In an experimental model of atherogenesis induced by hyperfibrinogenemia (HF), the pharmacological response of vitamin E was studied in order to assess its antioxidant effect on the mitochondrial morphofunctional alterations in aortic smooth muscle cells. Three groups of male rats were used: (Ctr) control, (AI) atherogenesis induced for 120 days, and (AIE) atherogenesis induced for 120 days and treated with vitamin E. HF was induced by adrenalin injection (0.1 mg/day/rat) for 120 days. AIE group was treated with the administration of 3.42 mg/day/rat of vitamin E for 105 days after the first induction. Mitochondria morphology was analyzed by electronic microscopy (EM) and mitochondrial complexes (MC) by spectrophotometry. In group AI the total and mean number of mitochondria reduced significantly, the intermembranous matrix increased, and swelling was observed with respect to Ctr and AIE (P < 0.01). These damages were related to a significant decrease in the activity of citrate synthase and complexes I, II, III, and IV in group AI in comparison to Ctr (P < 0.001). Similar behavior was presented by group AI compared to AIE (P < 0.001). These results show that vitamin E produces a significative regression of inflammatory and oxidative stress process and it resolved the morphofunctional mitochondrial alterations in this experimental model of atherogenic disease.
Background. Radiotherapy is commonly used to treat breast and thoracic cancers but it also causes delayed microvascular damage and increases the risk of cardiac mortality. Endothelial cell proliferation and revascularization are crucial to restore microvasculature damage and maintain function of the irradiated heart. We have therefore examined the potential of bone marrow-derived endothelial progenitor cells (BM-derived EPCs) for restoration of radiation-induced microvascular damage. Material & Methods. 16 Gy was delivered to the heart of adult C57BL/6 mice. Mice were injected with BM-derived EPCs, obtained from Eng +/+ or Eng +/− mice, 16 weeks and 28 weeks after irradiation. Morphological damage was evaluated at 40 weeks in transplanted mice, relative to radiation only and age-matched controls. Results. Cardiac irradiation decreased microvascular density and increased endothelial damage in surviving capillaries (decrease alkaline phosphatase expression and increased von Willebrand factor). Microvascular damage was not diminished by treatment with BM-derived EPCs. However, BM-derived EPCs from both Eng +/+ and Eng +/− mice diminished radiation-induced collagen deposition. Conclusion. Treatment with BM-derived EPCs did not restore radiation-induced microvascular damage but it did inhibit fibrosis. Endoglin deficiency did not impair this process.
Objectives . The aim of this study was to investigate the occurrence of myocardial injury in critically ill children through assessment of cardiac troponin T levels and whether levels are associated with disease severity and myocardial dysfunction measured by echocardiography. Methods . Over a 6-month period, this case control study included 50 patients admitted to Pediatric Intensive Care Unit of Zagazig University Children’s Hospital. Twenty-five healthy children were included as a control group. Demographic and clinical data including the pediatric index of mortality II score were recorded. Echocardiographic examination was done and level of cardiac troponin T was measured using Elecsys Troponin T STAT Immunoassay. Results . Cardiac troponin T levels were significantly higher in critically ill in comparison to healthy children (median 22 (18–28) pg/mL versus 10 (10-10) pg/mL, P < 0.05). Cardiac troponin T levels correlated positively with duration of ventilation as well as with disease severity and correlated negatively with left ventricular fractional shortening. Moreover, cardiac troponin T levels were significantly higher in nonsurvivors when compared to survivors (median 34.5 (27.5–41.5) pg/mL versus 20 (18–24) pg/mL, P < 0.05). Conclusion . In critically ill children, cardiac troponin T levels were elevated and were associated with duration of ventilation and disease severity.
We aimed to evaluate the frequency, clinical profiles and outcomes of abdominal aortic aneurysms (AAA), and their association with coronary artery disease (CAD) in a small country with high cardiovascular burden. Methods. Data were collected for all adult patients who underwent abdominal computed tomography scans at Hamad General Hospital in Qatar between 2004 and 2008. Results. Out of 13,115 screened patients for various reasons, 61 patients (0.5%) had abdominal aneurysms. The majority of AAA patients were male (82%) with a mean age of 67 ± 12 years. The incidence of AAA substantially increased with age reaching up to 5% in patients >80 yrs. Hypertension was the most prevalent risk factor for AAA followed by smoking, dyslipidemia, renal impairment, and diabetes mellitus. CAD and peripheral arterial disease (PAD) were observed in 36% and 13% of AAA patients, respectively. There were no significant correlations between CAD or PAD and site and size of AAA. Conclusion. This is the largest study in our region that describes the epidemiology of AAA with concomitant CAD. As the mortality rate is quite high in this high risk population, routine screening for AAA in CAD patients and vice versa needs further studies for proper risk stratification.
