Arterial-ventricular and interventricular interaction in isolated post-capillary and combined pulmonary hypertension in severe mitral stenosis.

BACKGROUND: Isolated post-capillary pulmonary hypertension (Ipc-PH) is characterized by elevated left atrial pressures that are passively transmitted upstream, whereas combined pre- and post-capillary PH (Cpc-PH) demonstrates additional reactive changes in pulmonary vasculature. The increased load imposed on the right ventricle (RV) influences left ventricular (LV) mechanics by means of interventricular interaction. However, there is lack of evidence to substantiate the effect of possible additional alterations in the arterio-ventricular (AV) coupling and their effect on LV function. Considering the discrepant RV load in Cpc-PH and Ipc-PH, we sought to investigate whether these two conditions are also characterized by differential alterations in AV coupling. METHODS AND RESULTS: Invasive hemodynamic and echocardiographic data of 120 patients with PH due to severe rheumatic mitral stenosis before and immediately after percutaneous valvulotomy, along with 40 age-matched healthy controls, were analyzed. Effective arterial (E a) and ventricular elastance (E es) were measured. PH patients demonstrated elevated LV afterload (E a) along with AV uncoupling, and these derangements were more evident in the Cpc-PH group [E a: 3.3 (2.3-5.4) vs 2.6 (2.1-3.5) mmHg/mL, E a/E es: 0.73 (0.6-0.9) vs 0.88 (0.7-1.2), p < 0.05]. In addition, PH was associated with reduced LV deformation, which was mainly determined by elevated E a, while the effect of interventricular interaction was limited to the septal wall. CONCLUSIONS: Our results suggest that in addition to the interventricular interaction, an abnormal AV coupling contributes to the altered LV mechanics that has been associated with adverse prognosis in Cpc-PH.

The impact of arterial load on left ventricular performance: an invasive haemodynamic study in severe mitral stenosis.

KEY POINTS: A hallmark of mitral stenosis (MS) is the markedly altered left ventricular (LV) loading. As most of the methods used to determine LV performance in MS patients are influenced by loading conditions, previous studies have shown conflicting results. The present study calculated LV elastance, which is a robust method to quantify LV function. We demonstrate that LV loading in MS patients is elevated but normalizes after valve repair and might be a result of reflex pathways. Additionally, we show that the LV in MS is less compliant than normal due to a combination of right ventricular loading and the valvular disease itself. Immediately after valve dilatation the increase in blood inflow into the LV results in even greater LV stiffness. Our findings enrich our understanding of heart function in MS patients and provide a simple reproducible way of assessing LV performance in MS. ABSTRACT: Left ventricular (LV) function in rheumatic mitral stenosis (MS) remains an issue of controversy, due to load dependency of previously employed assessment methods. We investigated LV performance in MS employing relatively load-independent indices robust to the altered loading state. We studied 106 subjects (32 ± 8 years, 72% female) with severe MS (0.8 ± 0.2 cm(2) ) and 40 age-matched controls. MS subjects underwent simultaneous bi-ventricular catheterization and transthoracic echocardiography (TTE) before and immediately after percutaneous transvenous mitral commisurotomy (PTMC). Sphygmomanometric brachial artery pressures and TTE recordings were simultaneously acquired in controls. Single-beat LV elastance (Ees ) was employed for LV contractility measurements. Effective arterial elastance (Ea ) and LV diastolic stiffness were measured. MS patients demonstrated significantly elevated afterload (Ea : 3.0 ± 1.3 vs. 1.5 ± 0.3 mmHg ml(-1) ; P < 0.001) and LV contractility (Ees : 4.1 ± 1.6 vs. 2.4 ± 0.5 mmHg ml(-1) ; P < 0.001) as compared to controls, with higher Ea in subjects with smaller mitral valve area (≤ 0.8 cm(2) ) and pronounced subvalvular fusion. Stroke volume (49 ± 16 to 57 ± 17 ml; P < 0.001) and indexed LV end-diastolic volume (LVEDVindex : 57 ± 16 to 64 ± 16 ml m(-2) ; P < 0.001) increased following PTMC while Ees and Ea returned to more normal levels. Elevated LV stiffness was demonstrated at baseline and increased further following PTMC. Our findings provide evidence of elevated LV contractility, increased arterial load and increased diastolic stiffness in severe MS. Following PTMC, both LV contractility and afterload tend to normalize.

