Angiotensin converting enzyme inhibitors and angiotensin II receptor blockers in atrial fibrillation.

Atrial fibrillation is the most prevalent clinically relevant arrhythmia; a major cause of morbidity and hospitalization. Additionally, atrial fibrillation carries a significant risk of thrombo-embolic events, specifically cerebrovascular accident. Among the most prevalent risk factors for atrial fibrillation, hypertension not only has the strongest correlation but is also the most prevalent. The renin-angiotensin-aldosterone system represents a prime target for the treatment of hypertension through the use of angiotensin-converting enzymes inhibitors and angiotensin II receptor blockers. In addition to blood pressure control, these medications have been shown to reduce the occurrence of atrial fibrillation. They have been shown to have effects at the cellular level in preventing atrial fibrosis. Additionally, these medications may prevent the development ofatrial fibrillation, reduce the duration of atrial fibrillation, and facilitate electrical cardioversion in patients with the arrhythmia. Therefore, patients with, or at risk for atrial fibrillation may benefit from treatment with renin-angiotensin-aldosterone system antagonists; deriving benefits from these medications beyond simple blood pressure control.

Candidacidal activity prompted by N-terminus histatin-like domain of human salivary mucin (MUC7)1.

Histidine-rich peptides (histatins, Hsn) in saliva are thought to provide a non-immune defense against Candida albicans. Sequence homology search of the human salivary mucin, MUC7, against histatins revealed a domain at the N-terminus (R3-Q17) having 53% identity to Hsn-5. To determine its candidacidal activity, this 15 residue basic histidine-rich domain of MUC7 (I) was prepared by solid-phase Fmoc chemistry. Various N- and C-terminal protected derivatives of I were also synthesized to correlate the effect of peptide overall charge in exhibiting cidal potency. Candidacidal activity measurement of I and its variants showed considerable ED50 values (effective dosage required to kill 50% of candida cells), albeit greater than Hsn-5 (ED50 approximately 4-6 microM). Of the various analogs tested, N-terminal free acid (I, ED50 approximately 40 microM) and amide (V, ED50 approximately 16 microM) exhibited appreciable candidacidal activities suggesting the possible role of peptide net charge in cidal action. Blocking of N-terminus with a bulky octanoyl group showed only marginal effect on the cidal activity of I or V, indicating that hydrophobicity of these synthetic constructs may not be important for exerting such activities. Membrane-induced conformational transition from random coil to helical structures of all the test peptides implied their tendency to adapt order structures at the lipid-membrane interface similar to that of Hsn-5. However, comparison of propensity for helical structure formation vs. ED50 indicated that cidal potency of MUC7 Hsn-like peptides depends largely on electrostatic interactions irrespective of secondary structural elements. Delineation of solution structure of the most active peptide (V) by 2D-NMR revealed essentially a non-structured conformation in aqueous medium, which further supported the fact that the peptide helical structure may not be a prerequisite for posing candidacidal activity. The formation of smaller truncated peptides and/or Hsn-like fragments on proteolytic degradation of intact MUC7 in the presence of oral flora provided indirect evidence that mucin could serve as a backup candidacidal agent to salivary Hsn.

Regional diastolic mechanics of ischemic and nonischemic myocardium in the pig heart.

To assess the role of segmental dyssynchrony as a determinant of ischemic diastolic dysfunction, systolic and diastolic mechanics of ischemic and nonischemic myocardium were compared in the open chest pig heart (n = 7). Pacing tachycardia (1.8 x heart rate at rest) was imposed for 3 to 5 min in the presence of a single critical stenosis of the left anterior descending artery (demand ischemia, n = 7). After 30 min of recovery, the left anterior descending artery was totally occluded for 1.5 min in the same pigs (primary ischemia, n = 6). Both demand and primary ischemia increased left ventricular end-diastolic pressure and prolonged the time constant of left ventricular pressure decline. Percent systolic shortening of ischemic segments (perfused by the left anterior descending artery) decreased by 32% during demand ischemia and by 120% during primary ischemia, but that of nonischemic segments (perfused by the left circumflex artery) did not change significantly during either type of ischemia. During demand ischemia (but not during primary ischemia), left ventricular diastolic pressure increased relative to segment length so that a higher diastolic pressure was needed to stretch the ischemic segment to the same length (decreased distensibility). In nonischemic areas, diastolic pressure and segment length increased commensurately during both types of ischemia, indicating no change in diastolic distensibility. During demand ischemia, peak early diastolic lengthening rates increased in nonischemic segments but remained unchanged in ischemic segments. Diastolic segmental dyssynchrony developed during both types of ischemia, but was more pronounced during primary ischemia. Therefore, segmental dyssynchrony is unlikely to account for the rise in diastolic pressure relative to segment length seen during demand ischemia.

