Bilateral coronary artery fistulas communicating with main pulmonary artery and left ventricle: case report.

Coronary artery fistula is an uncommon congenital malformation that generally drains into the main pulmonary artery or the right side of the heart. This is a case report on bilateral coronary artery fistulas communicating with the main pulmonary artery and the left ventricle. A 65-year-old woman was investigated for recurrent chest pain. Coronary angiography revealed this anomalous coronary artery connection without evidence of atherosclerotic coronary artery disease. The rarity of coronary artery fistulas involving both the main pulmonary artery and the left ventricle is emphasized.

Prognostic factors in patients with minor troponin-I elevation but without acute myocardial infarction.

OBJECTIVES: Although cardiac troponin I is widely used as a marker for myocardial infarction, its minor elevations are also observed in other clinical situations, and the prognostic factors in such clinical settings have not been well established. The aim of this study was to identify predictors of mortality in patients with minor troponin elevations without an acute myocardial infarction. METHODS: We consecutively enrolled 134 patients from the emergency department with a peak troponin I level greater than the lower limit of detectability (0.04 ng/ml) but less than the 10% coefficient of variation cutoff value for diagnosis of myocardial infarction (0.26 ng/ml). These patients had chest pain or nonspecific symptoms of a circulatory abnormality but lacked the traditional features of an acute myocardial infarction. End point was defined as death from all causes. Cox regression analysis was used to test relations between clinical and biochemical variables and the outcome. RESULTS: During the follow-up of 7.6+/-7.4 months, 12 patients died. Age, log creatine kinase myocardial isoform, and log C-reactive protein were found to be significantly correlated with death. After adjusting for possible confounders in the multivariate model, age (hazard ratio 1.09, confidence interval 1.02-1.16, P=0.012), log creatine kinase myocardial isoform (hazard ratio 13.11, confidence interval 2.01-85.52, P=0.007), and log C-reactive protein (hazard ratio 1.64, confidence interval 1.02-2.56, P=0.041) were identified as independent predictors of mortality. CONCLUSIONS: Creatine kinase myocardial isoform and C-reactive protein levels and age can be integrated to risk-stratify patients with minor troponin I elevation for reasons other than acute myocardial infarction.

Associations between C-reactive protein and circulating cell adhesion molecules in patients with unstable angina undergoing coronary intervention and their clinical implication.

BACKGROUND: There is growing evidence that C-reactive protein (CRP) may have a direct role in the pathogenesis of atherosclerosis. HYPOTHESIS: The purpose of this study was to assess associations between CRP and adhesion molecules and to determine the prognostic value of adhesion molecules as a predictor of cardiac events in patients with unstable angina. METHODS: Fifty-five consecutive patients (33 males, mean age 61 years) with unstable angina (Braunwald class IIb or IIIb) undergoing coronary stenting were included in this study. RESULTS: The test for a trend toward increasing intercellular adhesion molecule (ICAM)-1 concentrations by the 75th percentile of CRP levels at 72 h after coronary stenting was significant (p = 0.03). At 72 h after coronary stenting, CRP levels were the only determinants of ICAM-1 concentrations by multiple linear regression analysis. An elevated level of CRP (>5.4 mg/l) (odds ratio [OR] 1.5, 95% confidence interval [CI] 1.3-3.7, p < 0.05) and ICAM-1 (>321 ng/ml) (OR 1.2, 95% CI 1.1-2.1, p < 0.05) at 72 h after coronary stenting is an independent risk factor for an adverse cardiac event. CONCLUSIONS: These results suggest that in patients with unstable angina undergoing coronary stenting, the measurements of inflammatory parameters, especially CRP and ICAM-1, may be useful for identifying those at higher risk of a cardiac event, and CRP may play a direct role in promoting the inflammatory component of atherosclerosis by inducing significant expression of ICAM-1.