Pulsed radio wave as a sustainable control technology to improve indoor air quality.

The need for technologies that can clean the air indoors has grown in pace with the rise in outside pollution. Maintaining interior environment adaptability requires a permanent air purification system that may be utilized to control PM2.5/10. In addition to more traditional methods of air purification, developing advanced control systems that effectively reduce PM levels sustainably is necessary. Pulsed radio waves may expedite the dry deposition of particles having aerodynamic dimensions of less than 30 µm. The charging and coagulation processes are evaluated in an indoor restricted environment. Experimental results reveal a similar pattern to the Monte Carlo models. Distribution of charge due to the nature of the charging environment increases the coagulation rate. Contained experimental testing confirms the filtering system functions as expected, corroborated by the present research. Daily average levels of PM2.5 and PM10 were lowered by between 55 and 41% according to a study done in three indoor settings using the control technology. Research conducted throughout all seasons showed that the approach was consistently efficient in reducing PM2.5/10. It was shown that PM concentrations could be lowered by around 45 percent using pulse radio wave technology, leading to this conclusion. The use of electromagnetic waves (EM waves) to eliminate air pollution has been suggested as a radical new approach. Considering the limitations of already used strategies, this is of paramount significance while considering solutions to control air pollution.

CT-based diagnosis of diffuse coronary artery disease on the basis of scaling power laws.

PURPOSE: To provide proof of concept for a diagnostic method to assess diffuse coronary artery disease (CAD) on the basis of coronary computed tomography (CT) angiography. MATERIALS AND METHODS: The study was approved by the Cleveland Clinic Institutional Review Board, and all subjects gave informed consent. Morphometric data from the epicardial coronary artery tree, determined with CT angiography in 120 subjects (89 patients with metabolic syndrome and 31 age- and sex-matched control subjects) were analyzed on the basis of the scaling power law. Results obtained in patients with metabolic syndrome and control subjects were compared statistically. RESULTS: The mean lumen cross-sectional area (ie, lumen cross-sectional area averaged over each vessel of an epicardial coronary artery tree) and sum of intravascular volume in patients with metabolic syndrome (0.039 cm(2) ± 0.015 [standard deviation] and 2.71 cm(3) ± 1.75, respectively) were significantly less than those in control subjects (0.054 cm(2)± 0.015 and 3.29 cm(3)± 1.77, respectively; P < .05). The length-volume power law showed coefficients of 27.0 cm(-4/3) ± 9.0 (R(2) = 0.91 ± 0.08) for patients with metabolic syndrome and 19.9 cm(-4/3) ± 4.3 (R(2) = 0.92 ± 0.07) for control subjects (P < .05). The probability frequency shows that more than 65% of patients with metabolic syndrome had a coefficient of 23 or more for the length-volume scaling power law, whereas approximately 90% of the control subjects had a coefficient of less than 23. CONCLUSION: The retrospective scaling analysis provides a quantitative rationale for diagnosis of diffuse CAD.

Effects of yoga on inflammation and exercise capacity in patients with chronic heart failure.

BACKGROUND: Despite recent advances in pharmacologic and device therapy, morbidity and mortality from heart failure (HF) remain high. Yoga combines physical and breathing exercises that may benefit patients with HF. We hypothesized that an 8-week regimen of yoga in addition to standard medical therapy would improve exercise capacity, inflammatory markers, and quality of life (QoL) in patients with HF. METHODS AND RESULTS: New York Heart Association Class I-III HF patients were randomized to yoga treatment (YT) or standard medical therapy (MT). Measurements included a graded exercise test (GXT) to V O(2Peak) and the following serum biomarkers: interleukin-6 (IL-6), high-sensitivity C-reactive protein (hsCRP), and extracellular superoxide dismutase (EC-SOD). The Minnesota Living with Heart Failure Questionnaire (MLHFQ) was administered to assess changes in QoL. A total of 19 patients were enrolled after the initial screening. Of the 19 patients, 9 were randomized to YT and 10 to MT. Patients had a mean EF of 25%. GXT time and V O(2Peak) were significantly improved in the YT versus MT groups (+18% in the YT and -7.5% in MT; P = .03 vs. control and +17 in YT and -7.1 in MT; P = .02, respectively). There were statistically significant reductions in serum levels of IL-6 and hsCRP and an increase in EC-SOD in the YT group (all P < .005 vs. MT). MLHFQ scores improved by 25.7% in the YT group and by 2.9% in the MT group. CONCLUSIONS: Yoga improved exercise tolerance and positively affected levels of inflammatory markers in patients with HF, and there was also a trend toward improvements in QoL.

