series and comparison to conventional RFA are scarce.Methods: Between 2006 and 2008DC RFA was performed in 209 consecutive patients (143 (68%) paroxysmal and 66 (32%) persistent AF). As controls served 211 patients, 155 (73%) with paroxysmal and 56 (27%) with persistent AF (p=0.3). In DC RFA, the pulmonary veins (PV) were isolated followed by ablation at the septum and left atrium, if AF persisted. Conventional PV isolation was followed by anatomical lines at the roof and mitral isthmus.Results: Freedom of paroxysmal AF was demonstrated after 1.08DC RFA procedures per patient in 82% and after 1.19 conventional procedures in 87% after 8.5±6.5months (ns). In persistent AF, success rates were 79% after 1.35DC RFA procedures and 80% after 1.34 conventional procedures after 11.5±8.5months (ns). The subgroup analysis of 119 patients with follow-up ≥12months (17.5 [14.1–23.6] months) showed similar results. Left atrial flutter occurred in 3% and 8% after paroxysmal AF ablation (p<0.05) and in 12% and 23% after persistent AF ablation (p=0.1). Multivariate predictors for success in both groups were age, left atrial size, presence of persistent vs. paroxysmal AF and previous pacemaker implantation, but not the ablation technique used. Non-fatal complications were seen in 2.8% with no differences between the groups.Conclusion: Outcome in DC RFA is similar to conventional RFA with a final success rate exceeding 80% in both paroxysmal and persistent AF in the absence of fatal complications.

The N-terminal pro-B-type natriuretic peptide as a predictor of disease progression in patients with pericardial effusion

Dae-Seong Hwang, Shin-Jae Kim, Eun-Seok Shin, Sang-Gon Lee — 2011-01-03

Abstract: Background: The purpose of this study was to evaluate the value of N-terminal pro-B-type natriuretic peptide (NT-proBNP) as a predictor of disease progression in patients with pericardial effusions (PE).Method: We retrospectively studied consecutive patients that had moderate or large PEs. Patients with pericardial events, such as reaccumulation of PE, persistent drainage through a catheter longer than one week, or newly developed constrictive pericarditis were defined as the progression group (Group A), and patients without these findings were defined as the group with no progression (Group B). The NT-proBNP assay was performed when PE was detected.Results: Compared to Group B (27 patients), Group A (15 patients) exhibited lower systolic and diastolic blood pressures (106±13 vs. 118±19mmHg, p=0.028; 69±9 vs. 75±11mmHg, p=0.047), higher NT-proBNP levels (1063±756 vs. 578±1090ng/L, p=0.002), larger inferior vena cava (21±6 vs. 17±5mm, p=0.039) and higher estimated right ventricular systolic pressure (37±5 vs. 32±6mmHg, p=0.024). NT-proBNP was the only independent predictor of disease progression (p=0.034) by multivariate regression analysis. The receiver-operating characteristic curve analysis showed that NT-proBNP values ≥548ng/L demonstrated a sensitivity of 80% and a specificity of 78% for identifying disease progression (p=0.001).Conclusions: The NT-proBNP value may predict disease progression in patients with PE. However, additional prospective studies with more patients are needed.

Combined effects of up- and downstream therapies on atrial fibrillation in a canine rapid stimulation model

2011-01-03

Abstract: Background: Recent reports suggest angiotensin receptor blockers (ARBs) and some antiarrhythmic agents affect atrial remodeling in atrial fibrillation (AF). We evaluated the effect of combination therapy with olmesartan (Olm) and bepridil (Bep) in a canine model of AF.Methods and results: An atrial stimulation device was implanted in 10 dogs undergoing 6-week pacing at 400bpm. They were divided into Olm (2mg/kg/day) (n=5) and Olm+Bep (Olm, 2mg/kg/day; Bep, 10mg/kg/day) groups (n=5). Atrial effective refractory period (AERP), conduction velocity (CV), and AF inducibility were evaluated weekly, and hemodynamics, atrial histology, and mRNA expression and protein expression of ion-channel and gap junction-related molecules at 6weeks. Data were compared between groups and with non-pacing control and pacing-control groups from our previous report.The pacing-control group exhibited shortened AERP, decreased CV, increased AF inducibility and tissue fibrosis, and down-regulated L-type Ca2+ channel (LCC), SCN5A, Kv4.3 and connexin43 (Cx43). By comparison, the Olm group exhibited suppression of the decrease in CV and of the increase in AF inducibility, but no change in AERP shortening. The Olm+Bep group exhibited suppression of AERP shortening as well as the greatest decrease in AF inducibility. Histologically, tissue fibrosis was suppressed in Olm and Olm+Bep groups. Down-regulation of Cx43 was partly suppressed in the Olm group while that of LCC, SCN5A, and Cx43 was suppressed in the Olm+Bep group.Conclusion: Olm and Bep in combination suppressed AF inducibility more strongly than Olm alone, and may be more useful in the suppression of AF.

Defining high-risk patients with ST-segment elevation acute myocardial infarction undergoing primary percutaneous coronary intervention: A comparison among different scoring systems and clinical definitions

2011-01-14

Abstract: Background: Identification of high-risk patients with ST-segment elevation acute myocardial infarction (STEMI) is of the utmost importance for adequate patient stratification and evaluation of additive treatments. However, there is no consensus on the optimal definition of high-risk patients.Methods: We therefore compared 5 scoring systems in the assessment of the risk of 30-day mortality in 3214 patients with STEMI treated with primary percutaneous coronary intervention (PCI).Results: Clinical scores showed a large variability in risk stratifying patients. Identification of high-risk patients ranged from 15% (PAMI score≥9) to 66% (McNamara definition). McNamara, Antoniucci and Brodie definitions had the best sensitivity (0.87–0.88 and 95% confidence intervals (CI) ranging from 0.82–0.93) while PAMI≥9 had the best specificity (0.87 with 95% CI of 0.86–0.88), while its sensitivity was quite low (0.42). In a sample size simulation of a trial aimed at demonstrating a 33% difference in 30-day mortality between two hypothetical treatments, the number of STEMI patients needed to be screened varied from 4712 for the Brodie definition to 9038 for the PAMI≥9 score.Conclusions: There is a large variability in risk stratification, sensitivity, specificity and predictive values among different scoring systems. These considerations should be taken into account when designing randomised trials.

