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.

Effects of benazepril and metoprolol OROS alone and in combination on myocardial ischemia in patients with chronic stable angina.

The efficacy of benazepril, metoprolol OROS and their combination was evaluated in 29 patients (42 to 74 years of age) with chronic stable angina and documented coronary artery disease in a placebo-controlled, double-blind, crossover trial using serial quantitated exercise testing and ambulatory electrocardiographic (ECG) monitoring. The mean (+/- SEM) exercise time was 8.5 +/- 0.7 min with placebo, 8.3 +/- 0.6 min (95% confidence interval [CI]-1.06 to 0.54) with benazepril, 9.4 +/- 0.5 min (95% CI -0.32 to 2.14) with metoprolol OROS and 9.6 +/- 0.5 min (95% CI -0.25 to 2.47) with the combination of benazepril and metoprolol OROS. The mean exercise time to the development of 1 mm ST segment depression was prolonged from 6.0 +/- 0.6 min with placebo to 6.3 +/- 0.6 min (95% CI -0.93 to 1.45) with benazepril, 7.9 +/- 0.5 min (95% CI 0.83 to 3.0) with metoprolol OROS and 8.1 +/- 0.6 min (95% CI 0.88 to 3.29) with the combination of benazepril and metoprolol OROS. Benazepril did not alter the rest or maximal heart rate, whereas metoprolol OROS alone and in combination significantly lowered the heart rate at rest and during maximal exercise. Systolic blood pressure at rest was nonsignificantly reduced, whereas diastolic blood pressure was lowered significantly by all treatments in comparison with placebo. At maximal exercise, only metoprolol OROS, whether given alone or in combination with benazepril, was able to blunt significantly systolic blood pressure and rate-pressure product.(ABSTRACT TRUNCATED AT 250 WORDS)

Increased neopterin in patients with chronic and acute coronary syndromes.

OBJECTIVES: The aim of our study was to determine neopterin levels in patients with chronic and acute coronary syndromes. BACKGROUND: In chronic and acute coronary syndromes the release of different cytokines activates cellular defense. Infiltration of neutrophils and monocytes/macrophages is detected in the vessel wall as well as in the myocardium. Neopterin, which is a by-product of the guanosine triphosphate-biopterin pathway, is a marker for those activated macrophages. METHODS: We studied 123 subjects: 1) 21 consecutive patients (17 men, 4 women; mean age +/- SD 66 +/- 15 years, range 31 to 87) with acute myocardial infarction (AMI); 2) 62 consecutive patients (50 men, 12 women; mean age 61 +/- 8 years, range 43 to 81) with signs and symptoms of clinically stable coronary artery disease (CAD); and 3) 40 healthy blood donors (28 men, 12 women; mean age 35 +/- 13 years). Neopterin levels were determined with a commercially available enzyme-linked immunosorbent assay method. RESULTS: In patients with AMI before thrombolytic therapy, neopterin levels were significantly higher than levels in patients with CAD and control subjects (13.7 vs. 8.6 and vs. 6.8 nmol/liter, p < 0.0001). Values also differed significantly between patients with CAD and control subjects (p < 0.0001). Neopterin levels in patients with AMI were measured seven times during a 72-h period. Within-group comparison showed significant differences over this period (p < 0.00001). The lowest value (11.4 nmol/liter) was observed after 4 h and differed significantly from the initial value and values after 24 and 72 h (p < 0.05). After 72 h, neopterin increased to 14.9 nmol/liter, a value significantly different from all values other than the initial one. There was no correlation between neopterin and creatine kinase (CK); CK, MB isoenzyme; or lactate dehydrogenase as markers for the extent of the myocardial infarction during the observation period. CONCLUSIONS: Our data support the hypothesis of an activation of monocytes and macrophages in patients with an acute or chronic coronary syndrome. Neopterin as a marker for macrophage activation is significantly increased in patients with chronic CAD and more pronounced in patients with AMI shortly after the onset of symptoms.

