Dabigatran in patients with atrial fibrillation: perioperative and periinterventional management.

In any type of invasive surgery, the patient's individual risk of thromboembolism has to be weighed against the risk of bleeding. Based on various everyday situations in clinical routine, the purpose of the present expert recommendations is to provide appropriate perioperative and periinterventional management for patients with atrial fibrillation undergoing long-term treatment with the thrombin inhibitor dabigatran. As we currently have no routine laboratory test to measure therapeutic levels of the substance or the risk of bleeding, general measures such as a standardized documentation of the patient's history, a sufficient time interval between the last preoperative dose and the procedure, and careful control of local hemostasis should be given special attention.

A new oscillometric method for pulse wave analysis: comparison with a common tonometric method.

In the European Society of Cardiology-European Society of Hypertension guidelines of the year 2007, the consequences of arterial stiffness and wave reflection on cardiovascular mortality have a major role. But the investigators claimed the poor availability of devices/methods providing easy and widely suitable measuring of arterial wall stiffness or their surrogates like augmentation index (AIx) or aortic systolic blood pressure (aSBP). The aim of this study was the validation of a novel method determining AIx and aSBP based on an oscillometric method using a common cuff (ARCSolver) against a validated tonometric system (SphygmoCor). aSBP and AIx measured with the SphygmoCor and ARCSolver method were compared for 302 subjects. The mean age was 56 years with an s.d. of 20 years. At least two iterations were performed in each session. This resulted in 749 measurements. For aSBP the mean difference was -0.1 mm Hg with an s.d. of 3.1 mm Hg. The mean difference for AIx was 1.2% with an s.d. of 7.9%. There was no significant difference in reproducibility of AIx for both methods. The variation estimate of inter- and intraobserver measurements was 6.3% for ARCSolver and 7.5% for SphygmoCor. The ARCSolver method is a novel method determining AIx and aSBP based on an oscillometric system with a cuff. The results agree with common accepted tonometric measurements. Its application is easy and for widespread use.

[Image quality of CT angiography of coronary arteries depending on the degree of coronary calcification using a dual source CT scanner]. / Bildqualität von CT-Angiografien der Koronararterien in Abhängigkeit vom Ausmass der Koronarverkalkungen bei Einsatz eines Dual-Source-CTs.

PURPOSE: To evaluate the influence of severe calcification on image quality of CT angiography (CTA) of coronary arteries acquired with dual source CT. METHOD: 171 dual source CTAs in spiral mode were evaluated. Depending on the Agatston score (CS), patients where divided into four subgroups (I: CS 0 - 200, II: CS 201 - 600, III: CS 601 - 1000, IV: CS > 1000). Image quality was evaluated by two independent, blinded readers using a three-stage scale and the image quality of each subgroup was also shown with the help of an image quality index (BQI). In addition, a comparison with coronary catheter angiography was undertaken in a subgroup. RESULTS: Dual source CTA in spiral mode showed good image quality even in patients with Agatston scores of 601 - 1000 and > 1000. The four classes showed no significant difference in image quality. (BQI = 1,164 [I], BQI = 1,212 [II], BQI = 1,281 [III], BQI = 1,111 [IV]; p = 0,3145). The detailed analysis showed particularly good quality in patients with a heart rate < 75 bpm. The smaller subgroup of patients with CS > 200 and heart rates > 75 bpm showed a statistically significant reduction in image quality (BQI = 1,625; p = 0.0016). There were no gender differences in the image quality (p = 0.9881) although the calcium scores differed significantly in men (CS = 313 [+/- 449]) and women (CS = 145 [+/- 304]). The comparison with coronary catheter angiography showed a good correlation (92%). CONCLUSION: CTA of coronary arteries performed with dual source CT in spiral mode provides good image quality even in patients with higher calcification scores. The reduction of heart rates > 75 bpm improves the image quality significantly in patients with higher calcification scores.

Cardiac rupture in embolic myocardial infarction after implantation of a valved aortic conduit.

We report a case of an apical myocardial infarction complicated by left ventricular wall rupture due to coronary artery embolism four years after surgery of an acute type A dissection of an aortic aneurysm with implantation of a valved aortic conduit.

[Atherosclerotic renal artery stenosis]. / Atherosklerotische Nierenarterienstenose.