Doppler echocardiography in cardiac tamponade: exaggerated respiratory variation in transvalvular blood flow velocity integrals.

Pulsed Doppler echocardiography has been used previously to demonstrate marked changes in transvalvular blood flow velocities during cardiac tamponade in laboratory animals and a small number of patients. To further assess the respiratory changes in transvalvular blood flow during tamponade, pulsed Doppler tracings of flow velocity profiles across all four cardiac valves were recorded during inspiration and expiration in 13 patients during cardiac tamponade, in 6 of the 13 patients after relief of tamponade by pericardiocentesis and in 8 normal control subjects. Flow velocity integrals were calculated for each valve during inspiration and expiration. In the setting of cardiac tamponade, inspiration caused an 85 +/- 46% increase in the flow velocity integral across the pulmonary valve, an 81 +/- 34% increase across the tricuspid valve, a 33 +/- 13% decrease across the aortic valve and a 35 +/- 8% decrease across the mitral valve. These phasic respiratory changes were markedly reduced after relief of tamponade (p less than 0.05 compared with tamponade) and were observed to only a minimal extent in the normal individuals (p less than 0.01 compared with tamponade). The exaggerated respiratory variations in transvalvular flow velocity integrals suggest that Doppler evaluation may be a valuable tool in the diagnosis of cardiac tamponade. Transmitral Doppler indexes of left ventricular filling during cardiac tamponade revealed that inspiration caused a shift to increased filling during late diastole, with a greater contribution of atrial systole to total left ventricular filling. These Doppler indexes did not vary significantly with respiration in the group studied after relief of tamponade or in the control group.(ABSTRACT TRUNCATED AT 250 WORDS)

Implications of echocardiographically assisted diagnosis of pericardial tamponade in contemporary medical patients: detection before hemodynamic embarrassment.

Identification of suspected pericardial tamponade and the decision to perform invasive drainage of the pericardial space have historically been based on classic bedside findings. Two-dimensional echocardiography has improved detection of pericardial effusion, but it may be excessively sensitive in evaluation of patients for hemodynamic embarrassment. Therefore, 50 consecutive medical patients were examined who were identified by echocardiography to have probable tamponade (defined as the presence of right heart chamber collapse in the presence of a pericardial effusion) and who underwent combined right-sided cardiac catheterization and percutaneous pericardiocentesis. All patients had elevated pericardial pressure. However, many had minimal evidence of hemodynamic compromise (94% had systolic blood pressure greater than or equal to 100 mm Hg and 58% had a cardiac index greater than or equal to 2.3 liters/min per m2). Pericardiocentesis resulted in hemodynamic improvement, but frequently did not alleviate dyspnea or correct tachycardia. Patients with malignancy as the cause of tamponade had a high mortality rate (the cumulative probability of survival in such patients was only 17% at 1 year). Echocardiographically assisted diagnosis of pericardial tamponade in medical patients results in the identification of a substantial subset of patients with only subtle evidence of hemodynamic compromise. This subset of patients differs sharply from medical patients described in previous reports with classic tamponade. Although the patients can be managed by invasive catheter pericardiocentesis with few complications, the natural history and the optimal management strategy for this group are not resolved.

Clinical and angiographic results of balloon-expandable intracoronary stents in right coronary artery stenoses.

