Showing papers in "American Journal of Cardiology in 2004"
TL;DR: Several imagining techniques demonstrated that bone marrow mesenchymal stem cells significantly improved left ventricular function in patients undergoing primary percutaneous coronary intervention.
Abstract: Sixty-nine patients who underwent primary percutaneous coronary intervention within 12 hours after onset of acute myocardial infarction were randomized to receive intracoronary injection of autologous bone marrow mesenchymal stem cell or standard saline. Several imagining techniques demonstrated that bone marrow mesenchymal stem cells significantly improved left ventricular function.
1,190 citations
TL;DR: Thrombolysis In Myocardial Infarction frame counts were abnormal inall patients and often abnormal in all 3 major coronary vessels, suggesting that the diffuse impairment of coronary microcirculatory function may play a role in the pathogenesis of the syndrome.
Abstract: The characteristics of 16 women with transient left ventricular (LV) apical ballooning syndrome in a United States population are presented. Additionally, Thrombolysis In Myocardial Infarction (TIMI) frame counts were evaluated during the acute period. Patients generally presented with anterior ST-elevation acute coronary syndrome in the absence of obstructive coronary disease. All patients had LV apical wall motion abnormalities. An acute emotional or physiologic stressor preceded most cases. TIMI frame counts were abnormal in all patients and often abnormal in all 3 major coronary vessels, suggesting that the diffuse impairment of coronary microcirculatory function may play a role in the pathogenesis of the syndrome.
584 citations
TL;DR: It is demonstrated that the metabolic syndrome is associated with increased risk of MCEs in both hypercholesterolemic patients with coronary heart disease in 4S and in those with low high-density lipoprotein cholesterol but without coronaryHeart disease in AFCAPS/TexCAPS.
Abstract: The metabolic syndrome, which is a set of lipid and nonlipid risk factors of metabolic origin linked with insulin resistance, is believed to be associated with an elevated risk for cardiovascular disease, but few have studied this association in prospective long-term cardiovascular outcomes trials. Placebo data from the Scandinavian Simvastatin Survival Study (4S) and the Air Force/Texas Coronary Atherosclerosis Prevention Study (AFCAPS/TexCAPS) were used post hoc to estimate the long-term relative risk of major coronary events (MCEs) associated with the metabolic syndrome, after excluding diabetes mellitus. In 4S and AFCAPS/TexCAPS, respectively, placebo-treated patients with the metabolic syndrome were 1.5 (95% confidence interval 1.2 to 1.8) and 1.4 (95% confidence interval 1.04 to 1.9) times more likely to have MCEs than those without it. Of the components of the metabolic syndrome, low high-density lipoprotein levels were associated with elevated risk of MCEs in both studies, whereas high triglycerides in 4S and elevated blood pressure and obesity in AFCAPS/TexCAPS were associated with significantly increased relative risk. Patients with the metabolic syndrome showed increased risk of MCEs irrespective of their Framingham-calculated 10-year risk score category (>20% vs
534 citations
TL;DR: The comet-tail is a simple, non-time-consuming, and reasonably accurate chest ultrasound sign of extravascular lung water that can be obtained at bedside (also with portable echocardiographic equipment) and is not restricted by cardiac acoustic window limitations.
Abstract: The "comet-tail" is an ultrasound sign detectable with ultrasound chest instruments; this sign consists of multiple comet-tails fanning out from the lung surface. They originate from water-thickened interlobular septa and would be ideal for nonradiologic bedside assessment of extravascular lung water. To assess the feasibility and value of ultrasonic comet signs, we studied 121 consecutive hospitalized patients (43 women and 78 men; aged 67 +/- 12 years) admitted to our combined cardiology-pneumology department (including cardiac intensive care unit); the study was conducted with commercially available echocardiographic systems including a portable unit. Transducer frequencies (range 2.5 to 3.5 MHz) were used. In each patient, the right and left chest was scanned by examining predefined locations in multiple intercostal spaces. Examiners blinded to clinical diagnoses noted the presence and numbers of lung comets at each examining site. A patient lung comet score was obtained by summing the number of comets in each of the scanning spaces. Within a few minutes, patients underwent chest x-ray, with specific assessment of extravascular lung water score by 2 pneumologist-radiologists blinded to clinical and echo findings. The chest ultrasound scan was obtained in all patients (feasibility 100%). The imaging time per examination was always <3 minutes. There was a linear correlation between echocardiographic comet score and radiologic lung water score (r = 0.78, p <0.01). Intrapatient variations (n = 15) showed an even stronger correlation between changes in echocardiographic lung comet and radiologic lung water scores (r = 0.89; p <0.01). In 121 consecutive hospitalized patients, we found a linear correlation between echocardiographic comet scores and radiologic extravascular lung water scores. Thus, the comet-tail is a simple, non-time-consuming, and reasonably accurate chest ultrasound sign of extravascular lung water that can be obtained at bedside (also with portable echocardiographic equipment) and is not restricted by cardiac acoustic window limitations.
