Obstructive hypertrophic cardiomyopathy is associated with enhanced thrombin generation and platelet activation.

OBJECTIVES: To investigate the association of left ventricular outflow tract (LVOT) obstruction with blood coagulation, platelet activity and inflammatory response in patients with hypertrophic cardiomyopathy (HCM) and sinus rhythm. PATIENTS AND MAIN OUTCOME MEASURES: In 42 patients with HCM with sinus rhythm, including 16 patients with resting LVOT obstruction (gradient > or = 30 mm Hg) and 29 age- and sex-matched controls, markers of thrombin generation (thrombin-antithrombin complex (TAT), prothrombin fragment 1+2 (F1+2)), platelet activation (soluble CD40 ligand (sCD40L), beta-thromboglobulin (beta-TG), P-selectin) and inflammation (C-reactive protein (CRP), interleukin (IL)6, tumour necrosis factor-alpha (TNFalpha)) were determined. RESULTS: Thrombin, platelet and inflammatory markers were higher in the entire HCM group than in controls (p<0.005 for all compared parameters). Compared with non-obstructive HCM, obstructive HCM was associated with increased thrombin formation (TAT, F1+2), platelet activation (sCD40L, beta-TG, P-selectin) and both CRP and IL6 levels. Only the level of TNFalpha was similar in both forms of HCM. In contrast, a comparison of non-obstructive HCM with controls showed that all these variables (except for P-selectin) were similar; P-selectin was higher in non-obstructive HCM. The LVOT gradient correlated positively with all the raised blood markers (r from 0.39 to 0.73; p<0.05), except for TNFalpha. In multiple regression analysis models, the LVOT gradient was the only independent predictor of TAT (R(2) = 0.61; p<0.001), sCD40L (R(2) = 0.59; p<0.001), F1+2 (R(2) = 0.55; p = 0.002), P-selectin (R(2) = 0.49; p = 0.004) and beta-TG (R(2) = 0.38; p = 0.005) in patients with HCM. CONCLUSIONS: LVOT obstruction is independently associated with enhanced thrombin generation and platelet activity in patients with HCM with sinus rhythm.

Comparison of dual-chamber pacing with nonsurgical septal reduction effect in patients with hypertrophic obstructive cardiomyopathy.

OBJECTIVES: The aim of the study was to compare the influence of dual-chamber pacing vs. nonsurgical septal reduction on hemodynamic and morphological parameters in patients with obstructive form of hypertrophic cardiomyopathy. METHODS: Nineteen patients with dual-chamber pacing (group I) and 9 patients who underwent nonsurgical septal reduction (group II) were studied at baseline and after a 6-month follow-up. The changes of left ventricular outflow tract gradient and posterior wall thickness (as an index of left ventricular hypertrophy regression) were compared. RESULTS: The baseline left ventricular outflow tract gradient was comparable between group I and group II (77+/-25 vs. 82+/-25 mm Hg, p>0.05). At 6-month follow-up, the left ventricular outflow tract gradient was reduced to a similar level in both groups (28+/-19 vs. 25+/-12 mm Hg, p>0.05). At baseline, posterior wall hypertrophy was comparable between groups (12.9+/-1.7 vs. 13.6+/-2.2 mm, p>0.05). During follow-up, the posterior wall thickness was unchanged in the pacing group (12.9+/-1.7 vs. 12.6+/-1.6 mm, p>0.05), whereas nonsurgical septal reduction induced regression of left ventricular hypertrophy in myocardial region remote from the infarcted septal segment (13.6+/-2.2 vs. 10.5+/-2.3 mm, p<0.003). CONCLUSION: Despite comparable reduction of instantaneous left ventricular outflow tract gradient, the nonsurgical septal reduction decreased posterior wall thickness, whereas pacing did not reduce left ventricular hypertrophy. Thus, regression of left ventricular hypertrophy that appeared solely after nonsurgical septal reduction may reflect the more permanent reduction of left ventricular pressure overload. Thus, not only hemodynamic but also morphological benefit from nonsurgical septal reduction seems to indicate the superiority of this method over dual-chamber pacing.

[Platelet activation and endothelial factors in standard exercise test before and after menopause]. / Aktywacja plytek i wybrane parametry funkcji sródblonka w trakcie standardowego wysilku fizycznego u kobiet w okresie okolomenopauzalnym.