Mitral annular longitudinal function preservation after mitral valve repair: The MARTE study

2011-01-03

Abstract: Background: In patients with chronic mitral regurgitation (MR), undergoing surgical mitral valve repair, current Guidelines only recommend standard echocardiographic indices i.e. left ventricular (LV) ejection fraction (EF), and LV end-systolic and end-diastolic diameters as preoperative variables. However LV EF is often preserved until advanced stages of the valve disease. Aim of this study was to evaluate changes in LV systolic longitudinal function, 3months after mitral valve repair in patients with chronic degenerative MR and normal preoperative EF.Methods: We measured M-mode mitral lateral annulus systolic excursion (MAPSE) and Tissue Doppler (TD) peak systolic annular velocity (Sm) in 31 patients with moderate to severe MR and normal EF (59.9±4.7%) candidates for mitral valve repair, preoperatively and 3months after surgery.Results: After mitral valve repair, Sm increased from 7.8±1.4 to 9.6±2.2cm/s (p<0.0001) and MAPSE increased from 1.33±0.26 to 1.55±0.25cm (p=0.0013). EF decreased from 59.9±4.7 to 51.3±5.9% (p<0.0001). As expected, LV diameters and volumes, wall thicknesses, midwall fractional shortening (mFS), and left atrial (LA) size were all reduced after surgery.Conclusions: This study suggests that assessment of LV long axis systolic velocity and amplitude of excursion by echocardiography is more sensitive than simple determination of EF for revealing the beneficial impact of MR surgery on overall systolic function.

Circadian variation in coronary flow velocity reserve and its relation to α1-sympathetic activity in humans

2011-01-03

Abstract: Background: The circadian change in coronary microvascular function has not been directly assessed in human beings. Recent advances in transthoracic Doppler echocardiography (TTDE) provide noninvasive, physiological assessment of coronary flow velocity reserve (CFVR).Methods: This study consisted of 20 young healthy subjects (24±2years, 20 men) who underwent CFVR examinations at 3 different times; early morning (6AM), late morning (11AM) and late evening (10PM). The flow velocity in the distal portion of the left anterior descending coronary artery was measured with TTDE at baseline and during adenosine infusion to calculate CFVR. These examinations were repeated with the intake of α1-blocker (prazosin 1mg) on the other day.Results: CFVR showed a circadian variation with an increase from the early morning to the late morning, following a decrease to the late evening thereafter (4.4±0.9 at 6AM; 5.2±1.3 at 11AM; 4.2±1.1 at 10PM, p<0.001). In the study with α1-blocker, CFVR was comparable between the early morning and the late morning, whereas CFVR in the late evening was lower than those in other 2 time points (5.0±1.1 at 6AM; 4.9±0.9 at 11AM; 4.3±0.9 at 10PM, p<0.001).Conclusions: This study demonstrates that CFVR has a circadian variation in humans, with an increase from the late evening to the late morning. Adding α1-blocker ameliorated CFVR only in the early morning, indicating that α1-sympathetic activity plays a heterogeneous and important role in the circadian change of CFVR in humans.

Atrial tachyarrhythmias late after Fontan operation are related to increase in mortality and hospitalization

2011-01-03

Abstract: Background: Atrial tachyarrhythmias are a known complication late after Fontan operation. Limited information is available on their prognostic value.Methods: All patients with previous Fontan operation followed at our institution since 1999 were identified from the electronic database and included in this study. Demographic and clinical characteristics including history of atrial tachyarrhythmias were recorded at the earliest full clinical assessment and patients were followed thereafter for all-cause mortality and hospitalization.Results: A total of 98 patients, mean age 31.5±8.9years, 43.8% male, 31.6% with a total cavopulmonary connection (TCPC) were identified. A history of atrial tachyarrhythmia was present at baseline in 60.2% of patients who were older (33.0±8.3 vs 29.1±9.4years, p=0.002), less likely to have a TCPC (13.5% vs 58.9%, p<0.001), and more symptomatic in terms of NYHA class (51.9% vs 26.7%, p=0.007) compared to arrhythmia-free patients. During a median follow-up of 6.7years 18 patients died and 64 patients were hospitalized. Even after adjustment for baseline clinical characteristics, atrial tachyarrhythmia was an independent predictor of death (propensity score adjusted HR 9.35, 95% CI: 1.10–79.18, p=0.04, c-statistic 0.88) and composite of death or hospitalization (propensity score adjusted HR 5.00, 95% CI: 2.47–10.09, p<0.0001).Conclusions: In adult patients with a Fontan-type operation, the presence of atrial tachyarrhythmias is associated with higher morbidity and mortality at mid-term follow-up. Whether early arrhythmia targeting intervention may improve clinical outcome needs to be studied in a prospective manner.

Association between brachial-ankle pulse wave velocity and occult coronary artery disease detected by multi-detector computed tomography

2011-02-11

Abstract: Background: Arterial stiffness, assessed by aortic pulse wave velocity (PWV), has been reported to predict cardiovascular morbidity and mortality. We assessed the association between arterial stiffness, as determined by PWV, and occult coronary artery disease (CAD), as detected by multi-detector computed tomography (MDCT), in asymptomatic individuals.Method: We retrospectively enrolled 615 consecutive South Korean individuals who had undergone both brachial-ankle PWV (baPWV) and coronary CT angiography during general routine health evaluations at the Asan Medical Center in 2008.Results: We found that baPWV was positively correlated with age; body mass index; blood pressure; total cholesterol, homocysteine, and fasting blood glucose concentrations; and coronary artery calcium score. When we divided subjects into two groups according to the results of MDCT, we found that baPWV was significantly higher in subjects with (diameter of stenosis >50%) than without CAD (1573.2±275.6cm/s vs. 1409.6±235.6cm/s, p<0.01). The optimal baPWV cutoff value for detection of significant coronary arterial stenosis was 1426.0cm/s, which had a sensitivity of 77% and a specificity of 63% (area under curve=0.71). After adjusting for age, smoking status, hypertension, diabetes, and dyslipidemia, the odds ratio for significant occult CAD was 3.30 (95% CI=1.47–7.41, p<0.01).Conclusion: We found that baPWV was associated with risk factors for cardiovascular disease, including CACS, in asymptomatic individuals, and the optimal baPWV cutoff value for occult CAD detected by MDCT was 1426cm/s. These findings suggest that baPWV may be a useful screening tool for predicting occult CAD.