518 citations
TL;DR: In this paper, the authors studied the time and frequency-domain indexes of heart rate variability (HRV) in 653 patients without any evidence of heart disease relative to age, gender, heart rate, body mass index, and functional capacity.
Abstract: We studied the time- and frequency-domain indexes of heart rate variability (HRV) in 653 patients without any evidence of heart disease relative to age, gender, heart rate, body mass index, and functional capacity. There was an inverse correlation of HRV with heart rate (p <0.001). HRV indexes decreased with increasing age, differed by gender, and were higher in patients with higher functional capacity. No correlation was noted between HRV and body mass index.
510 citations
TL;DR: The Dallas Heart Study provides a phenotypically well-characterized probability sample for multidisciplinary research that will be used to improve the mechanistic understanding and prevention of cardiovascular disease, especially in black Americans.
Abstract: The decrease in cardiovascular death rates in the United States has been slower in blacks than whites, especially in patients <65 years of age. The Dallas Heart Study was designed as a single-site, multiethnic, population-based probability sample to (1) produce unbiased population estimates of biologic and social variables that pinpoint ethnic differences in cardiovascular health at the community level and (2) support hypothesis-driven research on the mechanisms causing these differences using genetics, advanced imaging modalities, social sciences, and clinical research center methods. A probability-based sample of Dallas County residents aged 18 to 65 years was surveyed with an extensive household health interview. The subset of participants 30 to 65 years of age provided in-home fasting blood and urine samples and underwent multiple imaging studies, including cardiac magnetic resonance imaging and electron beam computed tomography. Completed interviews were obtained for 6,101 subjects (54% black), phlebotomy visits for 3,398 (52% black), and clinic visits for 2,971 (50% black). Participation rates were 80.4% for interviews, 75.1% for phlebotomy visits, and 87.4% for clinic visits. Weighted population estimates of many measured variables agreed closely with those of the United States census and were relatively stable from the interview sample to the phlebotomy and clinic subsamples. Thus, the Dallas Heart Study provides a phenotypically well-characterized probability sample for multidisciplinary research that will be used to improve the mechanistic understanding and prevention of cardiovascular disease, especially in black Americans.
502 citations
TL;DR: The Framingham 10-year CHD risk prediction model may not identify subjects with low short-term but high lifetime risk for CHD, likely due to changes in risk factor status over time, and further work is needed to generate multivariate risk models that can reliably predict lifetime risk.
Abstract: We investigated whether the Framingham risk score, which was designed to estimate the 10-year risk of coronary heart disease (CHD), differentiates lifetime risk for CHD. All subjects in the Framingham Heart Study examined from 1971 to 1996 who were free of CHD were included. Subjects were stratified into age- and gender-specific tertiles of Framingham risk score, and lifetime risk for CHD was estimated. We followed 2,716 men and 3,500 women; 939 developed CHD and 1,363 died free of CHD. At age 40 years, in risk score tertiles 1, 2, and 3, respectively, the lifetime risks for CHD were 38.4%, 41.7%, and 50.7% for men and 12.2%, 25.4%, and 33.2% for women. At age 80 years, risks were 16.4%, 17.4%, and 38.8% for men and 12.8%, 22.4%, and 27.4% for women. The Framingham risk score stratified lifetime risk well for women at all ages. It performed less well in younger men but improved at older ages as remaining life expectancy approached 10 years. Lifetime risks contrasted sharply with shorter term risks: at age 40 years, the 10-year risks of CHD in tertiles 1, 2, and 3, respectively, were 0%, 2.2%, and 11.6% for men and 0%, 0.7%, and 2.3% for women. The Framingham 10-year CHD risk prediction model discriminated short-term risk well for men and women. However, it may not identify subjects with low short-term but high lifetime risk for CHD, likely due to changes in risk factor status over time. Further work is needed to generate multivariate risk models that can reliably predict lifetime risk for CHD.
480 citations
TL;DR: The RCIN risk score was a clinical assessment tool with excellent predictive ability in identifying the larger population at risk for nephropathy in whom preventative strategies are indicated.
