International Journal of Cardiology - Articles in Press

Discourse on pulse in medieval Persia—the Hidayat of Al-Akhawayni (?–983AD) - Corrected Proof

2012-05-17

Abstract: In a period of compilation, original observations and expansion (900–1100 AD), Persians described new clinical manifestations of the diseases and expanded the earlier knowledge of materia medica. In the epoch of the Arabic language domination in the scientific literature of this period, advent of medical authors to write in Farsi shined in the Persian principalities. Akhawayani Bokhari was by far the most outstanding scholar of the time who wrote one of the earliest pandects of medicine of the period, the Hidayat al-Mutallimin fi al-Tibb (Learner's Guide to Medicine) in new Persian. The Hidayat is a relatively short and simplified digest of medicine at the time providing a glimpse of high level of medical education at the Samanid period (819–999). The present article is a translation of the sections of the Hidayat related to the pulse and its characters and conditions affecting the pulse in an attempt to increase our knowledge of the medicine, and particularly the pulse examination throughout the medieval era.

Triggering of supraventricular premature beats. The impact of acute and chronic risk factors - Corrected Proof

Viktor Čulić, Nardi Silić, Dinko Mirić — 2012-05-17

Supraventricular premature beat (SPB) is usually considered a benign heart rhythm disturbance. However, an isolated SPB can trigger episodes of atrial fibrillation , supraventricular tachycardia and malignant ventricular tachyarrhythmia . A high frequency of SPB has been linked to the increased risk of death or stroke . Circadian, weekly and annual variations in the occurrence of ventricular tachyarrhythmias and triggering by emotional and physical stress have been well-described . Until now, factors that could be involved in the triggering of supraventricular arrhythmias have not been rigorously investigated.

Dynamic assessment of aortic annulus in patients with aortic stenosis throughout cardiac cycle with dual-source computed tomography - Corrected Proof

Li-qing Peng, Zhi-gang Yang, Jian-qun Yu, Zhi-gang Chu, Wen Deng, Heng Shao — 2012-05-17

Precise measurement of aortic annular diameter (AAD) is critical for choosing appropriate prosthetic valve size for transcatheter aortic valve implantation (TAVI), because annulus-prosthesis mismatch due to inaccurate sizing of the prosthesis may lead to paravalvular aortic regurgitation . Cardiac pulsatility and aortic compliance may result in aortic annulus changes . However, the dynamic changes of aortic annulus during the cardiac cycle have not been clarified in patients with aortic stenosis (AS) . Knowledge of the dynamic characteristics of aortic annulus in this population may improve our understanding of aortic annulus and help accurately size aortic annulus. Thus, we aimed to determine the dynamic features of aortic annulus in patients with severe AS throughout cardiac cycle with retrospectively ECG-gated dual-source computed tomography (DSCT) angiography.

Effects of home versus hospital-based exercise training in chronic heart failure - Corrected Proof

Aynsley Cowie, Morag K. Thow, Malcolm H. Granat, Sarah L. Mitchell — 2012-05-17

Many researchers have demonstrated that supervised hospital-based training yields improvements in exercise capacity and quality of life (QoL) for heart failure (HF) sufferers . Though comparatively under-researched, home-training does not involve a potentially tiring return journey to hospital, and can be undertaken whenever the individual feels best able to exercise, therefore may offer a more pragmatic exercise option for this frail group . Three previous non-controlled trials have compared effects of home and hospital-based exercise training in HF . Two found significant improvements in exercise capacity and QoL of up to 10% with both types of training, whilst the other found that only hospital-training significantly improved exercise capacity (by 19%). To date, this is the only trial to compare effects of home versus hospital-based aerobic exercise training versus control upon exercise capacity and QoL in HF.

How to distinguish takotsubo cardiomyopathy from acute myocardial infarction using multimodal cardiac imaging - Corrected Proof

2012-05-17

Takotsubo cardiomyopathy (TC) is characterised by a sudden transient regional weakening of the myocardium triggered by both physical and emotional stress . The aetiology of TC still remains unknown, although exaggerated sympathetic stimulation has been suggested as a possible pathophysiological mechanism . The majority of patients affected are postmenopausal women .

QT interval prolongation and bradycardia in lithium-induced nephrogenic diabetes insipidus - Corrected Proof

2012-05-17

Inherited or acquired QT interval prolongation on the ECG is a common problem for physicians. QT interval prolongation , diffuse T wave inversion , dysrhythmias (including sinus bradycardia, sinoatrial block, first-degree atrioventricular block, complete heart block) as well as protracted presyncope and neurological symptoms with coma have been reported in patients with lithium over range. Lithium may also induce all clinical physiological abnormalities of the polydipsia– polyuria syndrome nephrogenic diabetes insipidus . We present a case of QT interval prolongation and diffuse T wave inversion in a 74-year-old Italian woman admitted to the Emergency Department with hypotension, dysarthria, alternating sleeping and waking states and a just occurred syncope. Computerized Axial Tomography showed no pathology. A history of carbamazepine and lithium treatment for bipolar mood disorder was reported. Laboratory examination showed blood therapeutic carbamazepine levels and blood lithium levels over ranges 1.96mmol/l (normal range up to 1.2.), natremia 176mEq/L. The ECG was performed and it showed T wave inversion on I II avL v1–v2–v3–v4–v5–v6 leads with bradycardic rhythm and QT interval prolongation (). Also this case focuses attention on possible effects of lithium therapy.

Conservative management of left ventricle cardiac fibroma in an adult asymptomatic patient - Corrected Proof

Matteo Pozzi, Jean-François Deux, Matthias Kirsch — 2012-05-17

Primary cardiac tumours are rare with an autopsy frequency of 0.001–0.03% and approximately 90% of them are benign. Among these, cardiac fibromas represent a minority and, together with rhabdomyomas, are the most common benign cardiac tumours in paediatric patients. However, their occurrence in the adult patient is uncommon. Most originate from the left ventricle (LV) or interventricular septum. Patients with cardiac fibroma usually present with chest discomfort or pain, syncope, heart failure, cyanosis, arrhythmias or even sudden death but approximately one third of patients diagnosed with cardiac fibroma are asymptomatic and the tumour is discovered incidentally . There is a general agreement that surgical treatment should be performed whenever the cardiac fibroma is causing symptoms. In these patients, surgical options include complete surgical excision, partial resection or orthotopic heart transplantation. Indication for surgical treatment remains controversial in patients who are strictly asymptomatic. We report the case of an asymptomatic adult patient presenting with a giant LV cardiac fibroma and for whom we have opted for a conservative management.

Inspiratory muscle training improves submaximal exercise capacity in patients with heart failure: A systematic review of randomized controlled trials - Corrected Proof

Yan-Ming Chen, Tong Yin — 2012-05-17

Over the past decade, chronic heart failure (CHF) has become more prevalent world wide. Despite the introduction of therapies such as angiotensin-converting enzyme inhibitors, beta-blockers, spironolactone and device equipments, CHF still is a source of great morbidity, exercise intolerance and low quality of life. Recent scientific studies suggest that inspiratory muscle training (IMT) might be an effective intervention for heart failure through multiple mechanisms . The effects of IMT on quality of life have been published by Sbruzzi et al. , who concluded that IMT has no additional benefit on quality of life in CHF patients without inspiratory muscle weakness. However, the effect of IMT on submaximal exercise capacity in CHF patients remains controversial. The aim of this systematic review is to investigate the effect of IMT on submaximal exercise capacity in CHF patients.

