Non-ST-elevation acute coronary syndromes with previous coronary artery bypass grafting: a meta-analysis of invasive vs. conservative management.

BACKGROUND AND AIMS: A routine invasive strategy is recommended in the management of higher risk patients with non-ST-elevation acute coronary syndromes (NSTE-ACSs). However, patients with previous coronary artery bypass graft (CABG) surgery were excluded from key trials that informed these guidelines. Thus, the benefit of a routine invasive strategy is less certain in this specific subgroup. METHODS: A systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted. A comprehensive search was performed of PubMed, EMBASE, Cochrane, and ClinicalTrials.gov. Eligible studies were RCTs of routine invasive vs. a conservative or selective invasive strategy in patients presenting with NSTE-ACS that included patients with previous CABG. Summary data were collected from the authors of each trial if not previously published. Outcomes assessed were all-cause mortality, cardiac mortality, myocardial infarction, and cardiac-related hospitalization. Using a random-effects model, risk ratios (RRs) with 95% confidence intervals (CIs) were calculated. RESULTS: Summary data were obtained from 11 RCTs, including previously unpublished subgroup outcomes of nine trials, comprising 897 patients with previous CABG (477 routine invasive, 420 conservative/selective invasive) followed up for a weighted mean of 2.0 (range 0.5-10) years. A routine invasive strategy did not reduce all-cause mortality (RR 1.12, 95% CI 0.97-1.29), cardiac mortality (RR 1.05, 95% CI 0.70-1.58), myocardial infarction (RR 0.90, 95% CI 0.65-1.23), or cardiac-related hospitalization (RR 1.05, 95% CI 0.78-1.40). CONCLUSIONS: This is the first meta-analysis assessing the effect of a routine invasive strategy in patients with prior CABG who present with NSTE-ACS. The results confirm the under-representation of this patient group in RCTs of invasive management in NSTE-ACS and suggest that there is no benefit to a routine invasive strategy compared to a conservative approach with regard to major adverse cardiac events. These findings should be validated in an adequately powered RCT.

In-Hospital versus Out-of-Hospital Pulmonary Embolism: Clinical Characteristics, Biochemical Markers and Echocardiographic Indices.

BACKGROUND: A significant proportion of pulmonary embolisms (PEs) occurs in patients during hospitalisation for another reason. However, limited data regarding differences between out-of-hospital PE (OHPE) and in-hospital PE (IHPE) is available. We aimed to compare these groups regarding their clinical characteristics, biochemical markers, and echocardiographic indices. METHODS: This was a prospective, single-arm, single-centre study. Adult consecutive patients with non-COVID-related PE from September 2019 to March 2022 were included and followed up for 12 months. RESULTS: The study included 180 (84 women) patients, with 89 (49.4%) suffering from IHPE. IHPE patients were older, they more often had cancer, were diagnosed earlier after the onset of symptoms, they had less frequent pain and higher values of high sensitivity troponin I and brain natriuretic peptide levels compared to OHPE patients. Echocardiographic right ventricular (RV) dysfunction was detected in similar proportions in the 2 groups. IHPE had increased in-hospital mortality (14.6% vs. 3.3%, p = 0.008) and similar post-discharge to 12-month mortality with OHPE patients. CONCLUSIONS: In this prospective cohort study, IHPE differed from OHPE patients regarding age, comorbidities, symptoms, and levels of biomarkers associated with RV dysfunction. IHPE patients had higher in-hospital mortality compared to OHPE patients and a similar risk of death after discharge.

Comparative efficacy and safety of oral P2Y12 inhibitors after non-ST-elevation acute coronary syndromes: a network meta-analysis.

