Sertraline-induced ventricular tachycardia.

Sertraline is a selective serotonin reuptake inhibitor, which is a commonly used drug for major depressive disorder. Most frequently reported adverse effects of sertraline in patients receiving 50-150 mg/d are dry mouth, headache, diarrhea, nausea, vomiting, sweating, and dizziness. We hereby report one of the few cases of sertraline-induced ventricular tachycardia, which has been for the first time objectively assessed by the Naranjo scale. We therefore urge the primary care physicians and the cardiologists to keep sertraline as a possible precipitating factor for evaluation of ventricular tachycardia.

Coronary slow flow--prevalence and clinical correlations.

BACKGROUND: Coronary slow flow phenomenon (CSFP) is defined as delayed coronary opacification in the absence of obstructive coronary artery disease. In the present study, we sought to define its prevalence and clinical features. METHODS AND RESULTS: The 1,741 consecutive patients who underwent coronary angiography (CAG) were identified. Those with normal left ventricular ejection fraction and normal coronary arteries were included in the study (n=158). TIMI frame counts were calculated, and data on demographics, comorbidities, and medication use were collected. CSFP was defined as frame count > 27. Multivariate logistic regression analysis was used to identify independent predictors of CSFP. CSFP was identified in 96 (5.5%) subjects referred for CAG. Subjects with CSFP were more obese (body mass index [BMI] 33.9 vs. 29.8 kg/m², P=0.003) and had lower high-density lipoprotein levels (39.7 vs. 45.7 mg/dl, P=0.04). In the CSFP group, total cholesterol, low-density lipoprotein and frame counts increased significantly with increasing vessel involvement (1-, vs. 2-, vs. 3-vessel involvement; P<0.05 for each variable). By multivariate analysis, male sex (odds ratio 3.36, 95% confidence interval 1.17-8.61, P=0.02) and higher BMI independently predicted the presence of CSFP (odds ratio 1.09, 95% confidence interval 1.03-1.15, P=0.003). CONCLUSIONS: CSFP is associated with male sex and obesity. Multivessel involvement may be a marker of more severe, diffuse disease. Further studies are needed to investigate this hypothesis.

Fluoroscopy vs. traditional guided femoral arterial access and the use of closure devices: a randomized controlled trial.

OBJECTIVE: To compare the effectiveness of accessing the common femoral artery (CFA) using fluoroscopic guidance (FG) versus traditional anatomic landmark guidance (TALG) during cardiac catheterization and to determine the effect of the two modalities on the appropriateness for use of vascular closure devices (VCDs). BACKGROUND: Previous studies have shown a consistent relationship between the head of the femur and the CFA, yet there is no prospective data validating the superiority of fluoroscopy-assisted CFA access. METHODS: A total of 972 patients were randomized to either FG or TALG access. The primary endpoint of the study was the angiographic suitability of the puncture site for VCD use. Secondary endpoints included arteriotomy location, time and number of attempts needed to obtain access, and the incidence of vascular complications. RESULTS: Of these, 474 patients were randomized into the FG arm and 498 patients into the TALG arm. A total of 79.5% of patients in the fluoroscopy arm and 80.7% in the traditional arm (P = 0.7) were deemed angiographically suitable for VCD based on the arteriotomy. The fluoroscopy group had significantly less arteriotomies below the inferior border of the head of the femur (P = 0.03). Total time for sheath insertion (105.7 +/- 130.7 vs. 106.5 +/- 152.6 sec) and number of arterial punctures (1.1 +/- 0.4 vs. 1.1 +/- 0.5) did not differ among the FG and TALG, respectively. The rates of vascular complications were not different. CONCLUSION: The angiographic suitability for VCD was not different between FG and TALG groups. Fluoroscopy decreased the number of low arteriotomies. The time to sheath insertion, number of arterial punctures needed to obtain access, and the incidence of complications were also similar.

Coronary slow flow phenomenon and risk for sudden cardiac death due to ventricular arrhythmias: a case report and review of literature.

We report a case of coronary slow flow phenomenon (CSFP) in a patient who underwent coronary angiography due to anginal chest pain and recurrent syncope with complete normalization of flow after intracoronary adenosine. He was noted to have multiple episodes of nonsustained ventricular tachycardia on holter monitor and increased QTc dispersion on surface electrocardiogram (EKG). He responded very well to oral dipyridamole therapy with complete resolution of his symptoms and no episodes of ventricular tachycardia on the event recorder at 3 months. We review the diagnosis and clinical features of CSFP and its association with increased QTc dispersion and the role of oral dipyridamole therapy in this condition.