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.

Transient reduction of autoantibodies against oxidized LDL in patients with acute myocardial infarction.

Fifteen consecutive patients (mean age 66 +/- 14, range 31-82) with an acute myocardial infarction (MI) suitable for thrombolytic therapy were included in this study. Autoantibodies against oxidized low-density lipoprotein (LDL) were determined by enzyme-linked immunosorbent assay (ELISA). Patients (n = 10) with marked elevation of the MB isoenzyme of creatinine kinase (CK-MB)-mass had significant decreases of oLDL-Ab during the acute phase, with a minimum after 8 h following the onset of thrombolytic therapy (within-group significance: p < .001; between groups: p = .01). Patients (n = 5) with CK-MB-mass values less than 70 ng/ml did not show this phenomenon. Furthermore, significant correlations existed between CK-MB-mass and oLDL-Ab after 6 and 8 h (n = 15; r = .72; p = .003) and the time of the highest CK-MB-mass values (after 12 h) and the time of the maximal decrease of oLDL-Ab (after 8 h) (r = .74; p = .003). Our observations provide further evidence for the release of free radicals and for increased lipid peroxidation during reperfusion after prolonged ischemia. The decrease of oLDL-Ab appears to be a marker for the severity of MI.

Clinical significance of pleiotropic effects of statins: lipid reduction and beyond.

Statins significantly reduce cardiovascular-related morbidity and mortality in patients with and without coronary artery disease. The potential of this drug class has yet to be fully explored. Accumulating evidence from basic research and clinical trials indicates that statins have pleiotropic effects that may largely account for the clinical benefits observed. Potential beneficial effects of these agents include enhancement of nitric oxide production in vasculature and the kidney. Statins have been shown to stabilize unstable plaques, improve vascular relaxation, and promote new vessel formation. Clinical trials and animal studies have shown that these agents reduce cardiovascular disease (CVD) risks and events, progression of nephropathy, development of diabetes, and fracture rates; these are benefits that go beyond lipid lowering alone. Potential beneficial effects are due to the positive impact on vascular and glomerular nitric oxide (NO) production and attenuation of vascular inflammation. Effects on bone, including fracture reduction, are thought to be mediated by direct action on bone formation. Moreover, potential reduction in the development of diabetes as observed in the West of Scotland Coronary Prevention Study (WOSCOPS) may relate to the improvement in insulin sensitivity. These actions are mediated, in part, by the effects on small G-proteins, modulation of signaling cascades, transcription, and gene expression. In particular, the inhibition of small GTP-binding proteins, Rho, Ras, and Rac, whose proper membrane localization and function are dependent on isoprenylation, may play an important role in mediating the direct cellular effects of statins on the vascular wall. The clinical relevance of these effects is beginning to be recognized, and ongoing studies will be able to answer these many questions in the near future. Actions of statins on vascular, glomerular, bone, and insulin-sensitive tissue as well as effects of statins on cognitive function and oncoprotection will be discussed in this review.

Neuropsychologic correlates of MRI white matter hyperintensities: a study of 150 normal volunteers.

