Prognostic value of vasodilator response using rubidium-82 positron emission tomography myocardial perfusion imaging in patients with coronary artery disease.

BACKGROUND: Prognostic value of positron emission tomography (PET) myocardial perfusion imaging (MPI) is well established. There is paucity of data on how the prognostic value of PET relates to the hemodynamic response to vasodilator stress. We hypothesize that inadequate hemodynamic response will affect the prognostic value of PET MPI. METHODS AND RESULTS: Using a multicenter rubidium (Rb)-82 PET registry, 3406 patients who underwent a clinically indicated rest/stress PET MPI with a vasodilator agent were analyzed. Patients were categorized as, "responders" [increase in heart rate ≥ 10 beats per minute (bpm) and decrease in systolic blood pressure (SBP) ≥10 mmHg], "partial responders" (either a change in HR or SBP), and "non-responders" (no change in HR or SBP). Primary outcome was all-cause death (ACD), and secondary outcome was cardiac death (CD). Ischemic burden was measured using summed stress score (SSS) and % left ventricular (LV) ischemia. After a median follow-up of 1.68 years (interquartile range = 1.17- 2.55), there were 7.9% (n = 270) ACD and 2.6% (n = 54) CD. Responders with a normal PET MPI had an annualized event rate (AER) of 1.22% (SSS of 0-3) and 1.58% (% LV ischemia = 0). Partial and non-responders had higher AER with worsening levels of ischemic burden. In the presence of severe SSS ≥12 and LV ischemia of ≥10%, partial responders had an AER of 10.79% and 10.36%, compared to non-responders with an AER of 19.4% and 12.43%, respectively. Patient classification was improved when SSS was added to a model containing clinical variables (NRI: 42%, p < 0.001) and responder category was added (NRI: 61%, p < 0.001). The model including clinical variables, SSS and hemodynamic response has good discrimination ability (Harrell C statistics: 0.77 [0.74-0.80]). CONCLUSION: Hemodynamic response during a vasodilator Rb-82 PET MPI is predictive of ACD. Partial and non-responders may require additional risk stratification leading to altered patient management.

Prognostic significance of blood pressure response during vasodilator stress Rb-82 positron emission tomography myocardial perfusion imaging.

BACKGROUND: A drop in blood pressure (BP) or blunted BP response is an established high-risk marker during exercise myocardial perfusion imaging (MPI); however, data are sparse regarding the prognostic value of BP response in patients undergoing vasodilator stress rubidium-82 (Rb-82) Positron Emission Tomography (PET) MPI. METHODS AND RESULTS: From the PET Prognosis Multicenter Registry, a cohort of 3413 patients underwent vasodilator stress Rb-82 PET MPI with dipyridamole or adenosine. We used multivariable Cox proportional hazard regression to analyze the association with mortality of four BP variables: stress minus rest systolic BP (∆SBP), stress minus rest diastolic BP (∆DBP), resting systolic BP (rSBP), and resting diastolic BP (rDBP). Covariates that had univariate P values <.10 were entered into the multivariable model. After median 1.7 years follow-up, 270 patients died. In univariate analyses, ∆SBP (P = .082), rSBP (P = .008), and rDBP (P < .001) were of potential prognostic value (P < .10), but ∆DBP was not (P = .96). After adjustment for other clinical and MPI variables, ∆SBP no longer independently predicted mortality (P = .082); only lower rSBP (P = .026) and lower rDBP (P = .045) remained independently prognostic. CONCLUSIONS: In patients undergoing vasodilator stress MPI, only lower resting BP is an independent predictor of mortality along with other clinical and MPI variables; BP response does not appear to add to risk stratification in these patients.

Left Atrial Compression Caused by an Intrapericardial Hematoma after Coronary Artery Bypass Graft Surgery.

BACKGROUND: Left atrial compression (LAC) is an uncommon condition that causes left ventricular inflow obstruction. The clinical and pathologic features are similar to those of mitral stenosis. Impaired left ventricular filling may cause hypotension, syncope, or shock. The increased left atrial pressure causes retrograde increase of the pressure throughout the pulmonary circulation with subsequent signs of congestion. CASE REPORT: An 84-year-old man presented with LAC caused by a focal tamponade related to a pericardial hematoma as a complication of coronary artery bypass graft (CABG) surgery. The formation of the hematoma occurred 3 weeks postsurgery. The echocardiographic study before discharge at day 12 after CABG surgery showed neither a focal hematoma nor a tamponade. The diagnosis was made 6 days later. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Intrapericardial tamponade caused by bleeding is a known complication of CABG surgery in the early postoperative stage. However, emergency physicians should be aware that a postoperative hematoma may also present as a focal tamponade because of postoperative adhesion by scar formation. The literature of LAC is limited. The most reported causes of LAC are compression caused by structures of the gastrointestinal tract, followed by thoracic aortic pathology. A Medline search for the terms "left atrial compression and hematoma" and "left atrial compression and intrapericardial hematoma" found only 31 and 4 hits, respectively. We also briefly discuss the import role of bedside echocardiography in the diagnostic process of LAC in the emergency medicine department.