The most common cause of obstructive renal artery disease is atherosclerosis, accounting for 90 % of cases of renal artery stenosis. Atherosclerotic renal artery stenosis can be associated with renovascular hypertension, ischemic nephropathy, or both or it may occur alone. The prevalence of atherosclerotic renal artery stenosis among hypertensive patients is estimated between 1 and 5 %, but the frequency rises among patients with refractory hypertension (20 %) coronary heart disease (15 to 20 %) or peripheral arterial disease (30 to 40 %). The gold standard for diagnosing renal artery disease is contrast renal arteriography. MR angiography, CT angiography and color duplex ultrasonography have the highest sensitivity and specifity among the non invasive screening methods. Therapy is based on consequent medical treatment of hypertension, antiplatelet therapy and modification of risk factors for atherosclerosis. Revascularisation is advised in patients with severe hypertension, in patients with pulmonary edema and cases of acute worsening of renal function. Percutaneous angioplasty with stent implantation is the method of choice for revascularisation. The prognosis of patients with atherosclerotic renal artery stenosis is determined by cardiovascular and renal complications.

Influence of cardiopulmonary resuscitation on levels of tumour markers.

Tumour markers (TM), including alpha-fetoprotein (AFP), carcinoembryonic antigen (CEA), cancer antigen (CA) 15-3 and prostate-specific antigen (PSA), are serum markers for malignant diseases. Previous studies investigating the effect of acute and chronic inflammation, cardiopulmonary bypass surgery and cardiopulmonary resuscitation (CPR) on levels of TM showed conflicting results. Cardiopulmonary resuscitation (CPR) may result in a profound inflammatory response, and is frequently associated with severe tissue hypoperfusion. The present study investigated whether AFP, CEA, CA 15-3 and PSA are influenced by CPR. Alpha-fetoprotein (AFP), CEA, CA 15-3 and PSA (only in male patients) were assessed immediately after hospital admission, 6 h, 12 h and 2 days after prolonged CPR in eight male and 12 female patients. Serum levels of AFP, CEA, CA 15-3 did not change significantly after CPR. Prostate-specific antigen (PSA) levels increased significantly with a highest level in the study period 48 h after CPR (3.3 +/- 3.1 and 28.3 +/- 30.5 ng/mL for baseline and 48 h levels, respectively; P < 0.001). Alpha-fetoprotein (AFP), CEA, CA 15-3 and PSA (in men) values above the normal range were observed in 0%, 13.8%, 3.8% and 46.9% of all measurements respectively. At least one value above the normal range were observed in 0%, 20%, 5% and 75% of all patients for AFP, CEA, CA 15-3 and PSA (in men) respectively. Baseline values of AFP, CEA, CA 15-3 and PSA (in men) were above the normal range in 0%, 15%, 5% and 10% of all patients respectively. Levels for all markers did not differ significantly between survivors and non-survivors. In conclusion, prolonged CPR does not influence AFP, CEA, CA 15-3 serum levels, but is frequently associated with increases of PSA. Thus, in contrast to PSA, interpretation of AFP, CEA, CA 15-3 serum levels is not influenced by recent CPR.

Prolonged mechanical systole and increased arterial wave reflections in diastolic dysfunction.

OBJECTIVE: To evaluate whether left ventricular ejection time indexed for heart rate (left ventricular ejection time index (LVETI)) and arterial wave reflections (augmented pressure (AP)) are increased in patients with diastolic dysfunction (DD). DESIGN: Prospective observational study. SETTING: University teaching hospital providing primary and tertiary care. SUBJECTS: 235 consecutive patients undergoing left heart catheterisation were categorised as having definite DD, possible DD or no DD (controls) on the basis of their left ventricular end diastolic pressures and N-terminal brain natriuretic peptide concentrations. MAIN OUTCOME MEASURES: LVETI and AP were prospectively assessed non-invasively by radial applanation tonometry. In addition, all patients underwent comprehensive echocardiography, including tissue Doppler imaging of mitral annulus velocity in early diastole (E'). RESULTS: LVETI was longer in patients with definite DD than in patients with possible DD and in controls (433.6 (SD 17.2), 425.9 (17.9) and 414.3 (13.6) ms, respectively, p < 0.000001). Arterial wave reflections were higher in definite DD than in possible DD and control groups (AP was 19.4 (SD 8.9), 15.2 (8.0) and 10.7 (6.8) mm Hg, respectively, p < 0.000001). In receiver operating characteristic curve analysis, LVETI detected DD as well as echocardiography (E:E'). Area under the curve for LVETI to differentiate patients with definite DD from normal controls was 0.81 (95% CI 0.72 to 0.89, p < 0.0001). In multivariable logistic regression analysis, LVETI added significant independent power to clinical and echocardiographic variables for prediction of DD. CONCLUSIONS: Mechanical systole is prolonged and arterial wave reflections are increased in most patients with DD. Rapid non-invasive assessment of these parameters may aid in confirming or excluding DD.