Balloon-expandable stents were placed successfully in 35 (95%) of 37 patients whose right coronary artery lesion was believed to have a poor short- or long-term prognosis with conventional balloon angioplasty because of prior restenosis or adverse lesion morphology. Quantitative angiography showed a reduction in stenosis diameter from 83 +/- 14% to 42 +/- 14% after conventional balloon dilation, with a further reduction to -3 +/- 12% after stent placement (p less than 0.001). There were no acute stent thromboses, but one patient (with two stents and unstented distal disease) developed subacute thrombosis on day 8 after self-discontinuation of warfarin and was treated with thrombolytic therapy and redilation. Follow-up angiography was performed at 4 to 6 months in 25 patients, demonstrating restenosis (83 +/- 13%) in 4 (57%) of 7 patients with multiple stents, but only 3 (17%) of 18 patients with a single stent (p less than 0.05). Six of the seven in-stent restenotic lesions were subtotal (80 +/- 12%) and were subjected to repeat conventional balloon angioplasty (postdilation stenosis 13 +/- 21%). The 18 patients without restenosis had a maximal in-stent diameter stenosis of 29 +/- 15%, corresponding to a maximal focal neointimal thickness of 0.68 +/- 0.26 mm within the stented segment. These preliminary results suggest that the Schatz-Palmaz stent may be a useful adjunctive device in the performance of coronary angioplasty.

Novel approach to the analysis of restenosis after the use of three new coronary devices.

Restenosis after coronary intervention has remained a vexing problem despite the introduction of nearly 24 newer coronary interventional devices. To more clearly evaluate the potential impact of three such new devices on restenosis, coronary lumen diameters were measured before, immediately after and at 6 months after intervention, and restenosis was analyzed using continuous geometric techniques. Lumen diameters were measured before and immediately after intervention in 223 coronary vessels treated with one of three new devices: a single Palmaz-Schatz stent (n = 87), directional atherectomy (n = 125) and laser balloon angioplasty (n = 11); 184 (83%) of the patients underwent follow-up angiography 6 months after treatment. The immediate increase in lumen diameter produced by the intervention (acute gain) and the subsequent reduction in lumen diameter between the time of intervention to 6 month follow-up study (late loss) were examined. For each of the three interventions, the restenosis rate at follow-up study was analyzed using a traditional dichotomous definition (greater than or equal to 50% diameter stenosis), as well as a novel graphic technique. Although the apparent restenosis rates differed significantly among the three interventions (19% for stents, 31% for atherectomy and 50% for laser balloon angioplasty; p = 0.02), late loss among the three interventions was equivalent (average 1 mm; p = 0.91). There were, however, marked differences in the acute gain achieved by the three interventions: 2.6 mm for stents, 2.2 mm for atherectomy and 2 mm for laser balloon angioplasty; p less than 0.001). It was these differences in acute gain rather than late loss that explained the observed differences in restenosis rate.(ABSTRACT TRUNCATED AT 250 WORDS)

Angiographic and clinical outcome of intracoronary stenting: immediate and long-term results from a large single-center experience.

OBJECTIVES: The purpose of this study was to determine the immediate and long-term angiographic and clinical results of coronary stenting. BACKGROUND: Although preliminary trials of endovascular stenting have demonstrated promising results, lack of long-term follow-up has limited the critical evaluation of the role of coronary stenting in the treatment of obstructive coronary artery disease. METHODS: A total of 250 procedures using the Palmaz-Schatz stent, performed in 220 patients between June 1988 and July 1991, were examined. Minimal lumen diameter of the treated segments was measured on angiograms obtained before, after and 6 months after intervention. RESULTS: Stent placement was successful in 246 (98%) of 250 lesions, reducing diameter stenosis from 77% to -2.5%. There were no deaths or Q wave myocardial infarctions. One patient (0.4%) required emergency bypass surgery and one (0.4%) developed subacute thrombosis. Femoral vascular complications occurred in 36 patients (16%). Six-month angiographic follow-up was obtained in 91% of eligible patients. The overall angiographic restenosis rate (stenosis greater than or equal to 50%) was 25%. By univariable analysis, the rate of restenosis was significantly higher for stents in the left anterior descending versus the right coronary artery (44% vs. 12%; p = 0.002); in diabetic patients (56% vs. 20%; p = 0.006), and in vessels with post-stent lumen diameter less than 3.31 mm (34% vs. 16%; p = 0.05). Stenting of the left anterior descending artery was the strongest predictor (p = 0.01) of restenosis in a multivariable model. Total survival was 97% and event-free survival (freedom from death, myocardial infarction or revascularization) was 70% at 36 months. CONCLUSIONS: Palmaz-Schatz stents can be placed successfully with a low incidence of major complications. The angiographic restenosis rate was 25%, and 70% of patients remained free of cardiovascular events at 3 years. Diabetes, small postprocedure lumen diameter and stenting of the left anterior descending artery are associated with higher rates of restenosis.

