Upright T wave in precordial lead V1 indicates the presence of significant coronary artery disease in patients undergoing coronary angiography with otherwise unremarkable electrocardiogram.

OBJECTIVE: The goal of the current work was to assess the possible relationship between upright T wave in precordial lead V1 (TV1) and the occurrence of coronary artery disease (CAD) in patients undergoing coronary angiography with an otherwise unremarkable resting electrocardiogram (ECG). METHODS: Twelve-lead resting ECGs of 2,468 patients who underwent coronary angiography were analyzed by independent reviewers blinded to the patients' clinical data. Patients with any condition known to affect cardiac repolarization were not eligible for inclusion. RESULTS: Of 126 patients included in the study, 76 (60%) had at least one significant coronary artery stenosis. Significant CAD was more frequently found in patients with upright TV1 as compared to those with negative TV1 (74 vs. 43%, p = 0.001). Left circumflex (LCx) and left anterior descending (LAD) coronary artery lesions were more frequently observed in patients with upright TV1 than in those with inverted TV1. In univariate analysis, patients with upright TV1 were approx 4 times more likely to have significant CAD than those with inverted TV1 (odds ratio (OR) 3.7, 95% confidence interval (CI) 1.744-7.897). In addition, in the multivariate logistic regression model, upright TV1 was an independent predictor of significant CAD (OR 4.249, 95% CI 1.594-11.328), along with previous myocardial infarction (OR 17.533, 95% CI 3.338-92.091), male gender (OR 3.020; 95% CI 1.214-7.510), and age (OR 1.061; 95% CI 1.003-1.122). CONCLUSION: It might be worthwhile to routinely evaluate the polarity of the T wave in lead V1 in patients with suspected CAD, since it appears to have additional risk stratification potential.

The prevalence of polyvascular disease in patients referred for peripheral arterial disease.

OBJECTIVE: To objectively assess the presence of polyvascular disease in patients with peripheral arterial disease and its relation to inflammation and clinical risk factors. METHODS: A total of 431 vascular surgery patients (mean age 68 years, men 77%) with atherosclerotic disease were enrolled. The presence of atherosclerosis was assessed using ultrasonography. Affected territories were defined as: (1) carotid, stenosis of common or internal carotid artery of >or=50%, (2) cardiac, left ventricular wall motion abnormalities, (3) abdominal aorta, diameter >or=30 mm and (4) lower limb, ankle-brachial pressure index <0.9. Cardiovascular risk factors and high-sensitivity C-reactive protein (hs-CRP) levels were noted in all. RESULTS: One vascular territory was affected in 29% of the patients, whereas polyvascular disease was found in 71%: two affected territories in 45%, three in 23% and four in 3% of patients. Levels of hs-CRP increased with the number of affected vascular territories (p<0.001). Multivariable logistic regression analysis showed age >or=70 years, male gender, body mass index (BMI)>or=25 kg m(-2), and hs-CRP to be independently associated with polyvascular disease. CONCLUSION: Polyvascular disease is a common condition in patients who have undergone vascular surgery. The level of systemic inflammation, reflected by hs-CRP levels, is moderately associated with the extent of polyvascular disease.

Methionine loading does not enhance the predictive value of homocysteine serum testing for all-cause mortality or major adverse cardiac events.