Increased enddiastolic wall stress precedes left ventricular hypertrophy in dilative heart failure—Use of the volume-based wall stress index

2011-08-22

Abstract: Introduction: To examine a potential interrelation of left ventricular (LV) wall stress and hypertrophy, we assessed increased wall stress in patients with suspected non-ischemic dilative cardiomyopathy and addressed the question whether increased LV wall stress is involved in the development of LV hypertrophy.Methods: We studied 502 consecutive patients in whom LV mass, LV enddiastolic (LVEDV) and endsystolic volume (LVESV) was determined using cardiac magnetic resonance (CMR). Based on a thick-walled sphere, we introduced a myocardial and cavity volume-based wall stress index. Follow up CMR examinations were obtained in a representative subgroup of 71 patients.Results: LV mass was correlated with LVEDV (r=0.517, P<0.001) and LVESV (r=0.510, P<0.001). Despite LV hypertrophy, LV mass was not sufficient to compensate for LV dilatation resulting in an increased wall stress. Increased LV enddiastolic wall stress was found in 227 patients (45 %) and increased endsystolic wall stress in 198 (39 %). In patients with normal LV enddiastolic wall stress ≤4kPa at time of enrolment, no changes of LV mass occurred during follow up (142±46g vs. 141±47g). In contrast, patients with initially increased LV enddiastolic wall stress >4kPa developed greater LV hypertrophy (141±48g vs. 158±60g, P=0.0247).Conclusions: LV wall stress can be derived from CMR measurements of LV myocardium and cavity using the volume-based wall stress index. Increased LV enddiastolic wall stress leads to LV hypertrophy. Beyond a certain degree of LV dilatation, the extent of hypertrophy does not compensate LV dilatation. The ensuing increased wall stress promotes dilatation and consecutively hypertrophy with an unfavorable prognosis. It is proposed to use the volume-based wall stress index as new diagnostic criterion in heart failure.

Frequency, determinants and outcome of elevated troponin in acute ischemic stroke patients

2012-02-13

Abstract: Background: Myocardial injury indicated by elevation of cardiac troponins (cTnT) can be observed in acute ischemic stroke patients. Frequency, determinants and prognostic value are still unsettled.Methods: We performed a retrospective analysis including all consecutive ischemic stroke patients admitted to our stroke unit within 72h after symptom onset in a one-year period. Multivariable logistic regression analyses were conducted to identify determinants of cTnT elevation and to detect factors independently associated with unfavorable short-term outcome (modified Rankin scale >2), major neurologic improvement (improvement of NIHSS>=8 or NIHSS 0–1) and in-hospital mortality.Results: Admission cTnT levels were measured in 715 ischemic stroke patients. Frequency of cTnT elevation was 14% (n=103). Factors independently associated with increased cTnT were higher stroke severity (p=0.04), renal insufficiency (p<0.001), pre-existing coronary artery disease (p=0.03), hypercholesterolemia (p=0.02) and insular cortex involvement (p<0.001). After exclusion of patients with renal insufficiency and coronary artery disease frequency of cTnT elevation was 10% (n=44) and only insular cortex involvement remained significantly associated. Increased cTnT on admission was an independent predictor of unfavorable outcome (adjusted odds ratio 2.65 [95% confidence interval 1.29–5.46]) and in-hospital mortality (4.51 [1.93–10.57]). There was a trend towards a negative association of cTnT elevation with major neurologic improvement (0.54 [0.27–1.07]).Conclusions: Elevation of cTnT occurs in every seventh patient with acute ischemic stroke and is independently associated with poor short-term outcome and mortality. Patients with strokes affecting the insular cortex are particularly prone to myocardial injury justifying intensive cardiac monitoring.

Association of interleukin-6 circulating levels with coronary artery disease: A meta-analysis implementing mendelian randomization approach

Wenquan Niu, Yan Liu, Yue Qi, Zhijun Wu, Dingliang Zhu, Wei Jin — 2012-01-19

Abstract: Background: We aim to investigate whether the association between circulating interleukin 6 (IL-6) levels and the risk for coronary artery disease (CAD) is robust and perhaps even causal by a meta-analysis implementing mendelian randomization approach with IL-6 gene G–174C polymorphism as an instrument.Methods: Data were available from 19 articles encompassing 9417 CAD patients and 15982 controls. A random effects model was applied irrespectively of between-study heterogeneity, and publication bias was examined using a funnel plot and the corresponding statistics.Results: Overall, comparison of IL-6 gene alleles –174C with –174G had 4% increased risk for CAD (95% confidence interval [95% CI]: 0.97–1.10; P=0.285), accompanying marginal heterogeneity (I2=38.3%; P=0.033). This association was potentiated in dominant model as odds ratio (OR) reached 1.08 (95% CI: 0.96–1.22; P=0.204) and heterogeneity was significant (I2=58.4%; P<0.0005). Subgroup analysis by ethnicity indicated that carriers of –174C allele were associated with a 12% increased risk for CAD in prospective studies involving White populations (OR=1.12; 95% CI: 0.95–1.33; P=0.184), whereas the association in East Asians was remarkably reversed with 37–46% reduced risk. Relative to –174GG homozygotes, carriers of –174C allele had an overall 0.24pg/ml high circulating IL-6 levels (P=0.047). The predicted OR for 1pg/ml elevation in IL-6 levels was 1.60 (95% CI: 1.44–1.72; P<0.01) in prospective studies involving White populations. Publication biases were absent for all comparisons (P>0.1).Conclusion: Our findings provided strong evidence on the causal association of circulating IL-6 levels with the development of CAD in White populations.

Reply to “Is interleukin-6 circulating levels associated with coronary artery disease?”

Wenquan Niu — 2012-04-06

I thank Dr. Chibo Liu for the comments and interest in this study. Dr. Liu has expressed concerns over the opposite association of interleukin 6 (IL-6) gene G–174C polymorphism with coronary artery disease (CAD) between Caucasians and East Asians. It seems somewhat “conflicting” at first glance; however, considering the facts that overall association in East Asians is negative with wide 95% confidence interval, and the upper limit of this interval (1.12) is greater than the unity, we cannot exclude the possible risk-conferring effect of the −174C allele on CAD in East Asians, relative to that in Caucasians. Moreover, it is not uncommon in association studies to encounter genetic heterogeneity across different ethnicities. It is generally accepted that CAD is a complex syndrome, and divergent genetic linings or linkage patterns might account for these differences, and a polymorphism may be a contributory locus to CAD in one ethnic group but not in another. This might be the case for the IL-6 gene G–174C polymorphism and the risk for CAD.

