Showing papers in "Clinical Cardiology in 2008"

A Comparison of the Aldosterone‐blocking Agents Eplerenone and Spironolactone

Abstract: Improved understanding of the adverse pharmacological properties of aldosterone has prompted investigation of the clinical benefits of blocking aldosterone at the receptor level. This article reviews the pharmacology, clinical efficacy, and tolerability of the two available blocking agents, spironolactone and eplerenone. A Medline search identified clinical studies assessing spironolactone and eplerenone. Priority was given to large, well-controlled, clinical trials and comparative studies. Pharmacological differences between spironolactone and eplerenone include lower affinity of eplerenone for progesterone, androgen, and glucocorticoid receptors; more consistently demonstrated nongenomic properties for eplerenone; and the presence of long-acting metabolites for spironolactone. Both agents effectively treat hypertension and heart failure but comparisons are complicated by the deficiency of head-to-head trials and differences between patient populations. There are differences in the tolerability profiles; spironolactone is associated with dose-dependent sexual side effects. Both agents produce dose-dependent increases in potassium concentrations, although the effect with spironolactone appears to be greater when both agents are administered at recommended doses. Choice of a specific agent should be based on individual patient issues, such as the nature of heart failure and patient concerns about adverse events.

Frequency and outcome of arrhythmias complicating admission during pregnancy: experience from a high-volume and ethnically-diverse obstetric service.

Abstract: Background Arrhythmias are reported during pregnancy, although hospitalization for these infrequent events is not fully characterized. The frequency and outcome of arrhythmias during pregnancy are unknown. Methods Between 1992 and 2000, there were 136,422 pregnancy-related admissions to Parkland Memorial Hospital (Dallas, TX, USA). Using the discharge diagnosis data bank and the International Classification of Disease, 9th revision, Clinical Modification (ICD-9-CM) coding system, we identified 226 admissions (218 patients) where cardiac arrhythmias and intrauterine pregnancy were both reported. Results The most common rhythm disturbances during pregnancy were sinus tachycardia (ST), sinus bradycardia (SB), or sinus arrhythmia (SA) (104 episodes/100,000 pregnancies). This was followed by paroxysmal supraventricular tachycardia (PSVT) and premature beats, with a frequency of 24/100,000 and 33/100,000, respectively. Paroxysmal supraventricular tachycardia occurred most frequently in the third trimester or peripartum. All episodes terminated spontaneously or were safely terminated with medical therapy. Advanced heart block or lethal arrhythmias were exceedingly rare during pregnancy. Conclusion Most frequently reported cardiac arrhythmias in pregnancy are benign and do not require intervention. Supraventricular tachycardia (SVT), being one of the most common complicated cardiac arrhythmias during pregnancy, can be treated effectively and safely with standard medical therapy. Ventricular arrhythmias or high-degree atrioventricular block (AVB) during pregnancy are extremely rare. Cardiac arrest is also rare, and is often caused by a different etiology from the conventional ones for sudden cardiac death. Copyright © 2008 Wiley Periodicals, Inc.

Assessment of atrial electromechanical coupling and influential factors in nonrheumatic paroxysmal atrial fibrillation.

Abstract: Background Sequential analysis of atrial electromechanical coupling (P-A) by Doppler tissue imaging (DTI) might provide important insight into the mechanisms of paroxysmal atrial fibrillation (PAF). Hypothesis The purpose of this study was to evaluate P-A and the dispersion of P-A, and to analyze the influential factors of P-A. Methods One hundred and ten patients with PAF and 87 normal controls were enrolled. Using DTI, the time intervals from the beginning of P-wave to the onset of atrioventricular ring motion related to atrial contraction were measured. Results Atrial electromechanical coupling at the interventricular septum atrioventricular annulus (P-A1), left lateral mitral annulus (P-A2) and right lateral tricuspid annulus (P-A3) in PAF group were significantly longer than those in control (p < 0.001). The difference between P-A2 and P-A1 (T1), P-A2 and P-A3 (T3) in PAF group were greater than those in control before age correction (p < 0.05). The linear regression analysis showed that the duration of PAF episodes and age were the greatest influential factors of P-A1 (r = 0.564). Left atrial anterior-posterior dimension (LAD) and age were the greatest influential factors of P-A2 (r = 0.459). The LAD was the greatest influential factors of T1 and T3 (r = 0.408, 0.542). Conclusions The atrial electromechanical coupling was significantly longer and the dispersion of P-A at left lateral mitral annulus was greater in PAF patients. The prolongation of P-A may be related to left atrial enlargement, long episodes of PAF and aging and the dispersion of P-A at left lateral mitral annulus to LAD. Copyright © 2008 Wiley Periodicals, Inc.

Update on atrial fibrillation: Part II

Abstract: Antiarrhythmic drugs are an essential tool in the management of atrial fibrillation (AF). Although we are already on the threshold of a large expansion in the use of ablation therapies, these will not, however, be appropriate for all patients, and pharmacological therapies will continue to have an important place in the management of atrial fibrillation. The plethora of antiarrhythmic drugs currently available for the treatment of atrial fibrillation is a reflection that none is wholly satisfactory, each having limited efficacy combined with poor safety and tolerability. Improved class III antiarrhythmic drugs, such as dronedarone, new classes of antiarrhythmic agents, such as atrial repolarization delaying agents, and upstream therapies dealing with substrate, represent potential sources of new pharmacological therapies.