OBJECTIVES: Postmenopausal lack of estrogens may accelerate cardiovascular atheromatic changes. Standard exercise test (SET) challenges hidden signs of the vascular involvement. Although the test is known not to carry a risk of thromboembolic complications, it may influence plasma concentrations of endothelial and platelet factors. The question is if and to what extend the menopause aggravates the SET induced changes. AIM: Plasma concentrations of nitric oxide, endothelin-1, beta-thromboglobulin and von Willebrand factor activity before, at the maximum exercise and 15 minutes after the SET referred to, as a recovery time were estimated. METHOD: SET was performed according to Bruce protocol in group of 31 premenopausal and 57 postmenopausal women. Standard RIA kits for plasma beta-thromboglobulin (beta-TG) (Boehringer Mannheim) and endothelin-1 (Et-1) (Blotrack) concentration were used. The von Willebrand factor (vWF) activity was assayed by ELISA system (Boehringer Manheim). Plasma nitric oxide (NO) concentration was calculated from nitrides/nitrates levels, by Griess reaction, modified by use of NADPH reductase. RESULTS: Mean plasma levels of beta-TG, Et-1, NO and vWF activity do not differ between pre and postmenopausal women. The standard exercise test significantly increases both beta-TG plasma concentration and vWF activity (p < 0.00001). During the 15 minutes rest period the changed values do not return to preexercise levels. Neither plasma NO nor Et-1 plasma concentrations change during the exercise test. There was a similar increase in beta-TG plasma levels and vWF activity during the SET in pre- and postmenopausal women and a slighter increase of plasma Et-1 levels in postmenopausal women (p < 0.04). The close relationships between NO plasma concentration and both vWF activity (p < 0.002) and vascular endothelial growth factor (VEGF) level (p < 0.04) were observed in postmenopausal women. The vWF activity in postmenopausal; women inversely correlates with insulin-like growth factor-I (IGF-I) concentration (p < 0.001). In premenopausal women the important modulators of vWF activity were: body mass (p < 0.04), serum total cholesterol (p < 0.02) and sex hormone binding globulin (SHBG) levels (p < 0.04). The postmenopausal beta-TG increase during SET depends on body mass (p < 0.02), whereas the preexercise levels seem to be related to VEGF level (p < 0.03) and inversely to Et-1 (p < 0.007) and dehydroepiandrosterone sulfate (DHEAS) concentration (p < 0.03) Both the basal and stimulated by exercise vWF activity are higher in obese women (p < 0.003), but the net increase is larger in lean group (BMI < 30 kg/m2). In premenopausal women plasma NO concentration depends on 17 beta-estradiol serum level (p < 0.02). The higher VEGF (p < 0.01) levels as well as vWF activity was observed (p < 0.03) in hypercholesterolemic women. CONCLUSION: The standard exercise test increases the procoagulatory von Willebrand factor activity so as the platelets activity (beta-thromboglobulin concentration) in both pre and postmenopausal women. The slight endothelin-1 rise has been found at the maximum exercise in postmenopausal women. The close relation between plasma nitric oxide and endothelin-1 levels was found in postmenopausal women. Obesity and hypercholesterolemia may contribute to the observed changes.

[Restenosis after coronary balloon angioplasty. Prevention and treatment]. / Restenoza po balonowej angioplastyce. Zapobieganie i leczenie.

The paper describes the mechanisms as well as clinical and angiographic risk factors for the development of restenosis after balloon coronary angioplasty. Based on literature findings and personal experience the ways of preventing restenosis were reviewed taking into account the optimisation of immediate angioplasty results based upon intracoronary ultrasound and physiological measurements of the coronary flow reserve. The paper also reviews the available techniques in the management of restenosis after balloon coronary angioplasty.

[Direct stent implantation under control of intracoronary ultrasonography. Immediate and late results]. / Bezposrednia implantacja stentów pod kontrola ultrasonografii sródwiencowej. Wyniki bezposrednie i odlegle.