When tissue is not the only issue: Poorly differentiated lung squamous-cell carcinoma with adrenal, costochondral, and cardiac metastases - case report.

Nonmelanoma skin cancer is the most common cancer in the world, and lung cancer is the leading cause of death from cancer. Histologically, squamous cell carcinoma (SCC) is the second most prevalent type of both skin and lung cancers. We report the case of a 38-year-old female with metastatic, poorly differentiated lung SCC detected on chest X-ray after she presented to the hospital with cough and dyspnea. She had had a 7.5 cm moderately differentiated well-circumscribed posterior scalp SCC completely excised eight years earlier. CT scan showed a large right lung mass, nodular filling defect in the left atrium (LA), and metastases to the adrenal glands and the first rib. Her pulmonary tumor extends to the LA via the right superior pulmonary vein, which is rarely reported in the literature. Ultrasound-guided biopsy of the rib mass showed poorly differentiated SCC. The patient received urgent radiotherapy, given superior vena cava and mainstem bronchus compression. Head CT showed no brain metastasis. A biopsy of the left adrenal initially reported an undifferentiated pleomorphic sarcoma; however, a second pathologist reported it as a poorly differentiated carcinoma of lung origin. At least three pathologists verified the specimen, and it had a PD-L1 test with a 1-49% score. An initial echocardiogram confirmed the LA mass. The patient received a Paclitaxel-Carboplatin-Pembrolizumab regimen as the first-line treatment for metastatic SCC. A repeat echocardiogram after cycle 1 showed a decrease in the size of the tumor in the LA. Almost five months after her initial visit, this young woman's symptoms and performance status have improved post-palliative radiotherapy and chemo-immunotherapy. Follow-up CT showed smaller lung, nodal, adrenal, and costochondral masses, and evidence of necrosis. This case is clinically relevant because it represents a common problem presenting uncommonly. Moreover, it highlights that ultrasound-guided interventions and medical imaging are essential in directing metastatic cancer diagnosis, treatment, and follow-up, especially when pathology cannot confirm but only presume a specific diagnosis.

Cardiac myxomas: clinical presentation, diagnosis and management.

Cardiac myxomas (CM) are the most common type of primary cardiac tumours in adults, which have an approximate incidence of up to 0.2% in some autopsy series. The purpose of this review is to summarise the literature on CM, including clinical presentation, differential diagnosis, work-up including imaging modalities and histopathology, management, and prognosis. CM are benign neoplasms developed from multipotent mesenchyme and usually present as an undifferentiated atrial mass. They are typically pedunculated and attached at the fossa ovalis, on the left side of the atrial septum. Potentially life-threatening, the presence of CM calls for prompt diagnosis and surgical resection. Infrequently asymptomatic, patients with CM exhibit various manifestations, ranging from influenza-like symptoms, heart failure and stroke, to sudden death. Although non-specific, a classic triad for CM involves constitutional, embolic, and obstructive or cardiac symptoms. CM may be purposefully characterised or incidentally diagnosed on an echocardiogram, CT scan or cardiac MRI, all of which can help to differentiate CM from other differentials. Echocardiogram is the first-line imaging technique; however, it is fallible, potentially resulting in uncommonly situated CM being overlooked. The diagnosis of CM can often be established based on clinical, imaging and histopathology features. Definitive diagnosis requires macroscopic and histopathological assessment, including positivity for endothelial cell markers such as CD31 and CD34. Their prognosis is excellent when treated with prompt surgical resection, with postsurgical survival rates analogous to overall survival in the age-matched general population.

Emerging Epidemic of Inflammatory Bowel Disease in a Middle Income Country: A Nation-wide Study from Iran.