Coronary Slow Flow Phenomenon and Risk for Sudden Cardiac Death Due to Ventricular Arrhythmias: A Case Report and Review of Literature

Abstract: We report a case of coronary slow flow phenomenon (CSFP) in a patient who underwent coronary angiography due to anginal chest pain and recurrent syncope with complete normalization of flow after intracoronary adenosine. He was noted to have multiple episodes of nonsustained ventricular tachycardia on holter monitor and increased QTc dispersion on surface electrocardiogram (EKG). He responded very well to oral dipyridamole therapy with complete resolution of his symptoms and no episodes of ventricular tachycardia on the event recorder at 3 months. We review the diagnosis and clinical features of CSFP and its association with increased QTc dispersion and the role of oral dipyridamole therapy in this condition. Copyright © 2007 Wiley Periodicals, Inc.

Safety and efficacy of bariatric surgery in morbidly obese patients with severe systolic heart failure.

Abstract: Background Morbid obesity (MO) is a risk factor for congestive heart failure (CHF). The presence of MO impairs functional status and disqualifies patients for cardiac transplantation. Bariatric surgery (BAS) is a frontline, durable treatment for MO; however, the safety and efficacy of BAS in advanced CHF is unknown. Hypothesis We hypothesized that by utilizing a coordinated approach between an experienced surgical team and heart failure specialists, BAS is safe in patients with advanced systolic CHF and results in favorable outcomes. Methods We performed a retrospective chart review of 12 patients with MO (body mass index [BMI] 53 ± 7 kg/m2) and systolic CHF (left ventricular ejection fraction [LVEF] 22 ± 7%, New York Heart Association [NYHA] class 2.9 ± 0.7) who underwent BAS, and then compared outcomes with 10 matched controls (BMI 47.2 ± 3.6 kg/m2, LVEF 24 ± 7%, and NYHA class 2.4 ± 0.7) who were given diet and exercise counseling. Results At 1 y, hospital readmission in BAS patients was significantly lower than controls (0.4 ± 0.8 versus 2.5 ± 2.6, p = 0.04); LVEF improved significantly in BAS patients (35 ± 15%, p = 0.005), but not in controls (29 ± 14%, p = not significant [NS]). The NYHA class improved in BAS patients (2.3 ± 0.5, p = 0.02), but deteriorated in controls (3.3 ± 0.9, p = 0.02). One BAS patient was successfully transplanted, and another listed for transplantation. Conclusions Bariatric surgery is safe and effective in patients with MO and severe systolic CHF, and should be considered in patients who have failed conventional therapy to improve clinical status. Copyright © 2008 Wiley Periodicals, Inc.

Diagnostic approach and treatment strategy in tachycardia-induced cardiomyopathy.

Abstract: Background Due to the absence of differential guidelines for heart failure with tachyarrhythmia, it is difficult to diagnose tachycardia-induced cardiomyopathy (TIC) at the initial visit. Furthermore, clinical outcomes of rate versus rhythm control in TIC are unclear. Hypothesis Because the etiology of TIC is different from dynamic cardiomyoplasty (DCMP), differential parameters may be present. Methods We assessed 21 patients with TIC (15 men; mean age, 50 ± 14 years) and 21 control patients with idiopathic DCMP. We assessed clinical courses, echocardiographic parameters, as well as outcomes by treatment. Results In the TIC group, the related tachyarrhythmias were atrial fibrillation (n = 12), atrial flutter (n = 5), atrial tachycardia (n = 3) and paroxysmal supraventricular tachycardia (n = 1). After treatment, all patients became asymptomatic and the ejection fraction (EF) improvement (ΔEF ≥15%) was observed in all patients (left ventricular ejection fraction [LVEF], 30 ± 11%initial versus 58 ± 6%last). In the idiopathic DCMP group, no patient showed EF improvement (EF increase ≤ 5%), and 4 patients (19%) underwent heart transplantation. Left ventricle (LV) mass indices, volumes adjusted by BSA, and dimensions were smaller in the TIC group than in the idiopathic DCMP group. Of those, LV end-diastolic dimension was the only independent predictor of TIC in multiple regression analysis (odds ratio [OR] 0.742 per 1 mm, 95% confidence ratio [CI] 0.618 to 0.891, p = 0.001). The Association of University Cardiologists (AUC) was 0.908 on receiver-operating characteristic (ROC) curve analysis and LV end-diastolic dimension ≤ 61% mm could predict TIC with a sensitivity of 100% and a specificity of 71.4%. After restoration of sinus rhythm (n = 8), one experienced recurrent TIC after discontinuation of amiodarone. After control of heart rate (n = 13), one experienced recurrent TIC due to poor control of heart rate (log-rank test, p = 0.808). There were no differences in the echocardiographic parameters between the 2 groups before and after treatment except for the larger initial LV volumes in the rhythm control. Conclusions In patients presented as heart failure with tachyarrhythmia, initial echocardiographic parameters, especially LV end-diastolic dimension, help to differentiate TIC from idiopathic DCMP. Rate control was as effective as rhythm control for EF improvement and prognosis. Copyright © 2008 Wiley Periodicals, Inc.

Assessment of QT intervals and prevalence of short QT syndrome in Japan.