BACKGROUND: Currently, potent P2Y12 inhibition with the use of prasugrel or ticagrelor is the mainstay of treatment after an acute coronary syndrome (ACS). The 2020 European Society of Cardiology (ESC) Guidelines recommend the use of prasugrel over ticagrelor in patients with non-ST-elevation ACS (NSTE-ACS) intended to receive invasive management (class IIa recommendation), however there are contradictory views regarding this recommendation. AIM: To compare oral P2Y12 inhibitors in NSTE-ACS in terms of efficacy and safety with a focus on patients intended to proceed to invasive management. METHODS: We systematically searched PubMed, Cochrane Central Register of Controlled Trials and Web of Science to identify studies that compared different oral P2Y12 inhibitors (clopidogrel, prasugrel and ticagrelor) in patients with NSTE-ACS. Efficacy outcomes included the major adverse cardiovascular events outcome and safety outcomes included minor and major bleedings. We performed a frequentist network meta-analysis. RESULTS: Nine studies (n=35 441 patients) were included in the systematic review. There was no difference between prasugrel and ticagrelor in the composite cardiovascular end point (prasugrel vs ticagrelor HR=0.80, 95% CI=0.61 to 1.06) in all patients with NSTE-ACS. In patients intended to receive invasive management, prasugrel resulted in a reduction of the composite cardiovascular end point both versus clopidogrel (HR=0.76, 95% CI=0.61 to 0.95) and ticagrelor (HR=0.74, 95% CI=0.56 to 0.98). Inconsistency was moderate and non-significant (I2=27%, total Q p=0.2). Prasugrel ranked as the most efficient treatment in the composite cardiovascular efficacy outcome, all-cause death, myocardial infarction and definite stent thrombosis, while clopidogrel ranked as safest in the bleeding outcomes. CONCLUSION: In patients with NSTE-ACS intended to receive invasive management, an antiplatelet strategy based on prasugrel is more efficient than a similar strategy based on ticagrelor on a moderate level of evidence. This analysis supports the current recommendations by the ESC guidelines.

Elderly patients with non-cardiac admissions and elevated high-sensitivity troponin: the prognostic value of renal function.

BACKGROUND: High-sensitivity cardiac troponin (hs-cTn) levels are frequently elevated in elderly patients presenting to the emergency department for non-cardiac events. However, most studies on the role of elevated hs-cTn in elderly populations have investigated the prognostic value of hs-cTn in patients with a specific diagnosis or have assessed the relationship between hs-cTn and comorbidities. AIM: To investigate the in-hospital prognosis of consecutive elderly patients admitted to the Internal Medicine Department with acute non-cardiac events and increased hs-cTnI levels. METHODS: In this retrospective study, we selected patients who were aged ≥ 65 years and admitted to the Internal Medicine Department of our hospital between January 2019 and December 2019 for non-cardiac reasons. Eligible patients were those who had hs-cTnI concentrations ≥ 100 ng/L. We investigated the independent predictors of in-hospital mortality by multivariable logistic regression analysis. RESULTS: One hundred and forty-six patients (59% female) were selected with an age range from 65 to 100 (mean ± SD: 85.4 ± 7.61) years. The median hs-cTnI value was 284.2 ng/L. For 72 (49%) patients the diagnosis of hospitalization was an infectious disease. The overall in-hospital mortality was 32% (47 patients). Individuals who died did not have higher hs-cTnI levels compared with those who were discharged alive (median: 314.8 vs 282.5 ng/L; P = 0.565). There was no difference in mortality in patients with infectious vs non-infectious disease (29% vs 35%). Multivariable analysis showed that age (OR 1.062 per 1 year increase, 95%CI: 1.000-1.127; P = 0.048) and creatinine levels (OR 2.065 per 1 mg/dL increase, 95%CI: 1.383-3.085; P < 0.001) were the only independent predictors of death. Mortality was 49% in patients with eGFR < 30 mL/min/1.73 m2. CONCLUSION: Myocardial injury is a malignant condition in elderly patients admitted to the hospital for non-cardiac reasons. The presence of severe renal impairment is a marker of extremely high in-hospital mortality.

Simultaneous Transcatheter Aortic Valve Implantation and Infrarenal Aortic Aneurysm Repair for Severe Aortic Stenosis and Abdominal Aortic Aneurysm: Report of 2 Cases and Literature Review.

The prevalence of concomitant abdominal aortic aneurysm (AAA) and severe aortic stenosis (AS) has been increasing in the elderly population. Both conditions have adverse outcomes, if not adequately managed. No clear recommendations are available in the literature until today, in regards of the management sequence making thus the decision-making challenging. We report 2 cases of AAA and significant AS treated with endovascular aortic repair (EVAR) and transcatheter aortic valve implantation (TAVI) during the same procedure and a review of the literature on this topic. Based on our experience, the combined procedure with TAVI followed by EVAR seems to be feasible, safe, and effective while detailed preoperative planning and a carefully tailored management strategy by a multidisciplinary team are essential.

A comparison of three multimodality coronary 3D reconstruction methods.