Atrial fibrillation as a consequence of tuberculous pericardial effusion - Corrected Proof

2012-05-16

Tuberculous (TB) pericarditis is the dominant form of pericarditis in developing countries and carries a high mortality . Atrial fibrillation (AF) is uncommon in acute pericarditis, in the absence of concomitant structural heart disease . However, there are no prospective studies of the prevalence, natural course and impact on prognosis of AF in patients with subacute and chronic forms of pericarditis such as TB pericarditis. We have conducted a prospective observational study of the prevalence, correlates, and natural history of AF in patients with TB pericarditis who were enrolled in the ongoing Investigation of the Management of Pericarditis in Africa (IMPI Africa) Registry .

Hyperthyroidism induced autoimmune myocarditis. Evaluation by Cardiovascular Magnetic Resonance and endomyocardial biopsy - Corrected Proof

2012-05-16

Hyperthyroidism provokes hyperdynamic circulation and heart failure (HF), either due to combination of hypervolemia and tachyarrhythmias, or hyperthyroidism induced autoimmune myocarditis . HF is usually temporary and being reversed after hyperthyroidism treatment. However, hyperthyroidism induced myocarditis can persist even after successful treatment of thyroid dysfunction .

Aortic valve sclerosis is a marker of atherosclerosis independently of traditional clinical risk factors. Analysis in 712 patients without ischemic heart disease - Corrected Proof

2012-05-16

Aortic valve sclerosis (AVS) is a frequent echocardiographic finding , usually considered benign in that it does not affect hemodynamics, but different reports have underlined that the presence of AVS is associated with a considerably increased risk of adverse cardiovascular outcome . Several studies have documented a powerful association between AVS and atherosclerosis in different arterial districts, suggesting that AVS could be a “window to the arteries” . Nevertheless, on account mainly of the relatively small patient populations, these studies did not have enough power to discriminate whether the presence of AVS in addition to clinical risk factors could provide information about the presence of atherosclerosis. We therefore aimed to investigate in this study the relationship between AVS and the presence of carotid atherosclerosis.

Normalization of left ventricle systolic function after resynchronization therapy in patients with dilated cardiomyopathy - Corrected Proof

2012-05-16

Cardiac resynchronization therapy (CRT) improves the symptoms and survival of patients with advanced heart failure . Reverse remodelling determined by echocardiography is considered clinically relevant in the face of a reduction of telesystolic volume >10% , and recently a subset defined as hyper-responders, with different criteria, has presented additional benefits, which have not yet been clearly defined . We have undertaken this study in order to characterize patients who present reverse remodelling and normalize systolic function (EF) as the highest expression of echocardiographic response, and to track their clinical evolution.

Melatonin and cardioprotection in the acute myocardial infarction: A promising cardioprotective agent - Corrected Proof

Alberto Dominguez-Rodriguez, Pedro Abreu-Gonzalez, Russel J. Reiter — 2012-05-16

To the Editor: In the special report about pharmacological approaches for cardioprotection , the important role of melatonin as new adjunctive therapy was not mentioned. The evidence from the last 20years documents that melatonin positively influences the cardiovascular system. Melatonin is a multifunctional indolamine that counteracts virtually all pathophysiologic steps and displays significant beneficial actions against peroxynitrite-induced cellular toxicity, as well as, protecting against other damaging oxygen derivatives. Numerous investigations have confirmed the ameliorative effects of melatonin on abnormal function and cardiac tissue destruction resulting from ischemia/reperfusion (I/R) after the administration of pharmacologic doses of melatonin prior to ischemia and/or during reperfusion .

Comparison of single-plane and biplane area-length methods for right ventricular volume calculation: In vivo and vitro study - Corrected Proof

Ruiqin Xie, Wei Cui, Yuyin Guo, Jizeng Zhang, Yuming Hao — 2012-05-16

Currently, both single-plane and biplane area-length methods by two-dimensional echocardiography were commonly used for calculating RV volume in clinical practice, however, little is known regarding the correlation between the two modalities. We try to assess the accuracy of ventricular volume measurement of single-plane and biplane area-length methods by both in-vitro and in-vivo studies.

Circulating osteoprotegerin and Dickkopf-1 changed significantly after surgical aortic valve replacement but remained without any significant differences after transcatheter aortic valve implantation - Corrected Proof

Zuzana Motovska, Teodora Vichova, Petr Tousek, Ladislav Dusek, Petr Widimsky — 2012-05-16

Non-rheumatic, calcified aortic valve stenosis (CAS) is the most frequent valvular heart disease in adults, and carries substantial morbidity and mortality. Thus, aortic valve replacement is the most commonly performed valve intervention in the adult population. The main pathognomonic sign of valve degeneration (both – native and bioprosthesis) is progressive valve calcification . The presence of aortic valve calcium in patients with asymptomatic mild or moderate CAS has been recognized as the single most significant predictor of clinical progression.

Novel electrocardiographic findings related to new cardiac electronic devices functions - Corrected Proof

2012-05-16

An 81-year-old man was evaluated in the out-patient clinic after pacemaker generator replacement with an ECG performed in that moment that was described as “loss of capture in the stimulated beats” and “abnormal number of stimulation spikes” (). The patient was then referred to the ER for pacemaker interrogation with the suspected diagnosis of pacemaker dysfunction.

Left ventricular hypertrabeculation/non-compaction in a Duchenne/Becker muscular dystrophy carrier with epilepsy - Corrected Proof

Josef Finsterer, Claudia Stöllberger, Paul Wexberg, Christoph Schukro — 2012-05-16

Left ventricular hypertrabeculation (LVHT), also known as noncompaction, is an abnormality of the left ventricular myocardium, characterised by separation of the left ventricular wall into a compacted, thin outer layer and a thicker, crenated, inner layer, predominantly of the apex and the lateral wall, distally to the papillary muscles . LVHT is frequently associated with other cardiac abnormalities, chromosomal abnormalities, or neuromuscular disorders . LVHT patients carry an increased risk to develop malignant arrhythmias , heart failure , or possibly peripheral embolism. Though LVHT has been reported in patients with Duchenne muscular dystrophy (DMD) , it is unknown in female carriers of this disorder.

Statin therapy to reduce stent thrombosis in acute myocardial infarction patients with elevated high-sensitivity C-reactive protein - Corrected Proof

2012-05-16

Abstract: Objective: We investigated whether statin therapy and high-sensitivity C-reactive protein (hs-CRP) levels were associated with the risk of stent thrombosis (ST) in acute myocardial infarction (AMI) patients.Methods: A total of 9,162 AMI patients who underwent coronary stent implantation were analyzed in the Korean Acute Myocardial Infarction Registry. The study population was divided into four groups according to level of hs-CRP and peri-procedural statin treatment: low hs-CRP (≤2.0mg/L) and high hs-CRP (>2mg/L) with or without statin therapy. We compared the incidence of early ST among the groups.Results: Statin therapy did not significantly affect the development of early ST in the low hs-CRP group. In the high hs-CRP group, however, the incidence of early ST was significantly decreased with statin treatment. In a subgroup analysis of the high hs-CRP group, patients aged less than 65years, without diabetes, with a high body mass index, and with a high Killip class seemed to benefit more from statin therapy. In a multivariable Cox regression analysis of the high hs-CRP group, lack of statin therapy was a significant predictor of ST incidence.Conclusions: Peri-procedural statin treatment had an effect on reduced incidence of early ST in AMI patients with high levels of hs-CRP.