Abstract: Radiocontrast-induced nephropathy (RCIN) after percutaneous coronary intervention (PCI) is associated with grave consequences, but risk stratification of patients has not been well elucidated. This analysis derived a time-insensitive score to predict the risk of RCIN after PCI. A derivation cohort (1993 to 1998) and a validation cohort (1999 to 2002) comprised 20,479 patients who underwent PCI. RCIN after PCI was defined as a ≥1.0 mg/dl increase in serum creatinine. Variables having an independent correlation for RCIN after PCI were used to derive the RCIN risk score from the derivation cohort and were tested in the validation cohort. RCIN occurred in 2% of patients after PCI. Independent variables (with weighted scores) include estimated creatinine clearance 260 ml (1). The incidence of RCIN after PCI increased with each unit increase in score (p <0.0001, concordance statistic 0.89). No patient with a score ≤1 developed nephropathy, whereas 26% of patients with a score ≥9 developed RCIN after PCI (p <0.0001). Propensity score analysis showed that patients who developed RCIN after PCI, irrespective of the need for hemodialysis, had higher in-hospital rates of major adverse cardiac events (odds ratio 15, 95% confidence interval 11 to 20, p <0.0001). RCIN occurred in 2.0% of PCI patients and was associated with a 15-fold increase in adverse cardiac events. The RCIN risk score was a clinical assessment tool with excellent predictive ability in identifying the larger population at risk for nephropathy in whom preventative strategies are indicated.
475 citations
TL;DR: Of the 2,726 patients who had their DVT diagnosed while in the hospital, only 1,147 (42%) received prophylaxis within 30 days before diagnosis, and the 5 most frequent co-morbidities were hypertension, surgery within 3 months, immobilityWithin 30 days, cancer, and obesity.
Abstract: We enrolled 5,451 patients with ultrasound-confirmed deep vein thrombosis (DVT), including 2,892 women and 2,559 men, from 183 United States sites in our prospective registry. The 5 most frequent co-morbidities were hypertension (50%), surgery within 3 months (38%), immobility within 30 days (34%), cancer (32%), and obesity (27%). Of the 2,726 patients who had their DVT diagnosed while in the hospital, only 1,147 (42%) received prophylaxis within 30 days before diagnosis.
468 citations
TL;DR: In this article, the authors used tissue Doppler imaging (TDI) and color M-mode echocardiography to detect diastolic dysfunction in asymptomatic, normotensive patients with type 2 diabetes without significant coronary artery disease.
Abstract: To determine the prevalence of left ventricular diastolic dysfunction in asymptomatic, normotensive patients with type 2 diabetes mellitus, we studied 61 consecutive normotensive patients with type 2 diabetes using conventional Doppler echocardiography at rest (deceleration time, isovolumic relaxation time, early diastolic velocity [E]/peak atrial systolic velocity [A] ratio), and during the Valsalva maneuver. In addition, mitral annular velocity and velocity of flow propagation were assessed in all patients using tissue Doppler imaging (TDI) and color M-mode echocardiography. A standard resting echocardiogram excluded significant valvular disease and stress echocardiography excluded significant coronary artery disease in those with diastolic dysfunction. Diastolic dysfunction was found in 43 of 57 patients (75%) when all of the above echocardiographic techniques were used. TDI detected diastolic dysfunction more often (63%) than any other echocardiographic approach. Thus, the prevalence of left ventricular diastolic dysfunction in asymptomatic, normotensive patients with type 2 diabetes without significant coronary artery disease is much higher than previously suspected. TDI markedly improved the echocardiographic detection of diastolic dysfunction in asymptomatic patients with type 2 diabetes.
455 citations
TL;DR: It is demonstrated that differences in baseline time-to-speak velocities of opposing ventricular walls by TSI were greater in 15 patients, with an acute hemodynamic improvement, suggesting that acute response underestimates long-term effects.
Abstract: Echocardiographic tissue synchronization imaging (TSI) consists of color-coding time-to-peak tissue Doppler velocities. This study of 29 patients who underwent cardiac resynchronization therapy (CRT) demonstrated that differences in baseline time-to-speak velocities of opposing ventricular walls by TSI were greater in 15 patients, with an acute hemodynamic improvement. A >/=65 ms delay from the anterior septum to the posterior wall using the apical long-axis view had 87% sensitivity and 100% specificity for predicting an acute response. Although a subgroup without acute improvement had later decreases in end-systolic volume, suggesting that acute response underestimates long-term effects, TSI has potential to assist in guiding CRT.
TL;DR: It is found for the first time that an increase in epicardial fat is significantly related to a increase in left ventricular mass.
Abstract: Visceral adiposity is a cardiovascular risk factor of growing interest. This study sought to evaluate the hypothesis of a relation between epicardial adipose tissue, the visceral adipose tissue deposited around the heart, and left ventricular morphology in healthy subjects with a wide range of adiposity. We found for the first time that an increase in epicardial fat is significantly related to an increase in left ventricular mass.
TL;DR: The data indicate little association between long-term moderate alcohol consumption and the risk of AF, but a significantly increased risk ofAF among subjects consuming >36 g/day (approximatively >3 drinks/day).