International guidelines recommend ICD implantation in patients with severe left ventricular dysfunction of any origin only after careful optimization of medical therapy. Indeed, major randomized clinical trials suggest that suboptimal use of fundamental drugs, such as ACE inhibitors (ACE-i) and beta-blockers, may affect ICD shock-free survival, sudden cardiac death (SCD), and overall mortality. While solid evidence in favour of pharmacological therapy based on ACE-i with or without beta-blockers is available, data on SCD in HF patients treated with angiotensin receptor blockers (ARBs) are limited. The present paper systematically analyses the impact of ARBs on SCD in HF and reviews the contributory role of the renin-angiotensin system (RAS) to the establishment of arrhythmic substrates. The following hypothesis is supported: (1) the RAS is a critical component of the electrical remodelling of the failing myocardium, (2) RAS blockade reduces the risk of SCD, and (3) ARBs represent a powerful tool to improve overall survival and possibly reduce the risk of SCD provided that high doses are employed to achieve optimal AT1-receptor blockade.
Background. Transesophageal echocardiography (TEE) is used for the evaluation of the presence of left atrial appendage (LAA) thrombus prior to pulmonary vein isolation (PVI), while coronary computed tomography angiography (CCTA) is used for anatomic mapping during PVI. Methods. We compared the diagnostic performance of single phase CCTA to TEE in excluding the presence of LAA thrombus in patients undergoing PVI in 172 subjects performed during index hospitalization. Results. The mean age was 51 ± 13 years, a median CHADS2 score of 1 [IQR25,75 0,1, range 0–3] and a mean periprocedural INR of 2.1 ± 0.6. The prevalence of an LAA filling defect on single phase CCTA was 9.3% (6/183) and on TEE was 1.2% (2/183). Sensitivity, specificity, positive predictive value, and negative predictive value were 100% (95% CI, 19.8–100%), 91.8% (95% CI, 94–99%), 12.5% (95% CI, 60–76%), and 91.8% (95% CI, 97–100%) for the detection of LAA filling defect, respectively. Conclusion. Given the utility of a preprocedural single phase CCTA for the performance of PVI, the absence of a filling defect negates the need for a subsequent TEE as an adjunct for exclusion of LAA thrombus.
Objectives. Assess the impact of associating thrombolytics, anticoagulants, antiplatelets, and primary angioplasty (PA) on death, reinfarction (AMI), and major bleeding (MB) in STEMI therapy. Methods. Medline search was performed to identify randomized trials comparing these classes in STEMI treatment, at least 500 patients, providing death, AMI, and MB rates. Similar arms were grouped. Correlation between number of drugs and PA and the outcomes was evaluated, as well as correlation between the year of the study and the outcomes. Results. Fifty-nine papers remained after exclusions. 404.556 patients were divided into 35 groups of arms. There was correlation between the number of drugs and rates of death (r = -0.466, P = 0.005) and MB (r = 0.403, P = 0.016), confirmed by multivariate regression. This model also showed that PA is associated with lower mortality and increased MB. Year and period of publication correlated with the outcomes: death (r = -0.380, P < 0.001), MB (r = 0.212, P = 0.014), and AMI (r = -0.231, P = 0.009). Conclusion. The increasing complexity of STEMI treatment has resulted in significant reduction in mortality along with increased rates of MB. Overall, however, the benefits of treatment outweigh the associated risks of MB.
Background . We evaluated the incidence of mortality and myocardial infarction (MI) in endovascular repair (EVAR) as compared to open aneurysm repair (OAR) in both elective and ruptured abdominal aortic aneurysm (AAA ) setting. Methods . We analyzed the rates of 30-day mortality, 30-day MI, and hospital length of stay (LOS) based on comparative observation and randomized control trials involving EVAR and OAR. Results . 41 trials compared EVAR to OAR with a total pooled population of 37,781 patients. Analysis of elective and ruptured AAA repair favored EVAR with respect to 30-day mortality with a pooled odds ratio of 0.19 (95% CI 0.17–0.20; I 2 = 88.9 % ; P < 0.001). There were a total of 1,835 30-day MI events reported in the EVAR group as compared to 2,483 events in the OAR group. The pooled odds ratio for elective AAA was 0.74 (95% CI 0.58–0.96; P = 0.02) in favor of EVAR. The average LOS was reduced by 296.75 hrs (95% CI 156.68–436.82 hrs; P < 0.001) in the EVAR population. Conclusions . EVAR has lower rates of 30-day mortality, 30-day MI, and LOS in both elective and ruptured AAA repair.