The haematocrit – an important factor causing impaired haemostasis in patients with cyanotic congenital heart disease - Corrected Proof

2012-05-14

Abstract: Background: Patients with cyanotic congenital heart disease(CCHD) have haemostatic abnormalities, which result in an increased risk of bleeding. The cause is unknown, but recent studies have indicated that an elevated haematocrit, which is present in cyanotic patients, could be an important factor.The aim of this study was to characterize the haemostatic profile, examine how changes in haematocrit affect the haemostatic profile, and whether a haematocrit reduction could terminate bleeding in CCHD patients.Methods: This was a prospective, multicenter study. The haemostatic profile consisting of haematocrit, platelet count and thrombelastography(TEG) was characterized in ninety-eight CCHD patients. To evaluate the influence of haematocrit on the haemostatic profile, 21 of the patients underwent phlebotomy and 16 patients received treatment with an iron supplement. Furthermore ten patients with haemoptysis underwent phlebotomy. The haemostatic profile was reevaluated after interventions.Results: TEG revealed that patients with CCHD and elevated haematocrit were hypocoagulable due to reduced clot formation and strength. Furthermore a positive correlation between elevated haematocrit and hypocoagulability was present. Interventions such as phlebotomy and treatment with supplemental iron causing significant haematocrit changes confirmed the correlation between haematocrit and the haemostatic profile. Finally a haematocrit reduction by phlebotomy successfully terminated haemoptysis in ten CCHD patients.Conclusion: Patients with CCHD and elevated haematocrit are hypocoagulable. The hypocoagulable haemostatic profile is positively correlated to increasing haematocrit. An intervention, which increases or decreases haematocrit, changes the haemostatic profile. A haematocrit reduction seems to improve the haemostatic profile, and may thereby terminate bleeding. However, these results warrant further studies.

Understanding the Atrioventricular Dissociation - Corrected Proof

Righab Hamdan, Jean-Yves Le Heuzey, Eloi Marijon — 2012-05-14

A 56-year old male patient was addressed to our intensive cardiac care unit with a diagnosis of “complete atrioventricular (AV) block”, 4days following surgical treatment of symptomatic obstructive hypertrophic cardiomyopathy including large septal resection and mitral valve replacement. We noted no relevant medical history. On physical examination, at admission, the patient presented normal hemodynamic, regular heart rate about 60bpm, no signs of right heart failure. An abnormal transient jugular vein pulse was noted. The EKG on admission is presented in . Do you agree with the diagnosis of complete AV block?

Effectiveness of statin therapy for elderly acute myocardial infarction patients with normal levels of low-density lipoprotein cholesterol - Corrected Proof

2012-05-14

The effectiveness of 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitor (statin) therapy for patients with coronary artery disease has been extensively evaluated . According to current guidelines for secondary prevention, an adequate statin therapy is that which lowers low-density lipoprotein cholesterol (LDL-C) to <100mg/dL, or <70mg/dL in the case of very high-risk patients . However, elderly acute myocardial infarction (AMI) patients, a high-risk population themselves, often do not receive the dose of statins recommended by current guidelines because of poor general condition and comorbidities . Moreover, there is limited evidence for using statin therapy in elderly patients (≥75years) who have low levels of baseline LDL-C. This is the reason as to why elderly patients are less likely to be included in randomized controlled studies because of the higher prevalence of associated comorbidities and more depressed cardiac function. In this study, we retrospectively analyzed the effectiveness of statin therapy in elderly AMI patients who had baseline LDL-C levels below 100mg/dL.

Increased circulating mitochondrial DNA after myocardial infarction - Corrected Proof

2012-05-14

Aseptic trauma patients with massive muscular damage have increased plasma levels of mitochondrial DNA (mtDNA), acting as a danger associated molecular pattern molecule (DAMP) promoting inflammation and tissue damage . We hypothesized that an acute myocardial infarction (MI) would lead to increased circulating levels of mtDNA, potentially contributing to local and systemic inflammation following MI.

Non-linear contribution of glucose measures to cardiovascular diseases and mortality: Reclassifying the Framingham's risk categories: A decade follow-up from the Tehran lipid and glucose study - Corrected Proof

Homa Yadegari, Mohammadreza Bozorgmanesh, Farzad Hadaegh, Fereidoun Azizi — 2012-05-14

Abstract: Background: We investigated non-linear contribution of fasting plasma glucose (FPG) and 2-hour post-challenge plasma glucose (2h-PCPG) to the risk of CVD and mortality. We hypothesized that glucose measures improve risk-stratification made by the Framingham's general CVD risk algorithm.Methods: Among participants aged ≥30 (n=8071), not taking glucose-lowering agents, 6169 (3477 women) remained eligible. Non-linear contribution of FPG and 2h-PCPG to incident CVD and mortality were assessed using Cox models incorporating restricted cubic splines functions. Risk reclassification improvement conferred by FPG and 2h-PCPG was examined using an extended version of net reclassification index (NRI) that takes into account the censoring nature of survival data.Results: We documented 465 incident CVD events (402 CHD), 212 deaths from any cause (94 CVD deaths). Excluding the contribution of the 2h-PCGP to mortality (that was linear) dose–response relationships between glucose measures and CVD and mortality were curvilinear with nadirs below which decreasing levels of glucose were unlikely to offer any benefit. These nadirs were assigned to FPG of 4.9–5.3 and 2h-PCPG of 6.0mmol.l−1. Glucose measures added to the predictive ability of the Framingham's general CVD risk algorithm with cutpoint-free NRIs ranging from 19 to 54%.Conclusion: Glucose measures contributed to the risk of CVD and mortality in a curvilinear fashion, we observed increased risk below glucose thresholds currently used to define diabetes, supporting criteria for the diagnosis of impaired fasting glycemia and impaired glucose tolerance. Glucose measures were observed to add to predictive ability of the predictive model which included established cardiovascular risk factors.

A meta-analysis of effects of prosthesis–patient mismatch after aortic valve replacement on late mortality - Corrected Proof

Hisato Takagi, Hirotaka Yamamoto, Kotaro Iwata, Shin-nosuke Goto, Takuya Umemoto — 2012-05-14

Prosthesis–patient mismatch (PPM) describes a state in which the effective orifice area (EOA) of a normally functioning heart valve prosthesis is too small in relation to the patient's body size, which results in high transvalvular pressure gradients . For aortic valve prostheses, PPM is considered to be severe when the indexed EOA (IEOA) is <0.65cm2/m2 and moderate when this value is 0.65–0.85cm2/m2; and PPM is classed as not clinically significant when the IEOA is >0.85cm2/m2 . Patients with PPM have worse functional class and exercise capacity, reduced regression of left ventricular hypertrophy, inferior recovery of coronary flow reserve, impaired blood coagulation status, and more adverse cardiac events after aortic valve replacement (AVR) compared with patients without PPM . Further, PPM may be also associated with an increased risk of both perioperative and late mortalities. Although a lot of studies investigated whether PPM impaired late survival, there have been no formal attempts to conduct any meta-analysis of such studies to date. We performed the first meta-analysis of studies comparing late mortality in patients with and without PPM after AVR.