Improved Compliance and Comprehension of a Surgical Safety Checklist With Customized Versus Standard Training: A Randomized Trial.

OBJECTIVE: This study aimed to determine the effect of customized training versus standard readily available training on surgical safety checklist (SSCL) compliance and comprehension. BACKGROUND: The success of the SSCL in reducing surgical mortality and morbidity depends largely on the degree of compliance among health care workers with the checklist's components. We hypothesized that a customized training program would improve comprehension of the SSCL components among health care workers. METHODS: We prospectively evaluated compliance and comprehension of a locally modified SSCL among surgeons, anesthesiologists, nurses, and perfusionists who were randomized to standard versus customized training in the department of cardiac and thoracic surgery. Standard training included videos, posters, and didactic sessions obtained from the World Health Organization. Customized training consisted of a department-specific orientation video (using local staff as actors), locally made posters, and didactic sessions. Comprehension was assessed by a written exam after each training program. Verbal and written compliance with the SSCL was measured within the operating theater by trained observers. RESULTS: We observed a total of 244 surgeries for SSCL compliance. Comprehension of the didactic material provided in the training programs was higher in the customized versus the standard training group (75% versus 30%; P < 0.0001). Verbal compliance was higher in the customized versus standard training groups (87% versus 49%; P < 0.0001). Written compliance was 100% for both the customized and standard training groups. CONCLUSIONS: A customized training program improves verbal compliance and comprehension among health care workers when implementing an SSCL, compared with standard readily available training.

A Randomized Trial of Pocket-Echocardiography Integrated Mobile Health Device Assessments in Modern Structural Heart Disease Clinics.

OBJECTIVES: This study sought to determine whether mobile health (mHealth) device assessments used as clinical decision support tools at the point-of-care can reduce the time to treatment and improve long-term outcomes among patients with rheumatic and structural heart diseases (SHD). BACKGROUND: Newly developed smartphone-connected mHealth devices represent promising methods to diagnose common diseases in resource-limited areas; however, the impact of technology-based care on long-term outcomes has not been rigorously evaluated. METHODS: A total of 253 patients with SHD were randomized to an initial diagnostic assessment with wireless devices in mHealth clinics (n = 139) or to standard-care (n = 114) in India. mHealth clinics were equipped with point-of-care devices including pocket-echocardiography, smartphone-connected-electrocardiogram blood pressure and oxygen measurements, activity monitoring, and portable brain natriuretic peptide laboratory testing. All individuals underwent comprehensive transthoracic echocardiography to assess the severity of SHD. The primary endpoint was the time to referral for therapy with percutaneous valvuloplasty or surgical valve replacement. Secondary endpoints included the probability of a cardiovascular hospitalization and/or death over 1 year. RESULTS: An initial mHealth assessment was associated with a shorter time to referral for valvuloplasty and/or valve replacement (83 ± 79 days vs. 180 ± 101 days; p <0.001) and was associated with an increased probability for valvuloplasty/valve replacement compared to standard-care (34% vs. 32%; adjusted hazard ratio: 1.54; 95% CI: 0.96 to 2.47; p = 0.07). Patients randomized to mHealth were associated with a lower risk of a hospitalization and/or death on follow-up (15% vs. 28%, adjusted hazard ratio: 0.41; 95% CI: 0.21 to 0.83; p = 0.013). CONCLUSIONS: An initial mHealth diagnostic strategy was associated with a shorter time to definitive therapy among patients with SHD in a resource-limited area and was associated with improved outcomes. (A Randomized Trial of Pocket-Echocardiography Integrated Mobile Health Device Assessments in Modern Structural Heart Disease Clinics; NCT02881398).

Left atrial appendage filling defects identified by multidetector computed tomography in patients undergoing radiofrequency pulmonary vein antral isolation: a comparison with transesophageal echocardiography.