UNLABELLED: Stents of a new generation have been developed, permitting immediate implantation without predilatation of the lesion site. Intracoronary ultrasound (ICUS) has been found useful in precise evaluation of stent expansion and in improvement of long-term therapeutic outcomes. The purpose of the study was to evaluate the safety and efficacy of direct stent implantation using intracoronary ultrasound. The study comprised 30 patients (8 women and 22 men) aged below 70 years with stable and unstable angina pectoris. ICUS was performed at baseline before making a decision about direct stent implantation and during the procedure to evaluate stent expansion. Direct stenting was performed in 26 patients achieving an angiographically and clinically optimal result (100% efficacy). In four patients direct stenting was abandoned because of massive calcifications in the affected artery detected by ICUS at baseline. During the 9-month follow-up recurrence of anginal pain requiring repeated intervention was observed in 3 patients (11.5%). CONCLUSIONS: The use of ICUS prior to direct stenting considerably improves the efficacy of the procedure and long-term therapeutic outcomes. Before wide popularisation of direct stenting under ICUS guidance it is necessary to carry out multicentre randomised clinical studies to verify the expected improvement of long-term results as compared with conventional stent implantation with pre-dilatation.

Circulating N-terminal brain natriuretic peptide precursor and endothelin levels in patients with syndrome X and left bundle branch block with preserved systolic function.

BACKGROUND: Deterioration of left ventricular function during follow-up was reported in some patients with syndrome X and concomitant left bundle branch block. The patients with syndrome X and left bundle branch block has been frequently presented with elevated Endothelin-1 (ET-1) level while brain natriuretic peptide (BNP) (a sensitive marker of left ventricular dysfunction) has not been measured in patients with syndrome X. METHODS: The purpose of the present study was to assess left ventricular diastolic function, levels of N-terminal Brain Natriuretic Peptide (NT-proBNP) precursor and biochemical parameters of endothelial function in patients with syndrome X complicated by left bundle branch block but preserved left ventricular systolic function (group A, n=8). The echocardiographic and neurohormonal measures in these patients were compared to those in patients with syndrome X without left bundle branch block (group B, n=13), and controls (group C, n=15). RESULTS: At rest and after exercise the serum concentration of NT-proBNP was significantly higher in group A than in the controls (at rest: 232+/-96 vs. 133+/-23 fmol/ml, P=0.03; after exercise: 313+/-96 vs. 180+/-33 fmol/ml, P=0.02). The highest concentration of endothelin-1 was also found in group A, being significantly higher than in the controls (6.81 vs. 4.52 pg/ml, P<0.05). Mitral flow abnormalities were detected in left bundle branch block patients. Accordingly, the lowest E/A ratio was in group A and it differed significantly from that in group C (0.85 vs. 1.1, P<0.05). E/A ratio inversely correlated with plasma NT-proBNP concentration in patients with left bundle branch block (r=-0.48, P=0.02). CONCLUSIONS: Elevated NT-proBNP and endothelin-1 plasma concentrations were demonstrated in patients with syndrome X complicated by left bundle branch block even when left ventricular systolic function was still preserved. In this subgroup the magnitude of left ventricular diastolic dysfunction correlated with the increase of BNP level which reflects neurohormonal activation.

Impact of gender on the left ventricular cavity size and contractility in patients with hypertrophic cardiomyopathy.

BACKGROUND: The aim of the study was to assess gender-specific differences in left ventricular cavity size, contractility and left ventricular outflow tract obstruction in patients with hypertrophic cardiomyopathy. METHODS: We studied retrospectively 129 referred patients with hypertrophic cardiomyopathy (77 males and 52 females). The echocardiographically measured left ventricular end-systolic, end-diastolic dimensions, fractional shortening and occurrence of left ventricular outflow tract gradient > or =30 mmHg were compared between sexes. Logistic regression analysis was used to calculate the predictive values of left ventricular dimensions and contractility for left ventricular outflow tract obstruction for each gender separately. RESULTS: Left ventricular end-diastolic and end-systolic dimensions were significantly smaller in females than males (41.7+/-5.3 vs. 45.1+/-4.9 mm, P=0.0003; 23.1+/-44 vs. 25.6+/-5.3 mm, P=0.007 respectively). On the contrary, the value of fractional shortening was comparable in both sexes (44.7+/-7.3 vs. 43.6+/-7.9%, P>0.05). The left ventricular outflow tract gradient occurred in females as frequently as in males (28.8 vs. 33.8%, P>0.05). By logistic regression analysis the predictors of left ventricular outflow tract gradient in females were left ventricular end-systolic diameter (relative risk=0.74; confidence interval (CI) 0.61 to 0.91; P=0.0038), left ventricular end-diastolic diameter (relative risk=0.82; CI 0.72 to 0.96; P=0.0061) and fractional shortening (relative risk=1.11; CI 1.01 to 1.22; P=0.036). The most potent predictor appeared to be left ventricular end-systolic dimension. In males none of these parameters identified patients with left ventricular outflow tract obstruction. CONCLUSIONS: Females with hypertrophic cardiomyopathy featured smaller left ventricular cavity size, which predisposed to left ventricular outflow tract obstruction (the most potent predictor of left ventricular outflow tract obstruction was left ventricular end-systolic dimension). Higher left ventricular contractility also determined left ventricular outflow tract gradient occurrence in females with hypertrophic cardiomyopathy. In males despite a larger left ventricular cavity size the left ventricular outflow tract obstruction occurred with a similar frequency as in females. Left ventricular outflow tract obstruction was not predicted by left ventricular cavity size or contractility in males.

