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Showing papers in "Netherlands Heart Journal in 2011"


Journal ArticleDOI
TL;DR: Although the magnitude of platelet reactivity was higher in women, the absolute difference between genders was small and both the cut-off value to identify patients at risk and the incidence of the composite endpoint were similar between genders.
Abstract: Background Previous studies have suggested that women do not accrue equal therapeutic benefit from antiplatelet medication as compared with men. The physiological mechanism and clinical implications behind this gender disparity have yet to be established.

72 citations


Journal ArticleDOI
TL;DR: Electrical cardioversion during pregnancy is a rarely applied but highly effective procedure in the treatment of maternal cardiac arrhythmias and is assumed safe for both mother and child.
Abstract: Two pregnant patients with a sustained symptomatic maternal supraventricular arrhythmia are presented. Both patients were treated with direct-current cardioversion. Electrical cardioversion during pregnancy is a rarely applied but highly effective procedure in the treatment of maternal cardiac arrhythmias and is assumed safe for both mother and child. However, once foetal viability is reached, monitoring of the foetal heart rate is advised and facilities for immediate caesarean section should be available.

68 citations


Journal ArticleDOI
TL;DR: An effort at consolidating the information available in an attempt to avoid possible errors in diagnosis by house staff and internists of subarachnoid haemorrhage patients.
Abstract: Subarachnoid haemorrhage (SAH) is a neurological emergency with high mortality rates. It is mainly caused by rupture of an aneurysm (congenital/infectious/traumatic) or rupture of an arteriovenous malformation. Electrocardiograms (ECGs) done in patients with SAH have shown morphological changes as well as arrhythmias. Subarachnoid haemorrhage (SAH) patients have often been misdiagnosed to have cardiac abnormalities based on their ECGs when in many of those instances the ECG change had been the result of the SAH itself. They have led to unnecessary and wasteful investigations and therapies in many occasions. Hence the current article is an effort at consolidating the information available in an attempt to avoid possible errors in diagnosis by house staff and internists. There are two mechanisms that might mediate ECG changes in patients with SAH, i.e. autonomic neural stimulation from the hypothalamus or elevated levels of circulating catecholamine. Hypothalamic stimulation may cause ECG changes without associated myocardial damage whereas elevated catecholamine levels have been correlated with QT-interval prolongation and myocardial damage.

59 citations


Journal ArticleDOI
TL;DR: Pregnancy should still be regarded as contraindicated in women with pulmonary hypertension, and pregnancy and delivery should be managed by multidisciplinary services with experience in the management of both pulmonary hypertension and high-risk pregnancies.
Abstract: Women with pulmonary hypertension have a high risk of morbidity and mortality during pregnancy. The inability to increase cardiac output leads to heart failure while further risks are introduced with hypercoagulability and decrease in systemic vascular resistance. There is no proof that new advanced therapies for pulmonary hypertension decrease the risk, though some promising results have been reported. However, pregnancy should still be regarded as contraindicated in women with pulmonary hypertension. When pregnancy occurs and termination is declined, pregnancy and delivery should be managed by multidisciplinary services with experience in the management of both pulmonary hypertension and high-risk pregnancies.

56 citations


Journal ArticleDOI
TL;DR: Catheter-based renal denervation seems an attractive novel minimally invasive treatment option in patients with resistant hypertension, with a low risk of serious adverse events.
Abstract: Background In a subpopulation of patients with essential hypertension, therapeutic targets are not met, despite the use of multiple types of medication. In this paper we describe our first experience with a novel percutaneous treatment modality using renal artery radiofrequency (RF) ablation.

54 citations


Journal ArticleDOI
TL;DR: Familial idiopathic ventricular fibrillation determines an intriguing subset of the inheritable arrhythmia syndromes as there is no recognisable phenotype during cardiological investigation other than ventricular arrhythmias highly associated with sudden cardiac death.
Abstract: In this part of a series on founder mutations in the Netherlands, we review familial idiopathic ventricular fibrillation linked to the DPP6 gene. Familial idiopathic ventricular fibrillation determines an intriguing subset of the inheritable arrhythmia syndromes as there is no recognisable phenotype during cardiological investigation other than ventricular arrhythmias highly associated with sudden cardiac death. Until recently, it was impossible to identify presymptomatic family members at risk for fatal events. We uncovered several genealogically linked families affected by numerous sudden cardiac deaths over the past centuries, attributed to familial idiopathic ventricular fibrillation. Notably, ventricular fibrillation in these families was provoked by very short coupled monomorphic extrasystoles. We were able to associate their phenotype of lethal arrhythmic events with a haplotype harbouring the DPP6 gene. While this gene has not earlier been related to cardiac arrhythmias, we are now able, for the first time, to identify and to offer timely treatment to presymptomatic family members at risk for future fatal events solely by genetic analysis. Therefore, when there is a familial history of unexplained sudden cardiac deaths, a link to the DPP6 gene may be explored as it may enable risk evaluation of the remaining family members. In addition, when closely coupled extrasystoles initiate ventricular fibrillation in the absence of other identifiable causes, a link to the DPP6 gene should be suspected.