Feasibility of a novel radiofrequency signal analysis for in-vivo plaque characterization in humans: Comparison of plaque components between patients with and without acute coronary syndrome - Corrected Proof

2012-05-14

Abstract: Background: The iMAP™ is a novel intravascular ultrasound (IVUS)-based technology to classify coronary plaque into 4 components. The aim of this study was to evaluate the feasibility of iMAP™ technology by comparing plaque characteristics in patients with and without acute coronary syndrome (ACS and non-ACS).Materials and methods: A total of 93 culprit lesions from 87 patients were analyzed using the iMAP™. Each plaque was classified into 4 components with a newly introduced parameter, confidence level (CL).Results: iMAP™ analysis of the minimal lumen cross-sectional area (MLA) revealed that ACS lesions had significantly larger lipidic and necrotic areas than non-ACS lesions. Multivariate analysis revealed that the lipidic area at the MLA was an iMAP™ factor independently associated with ACS lesions (odds ratio −1.5, p=0.04). Based on receiver operating characteristic analysis with 4 different CL ranges, the lipidic area at the MLA with 25%–100% CL had the largest area under the curve (0.756), suggesting that 25%–100% is the best CL range for identifying ACS culprit lesions.Conclusions: The feasibility of the novel iMAP™ IVUS system was shown in discriminating culprit lesions in patients with and without ACS. Analyzing with a CL of 25%–100% may be the best option for discriminating lesions.

Mending injured endothelium in chronic heart failure: A new target for exercise training - Corrected Proof

Emeline M. Van Craenenbroeck, Viviane M. Conraads — 2012-05-14

Abstract: The recognition that poor cardiac performance is not the sole determinant of exercise intolerance in CHF patients has altered the target of exercise training. Endothelial dysfunction impairs exercise-induced vasodilation, thereby limiting oxygen supply to working muscles and increasing ventricular afterload. Since the 1990s, it has become clear that partial correction of this maladaptive reaction is a premise for the success of exercise training.Growing evidence indicates that increased NO bioavailability and reduction in oxidative stress result from regular physical activity. However, the basic concept of endothelial dysfunction has shifted from a pure “damage model” to a more dynamic process in which endothelial repair fails to keep pace with local injury. Indeed, recent evidence indicates that endothelial progenitor cells (EPC) and circulating angiogenic cells (CAC) contribute substantially to preservation of a structurally and functionally intact endothelium. In chronic heart failure, however, these endogenous repair mechanisms appear to be disrupted.In this review, we aim to give an overview on what is currently known about the influence of physical exercise on recruitment of EPC and activation of CAC in this particular patient group.

Aortic distensibility and its relationship to coronary and thoracic atherosclerosis plaque and morphology by MDCT: Insights from the ROMICAT Trial - Corrected Proof

2012-05-14

Abstract: Background: Multi-detector cardiac computed tomography (CT) allows for simultaneous assessment of aortic distensibility (AD), coronary atherosclerosis, and thoracic aortic atherosclerosis.Objectives: We sought to determine the relationship of AD to the presence and morphological features in coronary and thoracic atherosclerosis.Methods: In 293 patients (53±12years, 63% male), retrospectively-gated MDCT were performed. We measured intraluminal aortic areas across 10 phases of the cardiac cycle (multiphase reformation 10% increments) at pre-defined locations to calculate the ascending, descending, and local AD (at locations of thoracic plaque). AD was calculated as maximum change in area/(minimum area×pulse pressure). Coronary and thoracic plaques were categorized as calcified, mixed, or non-calcified.Results: Ascending and descending AD were lower in patients with any coronary plaque, calcified or mixed plaque than those without (all p<0.0001) but not with non-calcified coronary plaque (p≥0.46). Per 1mm Hg−1 10−3 increase in ascending and descending AD, there was an 18–29% adjusted risk reduction for having any coronary, calcified plaque, or mixed coronary plaque (ascending AD only) (all p≤0.04). AD was not associated with non-calcified coronary plaque or when age was added to the models (all p>0.39). Local AD was lower at locations of calcified and mixed thoracic plaque when compared to non-calcified thoracic atherosclerosis (p<0.04).Conclusions: A stiffer, less distensible aorta is associated with coronary and thoracic atherosclerosis, particularly in the presence of calcified and mixed plaques, suggesting that the mechanism of atherosclerosis in small and large vessels is similar and influenced by advancing age.

Letter in response to Andrea K.Y. Lee et al. “Normalcy rate of computed tomographic coronary angiography” - Corrected Proof

Ivo A. Joosen, Mathijs O. Versteylen, Marco Das, Bas L.J.H. Kietselaer — 2012-05-14

With interest we read the recently published letter by Andrea K.Y. Lee et al., entitled “Normalcy rate of computed tomographic coronary angiography” . The authors assessed the normalcy rate (NR) of computed tomographic coronary angiography (CTCA) in a clinical population of patients with a very low pretest probability (≤4%) for coronary artery disease (CAD). A total of 601 patients (mean pretest probability 2.7%) were analyzed for the presence and severity of CAD. Using thresholds of ≥50% and ≥70% coronary artery diameter stenoses, the NR of CTCA were 94% and 97%, respectively. We agree with the authors that these percentages are as expected, since statistics dictate there will be some patients with obstructive CAD despite of their very low pretest probability.

Myocardial infarction in the young - Corrected Proof

R. D'Amato, R. Spoladore, A. Esposito, A. Latib, E. Busnardo, P.G. Camici — 2012-05-14

Myocardial infarction in persons aged below 45years is a rare event, usually not related to coronary atherosclerosis, but mostly occurs as a consequence of cocaine abuse, congenital coronary abnormalities, or spasm. We present the case of a young man with an acute anterior myocardial infarction caused by a rare protein deficiency in the coagulation system.

Fatal cases of aortic dissection: An autopsy study - Corrected Proof

K. Bailey, J. Duflou, R. Puranik — 2012-05-11

Aortic dissection is a rapidly progressing, life threatening condition that continues to have high mortality rates despite advances in imaging and treatment. The diagnosis of aortic dissection is challenging because of often non-specific clinical signs and symptoms. It is commonly confused with a range of both benign and potentially lethal conditions and may not be considered in the initial differential diagnosis in as many as 39% of cases . Common screening modalities overlook aortic dissection with chest radiographs appearing normal in up to 40% of cases and ECG traces often showing no abnormalities , and hence a high index of clinical suspicion is still required for a diagnosis of dissection.