The effect of topical fluocinonide ointment on phototherapy of psoriasis.

The effect of fluocinonide ointment and 5% crude coal tar on clearance of plaque-type psoriasis vulgaris by phototherapy was studied in 25 hospitalized patients using the bilateral comparison technique. All treated areas received ultraviolet radiation from Westinghouse fluorescent FS-40 bulbs (290-400 nm) in doses calculated to produce a minimal delayed erythema. The topically applied compounds (fluocinonide ointment, 5% Crude coal tar, white petrolatum) were applied individually or in combination. In nearly all comparisons clearance of psoriatic plaques was obtained after the same number of ultraviolet exposures, although many (8 or 14) of the areas treated with fluocinonide ointment had an accelerated early response. It thus appears that although the use of topical corticosteroids may enhance the early therapeutic response of psoriatic plaques it does not hasten the clearance of these plaques.

Efficient production of biologically active human salivary cystatins in Escherichia coli.

Different Escherichia coli expression systems were used for expression of cDNA clones encoding the human salivary cysteine proteinase (CysP) inhibitors, cystatins SN and S (CsnSN and CsnS). These included pOTSNco12 that expresses foreign sequences as authentic (nonfusion) proteins, and pGEX-2T that directs the synthesis of foreign polypeptides as fusion proteins with glutathione S-transferase (GST). The pOTS vector produced low levels of recombinant CsnSN (reCsnSN) that was localized in the soluble fraction, but not easily purified. The pGEX vector, on the other hand, produced much higher yields of the fusion protein, GST::CsnSN, that was localized almost entirely in the insoluble protein fraction. Solubilized and refolded GST::CsnSN inhibited the CysP, papain, more efficiently than chicken egg white Csn, indicating that the recombinant product was biologically active and that the GST carrier did not interfere with the biological activity. The pGEX-2T vector was subsequently used for the large-scale production of reCsnSN and reCsnS that were cleaved from the GST by thrombin and purified by DE-52 cellulose chromatography. ReCsnSN inhibited papain almost as efficiently as salivary CsnSN, while the reCsnS showed lower inhibitory activity as compared to both salivary CsnS and reCsnSN.

Biological activities and secondary structures of variant forms of human salivary cystatin SN produced in Escherichia coli.

Using an Escherichia coli expression system, pGEX-2T, that expresses foreign sequences as fusion proteins with a glutathione S-transferase (GST) carrier, we have produced several recombinant human salivary cystatin SN (reCsnSN) variants. These include a N-terminal-truncated form (aa 17-121), a C-terminal-truncated form (aa 1-102) and two deletion mutants (delta 12-16 and delta 56-60). A large amount of the insoluble fusion protein (approx. 15 mg/l) was produced in each case. These were solubilized with urea and refolded by dialysis. The GST carrier was then cleaved with thrombin and the reCsn variants (except delta 56-60) were purified by anion-exchange chromatography. The CysP inhibitory activities against papain, and bovine and human cathepsin B, and secondary structures of the reCsnSN variants were determined and compared to natural salivary CsnSN. The full-length reCsnSN, the N-truncated and the delta 12-16 variants inhibited the CysP activity of papain and displayed circular dichroism (CD) spectra similar to that of natural CsnSN. On the other hand, the delta 56-60 mutant and the C-truncated variant exhibited very little inhibitory activity towards papain. The CD spectrum of the C-truncated variant indicated a change in the secondary structure (e.g., a decrease in beta-sheet and an increase of an alpha-helical content). Neither, the natural nor the full-length reCsnSN or the delta 12-16 mutant exhibited any inhibitory activity towards bovine and human cathepsin B.