Associations among oxidized low-density lipoprotein antibody, C-reactive protein, interleukin-6, and circulating cell adhesion molecules in patients with unstable angina pectoris.

Oxidized low-density lipoprotein (LDL) is believed to play a key role in the development of atherosclerosis. However, the significance of anti-oxidized LDL antibody in atherogenesis is unclear. The purposes of this study were to assess whether anti-oxidized LDL antibody titers are related to other inflammatory markers of possible interest in atherosclerotic development, such as soluble cell adhesion molecules, interleukin-6, and C-reactive protein (CRP), and to determine the prognostic value of anti-oxidized LDL antibody as a predictor of cardiac events in patients with unstable angina pectoris. Sixty patients (35 men and 25 women; mean age 60 years) with unstable angina were included in this study. The levels of CRP and of intercellular adhesion molecule-1 (ICAM-1) at 24 and 72 hours after admission were significantly higher than their baseline levels (p <0.05, respectively). After adjusting for age, gender, body mass index, and statin use, anti-oxidized LDL antibodies were positively correlated with CRP (r = 0.72, p <0.001) and ICAM-1 (r = 0.68, p <0.001). Elevated anti-oxidized LDL antibodies (mean >11.37 U/ml) and CRP levels (median >2.4 mg/L) on admission were correlated with a significantly lower 16-month, event-free survival rate (Kaplan-Meier event-free survival analysis, log-rank p <0.01 and p <0.05, respectively). Multivariate analysis by logistic regression revealed that elevated levels of anti-oxidized LDL antibody (mean >11.3 U/ml) on admission were an independent risk factor for an adverse cardiac event (odds ratio 2.2, 95% confidence interval 1.5 to 10.7, p = 0.001). This study demonstrates that anti-oxidized LDL antibody expression is associated with the expression of CRP and adhesion molecules, especially ICAM-1, and is a predictor of cardiac events in patients with unstable angina pectoris. The observed elevated levels of anti-oxidized LDL antibody suggest plaque instability and may be useful for identifying patients at higher risk of a cardiac event.

Determinants of preserved diastolic function at the lateral annulus in patients with isolated diastolic dysfunction.

AIMS: The reversal of the early diastolic mitral annular velocity (e') to the late diastolic mitral annular velocity (a') ratio (e'/a' <1) develops earlier in the septum than in the lateral mitral annulus on tissue Doppler imaging (TDI). Accordingly, patients with isolated diastolic dysfunction presenting as a reversed septal e'/a' ratio can be divided into two groups depending on the presence of a reversal of lateral e'/a'. The aim of this study was to identify the determinants of preserved diastolic function at the lateral annulus in patients with isolated diastolic dysfunction. METHODS AND RESULTS: A total of 1166 consecutive patients with isolated diastolic dysfunction presenting as a reversed septal e'/a' were classified on the basis of their diastolic function at the lateral mitral annulus. Two hundred and fifteen patients had a preserved lateral e'/a' (e'/a' >1) and 915 patients had a reversed lateral e'/a' (e'/a' <1). Patients with lateral e'/a' >1 were younger, male, and had a lower prevalence of diabetes and hypertension and showed less evidence of left ventricular (LV) diastolic dysfunction and structural remodelling as LV hypertrophy and LA enlargement, than those with a lateral e'/a' <1. Multivariate analysis revealed that age, septal e', septal peak systolic annular velocity, and LV mass indexed to height(2.7) (LVM/h(2.7)) were independently associated with preserved diastolic function at the lateral annulus. CONCLUSION: The age, septal TDI, and LVM/h(2.7) were independent determinants of preserved diastolic function at the lateral annulus in patients with isolated diastolic dysfunction presenting as a reversed septal e'/a' ratio.

Rationale and design of STOP DVT study: rosuvastatin for the prevention of deep vein thrombosis in patients undergoing total knee replacement arthroplasty--a prospective randomized open-label controlled trial.