BACKGROUND: The burden of inflammatory bowel disease (IBD) hasn't been reported in Iran. We aimed to estimate the prevalence and incidence of IBD and its trend in Iran at national and subnational level from 1990 to 2012. METHODS: We conducted a systematic review of English and Persian databases about the epidemiology of IBD. We also collected outpatient data from 17 provinces of Iran using almost all public and private referral gastroenterology clinics. Prevalence and incidence rate was calculated at national and subnational levels. The Kriging method was used to extrapolate provinces with missing data and GPR model to calculate time trends of rates at subnational level. RESULTS: We found 16 case series, two population-based studies, and two review articles. We collected 11,000 IBD cases from outpatient databases. Among them, 9,269 (84.26%) had ulcerative colitis (UC), 1,646 (14.96%) had Crohn's disease (CD), and 85 had intermediate colitis (IC). A total of 5,452 (49.56%) patients were male. Mean age at diagnosis was 32.80 years (CI: 13 - 61) for UC and 29.98 years (CI: 11 - 58) for CD. Annual incidences of IBD, UC, and CD in 2012 were 3.11, 2.70, and 0.41 per 100,000 subjects respectively. Prevalence of IBD, UC, and CD in 2012 were 40.67, 35.52, and 5.03 per 100,000 subjects respectively. The incidence of UC and CD showed a significant increase during the study period (P for trend < 0.05). CONCLUSIONS: The incidence and prevalence of IBD are increasing in Iran. Establishing a national IBD registry seems necessary for comprehensive care of IBD patients in Iran.

Tricuspid valve regurgitation following temporary or permanent endocardial lead insertion, and the impact of cardiac resynchronization therapy.

BACKGROUND: While some studies indicate that permanent pacemaker implantation is associated with development of tricuspid regurgitation (TR), other studies indicate no association.Little is known about the impact of temporary lead insertion during ablation procedures, or whether therapy (CRT) prevents TR post-device implantation. HYPOTHESIS: We hypothesized that permanent, but nottemporary endocardial leads, are associated with development of TR, and that CRT would prevent (physiologic) TR. METHODS: We performed a retrospective study of consecutive patients who underwent first device or radiofrequency catheter ablation over a 12-month period at a single, tertiary academic center who underwent pre- and post-procedure echocardiography. RESULTS: In the 89 patients in the device group, the degree of TR significantly increased ≥ 1 grade post-permanent lead implantation: 9 had less TR, 46 were unchanged, and 34 had more TR(p=0.005). TR increased in the 62 patients who underwent device implantation without CRT (p=0.005), but did not increase in the 27 patients with CRT (p=0.47). In the 66 patients in the ablation group, there was no significant change in TR post-ablation: 8 had less TR, 48 were unchanged, and 10 had more TR (p=0.31). CONCLUSION: Permanent endocardial lead implantation was associated with an increase in TR; however, patients who underwent device implantation with CRT did not have an increase in TR.Temporary lead insertion during ablation was not associated with changes in the degree of TR. A large, prospective study is needed to accurately define the incidence and exact mechanisms of permanent endocardial lead-related TR.

Lack of significant association between Helicobacter pylori infection and homocysteine levels in patients with cardiac syndrome X.

BACKGROUND: Helicobacter pylori (H.pylori) has been implicated in the pathogenesis of several diseases such as cardiac syndrome X (CSX), which includes chest pain, positive exercise stress test and normal angiography. Also, elevation of homocysteine (Hcy) level is associated with CSX, as it can severely disturb vascular endothelial function. We aimed to elucidate whether the infection of H.pylori affect the level of Hcy in CSX. METHODS: Eighty-eight patients with CSX (32 men, 56 women; mean age: 53.8 ± 11.9) and 97 healthy controls (36 men, 61 women; mean age: 45.7 ± 7.3) were enrolled. Plasma samples were tested for the presence of IgG antibody to H.pylori using enzyme linked immunosorbent assay method. Hcy levels were measured enzymatically. RESULTS: Plasma Hcy concentration in CSX patients is higher than control group (13.1 ± 2.6 vs. 11.8 ± 2.5 mmol/L; p = 0.002). There was no significant difference between Hcy in H.pylori(+) and H.pylori(-) individuals in CSX group (13.1 ± 2.7 vs. 12.2 ± 0.6 mmol/L; p = 0.554) and between two groups in controls, respectively (12.1 ± 2.2 vs. 11.4 ± 2.9 mmol/L; p = 0.148). CONCLUSIONS: Although there is Hcy level increase in H.pylori(+) CSX patients and controls comparing to H.pylori(-) subjects, but other factors may affect on Hcy level, too. (Cardiol J 2012; 19, 5: 466-469).

Lack of utility of transabdominal ultrasound in the detection of gastroesophageal reflux disease-induced esophagitis in comparison with endoscopy.

