Severe symptoms in mid and apical hypertrophic cardiomyopathy.

BACKGROUND: We analyzed the clinical and quantitative echocardiographic characteristics of patients with sub-basal hypertrophic cardiomyopathy (HCM) to define the characteristics of patients (pts) with severe symptoms. METHODS: Of 444 pts in a referral-based HCM program, 22 (5%) had midventricular or apical HCM. Quality of life (QoL) questionnaire was administered as an independent confirmer of symptomatic state. RESULTS: Ten pts were NYHA III and IV, and 12 pts were NYHA I and II; QoL scores (41 +/- 26 vs. 10 +/- 13, P = 0.001) confirmed a priori division of two groups based on NYHA classification. Pts with more severe symptoms were more likely female (70% vs. 25%, P = 0.001) with atrial fibrillation (40% vs. 0%, P = 0.02). They more frequently had midventricular HCM 60% versus 8% (P = 0.01) (mid-LV thickness 17 +/- 6 vs. 12 +/- 2 mm, P = 0.03) and had much smaller LV diastolic volumes 68 +/- 12 versus 102 +/- 22 ml (39 +/- 4 vs. 53 +/- 12 ml/m(2), P = 0.001). Septal E/E' was higher in the severely symptomatic pts (15 +/- 5 vs. 7 +/- 3, P = 0.001) indicating higher estimated LV filling pressure. Midobstruction with apical akinetic chamber was noted in 4/10 pts who developed refractory symptoms. Cardiac mortality was higher in the severely symptomatic patients, 4/10 who had midventricular HCM as compared to 0/12 in the mildly symptomatic apical HCM group (P = 0.03). CONCLUSIONS: In subbasal HCM, pts with severe symptoms have midventricular hypertrophy, with encroachment of the LV cavity and consequent very small LV volumes that may be complicated by mid-LV obstruction. Pts with mid-LV hypertrophy are more symptomatic than those with apical HCM, are often refractory to therapy, and have higher mortality.

Influence of albuminuria and glomerular filtration rate on blood pressure response to antihypertensive drug therapy.

BACKGROUND: Albuminuria and glomerular filtration rate (GFR), two factors linked to kidney and vascular function, may influence longitudinal blood pressure (BP) responses to complex antihypertensive drug regimens. METHODS: We reviewed the clinic records of 459 patients with hypertension in an urban, academic practice. RESULTS: Mean patient age was 57-years, 89% of patients were African American, and 69% were women. Mean patient systolic/diastolic BP (SBP/DBP) at baseline was 171/98 mmHg while taking an average of 3.3 antihypertensive medications. At baseline, 27% of patients had estimated (e)GFR <60 ml/min/1.73(2), 28% had micro-albuminuria (30-300 mg/g) and 16% had macro-albuminuria (>300 mg/g). The average longitudinal BP decline over the observation period (mean 7.2 visits) was 25/12 mmHg. In adjusted regression models, macro-albuminuria predicted a 10.3 mmHg lesser longitudinal SBP reduction (p < 0.001) and a 7.9 mmHg lesser longitudinal DBP reduction (p < 0.001); similarly eGFR <60 ml/min/1.73(2) predicted an 8.4 mmHg lesser longitudinal SBP reduction (p < 0.001) and a 4.5 lesser longitudinal DBP reduction (p < 0.001). Presence of either micro- or macro-albuminuria, or lower eGFR, also significantly delayed the time to attainment of goal BP. CONCLUSIONS: These data suggest that an attenuated decline in BP in drug-treated hypertensives, resulting in higher average BP levels over the long-term, may mediate a portion of the increased risk of cardiovascular-renal disease linked to elevated urinary albumin excretion and reduced eGFR.

Popliteal artery pseudoaneurysm following FoxHollow atherectomy: a rare complication.

Atherectomy using the FoxHollow device is an exciting treatment as an alternative to lower extremity arterial bypass for treatment of peripheral vascular disease in symptomatic patients with critical limb ischemia and disabling claudication. We present an interesting case of popliteal artery pseudoaneurysm following FoxHollow atherectomy, which is a rare complication. Mechanical factors have been implicated in causation of trauma to the vessel wall during atherectomy. Endovascular treatment of peripheral vascular disease has become increasingly common, thus it is important to know the rare complications associated with it. Pseudoaneurysm is one of the rare complications associated with the use of the FoxHollow atherectomy device.

Complex endocarditis in an immunocompromised host: the role of three-dimensional echocardiography.

This case report emphasizes the role of different echocardiography imaging modalities, including three-dimensional imaging, in defining the invasive complications of infective endocarditis. We report the case of an immunocompromised patient who was admitted for stroke workup and found to have complex culture negative endocarditis. Echocardiography showed an aortic root abscess and a large intramyocardial, echogenic area with central liquefaction, suggestive of an intramyocardial abscess. An aneurysm of the mitral-aortic intervalvular fibrosa was also visualized along with a prominent aneurysm of the right coronary cusp, best visualized with three-dimensional imaging. Our patient was considered inoperable and died of this illness 2 weeks later.