BACKGROUND: Hyperhomocysteinaemia is independently associated with atherosclerotic disease. Methionine loading could improve the predictive value of hyperhomocysteinaemia by detecting mild disturbances in enzyme activity. The aims of this study were to determine the beneficial effect of methionine loading on the predictive value of homocysteine testing for long-term mortality and major adverse cardiac events (MACE). METHODS: In an observational study, 1122 patients with suspected or known vascular disease, underwent homocysteine testing, which was measured fasting and again 6 h after methionine loading. Hyperhomocysteinaemia was defined as a fasting level > or =15 micromol/L and post-methionine loading level > or =45 micromol/L or an increase of > or =30 micromol/L above fasting levels. Primary end-points were death and MACE. Multivariate Cox regression analysis was used, adjusting for all cardiac risk factors. RESULTS: During follow up (mean 8.9 +/- 3.4 years), 98 patients died (8.7%), 86 had a MACE (7.7%), 579 patients had normal tests, 134 patients had only fasting hyperhomocysteinaemia, 226 only post-methionine hyperhomocysteinaemia and 183 patients had both. In multivariate analysis, overall survival and MACE-free survival were significantly worse for those with fasting hyperhomocysteinaemia, with hazard ratios of 1.86 (95% confidence interval (CI) 1.20-2.87) and 2.24 (95%CI 1.41-3.53), respectively. The addition of hyperhomocysteinaemia after methionine loading did not significantly increase the risk of death or MACE, with hazard ratios of 0.97 (95%CI 0.52-1.81) and 0.89 (95%CI 0.47-1.69), respectively. CONCLUSION: The presence of post-methionine hyperhomocysteinaemia did not significantly alter risk of death or MACE in patients with normal or increased fasting homocysteine levels, respectively. In conclusion, methionine loading does not improve the predictive value of homocysteine testing with regard to long-term mortality or MACE.

Impaired glucose regulation, elevated glycated haemoglobin and cardiac ischaemic events in vascular surgery patients.

AIMS: Cardiac morbidity and mortality is high in patients undergoing high-risk surgery. This study investigated whether impaired glucose regulation and elevated glycated haemoglobin (HbA(1c)) levels are associated with increased cardiac ischaemic events in vascular surgery patients. METHODS: Baseline glucose and HbA(1c) were measured in 401 vascular surgery patients. Glucose < 5.6 mmol/l was defined as normal. Fasting glucose 5.6-7.0 mmol/l or random glucose 5.6-11.1 mmol/l was defined as impaired glucose regulation. Fasting glucose > or = 7.0 or random glucose > or = 11.1 mmol/l was defined as diabetes. Perioperative ischaemia was identified by 72-h Holter monitoring. Troponin T was measured on days 1, 3 and 7 and before discharge. Cardiac death or Q-wave myocardial infarction was noted at 30-day and longer-term follow-up (mean 2.5 years). RESULTS: Mean (+/- sd) level for glucose was 6.3 +/- 2.3 mmol/l and for HbA(1c) 6.2 +/- 1.3%. Ischaemia, troponin release, 30-day and long-term cardiac events occurred in 27, 22, 6 and 17%, respectively. Using subjects with normal glucose levels as the reference category, multivariate analysis revealed that patients with impaired glucose regulation and diabetes were at 2.2- and 2.6-fold increased risk of ischaemia, 3.8- and 3.9-fold for troponin release, 4.3- and 4.8-fold for 30-day cardiac events and 1.9- and 3.1-fold for long-term cardiac events. Patients with HbA(1c) > 7.0% (n = 63, 16%) were at 2.8-fold, 2.1-fold, 5.3-fold and 5.6-fold increased risk for ischaemia, troponin release, 30-day and long-term cardiac events, respectively. CONCLUSIONS: Impaired glucose regulation and elevated HbA(1c) are risk factors for cardiac ischaemic events in vascular surgery patients.

[Percutaneous transluminal angioplasty of radiotherapy induced carotid stenosis--case report].

Frequent delayed effect of radiation therapy in the region of neck is stenosis of carotid arteries. We report the case of 32 years old man with history of radiation therapy due to Hodgkin lymphoma, and severe stenosis of the right common carotid artery. Stenosis was succesfuly treated by percutaneous transluminal angioplasty with implantation of two bare-metal stents.

Myocardial damage in high-risk patients undergoing elective endovascular or open infrarenal abdominal aortic aneurysm repair.