Chronic total occlusion--a definite state?

Successful recanalisation of a chronic coronary occlusion may result in survival advantage. This report describes a 61-year-old man with an initially chronic occluded right coronary artery. A follow-up angiography 2 years later revealed a spontaneous recanalisation.

Catecholamine therapy inducing dynamic left ventricular outflow tract obstruction.

Hypertrophic obstructive cardiomyopathy with significant hypertrophy of the basal septum is the most frequently reported cause of left ventricular outflow tract (LVOT) obstruction. Additionally, other conditions such as dehydration, sepsis, vasodilatation, or mitral valve repair have been associated with LVOT obstruction. In this report, we present a case of a patient without hypertrophy who developed severe dynamic left ventricular outflow tract obstruction during catecholamine stimulation for shock that complicated severe pancreatitis. The present case serves as a reminder that hypovolemia together with a hyperdynamic state resulting from catecholamine administration may result in the development of dynamic LVOT obstruction even if baseline cardiac evaluation is unremarkable. Early detection and intensive efforts to reverse the underlying conditions, including cessation of catecholamine therapy and correction of hypovolemia are essential.

Obesity, body fat and coronary atherosclerosis.

BACKGROUND: Recent prospective studies have provided compelling evidence that obesity is a risk factor for the occurrence of clinical coronary events. However, the link between angiographically determined coronary atherosclerosis and obesity still remains controversial. We conducted this cross-sectional study in a clinical setting to investigate the relation of the obesity and body fat (BF) with angiographically defined coronary atherosclerosis. PATIENTS AND METHODS: Six hundred and seventy-three men (median age 64 years) and four hundred and twenty-eight women (median age 69 years) who underwent coronary angiography for suspected or known coronary heart disease were analyzed. The body mass index (BMI) and the BF were used as main exposure variables, and either the presence of significant (> or =50%) coronary diameter stenosis or a coronary artery disease severity score were defined as outcome variables, in a sex-specific logistic regression analysis. RESULTS: Among male patients, BF was slightly higher with increasing number of vessels involved (adjusted P for trend <0.05). In contrast, BMI showed no association with presence and severity of coronary artery disease (CAD). The odds ratios (ORs) for the presence of significant stenosis across quartiles of BMI were 1.0 (reference), 0.9, 1.1 and 0.7 (adjusted P for trend 0.61). This result did not differ between younger and older men. Among females, however, both BF and BMI were not significantly associated with an increasing number of vessels involved. CONCLUSION: These results suggested that BF may be predictive of an increasing number of coronary vessels involved among male patients, but not among female patients. This study failed to detect a positive association of presence and severity of CAD with BMI.

Postoperative atrial fibrillation independently predicts prolongation of hospital stay after cardiac surgery.

AIM: Postoperative atrial fibrillation (AF) occurs in up to 50% of cardiac surgery patients and represents the most common postoperative arrhythmic complication. A reduction of the length of hospital stay is a desirable goal in preventive strategies of postoperative AF. The aim of the present investigation was to determine whether prolonged postoperative hospital stay associated with AF after cardiac surgery surgery is attributable to the arrhythmia itself or to baseline characteristics of patients who develop AF. METHODS: Patients undergoing elective cardiac surgery in the absence of heart failure and significant left ventricular dysfunction (n = 253; average age 65+/-11 years) were recruited to the present prospective study. Midline sternotomy procedures with standard surgical techniques for normothermic cardiopulmonary bypass in coronary artery bypass grafting and valvular surgery were used. RESULTS: A total of 99 patients (39.1%) of the study population developed AF during the postoperative period. AF patients were older and more likely to have surgery for valvular heart disease and less likely to have antiarrhythmic drugs including beta-adrenergic blockers than patients without AF, but both patients with and without AF had similar body mass index and duration of surgery. Postoperative hospital stays were longer in patients with AF compared to those without AF (14.9+/-5.7 vs 10.6+/-3.6, respectively; P = 0.001). Multivariate analysis, adjusted for age and postoperative complications, demonstrated that postoperative hospital stay was 14.2+/-5.3 days in patients with AF and 10.8+/-3.8 days in patients without AF (P < 0.01). Treatment with oral antiarrhythmic drugs that reduce AF is associated with a reduction of postoperative hospital stay. CONCLUSIONS: Despite baseline characteristics differed between patients with and without postoperative AF, most of the prolongation of hospital stay can be attributed to the rhythm disturbance itself.