[Intracoronary ultrasound assessment of balloon angioplasty with "stent-like' angiographic result]. / Ultrasonograficzna ocena skutecznosci balonowej angioplastyki wiencowej z wynikiem angiograficznym "porównywalnym do stentowania".

The aim of the study was to evaluate by intracoronary ultrasound (ICUS) the efficacy of optimal coronary balloon angioplasty (POBA) guided by quantitative coronary angiography (QCA). The study population included 40 patients who underwent conventional coronary balloon angioplasty, in whom a stent-like result was achieved (percent diameter stenosis (%DS) < 35% in QCA). In all patients diagnostic ICUS assessment was performed after the procedure. The site of stenosis and the proximal and distal reference segments were analysed with respect to residual plaque burden (RPB), true vessel dimension (the media-to-media diameter) and type of vascular remodelling. Despite an optimal angiographic result residual plaque burden was 70 +/- 6% at the site of stenosis, whereas in the reference segments it was around 45% indicating the severity of atherosclerosis in angiographically normal vascular segments. No significant differences were seen between averaged reference vessel diameter in QCA (Ref.D) and averaged luminal reference diameter in ICUS. In contrast, true vessel diameter in ICUS was significantly larger than Ref.D in QCA (p < 0.001). Positive vascular remodelling at the site of stenosis was observed in most patients. Optimal angiographic result of QCA-guided POBA does not indicate optimal dilatation of the lesion. In most patients ICUS reveals marked residual plaque burden, which is an independent predictor of restenosis after percutaneous coronary interventions.

[Clinical predictors of left ventricular function improvement after percutaneous coronary interventions in patients with ejection fraction below 45%]. / Kliniczne wskazniki poprawy funckji lewej komory u pacjentów z frackja wyrzutowa ponizej 45% poddanych zabiegom przezskórnej rewaskularyzacji wiencowej.

BACKGROUND: The value of clinical predictors of left ventricle function recovery after surgical revascularization in patients with decreased ejection fraction is well documented. However, there are no clinical studies assessing factors which can influence left ventricle function in patients with coronary disease and low ejection fraction (LVEF) undergoing percutaneous coronary interventions (PCI). OBJECTIVE: We tried to assess clinical prognostic factors of left ventricle function improvement after PCI in patients with coronary artery disease and impaired LVEF. PATIENTS AND METHODS: We studied patients with LVEF < 45% undergoing PCI. We assessed duration and grade of symptoms of heart failure, angina class and echocardiographic parameters of LV systolic function. After 6 months follow-up LVEF was obtained again. We analyzed influence of baseline clinical factors on LVEF recovery after PCI. RESULTS: We studied 29 patients (mean age 54.4 +/- 11 years) before and after PCI. In the whole group of patients we found significant increase in EF (38.4 +/- 6% vs 50.4 +/- 15%, p = 0.005) at follow up examination. There was significant improvement of EF in patients with NYHA class I or II (from 40.4 +/- 5% to 58.1 +/- 9%, p < 0.0001) as compared to NYHA class III or IV (from 31.4% +/- 9% to 31.8 +/- 11, p = NS). In multivariate regression analysis correlation between NYHA class and LVEF at control examination (beta = -0.54, p = 0.03) was independent from epidemiological variables and baseline LVEF. There was significant increase in LVEF in patients with severe angina (CCS III or IV) as compared to patients without angina (DEF 21.3 +/- 5% vs 7.9 +/- 10%, p = 0.009). There was also higher increase in LVEF in patients with chest pain during balloon inflation (delta EF 17.4 +/- 9% vs 5.7 +/- 9%, p = 0.01). CONCLUSIONS: Mild symptoms of heart failure and independent predictors of left ventricle function recovery after PCI in patients with impaired LVEF. The lack of angina symptoms negatively influence LVEF recovery after PCI.