44 citations


Journal ArticleDOI
TL;DR: TNNI3 mutations were found to be rare and associated with early onset and severe clinical presentation, and were identified in very young children with a poor prognosis.
Abstract: Background About 2-7% of familial cardiomyopathy cases are caused by a mutation in the gene encoding cardiac troponin I (TNNI3). The related clinical phenotype is usually severe with early onset. Here we report on all currently known mutations in the Dutch population and compared these with those described in literature.

42 citations


Journal ArticleDOI
TL;DR: Phenotypes with regard to LDL-C levels varied between the 12 most prevalent FH mutations, and for most of these mutations, a founder effect was observed.
Abstract: In the Netherlands, a screening programme was set up in 1994 in order to identify all patients with familial hypercholesterolaemia (FH). After 15 years of screening, we evaluated the geographical distribution, possible founder effects and clinical phenotype of the 12 most prevalent FH gene mutations. Patients who carried one of the 12 most prevalent mutations, index cases and those identified between 1994 and 2009 through the screening programme and whose postal code was known were included in the study. Low-density lipoprotein cholesterol (LDL-C) levels at the time of screening were retrieved. The prevalence of identified FH patients in each postal code area was calculated and visualised in different maps. A total of 10,889 patients were included in the study. Mean untreated LDL-C levels ranged from 4.4 to 6.4 mmol/l. For almost all mutations, a region of high prevalence could be observed. In total, 51 homozygous patients were identified in the Netherlands, of which 13 true homozygous for one of the 12 most prevalent mutations. The majority of them were living in high-prevalence areas for that specific mutation. Phenotypes with regard to LDL-C levels varied between the 12 most prevalent FH mutations. For most of these mutations, a founder effect was observed. Our observations can have implications with regard to the efficiency of molecular screening and physician’s perception of FH and to the understanding of the prevalence and distribution of homozygous patients in the Netherlands.

40 citations


Journal ArticleDOI
TL;DR: Recognising the clinical picture of SPES is relevant because surgical reconstruction of the chest can provide substantial relief of symptoms.
Abstract: Objectives There is no consensus among physicians as to whether or not pectus excavatum can produce symptoms sometimes even severe enough to justify a surgical procedure. The aim of this study was to assess the prevalence and severity of complaints and symptoms of senior patients with a pectus excavatum and to evaluate the results of surgical correction of the chest deformation.

39 citations


Journal ArticleDOI
TL;DR: A high degree of success with low in-hospital complications comparable with conventional PCI data can be expected in the hands of experienced CTO operators and a second try with a retrograde approach after antegrade failure should be considered.
Abstract: Objective Percutaneous treatment of coronary chronic total occlusions (CTO) remains one of the major challenges in interventional cardiology. The strategies of recanalisation in CTO have changed drastically due the development of new techniques such as the retrograde approach via collaterals. In this single-centre experience we sought to analyse the success rates with the use of different CTO techniques, the complication rates, and we evaluated predictors of failed CTO recanalisation attempts.

39 citations


Journal ArticleDOI
TL;DR: With the more recent addition of resynchronisation therapy to standard ICD therapy, it became possible to treat selected patients with advanced symptoms of heart failure and to lower the risk of sudden death.
Abstract: In 1980, Dr. Michel Mirowski and his team inserted the first implantable cardioverter defibrillator (ICD) in a patient. Initially, ICD therapy was not widely accepted, and many physicians actually considered this therapy unethical. Large secondary and primary prevention trials, demonstrating a beneficial effect of ICD therapy in selected patients not only on arrhythmic death but also on all-cause mortality, stimulated a rapid growth in the number of implants and increased patient’s and physician’s acceptance. Improvements in size and weight, arrhythmia discrimination capabilities, battery technology, shock waveform and output, monitoring capabilities and defibrillator electrode technology eventually resulted in the current large number of yearly implants. Today, almost 40 years after the conception of the ICD and 25 years after the first human implant, ICD therapy is the treatment of choice for patients at risk for life-threatening arrhythmias either as secondary or primary prevention. Furthermore, with the more recent addition of resynchronisation therapy to standard ICD therapy, it became possible to treat selected patients with advanced symptoms of heart failure and to lower the risk of sudden death.