BACKGROUND: Although upper gastrointestinal (GI) tract endoscopy is the investigation of choice for patients with suspected gastroesophageal reflux disease (GERD)-induced esophagitis, it is associated with complications and significant patient discomfort. The aim of the current study was to compare the accuracy of transabdominal ultrasonography with upper GI tract endoscopy in the detection of GERD-induced esophagitis. MATERIALS AND METHODS: In this descriptive study, 350 patients (mean age, 41.41 ± 14.52 years) referred to a gastroenterologist with symptoms suggestive of GERD were enrolled. The esophageal wall thickness was measured with transabdominal ultrasonography, and patients were subsequently assessed by upper GI endoscopy, representing the criterion standard in the diagnostic evaluation for GERD-induced esophagitis. RESULTS: Endoscopic evaluation identified 100 patients with esophagitis (case group), and 250 subjects were reported to have normal endoscopic findings (control group). The wall thickness was significantly higher in the case group compared with the control (P < 0.0001).In the receiver operating characteristic analysis, only 2 cutoff points had a positive predictive value (PPV) greater than 50%. The cutoff point of 2.7 mm had 38% sensitivity, 91% specificity, 63% PPV, and 79% negative predictive value in the detection of GERD. Its positive and negative likelihood ratios were 4.32 and 0.68, respectively. CONCLUSIONS: According to the identified sensitivity/specificity, low PPV and positive likelihood ratio, and relatively high negative likelihood ratio, we failed to find the transabdominal ultrasound effective in the detection of GERD-induced esophagitis.

Prevalence of Helicobacter pylori and cytotoxin-associated gene A in Iranian patients with non-erosive and erosive reflux disease.

BACKGROUND: The prevalence of Helicobacter pylori (H. pylori) infection and its virulent strain (cytotoxin-associated gene A: CagA) has not been evaluated in patients with gastroesophageal reflux disease (GERD) subgroups (erosive and non-erosive) in Iran. AIMS: This study was conducted to evaluate H. pylori infection and anti-CagA status in GERD. SETTING AND DESIGN: One hundred fifty-four patients (71 male and 83 female; mean age, 42.6+/- 15.5 years) were evaluated for symptoms--heartburn and acid regurgitation--compatible with GERD. MATERIALS AND METHODS: The esophagus was diagnosed endoscopically whether it was with erosion (erosive reflux disease, ERD) or without erosion (non-erosive reflux disease, NERD). Rates of anti-H. pylori and anti-CagA-IgG (immunoglobulin G) antibodies were determined for each subject by ELISA. H. pylori was considered by ELISA if the rapid urease test proved positive. STATISTICAL ANALYSIS: anti-H. pylori and anti-CagA statuses were compared in ERD and NERD patients with and without related IgG antibodies. Mean values and P values were calculated using SPSS (version 12). RESULTS: The overall prevalence of H. pylori infection was 75.3% (116/154). Anti-CagA antibody was found in 60.3% (70/116) of infected patients. The prevalence of H. pylori infection in patients with NERD and ERD was 81.2% (56/69) and 70.6% (60/85), respectively (OR=0.56; 95% CI [confidence interval]=0.26-1.20; P=.14). The prevalence of anti-CagA antibody in infected NERD and ERD patients was 58.9% (33/56) and 61.7% (37/60), respectively (OR=1.16; 95% CI=0.49-1.70; P=0.83). CONCLUSION: The results showed that more than 70% of the patients, either NERD or ERD, acquire H. pylori infection. Anti-CagA antibody is also common in patients with reflux disorders in our community.

Immunohistochemical analysis of selected molecular markers in esophagus precancerous, adenocarcinoma and squamous cell carcinoma in Iranian subjects.

BACKGROUND: The molecular and cellular mechanisms linking chronic inflammation and gastrointestinal malignancy are not known with certainty. AIM: To investigate changes in potential causative factors during progression of esophagus cancer in a population living in high-risk area in Iran. SUBJECTS: Formalin-fixed, paraffin-embedded esophageal specimens (n=87) from patients with gastroesophageal reflux disease (GERD), Barrett's metaplasia, adenocarcinoma (ADC) and squamous cells carcinoma (SCC) were collected based on their pathological diagnosis. METHODS: Immunohistochemical (IHC) technique was used to study tissue accumulation of P53, P21, cyclooxygenase-2 (COX-2), glutathione S-transferase-P (GST-Pi) and nitrotyrosine (NT) in patients and controls. RESULTS: P53 expression was not detected in esophageal tissues from normal and GERD samples, whereas it was found positive in Barrett's, ADC, and SCC samples. P21 positive sample was relatively higher in ADC patients as compared to that in SCC (ADC: 52.6%; SCC: 25%). GST-Pi expression was equally accumulated in all the samples. NT was predominantly expressed in ADC (72.7%). COX-2 expression was significantly higher in Barrett's (60.0%) and ADC (66.6%) as compared to that in GERD, SCC and normal. These data were further confirmed by detecting the scores of immunostainings in all the positive samples. CONCLUSION: The pathological changes in ADC and SCC samples which were associated with increasing frequency of NT and COX-2 provides further evidence for involvement of these inflammatory factors in progression of esophagus cancer.