Abstract: Atrial fibrillation (AF) is a major risk factor for stroke. Although acute alcohol intake has been associated with AF, it is not known whether long-term alcohol consumption in moderation is associated with an increased risk of AF. We used a risk set method to assess the relation of long-term alcohol consumption to the risk of AF among participants in the Framingham Study. For each case, up to 5 controls were selected and matched for age, age at baseline examination, sex, cohort, baseline history of hypertension, congestive heart failure, and myocardial infarction. Within each risk set, alcohol consumption was averaged from baseline until the examination preceding the index case of AF. Of the 1,055 cases of AF occurring during a follow-up of >50 years, 544 were men and 511 were women. In a conditional logistic regression with additional adjustment for systolic blood pressure, age at baseline examination, education, and cumulative history of myocardial infarction, congestive heart failure, diabetes mellitus, left ventricular hypertrophy, and valvular heart disease, the relative risks were 1.0 (reference), 0.97 (95% confidence interval [CI] 0.78 to 1.22), 1.06 (95% CI 0.80 to 1.38), 1.12 (95% CI 0.80 to 1.55), and 1.34 (95% CI 1.01 to 1.78) for alcohol categories of 0, 0.1 to 12, 12.1 to 24, 24.1 to 36, and >36 g/day, respectively. In conclusion, our data indicate little association between long-term moderate alcohol consumption and the risk of AF, but a significantly increased risk of AF among subjects consuming >36 g/day (approximatively >3 drinks/day).
TL;DR: Primary school students (817 apparently healthy 10-year olds) were screened by transthoracic 2-dimensional echocardiography to assess for the prevalence of bicuspid aortic valve, which was found in 0.5% of cases, with a higher prevalence in males than females.
Abstract: Primary school students (817 apparently healthy 10-year olds) were screened by transthoracic 2-dimensional echocardiography to assess for the prevalence of bicuspid aortic valve. Bicuspid aortic valve was found in 0.5% of cases, with a higher prevalence in males than females (0.75% vs 0.24%), and was significantly associated with aortic root enlargement compared with children who had tricuspid aortic valves.
TL;DR: Optimization of the VV interval significantly increased LV dP/dt(max) compared with simultaneous biventricular pacing, and such optimization could be easily, accurately, and reliably evaluated by a 0.014-in sensor-tipped pressure guidewire.
Abstract: Simultaneous biventricular pacing improves left ventricular (LV) function in patients with heart failure and LV asynchrony. Proper timing of the interventricular pacing interval (VV interval) may further optimize LV function. We investigated the acute hemodynamic response of changing the VV interval using maximum LV dP/dt (LV dP/dtmax) as a parameter for LV function. A biventricular pacemaker was implanted in 53 patients with severely impaired LV function, New York Heart Association class III and IV heart failure, left bundle branch block, LV asynchrony, and a QRS interval >150 ms. Optimization of the atrioventricular and VV intervals was based on measurement of LV dP/dtmax by a 0.014-in sensor-tipped pressure guidewire. Measurement of LV dP/dtmax was obtained without complications in all patients. In patients in sinus rhythm with ischemic cardiomyopathy or idiopathic dilated cardiomyopathy, mean improvements by simultaneous biventricular pacing were 17% and 18%, respectively. Patients in atrial fibrillation showed an improvement of 21%. Optimizing the VV interval resulted in further absolute increases of 8%, 7%, and 3%, respectively, in dP/dtmax in the 3 groups. Maximum dP/dt was achieved with LV pacing first in 44 patients, simultaneous right and left ventricular pacing in 6 patients, and right ventricular pacing first in 3 patients. The mean optimal VV intervals were 37 ± 32 ms in the atrial fibrillation group, 28 ± 30 ms in the idiopathic dilated cardiomyopathy group, and 52 ± 31 ms in the ischemic cardiomyopathy group. Optimization of the VV interval significantly increased LV dP/dtmax compared with simultaneous biventricular pacing, and such optimization could be easily, accurately, and reliably evaluated by a 0.014-in sensor-tipped pressure guidewire.
TL;DR: Control for all measured modifiable risk factors for cardiovascular disease did not entirely explain CRP differences, but body mass index was a significant predictor of elevated CRP concentrations among all race/ethnic groups, and control for body massIndex substantially attenuated the differences noted in CRP levels across race/ ethnic groups.
Abstract: The distribution of C-reactive protein (CRP) levels was compared among 24,455 white, 475 black, 357 Asian, and 254 Hispanic women, all of whom are participants in the Women's Health Study. Median CRP levels were significantly higher among black women (2.96 mg/L, interquartile range [IQR] 1.19 to 5.86) than among their white (2.02 mg/L, IQR 0.81 to 4.37), Hispanic (2.06 mg/L, IQR 0.88 to 4.88), and Asian (1.12 mg/L, IQR 0.48 to 2.25) counterparts. As expected, women taking hormone replacement therapy had higher baseline CRP levels than women not taking hormone replacement therapy. No differences in low-density lipoprotein cholesterol or total cholesterol levels were observed between ethnic groups. In multivariate regression models, body mass index was a significant (p <0.001) predictor of elevated CRP concentrations among all race/ethnic groups, and control for body mass index substantially attenuated the differences noted in CRP levels across race/ethnic groups, particularly among black women. Control for all measured modifiable risk factors for cardiovascular disease did not entirely explain CRP differences. Among these women, the distribution of CRP levels varied significantly between the various race/ethnic groups.