[Percutaneous renal artery angioplasty--review of current indicators]. / Angioplastyka tetnic nerkowych--aktualne wskazania.

The most frequent cause of secondary arterial hypertension is renal artery stenosis. The aetiology of renal artery stenosis is mainly atherosclerotic (75-80%), in the remaining cases fibromuscular dysplasia is the causative factor. Renovascular hypertension has a poorer prognosis than spontaneous because it is more resistant to antihypertensive treatment, signifies an increased risk for the development and progression of malignant hypertension and may lead to irreversible renal dysfunction due to ischaemia. Renal revascularisation has been proved an effective treatment modality in patients with arterial hypertension or renal failure due to renal artery stenosis. However, surgical treatment is associated with the mortality rate of 6-9% due to the concomitant presence of ischaemic heart disease, cerebral and peripheral arteriosclerosis. Percutaneous transluminal renal angioplasty is equally effective in the treatment of arterial hypertension as surgical operation, leading to the improvement or stabilisation of renal function. The advent of renal stenting has markedly changed the efficacy and safety of procedures with PTRA becoming an alternative to surgery. The high efficacy of PTRA is associated with low mortality and relatively few complications as compared with surgical treatment. However, there is continuous discussion concerning the efficacy of percutaneous and surgical renal revascularisation in arterial hypertension. PTRA is currently increasingly frequently recommended in patients with renovascular hypertension not only to control blood pressure but also to protect renal function.

[Therapeutic angiogenesis for coronary artery disease. Contemporary results and perspectives]. / Lecznicza angiogeneza jako potencjalna terapia w chorobie niedokrwiennej serca. Nadzieje i rzeczywistosc.

Therapeutic angiogenesis is referred to as development of new vasculature caused by various therapeutic measures such as: gene therapy, growth factors, percutaneous and transmyocardial laser revascularization. The scope of the current article is to provide review of performed clinical trials using therapeutic angiogenesis in patients with coronary artery disease.

[The assessment of safety of enoxaparin administration during percutaneous transluminal coronary angioplasty after ticlopidine pretreatment. Application of low molecular weigh heparins in prevention of coronary micro-embolization]. / Ocena bezpieczenstwa stosowania enoxaparyny podczas zabiegów przezskórnej rewaskularyzacji serca u pacjentów uprzednio otrzymujacych tiklopidyne Zastosowanie heparyn drobnoczasteczkowych w zapobieganiu zatorowosci mikrokrazenia wiencowego.

BACKGROUND: Administration of enoxaparin to patients with acute coronary syndromes can result in better outcomes in comparison to patients treated with unfractionated heparin. Use of enoxaparin during percutaneous coronary interventions (PCI) can also improve the outcome. Administration of ticlopidine and aspirin for a few days before PCI decreases frequency of ischaemic complications. There is lack of data about safety and efficacy of combined administration of enoxaparin, ticlo-pidine and aspirin during PCI. METHODS: 61 patients with coronary artery disease were involved in the study. All patients were pretreated with aspirin (75-325 mg/d) and ticlopidine (2 x 250 mg) for at least 3 days before PCI. PCI procedures were conducted after i.v. administration of 1 mg/kg of enoxaparin. After PCI bleeding and ischaemic complications were monitored. RESULTS: In the treated group, no major bleeding occurred, while minor bleeding was noted in 6.5% of patients. No periprocedural major adverse cardiac events (death, Q wave infarction, urgent revascularisation) were observed. Microembolisation was present in 4.9% patients (expressed as CK-MB > 3 times the reference level). CONCLUSIONS: Intravenous administration of enoxaparin 1 mg/kg during PCI in patients pretreated with aspirin and ticlopidine for at least 3 days before intervention appears to be safe. Safety and high efficacy of enoxapirine in this pilot trial justify initiating the randomized, multicenter trial comparing use of low molecular weight heparin to unfractionated heparin during PCI.

The effect of verapamil on response of coronary vasomotion to handgrip exercise in symptomatic patients with hypertrophic cardiomyopathy.