Interaction of HIV-1 and human salivary mucins.

Previous studies have suggested that salivary secretions may act as inhibitors of HIV-1 replication in vitro. This inhibitory activity was determined to be associated mainly with secretions obtained from the human submandibular-sublingual glands, and subsequent electron micrographs revealed the association of viral particles with the salivary sediment. Fractionation of human submandibular-sublingual (HSMSL) saliva by size-exclusion chromatography was initiated, and resulting fractions were tested for their ability to modulate the replication of HIV-1 using a plaque assay on HeLa CD4+ cell monolayers. Results indicated that the filtration-sensitive inhibitory activity was primarily associated with the mucin-rich fractions, and the inhibitory activity was found to reduce the number of infectious units by 75%. To determine the identity of the salivary components involved, adsorption experiments involving the interaction of HIV particles with immobilized salivary components were performed. Immunological counter staining revealed an interaction of HIV particles as well as recombinant gp120 with the lower-molecular-weight mucin. Electron microscopic examination of the mucin-rich fractions-HIV incubates revealed the aggregation of virus particles by salivary components. These results suggest that human salivary mucins may have a role in modulating the infectivity of HIV-1.

Polymorphic radiation sensitivity of human natural killer activity: possible role of DNA strand breakage.

Natural killer (NK) activity of human mononuclear cells is sensitive to inhibition by radiation, under the control of polymorphic X linked genes. In order to define the mechanism of this inhibition, we have evaluated the ability of treatments known to damage DNA to inhibit NK activity. The alkylating agents streptozotocin (SZ) and N-methyl-N'-nitro-N-nitrosoguanidine (MNNG) were potent inhibitors of NK activity. Further, a specific competitive inhibitor of adenosine diphosphoribosyl polymerase (ADPRP), 3-aminobenzamide, was able to prevent inhibition by gamma-radiation, UV radiation, and the two alkylating drugs, SZ and MNNG, suggesting the ADPRP, known to be activated by DNA strand breakage, mediates the inhibition by these treatments. NK activity of radioresistant subjects was somewhat more resistant to inhibition by SZ or UVR when compared to radiosensitive NK activity but neither of these treatments gave the clear phenotypic distinction of gamma-radiation, suggesting that chemical strand breakage does not precisely model gamma-radiation and also that the mechanism of UVR inhibition may differ from that of gamma-radiation. These results indicate a role for activation of ADPRP in the inhibitory effect of UV and gamma-radiation on human NK activity and suggest that the biochemical basis for polymorphism in the sensitivity of NK activity to gamma-radiation will be found in the sensitivity to ADPRP activation or the level of activation of this enzyme, known to be the key to DNA repair.

Mechanical assistance of the left ventricle: acute effect on cardiac performance and coronary flow of different perfusion patterns.

Mechanical circulatory assistance by ventricular assist devices provides an opportunity to influence the aortic pressure pattern, which may affect ventricular loading and coronary perfusion. The effect of synchronous, pulsatile coronary perfusion of an assist device-supported left ventricle has not been studied. To analyze the effect of different perfusion patterns on left ventricular performance and on coronary flow, independent of pressure and volume loading, we used three different modes of aortic perfusion in an isometric, contracting, isolated canine heart model. The effect of nonpulsatile, counter-pulsatile, and copulsatile coronary perfusion was analyzed in four subgroups to simulate different, clinically relevant situations (using two different ventricular end-diastolic volumes [normal and high] and two mean perfusion pressures [normal and critically low]). Our experiments demonstrated that total coronary flow is optimized by making the perfusion pressure pulsatile and by synchronously timing the pump systole with ventricular diastole (counterpulsation). Under identical conditions of preload and mean perfusion pressure, coronary flow and left ventricular contractility were decreased during non-pulsatile and copulsatile aortic perfusion when compared with counterpulsatile flow. There were no significant differences between the nonpulsatile and copulsatile modes. We conclude from these data that a nonejecting, but contracting, left ventricle will have improved systolic function and coronary blood flow if the coronary perfusion pressure is synchronized in a counterpulsatile manner. This is a significant implication for mechanical left ventricular assist devices when used to promote myocardial recovery.