Journal ArticleDOI
TL;DR: The safety of pregnancy for women with heart disease can be enhanced by adequate risk assessment and counselling, and a system that integrates all available knowledge about the risk of pregnancy is the adapted World Health Organisation risk classification.
Abstract: Pregnant women with heart disease often have an increased risk of maternal cardiovascular and offspring complications. The magnitude of these risks varies depending on the type and severity of the underlying disease. Therefore risk assessment should be performed before pregnancy. This can be accomplished by taking into account predictors and risk scores that have been developed in large populations of pregnant women with heart disease, as well as by consulting disease-specific pregnancy literature. A system that integrates all available knowledge about the risk of pregnancy is the adapted World Health Organisation risk classification. The safety of pregnancy for women with heart disease can be enhanced by adequate risk assessment and counselling.

Journal ArticleDOI
TL;DR: Among unselected patients with severe aortic valve stenosis, a high percentage of patients with BAV were found and a significant difference was found between the surgeon and pathologist in determining valve morphology.
Abstract: Background Bicuspid aortic valve (BAV) is one of the most common congenital heart defects with a population prevalence of 0.5% to 1.3%. Identifying patients with BAV is clinically relevant because BAV is associated with aortic stenosis, endocarditis and ascending aorta pathology.

Journal ArticleDOI
TL;DR: The economic and clinical impact of AF in the Netherlands is described, which is a serious disease with a high clinical and economic burden, especially due to hospitalisations as a result of cardiovascular events.
Abstract: Background Atrial fibrillation (AF) is the most common sustained atrial arrhythmia and it is independently associated with an increased morbidity and mortality. As a result of the high prevalence of AF, the economic and clinical impact of the disease is substantial. This study describes the economic and clinical impact of AF in the Netherlands.

Journal ArticleDOI
TL;DR: Several diagnostic imaging techniques are available for assessment of the anatomical and functional characteristics of CAFs, and high success rates were found in both treatment groups.
Abstract: Coronary artery fistulas (CAFs) are infrequent anomalies, coincidentally detected during coronary angiography (CAG). To elucidate the currently used diagnostic imaging modalities and applied therapeutic approaches. Five Dutch patients were found to have CAFs. A total of 170 reviewed subjects were subdivided into two comparable groups of 85 each, treated with either percutaneous ‘therapeutic’ embolisation (PTE group) or surgical ligation (SL group). In our series, the fistulas were visualised with several diagnostic imaging tests using echocardiography, multidetector computed tomography, and CAG. Four fistulas were unilateral and one was bilateral; five originated from the left and one originated from the right coronary artery. Among the reviewed subjects, high success rates were found in both treatment groups (SL: 97% and PTE: 93%). Associated congenital or acquired cardiovascular disorders were frequently present in the SL group (23%). Bilateral fistulas were present in 11% of the SL group versus 1% of the PTE group. The fistula was ligated surgically in one and abolished percutaneously in another. Medical treatment including metoprolol was conducted in two, and watchful waiting follow-up was performed in one. Several diagnostic imaging techniques are available for assessment of the anatomical and functional characteristics of CAFs.

Journal ArticleDOI
TL;DR: Among patients who receive ICDs and CRT devices, women appear to be under-represented, while they may benefit more from these novel therapies, and the utilisation of implantable defibrillators and cardiac resynchronisation therapy.
Abstract: Many important differences in the presentation and clinical course of cardiac arrhythmias are present between men and women that should be accounted for in clinical practice. In this paper, we review published data on gender differences in cardiac excitable properties, supraventricular tachycardias, ventricular tachycardias, sudden cardiac death, and the utilisation of implantable defibrillators and cardiac resynchronisation therapy. Women have a higher heart rate at rest, and a longer QT interval than men. They further have a narrower QRS complex and lower QRS voltages on the 12-lead ECG with more often non-specific repolarisation abnormalities at rest. Supraventricular tachycardias, such as AV nodal reentrant tachycardia, are twice as frequent in women compared with men. Atrial fibrillation, however, has a 1.5-fold higher prevalence in men. The triggers for idiopathic right ventricular outflow tract tachycardia (VT) initiation are gender specific, i.e. hormonal changes play an important role in the occurrence of these VTs in women. There are clear-cut gender differences in acquired and congenital LQTS. Brugada syndrome affects men more commonly and severely than women. Sudden cardiac death is less prevalent in women at all ages and occurs 10 years later in women than in men. This may be related to the later onset of clinically manifest coronary heart disease in women. Among patients who receive ICDs and CRT devices, women appear to be under-represented, while they may benefit even more from these novel therapies.