OBJECTIVES: To assess the effect of verapamil on the response of diastolic coronary blood flow velocity (CBFV) and coronary vascular resistance index to handgrip exercise in symptomatic HCM patients. DESIGN: In 13 patients with HCM, the CBFV was detected in the distal portion of left anterior descending coronary artery using high-sensitivity transthoracic Doppler echocardiography. The peak diastolic CBFV and coronary vascular resistance index (calculated as the ratio of mean aortic pressure to CBFV) was measured at baseline and during handgrip exercise. Changes of these parameters induced by the exercise (expressed as the percentage of baseline values) were compared on verapamil treatment and after verapamil withdrawal. The same measurements were obtained in 10 healthy control subject. RESULTS: In HCM patients, the increase in CBFV during exercise was significantly higher on than off verapamil therapy (16.2 +/- 5% versus 6.8 +/- 3.8%, p < 0.001). In healthy controls, exercise-induced increase in CBFV was comparable to CBFV changes in HCM patients receiving verapamil (17.4 +/- 5.7 versus 16.2 +/- 5%, p > 0.05) and was significantly greater than the CBFV response in HCM patients off verapamil (17.4 +/- 5.7% versus 6.8 +/- 3.8% p < 0.005). During exercise the coronary vascular resistance index decreased on verapamil and increased after drug withdrawal (-5.8 +/- 5.6% versus 1.1 +/- 5.1%, p < 0.001). In healthy controls the coronary vascular resistance index decreased during exercise -8.5 +/- 4.5% to similar extent as in HCM patients on verapamil. CONCLUSION: In HCM symptomatic patients, verapamil improved coronary vasomotor response to physical stress. Verapamil was able to restore adequate vasodilator response to handgrip exercise.

The importance of ventricular septal morphology in the effectiveness of dual chamber pacing in hypertrophic obstructive cardiomyopathy.

It has been reported that older patients with hypertrophic obstructive cardiomyopathy (HOCM) benefited the most from dual chamber (DDD) pacing. Since in older patients the distribution of septal hypertrophy and left ventricular (LV) cavity shape differs from that in younger patients, we decided to study the efficacy of DDD pacing on the reduction of LV outflow tract (LVOT) gradient in different patterns of septal hypertrophy. We compared HOCM patients with nonreversed septal curvature, thus preserving the elliptical LV cavity contour (common in the elderly), (group I) versus patients with reversed septal curvature, deforming the LV cavity to a crescent shape (common in the young), (group II). Eighteen HOCM patients were studied (11 patients in group I and 7 patients in group II). After implantation of a DDD pacemaker, the LVOT gradient was measured using Doppler echocardiography at various programmed AV delay intervals to determine the maximal percentage decrease of LVOT gradient from baseline. The measurement was repeated after at least a 6-month follow-up (chronic DDD pacing). The baseline LVOT gradient was comparable between groups (79 +/- 28 vs 81 +/- 25 mmHg, P = 0.92). The LVOT gradient reduction at acute DDD pacing was significantly greater in group I than group II (61 +/- 18% vs 23 +/- 10%, P = 0.0001). This difference in favor of the patients from group I was maintained at midterm follow-up (69 +/- 17% vs 40 +/- 17% P = 0.0076). In conclusion, patients with normal septal curvature and preserved elliptical LV cavity shape had a greater reduction of LVOT gradient after DDD pacing than patients with reversed septal curvature deforming LV cavity. The proposed criterion assessing the septal curvature may be useful to predict the efficacy of DDD pacing in the reduction of LVOT gradient.

[Depressive disturbance and quality of life in patients with coronary artery disease]. / Zaburzenia depresyjne a jakosc zycia u pacjentów z choroba niedokrwienna serca.

The aim the study was to evaluate the impact of mood disturbances on the subjective quality of life in patients with coronary artery disease after an effective angioplasty. The study covered 100 patients with the optimum result of PTCA. Their condition was evaluated one day before and four weeks after angioplasty. Significant differences in the subjective quality of life assessment were detected depending on the occurrence and dynamics of depressive symptoms. The authors postulate evaluation of psychological state and introduction of anti-depressive therapy in patients with coronary artery disease subjected to revascularisation.

Balloon positioning difficulties during nonsurgical septal reduction therapy in a patient with hypertrophic obstructive cardiomyopathy.

Dual chamber (DDD) pacing and catheter-based nonsurgical septal reduction therapy (NSRT) with ethanol are evaluated for treatment of patients with hypertrophic cardiomyopathy. This report describes a patient with hypertrophic cardiomyopathy and left ventricular outflow tract obstruction who had failed to respond to DDD pacing but showed benefit from subsequent NSRT. Procedural difficulties during NSRT due to massive septal hypertrophy are presented.