BACKGROUND: Patients referred for radiofrequency pulmonary vein antral isolation undergo contrast-enhanced multidetector computed tomography (MDCT) to assess pulmonary vein and left atrial anatomy as well as transesophageal echocardiography (TEE) to detect intraatrial thrombus. We sought to determine the accuracy of MDCT to qualitatively and quantitatively detect severe spontaneous echo contrast (SEC) or thrombus by TEE in the left atrial appendage (LAA). METHODS: Two hundred twenty-three consecutive MDCT and TEE studies performed within 7 days of each other were retrospectively identified. The LAA was evaluated by MDCT for filling defects and by TEE for thrombus or SEC. Severe SEC or thrombus on TEE was considered positive. In patients with preserved ejection fraction, the Hounsfield unit (HU) density of a 1-cm2 region of interest was measured in the LAA and ascending aorta (AA) of the same slice to calculate an LAA/AA HU ratio. RESULTS: Visually identified filling defects in LAA by MDCT correspond to severe SEC and thrombus with a sensitivity, specificity, positive predictive value, and negative predictive value of 93%, 85%, 31%, and 99%, respectively. Multidetector CT missed severe SEC detected by TEE in one examination; all thrombi, however, were correctly identified. There is a significant inverse association between mean LAA/AA HU ratios with increasing grades of SEC or thrombus (P < .001). Using an LAA/AA HU ratio cutoff of 0.25, the positive predictive value and specificity increased to 75% and 96%, respectively, while preserving a high negative predictive value (96%). CONCLUSIONS: Multidetector CT can qualitatively and quantitatively identify and distinguish severe LAA SEC/thrombus from lesser grades of SEC.

The role of quinapril in the presence of a weight loss regimen: endothelial function and markers of obesity in patients with the metabolic syndrome.

Forty-four patients with the metabolic syndrome were placed on a reduced-calorie and reduced-fat regimen to lose weight throughout a 56-week period. The patients were treated in a crossover fashion with placebo and the angiotensin-converting enzyme inhibitor quinapril for 24 weeks each. The study measured endothelial-dependent flow-mediated dilation plus serum obesity markers of adiponectin and leptin. Metabolic parameters improved after 56 weeks. Serum adiponectin level increased by 18% (P<.05 vs baseline) and serum leptin level decreased by 16% with placebo (P<.05 vs baseline). These findings were potentiated further in the quinapril group. In comparison with baseline, flow-mediated dilation was increased by 13% in the placebo group (P=.055 vs baseline) and by 43% in the quinapril group (P<.001 vs baseline and placebo). These findings suggest that weight loss therapy improves endothelial function and markers of obesity. These results are potentiated with quinapril and are independent of changes in metabolic parameters.

Cardiovascular MRI: what cardiologists need to know.

During the past decade, cardiovascular magnetic resonance imaging has firmly established itself as an important non-invasive imaging technique for comprehensive evaluation of cardiovascular diseases. Gradually, this technique has become the 'gold standard' for the assessment of numerous cardiovascular conditions. Among the important clinical indications assessed by this technique are heart failure, ischemic heart disease, cardiac masses, congenital heart disease, and diseases of the myocardium, pericardium, valves and the entire vascular tree. Continued research and further progress in magnetic resonance imaging technology herald an exciting growth of clinical applications, including coronary imaging and interventional magnetic resonance imaging.

The role of Lp-PLA2 and biochemistry parameters as potential biomarkers of coronary artery disease in Asian South-Indians: a case-control study.