Journal ArticleDOI
TL;DR: The bridging protocol in patients requiring surgery after recent PCI with DES seems adequate to prevent stent thrombosis in this high-risk group and the bleeding risk is not insignificant but in this patient group controllable without major late sequelae.
Abstract: Objectives To evaluate stent-related adverse cardiac events and bleeding complications within 30 days after surgical procedures in patients with recent drug-eluting stent (DES) implantation, in whom a bridging protocol was used.

Journal ArticleDOI
TL;DR: It is found that all hearts show similar structural and functional characteristics, which suggests that the mammalian heart remained well conserved during evolution and in this aspect it differs from other organs and parts of the mammalian body.
Abstract: Forty years ago, we started our quest for ‘The Holy Grail’ of understanding ventricular rate control and rhythm in atrial fibrillation (AF). We therefore studied the morphology and function of a wide range of mammalian hearts. From mouse to whale, we found that all hearts show similar structural and functional characteristics. This suggests that the mammalian heart remained well conserved during evolution and in this aspect it differs from other organs and parts of the mammalian body. The archetype of the mammalian heart was apparently so successful that adaptation by natural selection (evolution) caused by varying habitat demands, as occurred in other organs and many other aspects of mammalian anatomy, bypassed the heart. The structure and function of the heart of placental mammals have thus been strikingly conserved throughout evolution. The changes in the mammalian heart that did take place were mostly adjustments (scaling), to compensate for variations in body size and shape. A remarkable scaling effect is, for instance, the difference in atrioventricular (AV) conduction time, which is vital for optimal cardiac function in all mammals, small and large. Scaling of AV conduction takes place in the AV node (AVN), but its substrate is unknown. This sheds new light on the vital role of the AVN in health and disease. The AVN is master and servant of the heart at the same time and is of salient importance for our understanding of supraventricular arrhythmias in humans, especially AF. In Information Technology a software infra-structure called ‘enterprise service bus’ (ESB) may provide understanding of the mammalian heart’s conservation during evolution. The ESB is quite unspecific (and thus general) when compared with the specialised components it has to support. For instance, one of the functions of an ESB is the routing of messages between system nodes. This routing is independent and unaware of the content of the messages. The function of the heart is likewise independent and unaware of the routing of blood (oxygen) and of the specialised components of the mammalian body it has to support. Conclusions Evolution seems to have bypassed the heart, which is in contrast to the sometimes similarly looking, but yet quite differently functioning of the other organs of the mammalian body.

Journal ArticleDOI
TL;DR: Contrast-enhanced CT coronary angiography (CTCA) has evolved as a reliable alternative imaging modality technique and may be the preferred initial diagnostic test in patients with stable angina with intermediate pre-test probability of CAD.
Abstract: Contrast-enhanced CT coronary angiography (CTCA) has evolved as a reliable alternative imaging modality technique and may be the preferred initial diagnostic test in patients with stable angina with intermediate pre-test probability of CAD However, because CTCA is moderately predictive for indicating the functional significance of a lesion, the combination of anatomic and functional imaging will become increasingly important The technology will continue to improve with better spatial and temporal resolution at low radiation exposure, and CTCA may eventually replace invasive coronary angiography The establishment of the precise role of CTCA in the diagnosis and management of patients with stable angina requires high-quality randomised study designs with clinical outcomes as a primary outcome

Journal ArticleDOI
TL;DR: Three cases of SVC syndrome treated with venoplasty and venous stenting illustrate that the definitive diagnosis, and the extent and location of venous obstruction, can only be determined by venography.
Abstract: Superior vena cava (SVC) syndrome is a rare but serious complication after pacemaker implantation. This report describes three cases of SVC syndrome treated with venoplasty and venous stenting, with an average follow-up of 30.7 (±3.1) months. These cases illustrate that the definitive diagnosis, and the extent and location of venous obstruction, can only be determined by venography.