BACKGROUND: Deep vein thrombosis (DVT) frequently occurs in high-risk cardiovascular patients receiving orthopedic surgery, despite prophylactic measures for its prevention. Statins, a class of drugs used to lower cholesterol levels, have been reported to help prevent the development of DVT. METHODS: We will conduct a prospective randomized clinical trial to compare the effects of high-dose rosuvastatin plus a low-molecular-weight heparin (LMWH), enoxaparin, with conventional LMWH therapy in the prevention of DVT. Patients will be naive to both statins and anti-coagulants and then underwent total knee replacement arthroplasty (TKRA). In total, 180 patients will be randomized into two groups of 90, consisting of a LMWH group (40 mg enoxaparin subcutaneously beginning at 12h prior to surgery and continuing for 7 days every 24h after surgery) and a statin plus LMWH group (20mg rosuvastatin orally for 14 days, 7 days before and after surgery in combination with LMWH). All patients will undergo computed tomography angiography of both extremities 7 days after index surgery to assess the development of DVT. DISCUSSION: DVT remains prevalent despite the use of conventional prophylactic measures, in part because certain patients (particularly the elderly) are unable to receive preventive treatment because of a high risk of bleeding complications and co-morbidity. Statins have been shown to have beneficial effects in arterial atherothrombosis and are frequently administered to elderly patients to treat coronary artery. We hypothesize that peri-operative statin treatment may be beneficial in those patients restricted from the conventional prophylaxis for DVT.

Austrian syndrome with a delayed onset of heart failure.

A 59-year-old man treated with pneumococcal meningitis 4 months ago was hospitalized for acute heart failure and performed aortic valve replacement by rupture of aortic valve. The frequent association of pneumococcal meningitis and endocarditis is known as Austrian syndrome. Though Austrian syndrome is a clinically rare disease, the evolution of pneumococcal endocarditis is very aggressive and associated with high mortality, and early recognition for evidence of endocardial lesion in patients with pneumococcal meningitis is important to reduce the complications and mortality rate.

Left transradial coronary angiography in a patient with dextrocardia.

Although dextrocardia occurs rarely, the incidence of coronary artery disease is similar to the general population. Because of unfamiliarity with performing catheterization, transradial coronary angiography has seldom been performed in a patient with dextrocardia. We successfully performed left transradial coronary angiography in a patient with a right side heart using counter-directional torquing of the catheters and mirror-image angiographic angles.

Left atrial dyssynchrony assessed by strain imaging in predicting future development of atrial fibrillation in patients with heart failure.

BACKGROUND: The clinical and echocardiographic parameters associated with the risk of developing new onset atrial fibrillation (AF) in congestive heart failure (CHF) have not been studied comprehensively. We determined if dyssynchronous left atrial (LA) lengthening and contraction predicted future development of new onset AF in patients with CHF. METHODS: One hundred fifty-eight patients who were admitted for CHF without past or current AF were evaluated. We measured the time to peak velocity and time to peak strain with reference to the QRS complex during ventricular systole (reservoir) and late diastole (atrial contraction) in mid-portion of 4 LA walls. Dyssynchronous atrial lengthening and contraction (atrial dyssynchrony) was defined as the standard deviation of each parameter. RESULTS: New onset AF developed in 21 patients (13.3%) after a mean follow-up of 43+/-15 months. Based on univariate Cox analysis, older age, larger LA dimension and volume index, lower LA fractional shortening, and the presence of atrial dyssynchrony were associated with new onset AF. In multivariate Cox analysis, atrial dyssynchrony based on strain (>39 ms, HR 10.0, p=0.003) and LA size (> or =45 mm, HR 4.3, p=0.016) were independent predictors of new onset AF in CHF. CONCLUSIONS: We demonstrated that atrial dyssynchrony based on strain is the strongest univariate and multivariate predictor for new onset AF in hospitalized patients with CHF.