The assessment of the severity of arterial stenoses is of utmost importance in clinical practice. Several image modalities invasive and non-invasive are nowadays available and can be utilized for the 3-dimensional (3D) reconstruction of the arterial geometry. Following our previous study, the present study was conducted to further strengthen the evaluation of three reconstruction methodologies, namely: (i) the Quantitative Coronary Analysis (QCA), (ii) the Virtual Histology Intravascular Ultrasound VH-IVUS-Angiography hybrid method and (iii) the Coronary Computed Tomography Angiography (CCTA). Data from 13 patients were employed to perform a quantitative analysis using specific metrics, such as, the Mean Wall Shear Stress (mWSS), the Minimum Lumen diameter (MLD), the Reference Vessel Diameter (RVD), the Degree of stenosis (DS%), and the Lesion length (LL). A high correlation was observed for the mWSS metric between the three reconstruction methods, especially between the QCA and CCTA (r=0.974, P<; 0.001).

Association of vascular indices with novel circulating biomarkers as prognostic factors for cardiovascular complications in patients with type 2 diabetes mellitus.

BACKGROUND: The pathophysiology of atherosclerosis in type 2 diabetes mellitus (T2DM) is multifactorial. The association of vascular indices with circulating biomarkers of inflammation and insulin resistance and their role in the long-term cardiovascular prognosis in T2DM patients were currently investigated. PATIENTS AND METHODS: Patients with T2DM and poor glycemic control without known cardiovascular diseases (n=119) at baseline were enrolled and followed for about 9years. The end-point was the occurrence of any cardiovascular event (coronary heart disease, stroke, peripheral artery disease or cardiovascular death). Aortic pulse wave velocity (PWV), augmentation index (AIx), brachial flow-mediated dilation (FMD), hsCRP, Chitinase-3-like protein 1 (YKL-40), Neutrophil Gelatinase-Associated Lipocalin (NGAL), Fatty Acid Binding Protein (FABP-4) were assessed. RESULTS: Higher YKL-40 and NGAL were associated with higher PWV, while higher YKL-40 and FABP-4 were related to higher AIx (p<0.05 for all). In univariate Cox regression analysis, PWV>10m/s, YKL-40>78ng/ml and NGAL>42ng/ml were associated with cardiovascular events (p<0.05 for all). In multivariate analysis, after adjusting for classical risk factors and glycemic control, increased NGAL, YKL-40 and PWV and decreased FMD (i.e. ≤2.2%) (p<0.05 for all) were independently associated with cardiovascular events. CONCLUSION: In T2DM patients without established cardiovascular disease, novel indices of vascular inflammation (NGAL and YKL-40) were associated with subclinical atherosclerosis (arterial stiffness) but also with adverse clinical prognosis. Arterial stiffness and endothelial dysfunction were also independently related to adverse prognosis.

Detecting Myocardial Ischemia With 99mTechnetium-Tetrofosmin Myocardial Perfusion Imaging in Ischemic Stroke.

BACKGROUND: To assess the myocardial status in patients with stroke, employing myocardial perfusion imaging (MPI) with 99mTechnetium-tetrofosmin (99mTc-TF)-single-photon emission computed tomography (SPECT). METHODS: Fifty-two patients with ischemic stroke were subjected to 99mTc-TF-SPECT MPI within 1 month after stroke occurrence. None of the patients had any history or symptoms of coronary artery disease or other heart disease. Myocardial perfusion imaging was evaluated visually using a 17-segment polar map. Myocardial ischemia (MIS) was defined as present when the summed stress score (SSS) was >4; MIS was defined as mild when SSS was 4 to 8, and moderate/severe with SSS ≥9. Patients with SSS >4 were compared to patients with SSS <4. Parameters such as age, body mass index, waist perimeter, smoking habits, and medical history (diabetes mellitus, dyslipidemia, etc) were evaluated according to MPI results. RESULTS: Myocardial ischemia was present in 32 (62%) of 52 patients with stroke. Among them, 20 (62%) of 32 patients had mild abnormalities and 12 (38%) of 32 had moderate/severe. The age and waist perimeter showed a tendency to relate to severe MIS when patients with SSS >9 were compared to patients with SSS <4. In MPI-positive patients, an age was to be association with SSS, with the oldest age exhibiting the highest SSS (P = .01). The association of age with SSS remained statistically significant in the multivariate analysis (P = .04). CONCLUSION: The study suggested that more than half of patients with stroke without a history of cardiac disease have MIS. Although most of them have mild MIS, we suggest a thorough cardiological evaluation in this group of patients for future prevention of severe myocardial outcome.