Journal ArticleDOI
TL;DR: A case of iatrogenic left main coronary artery dissection is presented, successfully treated by prompt bail-out stenting, and a brief discussion on its occurrence and treatment is provided.
Abstract: We present a case of iatrogenic left main coronary artery dissection, successfully treated by prompt bail-out stenting, and provide a brief discussion on its occurrence and treatment, as well as the immediate and long-term outcome of percutaneous coronary intervention, including our own single-centre experience, for this potentially catastrophic complication.

Journal ArticleDOI
TL;DR: There is too much inhomogeneity in citation characteristics even within a relatively homogeneous group of clinical cardiologists, therefore, citation analysis should be applied with great care in science policy.
Abstract: In this paper, we assess the bibliometric parameters of 37 Dutch professors in clinical cardiology. Those are the Hirsch index (h-index) based on all papers, the h-index based on first authored papers, the number of papers, the number of citations and the citations per paper. A top 10 for each of the five parameters was compiled. In theory, the same 10 professors might appear in each of these top 10s. Alternatively, each of the 37 professors under assessment could appear one or more times. In practice, we found 22 out of these 37 professors in the 5 top 10s. Thus, there is no golden parameter. In addition, there is too much inhomogeneity in citation characteristics even within a relatively homogeneous group of clinical cardiologists. Therefore, citation analysis should be applied with great care in science policy. This is even more important when different fields of medicine are compared in university medical centres. It may be possible to develop better parameters in the future, but the present ones are simply not good enough. Also, we observed a quite remarkable explosion of publications per author which can, paradoxical as it may sound, probably not be interpreted as an increase in productivity of scientists, but as the effect of an increase in the number of co-authors and the strategic effect of networks.

Journal ArticleDOI
TL;DR: Treatment includes general measures and drugs targeting the pulmonary artery tone and vascular remodelling, which has significantly improved morbidity and mortality in patients with PAH in the last decade.
Abstract: Pulmonary arterial hypertension (PAH), defined as group 1 of the World Heart Organisation (WHO) classification of pulmonary hypertension, is an uncommon disorder of the pulmonary vascular system. It is characterised by an increased pulmonary artery pressure, increased pulmonary vascular resistance and specific histological changes. It is a progressive disease finally resulting in right heart failure and premature death. Typical symptoms are dyspnoea at exercise, chest pain and syncope; furthermore clinical signs of right heart failure develop with disease progression. Echocardiography is the key investigation when pulmonary hypertension is suspected, but a reliable diagnosis of PAH and associated conditions requires an intense work-up including invasive measurement by right heart catheterisation. Treatment includes general measures and drugs targeting the pulmonary artery tone and vascular remodelling. This advanced medical therapy has significantly improved morbidity and mortality in patients with PAH in the last decade. Combinations of these drugs are indicated when treatment goals of disease stabilisation are not met. In patients refractory to medical therapy lung transplantation should be considered an option.

Journal ArticleDOI
TL;DR: Predictive genetic testing for multifactorial forms of cardiovascular disease clearly lacks benefits for the public and prevention of disease should remain focused on family history and on non-genetic risk factors as diet and physical activity that can have the strongest impact on disease risk, regardless of genetic susceptibility.
Abstract: Expectations are high that increasing knowledge of the genetic basis of cardiovascular disease will eventually lead to personalised medicine—to preventive and therapeutic interventions that are targeted to at-risk individuals on the basis of their genetic profiles. Most cardiovascular diseases are caused by a complex interplay of many genetic variants interacting with many non-genetic risk factors such as diet, exercise, smoking and alcohol consumption. Since several years, genetic susceptibility testing for cardiovascular diseases is being offered via the internet directly to consumers. We discuss five reasons why these tests are not useful, namely: (1) the predictive ability is still limited; (2) the risk models used by the companies are based on assumptions that have not been verified; (3) the predicted risks keep changing when new variants are discovered and added to the test; (4) the tests do not consider non-genetic factors in the prediction of cardiovascular disease risk; and (5) the test results will not change recommendations of preventive interventions. Predictive genetic testing for multifactorial forms of cardiovascular disease clearly lacks benefits for the public. Prevention of disease should therefore remain focused on family history and on non-genetic risk factors as diet and physical activity that can have the strongest impact on disease risk, regardless of genetic susceptibility.