TL;DR: The calcified aortic valve lesion develops in the setting of endothelial injury and inflammation and displays hallmarks of atherosclerosis, including lipids accumulation, matrix metalloproteinase activation, and interaction with renin-angiotensin system.
Abstract: The calcified aortic valve lesion develops in the setting of endothelial injury and inflammation and displays hallmarks of atherosclerosis, including lipids accumulation, matrix metalloproteinase activation, and interaction with renin-angiotensin system. Current evidence indicates that modification of atherosclerotic risk factors will slow the progression of aortic valve calcification, and valve risk factors should be addressed in all patients who have aortic valve calcification.
TL;DR: The results indicate that AF is a much more pronounced risk factor for stroke and cardiovascular death in women than in men.
Abstract: The Copenhagen City Heart Study is a population-based cohort study. Using baseline data from 3 cohort examinations (1976 to 1978, 1981 to 1983, and 1991 to 1994), we analyzed the gender-specific effect of atrial fibrillation (AF) on the risk of stroke and cardiovascular death during 5 years of follow-up. Baseline data from 29,310 subjects were included. AF was documented in 276 subjects (110 women and 166 men). During a mean follow-up of 4.7 years, 635 strokes were identified, 35 of which occurred in subjects who had AF (22 women and 13 men). After adjustment for age and co-morbidity, the effect of AF on the risk of stroke was 4.6-fold greater in women (hazard ratio 7.8, 95% confidence interval 5.8 to 14.3) than in men (hazard ratio 1.7, 95% confidence interval 1.0 to3.0). Cardiovascular death occurred in 1,122 subjects, 63 of whom had AF (28 in women and 35 in men). The independent effect of AF on cardiovascular mortality rate was 2.5-fold greater in women (hazard ratio 4.4, 95% confidence interval 2.9 to 6.5) than in men (hazard ratio 2.2, 95% confidence interval 1.6 to 3.1). Our results indicate that AF is a much more pronounced risk factor for stroke and cardiovascular death in women than in men.
TL;DR: It is suggested that fish consumption may be an important component of lifestyle modification for the prevention of CHD and is associated with a significantly lower risk of fatal and total CHD.
Abstract: Fish consumption has been associated with a lower risk of coronary heart disease (CHD) in some but not all studies. We conducted a meta-analysis of observational studies to determine if fish consumption is associated with lower fatal and total CHD. English language articles published before May 2003 were searched. In all, 19 observational studies (14 cohort and 5 case-control) in which there was a group that consumed fish on a regular basis and a comparison group that consumed little or no fish were included. With use of a standardized protocol and data extraction form, information on study design, sample size, participant characteristics, duration of follow-up, assessment of end points, and consumption of fish was abstracted. Using a random effects model, we pooled data from each study. Fish consumption versus little to no fish consumption was associated with a relative risk of 0.83 (95% confidence interval 0.76 to 0.90; p <0.005) for fatal CHD and a relative risk of 0.86 (95% confidence interval 0.81 to 0.92; p <0.005) for total CHD. The results indicate that fish consumption is associated with a significantly lower risk of fatal and total CHD. These findings suggest that fish consumption may be an important component of lifestyle modification for the prevention of CHD.
TL;DR: It is shown that RA and SLE increase the risk of AMI, and in subjects with both RA and diagnosed hyperlipidemia, the OR was 7.12 (95% CI 4.16 to 12.18).
Abstract: We explored the association between diagnosed rheumatoid arthritis (RA) or systemic lupus erythematosus (SLE) and the risk of developing a first-time acute myocardial infarction (AMI) by conducting a population-based, case-control analysis using data from the United Kingdom-based General Practice Research Database (GPRD). Among 8,688 patients with AMI and 33,329 matched controls, the adjusted odds ratio (ORs) of AMI for subjects with RA was 1.47 (95% confidence interval [CI] 1.23 to 1.76), and in subjects with both RA and diagnosed hyperlipidemia, the OR was 7.12 (95% CI 4.16 to 12.18). The risk associated with SLE was 2.67 (95% CI 1.34 to 5.34). These results underline that RA and SLE increase the risk of AMI.
TL;DR: Pravastatin has a neutral drug interaction profile relative to cytochrome P450-3A4 inhibitors, but these substrates markedly increase systemic exposure to simvastatin and atorvastati, particularly when co administered with medications that increase their systemic exposure.