KLOTHO gene polymorphism is associated with coronary artery stenosis but not with coronary calcification in a Korean population.

Experimental studies have demonstrated KLOTHO gene polymorphism might be associated with vascular atherosclerosis and calcification. However, the impact of this genetic variant on human coronary arteries still remains to be elucidated. We investigated the effect of a KLOTHO gene variant on coronary artery stenosis and calcification. Four hundred and thirty-four patients referred for chest pain were enrolled. All the patients underwent coronary angiography and were investigated for polymorphism of the KLOTHO G395A gene. Coronary artery disease (CAD) was defined as > or = 50% diameter stenosis in at least one coronary artery. The other patients were considered to be controls. Homozygotes or heterozygotes for G395A were significantly more common in the CAD patients than in the controls (30.2% versus 21.5%, P = 0.039). In the subgroup aged < 60 years, the G395A mutant was more frequent in CAD than in control (35.3% versus 18.8%, P = 0.016), but in patients > or = 60 years, there was no difference (28.0% versus 24.1%, P = 0.473). Using multivariate analysis, we identified the KLOTHO gene G395A mutant as an independent risk factor of CAD (OR 1.712, 95% CI [1.066-2.749], P = 0.026). The frequency of the KLOTHO gene G395A mutant was not different between the calcified and noncalcified coronary artery groups (25.7%, 26.4%, respectively, P = 0.861) and an A allele carrier state was not an independent risk factor of coronary artery calcification. In conclusion, the KLOTHO gene G395A allele carrier state may be associated with CAD but not with coronary artery calcification in this Korean population.

Spontaneous coronary artery dissection mimicking acute aortic dissection.

Spontaneous coronary artery dissection is a rare cause of acute coronary syndrome or sudden cardiac death, occurring predominantly in the female sex without cardiovascular risk factors. Although the etiology and pathogenesis remain uncertain, hypertension has not appeared to be one of the most important factors. This case report describes a patient with spontaneous coronary artery dissection in proximal right coronary artery who presented the signs and symptoms of acute aortic dissection. The authors postulate that hypertension may have been an important factor for the pathogenesis of the spontaneous coronary artery dissection.

Comparative study of nicorandil and a spasmolytic cocktail in preventing radial artery spasm during transradial coronary angiography.

BACKGROUND: Radial artery spasm is one of the most common complications during coronary angiography via the transradial approach, causing patient discomfort or sometimes interrupting the procedure. This study was designed to compare the spasmolytic effect between nicorandil and a cocktail during transradial coronary angiography. METHODS: A randomized study to compare 4 mg of nicorandil and a cocktail (mixture of normal saline, 200 microg of verapamil) was performed in 150 patients. We examined vasospasms of the radial artery that were expressed as stenosis of the radial artery vessel diameter after the procedure. RESULT: The reductions of systolic and diastolic blood pressures showed no significant differences between the two groups (15.4+/-11.5/7.7+/-7.8 mmHg for nicorandil and 16.3+/-13.4/6.2 mmHg for cocktail). Both agents induced a significant radial artery vasodilation after transradial administration at proximal and mid segments (P < 0.001 for all). Nicorandil showed a significant increase of the mean change of the radial artery diameter compared to the cocktail at mid-segment (0.32+/-0.23 mm for nicorandil and 0.24+/-0.15 mm for a cocktail, P < 0.05). There was no statistically significant difference between the two groups in radial artery spasm (50.7% vs. 52.0% in nicorandil and a cocktail, respectively) after catheterization. CONCLUSION: Nicorandil with vasodilator effects by a dual mechanism was effective as the cocktail in preventing radial artery spasm during transradial coronary angiography.

Impact of chronotropic effect of cilostazol after acute myocardial infarction: insights from change in left ventricular volume and function.