Atorvastatin therapy reduces serum uric acid levels: A meta-analysis of randomized controlled trials

Hisato Takagi, Takuya Umemoto — 2012-02-23

Elevated serum uric acid (SUA) levels are associated with increased cardiovascular disease (CVD) risk in patients with metabolic syndrome , chronic kidney disease , established coronary artery disease , and in the general population . In a large cohort of men and women at high risk of CVD, there was an unadjusted 39% increase in the risk of death for each 1-mg/dL increase in the SUA level, and the SUA level continued to predict the risk of death (hazard ratio, 1.26) even after adjusting for multiple CVD risk factors . Accordingly, SUA-level reduction could contribute to the reduction in CVD events. A subgroup analysis of the GREek Atorvastatin and Coronary-heart-disease Evaluation (GREACE) study suggests in patients with coronary heart disease (CHD) not treated with statins that SUA levels increase over time, contributing to the increase in risk for subsequent events. Conversely, long-term atorvastatin treatment (titrated to achieve the National Cholesterol Educational Program low-density lipoprotein [LDL] goal) significantly improves renal function and reduces SUA levels in these patients, thus offsetting an additional factor associated with CHD risk . In the ATOrvastatin and ROSuvastatin (ATOROS) study , SUA levels decreased in the atorvastatin-treated group but did not significantly change from baseline after rosuvastatin treatment. In the Pitavastatin, Atorvastatin, and Rosuvastatin for Safety and Efficacy (Quantity and Quality of LDL) (PATROL) trial , however, SUA was decreased in the atorvastatin and rosuvastatin groups not in the pitavastatin group; but no significant differences were seen among them. There has been no meta-analysis of these randomized controlled trials to date. To determine whether atorvastatin therapy reduces SUA levels, we performed a meta-analysis of randomized controlled trials.

Subclinical and clinical presentation of Kounis syndrome: Another cause of troponin elevation?

2012-04-09

The development of acute coronary syndrome with ST-segment elevation as a consequence of an allergic reaction has been described for patients with known coronary artery disease, as well for patients with normal coronary arteries ( type II and type I variants of Kounis syndrome) , due to release of inflammatory factors and their influence on epicardial heart vessels. However, the strict release of high sensitivity cardiac troponins during an allergic reaction, without the typical clinical and laboratory characteristics of an acute coronary syndrome has not been described and may implicate a direct primary allergic myocardial injury.

Real-time CartoSound imaging of the esophagus: A comparison to computed tomography

2012-04-20

Atrioesophageal fistula is a rare, yet highly fatal complication of atrial fibrillation (AF) ablation occurring as a result of thermal injury to the esophagus during radiofrequency ablation (RFA) of the posterior left atrial wall. Accurate imaging of the left atrial–esophageal relationship facilitates modification of posterior left atrial RFA such that esophageal injury is minimized. Computed tomography (CT), is generally performed in the days preceding ablation to define the 3D anatomy of the left atrium and surrounding structures. However, it is not known if it reflects the anatomy during ablation. Techniques including temperature probes, barium esophagram and intracardiac echocardiography (ICE) have been devised to determine real-time esophageal location during AF ablation with variable success . The current study aimed to describe the initial, single-center experience using 2-dimensional ICE with CartoSound to obtain a 3-dimensional esophageal map. In addition, we compared esophageal location between CT performed in the week preceding ablation, and CartoSound performed immediately prior to ablation.

Constructing a point-based prediction model for the risk of coronary artery disease in a Chinese community: A report from a cohort study in Taiwan

2012-04-16

Identifying individuals in a community who are at high risk of coronary artery disease will improve the efficiency of primary prevention strategies. Recent cohort studies have provided many risk prediction models for clinical practice . Routinely available and easily collected clinical information and lifestyle-related factors have been found to be effective to recognizing coronary risk . However, the available prediction models providing absolute risk for coronary risk are not only scanty but have also been developed primarily based on Caucasians whose coronary risks were high. The performance of prediction models applied in relatively low coronary artery disease events is unknown. Moreover, previous studies based on coronary artery diseases have been limited due to various outcome definitions , an inability to discriminate total and LDL cholesterol , lack of laboratory and biomarker data, limited validation, and a lack of a simple manually-friendly algorithm usage . Furthermore, the various coronary artery disease outcome definitions may invalidate the generalization of the model application to other populations. Previous studies have demonstrated that the Framingham risk score, the most popular tool, overestimated the risk in other ethnic populations . We therefore constructed the prediction models for coronary artery disease risk using a community-based cohort of middle-aged and elderly ethnic Chinese in Taiwan by the following strategies. First, we incorporated gender, age, body mass index (BMI), systolic blood pressure, and smoking status as the clinical models, and included high density lipoprotein (HDL) cholesterol, total cholesterol and low density lipoprotein (LDL) cholesterol as the biochemical models. We also included electrocardiographic (ECG) left ventricular hypertrophy (LVH) and white blood cell count, an inflammatory marker, into the full model. Second, we constructed a simple points-based algorithm for clinical practice and public health screening. Third, we tested the performance measures of these prediction models and compared them with the available models, including the Framingham risk score and PROCAM model .

Role of sympathetic nervous system in myocardial ischemia injury: Beneficial or deleterious?

Xiaorong Hu, Xinhong Yang, Hong Jiang — 2012-03-29

It is well known that the activity of the autonomic nervous system is an important factor for the initiation of ischemia-induced ventricular arrhythmias and reperfusion injury after myocardial ischemia. Activation of the sympathetic nervous system could promote the occurrence of ischemia-induced ventricular arrhythmias and reperfusion injury after myocardial ischemia while the parasympathetic nervous system could provide a cardioprotective role in the ventricles, including ischemia-induced ventricular arrhythmias and reperfusion injury after myocardial ischemia . Recently, Buchholz et al. showed that efferent vagal nerve stimulation before ischemia could increase size of myocardial infarction after reperfusion. Meanwhile, they found that efferent vagal nerve stimulation could promote the release of noradrenaline and adrenaline plasma concentration ; while efferent vagal nerve stimulation during ischemia could inhibit the release of myocardial interstitial noradrenaline . These results suggested that efferent vagal nerve stimulation before ischemia could increase the infarct size which may be partly associated with activating sympathetic nervous activity.

Is interleukin-6 circulating levels associated with coronary artery disease?