Journal ArticleDOI
TL;DR: In two high-risk subgroups for bleeding, patients ≥ 75 years and patients with previous stroke, on-clopidogrel platelet reactivity is increased, suggesting that a stronger response to a thienopyridine might only lead to more bleeds in patients with low body weight.
Abstract: Background The TRITON-TIMI 38 study has identified three subgroups of patients with a higher risk of bleeding during treatment with the thienopyridine prasugrel: patients with a history of stroke or transient ischaemic attack (TIA), patients ≥75 years and patients with a body weight <60 kg. However, the underlying pathobiology leading to this increased bleeding risk remains to be elucidated. The higher bleeding rate may be due to a stronger prasugrel-induced inhibition of platelet aggregation in these subgroups. The aim of the present study was to determine whether on-treatment platelet reactivity is lower in these risk subgroups as compared with other patients in a large cohort on the thienopyridine clopidogrel undergoing elective coronary stenting.

Journal ArticleDOI
TL;DR: This study shows that a TEE-based approach for fine-tuning stroke risk in AF patients with a moderate risk for stroke is feasible and safe and compares randomised to non-randomised patients.
Abstract: Background Antithrombotic management in atrial fibrillation (AF) is currently based on clinical characteristics, despite evidence of potential fine-tuning with transoesophageal echocardiography (TEE). This open, randomised, multicentre study addresses the hypothesis that a comprehensive strategy of TEE-based aspirin treatment in AF patients is feasible and safe.

Journal ArticleDOI
TL;DR: Pulmonary endarterectomy is associated with good long-term survival and freedom from clinical worsening in patients with CTEPH, however, clinical worsening occurred in a substantial number of patients at long- term follow-up.
Abstract: Pulmonary endarterectomy (PEA) is the most effective treatment for chronic thromboembolic pulmonary hypertension (CTEPH). The aim of this study is to evaluate long-term survival and freedom from clinical worsening after PEA. All patients who underwent PEA in our hospital between May 2000 and August 2009 were included. Follow-up parameters were all-cause mortality and time to clinical worsening, defined as a combination of death, need for pulmonary hypertension-specific medication or 15% decrease in six-minute walk distance without improvement in functional class. The Cox proportional hazard regression was used to identify predictors. Seventy-four consecutive patients (mean age 55.9 ± 13.8 years, 51% female) underwent PEA. Prior to surgery, 55 patients were in NYHA functional class III or higher. The mean pulmonary artery pressure was 41.3 ± 11.9 mmHg with a mean pulmonary vascular resistance of 521 ± 264 dyn·s·cm−5 (range 279–1331 dyn·s·cm−5). Five patients (6.8%) died in-hospital. Out of hospital, 5 out of 69 patients (7.2%) died during a median follow-up of 3.7 ± 2.2 years [range 0.1–8.5 years]). The one- and five-year survival rates were 93% and 89%, respectively. During follow-up, clinical worsening occurred in 13 out of 69 patients (18.8%). The one- and five-year rates of freedom from clinical worsening were 94% and 72%, respectively. The baseline NT-pro BNP level tended to be a predictor for occurrence of clinical worsening. Pulmonary endarterectomy is associated with good long-term survival in patients with CTEPH. However, clinical worsening occurred in a substantial number of patients at long-term follow-up.

Journal ArticleDOI
TL;DR: The Clinical Algorithm for Cardiac Rehabilitation was thoroughly revised mainly by incorporating more objective assessment methods and by adding several new key areas.
Abstract: Background In 2004, the Netherlands Society of Cardiology released the current guideline on cardiac rehabilitation. Given its complexity and the involvement of various healthcare disciplines, it was supplemented with a clinical algorithm, serving to facilitate its implementation in daily practice. Although the algorithm was shown to be effective for improving guideline adherence, several shortcomings and deficiencies were revealed. Based on these findings, the clinical algorithm has now been updated. This article describes the process and the changes that were made.