Endothelial dysfunction, but not structural atherosclerosis, is evident early in children with heterozygous familial hypercholesterolemia.

Children with heterozygous familial hypercholesterolemia (heFH) are prone to premature atherosclerosis. Vascular endothelial dysfunction may predict increased cardiovascular risk in children with heFH. The aim of this study was to assess for early functional and structural vascular changes in children with heFH. This cross-sectional study included 30 children with heFH (mean age 12 years) and 30 age- and sex-matched controls. Brachial artery flow-mediated dilation (FMD), carotid intima-media thickness (cIMT), carotid-femoral pulse wave velocity, and large- and small vessel compliance were measured noninvasively. HeFH children exhibited significantly greater total and LDL cholesterol, apolipoprotein B, and lipoprotein (a) levels (p < 0.05 for all) and lower FMD (6.23 ± 3.88 vs. 9.46 ± 4.54 %, p < 0.004) compared with controls. When children were divided in age subgroups, FMD was found to be significantly decreased in heFH compared with control subjects only in ages >10 years (p < 0.05). However, FMD was found to be similarly impaired in heFH children in all age subgroups (two-way analysis of variance, p = 0.39). No differences in other vascular function indices were found. In heFH patients, but not in controls, FMD was inversely correlated with cIMT (r = -0.378, p = 0.036). In conclusion, endothelial dysfunction occurs early in heFH children indicating an increased risk for premature cardiovascular disease and reflecting probably the need for early initiation of anticholesterolemic treatment. Decreased FMD is detected before structural atherosclerotic changes occur.

Novel next-generation sequencing and networks-based therapeutic targets: realistic and more effective drug design and discovery.

Reductionist approaches and linear experimentation have expanded our knowledge in biology over the past century and represent till today the basis for the prevention, diagnosis and treatment of all diseases in clinical medicine. However, major diseases still remain incurable. All currently available drugs target a single gene or protein ignoring dynamics of highly complex biomolecular networks driving collectively gene expression and cell's function. No surprise that most of these agents don't cure common multifactorial disorders while available diagnostics and biomarkers are unable to predict tissue-specific cellular reactions to genetic and epigenetic alterations as well as drug effects in individual patients and populations. In this review we discuss latest advances in genome localization of genomewide association studies variants, whole genome/whole exome data analysis, protein-protein interactions networks databases, and more recent Encyclopedia of DNA Elements (ENCODE) data on regulatory networks including transcription factors-binding sites and genegene interactions. In addition challenges for a comprehensive analysis of intracellular signaling pathways network is described. Such analysis, despite genome-scale scarce data and lack of sophisticated methods to predict dynamics of a global hierarchy or 'cloud"of biological networks, appears essential for the discovery of new therapeutic network targets, which could dramatically increase treatment efficacy, while minimizing at the same time major adverse effects. In this review we describe potential and challenges of modern approaches for applying next-generation sequencing and patient's personal whole genome analysis for personalized treatment using available drugs. Additionally, we report why the discovery of next-generation drugs should be shifted from our linear world to motifsand network-associated disease integrating genome science and dynamics of network biology advances.

Increased vascular inflammation in early menopausal women is associated with hot flush severity.

CONTEXT: Menopause has been related to an increased atherosclerotic risk. Presence and severity of hot flushes in menopausal women have been associated with impaired endothelial function and advanced subclinical atherosclerosis. OBJECTIVE: The objective of the study was to evaluate the effect of menopausal transition on vascular inflammation indices and investigate the association of hot flush severity with these indices in early menopausal women. DESIGN, SETTING, AND PARTICIPANTS: This was a cross-sectional study that included 120 early menopausal women (age range 42-55 yr, <3 yr in menopause) recruited from the menopause outpatient clinic of an academic hospital and 24 age-matched premenopausal women (controls). MAIN OUTCOMES: Serum high-sensitivity C-reactive protein, P-selectin, and soluble CD40 ligand (sCD40L) levels were measured. RESULTS: P-selectin and sCD40L were increased in early menopausal compared with control women (P = 0.006 and P = 0.02 respectively), whereas high-sensitivity C-reactive protein levels did not differ (P = 0.4) between the groups. Hot flush severity was the most important independent predictor of P-selectin levels (P = 0.011) in early menopausal women. Women with moderate/severe/very severe hot flushes had increased P-selectin compared with women with no/mild hot flushes or controls (P < 0.05 for both). The sCD40L levels were also higher in menopausal women with moderate/severe/very severe hot flushes compared with controls (P = 0.03) but did not differ significantly compared with women with no/mild hot flushes (P = 0.2). CONCLUSIONS: Increased indices of vascular inflammation in early menopausal compared with age-matched premenopausal women may indicate a higher atherosclerotic risk. Increased severity of hot flushes was associated with adverse changes in vascular inflammation, further supporting the emerging role of hot flushes in cardiovascular prognosis in these women.