Abstract: Three-hydroxy-3-methylglutaryl coenzyme-A reductase inhibitors (statins) are first-line treatments for hypercholesterolemia. Although exceedingly well tolerated, treatment with statins incurs a small risk of myopathy or potentially fatal rhabdomyolysis, particularly when coadministered with medications that increase their systemic exposure. Studies compared the multiple-dose pharmacokinetic interaction profiles of pravastatin, simvastatin, and atorvastatin when coadministered with 4 inhibitors of cytochrome P450-3A4 isoenzymes in healthy subjects. Compared with pravastatin alone, coadministration of verapamil, mibefradil, or itraconazole with pravastatin was associated with no significant changes in pravastatin pharmacokinetics. However, concomitant verapamil increased the simvastatin area under the concentration:time curve (AUC) approximately fourfold, the maximum serum concentration (C max ) fivefold, and the active metabolite simvastatin acid AUC and C max approximately four- and threefold, respectively (all comparisons p 60% increase in the serum half-life (p = 0.03) of atorvastatin were observed when coadministered with mibefradil. The half-life of atorvastatin also increased by ≈60% (p = 0.052) when coadministered with itraconazole, which elicited a 2.4-fold increase in the C max of atorvastatin and a 47% increase in the AUC (p max and AUC). Clarithromycin significantly (p max ) of all 3 statins, most markedly simvastatin (∼10-fold increase in AUC) and simvastatin acid (12-fold), followed by atorvastatin (greater than fourfold) and then pravastatin (almost twofold). Pravastatin has a neutral drug interaction profile relative to cytochrome P450-3A4 inhibitors, but these substrates markedly increase systemic exposure to simvastatin and atorvastatin.
TL;DR: This trial represents the largest prospective dataset of bivalirudin administered concomitantly with planned GP IIb/IIIa blockade and provides evidence of the safety and efficacy of this combined antithrombotic approach.
Abstract: To assess the efficacy of the direct thrombin inhibitor bivalirudin relative to heparin during contemporary coronary intervention, 1,056 patients who underwent elective or urgent revascularization were randomized in a large-scale pilot study to receive heparin (70 U/kg initial bolus) or bivalirudin (0.75 mg/kg bolus, 1.75 mg/kg/hour infusion during the procedure). All patients received aspirin; pretreatment with clopidogrel was encouraged, and glycoprotein (GP) IIb/IIIa blockade was at the physician's discretion. Stents were placed in 85% of patients; 72% received a GP IIb/IIIa inhibitor, and 56% were pretreated with clopidogrel. Activated clotting times were higher among patients randomized to bivalirudin than among those given heparin before device activation (median 359 vs 293 seconds, p <0.001). The composite efficacy end point of death, myocardial infarction, or repeat revascularization before hospital discharge or within 48 hours occurred in 5.6% and 6.9% of patients in the bivalirudin and heparin groups, respectively (p = 0.40). Major bleeding occurred in 2.1% versus 2.7% of patients randomized to bivalirudin or heparin, respectively (p = 0.52). This trial represents the largest prospective dataset of bivalirudin administered concomitantly with planned GP IIb/IIIa blockade and provides evidence of the safety and efficacy of this combined antithrombotic approach.
TL;DR: Patients who had AF demonstrated comparable benefit from CRT as those who had sinus rhythm, and the long-term survival rate was comparable between patients who had Sinus rhythm and those whoHad AF.
Abstract: Cardiac resynchronization therapy (CRT) is a new therapeutic option for patients who have drug-refractory end-stage heart failure. Much information has been obtained from patients who have sinus rhythm, but the use of CRT in patients who have chronic atrial fibrillation (AF) has not been studied extensively. Accordingly, we evaluated the clinical response and long-term survival rate of CRT in patients who had heart failure and chronic AF, and the results were compared with those in patients who had sinus rhythm and who underwent CRT. Sixty patients who had end-stage heart failure (30 had sinus rhythm and 30 had chronic AF), New York Heart Association classes III to IV, left ventricular ejection fraction 120 ms, and a left bundle branch block received a biventricular pacemaker. New York Heart Association class, Minnesota Quality of Life score, and 6-minute walking distance were evaluated at baseline and after 6 months of CRT. Long-term follow-up was ≤2 years. New York Heart Association class, Minnesota Quality of Life score, and 6-minute walking distance improved significantly in the 2 groups after 6 months of CRT. The number of nonresponders was greater among patients who had AF. Nevertheless, the long-term survival rate was comparable between patients who had sinus rhythm and those who had AF. Patients who had AF demonstrated comparable benefit from CRT as those who had sinus rhythm.
TL;DR: Three-month therapy with allopurinol improved FMD in hyperuricemic subjects, showing an intrinsic negative effect of elevated UA levels on the arterial wall; conversely, FMD remained unchanged in controls, thus suggesting that the reduction of UA to less than a certain value does not affect endothelial function.