Journal ArticleDOI
TL;DR: Although no model completely mimics human atherosclerosis, much can be learned from existing models in the study of this disease, also with respect to the development of new interventions.
Abstract: Experimental disease models have enhanced our understanding of the pathogenesis of atherosclerosis development. For example, insight has been gained into the role of the endothelium, lipids, platelets and inflammation, as well as into potential diagnostic and therapeutic interventions. Moreover, transgenic and knock-out technologies have become a widespread approach and this is a growing field to assess the role of individual genes in vascular biology and pathology. However, atherosclerosis is most of all a multifactorial disease, influenced by a multitude of environmental factors. Therefore, it is important to also study non-transgenic animal models that closely resemble the human situation with atherosclerotic lesions at anatomical locations that mimic the clinical manifestation of the disease, e.g. coronary artery disease (CAD). Although no model completely mimics human atherosclerosis, much can be learned from existing models in the study of this disease, also with respect to the development of new interventions. Here, we describe the most relevant animal models of atherosclerosis, while focusing on CAD development and the use of coronary diagnostic and therapeutic interventions. In addition, we show examples of features of a large animal model of CAD including pictures of invasive coronary imaging.

Journal ArticleDOI
TL;DR: C cognition and measures of structural brain integrity should be considered in the evaluation of novel treatments for atrial fibrillation, and cerebrovascular dysfunction may lead to electrocardiographical disorders and cardiac rhythm disturbances.
Abstract: Over the past months three interesting cardiovascular findings have been published: 1) Transient ischaemic attacks (TIAs) may increase the risk for later heart attack, 2) early morning heart attacks may be more severe, and 3) too much television may increase future cardiovascular risk for children. Regarding finding 1, a TIA appears to double the risk for a heart attack later according to a study published online in the journal Stroke: mortality associated with a myocardial infarction after TIA was 3 times that of patients who did not have a myocardial infarction. Regarding finding 2, it was reported that a heart attack in the morning is likely to be more severe than having one at any other time of day, according to a study published online in the journal Heart. This phenomenon may be due to the changes in the body's blood pressure, hormone levels and metabolic rates that naturally occur when a person wakes up. Regarding finding 3, it was shown that young children who spend too much time watching TV or playing computer games have narrower eye arteries than kids who are more physically active, according to an Australian study published online in the journal ATVB (Arteriosclerosis, Thrombosis and Vascular Biology). After adjustment for age, sex, ethnicity, eye colour, axial length, body-mass index, birth weight, and mean arterial blood pressure, the retinal arteriolar caliber in 1500 children who were in the highest tertile of outdoor sporting activities was an average of 2.2 μm wider than those of the children in the lowest tertile of outdoor physical activity (predominantly TV watchers). Although these findings have their own specific implications, the common denominator of these observations is the interaction between the heart and the brain and vice versa. The speciality that deals with the brain-heart connection has become known as neurocardiology. Neurocardiology refers to (patho)physiological interplays of the nervous and cardiovascular systems. Over the past years, there is increasing evidence about brain-heart interaction with major potential implications for treatment of cardiovascular diseases. For instance, cerebrovascular accidents (CVAs) and TIAs are frequently caused by cardiac arrhythmias. In particular atrial fibrillation may result in cognitive disorders preceding the occurrence of transient ischaemic attacks or CVAs. Even in the absence of manifest stroke, atrial fibrillation is a risk factor for cognitive impairment and hippocampal atrophy. Therefore, cognition and measures of structural brain integrity should be considered in the evaluation of novel treatments for atrial fibrillation. On the other hand, cerebrovascular dysfunction may lead to electrocardiographical disorders and cardiac rhythm disturbances. Coronary artery bypass surgery (CABG) has major effects on neuron-cognitive functioning. However, the literature still remains undecided on the role of intra-operative emboli and cognitive decline after surgery. More attention should be focussed on the composition, size and location instead of the absolute number of intra-operative emboli; growing awareness of neuron-cognitive decline in chronic vascular disease patients must challenge both clinicians and investigators. Exercise stimuli may prevent or slow down the cognitive decline in elderly patients with heart failure. In particular, the therapeutic implications in the direct interrelation between the nervous system, the brain and the heart will increasingly become a dominant focus of forthcoming studies. The future of therapeutic approaches in neurocardiology lies both in novel treatment as in applying scientific integrative medical ideas that takes into account concurrent chronic degenerative and vascular disorders and interactions of multiple drug and non-drug treatments. Various patient groups (atrial fibrillation, heart failure, post-CABG) may benefit when the appropriate mechanisms of the interrelation between nervous system, brain and heart will become elucidated. When these relationships are better understood, more appropriate therapeutic measures can be taken to benefit patients with cardiovascular and cerebrovascular diseases.