Short-term hormone therapy improves sCD40L and endothelial function in early menopausal women: potential role of estrogen receptor polymorphisms.

OBJECTIVE: Hormone therapy (HT) has been suggested to improve vascular function and inflammation in menopausal women, although not consistently. We aimed to investigate the effects of HT on endothelial function and inflammation, especially sCD40L, in early menopausal women, and the effect of common estrogen receptor (ER) polymorphisms on vascular responses to HT. STUDY DESIGN: Eighty-four early menopausal women (<3 years in menopause) with menopausal complaints eligible for HT. Forty women received transdermal 17ß-estradiol plus cyclical micronized progesterone for 3 months while 44 did not (controls). MAIN OUTCOME MEASURES: Brachial artery flow-mediated dilation (FMD) and vascular inflammation markers (sICAM, sP-Selectin and sCD40L). Genetic polymorphisms of ERα (PvuII 454-397T>C and XbaI 454-351A>G) and ERß (AluI 1730A>G) were also assessed. RESULTS: The two groups did not differ at baseline. Following HT, vasomotor complaints' severity, blood pressure, LDL, sCD40L, sICAM and sP-Selectin decreased and FMD increased compared to controls (P<0.05 for all). ERß AluI A allele presence was the most important independent predictor of HT-induced increase in FMD while ERα XbaI A allele was the only independent predictor of decrease in sCD40L. CONCLUSIONS: Short-term HT in early menopausal women improved endothelial function and inflammation. Specific ER polymorphisms that were found to be main determinants of HT-induced effects on endothelium could identify subgroups of women who may benefit the most from HT.

Stenting of the descending thoracic aorta: a six-year single-center experience.

OBJECTIVES: The aim of this study was to review the six-year results of the endovascular repair of descending thoracic aortic pathologies, reporting the early perioperative outcomes as well as the mid-term follow-up of the treated patients. METHODS: Fifty-five consecutive patients who underwent endovascular repair for thoracic aortic pathology (32 aneurysms, 17 acute thoracic aortic syndromes, and six traumatic aortic ruptures) during a six-year period were retrospectively reviewed. From these patients, 30 (54.5%) were treated electively and 25 (45.5%) on an emergency basis. In eight cases (14.5%) there was a need for left subclavian artery orifice overstenting. In seven patients (12.7%) an abdominal aortic lesion was simultaneously treated, while three more patients (5.5%) had previously had their abdominal aortic aneurysm repaired. RESULTS: The primary technical success was 92.7%. Seven patients (12.7%) underwent some operation related complication, while postoperative complications occurred in five patients (9.1%), namely four myocardial infarctions, one acute respiratory distress syndrome and two delayed parapareses resulting in an overall incidence of neurological complications of 3.6%. The combined 30-day and in-hospital mortality was 9.1%, exclusively related to patients treated emergently (P = 0.01). In a mean follow-up period of 34 months there were six deaths, and the overall cumulative survival at four years was estimated at 72.6%. Only one type II endoleak was observed one month after the procedure and it spontaneously disappeared 18 months later. CONCLUSIONS: The endovascular repair of descending thoracic aortic pathologies seems to be a well-established method, with favorable morbidity and mortality rates, at least for 30 days and in the mid-term. Taking into account the potential of a wide application of the endovascular technique in many vascular centers, stenting of the thoracic aorta might offer an overall better solution for patients suffering from these devastating pathologies.

Effect of ethinylestradiol/cyproterone acetate on endothelial function in young non-obese women with polycystic ovary syndrome: a pilot study.