To determine the effects of MRI white matter hyperintensities (WMH) on cognitive functioning, we used neuropsychologic tests and MRI to study 150 elderly volunteers free of neuropsychiatric or general disease. There were 76 (50.3%) individuals without and 74 (49.7%) with WMH. The latter subset was older (61.3 +/- 6.6 years versus 58.5 +/- 5.8 years, p = 0.005), had a higher mean arterial blood pressure (103.7 +/- 11.4 mm Hg versus 99.9 +/- 10.3 mm Hg, p = 0.03), and a larger ventricular-to-intracranial-cavity ratio (6.3 +/- 5.6% versus 4.7 +/- 1.6%, p = 0.02). Individuals with WMH performed worse than their counterparts without such abnormalities on all tests administered. After adjusting for the group differences in age, arterial blood pressure, and ventricular size, we noted statistically significant results on form B of the Trail Making Test (121.8 +/- 37.8 msec versus 100.3 +/- 47.9 msec, p = 0.04), a complex reaction time task (680.8 +/- 104.9 msec versus 607.1 +/- 93.9 msec, p = 0.001), and the assembly procedure of the Purdue Peg-board Test (27.5 +/- 5.8 versus 30.6 +/- 5.9, p = 0.02). Partial correlations did not reveal any relationship between test scores and the semiautomatically assessed total area of WMH. Our data suggest that the presence of WMH exerts a subtle effect on neuropsychologic performance of normal elderly individuals, which becomes particularly evident on tasks measuring the speed of more complex mental processing.

The Mattis Dementia Rating Scale: normative data from 1,001 healthy volunteers.

We administered the Mattis Dementia Rating Scale (MDRS) to 1,001 healthy volunteers, aged 50 to 80 years, randomly selected from our community. Multivariate regression analysis revealed educational level (p = 0.000004) and age (p = 0.00001), but no other sociodemographic or risk factors for stroke, to be significantly associated with the MDRS score. The age- and education-specific lowest quintile cutoff scores ranged from 140 in subjects aged 50 to 59 years with at least college experience to 130 in subjects aged 70 to 80 years with only 4 to 9 years of schooling. These percentile distributions obtained for decades of age and different levels of education should be useful reference values for clinicians and investigators when applying the MDRS to assess cognitive functioning.

Subclinical hyperthyroidism as a risk factor for atrial fibrillation.

OBJECTIVES: Atrial fibrillation is a well-known manifestation of hyperthyroidism. We studied whether subclinical hyperthyroidism with low serum thyrotropin concentrations and free thyroid hormone concentrations within the normal range in clinically euthyroid persons is a risk factor for subsequent atrial fibrillation. METHODS: We studied 23,638 persons. The subjects were classified according to their serum thyrotropin concentrations: group 1 comprised those with normal values of serum thyrotropin concentration (>0.4-5.0 mU/L) and free tri-iodothyronine and free thyroxine concentrations were within the normal range (22,300 subjects), group 2 comprised those with both low serum thyrotropin values (5-fold higher likelihood for the presence of atrial fibrillation with no significant difference between subclinical and overt hyperthyroidism.

Increased IgM-anticardiolipin antibodies in patients with restenosis after percutaneous transluminal coronary angioplasty.

Increased anticardiolipin antibodies (acL) are often associated with arterial thrombosis in patients with autoimmune diseases. A mural thrombus at the site of percutaneous transluminal coronary angioplasty (PTCA) has been suggested as the initial cause for restenosis after primarily successful PTCA. In this study, IgM- and IgG-acL were determined in 65 men with coronary artery disease treated by PTCA; patients with infectious and autoimmune diseases were excluded from the study. Follow-up coronary angiography was performed 12 months after PTCA; restenosis was defined as greater than or equal to 50% reduction in diameter of the coronary vessel. The series comprised 2 groups: 34 patients (mean age 56 +/- 8 years) with (group A) and 31 (mean age 55 +/- 9 years) without (group B) restenosis. Medical history and laboratory findings were comparable in both groups. In patients with restenosis, IgM-acL were more often increased (9 of 34) than were those in patients without restenosis (2 of 31; p less than 0.05); IgG-acL values did not differ in both groups. Furthermore, there was no correlation between any vascular risk factors or laboratory findings, or both, with both IgM- and IgG-acL levels. Thus, IgM-acL appear to be independent indicators for an increased risk for restenosis after PTCA. Our observations suggest that an autoimmune mechanism may have a role in restenosis.

Frequency of magnetic resonance signal abnormalities of the brain in patients aged less than 50 years with idiopathic dilated cardiomyopathy.