Chibo Liu — 2012-03-28

I read with great interest the meta-analysis by Niu et al. who reported that interleukin 6 (IL-6) gene G-174C polymorphism might increase the risk of coronary artery disease (CAD) among allelic model (odds ratio (OR)=1.04, 95% confidence interval (CI) 0.97–1.10) and dominant model (OR=1.08, 95%CI 0.96–1.22). Interestingly, the associations among European populations (OR=1.04, 95%CI 0.97–1.12) and East Asians (OR=0.54, 95%CI 0.26–1.12) were somewhat conflicting. However, the all associations above were not statistically significant. In addition, the authors found statistically significant associations between G-174C polymorphism and circulating IL-6 levels (P=0.047), and between IL-6 levels and CAD (OR=1.60, 95%CI 1.44–1.72) among European population. Even though, several issues should be considered in this meta-analysis.

Relationship between Holter findings immediately after ablation of typical atrial flutter and subsequent risk of atrial fibrillation

2012-03-29

Radiofrequency catheter ablation is an established effective treatment for typical atrial flutter (AFL) but many patients will subsequently develop atrial fibrillation (AF) . We have previously reported that 73% of 135 patients who underwent successful AFL ablation experienced AF during a median follow-up of 7.1years . History of preablation AF and left atrial (LA) enlargement predicted postablation AF. A subset of 114 patients had a 24-hour Holter recording before discharge. In this report we analyzed whether early Holter findings could predict AF occurrence.

Suppressed left atrial function in PAF

Mark Henein, Per Lindqvist, Michael Y. Henein — 2012-03-23

We thank Dr Li and his colleagues for their correspondence and for highlighting the differences between our published study in IJC and theirs . Our study aimed at assessing left atrial contractile function using speckle tracking echocardiography in a group of paroxysmal atrial fibrillation (PAF) patients over a month after the last episode. The results showed clear evidence for reduced left atrial systolic function as shown by strain and strain rate measurements of the whole cavity mainly involving as well the lateral wall. These findings are in agreement with Dr Li's results in a similar group of PAF patients (as stated in his letter). Despite their study being unpublished and therefore difficult to compare the main difference between the two studies was our control group which consisted of healthy age and gender matched subjects with no risk factors compared to hypertensives with no PAF in Dr Li's study. An additional interesting finding was the time to peak longitudinal strain which was delayed in Dr Li's patients. Although we did not measure this time interval, such finding concurs with our previously published work where we found atrial electromechanical delay, measured from M-mode recordings of the atrial function, significantly prolonged in patients prone to atrial arrhythmia . Furthermore, using STE with its limited frame rate (commonly less than 100f/s) limits the accuracy of time interval measurements.

Normalcy rate of computed tomographic coronary angiography

Andrea K.Y. Lee, Yeung Yam, Benjamin J.W. Chow — 2012-03-29

Computed tomographic coronary angiography (CTCA) is an effective non-invasive tool for the detection and risk stratification of patients with suspected coronary artery disease (CAD) . Many previous studies have focused upon a biased population already referred to invasive coronary angiography (ICA). As such, operating characteristics measured in these studies may not reflect diagnostic accuracy in the routine clinical CTCA population. To account for such bias, the normalcy rate (NR) has been employed to estimate the true specificity of a diagnostic test in clinical practice . We sought to assess the NR of CTA in a clinical CTCA patient population with low pretest probability (≤4%) for CAD.

Heart failure and atrial fibrillation — Does practice meet the anticoagulation guidelines?

2012-04-04

Heart failure (HF) and atrial fibrillation (AF) are common and commonly overlapping conditions . HF coexisting with AF is one of the factors associated with higher risk of thromboembolic stroke. Accordingly, HF is included both in the CHADS2 and CHA2DS2-VASc, used to estimate the need for anticoagulation in patients with AF.

Questionnaire survey on depression for patients with heart failure: Validation for selecting appropriate cut-off points

Tomoyuki Kawada — 2012-03-28

Angermann et al. conducted the prospective study on the prevalence of depression in 702 patients (501 males and 201 females) hospitalized for heart failure with a left ventricular ejection fraction ≤40% . They defined suspected episodes of depression using the Patient Health Questionnaire (PHQ-9). PHQ-9 score≥11 (9–11) was defined as suspected major (minor) depression.

The implications of a fragmented QRS complex and newly reclassified revised cardiac risk index including fragmented QRS in patients undergoing non-cardiac vascular surgery

2012-03-30

The Revised Cardiac Risk Index (RCRI) is used for stratifying the risk of patients before vascular surgery. However, previous studies showed that the RCRI was limited in its ability to predict patients with high cardiac risks when this scoring system was used in a real clinical setting . Twelve-lead resting ECG is currently the gold standard in differential diagnosis and performing risk stratification of acute coronary syndrome . Among several ECG parameters, a fragmented QRS complex (fQRS), a novel marker of cardiovascular disease, has been shown to be a sign of myocardial ischemia or scar, as detected by myocardial perfusion single photon emission computed tomography (SPECT) . The purpose of this study was to assess the implication of the fQRS and newly reclassified RCRI including the fQRS (fRCRI) for cardiac risk stratification in patients undergoing non-cardiac vascular surgery.

Screening children with suspected myocarditis for global and regional myocardial dysfunction using two-dimensional speckle tracking echocardiography: Is it of use?

2012-03-29

Myocarditis may be difficult to diagnose in children when no pronounced cardiac dysfunction is present . Although endomyocardial biopsy has been considered the diagnostic standard for acute myocarditis, it is not performed routinely due to many inherent risks and the low sensitivity of the Dallas criteria . Moreover, the diagnostic value of conventional echocardiography seems limited because many patients have a normal echocardiogram . However, two-dimensional speckle tracking echocardiography (STE), a new technique for the assessment of regional and global myocardial strain and strain rate, may have a clinical utility in this setting .

The impact of blood transfusion on short and long term prognosis in STEMI patients treated with primary percutaneous coronary intervention: A single center-experience

2012-04-04

Conflicting results have been reported in studies exploring the effect(s) of blood transfusion in ST-elevation myocardial infarction (STEMI) and discrepancies are to be related to patient selection criteria (acute coronary syndromes vs STEMI), type of revascularization (thrombolysis vs PCI) and to the hemoglobin (or hematocrit) threshold chosen to perform transfusions.