BACKGROUND: Combined oral contraceptives are used in polycystic ovary syndrome (PCOS) women for the treatment of hyperandrogenism and menstrual cycle disturbances. AIM: To assess the effect of ethinylestradiol and cyproterone acetate (EE/CA) on endothelial function in young, non-obese PCOS women in a pilot study. METHODS: Thirteen young, non-obese PCOS women (20.9 ± 3.7 years, 23.0 ± 4.0 kg/m(2)) received 35 mcg EE & 2 mg CA for 6 months. Fourteen age- and body mass index (BMI)-matched healthy women served as controls. Endothelial function assessed by brachial artery flow-mediated dilation (FMD), indices of hyperandrogenism, and insulin resistance were studied at baseline and 6-month follow-up. RESULTS: FMD was impaired in PCOS compared to control women (4.67 ± 2.38% vs. 10.12 ± 3.19%, p < 0.001), but increased significantly following EE/CA (9.99 ± 2.11%, p < 0.001 vs. baseline), reaching normal values (p = NS vs. controls). EE/CA also significantly decreased hyperandrogenism indices and increased total and HDL cholesterol and triglycerides (p < 0.05 vs. baseline). The only independent predictor of treatment-induced FMD improvement in PCOS women was the decrease in free androgen index. CONCLUSIONS: Treatment with combination of estrogens and antiandrogens reverses endothelial dysfunction in young, non-obese PCOS women mainly via improving hyperandrogenism. Further research is needed to investigate whether this treatment may also reduce cardiovascular risk in these women.

A highly constrained cyclic (S,S)-CDC- peptide is a potent inhibitor of carotid artery thrombosis in rabbits.

Inhibition of platelet aggregation is indispensable for the treatment of acute arterial thrombotic episodes. We have previously reported the synthesis of a highly constrained cyclic peptide, that incorporates the -CDC- sequence, (S,S) PSRCDCR-NH(2), which potently inhibits aggregation and fibrinogen binding to human platelets in vitro. We have tested the safety and efficacy of the peptide on the electrically induced carotid artery thrombosis experimental rabbit model. The peptide's effects on carotid blood flow, thrombus weight, in vitro and ex vivo platelet aggregation, and bleeding and hemostatic parameters were evaluated. The peptide was administered via the femoral vein. Carotid blood flow was continuously monitored for 90 min after electrical thrombus formation. The peptide, at 12 mg/kg, prevented total artery occlusion and significantly preserved carotid artery's patency compared with placebo and eptifibatide. Furthermore, (S,S) PSRCDCR-NH(2) administration at 12 mg/kg reduced thrombus weight, whereas it inhibited ex vivo ADP, arachidonic acid (AA) and collagen-induced platelet aggregation. Moreover (S,S) PSRCDCR-NH(2) at 12 mg/kg presented significantly higher inhibitory effects on AA and collagen-induced ex vivo platelet aggregation compared to eptifibatide. The peptide at any dose did not affect the coagulation cascade, the bleeding times or the hemostatic response of the animals. Thus highly constrained cyclic peptides like (S,S) PSRCDCR-NH(2) that incorporate the -CDC- motif and fulfil certain conformational criteria represent novel compounds that potently inhibit thrombus formation, ex vivo platelet aggregation and carotid artery occlusion superiorly to other non-RGD peptides, such as YMESRADR, without causing hemorrhagic complications in a rabbit model of arterial thrombosis.

Effect of the insulin sensitizers metformin and pioglitazone on endothelial function in young women with polycystic ovary syndrome: a prospective randomized study.

OBJECTIVE: To compare the effect of two different insulin sensitizers, metformin and pioglitazone, on endothelial function in women with polycystic ovary syndrome (PCOS). DESIGN: Prospective randomized study. SETTING: University Hospital endocrinology outpatient clinic. PATIENT(S): Young women with PCOS (aged 23.3±4.9 years). INTERVENTION(S): Patients were assigned randomly to no treatment (n=14), metformin 850 mg two times per day (n=15), and pioglitazone 30 mg daily (n=14) for 6 months. Healthy age- and body mass index-matched women served as controls (n=14). MAIN OUTCOME MEASURE(S): Brachial artery flow-mediated dilation was studied at baseline and 6 months. RESULT(S): Women with PCOS had higher insulin resistance and hyperandrogenism indices and lower flow-mediated dilation compared with controls. The three groups of women with PCOS did not differ at baseline. No differences were observed at follow-up in women who received no treatment. Metformin and pioglitazone improved flow-mediated dilation to a similar extent, restoring it to normal values at 6 months. Both insulin sensitizers induced favorable changes in insulin resistance and hyperandrogenism indices in women with PCOS. Independent predictors of flow-mediated dilation improvement at 6 months were treatment with insulin sensitizers and reduction in insulin resistance. CONCLUSION(S): In young women with PCOS, treatment with metformin or pioglitazone for 6 months induces a similar beneficial effect on endothelial function; this may be partially attributed to an improvement in insulin resistance. Further research is needed to investigate whether treatment with insulin sensitizers in women with PCOS also reduces cardiovascular risk.