Adherence to ACC/AHA Performance Measures for Myocardial Infarction in Six Middle-Eastern Countries: Association with In-Hospital Mortality and Clinical Characteristics - Corrected Proof

2012-05-11

Abstract: Background/Objectives: This study assesses adherence to performance measures for acute myocardial infarction (AMI) in six Middle-Eastern countries, and its association with in-hospital mortality. Few studies have previously assessed these performance measures in the Middle East.Methods: This cohort study followed 5813 patients with suspected AMI upon admission to discharge. Proportions of eligible participants receiving the following performance measures were calculated: medications within 24 hours of admission (aspirin and beta-blocker) and on discharge (aspirin, beta-blockers, angiotensin converting enzyme inhibitors [ACEI], and lipid-lowering therapy), reperfusion therapy, and low-density lipoprotein (LDL) cholesterol measurement. A composite adherence score was calculated. Associations between performance measures and clinical characteristics were assessed using multivariate logistic regression.Results: Adherence was above 90% for aspirin, reperfusion, and lipid-lowering therapies; between 60% and 82% for beta-blockers, ACEI, statin therapy, time-to-balloon within 90 minutes, and LDL-cholesterol measurement; and 33% for time-to-needle within 30 minutes. After adjustment, factors associated with high composite performance score (>85%) included Asian ethnicity (Odds Ratio, OR=1.3; p=0.01) and history of hyperlipidemia (OR=1.4; p=0.001). Factors associated with a lower score included atypical symptoms (OR=0.6; p=0.003) and high GRACE score (OR=0.6; p<0.001). Lower in-hospital mortality was associated with provision of reperfusion therapy (OR=0.54, p=0.047) and beta-blockers within 24 hours (OR=0.33, p=0.005).Conclusions: Overall adherence was lowest among the highest-risk patients. Lower in-hospital mortality was independently associated with adherence to early performance measures, comprising observational evidence for their effectiveness in a Middle East cohort. These data provide a focus for regional quality improvement initiatives and research.

Effects of atorvastatin on carotid intima media thickness: a meta-analysis of randomized controlled trials - Corrected Proof

Hisato Takagi, Hirotaka Yamamoto, Kotaro Iwata, Shin-nosuke Goto, Takuya Umemoto — 2012-05-11

Measurements of carotid intima media thickness (CIMT) are widely used in clinical research as a measure of atherosclerosis, and many randomized controlled trials (RCTs) have been performed using the rate of change in CIMT as the primary endpoint to study the efficacy of lipid-modifying therapies . In their meta-regression analysis of 28 RCTs, Goldberger et al. found that differences in mean change in CIMT over time between treatment and control groups correlated with developing nonfatal myocardial infarction during follow-up. A meta-analysis by Bedi et al. showed a statistically significant benefit with statin therapy in slowing down the progression of CIMT. The meta-analysis included 11 RCTs of atorvastatin , fluvastatin , lovastatin , pravastatin , rosuvastatin , and simvastatin . However, drug-specific effects of statins on CIMT remain unclear. To determine whether atorvastatin prevents progression (or causes regression) of CIMT, we performed a meta-analysis of RCTs.

QRS fragmentation as a marker of arrhythmias in coronary artery disease, in cardiomyopathies and ion channel diseases - Corrected Proof

Stefan Peters — 2012-05-11

QRS fragmentation analysed from surface ECG seems to be a new marker of disease abnormalities and arrhythmias in many different diseases. The phenomenon of QRS fragmentation is defined as deflections at the beginning of the QRS complex, on top of the R wave or in the nadir of the S wave with 40Hz and 50Hz filtering technique.

Recanalization of isolated chronic total occlusions in patients with stable angina - Corrected Proof

2012-05-11

Abstract: Background: Despite procedural advances, recanalization of chronic total occlusions (CTOs) with percutaneous coronary intervention (PCI) remains controversial, particularly given that its long-term benefits are unclear. We assessed the association between successful PCI and symptom improvement as well as outcomes in patients with CTO and stable angina.Methods: We performed a retrospective study of 386 consecutive patients undergoing attempted PCI of an isolated CTO (i.e., no other angiographically-significant disease was present). We analyzed prospectively the change in Canadian Cardiovascular Society (CCS) classification system and occurrence of major adverse cardiovascular events (death, myocardial infarction or target vessel revascularization), after stratifying patients by procedural success. To understand which patients might benefit most from attempted PCI, multivariable models were constructed to predict: likelihood of successful PCI and symptom improvement, defined as resolution of angina or improvement of ≥2 CCS classes.Results: A total of 247 (64%) patients had successful PCI. Greater symptom improvement was noted after successful PCI at both 6months (79.8% versus 34.5% with resolution of angina or improvement of ≥2 CCS classes, p<0.01) and 24months (71.7% and 20.9%, respectively, p<0.01). No differences were noted in MACE (11.3% vs. 10.0% at 6months, p=0.70; and 18.6% vs. 19.4% at 24months, p=0.84). Multivariable analysis identified several factors associated with successful PCI, but not predictive of symptom improvement. In conclusion, successful PCI of an isolated CTO improves symptom burden, but is not associated with MACE at 6 or 24months.Conclusions: Several factors are associated with successful PCI, but identifying those most likely to have symptom improvement remains challenging.

Right ventricular dysfunction and dilatation in patients with mitral regurgitation: Analysis using ECG-gated multidetector row computed tomography - Corrected Proof

Ying-kun Guo, Zhi-gang Yang, Heng Shao, Wen Deng, Gang Ning, Zhi-hui Dong — 2012-05-11

Abstract: Background: This study prospectively compared the accuracy of a sixty-four slice multidetector row CT (64-MDCT) in cardiac magnetic resonance imaging (MRI) for the assessment of right ventricular (RV) dysfunction and dilatation in patients with mitral regurgitation.Methods: Eighty-four patients underwent ECG-gated 64-MDCT for the assessment of RV dysfunction and dilatation; 54 of these patients had known mitral regurgitation. End-diastolic and end-systolic volumes, stroke volume, and ejection fraction were measured using the 64-MDCT, and these results were retrospectively compared to the results of MRI (reference standard). Agreement between the 64-MDCT and MRI results was investigated using linear regression and Bland–Altman analyses. Receiver operating characteristic analyses calculated the sensitivity and specificity of RV dilatation on 64-MDCT scans for the prediction of mitral regurgitation severity and dysfunction, respectively.Results: No significant differences in RV function parameters were calculated between 64-MDCT and MRI (r=0.87 to 0.94; all p<0.001). Good intertechnique agreement was obtained using linear regression and Bland–Altman analyses. ROC analyses revealed that RV enlargement (>33mm) on 64-MDCT scans predicted the RV dysfunction of mitral regurgitation with a sensitivity of 92.9% and a specificity of 82.9%.Conclusions: ECG-gated 64-MDCT accurately and reliably assessed RV function in patients with and without mitral regurgitation. Moreover, the presence of RV dilatation on the 64-MDCT scan assisted in the prediction of RV dysfunction and mitral regurgitation severity.