BACKGROUND: Coronary artery disease (CAD) is the leading cause of death and disability worldwide. Lipoprotein associated phospholipase A2 (Lp-PLA2) is an emerging biomarker for inflammation that has shown association with CAD. Its significance in the Asian Indian population is not clearly known. We sought to compare the possible association of various biomarkers of atherosclerosis along with Lp-PLA2, in symptomatic individuals with CAD vs. healthy controls in Asian South-Indians. METHODS: We conducted a cross-sectional case control study at three centers in a South Indian population. A total of 100 CAD patients with acute coronary syndrome (ACS), 100 age and gender matched healthy controls participated, of which, 166 subjects or 83 case-control pairs with complete data for both participants were identified for the statistical analysis. Lp-PLA2 concentration and activity were measured using PLAC test and PLAC activity assay respectively (diaDexus Inc., San Francisco, CA, USA), while all other parameters were measured using standard commercially available kits. RESULTS: We enrolled a total of 200 subjects (mean age 50.7±9.6 years, 87.5% males). A total of 83 subjects completed the study in the CAD group (mean age 51 ±8.9 years, 85% males) and 83 subjects in the control group (mean age 50±8.9 years, 86.5% males). In the CAD group, Lp-PLA2 concentration positively correlated with TC (ρ=0.19, P=0.02), non-HDL-C (ρ=0.20, P=0.02), Lp-PLA2 activity (ρ=0.27, P=0.001) and Lp(a) (r=0.25, P=0.02). Lp-PLA2 activity correlated positively with TC (ρ=0.28, P=0.001), LDL-C (ρ=0.30, P<0.001), non-HDL-C (ρ=0.35, P<0.001), ApoB (ρ=0.35, P<0.001) and negatively correlated to HDL-C (ρ=-0.24, P=0.004). Cox proportionality hazards model revealed Lp-PLA2 concentration (ß=0.006, SE =0.002, P=0.009) to have positive association with the event of CAD, while negative association was observed for ApoA1 (ß=-0.06, SE =0.02, P=0.001). ROC analysis revealed that the highest quartile of Lp-PLA2 concentration to have area under curve (AUC) of 0.80 (95% CI, 0.65-0.9; P<0.001) with cut off value of >427 ng/mL and ApoA1 with AUC of 0.78 (95% CI, 0.70-0.85; P<0.001) with cut off value of ≤129.6 mg/dL with the optimum balance of sensitivity and specificity. CONCLUSIONS: In this study population, circulating plasma Lp-PLA2 was found to be elevated in CAD group. ApoA1 showed negative association and Lp-PLA2 concentration showed positive association with risk for CAD. In the highest quartile, Lp-PLA2 concentration had the best diagnostic utility. Our results support the hypothesis that Lp-PLA2 may be a potential risk marker for CAD in Asian Indians.

Irbesartan and lipoic acid improve endothelial function and reduce markers of inflammation in the metabolic syndrome: results of the Irbesartan and Lipoic Acid in Endothelial Dysfunction (ISLAND) study.

BACKGROUND: The metabolic syndrome is associated with increased angiotensin II activity, induction of a proinflammatory and oxidative state, and endothelial dysfunction. We evaluated the ability of irbesartan, an angiotensin receptor blocker, and lipoic acid, an antioxidant, to affect endothelial function and inflammation in patients with the metabolic syndrome. METHODS AND RESULTS: We randomized 58 subjects with the metabolic syndrome in a double-blinded manner to irbesartan 150 mg/d (n=14), lipoic acid 300 mg/d (n=15), both irbesartan and lipoic acid (n=15), or matching placebo (n=14) for 4 weeks. Endothelium-dependent and -independent flow-mediated vasodilation was determined under standard conditions. Plasma levels of interleukin-6, plasminogen activator-1, and 8-isoprostane were measured. After 4 weeks of therapy, endothelium-dependent flow-mediated vasodilation of the brachial artery was increased by 67%, 44%, and 75% in the irbesartan, lipoic acid, and irbesartan plus lipoic acid groups, respectively, compared with the placebo group. Treatment with irbesartan and/or lipoic acid was associated with statistically significant reductions in plasma levels of interleukin-6 and plasminogen activator-1. In addition, treatment with irbesartan or irbesartan plus lipoic acid decreased 8-isoprostane levels. No significant changes in blood pressure were noted in any of the study groups. CONCLUSIONS: Administration of irbesartan and/or lipoic acid to patients with the metabolic syndrome improves endothelial function and reduces proinflammatory markers, factors that are implicated in the pathogenesis of atherosclerosis.

Cocaine use in an urban medical population and the development of angiographically significant coronary artery disease.

Cocaine is a common drug of abuse in the United States. Although long-term cocaine use has been associated with premature coronary artery disease (CAD), the relationship between cocaine use and the presence of angiographically significant CAD (> or =70%) is not clear. A retrospective analysis of all patients who had undergone cardiac catheterization at an urban medical center over a 1-year period was performed. Five hundred twelve patients were enrolled in the study; 84 (16.4%) had evidence of cocaine use, and 111 (21.7%) were admitted with a myocardial infarction. At the time of cardiac catheterization, 31 (36.9%) cocaine-positive patients had > or =70% stenosis in at least one epicardial vessel, compared with 200 (46.7%) cocaine-negative patients (p = 0.09). Although a trend toward an association was noted on unadjusted analysis, after adjusting for CAD risk factors, cocaine use was not associated with angiographically significant CAD (odds ratio, 0.9; 95% confidence interval, 0.55-1.5; p = 0.7).