Antiarrhythmic therapy on prevention of postoperative atrial fibrillation in patients after heart surgery.

The incidence of supraventricular arrhythmias is high following open-heart surgery, occurring in 25% to about 50% of patients. The most common of these arrhythmias is atrial fibrillation (AF). Postoperative AF has been associated with increased incidence of other complications and increased hospital length of stay. Atrial arrhythmias are most frequent in the first two to three days after cardiothoracic surgery, but they can occur at any point in the recovery period. Age and concomitant valular heart disease are consistently the independent factors most strongly associated with postoperative atrial fibrillation. Prevention of AF seems to be a reasonable clinical goal, and, consequently, many randomized trials have evaluated the effectiveness of pharmacological and nonpharmacological interventions for prevention of AF. The main indication for AF prophylaxis remains the shorteningof length of hospital stay and possibly reduction in stroke. The optimal treatment strategies for reducing postoperative AF are not well established. Commonly used therapeutic approaches include the use of rate-controlling drugs such as beta-blockers, calcium antagonists, and digoxin. Some pharmacological strategies including beta-blockers, sotalol, and amiodarone have shown to reduce risk of postoperative AF and may reduce length of hospital stay. There is no convincing evidence that reducing postoperative AF reduces stroke. This review summarizes current evidence from randomized controlled trials to estimate the effect of pharmacological and non pharmacologic interventions on the occurrence of AF after open-heart surgery and its effects on postoperative outcome.

Spontaneous coronary artery dissection involving the left main stem: assessment by intravascular ultrasound.

This case report describes the devastating consequences of spontaneous coronary dissection in a 36 year old female patient who otherwise had a normal coronary arteriogram. Intravascular ultrasound showed coronary artery dissection and intramural haematoma at the left main stem coronary artery. Acute coronary syndrome developed and subsequently surgical revascularisation was performed successfully.

Increased serum concentrations of soluble CD95/Fas and caspase 1/ICE in patients with acute angina.

OBJECTIVES: To investigate the expression of death inducing receptors in the sera of patients with stable and unstable angina. DESIGN: 80 consecutive patients with stable (n = 40) or unstable (n = 40) angina pectoris were studied. Serum concentrations of soluble CD95 (sCD95), soluble CD95 ligand (sCD95L; CD178), tumour necrosis factor (TNF) alpha, soluble TNFalpha receptor type 1 (sTNFR1), and interleukin 1beta converting enzyme (ICE; caspase 1) were measured by enzyme linked immunosorbent assay (ELISA). RESULTS: Significant increases in the concentrations of sCD95 and ICE (p < 0.001 and p < 0.023, respectively) were found in the serum from patients with unstable angina relative to those with stable angina. There were no significant differences in the concentrations of sCD95L, TNF alpha, and sTNFR1 between the groups. CONCLUSIONS: These data provide the first evidence that sCD95 and ICE are important serological markers that may help to discriminate between stable and unstable angina. This observation may warrant further clinical study to elucidate the clinical impact of sCD95 and ICE in acute coronary syndromes.

Thyroid function is associated with presence and severity of coronary atherosclerosis.

BACKGROUND: Overt hypothyroidism has been found to be associated with cardiovascular disease. Moreover, subclinical hypothyroidism is a strong indicator of risk for aortic atherosclerosis and myocardial infarction. HYPOTHESIS: We hypothesized that variation of thyroid function within the normal range may influence the presence and severity of coronary atherosclerosis. METHODS: We studied a total of 100 consecutive men and women (59 men, 41 women, age 63.7 +/- 11.0 years) who underwent coronary angiography. Blood was tested for serum thyrotropin concentrations and for free tri-iodothyronine and free thyroxine concentrations. In addition to the assessment of thyroid function, conventional risk factors for coronary artery disease (CAD), clinical characteristics, serum lipid levels, fasting total homocysteine, and angiographic results of coronary artery assessment were obtained. Two experienced cardiologists blinded to clinical and laboratory data reviewed the cinefilms. The severity of CAD was scored as 0 for those with smooth normal epicardial coronary arteries, 0.5 for plaquing (< 50% diameter stenosis), and 1, 2, or 3 for those with single-, double-, or triple-vessel epicardial coronary artery stenosis of > 50%, respectively. RESULTS: The severity of CAD was scored as 0, 0.5, 1, 2, and 3 in 14, 26, 25, 22, and 13 patients, respectively. Higher levels of serum-free thyroid hormone concentrations were associated with decreased severity of coronary atherosclerosis. Serum-free tri-iodothyronine was 2.99 +/- 0.33 pg/ml in patients with a CAD severity score of 0 to 1 and 2.74 +/- 0.49 pg/ml in patients with CAD severity scores of 2 and 3 (p < 0.01). Moreover, serum-free thyroxine concentrations showed a trend toward higher levels in patients with CAD severity score 0 to 1 compared with patients with CAD severity scores 2 and 3 (11.65 +/- 1.87 pg/ml vs. 10.9 +/- 2.3 pg/ml; p = 0.09). Higher levels of serum thyrotropin concentrations were associated with increased severity of coronary atherosclerosis (1.37 +/- 1.02 mU/l vs. 1.98 +/- 2.13 mU/l in patients with CAD severity score 0 to 1 versus CAD severity scores 2 and 3; p = 0.049). When grouped into three subsets according to their serum free tri-iodothyronine levels (< 2.79, 2.8 to 3.09, and +/- 3.1 pg/ml), the prevalence of CAD scores 2 and 3 was significantly higher in the subset of patients with low serum free tri-iodothyronine levels (48.5%) than in the subsets of patients with medium or high tri-iodothyronine concentrations (32.25 and 25%, respectively, p for trend < 0.05). CONCLUSION: These data in patients referred for coronary angiography suggest that variation of thyroid function within the statistical normal range may influence the presence and severity of coronary atherosclerosis.