The clinical relevance of dysfunctional HDL in patients with coronary artery disease: A 3-year follow-up study - Corrected Proof

2012-05-10

The well known atheroprotective effects of high density lipoprotein cholesterol (HDL) are based on reverse cholesterol transport as well as anti-inflammatory properties . Primary prevention studies have confirmed that HDL levels are strongly associated with reduced cardiovascular events . However, recent evidence supports the notion that HDL functionality may be impaired under certain conditions . Ansell and colleagues reported that HDL isolated from subjects with coronary artery disease (CAD) had less anti-inflammatory activity than HDL derived from healthy controls, thus providing the first evidence that HDL may be dysfunctional in this setting . Interestingly, in CAD patients HDL has shown to be even proinflammatory, thus increasing monocyte chemiotaxis, reactive oxygen species production, endothelial dysfunction and cellular apoptosis . Hence, HDL may not be protective in secondary prevention of coronary artery disease. This issue needs to be rapidly clarified since therapies that raise HDL levels are being investigated for the treatment of CAD patients .

SRC kinase family inhibitor PP2 promotes DMSO-induced cardiac differentiation of P19 cells and inhibits proliferation - Corrected Proof

2012-05-10

Abstract: Background: It has been reported recently that PP2, a Src family kinase inhibitor, promotes selective cardiogenesis in embryonic stem cells. However, there is no other research proved pro-cardiogenic characteristic of PP2 so far. In this study, we explored the potential cardiogenic effect of PP2 on P19 cells differentiation.Methods: P19-αMHC-EGFP cell line was established by transfecting P19 cells with αMHC-EGFP vector in order to evaluate cardiogenesis with EGFP. P19-αMHC-EGFP cells and P19 cells were induced to differentiate into cardiomyocytes with 1%DMSO, 5μmol/L PP2, or both 1%DMSO and 5μmol/L PP2. Differentiated cells from P19-αMHC-EGFP cells were then assessed under confocal microscope. Western-blot and RT-PCR were also performed to detect expression of cardiac troponin I and cardiac transcription factors respectively. In addition, the effects of PP2 on proliferation of P19 cells were further examined using Cell Counting Kit-8.Results: EGFP positive cells were firstly detected on day 7 and PP2 alone cannot induce efficient cardiac differentiation of P19-αMHC-EGFP cells. However PP2 supplementation dramatically increases DMSO induced cardiac differentiation than DMSO alone. It was also found that PP2 inhibit proliferation of P19 cells in both a dose-dependent manner and a time-dependent manner.Conclusion: PP2 alone cannot substitute DMSO to induce cardiac differentiation, however, PP2 supplementation drastically promotes DMSO-induced cardiac differentiation of P19 cells. The increased percentages of differentiated cardiac myocytes is partly resulting from cell proliferative inhibit effect of PP2 in undifferentiated P19 cells. P19-αMHC-EGFP cell line has the potential to be used for regenerative therapies in experimental models of heart repair.

Efficacy of allopurinol pretreatment for prevention of contrast-induced nephropathy: a randomized controlled trial - Corrected Proof

2012-05-10

Abstract: Background: Contrast-induced nephropathy (CIN) remains a common complication of radiographic procedures. Radiocontrast agents can cause a reduction in renal function that may be due to reactive oxygen species. Conflicting evidence suggests that administration of antioxidants prevents CIN.Methods: We assessed the efficacy of allopurinol in preventing CIN. We prospectively randomized 159 patients with a serum creatinine concentration >1.1mg/dL undergoing cardiac catheterization/interventions to receive allopurinol (300mg, p.o.) 24h before administration of radiocontrast agent and hydration (1mg/kg/hN/saline for 12h pre- and post-contrast, n=79), or hydration alone (1mg/kg/hN/saline for 12h pre- and post-contrast, n=80).Results: CIN occurred in 6 of 80 patients (7.5%) in the control group and no subjects in the allopurinol group (p=0.013). In the allopurinol group, median serum creatinine concentration decreased significantly from 1.43mg/dL [1.1–4.15mg/dL] to 1.35mg/dL [0.7–4.15mg/dl] at 48h and to 1.27mg/dL [0.66–4.37mg/dL] at 4days after radiocontrast administration (p<0.0001 and p<0.0001 compared with baseline, respectively). In the control group, median serum creatinine concentration decreased non-significantly from 1.48mg/dL [1.1–2.96mg/dL] to 1.43mg/dL [0.73–3.02mg/dL] and to 1.45mg/dL [0.86–3.71mg/dL] (p=0.045 and p=0.57, respectively) 48h and 4days after radiocontrast administration.Conclusions: Prophylactic oral administration of allopurinol, along with hydration, may protect against CIN in high-risk patients undergoing coronary procedures.

Effective secondary prevention through cardiac rehabilitation after coronary revascularization and predictors of poor adherence to lifestyle modification and medication. Results of the ICAROS Survey - Corrected Proof

2012-05-10

Abstract: Background and aim: Secondary prevention is a priority after coronary revascularization. We investigate the impact of a cardiac rehabilitation (CR) program on lifestyle, risk factors and medication modifications and analyze predictors of poor behavioral changes and events in patients after coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI).Methods: Multicenter (n=62), prospective, longitudinal survey in post-CABG or -PCI consecutive patients after a comprehensive CR program. Cardiac risk factors, lifestyle habits, medication and 1year cardiovascular events were collected. Logistic regression analyzed the association between risk factors, events and predictors of non-adherence to treatment and lifestyle.Results: At 1year, of the 1262 patients (66±10years, CABG 69%, PCI 31%), 94% were taking antiplatelet agents (vs. 91.8% at CR admission and 91.7% at CR discharge, p=ns), 87% statins (vs. 67.5%, p<.0001, and 86.3%, p=ns), 80.7% beta-blockers (vs. 67.4%, p<.0001, and 88.8%, p=ns), and 81.1% ACE inhibitors (vs. 57.5% p<.0001, and 77.7%, p=ns). 89.9% of the patients showed good adherence to treatment, 72% adhered to diet and 51% to exercise recommendations; 74% of smokers stopped smoking. Younger age was predictive of smoking resumption (OR 8.9, CI 3.5–22.8). Pre-event sedentary lifestyle (OR 3.3, CI 1.3–8.7) was predictive of poor diet. Older patients with comorbidity (OR 3.1; CI, 1.8–5.2) tended to persist in sedentary lifestyle and discontinue therapy and diet recommendations. Age, diabetes, smoking and PCI indication were predictors of recurrent CV events which occurred in 142 patients.Conclusion: Participation in CR results in excellent treatment after revascularization, as well as a good lifestyle and medication adherence at 1year and provides further confirmation of the benefit of secondary prevention. Several clinical characteristics may predict poor behavioral changes.

Symptoms of anxiety and depression after percutaneous coronary intervention are associated with decreased heart rate variability, impaired endothelial function and increased inflammation - Corrected Proof

2012-05-10

Symptoms of depression and anxiety are prevalent among patients suffering from an acute coronary syndrome . There is considerable evidence that both depression and anxiety are substantially associated with negative cardiac outcomes in patients with stable coronary artery disease (CAD) and after myocardial infarction (MI) . Despite their high prevalence, these psychiatric syndromes often go undiagnosed and untreated over years and have a substantial impact on prognosis and quality of life in these patients .

