It reflects current UK and international guidelines and provides key evidence based references. Wherever possible, published guidelines are incorporated to ensure the book reflects current recommended management. It indicates where practice differs from that of younger adults, and provides guidance on the ethical and clinical dilemmas particular to the elderly. The handbook covers many aspects of cardiovascular disease in the elderly and focuses on common problems, including heart failure, atrial fibrillation and isolated systolic hypertension.

Cardiovascular disease in the elderly.

BACKGROUND AND PURPOSE In cardiovascular pharmacology, electrical and mechanical events can be distinguished, and the phrase ‘electro-mechanical window’ (EMw) describes the temporal difference between these events. We studied whether changes in EMw have potential predictive value for the occurrence of arrhythmias in fentanyl/etomidate-anaesthetized beagle (FEAB) dogs.



EXPERIMENTAL APPROACH The EMw was calculated as differences between the QT interval and QLVPend in FEAB dogs during atrial pacing, treatment with isoprenaline or atropine, body temperature changes and induction of Torsade de Pointes (TdP) in an LQT1 model.



KEY RESULTS The electrical systole (QT interval) was shorter than the duration of the mechanical event (QLVPend), providing a positive EMw. Atrial pacing, atropine or body temperature changes had no major effects on EMw, despite large changes in QT duration. However, β-adrenoceptor stimulation (with isoprenaline) decreased the EMw (from 90 to 5 ms) and in combination with HMR1556, a blocker of the slowly activating potassium current (IKs), induced a large negative EMw (–109 ms) and TdP. Prevention of TdP by atenolol or verapamil was associated with a less negative EMw (–23 to –16 ms). Mexiletine, a poorly effective long QT treatment, did not affect the EMw or prevent TdP induction.



CONCLUSIONS AND IMPLICATIONS The EMw is a marker, other than QT prolongation, of TdP risk in the FEAB model. Therefore, we suggest examining the EMw as a risk marker in cardiovascular safety studies and as a potential biomarker to improve clinical management of long QT syndrome patients, especially in patients with borderline QT prolongation.



LINKED ARTICLE This article is commented on by Vargas, pp. 1441–1443 of this issue. To view this commentary visit http://dx.doi.org/10.1111/j.1476-5381.2010.00980.x

/pdf/the-electro-mechanical-window-a-risk-marker-for-torsade-de-47jgfvx3o5.pdf

The Electro-Mechanical window: a risk marker for Torsade de Pointes in a canine model of drug induced arrhythmias

Introduction The goal of HAART is to achieve maximal and durable suppression of virus replication. Adherence plays a very important role in success of antiretroviral therapy. Aims and objectives To find out the rate of adherence and factors that influence adherence to antiretroviral therapy (ART). Material and methods The present study was conducted in the Department of Medicine in a tertiary care hospital from November 2007 to September 2009. Patients attending ART centre OPD and started on ART for at least 6 months were included in the study. A pretested proforma and MMAS adherence questionnaire of every patient was used for data collection. Univariate and multivariate logistic regression analysis was done to identify factors associated with adherence. Observations and results A total of 300 patients attending ART OPD and satisfying inclusion criteria were studied. Adherence rate of >95% was reported by 290 (97%) patients. On MMAS scale 78% of the patients were found adherent to the treatment. On multivariate analysis factors such as age, addictions, difficulty in remembering treatment, finding treatment to be difficult, taking traditional medicines and having no one to remind about medicines were found to be associated with nonadherence. The most common reason for nonadherence were missing pills while travelling or being out of home. Conclusions Adherence to antiretroviral treatment in the ART centre is high. During counseling sessions giving up addictions, avoiding traditional medicines, addressing the apprehensions about treatment, and identifying reminder systems should be emphasized. The patients should be advised to carry medications while traveling and when away from home.

Adherence to antiretroviral therapy.

Background Systemic lupus erythematosus (SLE) is characterized by various clinical manifestations and immunologic abnormalities. Cardiovascular and respiratory system involvement are increasingly recognized as critical for patients' prognosis. In this review, current knowledge concerning diagnosis, pathogenesis and treatment of the cardiac and pulmonary lupus manifestations are discussed. Method Review of the literature. Results Although pericarditis is the most frequent heart manifestation in the context of lupus, valvular disease and less often myocarditis may be detected. In the latter, treatment should be prompt and aggressive to prevent chronic sequelae like congestive heart failure. Later on disease course, accelerated atherosclerosis is considered as one of the most important co-morbidities of SLE with cardiovascular events being one of the leading causes of death at relatively young ages. Stratification of the patients at risk and stringent management of the traditional risk factors are warranted. Respiratory system involvement affects all anatomic structures of the lungs, pleura and pulmonary vasculature while its severity ranges from asymptomatic pleural disease to acute respiratory failure. The most common features include pleuritis, interstitial lung disease and pulmonary embolism on the background of antiphospholipid syndrome. Less usual complications include lupus pneumonitis, diffuse alveolar hemorrhage, shrinking lung syndrome and pulmonary arterial hypertension. Conclusion There are no specific guidelines for the management of these manifestations and therapeutic approach remains empiric.

Cardiovascular and Pulmonary Manifestations of Systemic Lupus Erythematosus.