OBJECTIVE: Dobutamine stress echocardiography (DSE) provides an objective assessment of the presence and extent of coronary artery disease. Therefore we compared cardiac outcome in patients at high-cardiac risk undergoing open or endovascular repair of infrarenal AAA using preoperative DSE results. METHODS: Consecutive patients with >or=3 cardiac risk factors (age >70 years, angina pectoris, myocardial infarction, heart failure, stroke, renal failure, and diabetes mellitus) undergoing infrarenal AAA repair were reviewed retrospectively. All underwent cardiac stress testing using DSE. Postoperatively data on troponin release and ECG were collected on day 1, 3, 7, before discharge, and on day 30. The main outcome measures were perioperative myocardial damage and myocardial infarction or cardiovascular death. RESULTS: All 77 patients (39 endovascular, 38 open) had a history of cardiac disease. The number and type of cardiac risk factors were similar in both groups. Also DSE results were similar: 55 vs 56%, 24 vs 28%, and 21 vs 18% had no, limited, or extensive stress induced myocardial ischemia respectively. The incidence of perioperative myocardial damage (47% vs 13%, p=0.001) and the combination of myocardial infarction or cardiovascular death (13% vs 0%, p=0.02) was significantly lower in patients receiving endovascular repair. CONCLUSION: In patients with similar high cardiac risk, endovascular repair of infrarenal aortic aneurysms is associated with a reduced incidence of perioperative myocardial damage.

Prognostic significance of declining ankle-brachial index values in patients with suspected or known peripheral arterial disease.

BACKGROUND: Peripheral arterial disease (PAD) is a risk factor for cardiovascular events. This study assessed the prognostic significance of repeated ankle-brachial index (ABI) measurements at rest and after exercise in patients with PAD receiving conservative treatment. METHODS: In a cohort study of 606 patients (mean age 62+/-12 years, 68% male), ABI at rest and after exercise was measured at baseline and after 1 year. Patients with reductions in ABI were divided into three equally-sized groups (minor, intermediate and major reductions) and were compared to patients without reductions. During a mean follow-up of 5+/-3 years, all-cause mortality, cardiac events, stroke and progression to kidney failure were noted. RESULTS: Death was recorded in 83 patients (14%) of which 49% were due to cardiac causes. Non-fatal myocardial infarction occurred in 38 patients (6%), stroke in 46 (8%) and progression to kidney failure in 35 (6%). By multivariate analysis, patients with major declines in resting (>20%) and post-exercise (>30%) ABI were at increased risk of all-cause mortality (HR: 3.3, 95% CI: 1.5-7.2, HR: 3.0, 95% CI: 1.4-6.4, respectively), cardiac events (HR: 3.1, 95% CI: 1.3-7.2, HR: 2.4, 95% CI: 1.1-5.6, respectively), stroke (HR: 4.2, 95% CI: 1.6-10.4, HR: 3.9, 95% CI: 1.4-10.2, respectively) and kidney failure (HR: 2.7, 95% CI: 1.1-7.5, HR: 6.9, 95% CI: 1.5-31.5, respectively), compared to patients with no declines in ABI. CONCLUSIONS: This study shows that major 1-year declines in resting and post-exercise ABI are associated with all-cause mortality, cardiac events, stroke and kidney failure in patients with PAD.

Abdominal aortic aneurysm screening using non-imaging hand-held ultrasound volume scanner--a pilot study.

BACKGROUND: Screening for abdominal aortic aneurysms (AAA) is cost-effective and timely repair improves outcome. Using standard ultrasound (US) an AAA can be accurately diagnosed or ruled-out. However, this requires training and bulk equipment. AIM: To evaluate the diagnostic potential of a new hand-held ultrasound bladder volume indicator (BVI) in the setting of AAA screening. METHODS: In total, 94 patients (66 +/- 14 years, 67 men) referred for atherosclerotic disease were screened for the presence of AAA (diameter > 30 mm using US). All patients underwent both examinations, with US and BVI. Using the BVI, aortic volume was measured at 6 pre-defined points. Maximal diameters (US) and volumes (BVI) were used for analyses. RESULTS: In 54 (57%) patients an AAA was diagnosed using US. The aortic diameter by US correlated closely with aortic volume by BVI (r = 0.87, p < 0.0001). Using a cut-off value of > or = 50 ml for the presence of AAA by BVI, sensitivity, specificity, positive and negative predictive value of BVI in detection of AAA were 94%, 82%, 88% and 92%, respectively. The agreement between the two methods was 89%, kappa 0.78. CONCLUSION: The bladder volume indicator is a promising tool in screening patients for AAA.