Twenty patients with idiopathic dilated cardiomyopathy (IDC) aged less than 50 years (mean 41) and an age-matched group of 20 healthy volunteers were studied. All subjects were free of cerebrovascular symptoms and risk factors for stroke. Magnetic resonance imaging of the brain, extracranial Doppler ultrasonography, heart catheterization and echocardiography were performed. In patients with IDC, a higher frequency of ventricular enlargement (p less than 0.02), cortical atrophy (p less than 0.01) and white matter lesions (p less than 0.05) was observed. Cerebral infarcts were found in 4 patients (p less than 0.05) who showed clinically severe limitation of functional capacity (New York Heart Association class III or IV). The extent of cortical atrophy, and the duration of clinical evidence of IDC showed a significant correlation (p less than 0.04). The data indicate a high incidence of parenchymal abnormalities of the brain in young, neurologically asymptomatic patients with IDC.

Prevalence of coronary artery disease in obese versus lean men with angina pectoris and positive exercise stress test.

The present study assesses the extent of coronary artery disease in men with angina pectoris and definite signs of myocardial ischemia in relation to body mass index. Our results demonstrate that exercise-induced myocardial ischemia in the absence of coronary artery disease in men with angina pectoris is more (2.6-fold) frequent in obese than in lean patients.

Sulfoconjugated and free plasma catecholamine levels at rest and during exercise in patients with idiopathic dilated cardiomyopathy.

Plasma levels of sulfoconjugated (sc) catecholamines (CA) have been shown to be increased with activation of the sympathoadrenal system in a number of clinical settings. We evaluated the relation between scCA and clinical or hemodynamic parameters of patients with idiopathic dilated cardiomyopathy (IDC) at rest and during incremental exercise testing. Eleven healthy subjects, nine patients in New York Heart Association (NYHA) functional class I (IDC-A group) and 11 in NYHA functional class II and III (IDC-B group) performed a symptom-limited, graded bicycle exercise test. Resting, peak and various postexercise levels of plasma free and scCA were determined by high-pressure liquid chromatography. Resting CA levels obtained in the supine position were remarkable for elevations of free norepinephrine (NE) in IDC-B patients (355 +/- 157 ng/l) as compared to IDC-A patients (177 +/- 54, p = 0.006) or healthy controls (193 +/- 74, p = 0.007). Similarly, scNE was highest in IDC-B patients with 1856 +/- 1089 ng/l, followed by IDC-A (1028 +/- 187, p = 0.025) and control subjects (1109 +/- 440, p = 0.025). There was a highly significant correlation between free and scNE (r = 0.76, p < 0.0005). Whereas resting free dopamine (DA) levels were comparable in all three groups, scDA was found to be elevated clearly in IDC-B patients (8772 +/- 2097 ng/l) and significantly different to IDC-A (5786 +/- 2481, p = 0.01) or control subjects (4892 +/- 1575, p = 0.0005). The NYHA functional class and maximum exercise performance correlated best with resting scDA (r = 0.68, p = 0.001 and r = 0.56, p = 0.005, respectively). At peak exercise, IDC-B patients exhibited a significant decrease in scNE and sc epinephrine (E) (from 1856 +/- 1089 to 1495 +/- 932 ng/l, p < 0.005 and from 491 +/- 173 to 282 +/- 143 ng/l, p < 0.01) compared to controls (from 1109 +/- 444 to 1094 +/- 548 ng/l and from 379 +/- 200 to 329 +/- 134 ng/l). In IDC-B patients this decrease in scNE and scE at peak exercise was related inversely to the rise in free NE and E (r = -0.81, p < 0.005 and r = -0.68, p < 0.05). Resting hemodynamic indices generally were reflected better by some free CA rather than by conjugated forms or by parameters of clinical performance. These findings suggest that in addition to free or scNE levels, resting scDA is elevated in symptomatic patients with IDC.(ABSTRACT TRUNCATED AT 400 WORDS)

A clinical focus on statins.