Dose indices of radiation to skin in fluoroscopically guided invasive cardiology procedures.

Tissue injury depends on the extent as well as the intensity of the assault. It would be helpful to develop skin dose indices that are more descriptive of the skin area receiving radiation above a threshold value of potential injury. For monitoring radiation exposure to patients, radiochromic film was placed close to the skin of a patient undergoing cardiac catheterization procedures. With the approval of the Institutional Review Board, films from 36 patients were scanned. Contours were drawn at the increment of 100 cGy in air kerma. Using each contour value as a threshold, the area exceeding this threshold and the average dose within this area were computed. For the four patients who had skin doses exceeding the 200 cGy threshold, the peak entrance doses have a range from 230 cGy to 409 cGy. However, these high radiation exposures were confined to limited skin areas and support the absence of any significant skin injury in these patients. The area exceeding a chosen threshold value and the average dose within the area circumscribed might therefore serve as helpful measures of the assault to the skin. This investigation has demonstrated the technical feasibility of providing such dose indices.

Relationship of the 1793G-A and 677C-T polymorphisms of the 5,10-methylenetetrahydrofolate reductase gene to coronary artery disease.

Numerous studies have investigated the relationship between polymorphisms, in particular 677C-T and 1298A-C, of the methylene-tetrahydrofolate reductase (MTHFR) gene and coronary artery disease (CAD) with conflicting results. This study investigates the potential association of two point mutations in MTHFR, 677C-T and 1793G-A, along with other risk factors, with CAD. This is the first hospital-based study to investigate 1793G-A in this context. Genotype analysis was performed on 729 Caucasians and 66 African Americans undergoing coronary angiography using a novel PCR-based assay involving formation of Holliday junctions. Allelic frequencies for 677C-T were 66.2% C and 33.8% T for Caucasians and 90.9% C and 9.1% T for African Americans. With respect to the 1793G-A polymorphism, allelic frequencies were 94.7% G and 5.3% A for Caucasians and 99.2% G and 0.8% A for African Americans. Disease associations were examined in the Caucasian patients due to their greater genotype variability and larger number in the patient cohort. Results suggest that neither 677CT heterozygotes (OR-1.36; 95% CI 0.95 to 1.96) nor mutant homozygotes (OR-0.73; 95% CI 0.44 to 1.20) have either an increased or decreased risk for CAD compared to the 677CC genotype. Likewise, the 1793GA genotype did not demonstrate a statistically significant association with CAD compared to 1793GG patients (OR-0.79; 95% CI 0.47 to 1.33). Mean homocysteine levels (mumol/L) increased from normal to mutant for 677C-T (677CC: 10.2; 677CT: 11.0; 677TT: 11.6) and normal to heterozygous in 1793G-A (1793GG: 10.7; 1793GA: 11.5). These MTHFR polymorphisms did not contribute to the prediction of clinically defined CAD in Caucasians.

Neural network predictions of significant coronary artery stenosis in men.

OBJECTIVE: A neural network system was designed to predict whether coronary arteriography on a given patient would reveal any occurrence of significant coronary stenosis (>50%), a degree of stenosis which often leads to coronary intervention. METHODOLOGY: A dataset of 2004 records from male cardiology patients was derived from a national cardiac catheterization database. The catheterizations selected for analysis from the database were first-time and elective, and they were precipitated by chest pain. Eleven patient variables were used as inputs in an artificial neural network system. The network was trained on the earliest 902 records in the dataset. The next 902 records formed a cross-validation file, which was used to optimize the training. A third file composed of the next 100 records facilitated the choice of a cutoff number between 0 and 1. The cutoff number was applied to the last 100 records, which comprised a test file. RESULTS: When a cutoff of 0.25 was compared to the network outputs of all 100 records in the test file, 12 of 46 (specificity=26%) patients without significant stenosis had outputs0.25 (sensitivity=100%). Therefore, the network identified a fraction of the patients in the test file who did not have significant coronary artery stenosis, while at the same time the network identified all of the patients in the test file who had significant stenosis capable of causing chest pain. CONCLUSION: Artificial neural networks may be helpful in reducing unnecessary cardiac catheterizations.

Primary PCI for ST-segment elevation myocardial infarction in a patient treated with subcutaneous enoxaparin utilizing point-of-care Enox test.