The pericardium plays an important role in optimizing cardiac motion and chamber pressures and serves as a barrier to pathology. In addition to pericardial anatomy and function, this review article covers a variety of pericardial conditions, with mention of potential pitfalls encountered during interpretation of diagnostic imaging. Normal and abnormal appearance of pericardium on CT and MR imaging is emphasized, including dynamic imaging correlates of pericardial pathophysiology.
Objectives. Doxapram hydrochloride is a respiratory stimulant that has an inhibitory effect on myocardial IK1 potassium channels and is thought to increase membrane instability and excitability in myocardial cells. We examined the arrhythmogenic effects of doxapram hydrochloride in a rat model of halothane adrenaline-induced arrhythmia. Methods. Thirteen female Wistar rats (12–14 weeks old) were used in the study. Animals were anesthetized with inhalation of halothane to permit observation of the effects of doxapram hydrochloride on halothane adrenaline-induced arrhythmia. Time-dependent changes in ECG repolarization characteristics (QT, QTc, JTp, JT, and Tp-e intervals) were studied. Results. Doxapram hydrochloride itself did not induce arrhythmia but did induce bidirectional ventricular tachycardia after addition of adrenaline. Conclusion. Drug-induced impairment of intracellular Ca2+ regulation caused BVT in the absence of genetic abnormalities in proteins in the sarcoplasmic reticulum.
Context. Whether angiotensin converting-enzyme inhibitors (ACEI) and angiotensin-receptor blockers (ARB) are useful in high risk patients without heart failure is unclear. We perform a meta-analysis of prospective randomized placebo-controlled ACEI or ARB trials studying patients with a combination of risk factors to assess treatment impact on all cause mortality, cardiovascular mortality, nonfatal myocardial infarction (MI) and stroke. Method. A PubMed search was made for placebo-controlled trials recruiting at least 1,200 high risk patients randomized to either ACEI or ARB, with follow-up of at least 2 years. Meta-analysis was performed using the RevMan 5 program and Mantel-Haenszel analysis was done with a fixed effects model. Results. Ten trials recruiting 77,633 patients were reviewed. All cause mortality was significantly reduced by ACEI (RR 0.89; P = 0.0008), but not by ARB treatment (RR 1.00; P = 0.89). Cardiovascular mortality and nonfatal MI were also reduced in the ACEI trials but not with ARB therapy. Stroke was significantly reduced in the ACEI trials (RR 0.75; P < 0.00001) and more modestly reduced in the ARB trials (RR 0.90; P = 0.01). Conclusion. ACEI treatment reduced stroke, nonfatal MI, cardiovascular and total mortality in high risk patients, while ARB modestly reduced stroke with no effect on nonfatal MI, cardiovascular and total mortality.
Elevation of cardiac troponins and creatinine kinase is frequently observed in setting of systemic inflammatory response syndrome (SIRS), sepsis, or septic shock. Underlying pathophysiologic mechanism for such troponin leak, its clinical significance, and what different could be done in such settings remain elusive. In this paper we have briefly overviewed the proposed pathogenic mechanisms for SIRS, sepsis, or septic shock-related troponin elevation (SRTE) and have provided brief overview on its clinical significance. Upon review of the relevant literature we found that majority of patients with the SRTE with no prior history of coronary artery disease (CAD) upon testing are found not to have any CADs. We have also briefly discussed the possible pharmacologic agents and potential targets which are important from pathophysiologic and pharmacologic point of view that may alter the outcomes of SRTE-related myocardial depression in near future.