Abstract: Background Long QT syndrome causes ventricular tachyarrhythmias and sudden death. Recently, a short QT interval has also been shown to be associated with an increased risk of tachyarrhythmia and sudden death. However, the prevalence of short QT syndrome is not well-known. Hypothesis The aim of this study was to assess the distribution of corrected QT intervals (QTc) and prevalence of short QT syndrome. Methods This study comprised 12,149 consecutive subjects who received a consultation at Kanazawa University Hospital, Kanazawa, Japan, and had an electrocardiogram (ECG) between February 2003 and May 2004. Of these subjects, 1,165 subjects were excluded because of inappropriate ECGs, while the remaining 10,984 subjects had their last-recorded ECGs analyzed. Results The QTc values showed a nearly normal distribution (408 ± 25 msec1/2), and were significantly longer in females (412 ± 24 msec1/2) than in males (404 ± 25 msec1/2) (p < 0.05). Among 5,511 males, 69 subjects (1.25%) exhibited QTc < 354 msec1/2 (2 standard deviations [SDs] below the mean in males), and among 5,473 females, 89 subjects (1.63%) exhibited QTc < 364 msec1/2 (2 SDs below the mean in females). Only 3 subjects (0.03% in all subjects and 0.05% in males) exhibited QTc < 300 msec1/2, however, none had clinical symptoms of short QT syndrome. Conclusions Short QT syndrome may be very rare. Copyright © 2008 Wiley Periodicals, Inc.

Enhanced external counterpulsation in the treatment of chronic refractory angina: a long-term follow-up outcome from the International Enhanced External Counterpulsation Patient Registry.

Abstract: Background: The management of patients who suffer from medically refractory angina and are unsuitable for conventional revascularization therapy is often unsatisfactory. Enhanced external counterpulsation (EECP) is a noninvasive treatment that is safe and effective immediately after a course of treatment. However, the duration of benefit is less certain. Hypothesis: To evaluate the 3-year outcome of EECP treatment. Methods: One thousand four hundred and twenty seven patients from 36 centers registered in the International EECP Patient Registry (IEPR)—Phase 1 was prospectively followed for a median of 37 months. Two hundred and twenty patients (15.4%) died, while 1,061 patients (74.4%) completed their follow-up. Results: The mean age was 66 ± 11 years and 72% were men. Seventy-six percent had multivessel coronary disease for 11 ± 8 years. Eighty-eight percent had a prior percutaneous or surgical revascularization and 82% were unsuitable for further coronary intervention. Immediately post-EECP, the proportion of patients with severe angina (Canadian Cardiovascular Angina Classification [CCS] III/IV) were reduced from 89% to 25%, p<0.001. The CCS class was improved by at least 1 class in 78% of the patients and by at least 2 classes in 38%. This was sustained in 74% of the patients during follow-up. Thirty-six percent of the patients had CCS II or less angina, which was better than pre-EECP state without a major adverse cardiovascular event during follow-up. More severe baseline angina and a history of heart failure or diabetes were independent predictors of unfavorable outcome. Conclusion: An EECP improves angina and quality of life immediately after a course of treatment. For most of the patients, these beneficial effects are sustained for 3 years.

Epidemiology of Heart Failure in a Tertiary Pediatric Center

Abstract: Background: In contrast to the adult age group, epidemiologic studies on heart failure (HF) in the pediatric population are lacking. The aim of this prospective study was to analyze the epidemiology of HF during infancy and childhood. Methods: Of the 1,196 children with congenital and acquired heart diseases, primarily diagnosed during a 10-y period in one hospital, we identified those patients who developed HF. Results: Within 10 y, 1,196 children with heart disease were indexed. Heart failure occurred in 124 of these patients (10.4%): 64 out of 1,031 children with congenital heart diseases (6.2%), 13 out of 96 children with rhythm or conduction disturbances (13.5%), 23 out of 39 children with acquired heart diseases (59.0%), and 24 out of 30 children with cardiomyopathies (80.0%). Heart failure occurred in 72 cases (58.1%) during the first year of life. The incidence in infancy was much more pronounced for congenital heart diseases than for other cardiac conditions. The mortality associated with HF and its cause was also lower for children with congenital heart disease (4.7%) than for the other cardiac conditions (8.7%, 23.0%, and 25.0%, for acquired heart diseases, rhythm disturbances, and cardiomyopathies, respectively). Conclusion: Clear differences exist between HF in infants and HF in children. Our study supports the observation that congenital heart disease is the most common causative factor of HF during infancy. Older children with HF are more likely to have acquired heart diseases, cardiomyopathies, and arrhythmias, and these conditions have a considerable mortality.

Echocardiographic evaluation and clinical implications of aortic stiffness and coronary flow reserve and their relation.

Abstract: The normal human aorta is not a stiff tube but is characterized by elastic properties with a buffering Windkessel function. Aortic stiffening may cause an increase in aortic pulse pressure, left ventricular load, and ultimately left ventricular hypertrophy. This, together with the decreased diastolic transmyocardial pressure gradient interacts with coronary flow and flow reserve. In recent studies, significant correlations between coronary flow reserve and aortic stiffness have been demonstrated in different patient populations. The aim of the present review is to describe the current echocardiographic modalities to measure aortic stiffness and coronary flow reserve and to overview our knowledge about the relationship between aortic stiffness and coronary flow reserve.

The impact of computer-assisted auscultation on physician referrals of asymptomatic patients with heart murmurs.