Additive impact of diabetes mellitus on patients with metabolic syndrome and acute ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention

2012-04-09

Metabolic syndrome (MetS) and its constituent components have been reported to play a pivotal role in the development of coronary artery disease (CAD) and type 2 diabetes mellitus (DM) . There have been several studies indicating that MetS itself is associated with a risk of CAD progression or mortality, both in patients with and without preexisting CAD, regardless of the presence of DM . However, the consequence of DM on clinical outcome in MetS patients who underwent primary percutaneous coronary intervention (PCI) due to acute ST-segment elevation myocardial infarction (STEMI) still remains unclear. We investigated whether DM constitutes a risk factor for poor mid-term clinical outcomes in MetS patients who suffered from acute STEMI and underwent primary PCI.

Survey of antibiotic prophylaxis for implantable cardiac electronic device (ICED) insertion in England

Emma Lowe, Muzahir H. Tayebjee, Jyoshna Pratty, Jonathan A.T. Sandoe — 2012-04-02

A recent study showed that implantable cardiac electronic device (ICED) infection occurred at 4.82/1000 pacemaker years . With increasing indications for ICED implantation , and therefore more patients undergoing implantation , especially in patients with multiple co-morbidities, the incidence of infection has increased . The consequences of ICED infection are serious and the subsequent management is often complex, making it a significant health problem. These infections may involve the generator pocket or the electrodes or both and may be associated with bloodstream infection, severe sepsis, infective endocarditis and a variety of other secondary foci of infection . With a 1year mortality of approximately 17% there is a significant potential cost for the patient as well as economic consequences for the National Health Service (NHS).

Residual aortic regurgitation is a major determinant of late mortality after transcatheter aortic valve implantation

2012-04-11

After the implantation of catheter-based aortic prostheses, residual aortic regurgitation (AR) has been shown to occur in a sizable proportion of patients . However, the importance of residual AR on the prognosis after TAVI remains largely unexplored.

A population-based follow-up study on the risk of acute myocardial infarction following adhesive capsulitis

Jiunn-Horng Kang, Joseph J. Keller, Herng-Ching Lin — 2012-04-04

Adhesive capsulitis (AC), or frozen shoulder, is a common disease involving the shoulder which manifests with chronic pain and progressive stiffness . AC is considered to be a regional rheumatic disease. Several systemic rheumatic diseases including rheumatoid arthritis, ankylosing spondylitis, and systemic lupus erythematous have been reported to increase the risk of developing cardiovascular disease . However, any association between regional rheumatic disease and cardiovascular disease is seldom mentioned. In one of our previous studies we noted that patients with AC were at an increased longitudinal risk for stroke. That finding supports the hypothesis that AC patients may suffer from unfavorable effects contributory to cardiovascular risk . Since acute myocardial infarction (AMI) is one of the most life-threatening cardiovascular diseases, the present study aimed to explore the prevalence and risk of AMI following AC with a retrospective population-based cohort design.

Optical coherence tomography assessment of early stent strut coverage in patients treated with a thin-strut bare cobalt-chromium stent coated with silicon carbide

2012-04-09

Although coronary stenting has significantly improved procedural and long-term outcomes in patients undergoing percutaneous coronary intervention (PCI), these procedures are still associated with significant rates of restenosis and thrombosis . Although early stent thrombosis is mainly related to technical aspects of the procedure, many studies have shown that late and very late thrombosis after bare metal stent (BMS) or drug eluting stent (DES) implantation may be related to incomplete endothelialisation and uncovered stent struts . The PRO-Kinetic (Biotronik, Bulach, Switzerland) cobalt-chromium stent is a new generation stent with thin struts (60μm) and a passive coating. These features may reduce restenosis rates as compared to old thick-strut stainless-steel BMS and facilitate faster healing processes. This latter feature is obtained with PROBIO®, which is an amorphous, hydrogen-rich, phosphorous-doped silicon carbide (a-SiC:H) coating considered to be biologically inert and proven to induce less inflammation and thrombogenicity when used as stent coating . Silicon carbide-coated surfaces allow for faster cell coverage and improved cell structure as compared to bare metal surfaces . Animal studies have demonstrated an almost complete re-endothelialisation process 14days after PRO-Kinetic stent implantation . In the present study we used optical coherence tomography (OCT), which provides detailed insights into the biological reaction to stent implantation, to assess the short-term (3 to 6weeks) stent strut coverage in patients treated with PRO-Kinetic coronary stents.

Combination cell therapy for the treatment of acute myocardial infarction

G.P. Lasala, J.A. Silva, C. Allers, J.J. Minguell — 2012-04-09

Over the past 10years, several studies have been carried out to determine whether the infusion of peripheral blood (PBSC) or bone marrow-derived cell products (mononuclear, CD34+, CD133+ or ALDH+ cells) may improve cardiac function, after myocardial infarction (MI). The hypothesis behind these studies has been that infusion of a product containing endothelial progenitor cells (ECs) may enhance the formation of new blood vessels. Results have shown that while the infusion of these products is safe and feasible, the effect on left ventricular function has been negligible or modest. The poor responses observed could be related to timing, type and number of cells used, route of administration or other variables .

The missing link between heart failure and sleep disordered breathing: Increased left ventricular wall stress

2012-04-09

Sleep disordered breathing (SDB) is a frequent finding in patients with heart failure . Central sleep apnoea (CSA) , obstructive sleep apnoea (OSA) and complex types have been observed . CSA is closely linked to the sympathetic tone . Although several surrogate markers of heart failure improved during therapy, influences on the outcome remain controversial . It is unknown whether SDB is an epiphenomenon or promotes by itself progression of heart failure . Left ventricular (LV) dilatation leads to increased wall stress that precedes LV hypertrophy . Inappropriate LV hypertrophy is associated with adverse prognostic consequences . We hypothesized that LV wall stress based on cardiac magnetic resonance (CMR) imaging is associated with SDB.

Diagnosis of cardiac tumors: Contribution of non-invasive cardiac imaging in routine practice

2012-04-09

Cardiac tumors are rare . Transthoracic echocardiography (TTE) is usually performed to detect an abnormal cardiac mass and can be completed by transesophageal echocardiography (TEE) . However, cardiac ultrasonography may be limited . Cardiac cross-sectional imaging (CCSI), including computed tomography (CT) and magnetic resonance imaging (MRI), has many applications, including diagnosis and analysis of cardiac tumors . A lot of case reports and reviews have been published, describing the characteristics of various cardiac tumors using CCSI. However, very few studies have assessed the precise contribution of these examinations for the diagnosis and treatment of cardiac tumors in routine practice.