Prognostic models for cardiovascular events after successful primary percutaneous coronary intervention - Corrected Proof

2012-05-10

Several prognostic models have been proposed for the prediction of the outcome of patients with chronic stable angina or acute coronary syndromes undergoing revascularization. The introduction of the SYNTAX (Synergy between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery) score (SXscore), has shifted the attention toward stratifying the individual risk according to lesion complexity, and to the extent and distribution of coronary atheromatosis . However, the absence of clinical factors has led to the creation of a pure clinical model (Age, Creatinine, and Ejection Fraction; ACEF) and of two combined risk models, the Global Risk Classification (GRS) and the Clinical SYNTAX score (CSS) that have incorporated clinical variables into the SXscore.

Intra-individual head-to-head comparison of Sirolimus®- and Paclitaxel®-eluting stents for coronary revascularization. A randomized, multi-center trial - Corrected Proof

2012-05-10

Abstract: Background: Despite the known effects of drug-eluting stents (DES), other cofactors attributed to patient characteristics affect their success. Interest focused on designing a study minimizing these factors to answer continuing concerns on the heterogeneity of response to different DESs. The study's aim was to investigate the feasibility and impact of an intra-individual comparison design in patients (pts) with two coronary artery stenosis treated with a Sirolimus- (SES) and a Paclitaxel- (PES) eluting stent.Methods and results: The study was conducted as a prospective, randomized, multi-center trial in 112 pts who consented to treatment with a SES and a PES. Pts were eligible if they suffered from the presence of two single primary target lesions in two different native coronary arteries. Lesions were randomized to either SES or PES treatment. The primary endpoint was in-stent luminal late loss (LLL), as determined by quantitative angiography at 8months; clinical follow up was obtained at 1, 8, and 12months additionally. The LLL (0.13±0.28mm SES vs. 0.26±0.35mm PES, p=0.011) showed less neointima in SES. With a predefined cut-off criterion of 0.2mm difference in LLL, 53/87 pts SES and PES were similar effective. 34/87 pts had a divergent result, 26 pts had greater benefit from SES while 8 pts had greater benefit from PES. Overall, MACE (MI, TLR, and death) occurred in 19 (17%) pts. Based on lesion analysis of 108 lesions treated with SES and 110 lesions treated with PES, 5 (4.6%) lesions with SES and 3 (2.7%) lesions with PES required repeated TLR.Conclusion: An intra-individual comparison design to assess differences in efficacy of different DESs is feasible, safe and achieves similar results to inter-individual studies. This study is among the first to show that failure of one DES does not necessarily implicate failure of another DES and vice versa.

Role of coronary revascularisation among patients receiving implantable defibrillators: a review - Corrected Proof

Karthik Viswanathan, A.C. Qureshi, M.H. Tayebjee — 2012-05-10

Abstract: Patients with coronary artery disease (CAD) can present with spontaneous ventricular arrhythmias occurring outside the context of an acute coronary syndrome with no apparent identifiable reversible cause. In addition to secondary prevention medications, implantable cardiac defibrillator (ICD) remains the main therapeutic intervention to reduce the risk of subsequent mortality and morbidity. Investigations prior to ICD implantation may identify the presence of angiographically significant epicardial coronary stenoses in previously asymptomatic patients, alongside other arrhythmic substrates such as myocardial scar and impaired left ventricular systolic function. So does coronary revascularisation in these patients reduce the occurrence of appropriate ICD shocks in the long run? In this article we comprehensively review the literature to answer the primary question of whether coronary revascularisation reduces recurrent ventricular arrhythmia burden among patients with CAD receiving an ICD, with focus on those presenting with ventricular arrhythmias outside the context of acute coronary syndrome. With growing evidence of the adverse prognostic impact of appropriate ICD discharges and an ever-increasing number of ICD implants world-wide, we believe that this question is of paramount importance. We summarise the available evidence to draw conclusions about the appropriate management strategy and also highlight areas of uncertainty that require attention in future research.

Choosing between velocity-time-integral ratio and peak velocity ratio for calculation of the dimensionless index (or aortic valve area) in serial follow-up of aortic stenosis - Corrected Proof

2012-05-10

Abstract: Background: It remains unclear which echocardiographic measure is most suitable for serial measurement in real-world aortic stenosis (AS) follow-up. We determine whether the dimensionless index (DI) between aortic valve and left ventricular outflow tract velocities is measured more consistently using velocity-time-integral (VTI) or peak velocities (Vpeak) in real life.Methods: Serial echocardiograms acquired within 6months in subjects with AS were analysed with blinding, to compare the variability over time of DI calculated using Vpeak, with that of DI calculated using VTI.Results: Paired echocardiograms, acquired on average 72days apart, were analysed from 70 patients with a range of severities of AS (59% severe). DI, calculated using either Vpeak or VTI, did not significantly change over this short time. Coefficient of variation was significantly better when DI was calculated using Vpeak than VTI (12.6 versus 25.4%, p<0.0001). The variabilities of mean and peak trans-aortic valve 4v2 and left ventricular outflow tract VTI were no better: 26.9%, 19.1% and 22.1% respectively.Conclusions: Serially-followed variables require minimal noise to maximise detection of genuine change. For AS surveillance, calculating DI – or effective orifice area – from the ratio of Vpeak rather than VTIs would reduce 95% confidence intervals from ±51% to a still-disappointing ±25%. Guidelines recommend noisy surveillance measures, causing conscientious echocardiographers to ‘peek’ at previous values, and impairing clinicians' faith in echocardiographically-observed changes when making clinical decisions. For us in echocardiography to improve our ability to contribute to AS follow-up requires us to first acknowledge and discuss this honestly.

Chronic kidney disease and long-term outcomes of myocardial infarction - Corrected Proof

2012-05-09

Abstract: Background: Although chronic kidney disease (CKD) is a risk factor for cardiovascular disease, information about myocardial infarction (MI) with CKD is limited in the acute revascularization era.Methods: To clarify the relationship between CKD and long-term outcomes of MI, consecutive 4550 patients with acute MI treated at 17 participating hospitals were analyzed. The primary study outcome was death from any cause, and a secondary endpoint was the first appearance major adverse cardiovascular events.Results: Acute revascularization therapies were performed in 75.2% of the patients and the mean left ventricular ejection fraction (LVEF) was 53%. The median follow-up was 4.1years (follow-up rate, 95.2%). Patients were divided into four categories (<45.0, 45.0 to 59.9, 60.0 to74.9, and ≥75.0mL/min per 1.73m2 of body-surface area) according to the glomerular filtration rate (GFR) estimated by the Modification of Diet in Renal Disease equation. A total of 1941 (42.7%) patients had an estimated GFR of <60.0mL/min per 1.73m2. Mortality rates increased with declining estimated GFR. Unadjusted hazard ratios for total and cardiovascular death in the group with an estimated GFR of 45.0 to 59.9mL/min per 1.73m2 using the group with an estimated GFR of ≥75.0mL/min per 1.73m2 as the reference were 1.63 (95% CI, 1.28 to 2.07) and 2.09 (95% CI, 1.45 to 3.01), respectively.Conclusions: Even early-stage CKD should be considered a powerful risk factor for long-term cardiovascular death after acute MI with preserved LVEF in the acute revascularization era.