Abstract: Summary sensitivity of correctly identifying pathological murmur cases from 824 to 900%, and specificity of correctly identifying benign cases (with innocent or no murmurs) from 749 to 888% (p < 0001) Referral sensitivity increased from 867 to 929%, while specificity increased from 635 to 786% using CAA (p < 0001) Conclusions: Computer-assisted auscultation appears to be a promising new technology for informing the referral decisions of primary care physicians

Clinical implications of elevated serum interleukin-6, soluble CD40 ligand, metalloproteinase-9, and tissue inhibitor of metalloproteinase-1 in patients with acute ST-segment elevation myocardial infarction.

Abstract: Background Atherosclerosis is widely accepted as a chronic inflammatory disease. Research paid much attention to sensitive specific serum biomarkers for vulnerable plaques. The markers not only serve as diagnostic tools for the identification of patients with acute coronary syndrome (ACS), but also help us to identify high-risk patients. However, the existing data are limited and have been conflicting. Hypothesis Circulating interleukin-6 (IL-6), soluble CD40 ligand (sCD40L), metalloproteinase-9 (MMP-9), and tissue inhibitor of metalloproteinase-1 (TIMP-1) might correlate with the onset and the cardiac mortality of patients with ST-segment elevation myocardial infarction (STEMI). Methods Serum levels of IL-6, sCD40L, MMP-9, and TIMP-1 were measured by sandwich enzyme-linked immunosorbent assay (ELISA) in 263 patients with STEMI and 262 age- and gender-matched control subjects without coronary artery disease (CAD). The patients with STEMI were then followed prospectively for 24 mo for the occurrence of cardiac mortality. Results Compared with the control subjects, patients with STEMI exhibited higher levels of IL-6 (p < 0.001), sCD40L (p < 0.001), MMP-9 (p < 0.001), TIMP-1 (p = 0.045), and MMP-9/TIMP-1 ratio (p = 0.007). Significant and positive correlations between MMP-9 and TIMP-1 (r = 0.610, p≤0.001]), IL-6 and creatine kinase (CK) (r = 0.159, p = 0.022), and IL-6 and Troponin-I (TnI) (r = 0.141, p = 0.042) were observed by Spearman's correlations analysis. Logistic regression analysis revealed that IL-6 significantly and independently correlated with the occurrence of STEMI, and IL-6 was an independent predictor for cardiac mortality during a 24-mo follow-up in patients with STEMI. Conclusion The present study indicates that elevated admission level of IL-6, but not of sCD40L, MMP-9, or TIMP-1, might indicate the onset of STEMI, and could provide prognostic value for future cardiac mortality within 2 y in patients with STEMI. Copyright © 2008 Wiley Periodicals, Inc.

Alcohol, wine, and cardiovascular health.

Abstract: Studies evaluating the health benefits of alcohol and wine have demonstrated that moderate consumption is associated with a decrease in all-cause and cardiovascular mortality. Various populations and alcoholic beverages exhibit this effect to different degrees. Alcoholic beverages exhibit multiple mechanisms that may favorably influence cardiac risk potential actions on platelets, antioxidants, fibrinolysis, and lipids. However, other data suggest that the perceived benefit of alcoholic beverages in general, and wine in particular, are the result of socioeconomic confounders. In the absence of more rigorous evidence, it is not currently possible to define the role of wine in human health.

Reassessing the cardiovascular risks and benefits of thiazolidinediones.

Abstract: This article is designed for the general cardiologist, endocrinologist, and internist caring for patients with diabetes and coronary artery disease. Despite the burden of coronary disease in diabetics, little is known about the impact of commonly used oral hypoglycemic agents on cardiovascular outcomes. As the untoward effects of insulin resistance (IR) are increasingly recognized, there is interest in targeting this defect. Insulin resistance contributes to dyslipidemia, hypertension, inflammation, hypercoagulability, and endothelial dysfunction. The aggregate impact of this process is progression of systemic atherosclerosis and an increased risk of adverse cardiovascular outcomes. As such, much attention has been paid to the peroxisome-proliferator-activated receptor gamma (PPARg) agonists rosiglitazone and pioglitazone (thiazolidinediones [TZDs]). Many studies have demonstrated a beneficial effect on the atherosclerotic process; specifically, these agents have been shown to reduce markers of inflammation, retard progression of carotid intimal thickness, prevent restenosis after coronary stenting, and prevent cardiovascular death and myocardial infarction in 1 large trial. Such benefits come at the risk of fluid retention and heart failure (HF) exacerbation, and the net effect on plasma lipids is still poorly understood. Thus, the aggregate risk-benefit ratio is poorly defined. A recent meta-analysis has raised significant concerns regarding the overall cardiovascular safety of 1 particular PPARg agonist (rosiglitazone), prompting international debate and regulatory changes. This review scrutinizes the clinical evidence regarding the cardiovascular risks and benefits of PPARg agonists. Future studies of PPARg agonists, and other emerging drugs that treat IR and diabetes, must be designed to look at cardiovascular outcomes.

Small heart syndrome in patients with chronic fatigue syndrome.