[Cardiovascular risk factor profiles and angiography results in young patients]. / Kardiovaskuläres Risikoprofil und koronarangiografischer Befund bei jungen Patienten.

There is a clear correlation between the incidence of coronary artery disease and existing cardiovascular risk factors. Therefore, it is a matter of interest if there is an accumulation of risk factors in younger patients with premature coronary artery disease compared to those without. We evaluated 1708 consecutive patients who underwent coronary angiography at our institution between August 2001 to February 2002; 85 symptomatic patients under the age of 46 were included in our analysis. In 46 patients (54.1%)--mean age 41.5 +/- 3.6 years--a coronary artery disease was documented, in 39 patients (45.9%)--mean age 39.9 +/- 5.6 years (n.s.)--normal coronary arteries were shown at angiography. Regarding the cardiovascular risk factors in young patients with coronary artery disease compared to young patients without we found a family history of premature coronary artery disease in 54.5% versus 43.6% (n.s.), hypercholesterolemia in 56.5% versus 53.8% (n.s.), LDL cholesterol of 138 +/- 40 mg/dl versus 123.3 +/- 27 mg/dl (s.), HDL cholesterol of 39 +/- 9 mg/dl versus 45.6 +/- 12.6 mg/dl (s.), serum triglycerides of 194.6 +/- 114.9 mg/dl versus 162.1 +/- 98.4 mg/dl (n.s.), diabetes mellitus in 15.2% versus 10.3% (n.s.), hypertension in 45.7% versus 46.4% (n.s.), body mass index > 24.9 kg/m2 in 67.4% versus 69.2% (n.s.), cigarette smoking in 54.6% versus 56.4% (n.s.). And finally, a minimum of two of those risk factors was found in 93.5% versus 87.2% (n.s.). Due to the high prevalence of cardiovascular risk factors in both groups it is impossible to reliably predict the incidence of coronary artery disease from those risk factors. This has to be considered while deciding about the indication for coronary angiography.

Hepatitis A IgG seropositivity and coronary atherosclerosis assessed by angiography.

BACKGROUND: Infectious agents, in particular intracellular pathogens that can establish long-term, persistent infection, may play an important role in atherogenesis. We tested the hypothesis that hepatitis A virus (HAV) could be associated with significant coronary artery disease. METHODS: The possible association between HAV infection and angiographically proven coronary artery disease (CAD) was studied. Blood from 218 patients undergoing coronary angiography was tested for serum IgG antibodies to HAV. RESULTS: Of the 218 patients, 178 (81.7%) had anti-HAV IgG antibodies. CAD prevalence was 66.3% in HAV seropositive and 57.5% in HAV seronegative patients (P=0.385). In contrast, the number of infectious pathogens to which an individual has been exposed correlates with CAD. Four or more of the six seromarkers tested for particular infections (HAV, Chlamydia pneumoniae, Helicobacter pylori, cytomegalovirus, influenza type A and type B) were positive in 48.8% of patients with CAD and in 31.2% of patients in patients without CAD (P=0.02). CONCLUSIONS: This analysis demonstrated that HAV seropositivity is not a predictor of risk for CAD. HAV infection, therefore, seems not to be associated with CAD. The number of infectious agents to which an individual has been exposed ('infectious burden') correlates with CAD.