Introduction. Amiodarone has been used for more than 5 decades for the treatment of various tachyarrhythmias and previously for the treatment of refractory angina. There are multiple well-established side effects of amiodarone. However, amiodarone-induced cirrhosis (AIC) of liver is an underrecognized complication. Methods. A systematic search of Medline from January 1970 to November 2012 by using the following terms, amiodarone and cirrhosis, identified 37 reported cases of which 30 were used in this analysis. Patients were divided into 2 subsets, survivors versus nonsurvivors, at 5 months. Results. Aspartate aminotransferase was significantly lower (P = 0.03) in patients who survived at 5-months (mean 103.33 IU/L) compared to nonsurvivors (mean 216.88 IU/L). There was no statistical difference in the levels of prothrombin time, total bilirubin, alanine aminotransferase, alkaline phosphatase, gamma-glutamyl transpeptidase, cumulative dose, and latency period between the two groups. The prevalence of DM, HTN, HLD, CAD, and CHF was similar in the two groups. None of the above-mentioned variables could be identified as a predictor of survival at 5 months. Conclusion. AIC carries a mortality risk of 60% at 5 months once the diagnosis is established. Further prospective studies are needed to identify predictors of AIC and of mortality or survival in cases of AIC.
Modern cardiac rhythm management systems have become increasingly complex. The decision on which specific system to implant in a given patient often rests with the implanting physician. We conducted a multiple-choice survey to assess the opinions and preferences of cardiologists and electrophysiologists who implant and follow cardiac rhythm management systems. Reliability and battery longevity were viewed as the most important characteristics in device selection. Patient characteristics which most affected device choice were pacing indication and life expectancy. Remote technology was used in 47% of pacemaker patients, 64% of ICD patients, and 65% of CRT-D patients, with wireless (radiofrequency) remote patient monitoring associated with higher patient compliance rates (74% versus 64%, resp.). Wireless remote patient management with alerts for atrial tachyarrhythmias was felt to be important by 76% of respondents. When choosing an MR-conditional device, physicians deemed patients with prior orthopedic problems, a history of cancer, or neurological disorders to be more likely to require a future MRI. Device longevity and reliability remain the most important factors which influence device selection. Wireless remote patient monitoring with alerts is considered increasingly important when choosing a specific cardiac rhythm management system to implant.
Objective. To evaluate the association of BNP and CRP with the development of postoperative atrial fibrillation following coronary artery bypass grafting surgery. Methods. The series consists of 125 patients (aged 65 ± 9 years), who underwent isolated CABG-surgery. BNP and CRP levels were measured pre- and 24 hours postoperatively and their correlation to the development of postoperative AF was analyzed. Results. Forty-four patients (35%) developed AF postoperatively. They were significantly older (68 ± 8 versus 63 ± 9, P = 0.01) and predominantly nonsmokers (18% versus 46%, P = 0.004), compared to the non-AF cases. In addition they showed significant higher preoperative mean BNP levels of 629 versus 373 pg/mL (P = 0.019). Postoperative BNP levels were significantly higher in both groups (AF-group: 1032 pg/mL versus non-AF group: 705 pg/mL; P < 0.001), while there was a trend of more increased postoperative levels in AF-cases (P = 0.065). AF-episodes appeared significantly more frequent in the two highest quartiles of BNP levels with 44% (P = 0.035). On the contrary pre- and postoperative CRP levels were not associated with AF. Multivariable analysis revealed only increased preoperative BNP levels as independent predictor for postoperative AF (P = 0.036). Conclusion. Elevated preoperative BNP serum levels are associated with the development of post-CABG AF, while CRP does not seem to be influential.
The complication of stent thrombosis (ST) emerged at a rate of 0.5% annually for first-generation drug-eluting stents (DES), often presenting as death or myocardial infarction. Procedural factors such as stent underexpansion and malapposition are risk factors for ST in patients. The type of lesion being treated and lesion morphology also influence healing after treatment with DES and can contribute to ST. Second-generation DES such as the XIENCE V everolimus-eluting stent differ from the first-generation stents with respect to antiproliferative agents, coating technologies, and stent frame. Improvements in stent structure have resulted in a more complete endothelialization, thereby decreasing the incidence of ST. Bioresorbable scaffolds show promise for restoring vasomotor function and minimizing rates of very late ST. Post-PCI treatment with aspirin and clopidogrel for a year is currently the standard of care for DES, but high-risk patients may benefit from more potent antiplatelet agents. The optimal duration of DAPT for DES is currently unclear and will be addressed in large-scale randomized clinical trials.