Abstract: Background Small heart syndrome has previously been reported as neurocirculatory asthenia, associated with a small heart shadow on a chest roentgenogram. This is characterized as weakness or fatigue even after ordinary exertion, palpitation, dyspnea, and fainting, resembling patients with chronic fatigue syndrome (CFS). Hypothesis Small heart syndrome may be prevalent in patients with CFS. Methods The study population consisted of 56 patients (<50 y of age) with CFS, and 38 control subjects. Chest roentgenographic, echocardiographic, and physical examinations were performed. Results Small heart syndrome (cardiothoracic ratio ≤ 42%) was significantly more prevalent in the CFS group (61%) than in the control group (24%) (p < 0.01). In CFS patients with a small heart (n = 34), narrow chest (88%), orthostatic dizziness (44%), foot coldness (41%), pretibial pitting edema (32%), r-kidney palpability (47%), and mitral valve prolapse (29%), were all significantly more prevalent than in the control group, and also in the CFS patients without small heart syndrome. Echocardiographic examination demonstrated significantly smaller values of both the left ventricular (LV) end-diastolic dimensions and end-systolic, and stroke volume and cardiac indexes in CFS with a small heart, as compared with control subjects with a normal heart size (42% < cardiothoracic ratio < 50%). Conclusions A considerable number of CFS patients have a small heart. Small heart syndrome may contribute to the development of CFS as a constitutional factor predisposing to fatigue, and may be included in the genesis of CFS. Copyright © 2008 Wiley Periodicals, Inc.

Genetic heterogeneity of left-ventricular noncompaction cardiomyopathy.

Abstract: Isolated noncompaction of the ventricular myocardium (INVM) sometimes referred to as spongy myocardium is a rare, congenital and also acquired cardiomyopathy. It appears to divide the presentation into neonatal, childhood and adult forms of which spongy myocardium and systolic dysfunction is the commonality. The disorder is characterized by a left ventricular hypertrophy with deep trabeculations, and with diminished systolic function, with or without associated left ventricular dilation. In half or more of the cases, the right ventricle is also affected. The sporadic type, however, in some patients, may be due to chromosomal abnormalities and the occurrence of familial incidence. Isolated noncompaction of the left ventricular myocardium in the majority of adult patients is an autosomal dominant disorder. The familial and X-linked disorders have been described by various authors. We here describe the genetic background of this disorder: some of the most mutated genes that are responsible for the disease are (G4.5 (tafazzin gene): alpha-dystrobrevin gene (DTNA); FKBP-12 gene; lamin A/C gene; Cypher/ZASP (LIM, LDB3) gene); and some genotype-phenotype correlations (Becker muscular dystrophy, Emery-Dreifuss muscular dystrophy or Barth syndrome) based on the literature review.

Sudden cardiac death caused by migration of a TrapEase inferior vena cava filter: case report and review of the literature.

Abstract: Case A 43-year-old female presented with sudden onset of palpitations, chest pain, and shortness of breath associated with hypoxemia. A helical computed tomography (CT) scan of the chest revealed a large saddle pulmonary embolism. Intravenous tPA relieved the shortness of breath and improved the hypoxemia. Inferior vena cava (IVC) filter (TrapEase, Cordis Corp., Miami, FL, USA) was placed. On day 6 of her hospitalization, she went into cardiopulmonary arrest while walking back from the rest room. The patient died despite a prolonged attempt at cardiopulmonary resuscitation. At that time, ventricular tachycardia and then ventricular fibrillation were recorded. Autopsy of the heart showed the IVC filter entrapped within the tricuspid valve. Discussion The incidence of IVC filter migration ranges from 0.3 to 6% with rare migration to the heart or lung (0.1–1.25%). Sudden cardiac death from migration of IVC filter is extremely rare. We report the first case of sudden cardiac death caused by migration of the TrapEase filter to the heart. There are two reports in the literature of death from migrating Greenfield and Antheor filters. Conclusion An IVC filter migration to the heart, although rare, can cause serious arrhythmia and sudden cardiac death. Copyright © 2008 Wiley Periodicals, Inc.

A prior myocardial infarction: how does it affect management and outcomes in recurrent acute coronary syndromes?

Abstract: Background: Despite improved secondary prevention efforts, acute coronary syndrome (ACS) recurrence among patients with prior history of coronary events remains high. The differences in presentation, management, and subsequent clinical outcomes in patients with and without a prior myocardial infarction (MI) and presenting with another episode of ACS remain unexplored. Methods: A total of 3,624 consecutive patients admitted to the University of Michigan with ACS from January 1999 to June 2006 were studied retrospectively. In-hospital management, outcomes, and postdischarge outcomes such as death, stroke, and reinfarction in patients with and without a prior MI were compared. Results: Patients with a prior MI were more likely to be older and have a higher incidence of diabetes mellitus, hypertension, hyperlipidemia, and peripheral vascular disease. In-hospital outcomes were not significantly different in the 2 groups, except for a higher incidence of cardiac arrest (4.3% versus 2.5%, p<0.01) and cardiogenic shock (5.7% versus 3.9%, p = 0.01) among patients without a prior MI. However, at 6 mo postdischarge, the incidences of death (8.0% versus 4.5%, p<0.0001) and recurrent MI (10.0% versus 5.1%, p<0.0001) were significantly higher in patients with a prior history of MI compared with those without. Conclusion: Patients with prior MI with recurrent ACS remain at a higher risk of major adverse events on follow-up. This may be partly explained by the patients not being on optimal medications at presentation, as well as disease progression. Increased efforts must be directed at prevention of recurrent ACS, as well as further risk stratification of these patients to improve their overall outcomes.