MRI of the heart: promises fulfilled?

Cardiac magnetic resonance imaging (MRI) has established itself as an important noninvasive method of evaluating a wide array of cardiovascular diseases. Despite these successes, questions remain about whether cardiac MRI is the best way to evaluate patients with complex cardiac conditions in whom more traditional diagnostic techniques have been inconclusive. We review the most important current applications of MRI in heart failure, ischemic heart disease, and myocardial disease.

Quinapril, an ACE inhibitor, reduces markers of oxidative stress in the metabolic syndrome.

OBJECTIVE: Patients with the metabolic syndrome often have abnormal levels of proinflammatory and pro-oxidative mechanisms within their vasculature. We sought to determine whether the ACE inhibitor quinapril regulates markers of oxidative stress in the metabolic syndrome. RESEARCH DESIGN AND METHODS: Forty patients with the metabolic syndrome were randomized in a double-blind manner to either the ACE inhibitor quinapril (20 mg/day) or matching placebo for 4 weeks. Serum markers of vascular oxidative stress were measured. RESULTS: After 4 weeks of therapy, serum 8-isoprostane was reduced by 12% in the quinapril group when compared with placebo (quinapril, 46.7 +/- 1.0; placebo, 52.7 +/- 0.9 pg/ml; P = 0.001). Erythrocyte superoxide dismutase activity increased 35% in the quinapril group when compared with placebo (quinapril, 826.3 +/- 17.1; placebo, 612.3 +/- 6.9 units/g Hb; P < 0.001). In addition, lag time to oxidation of LDL, a marker of oxidative stress, was increased by 48% in the quinapril group when compared with placebo (quinapril 89.2 +/- 9.2 vs. placebo 60.1 +/- 12.3 min; P < 0.001). Therapy with quinapril was well tolerated. CONCLUSIONS: The addition of the ACE inhibitor quinapril reduces markers of vascular oxidative stress and may attenuate the progression of the pathophysiology seen in the metabolic syndrome.

Effects of labetalol on hemodynamic parameters and soluble biomarkers of inflammation in acute coronary syndrome in patients with active cocaine use.

Cocaine use is associated with increased cardiovascular mortality and can promote acute coronary syndrome (ACS). Use of beta-blockers is controversial in patients who use cocaine, and the safety and efficacy of these medications in ACS in patients actively using cocaine is unknown. We enrolled 90 patients with ACS and positive urine drug screen for cocaine. Patients received standard ACS therapy plus either labetalol (n = 60) or diltiazem (n = 30). Blood pressure and heart rate were measured at baseline and 48 hours. Levels of serum CD40 ligand, interleukin (IL)-6, and choline at baseline and 48 hours were determined. There were no baseline differences in hemodynamics or serum levels of inflammatory markers between the labetalol and diltiazem groups. Both groups experienced a significant and equivalent decrease in BP and HR at 48 hours compared with baseline. At 48 hours of treatment, there were significant decreases of 17% in CD40 ligand (P < .005) and 16% in IL-6 (P < .005) but no change in choline in the diltiazem group. Furthermore, in the labetalol group, there were significant differences of 30% in CD40 ligand (P < .005 time and group comparison), 22% in IL-6 (P < .005 time and group comparison), and 18% in choline (P < .005 time and group comparison). There were no adverse events during hospitalization in any patients who received labetalol. In conclusion, labetalol appears to be safe in cocaine-associated ACS. Furthermore, labetalol provides a beneficial hemodynamic response and, in comparison to diltiazem, potentiates an anti-inflammatory vascular response in this setting.

Extent of thoracic aortic atheroma burden and long-term mortality after cardiothoracic surgery: a computed tomography study.