Body mass index is related to the perception of exertional breathlessness in patients presenting with dyspnoea of unknown origin

Lee Ingle, John G. Cleland, Andrew L. Clark — 2012-04-09

Exercise intolerance is the primary symptom of chronic heart failure (CHF) regardless of aetiology. That patients with left ventricular systolic dysfunction (LVSD) have reduced exercise capacity is well known , but many patients who present with breathlessness have no obvious underlying cause. They may have normal (or near normal) hearts on echocardiography and no evidence of inducible myocardial ischaemia, have normal (or near normal) spirometry, and have no other obvious cause for their symptoms such as anaemia. The causes of their breathlessness are poorly understood, and, many such patients acquire the label of “heart failure with normal ejection fraction” (HeFNEF) or “diastolic heart failure” .

Efficacy and safety profile of dronedarone in clinical practice. Preliminary results of the Magdeburg Dronedarone Registry

2012-04-11

Dronedarone, a relatively new antiarrhythmic drug, has recently been approved for the therapy of atrial fibrillation (AF). So far dronedarone has been evaluated only in a few controlled trials, and there still is a paucity of practical experience in the clinical context and the safety profile of the drug is not well established. Therefore, we conducted an inception cohort study to monitor the efficacy and tolerance of dronedarone in patients admitted to the hospital with paroxysmal or persistent AF. In this letter we present preliminary results of the Magdeburg Dronedarone Registry (MADRE) study. The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology .

Mutational spectrum of the GATA5 gene associated with familial atrial fibrillation

2012-04-09

Atrial fibrillation (AF) is the most common cardiac arrhythmia seen in clinical practice, with an estimated prevalence of 1–2% in the general population. The incidence of AF increases dramatically with age, ranging from less than 1% in patients under 60years of age to almost 10% in those aged 80 and over . AF is associated with substantial morbidity, mortality and health care burden. AF confers a five-fold increased risk of stroke, and about 15–20% of all strokes result from this tachycardia. AF also accounts for an approximately two-fold increase in risk of death, and a third of all hospitalizations for cardiac rhythm disturbances . AF frequently arises from diverse cardiac and systemic disorders, including hypertension, coronary artery disease, valvular heart disease, and hyperthyroidism . However, in 30% to 45% of AF cases, an underlying cause cannot be detected by routine methods, a condition usually defined as idiopathic or lone AF, of which at least 15% have a positive family history, hence termed familial AF . There is now growing evidence demonstrating that genetic defects play an important role in the pathogenesis of AF and multiple genes involved in AF have been identified . Nevertheless, AF is genetically heterogeneous and the genetic determinants of AF remain largely unclear.

Serial cardiac imaging in peripartum cardiomyopathy

2012-04-12

Peripartum cardiomyopathy (PPCM) is a rare and life-threatening disease that occurs most frequently in the last trimester of pregnancy and in the first months after delivery . The etiology of PPCM is still largely unknown. Uncertainty also exists concerning the time point of disease onset. Early (17th gestational week) and late presentations of PPCM are described and both regarded as a continuum of the same disease .

Adequacy of antithrombotic therapy and gender differences in hypertensive patients with atrial fibrillation

Teresa Gijón-Conde, Auxiliadora Graciani, José R. Banegas — 2012-04-11

Atrial fibrillation (AF) is the most common type of arrhythmia . Stratification of the risk of stroke is based on the presence of certain risk factors , and clinical practice guidelines base the indication for anticoagulation or antiplatelet therapy on the different scores . However, despite these recommendations, the use of anticoagulation is suboptimal and patients do not always receive it adequately . Few data are available on adherence to clinical guidelines regarding prescription of anticoagulants in relation to stroke risk stratification according to the CHADS2 scale. Studies have reported anticoagulation levels between 39 and 70% in high risk patients . One study, however, reports similar levels of oral anticoagulant (OAC) use for all scale scores, with underuse in high risk patients and overuse in those with low risk .

A significant association of plasma serotonin to cardiovascular risk factors and changes in pulse wave velocity in patients with type 2 diabetes

Hidekatsu Yanai, Yuji Hirowatari — 2012-04-18

Recently, platelet dense-granule secretion has been reported to play a critical role in not only thrombosis but also subsequent atherosclerotic vascular remodeling after vascular injury in atherosclerotic mice . Serotonin is one of the most important constituents of platelet dense granule. Very recently, plasma 5-hydroxyindole-3-acetic acid (5-HIAA), a derivative end product of serotonin, has been reported to be positively correlated with fasting plasma glucose and negatively correlated with high-density lipoprotein cholesterol in subjects with the metabolic syndrome . Further, plasma 5-HIAA levels were higher in subjects with the metabolic syndrome than in subjects without the metabolic syndrome, suggesting the potential importance of serotonin in the development of cardiovascular disease in the metabolic syndrome .

Sutureless valve implantation in a patient with bicuspid aortic valve

Giuseppe Santarpino, Steffen Pfeiffer, Theodor Fischlein — 2011-10-04

As the general population ages, the number of elderly patients referred for aortic valve surgery is growing. Surgical candidates often show multiple comorbid conditions, and new implantation techniques have been developed to minimize the surgical risk .

Adrenal venous sampling by using gadopentetate dimeglumine in patients with contraindications for iodinated contrast agents

2011-09-28

Primary aldosteronism, which is characterized by hypertension, hypokalemia, decreased plasma renin activity (PRA) and increased aldosterone secretion, can be caused by both unilateral and bilateral adrenal lesions . It is important to distinguish unilateral lesion from bilateral lesion because unilateral lesion is a curable form of secondary hypertension. Adrenal venous sampling guided by adrenal venography remains the most reliable examination . Iodinated contrast agents are routinely used in angiography. Anaphylactoid reaction to iodinated contrast agents is a rare, but life-threatening complication of angiography . The use of gadolinium contrast agents of visceral, peripheral, carotid or coronary arteries has been recently reported in patients with contraindications for iodinated contrast agents or renal insufficiency . In this report, we describe 2 cases of primary aldosteronism as well as contraindications for iodinated contrast agents, in which gadopentetate dimeglumine, gadolinium chelated by DTPA, was used as an alternative contrast agent for adrenal venography.

Arrhythmogenic right ventricular cardiomyopathy/dysplasia and troponin release. Myocarditis or the “hot phase” of the disease?