Statins are associated with a reduced infrarenal abdominal aortic aneurysm growth.

OBJECTIVE: To evaluate the effect of statins on aneurysm growth in a group of consecutive patients under surveillance for infrarenal aortic aneurysms (AAA). MATERIALS AND METHODS: All patients (59 statin users, 91 non-users) under surveillance between January 2002 and August 2005 with a follow-up for aneurysm growth of at least 12 months and a minimum of three diameter evaluations were retrospectively included in the analysis. Multiple regression analysis, weighted with the number of observations, was performed to test the influence of statins on AAA growth rate. RESULTS: During a median period of 3.1 (1.1-13.1) years the overall mean aneurysm growth rate was 2.95+/-2.8 mm/year. Statin users had a 1.16 mm/year lower AAA growth rate compared to non-users (95% CI 0.33-1.99 mm/year). Increased age was associated with a slower growth (-0.09 mm/year per year, p = 0.003). Female gender (+1.82 mm/year, p = 0.008) and aneurysm diameter (+0.06 mm/year per mm, p = 0.049) were associated with increased AAA growth. The use of non-steroidal anti-inflammatory drugs, chronic lung disease, or other cardiovascular risk factors were not independently associated with AAA growth. CONCLUSIONS: Statins appear to be associated with attenuation of AAA growth, irrespective of other known factors influencing aneurysm growth.

[Percutaneous transluminal ablation of the myocardial septum by embolization of the first branch of the anterior descending coronary artery using a small amount of absolute alcohol]. / Perkutana transluminalna ablacija septuma miokarda embolizacijom prve septalne grane prednje descedentne koronarne arterije malom kolicinom apsolutnog alkohol.

Percutaneous transluminal septal myocardial ablation (PTSMA) is becoming more and more significant in the therapy of symptomatic patients with hypertrophic obstructive cardiomyopathy (HOCM). We report on the first successful PTSMA done in Yugoslavia in a 65-year old female patient with HOCM and in NYHA functional class III. The procedure was performed with infection of a relatively small amount of absolute alcohol (3 ml) in the first septal branch of LAD, and short duration of balloon inflation (3 minutes), with reduction of the left ventricular outflow tract gradient at rest from 88 mm Hg to 11 mmHg. The patient's in-hospital course was uneventful and has improved to NYHA functional class I.

Myocardial fibrosis assessment by semiquantitative, point-counting and computer-based methods in patients with heart muscle disease: a comparative study.

AIMS: No study has directly compared different histomorphometric methods of quantification of myocardial fibrosis. Therefore we compared the results of semiquantitative, point-counting and computer-based methods in the assessement of myocardial fibrosis in a consecutive series of endomyocardial biopsy samples from patients with heart muscle disease. METHODS AND RESULTS: Histological samples (at least three per patient) were obtained by endomyocardial biopsy from 11 patients with focal myocarditis and from 24 ambulatory patients with idiopathic dilated cardiomyopathy, or during surgery in 10 patients who underwent partial left ventriculectomy. Samples were cut and stained with Masson-trichrome for better contrast. From each sample, a representative field was digitized, and the amount of fibrosis was assessed by semiquantitative scoring, by point-counting, and by computer-based software. Semiquantitative scoring correlated with both point-counting (Spearman's r = 0.69, P < 0.0001) and computer-based (Spearman's r = 0.83, P < 0.0001) methods. There was also a good correlation between point-counting and computer-based methods (r = 0.71, P < 0.0001). However, when compared with the point-counting method, the computer-based method overestimated percent fibrosis by 3.0 +/- 6.7% (P = 0.004). This overestimation correlated with the mean percent fibrosis (r = 0.38, P = 0.014). CONCLUSIONS: Our data show good correlations between the three methods of myocardial fibrosis assessment. However, systematic differences between them emphasize that this should be taken into consideration when comparing results of the studies using different methods of fibrosis assessment.