The superiority of enoxaparin compared with unfractionated heparin in the medical management of patients with non-ST elevation acute coronary syndromes (NSTE ACS) has been demonstrated in clinical trials. Further, enoxaparin has been shown to be safe and effective during PCI, including in combination with glycoprotein IIb/IIIa inhibitors. Whether enoxaparin is superior to unfractionated heparin in patients with NSTE ACS under-going early invasive strategy is currently being tested in a large clinical trial. Data on the use of enoxaparin in patients undergoing primary angioplasty for ST-segment elevation myocardial infarction are limited. Unlike patients who present to the catheterization laboratory after several doses of enoxaparin where in a steady state anticoagulation might have been achieved, patients who present early after administration of a single dose of subcutaneous enoxaparin may not have an adequate level of anticoagulation for PCI. The ability to monitor activity of enoxaparin in such patients using a point-of-care test might be useful. This report describes a patient with ST-segment elevation myocardial infarction who presented for primary angioplasty 75 minutes after administration of subcutaneous enoxaparin. The Rapidpoint Enox test measured 135 seconds and the patient's corresponding serum anti-Xa level was 0.12 IU/mL indicating a suboptimal level of anticoagulation for PCI. Procedural success was attained using additional 0.3-mg/kg intravenous enoxaparin.

Is risk factor control and guideline-based medical therapy optimal in patients with nonobstructive coronary artery disease? A Veterans Affairs study.

BACKGROUND: Aggressive risk factor modification using evidence-based secondary prevention strategies is recommended in coronary artery disease (CAD). Utilization of such strategies was compared in patients with nonobstructive CAD (NOCAD) and obstructive CAD (OCAD). METHODS: Patients undergoing coronary angiography (excluding normal coronary angiograms), between January 2006 and June 2006, at the Veterans Affairs Medical Center were included. Demographic, clinical and treatment data were compared between the groups at baseline and 1 year. RESULTS: Of the 354 patients who underwent coronary angiography, 222 (63%) had follow-up data available at 12 ± 2 months. The mean age in the NOCAD (n = 119) and OCAD (n = 103) groups was similar. There was a lower prevalence of hypertension and heart failure (P < 0.05) in the NOCAD group. Compared with the OCAD group, aspirin use was similar but statin use was lower in the NOCAD group (P = 0.008). At 1 year, statin use (P = 0001) and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker use (P = 0.001) were significantly lower, whereas the use of aspirin was numerically lower (P = 0.06) in the NOCAD group. Mean low-density lipoprotein cholesterol levels were at goal (<100 mg/dL) in the NOCAD group at baseline and 1 year, whereas the same slightly worsened in the OCAD group at 1 year. CONCLUSIONS: The use of evidence-based medical therapy is lower in patients with NOCAD compared with those with OCAD. Improved awareness among health care providers and a unified effort to implement secondary prevention strategies may help correct such deficiencies.

HFE mutations in heart disease.

Given the reported association of cardiac complications with hereditary hemochromatosis and the high carrier frequency of HFE gene mutations in the natural population, it seems reasonable that such mutations might appear more frequently than expected among symptomatic cardiac patients. Thus, H63D, C282Y, and S65C mutations and their possible associations were examined in 477 Caucasian males undergoing coronary angiography. Genotypes were analyzed for differences between ferritin and transferrin levels, coronary artery disease (CAD), cardiomyopathy (CM), and cardiovascular disease (CVD) mortality. No significant differences were found in ferritin levels between those with or without HFE mutations (C282Y P = 0.632, H63D P = 0.765, S65C P = 0.568, and HFE mutation P = 0.568); however, there was a significant difference (P = 0.005) in mean transferrin levels between those with (252 microg/l) and without (275 microg/l) C282Y. No relationship between HFE mutations and CAD (C282Y, P = 0.402; H63D, P = 0.112; S65C, P = 0.170) or CVD death (C282Y, P = 0.560; H63D, P = 0.682; S65C, P = 0.664) was demonstrated using logistic regression. However, an association between S65C and CM was found (odds ratio 4.4; 95% confidence interval 1.3-13.3, P = 0.018). This suggests that the S65C allele may contribute to the development of CM, but that these three HFE mutations do not appear to play a significant role in development of ischemic heart disease.

Transfemoral venous access through inferior vena cava filters for interventions requiring large sheaths.

The presence of a filter in the inferior vena cava (IVC) to prevent pulmonary embolism from lower extremity deep vein thrombosis has traditionally been a contraindication for venous catheterization from the femoral vein. Certain interventional procedures require femoral access and occasionally, patients with IVC filters require these procedures. The authors report two such patients, one with a Greenfield filter requiring balloon mitral valvuloplasty and one with a Trapease filter requiring atrial septostomy. These cases demonstrate the technical feasibility of interventions across vena cava filters. Based on this experience and a review of the literature we describe in detail the techniques that allowed the procedures to be performed safely and successfully.