Endothelial function, but not carotid intima-media thickness, is affected early in menopause and is associated with severity of hot flushes.

CONTEXT: The effect of early menopause on indices of vascular function has been little studied. OBJECTIVE: The objective of the study was to investigate the effect of early menopause on indices of subclinical atherosclerosis and identify predictors of those indices in early menopausal women. DESIGN, SETTING, AND PARTICIPANTS: This was a cross-sectional study that included 120 early menopausal women (age range 42-55 yr, <3 yr in menopause) recruited from the menopause outpatient clinic of an academic hospital and 24 age-matched premenopausal women. MAIN OUTCOME MEASURES: Brachial artery flow-mediated dilation (FMD) and common carotid intima-media thickness (IMT) were studied. Estrogen receptor (ER)-alpha (rs2234693 T-->C and rs9340799 A-->G) and ERbeta (rs4986938 A-->G) polymorphisms were studied in menopausal women. RESULTS: FMD was significantly lower in early menopausal women compared with controls (5.43 +/- 2.53 vs. 8.74 +/- 3.17%, P < 0.001), whereas IMT did not differ between groups (P > 0.8). Severity of hot flushes was the most important independent predictor for FMD (P < 0.001) in menopausal women. Women with moderate/severe/very severe hot flushes had impaired FMD in contrast to women with no/mild hot flushes or controls. Women with no/mild hot flushes did not differ compared with controls. Age and systolic blood pressure were the main determinants of IMT (both P = 0.004). ER polymorphisms were not associated with vascular parameters. CONCLUSIONS: Impairment of endothelial function is present in the early menopausal years, whereas carotid IMT is not affected. Severity of hot flushes is the main determinant of endothelial dysfunction in early menopausal women. The studied ER polymorphisms do not offer important information on vascular health in early menopause.

Abdominal aortic endograft proximal collapse: Successful repair by endovascular means.

Infolding of an aortic endograft, usually characterized as endograft collapse, is a quite rare complication reported to occur mainly in thoracic aortic grafts. This report presents a case of an early proximal collapse of an endoprosthesis in an abdominal aortic aneurysm. The complication was diagnosed during the first month of follow-up and was not associated with any endoleak. It was treated with the deployment of a proximal endograft cuff with suprarenal fixation. Endograft collapse may complicate endovascular repair of the abdominal aorta in rare situations. Upon diagnosis of the problem, endovascular repair of graft collapse seems to be feasible.

Radiation burden of patients undergoing endovascular abdominal aortic aneurysm repair.

INTRODUCTION: Endovascular repair of abdominal aortic aneurysm (EVAR) requires the patient's extended exposure to x-rays, before, during, and after the intervention. The aim of this study was to determine the radiation exposure of patients undergoing EVAR and to assess the probability for the induction of both late and early radiation-related effects. METHODS: During the period of May 2006 to December 2007 EVAR was carried out in 62 patients using a mobile C-arm unit. The following dosimetric quantities were assessed: fluoroscopy time, cumulative dose in air, dose-area product, field area, and peak skin dose. RESULTS: The duration of fluoroscopy and the body mass index were found to be the main factors that influence the radiation burden in our hospital. The mean effective dose per procedure, 6.2 mSv, was between that from a planar coronary angiography and a coronary angioplasty. Taking into account the computed tomography (CT) procedure-related angiographies carried out during the first year, patients receive a total effective dose of about 62 mSv within the first year. In vivo dosimetry showed that the peak skin dose was linearly correlated with cumulative dose in air and did not exceed 1.0 Gy, ie, it was less than the threshold for any acute skin reaction. CONCLUSION: Repair of abdominal aortic aneurysm results in substantial radiation burden. Radiation-related risks for carcinogenesis and skin injuries are factors that have to be taken into account in the selection of the strategy of each facility.