Pharmacokinetic interactions between clopidogrel and rosuvastatin: Effects on vascular protection in subjects with coronary heart disease - Corrected Proof

2012-05-09

Significant decrease in outcomes with statins administration in the first 24h of an acute myocardial infarction and reduction of myocardial injury markers after high-dose statin given few hours before percutaneous interventions were observed. These effects of statins take place before lipid changes . Clopidogrel, a pro-drug largely prescribed for patients undergoing stent implantation, is metabolized in the liver via cytochrome P450 (CYP2C19 and CYP3A4) to form an active metabolite that inhibits the P2Y(12) ADP platelet receptor . Rosuvastatin is partially metabolized by CYP2C9 and CYP2C19 . Functional and anatomical changes of the endothelium, an inflammatory substrate and coagulation activation participate on the pathophysiology of acute coronary syndromes . New biomarkers, such as endothelial and platelet microparticles (EMP and PMP), endothelial progenitor cells (EPC), platelet function tests and endothelial-dependent flow-mediated dilation (FMD) have been proposed for the evaluation of vascular homeostasis . Thus, we examined possible pharmacokinetic interactions between clopidogrel and rosuvastatin, and the consequences on these biomarkers.

D-dimer levels positively correlate with B-type natriuretic peptide levels in patients with atrial fibrillation - Corrected Proof

Tsuneaki Sadanaga, Hideo Mitamura, Keiichi Fukuda, Satoshi Ogawa — 2012-05-09

Atrial fibrillation (AF) is associated with hemostatic abnormality and increased risk of thromboembolic events . Congestive heart failure (CHF) is also recognized as an established risk factor for stroke . However, there are certain challenges in AF patients because the symptoms of heart failure, such as dyspnea and palpitation may be similar to those of AF. B-type natriuretic peptide (BNP) was recognized as the single most accurate predictor of heart failure . Thus, it could be used as an alternative to the current method, which is based on clinical assessment alone, as a marker for the delineation of CHF in AF patients. On the other hand, D-dimer, which originates from the formation and lysis of cross-linked fibrin and indicates activation of coagulation and fibrinolysis, can be used as a coagulation marker in patients with AF. We reported that D-dimer levels predicted subsequent thromboembolic events in AF patients and that BNP levels (≥200pg/ml) could be a useful marker for predicting subsequent thromboembolic events in patients with AF during anticoagulant therapy . The aims of the present study are to evaluate the association between BNP levels and D-dimer levels and to elucidate the usefulness of measuring BNP levels to provide more information for risk-stratification of AF patients not taking anticoagulant therapy.

Clinical and angiographic characteristics of patients with coronary artery ectasia - Corrected Proof

2012-05-09

Abstract: Background: The relationship of the extent of coronary artery ectasia (CAE) with coronary blood flow in the major epicardial arteries has not been adequately assessed.This study aimed at investigating the association of the topographical extent of CAE with coronary flow velocity and clinical characteristics in patients with isolated CAE and in patients with coexisting obstructive coronary artery disease (CAD).Methods: We reviewed 3764 consecutive coronary angiograms performed at Athens Euroclinic and identified patients with CAE according to standard criteria. The topographical extent of ectasia was considered, and coronary flow velocity was determined using the TIMI frame count (TFC). The severity of CAD was assessed using the modified Gensini index and the number of diseased vessels. Clinical data were correlated with TFC and CAD severity analysis.Results: Ectatic lesions were identified in 119 patients. The mean TFC correlated positively with the topographical extent of CAE (rs=0.733, p<0.001). Stepwise multiple linear regression revealed that the topographical extent of CAE and the maximum diameter of the ectatic segment in the corresponding artery are independent predictors of TFC in LAD and RCA. Using multivariate analysis, a history of myocardial infarction was independently associated with CAE extent, and CAD severity.Conclusions: The extent of ectasia in the coronary vasculature is correlated with coronary flow velocity and associated with clinical presentation independent of coexisting significant coronary stenoses.

Coronary CT angiography outperforms calcium imaging in the triage of acute coronary syndrome - Corrected Proof

2012-05-09

Abstract: Background: In this prospective study we determine the diagnostic value of coronary CT angiography (CTA) and calcium imaging in low to intermediate risk acute chest pain patients.Methods: One hundred and eleven consecutive patients (57±11years, 71 males) presenting to the emergency department with chest pain suggestive of acute coronary syndrome (ACS), but without indication for immediate catheter angiography, underwent both coronary CTA and calcium imaging without disclosure of the findings to the treating physicians.Results: ACS was diagnosed in 19 patients (17%). Coronary calcium was present in 71 patients (64%). Coronary CTA identified 74 (67%) patients with coronary plaque and 36 (32%) patients with obstructive (≥50%) plaque. The sensitivity and specificity of the calcium scan were: 89% and 41%. The sensitivity and specificity of coronary CTA were: 100% and 40% based on the presence of any plaque and 89% and 79% based on the presence of >50% stenosis.C-statistics of the GRACE risk score (0.77 [95% CI 0.66–0.89]) improved after addition of coronary CTA (0.93 [0.88–0.98], p<0.01), though not after addition of calcium scores (0.81 [0.71–0.91], p=0.52).Follow-up at 3months revealed four late revascularizations (no deaths or myocardial infarctions), all of whom had obstructive CAD with calcium on CT at presentation.Conclusions: Coronary CTA outperforms calcium imaging in the triage of patients suspected of developing ACS. Absence of plaque on coronary CTA allows safe discharge. Coronary CTA has incremental value to clinical risk scores and has the potential to reduce unnecessary hospital admissions.

Blunted heart rate recovery is improved following exercise training in overweight adults with obstructive sleep apnea - Corrected Proof

2012-05-09

Abstract: Background: Obstructive sleep apnea (OSA) predisposes individuals to cardiovascular morbidity, and cardiopulmonary exercise test (CPET) markers prognostic for cardiovascular disease have been found to be abnormal in adults with OSA. Due to the persistence of OSA and its cardiovascular consequences, whether the cardiovascular adaptations normally conferred by exercise are blunted in adults not utilizing established OSA treatment is unknown. The aims of this study were to document whether OSA participants have abnormal CPET responses and determine whether exercise modifies these CPET markers in individuals with OSA.Methods: The CPET responses of 43 sedentary, overweight adults (body mass index [BMI]>25) with untreated OSA (apnea–hypopnea index [AHI]≥15) were compared against matched non-OSA controls (n=9). OSA participants were then randomized to a 12-week exercise training (n=27) or stretching control treatment (n=16), followed by a post-intervention CPET. Measures of resting, exercise, and post-exercise recovery heart rate (HRR), blood pressure, and ventilation, as well as peak oxygen consumption (VO2peak), were obtained.Results: OSA participants had blunted HRR compared to non-OSA controls at 1 (P=.03), 3 (P=.02), and 5‐min post-exercise (P=.03). For OSA participants, exercise training improved VO2peak (P=.04) and HRR at 1 (P=.03), 3 (P<.01), and 5‐min post-exercise (P<.001) compared to control. AHI change was associated with change in HRR at 5-min post-exercise (r=−.30, P<.05), but no other CPET markers.Conclusions: These results suggest that individuals with OSA have autonomic dysfunction, and that exercise training, by increasing HRR and VO2peak, may attenuate autonomic imbalance and improve functional capacity independent of OSA severity reduction.