Salivary macromolecules. A structure/function synopsis.

The status of our structure/function studies is at a crossroad. Further studies are needed to understand events on a molecular level, particularly how saliva is made and processed. Animal models as well as tissue and cell culture systems are being developed to address these issues. Nevertheless, enough information is now available to begin enhancing the natural defense properties of salivary secretions through clinical modalities such as the development of (1) diagnostic reagents and tests for local and systemic disease, (2) artificial salivas for the treatment of salivary dysfunction, and (3) topical vaccines to combat against oral diseases.

Development of a novel, rapid processing protocol for polymerase chain reaction-based detection of bacterial infections in synovial fluids.

We describe the development of a molecular detection system designed for use with synovial fluid (SF)-based infections. The methodology employs a lysis/extraction procedure that effectively disrupts microorganisms allowing for release of the microbial DNA and its amplification by polymerase chain reaction (PCR). We tested the effectiveness of adding a mixed-bed, ion-exchange resin to the extract to remove PCR inhibitory components present in the SF. After centrifugation to separate the resin, DNA contained in the supernatant is subjected to PCR using oligonucleotide primers designed for broad-spectrum microorganism detection. Amplification products are analyzed by agarose gel electrophoresis and/or DNA hybridization methodology. We report here the detection sensitivity and specificity of the protocol using SF inoculated with Escherichia coli and Staphyloccocus aureus. We have applied this new methodology to clinical SF specimens with results superior to standard laboratory culturing assays.

Phototherapy of pityriasis lichenoides.

Eleven patients with chronic pityriasis lichenoides chronica were treated with topically applied bland emollient cream and minimally erthemogenic doses of UV radiation from fluorescent sunlamps. The conditions of all patients cleared completely in an average of 29 treatments, requiring an average UV dose of 388 millijoules/sq cm at clearance. Phototherapy provides a convenient effective outpatient therapy for pityriasis lichenoides chronica.

Erythema resulting from suberythemogenic doses of ultraviolet radiation and methotrexate.

A tender diffuse erythema developed in a 47-year-old man who had psoriasis when he was treated with either suberythemogenic oral methoxsalen photochemotherapy or ultraviolet (UV)-B phototherapy and intramuscular methotrexate (MTX). Phototests with middle- and long-wavelength UV fluorescent lamps indicated that the sequence and timing of each therapeutic exposure were important to the development of the erythema. Histologic examination of the erythematous area demonstrated an increased number of pyknotic keratinocytes (sunburn cells) in the upper epidermis. It is possible that MTX prevented the repair of DNA damage caused by UV exposure, leading to the appearance of the sunburn cells and erythema. Care must be exercised when using UV radiation and MTX in combination.

Idiopathic photodermatitis with a positive paraphenylenediamine photopatch test.

A 61-year-old man was seen for a long-standing, recurrent eczematous dermatitis that appeared only in the summer. A patch test with ammoniated mercury was positive. Photopatch reactions to caine mix and paraphenylenediamine were positive, and phototesting disclosed an idiopathic photosensitivity to UV-A. Avoidance of sunlight exposure and the use of chemical sunscreening agents prevented further recurrence of the dermatitis.

Outpatient phototherapy of psoriasis.

Twenty-six outpatients with chronic plaque-type psoriasis vulgaris were treated five times weekly with topically applied white petrolatum and subsequent exposure to erythemogenic doses of ultraviolet radiation from fluorescent bulbs with a wavelength of 280 to 400 nm. All patients were cleared of psoriasis in ultraviolet-exposed sites in an average of 27 treatments. The combination of topically applied white petrolatum and ultraviolet radiation provides a convenient, cosmetically acceptable outpatient therapy for psoriasis.