2011-10-03

A 21-year-old man was admitted due to sustained palpitations and an episode of presyncope. Twelve-lead resting ECG revealed sustained ventricular tachycardia with an average rate of 220bpm, LBBB configuration and superior axis (A). The patient was hemodynamically stable with arterial blood pressure 110/80mmHg and was converted to sinus rhythm (SR) with bolus infusion of 150mg amiodarone over 10min. After conversion to SR, a new 12-lead ECG exhibited inverted T waves in leads V1 to V4 and frequent ventricular extrasystoles of LBBB type and axis similar to that of VT (B).

Histological confirmation of hypersensitivity as a contributor to very-late coronary stent thrombosis

Rinku Rayoo, Mukta Rayoo, Giuseppe Ferrante, Peter Barlis — 2011-09-26

Drug-eluting stents (DES) have been an enormous success in reducing repeat revascularisations when compared to bare metal stents for patients with coronary artery disease. Nevertheless, their continued use is clouded by the fortunately uncommon, yet catastrophic complication of stent thrombosis . Thrombosis occurring beyond 1year after stent implantation, or very-late stent thrombosis (VLST), is multi-factorial. Premature discontinuation of dual anti-platelet therapy, incomplete apposition and delayed endothelialisation have all been implicated . An uncommon contributing factor is hypersensitivity occurring secondary to the permanent polymer coating of DES . In particular, the polymer of the first generation sirolimus-eluting stent (SES) has been associated with eosinophilic infiltration in post-mortem analyses of subjects with stent thrombosis . This report confirms such a phenomenon in a patient successfully treated with VLST 7years following SES implantation.

Never forget the abdomen in the evaluation of pediatric cardiac computed tomography

2011-10-17

A baby girl was diagnosed as double outlet right ventricle, subaortic ventricular septal defect, pulmonary atresia, and major aortopulmonary collateral arteries (MAPCAs) by echocardiography after delivery. Her vital signs were stable with saturation of 90%. She started feeding at 2days of age. Cardiac computed tomography (CT) was performed at 8-day-old for detailed anatomical evaluation. In addition to absent intrapericardial central pulmonary artery and MAPCAs (), portal venous gas was also noted incidentally (). Decreased activity and elevation of bilirubin (27.6mg/dL) developed one day later. Under the suspicion of pneumatosis intestinalis and sepsis, we gave broad spectrum antibiotics, ordered nothing-by-mouth, and started intensive phototherapy and double volume blood exchange for impending kernicterus. Because of progressively distended abdomen, plain abdomen X-ray was taken 3days after cardiac CT and showed subphrenic free air with the outline of the falciform ligament (). It suggested pneumoperitoneum and necrotizing enterocolitis (NEC) with possible bowel perforation.

A case of fulminant myocarditis ultimately diagnosed by tenascin C staining

2011-10-13

A 20-year-old young male college student, who was previously healthy, suddenly fell down and had a cardiopulmonary arrest in a train on the way to the college. The patient had no previous cardiac symptoms and no family history of cardiac disease or sudden death. A bystander immediately started cardiopulmonary resuscitation on him. Then, an emergency and rescue squad arrived at the scene after 17minutes and gave him defibrillation shock because the electrocardiographic monitoring showed ventricular fibrillation. The patient was transferred to our hospital with sustained ventricular fibrillation, and finally his sinus rhythm was restored after IABP and PCPS started.

Successful dual-valve transcatheter therapy for severe aortic stenosis and mitral regurgitation

2011-10-12

Transcatheter valve therapies have emerged to be a feasible alternative to patients with significant valvular diseases who are deemed too high risk for conventional open-heart surgery. Studies have demonstrated that Transcatheter Aortic Valve Implantation (TAVI) shows a mortality benefit over conservative management and non-inferior to surgical aortic valve replacement in patients with symptomatic severe aortic stenosis . For mitral regurgitation, edge-to-edge mitral valve repair using MitraClip system, when compared with conventional surgery, has been associated with superior safety and similar clinical outcome . However, unlike performing an open heart operation for concomitant aortic stenosis/regurgitation and mitral regurgitation, little is known about using transcatheter valve therapy to treat concomitant valve pathologies.

Turbulent flow inside coronary artery mimicking acute coronary syndrome in multislice computed tomography

2011-10-12

A 60-year-old man with hyperlipidemia and diabetes mellitus was referred for 64-slice multislice computed tomography (MSCT) coronary angiography following a repetitive episode of chest pain at rest. Coronary artery calcium scoring before contrast enhanced CT angiography showed no detectable calcium within coronary artery. Contrast enhanced CT angiography demonstrated a suspicious image of significant stenosis with non-calcified plaque at the distal right coronary artery (RCA) (-A, B). Coupled with clinical presentation, the patient was assumed to be acute coronary syndrome and emergent invasive coronary angiography was performed. Surprisingly, no significant stenosis was detected by invasive coronary angiography although turbulent flow was observed at the distal RCA where severe stenosis was revealed by CT angiography (-C, D). In multi-planar reconstruction image and cross sectional images, CT density value at the lesion site in MSCT was analyzed. A lot of spotty high attenuation areas larger than 130 Hounsfield Units which is the cut-off CT density value for coronary calcification were found. In this patient, coronary calcium score was zero, which indicated the speckled high attenuations depicted in MSCT were contrast media within coronary artery. In addition, vessel area at the site of lesion was almost the same as at proximal and distal intact site (). These results implied that no plaque was present at distal RCA and turbulent flow inside the coronary artery was interpreted as coronary artery disease in error. The symptom of the patient was relieved spontaneously and has been observed uneventfully.

Vasospastic angina causing infarction detectable on myocardial contrast echocardiography

Sukhjinder Nijjer, Michael Bellamy, Petros Nihoyannopoulos — 2011-10-17

A 42-year-old woman presented with sudden-onset central chest pain at rest. She had presented elsewhere with chest pain one month previously and had been treated with balloon angioplasty and dual antiplatelet therapy. Electrocardiography showed anterior ST elevation. Immediate angiography demonstrated a severe tubular stenosis in the mid left anterior descending artery (LAD) (, Panel A). A severe dynamic lesion was seen in the right coronary artery (RCA, Panels B, C). Both lesions resolved completely following intra-coronary nitrate (, Panels D, E). Moderate underlying coronary atheroma was present at the sites of vasospasm but was non-obstructive. Angioplasty was not performed and a glyceryl trinitrate infusion was started. ST segments resolved but new T-wave inversion developed anteriorly with a low cardiac output state.