Clinical trials have demonstrated that inhibitors of 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase (statins) significantly reduce cardiovascular-related morbidity and mortality in patients with and without coronary artery disease. Furthermore, statins are currently the most potent cholesterol-lowering drugs available. Subanalyses of the LIPID study have shown that patients suffering from unstable angina pectoris had at least the same benefit from statin therapy as did patients after myocardial infarction. Studies, recently published (AVERT or MIRACL) provide more information on the topic of therapy with statins in the early phase of acute coronary syndromes.

Cardiac tamponade following acupuncture.

We present a rare complication of acupuncture in a 83-year-old woman who developed syncope and cardiogenic shock shortly after an acupuncture procedure into the sternum. Echocardiography revealed cardiac tamponade, and pericardiocentesis disclosed hemopericardium. Due to hemodynamic instability, thoracotomy was indicated. A small but actively bleeding perforation of the right ventricle was found and successfully closed. Although acupuncture represents a relatively safe therapeutic intervention, this case report should remind all acupuncturists of possible and sometimes life-threatening adverse effects.

Estrogen replacement therapy in older women: a neuropsychological and brain MRI study.

OBJECTIVE: To determine if postmenopausal women receiving estrogen perform better on demanding cognitive tests than women without estrogen replacement and if this beneficial effect on cognition is caused by estrogen-related prevention of silent ischemic brain damage. DESIGN: Cross-sectional study comparing postmenopausal estrogen users and non-users. SETTING: Austrian Stroke Prevention Study. PARTICIPANTS: A total of 70 women currently using estrogen and 140 women who have never used estrogen from a subset of 222 postmenopausal women without neuropsychiatric or general disease undergoing extensive diagnostic work-up in a large-scale stroke prevention study among randomly selected community members. MEASUREMENTS: Neuropsychological test scores and focal brain abnormalities as well as size of ventricles and cortical sulci as assessed by 1.5 Tesla MRI. RESULTS: Estrogen users performed better than non-users on almost all neuropsychological tests administered. When ANCOVA was used to correct for slight differences between groups in age, length of education, mean arterial blood pressure and self-reported activation, values of P < .05 were noted on tasks assessing conceptualization, attention, and visuopractical skills. After adjustment for multiple comparisons, the differences in conceptualization and visuopractical skills remained significant. MRI showed a lower rate and extent of white matter hyperintensities and a significantly smaller total white matter hyperintensity area in women treated with estrogen (P = .043). The total white matter hyperintensity area was inversely related to the duration of estrogen replacement therapy(P = .040). However, there was no difference in neuropsychological performance between estrogen users with and without white matter abnormalities, and this was also supported by the lack of an association between cognitive test results and the extent of white matter disease. CONCLUSIONS: Our study demonstrated an association between estrogen replacement therapy and better cognitive functioning and a lower rate of clinically unsuspected ischemic brain damage in postmenopausal women.

Severe hypotension and coma secondary to unrecognized chronic anterior hypophysitis.

We report an endocrine emergency of a 52-year-old woman with chronic anterior-pituitary failure of autoimmune origin who developed hypopituitary crisis with coma and severe hypotension provoked by an intercurrent bronchopneumonia. At admission to the ICU hypopituitarism had not been diagnosed and only Hashimoto's thyroiditis with thyroid replacement therapy could be obtained from the patient's history. Although the patient presented with somatic signs suggestive of hypopituitarism, other causes of coma and hypotension had first to be excluded. In the absence of specific treatment the patient died 18 h later with refractory cardiac arrest. Diagnosis of acute decompensated chronic hypophyseal failure must be considered if hypothermia, refractory hypotension and signs of infection without fever are associated with a short stature and the loss of axillary and public hair. Waiting for laboratory confirmation of the diagnosis must not delay immediate life-saving specific glucocorticoid treatment.