BACKGROUND: Cilostazol, a phosphodiesterase inhibitor, is an antiplatelet agent with positive chronotropic effect, the impact of which on left ventricular (LV) volume and function in acute myocardial infarction (AMI) was evaluated in the present study. METHODS AND RESULTS: In 56 patients with AMI treated with primary coronary stenting, serial echocardiographic studies within 24 h and at 6 months were performed. Patients received a conventional antiplatelet regimen either without cilostazol (group 1, n=29) or with cilostazol (group 2, n=27). At 6 months, the difference in the change in heart rate between group 1 and group 2 was statistically significant (9.9 beats/min; p=0.04). However, changes in LV end-systolic volume (LVESV) (7.1+/-8.2 vs 10.0+/-21.7 ml, p=0.60), LV ejection fraction (EF) (8.2+/-9.9 vs 9.0+/-12.6%, p=0.85) and the ratio of early mitral inflow velocity to the mitral annular velocity (E/E') (0.6+/-3.7 vs -1.7+/-3.2) were not different between the 2 groups. Cardiac event rate was similar between the 2 groups. On multivariate regression analyses, cilostazol therapy had no significant influence on the changes in LVESV, LVEF or E/E'. CONCLUSIONS: In this study, the addition of cilostazol on conventional drug therapy had no adverse influence on LV remodeling or LV function after AMI.

Determinants of brain natriuretic peptide levels in patients with lone atrial fibrillation.

BACKGROUND: Although brain natriuretic peptide (BNP) is increasingly being used for screening and monitoring of congestive heart failure, its utility in patients with lone atrial fibrillation (AF) is unclear. METHODS AND RESULTS: Plasma BNP levels were measured and comprehensive transthoracic echocardiography was performed in 96 subjects (47: sinus rhythm, 49: AF). Patients with structural heart disease were excluded. Potential determinants of BNP levels were identified by univariate and multivariate analyses. Individuals with AF had higher BNP levels than those with sinus rhythm (150 +/- 114 vs 49 +/- 61 pg/ml, p<0.001) The left atrial (LA) volume index (r=0.63, p<0.001), the pulmonary artery systolic pressure (r=0.45, p=0.006), and the early mitral inflow velocity (E)/mitral annular velocity (E') (r=0.36, p=0.04) were found to be independently correlated with BNP level. The correlations between BNP level and LA volume index (p=0.001) or E/E' (p=0.03) were unaltered when subjects with sinus rhythm were removed from the analysis. CONCLUSIONS: BNP levels significantly correlated with LA volume index and E/E' in patients with lone AF, which indicates that the BNP level may reflect early left ventricular dysfunction and LA enlargement in this patient population.

Exercise intolerance in patients with atrial fibrillation: clinical and echocardiographic determinants of exercise capacity.

Although exercise intolerance is a major symptom of patients with atrial fibrillation (AF), the factors limiting these patients' exercise capacity remains uncertain. This study evaluated the correlation of clinical and echocardiographic parameters with exercise capacity of patients with AF. In all, 73 patients (61 men and 12 women; mean age 61 years) with chronic AF were included in this study. Those patients with primary valvular diseases were excluded. Standard 2-dimensional and Doppler echocardiography was performed, and we averaged 10 consecutive measurements of each variable. Patients then underwent a symptom-limited treadmill exercise testing. We also measured patients' plasma levels of B-type natriuretic peptide before exercise testing. Of all clinical and echocardiographic parameters we assessed, age (r = -0.45, P = .006), ratio of early mitral inflow velocity to mitral annular velocity (r = -0.35, P = .032), and baseline heart rate were independent predictors of exercise capacity on multivariate regression analysis. In conclusion, patient's age, averaged ratio of early mitral inflow velocity to mitral annular velocity, and baseline heart rate provided useful information on exercise intolerance for patients with AF. Ratio of early mitral inflow velocity to mitral annular velocity, a noninvasive tool for estimating left ventricular filling pressure, may especially have important value for predicting functional capacity in this population as it has in individuals with in sinus rhythm.