The Problem of Persistent Platelet Activation in Acute Coronary Syndromes and Following Percutaneous Coronary Intervention

Abstract: Platelets play a central role in the atherosclerotic inflammatory response, thrombotic vascular occlusion, microembolization, vasoconstriction, and plaque progression. Persistent platelet activation poses a serious problem among patients with acute coronary syndromes (ACS) and those who have undergone percutaneous coronary intervention (PCI), placing them at risk for ischemic events and subacute stent thrombosis. Patients undergoing PCI are at risk for further ischemic events because of procedure-related platelet activation as well as the inherent persistent platelet hyperreactivity and enhanced thrombin generation associated with ACS. Persistent platelet activation following an acute coronary event and/or PCI supports incorporating antiplatelet strategies into the standard medical management of such patients. In this clinical setting, antiplatelet therapies are capable of improving outcomes. Aspirin, thienopyridines, and glycoprotein IIb/IIIa inhibitors, the 3 major pharmacologic approaches to persistent platelet activation, target various levels of the hemostatic pathways and thrombus formation.

Histiocytoid cardiomyopathy: a mitochondrial disorder.

Abstract: Histiocytoid cardiomyopathy (HICMP) is a rare, genetic, cardiac disorder of infancy or childhood, predominantly affecting girls, and clinically manifesting as severe cardiac arrhythmias or dilated cardiomyopathy. Pathoanatomically, HICMP is characterized by subendocardial, epicardial, or valvular yellow-tan nodules, which are histologically built up of abnormal Purkinje fibers and multiple, scattered clusters of histiocytoid myocytes, which are filled with an increased number of normal or abnormal mitochondria. Within the myocardium, yellowish areas with irregular outlines are found and are histologically built up of enlarged, polygonal, histiocyte-like cells with foamy granular cytoplasm. Since HICMP is frequently found in patients with mitochondrial deoxyribonucleic acid (DNA) mutations, HICMP cardiomyocytes carry an increased number of normal or abnormal mitochondria, and may show markedly decreased succinate-cytochrome c reductase or NADH-cytochrome c reductase activity; HICMP should be regarded as mitochondrial cardiomyopathy.

Positive Troponin in Diabetic Ketoacidosis without Evident Acute Coronary Syndrome Predicts Adverse Cardiac Events

Abstract: Background Elevated troponin I has been associated with increased mortality in critically ill patients without acute coronary syndrome (ACS). However, the prognostic significance of troponin elevation in patients with diabetic ketoacidosis (DKA) without evident ACS has not been studied. Methods Retrospective study of all patients admitted to a U.S. tertiary center between 01/98 and 12/00 with DKA and had troponin I level measured. Patients with evidence of ACS or who met the American College of Cardiology/European Society of Cardiology (ACC/ESC) definition for myocardial infarction were excluded. Baseline characteristics, cardiac evaluation and 2 year major adverse coronary event (MACE) rate were compared between patients with positive and negative troponin. Results Ninety-six patients fulfilled the inclusion criteria of this study, 26 had positive troponin. There were no differences in baseline characteristics between the two groups. After a 2 year follow-up, there was significantly increased mortality in patients with elevated troponin (50.0% versus 27.1%, hazard-ratio (HR) 2.3, 95% confidence intraval (CI) 1.2–4.8, p = 0.02). Patients with elevated troponin also had significantly increased MACE rate at 2 years (50.0% versus 28.6%, HR 2.6, 95% CI 1.3–5.3, p = 0.007) driven primarily by mortality. Using Cox Proportional Hazard Analysis, elevated troponin was a predictor of increased MACE after adjusting for confounding variables. (Adjusted HR 2.3, 95% CI 1.1–4.6, p = 0.02) Conclusions Elevated troponin I in diabetic patients admitted with DKA identifies a group at very high risk for future cardiac events and mortality. Whether cardiac risk stratification of these patients will improve long term outcome remains to be studied. Copyright © 2008 Wiley Periodicals, Inc.

Assessing the current role of platelet function testing.

Abstract: In vitro platelet function tests are commonly applied in research and offer justification for using antiplatelet therapy. However, studies assessing the ability of standardized platelet function tests to predict patients' clinical response to aspirin or clopidogrel have generated contradictory results. At this time, there is no standardized definition for resistance to antiplatelet therapy, and the appropriate treatment of patients who are hyporesponsive to these agents is not known. Although such tests have a role in research, their place in guiding therapy remains to be established, and prospective trials are urgently needed. The ideal platelet function test for clinical practice would be rapid, easy-to-use, inexpensive, and reliable.

Using virtual patients to improve cardiac examination competency in medical students.

Abstract: Background Cardiac examination (CE) skills are in decline. Most prior studies employed audio recordings, evaluating only one aspect of CE (i.e., auscultation) that precluded correlation with visible observations. To address these deficiencies, we developed a curriculum using virtual patient examinations (VPEs); bedside recordings of patients with visible and audible cardiovascular findings presented as interactive multimedia. Hypothesis The purpose of this study was to evaluate whether VPEs improve CE skills, and whether any improvements are retained. We assessed CE competency overall and in 4 categories: inspection, auscultation, knowledge, and integration of audio and visual skills. Methods Students (n = 24) undergoing the 8-wk Internal Medicine (IM) clerkship rotation and receiving supervised instruction with VPEs (intervention group) were compared with students (n = 58) undergoing IM clerkship rotation without supplemental CE instruction (control group). The groups were tested at the beginning and the end of their rotations. Results The Intervention group improved significantly in overall mean scores: from 58.7 to 73.5 (p = 0.0001). The Control group did not improve: from 60.1 to 59.5 (p = 0.788). The Intervention group improved inspection, auscultation, and knowledge (all p ≤0.02); control group showed no improvement. Fourteen months after the study, 8 students from the intervention group were re-tested and mean scores improved further to 83.6 without additional intervention (p = 0.004); controls showed improvement on re-testing, but it was not significant: 65.0 (p = 0.464). Conclusions Cardiac examination inspection, auscultation, and knowledge improved by using VPEs to the level of cardiology fellows. These skills were retained 1 y later. The teaching and testing tools emphasizing the bedside use of both sight and sound, identify which CE skills needed improvement and additional training. Copyright © 2008 Wiley Periodicals, Inc.