Aims. Previous studies have suggested that intravenous administration of adenosine improves myocardial reperfusion and reduces infarct size in ST-elevation myocardial infarction (STEMI) patients. Intracoronary administration of adenosine has shown conflicting results. Methods. In this retrospective, single-centre, blinded clinical study, we assessed whether selective intracoronary administration of adenosine distal to the occlusion site immediately before initial balloon inflation reduces microvascular obstruction (MVO) as assessed with cardiac magnetic resonance imaging (MRI). Using contrast-enhanced sequences, microvascular obstruction (MVO) was calculated. We found 81 patients presenting with STEMI within 12 h from symptom onset who were eligible for the study. In 80/81 (100%) patients receiving the study drug, MRI was performed on Day 1 after primary angioplasty. Results. The prevalence of MVO was reduced in the patients treated with intracoronary adenosine, (45%) compared to 85% of patients who were administered intravenous adenosine (P = 0.0043). We found that the size of MVO in patients receiving intracoronary adenosine was significantly reduced compared to 0.91 g in the intravenous-treated group (P = 0.027). There was no statistically significant difference in TIMI flow and clinical outcomes after primary PCI. Conclusion. We found significant evidence that selective high-dose intracoronary administration of adenosine distal to the occlusion site of the culprit lesion in STEMI patients results in a decrease in microvascular obstruction.
Advances in surgery for atrial fibrillation from cut and sew technique to thoracoscopy and new energy source have enabled minimally invasive approach which avoids median sternotomy and cardiopulmonary bypass. However, minimally invasive approach is unable to match the outcome of classic surgical technique due to difficulty in creating some of linear ablation lines. Hybrid procedure using catheter mapping and ablation in addition to minimally invasive surgical ablation has gained interest to combine the advantages of both procedures. No large study has been conducted to date comparing this new technique to other existing treatments. The aim of this paper is to review the data on hybrid procedure for atrial fibrillation and assess its early outcome and efficacy.
Adiponectin is an adipocyte specific cytokine which, in contrast to other adipokines, has been described to have antiinflammatory, antithrombotic, and anti-atherogenic properties. This study evaluates the association between plasma adiponectin levels with acute coronary syndrome (ACS) and angiographic coronary lesion severity in Indian population. Ninety patients included in the study were divided in two groups in 1 : 1 ratio-patients admitted with a diagnosis of ACS and those without ACS. Adiponectin and other risk markers are measured in forty-five consecutive patients in each group undergoing coronary angiography. Patients without ACS were found to have higher adiponectin (16.47 ± 7.88 μ g/mL) levels than patients with ACS (9.03 ± 3.13 μ g/mL) (P < 0.001). In multiple regression analysis adjusted for all other risk markers, higher adiponectin levels remain positively associated with a lower risk of ACS (P value > 0.002). The greatest increase in risk for ACS was seen at adiponectin levels ≤12.20 μ g/mL in study subjects. The adiponectin levels were inversely related to the angiographic severity of coronary artery stenosis increases (P value > 0.02). The study concluded that higher adiponectin levels are independently associated with lower risk of ACS, and patients with severe angiographic coronary artery disease have lower levels of adiponectin.
Objective. The aim of the study was to describe echocardiographic abnormalities in patients with rheumatoid arthritis, concurrent systemic comorbidities, rheumatologic clinical activity, serologic markers of rheumatoid arthritis, and inflammatory activity. Methods. In an observational, cross-sectional study, rheumatoid arthritis outpatients were included (n = 105). Conventional transthoracic echocardiographic variables were compared between patients with arthritis and non-RA controls (n = 41). For rheumatoid arthritis patients, articular activity and rheumatologic and inflammatory markers were obtained. Results. Ventricular dysfunction was found in 54.3% of the population: systolic (18.1%), diastolic (32.4%), and/or right (24.8%), with lower ejection fraction (P < 0.0001). Pulmonary hypertension was found in 46.9%. Other echocardiographic findings included increased left atrial diameter (P = 0.01), aortic diameter (P = 0.01), ventricular septum (P = 0.01), left ventricular posterior wall (P = 0.013), and right ventricular (P = 0.01) and atrial diameters compared to control subjects. Rheumatoid factor and anti-CCP antibodies levels were significantly elevated in cases with ventricular dysfunction. Angina and myocardial infarction, diabetes, and dyslipidemia were the main risk factors for ventricular dysfunction. Conclusions. Ventricular dysfunction is common in rheumatoid arthritis and associated with longer disease duration and increased serologic markers of rheumatoid arthritis. Screening for cardiac abnormalities should be considered in this kind of patients.
