Atrial myxoma presenting with orthostatic hypotension in an 84-year-old Hispanic man: a case report.

INTRODUCTION: Left atrial myxomas remain the most common benign primary cardiac tumors, and these cardiac growths can masquerade as mitral stenosis, infective endocarditis and collagen vascular disease. Atrial myxomas are found in approximately 14-20% of the population and can lead to embolization, intercardiac obstructions, conduction disturbances and lethal valve obstructions. CASE PRESENTATION: An 84-year-old Hispanic man presented with complaints of dizziness upon standing, and with no prior history of heart murmurs, syncope, shortness of breath, or chest pain. Physical examination revealed evidence of orthostatic hypotension and a soft grade 1/6 systolic murmur at the left sternal border. A transthoracic echocardiogram revealed a large atrial myxoma occupying the majority of the left atrium, with the posterior border of the large atrial mass defined by eccentric mitral regurgitation identified during cardiac catheterization. Left atrial myxoma excision was performed, revealing a 7 x 6.5 x 4.5 cm atrial tumor attached to a 4 x 3 x 2 cm stalk of atrial septal tissue. CONCLUSION: This patient didn't present with the common symptoms associated with an atrial myxoma, which may include chest pain, dyspnea, orthopnea, peripheral embolism or syncope. Two-dimensional echocardiography provides substantial advantages in detecting intracardiac tumors. We recommend a two-dimensional echocardiogram in the workup of orthostatic hypotension of unknown etiology after the common causes such as autonomic disorders, dehydration, and vasodilative dysfunctions have been ruled out. By illustrating this correlation between orthostasis and an atrial myxoma, we hope to facilitate earlier identification of these intracardiac growths.

Torcetrapib and carotid intima-media thickness in mixed dyslipidaemia (RADIANCE 2 study): a randomised, double-blind trial.

BACKGROUND: Patients with mixed dyslipidaemia have raised triglycerides, low high-density lipoprotein (HDL) cholesterol, and high low-density lipoprotein (LDL) cholesterol. Augmentation of HDL cholesterol by inhibition of the cholesteryl ester transfer protein (CETP) could benefit these patients. We aimed to investigate the effect of the CETP inhibitor, torcetrapib, on carotid atherosclerosis progression in patients with mixed dyslipidaemia. METHODS: We did a randomised double-blind trial at 64 centres in North America and Europe. 752 eligible participants completed an atorvastatin-only run-in period for dose titration, after which they all continued to receive atorvastatin at the titrated dose. 377 of these patients were randomly assigned to receive 60 mg of torcetrapib per day and 375 to placebo. We made carotid ultrasound images at baseline and at 6-month intervals for 24 months. The primary endpoint was the yearly rate of change in the maximum intima-media thickness of 12 carotid segments. Analysis was restricted to 683 patients who had at least one dose of treatment and had at least one follow-up carotid intima-media measurement; they were analysed as randomised. Mean follow-up for these patients was 22 (SD 4.8) months. This trial is registered with ClinicalTrials.gov, number NCT00134238. FINDINGS: The change in maximum carotid intima-media thickness was 0.025 (SD 0.005) mm per year in patients given torcetrapib with atorvastatin and 0.030 (0.005) mm per year in those given atorvastatin alone (difference -0.005 mm per year, 95% CI -0.018 to 0.008, p=0.46). Patients in the combined-treatment group had a 63.4% relative increase in HDL cholesterol (p<0.0001) and an 17.7% relative decrease in LDL cholesterol (p<0.0001), compared with controls. Systolic blood pressure increased by 6.6 mm Hg in the combined-treatment group and 1.5 mm Hg in the atorvastatin-only group (difference 5.4 mm Hg, 95% CI 4.3-6.4, p<0.0001). INTERPRETATION: Although torcetrapib substantially raised HDL cholesterol and lowered LDL cholesterol, it also increased systolic blood pressure, and did not affect the yearly rate of change in the maximum intima-media thickness of 12 carotid segments. Torcetrapib showed no clinical benefit in this or other studies, and will not be developed further.

Atherosclerosis and teen eating study.

BACKGROUND: Low-density lipoprotein, high-density lipoprotein, serum triglyceride concentrations, blood pressure, obesity, and blood glucose are all known to contribute to risk for development of atherosclerosis. Research demonstrates that dietary modifications, which reduce saturated fat intake, impact the likelihood of development of atherosclerosis. OBJECTIVE: The Atherosclerosis and Teen Eating Study was designed to determine whether a short-term health educational program, complemented by availability of alternative low-fat school lunches, could result in favorable changes to healthier eating patterns. Additionally, the study was designed to measure whether changes in eating behaviors were sufficient to result in risk-factor reduction. METHODS: The 6-week study consisted of a defined educational curriculum in addition to the availability of alternative low-fat cafeteria meals. Six 1-hour educational sessions on heart-healthy nutrition and exercise were presented over a period of 2 weeks. Self-perceived nutritional intake was assessed at baseline and the conclusion of the trial via a documented method, the Eating Pattern Assessment Tool. Routine laboratory work and blood pressure were measured at baseline and conclusion of the study. RESULTS: Eating Pattern Assessment Tool score decreased by 14 points (P < 0.001), indicating a significant fall in fat consumption. Fasting glucose and diastolic blood pressure were also reduced. Mean fasting glucose decreased by 3.1 mg/dL (P = 0.041) and mean diastolic blood pressure fell by 6.6 mmHg (P < 0 .001). The percentage reduction in low-density lipoprotein, the primary endpoint, showed a trend downward but did not achieve statistical significance (P = 0.075). CONCLUSION: School-based educational programs and improved choice of foods focused on cardiovascular risk reduction have the capacity to positively influence eating patterns and risk factors associated with future development of atherosclerosis.

Efficacy and safety of fasudil in patients with stable angina: a double-blind, placebo-controlled, phase 2 trial.

OBJECTIVES: This study sought to evaluate the efficacy and safety of fasudil, an orally available rho kinase inhibitor, in patients with stable angina. BACKGROUND: Several small, non-placebo-controlled trials suggest that fasudil reduces myocardial ischemia in patients with stable or vasospastic angina. METHODS: In a multicenter, double-blind, placebo-controlled, randomized trial, the efficacy and safety of fasudil were evaluated in stable angina patients. Of the 206 patients screened, 84 patients with reproducible exercise times were randomized 1:1 to fasudil or placebo. Nitroglycerin as needed and a beta- or calcium-channel blocker were allowed. Fasudil or matching placebo was force-titrated from 20 mg three times daily to 80 mg twice daily with 20 mg twice-daily increments every two weeks. Symptom-limited exercise testing was performed after two, four, six, and eight weeks of treatment. RESULTS: At peak, exercise duration was significantly improved at all visits in both groups, although exercise duration was numerically greater in patients receiving fasudil versus those receiving placebo. Time to > or =1 mm ST-segment depression was increased with fasudil at both peak and trough compared with placebo (172.1 s vs. 44.0 s, p = 0.001, and 92.8 s vs. 26.4 s, p = 0.02, respectively). Fasudil improved Seattle Angina Questionnaire scores. No significant differences in Canadian Cardiovascular Society class, time to angina, or frequency of angina or nitroglycerin use were noted between groups. Fasudil did not affect heart rate or blood pressure, and was well tolerated. CONCLUSIONS: Fasudil up to 80 mg three times daily significantly increased the ischemic threshold of angina patients during exercise with a trend toward increased exercise duration. Further investigation of fasudil doses >80 mg three times daily is indicated.