OBJECTIVES: We hypothesized that the extent of aortic atheroma of the entire thoracic aorta, determined by pre-operative multidetector-row computed tomographic angiography (MDCTA), is associated with long-term mortality following nonaortic cardiothoracic surgery. BACKGROUND: In patients evaluated for cardiothoracic surgery, presence of severe aortic atheroma is associated with adverse short- and long-term post-operative outcome. However, the relationship between aortic plaque burden and mortality remains unknown. METHODS: We reviewed clinical and imaging data from all patients who underwent electrocardiographic-gated contrast-enhanced MDCTA prior to coronary bypass or valvular heart surgery at our institution between 2002 and 2008. MDCTA studies were analyzed for thickness and circumferential extent of aortic atheroma in 5 segments of the thoracic aorta. A semiquantitative total plaque-burden score (TPBS) was calculated by assigning a score of 1 to 3 to plaque thickness and to circumferential plaque extent. When combined, this resulted in a score of 0 to 6 for each of the 5 segments and, hence, an overall score from 0 to 30. The primary end point was all-cause mortality during long-term follow-up. RESULTS: A total of 862 patients (71% men, 67.8 years) were included and followed over a mean period of 25 ± 16 months. The mean TPBS was 8.6 (SD: ±6.0). The TPBS was a statistically significant predictor of mortality (p < 0.0001) while controlling for baseline demographics, cardiovascular risk factors, and type of surgery including reoperative status. The estimated hazard ratio for TPBS was 1.08 (95% confidence interval: 1.045 to 1.12). Other independent predictors of mortality were glomerular filtration rate (p = 0.015), type of surgery (p = 0.007), and peripheral artery disease (p = 0.03). CONCLUSIONS: Extent of thoracic aortic atheroma burden is independently associated with increased long-term mortality in patients following cardiothoracic surgery. Although our data do not provide definitive evidence, they suggest a relationship to the systemic atherosclerotic disease process and, therefore, have important implications for secondary prevention in post-operative rehabilitation programs.

Usefulness of elevations in serum choline and free F2)-isoprostane to predict 30-day cardiovascular outcomes in patients with acute coronary syndrome.

Our objectives were to evaluate the prognostic value of several biomarkers in patients with acute coronary syndrome (ACS) through an evaluation of the 30-day clinical outcomes. Multiple biomarkers have emerged as potentially useful in risk stratification of ACS. Specifically, markers of vascular inflammation and oxidative stress might be helpful in the determination of clinical outcomes. We evaluated patients presenting with chest pain. ACS was defined by symptoms of cardiac ischemia plus electrocardiographic changes or positive troponin I. Levels of serum troponin I, high sensitivity C-reactive protein, serum choline, and free F(2)-isoprostane were obtained. Patients were followed up for 30 days (n = 108) with determination of nonfatal myocardial infarction, congestive heart failure, need for revascularization, and death. Of the 108 patients, 26 had a cardiac event. Free F(2)-isoprostane and choline levels (but not high-sensitivity C-reactive protein levels) predicted 30-day cardiac events. To determine the value of choline and F(2)-isoprostane levels in predicting 30-day cardiac events, receiver operating curves were generated. The optimal cutoff point of these markers was a serum F(2)-isoprostane level of 124.5 pg/ml (r = 0.82) and a serum choline level of 30.5 mumol/L (r = 0.76). F(2)-isoprostane and choline had a positive predictive value of 57% and 44% and a negative predictive value of 90% and 89%, respectively. In conclusion, serum choline and free F(2)-isoprostane are predictors of cardiac events in ACS. A model that includes an array of biomarkers, including troponin, choline, and free F(2)-isoprostane, might be useful in predicting patients at greater risk of future events in ACS.

Temporal trends in utilization of cardiac computed tomography.

BACKGROUND: Appropriate, inappropriate, and uncertain indications for the use of cardiac computed tomography (CT) were defined by a multisociety document in 2006. We sought to compare the appropriateness of cardiac CT examinations before and after these criteria were published. METHODS: We retrospectively evaluated all patients presenting for cardiac CT examinations in the first 3 months of 2006 and 2007 at a large academic medical center and an unaffiliated large cardiology group private practice. The indication for the examinations were determined from the patients' medical records. The examinations were then classified as "appropriate," "inappropriate," or "uncertain," based on appropriateness criteria. Examinations that did not fall into any of these categories were classified as "uncategorized." RESULTS: We evaluated a total of 1409 patients (64.9% men; mean age, 57.6 +/- 13.4 years). The proportion of appropriate CT examinations increased from 69.5% during the study period in 2006 to 78.5% in 2007 (P = 0.001). A corresponding decrease was observed in inappropriate CT examinations from 11.5% in 2006 to 4.6% in 2007 (P = 0.001). No change was observed in the number of CT examinations that were deemed uncertain (12.7% in 2006, and 13.3% in 2007; P = NS). CONCLUSION: The number of CT examinations considered appropriate increased during the study period, whereas the number of inappropriate examinations decreased. Cardiologists were more likely than noncardiologists to order examinations that were appropriate during the study period.