Effect of verapamil on systolic and diastolic coronary blood flow velocity in asymptomatic and mildly symptomatic patients with hypertrophic cardiomyopathy.

OBJECTIVE: To assess non-invasively the effect of verapamil treatment on coronary blood flow velocity in asymptomatic and mildly symptomatic patients with hypertrophic cardiomyopathy. DESIGN: High frequency transthoracic Doppler echocardiography was used to compare resting phasic coronary blood flow velocity before and after a one month period of verapamil treatment in 17 patients (14 men and three women) with non-obstructive hypertrophic cardiomyopathy. Eighteen healthy subjects formed an age and sex matched control group. Systolic and diastolic coronary blood flow velocity was measured in the distal portion of left anterior descending coronary artery using high frequency transthoracic Doppler echocardiography. Blood flow velocity before and after verapamil was compared in the patients with cardiomyopathy and with the results in the control group. RESULTS: Compared with the controls, patients with hypertrophic cardiomyopathy had increased diastolic coronary blood flow velocity (41.8 (8.1) v 59.9 (21.9) cm/s, p < 0.01) and a lower mean systolic coronary blood flow velocity (18.7 (10.8) v -11.2 (27.5) cm/s, p < 0. 01) before verapamil treatment. A backward pattern of systolic flow, manifested by negative values of coronary blood flow velocity, was recorded in eight of the patients, while no negative values were found in the controls. After verapamil treatment the retrograde systolic blood flow was restored to an anterograde pattern in only one patient. The mean value of systolic coronary blood flow velocity did not change significantly and remained lower than the systolic forward flow velocity in the controls (-3.6 (31.8) v 18.7 (10.8) cm/s, p < 0.05). However, diastolic coronary blood flow velocity decreased significantly after verapamil (59.9 (21.9) v 50.7 (19.5) cm/s p < 0.05), reaching a level comparable with that in the controls (50.7 (19.5) v 41.8 (8.1) cm/s, p > 0.05). CONCLUSIONS: In contrast to healthy subjects, in non-obstructive hypertrophic cardiomyopathy the systolic pattern of coronary blood flow was heterogeneous (both retrograde and anterograde), and diastolic coronary blood flow velocity was abnormally increased, despite a lack of significant symptoms. Verapamil treatment did not restore the forward pattern of systolic blood flow but decreased diastolic blood flow velocity to a level comparable with that in healthy subjects.

Comparison of the effect of verapamil and propranolol on response of coronary vasomotion to cold pressor test in symptomatic patients with hypertrophic cardiomyopathy.

Impaired endothelium-dependent vasodilatation of coronary resistance vessels has been demonstrated in patients with hypertrophic cardiomyopathy (HC). The aim of this study was to compare the effect of verapamil and propranolol on the response of diastolic coronary blood flow velocity (CBFV) and coronary vascular resistance index to the cold pressor test (CPT) in symptomatic HC patients. In 15 patients with HC, the CBFV was measured in the distal portion of the left anterior descending coronary artery using high-sensitivity transthoracic Doppler echocardiography. Peak diastolic CBFV and coronary vascular resistance index (calculated as ratio of mean aortic pressure/CBFV ratio) were measured at baseline and after CPT. Changes of these parameters induced by the CPT (expressed as percentage of baseline values) were compared after verapamil and propranolol treatment in a crossover study. The same measurements were obtained in nine healthy control subjects. CPT induced an increasing pattern of CBFV during verapamil therapy, which was absent in CPT after propranolol administration (10.1 +/- 5.6% vs. -0.9 +/- 4.1%, P < 0.01). In healthy controls CBFV increased in response to CPT more than in HC patients receiving verapamil or propranolol (23.1+/- 12.8% P < 0.01 and P < 0.05, respectively). The coronary vascular resistance index increased during the CPT significantly less on verapamil than on propranolol treatment (3.5 +/- 9.2% vs. 18.1 +/- 13.5%, P < 0.01). In healthy controls the coronary vascular resistance index decreased during CPT -4.5 +/- 8.5% (P < 0.05 vs. verapamil and P < 0.01 vs. propranolol). Verapamil improved the coronary vasomotor response to CPT in relation to propranolol. Verapamil blunted the increase of the coronary vascular resistance index to the CPT in comparison with its change at CPT after propranolol. Thus, coronary endothelial dysfunction in symptomatic HC patients may be partially reduced by verapamil in comparison with propranolol treatment.