The antiphospholipid syndrome (APLS) is a complex autoimmune disease often connected to systemic lupus erythematodes. Main features are thromboses, fetal loss and specific antibodies. The involved autoantibodies are directed against plasma proteins such as beta2glycoprotein1 (beta2GPI) or prothrombin which depend on negatively charged phospholipids. Direct antibodies against phospholipids are of no importance for APLS. Clotting tests such as activated partial thromboplastin time or diluted Russell's viper venom test (dRVVT) can show a prolonged time for coagulation despite a prothrombotic state in vivo but the investigator needs awareness about disturbing phospholipid sources and other influential factors. Enzyme linked immuno sorbent assay tests for antibodies against cardiolipin, beta2GPI and prothrombin are valuable solid phase tests with different specificity. Antiphospholipid, anticardiolipin or lupus anticoagulant are misnomers in connection with APLS. They are preserved as a reminiscence of the pioneering work on the way to the still not exactly revealed basics of APLS. Valve operations in APLS patients seem to be rare; a meta-analysis of 57 cases proves that the perioperative management is, at the moment, an empirical approach with high morbidity and mortality in these young patients.

/pdf/the-antiphospholipid-syndrome-and-heart-valve-surgery-41i6qddrvz.pdf

The antiphospholipid syndrome and heart valve surgery.

Objective - Doppler tissue imaging (DTI) enables the study of the velocity of contraction and relaxation of myocardial segments. We established standards for the peak velocity of the different myocardial segments of the left ventricle in systole and diastole, and correlated them with the electrocardiogram. Methods - We studied 35 healthy individuals (27 were male) with ages ranging from 12 to 59 years (32.9 ± 10.6). Systolic and diastolic peak velocities were assessed by Doppler tissue imaging in 12 segments of the left ventricle, establishing their mean values and the temporal correlation with the cardiac cycle. Results - The means (and standard deviation) of the peak velocities in the basal, medial, and apical regions (of the septal, anterior, lateral, and posterior left ventricle walls) were respectively, in cm/s, 7.35(1.64), 5.26(1.88), and 3.33(1.58) in systole and 10.56(2.34), 7.92(2.37), and 3.98(1.64) in diastole. The mean time in which systolic peak velocity was recorded was 131.59ms (±19.12ms), and diastolic was 459.18ms (±18.13ms) based on the peak of the R wave of the electrocardiogram. Conclusion - In healthy individuals, maximum left ventricle segment velocities decreased from the bases to the ventricular apex, with certain proportionality between contraction and relaxation (P<0.05). The use of Doppler tissue imaging may be very helpful in detecting early alterations in ventricular contraction and relaxation.

/pdf/study-of-the-myocardial-contraction-and-relaxation-5fmm64t6tf.pdf

Study of the myocardial contraction and relaxation velocities through Doppler tissue imaging echocardiography: A new alternative in the assessment of the segmental ventricular function.

OBJECTIVE: The purpose of this study is to evaluate the impact of transeophageal echocardiography on management of patients at low-risk for cardiogenic embolism to prevent new potential cardiovascular sources of emboli. METHODS: We studied 69 patients with ischemic stroke at low-risk for cardiogenic embolism. Transeophageal echocardiography was performed to access: left atrium enlargement; communication or aneurysm of the interatrial septum; patent foramen ovale; spontaneous echo contrast or intracavitary thrombi; the presence of intraaortic atherosclerotic plaques or thrombi; significant valvar morphologic alteration or dysfunction; left ventricle enlargement, hypertrophy, or contractile abnormality. Transesophageal echocardiography altered clinical management, and we adopted anticoagulant therapy or another procedure apart from the use of acetylsalicylic acid. RESULTS: Transeophageal echocardiography detected at least one abnormality in 40 cases (58%). Clinical conduct was adjusted after the performance of transesophageal echocardiography in 11 patients (15.9%); anticoagulation was added in 10 cases and surgical correction in one patient. CONCLUSION: Transeophageal echocardiography was a very useful tool in the secondary prevention for stroke in patients at low risk for cardiogenic embolism.

/pdf/clinical-impact-of-transesophageal-echocardiography-in-4tdy3cl5fv.pdf

Clinical impact of transesophageal echocardiography in patients with stroke without clinical evidence of cardiovascular sources of emboli

Different vascular abnormalities have been reported under the denomination of "persistence of the fifth aortic arch." Detailed studies on experimental embryology raised the discussion about the existence of the fifth aortic arch as an embryological structure, both in humans and mammals. In 1969 the Van Praaghs described the occurrence of double left aortic arch, denominating such anomaly as persistence of the fifth arch. We describe here a female patient showing the presence of an anomalous vessel in parallel with the aortic arch. The finding was occasional, during a preoperative evaluation for cholecystectomy.

Double lumen aortic arch or persistence of fifth aortic arch?- Report of a case with no associated cardiac defects and literature review.

/pdf/impacto-clinico-da-ecocardiografia-transesofagica-em-14c4c7hfim.pdf

Impacto clínico da ecocardiografia transesofágica em pacientes com acidente vascular cerebral sem evidência clínica de fonte emboligênica cardíaca

http://www.scielo.br/pdf/abc/v82s2/18614.pdf

Luiz Darcy Cortez Ferreira

Papers

Study of the myocardial contraction and relaxation velocities through Doppler tissue imaging echocardiography: A new alternative in the assessment of the segmental ventricular function.

Clinical impact of transesophageal echocardiography in patients with stroke without clinical evidence of cardiovascular sources of emboli

Double lumen aortic arch or persistence of fifth aortic arch?- Report of a case with no associated cardiac defects and literature review.

Impacto clínico da ecocardiografia transesofágica em pacientes com acidente vascular cerebral sem evidência clínica de fonte emboligênica cardíaca

Normatização dos Equipamentos e Técnicas de Exame para Realização de Exames Ecocardiográficos