Abstract: The aim of the present study was to evaluate the effect of increased serum uric acid (UA) levels and their therapeutic reduction with allopurinol on endothelium-dependent dilation in subjects with a high cardiovascular (CV) risk but who were free from clinical CV disease. Patients with hyperuricemia had impaired flow-mediated dilation (FMD) compared with matched controls with normal UA levels and elevated CV risk. Three-month therapy with allopurinol improved FMD in hyperuricemic subjects, showing an intrinsic negative effect of elevated UA levels on the arterial wall; conversely, FMD remained unchanged in controls, thus suggesting that the reduction of UA to less than a certain value does not affect endothelial function.
TL;DR: Reduced sodium intake and the DASH diet should be advocated for the prevention and treatment of high BP, particularly because the benefits to BP strengthen as subjects enter middle age, when the rate of cardiovascular disease increases sharply.
Abstract: This study presents an extensive analysis of the effects on blood pressure (BP) of changes in sodium intake over a wide array of subgroups, including joint subgroups defined by age and hypertension status, race or ethnicity and hypertension status, and gender and race or ethnicity. Participants were given 3 levels of sodium (50, 100, and 150 mmol/2,100 kcal) for 30 days while consuming the Dietary Approaches to Stop Hypertension (DASH) diet (rich in fruits, vegetables, and low-fat dairy) or a more typical American diet. Within each diet and subgroup, there was a general pattern such that the lower the sodium level, the greater the mean reduction in BP. Sodium reduction from 100 to 50 mmol/2,100 kcal generally had twice the effect on BP as reduction from 150 to 100 mmol/2,100 kcal. Age had a strong and graded influence on the effect of sodium within the typical and DASH diets, respectively: -4.8 and -1.0 mm Hg systolic for 23 to 41 years, -5.9 and -1.8 mm Hg for 42 to 47 years, -7.5 and -4.3 mm Hg for 48 to 54 years, and -8.1 and -6.0 mm Hg for 55 to 76 years. The influence of age on the effect of sodium reduction was particularly strong in nonhypertensive patients: -3.7 mm Hg systolic for 45 years with the typical diet and -0.7 and -2.8 mm Hg with the DASH diet. Reduced sodium intake and the DASH diet should be advocated for the prevention and treatment of high BP, particularly because the benefits to BP strengthen as subjects enter middle age, when the rate of cardiovascular disease increases sharply.
TL;DR: The MS score provides a clinically useful index of MS severity and the associated atherosclerotic risk factor profile, and correlates with the angiographic severity of CAD and its clinical complications.
Abstract: The metabolic syndrome (MS) is a frequent cause of coronary artery disease (CAD), and recently the National Cholesterol Education Program Adult Treatment Panel III suggested its diagnosis in the presence of 3 to 5 quantitatively defined markers. Because the consequences of the MS are likely related to the number and diversity of markers, we studied the relation between the number of markers—the MS score—and the degree of abdominal obesity, risk factor profile, and severity of CAD. One thousand one hundred eight subjects of a mostly white population with symptoms of CAD (793 men and 315 women; 58.1 ± 9.8 years of age) were divided into 6 groups based on their MS scores. A low high-density lipoprotein cholesterol level was the most frequently observed marker, followed by increased blood pressure, triglycerides, waist circumference, and fasting glucose. As the MS score increased so did abdominal obesity, parameters of “nontraditional” dyslipidemia with surrogate markers of dense low-density lipoprotein and high-density lipoprotein particles, blood pressure, fasting glucose, insulin, and the homeostatic model assessment insulin resistance index. Similarly, an increasing MS score was significantly related to more severe coronary angiographic alterations and higher frequencies of unstable angina, myocardial infarction, percutaneous coronary intervention, and coronary artery bypass grafting. Therefore, the MS score provides a clinically useful index of MS severity and the associated atherosclerotic risk factor profile. It also correlates with the angiographic severity of CAD and its clinical complications.
TL;DR: It is demonstrated that clinically unrecognized hypervolemia is frequently present in nonedematous patients with CHF and is associated with increased cardiac filling pressures and worse patient outcomes.