Current and future status of beta-blockers in the treatment of hypertension.

Abstract: Beta-adrenergic receptor blockers (beta-blockers) are effective and safe antihypertensive drugs, and have been recommended as first-line therapy for hypertension by all Joint National Committees (JNCs) for the prevention, detection, evaluation, and treatment of high blood pressure (BP) from the first to the last (JNC-7) in 2003. However, recently questions have been raised by several investigators regarding the antihypertensive effectiveness and safety of these drugs. The Medline literature on this subject was searched and pertinent studies were retrieved. Other pertinent references from existing publications were retrieved and analyzed up to 2007. Additionally, a historical perspective on the discovery of beta-blockers and their mechanism of action is given. Most of the reviewed short-term and long-term clinical trials demonstrate an effective and safe antihypertensive pattern for the beta-blockers. The weaknesses identified include the adverse effect of older beta-blockers on glucose control and stroke protection, especially in older persons. These adverse effects are attributed to their mechanism of action and BP effectiveness. On the basis of the evidence presented, beta-blockers are effective and safe antihypertensive drugs and should still be recommended as first-line therapy in most uncomplicated hypertensive patients, either alone or in combination with other drugs. There are reservations regarding their administration to diabetic and older hypertensive patients. However, when compelling indications for their use exist, they should not be withheld. Copyright © 2008 Wiley Periodicals, Inc.

Factors associated with non-adherence to therapy with warfarin in a population of chronic heart failure patients.

Abstract: Background Adherence to heart failure therapy is important in reducing morbidity and mortality over the course of the disease process. The aim of this study was to examine factors associated with non-adherence to warfarin in chronic heart failure patients. Methods Eighty patients receiving warfarin therapy in 2002 were included. Adherence was defined as maintenance of international normalized ratio (INR) between 2 and 3.5 and keeping scheduled appointments for INR checks at least 75% of the time. Clinical variables examined included age, gender, race, insurance, left ventricular ejection fraction (LVEF), etiology, New York heart association (NYHA) class, comorbidities, smoking, and alcohol use. Results Of 80 patients studied, 59 were male with mean age ( ± standard deviation) 52 ± 13 years, 24 had ischemic etiology with mean LVEF of 24% ± 9%. Non-adherence was associated with tobacco use, odds ratio of 6.5 (p <0.01). Ischemic etiology was associated with adherence, odds ratio of 4.5 (p <0.01). Non-adherent patients were more likely to be insured with Medicare/Medicaid (p = 0.04) and have better NYHA class (p = 0.04). Adherence positively correlated with older age and lower LVEF, and negatively correlated with number of hospitalizations (p<0.01 for all). In a multiple regression model, patients with improvement in LVEF had decreased adherence over the year (p<0.01). Conclusions The profile of heart failure patients who demonstrated non-adherence to warfarin therapy included younger age, nonischemic etiology, better NYHA class, smoking, insurance with Medicare/Medicaid and improved LVEF over the study. Measures targeting these patients may result in improved adherence to other pharmacologic treatments of heart failure. Copyright © 2008 Wiley Periodicals, Inc.

Prognosis of large, symptomatic pericardial effusion treated by echo-guided percutaneous pericardiocentesis.

Abstract: Backgrounds The causes and prognosis of pericardial effusion (PE) may be different according to time, region, economy, and hospital. This study was performed to evaluate the etiology, clinical outcome, and prognosis of patients with large, symptomatic PE treated by echo-guided pericardiocentesis at Kangnam St. Mary's Hopital (the Catholic University of Korea, Seoul, Korea). Hypothesis According to etiologies of large, symptomatic PE, the prognosis of patients may be different. Methods We reviewed 116 consecutive patients who underwent echo-guided pericardiocentesis due to large, symptomatic PE over the last 12 y. The Kaplan-Meier survival curve with log-rank method was applied for the survival analysis. Results Procedural success rate of echo-guided pericardiocentesis was 99.1%. Common causes of PE requiring pericardiocentesis were lung cancer (27.6%), tuberculosis (TB) (13.8%), and uremia (6.9%). The mortality rate of 6 mo after the pericardiocentesis was 80.3% in malignant PE, whereas the over-all mortality rate was 18.2% in nonmalignant PE (p < 0.0001). Among the malignant PE, lung cancer (27.6%) and breast cancers (6.9%) were the most common causes. The mean cytologic detection rate and mean life expectancy of malignant PE were 44% and 5-7 mo. Patients with breast cancer and lymphoma had relatively better life expectancy (11.4 and 7.7 mo), whereas those with stomach cancer and metastases of unknown origin (MUO) had poorer prognosis (1.2 and 2.3 mo). The most common causes of nonmalignant PE were TB, uremia, and iatrogenic, and their mean life expectancy was approximately 54 mo. Conclusions Malignancy, especially lung cancer and TB, were the most common causes of large symptomatic PE. The prognosis of large symptomatic PE was related to the underlying disease. Malignant PE was associated with the poorest prognosis. Copyright © 2008 Wiley Periodicals, Inc.

Myocardial and aortic stiffening in the early course of primary aldosteronism.

Abstract: Background Primary aldosteronism (PA) has been experimentally and clinically linked to myocardial and vascular fibrosis, and it has been further associated with left ventricular (LV) structural adaptations. Hypothesis Functional cardiovascular adaptations in hypertensive patients with PA precede structural alterations in the early stages of the disease. Methods We studied 17 hypertensive subjects with a recent diagnosis of PA (10 male patients, aged approximately 55 y, with office blood pressure [BP] of 137/88 mm Hg), and 30 essential hypertensives matched for age, sex, office BP levels, treatment status, and LV mass index (LVMI). Apart from standard 2-Dimensional (2-D) and conventional Doppler parameters, tissue Doppler imaging (TDI) methodology was used to assess LV diastolic function; averaging early and late diastolic mitral annular peak velocities (Emav/, Amav, Emav/Amav ratio) from 4 separate sites of measurement (septal, lateral, anterior, and inferior walls). Aortic stiffness was evaluated by means of carotid-femoral pulse wave velocity (cf-PWV) measurements. Results Although transmitral E/A ratio was similar in both groups (0.95 ± 0.26 versus 0.98 ± 0.24, ± p 0.66), hypertensive subjects with PA compared with essential hypertensives are characterized by significantly higher relative wall thickness (0.50 ± 0.07 versus 0.41 ± 0.06, p ≤ 0.001), decreased values of Emav (7 ± 1.7 versus 8.1 ± 1.8 cm/s, p= 0.048), and Emav/Amav ratio (0.63 ± 0.16 versus 0.77 ± 0.17, p = 0.015). The higher PWV in the PA population failed to reach statistical significance (8.5 ± 1.6 versus 7.9 ± 0.9 msec, p = 0.19). Conclusion Our study demonstrates altered LV geometry and TDI-revealed diastolic dysfunction in hypertensives with PA compared with demographically- and LVMI-matched essential hypertensives. Furthermore, the increased aortic stiffening in PA patients failed to reach statistical significance. Copyright © 2008 Wiley Periodicals, Inc.

Prevalence of emerging cardiovascular risk factors in younger individuals with a family history of premature coronary heart disease and low Framingham risk score.

Abstract: Introduction The purpose of this study was to assess the prevalence of emerging cardiac risk factors in individuals with a family history of premature coronary heart disease (CHD) and who were predicted to be low-risk for cardiovascular (CV) disease based on their Framingham risk score. Methods We prospectively evaluated 89 younger men and women with a family history of premature CHD and who had a low Framingham risk score. Patients with CHD or CHD equivalents were excluded. All patients were screened for emerging clinical and lipid risk factors. Results Coronary calcium was present in 38% of patients and C-reactive protein > 3 mg/dl was present in 24% of patients. Low levels of high-density lipoprotein (HDL2) cholesterol were the most prevalent emerging lipid risk factor and was present in 72% of the study group. More individuals had low levels of HDL2 than total HDL (34% versus 71%; p-value =0.001). Triglyceride- (TG)-rich remnant lipoproteins were present in 49% of patients. Conclusions The Framingham risk score poorly predicts CV risk in younger healthy persons with a family history of premature CHD. The prevalence of subclinical CHD and emerging clinical and lipid risk factors is high in these patients. The most prevalent lipid risk factor was low levels of HDL2. Individuals with a family history of premature CHD may benefit from screening for emerging risk factors to better assess their CV risk. Copyright © 2008 Wiley Periodicals, Inc.

Atrioventricular block: a serious complication in and after transcatheter closure of perimembranous ventricular septal defects.

Abstract: Background Transcatheter closure is an effective approach for perimembranous ventricular septal defects (PMVSD). However, atrioventricular blocks (AVB) emerged possibly due to the close proximity of the PMVSD to the conduction system, but concern for the complication was not adequately emphasized. In this study, we report the incidence of AVBs, in and after transcatheter closure of a PMVSD, and the outcome of the complication in our center. Methods One hundred and sixty-eight PMVSD patients were accepted for transcatheter closure with Amplazter PMVSD occluder (AGA Medical, Plymouth, Minn., USA). The procedure was discontinued when a second- or third-degree AVB occurred. A steroid was administered to all patients who developed AVBs. Temporary pacemakers were inserted in patients who developed a complete AVB or Mobitz type II AVB during or after the procedure. Results During the follow-up period of 6–24 mo (mean 10.6 ± 3.9), the incidence of AVBs occurring during or after transcatheter closure of PMVSD was 3.5%. The AVB disappeared quickly after discontinuing the procedure in patients who developed AVBs during the procedure, whereas the AVBs disappeared between 2 and 21 d (mean 8.0 ± 8.8) in the patients who developed AVBs after the procedure. However, complete right bundle branch block (CRBBB) was observed, and a transient complete AVB emerged after 8 mo in 1 case, incomplete right bundle branch block (IRBBB) in 1 case, and CRBBB and left anterior hemiblock (LAH) in 1 case. Conclusions The AVB is a serious complication during and after transcathter closure of PMVSD. More attention should be paid to the complication, and multicentres are required to monitor the complication. Copyright © 2008 Wiley Periodicals, Inc.