Abstract: Clinically unrecognized intravascular volume overload may contribute to worsening symptoms and disease progression in patients with chronic heart failure (CHF). The present study was undertaken to prospectively compare measured blood volume status (determined by radiolabeled albumin technique) with clinical and hemodynamic characteristics and patient outcomes in 43 nonedematous ambulatory patients with CHF. Blood volume analysis demonstrated that 2 subjects (5%) were hypovolemic (mean deviation from normal values −20 ± 6%), 13 subjects (30%) were normovolemic (mean deviation from normal values −1 ± 1%), and 28 subjects (65%) were hypervolemic (mean deviation from normal values +30 ± 3%). Physical findings of congestion were infrequent and not associated with blood volume status. Increased blood volume was associated with increased pulmonary capillary wedge pressure (p = 0.01) and greatly increased risk of death or urgent cardiac transplantation during a median follow-up of 719 days (1-year event rate 39% vs 0%, p
TL;DR: The large patient numbers in the TNT study and long follow-up should ensure that there is adequate power to definitively determine if reducing LDL cholesterol levels to approximately 75 mg/dl (1.9 mmol/L) can provide additional clinical benefit.
Abstract: The Treating to New Targets (TNT) trial is a parallel-group study that has randomized 10,003 patients from 14 countries to double-blind treatment with either atorvastatin 10 or 80 mg. During the double-blind period, low-density lipoprotein (LDL) cholesterol levels are expected to reach approximate mean values of 100 mg/dl (2.6 mmol/L) for the low-dose atorvastatin group and 75 mg/dl (1.9 mmol/L) for the high-dose group. Randomized patients are expected to be followed for an average of 5 years. The primary end point is the time to occurrence of a major cardiovascular event, defined as coronary heart disease death, nonfatal myocardial infarction, resuscitated cardiac arrest, or stroke. The large patient numbers in the TNT study and long follow-up should ensure that there is adequate power to definitively determine if reducing LDL cholesterol levels to approximately 75 mg/dl (1.9 mmol/L) can provide additional clinical benefit.
TL;DR: The results suggest that a considerable proportion of patients who were discharged from the hospital after an ACS remain at increased risk for adverse outcomes during the relatively brief post-discharge period, and the need for better long-term medical management and more intense follow-up of patients with an ACS to improve their long- term outlook.
Abstract: Relatively limited data are available, particularly from the perspective of a multinational registry, about the post-discharge outcomes and management practices of patients with an acute coronary syndrome (ACS). The objectives of this longitudinal study were to examine 6-month outcomes in a large multinational sample of patients hospitalized with an ACS. A total of 5,476 patients with ST-segment elevation acute myocardial infarction (STEAMI), 5,209 patients with non-ST-segment elevation acute myocardial infarction (NSTEAMI), and 6,149 patients with unstable angina pectoris discharged from 90 hospitals in 14 countries comprised the study population. The study sample was recruited from 18 cluster sites in 14 countries that are currently collaborating in the Global Registry of Acute Coronary Events (GRACE) study. The 6-month post-discharge death rates were 4.8% in patients with STEAMI, 6.2% in patients with NSTEAMI, and 3.6% in patients with unstable angina pectoris. Approximately 1 in 5 of each of our comparison groups were rehospitalized for heart disease during the 6-month follow-up, and approximately 15% of each of the respective study cohorts underwent coronary revascularization during follow-up. Demographic and clinical characteristics of post-discharge decedents were identified according to type of ACS. Our results suggest that a considerable proportion of patients who were discharged from the hospital after an ACS, with some differences noted according to type of ACS, remain at increased risk for adverse outcomes during the relatively brief post-discharge period. These data suggest the need for better long-term medical management and more intense follow-up of patients with an ACS to improve their long-term outlook.
TL;DR: A greater LDL cholesterol decrease and HDL cholesterol increase were attained by treating patients with co-administration of ezetimibe and simVastatin than with atorvastatin.
Abstract: This study compared the efficacy and safety of co-administered ezetimibe + simvastatin with atorvastatin monotherapy in adults with hypercholesterolemia. Seven hundred eighty-eight patients were randomized 1:1:1 to 3 treatment groups; each group was force-titrated over four 6-week treatment periods: (1) 10 mg of atorvastatin as the initial dose was titrated to 20, 40, and 80 mg; (2) co-administration of 10 mg of ezetimibe and 10 mg of simvastatin (10/10 mg) was titrated to 10/20, 10/40, and 10/80 mg of ezetimibe + simvastatin; and (3) co-administration of 10/20 mg of ezetimibe + simvastatin was titrated to 10/40 mg (for 2 treatment periods) and 10/80 mg of ezetimibe + simvastatin. Key efficacy measures included percent changes in low-density lipoprotein cholesterol (LDL) and high-density lipoprotein cholesterol (HDL) from baseline to the ends of (1) treatment periods 1 and 2 (for LDL cholesterol) comparing co-administration of 10/20 mg and 10/10 mg of ezetimibe + simvastatin with 10 mg of atorvastatin and (2) treatment period 4 (for LDL cholesterol and HDL cholesterol) comparing co-administration of 10/80 mg of ezetimibe + simvastatin with 80 mg of atorvastatin. Baseline LDL and HDL cholesterol levels were comparable between treatment groups. At the end of treatment period 1, the mean decrease of LDL cholesterol was significantly (p