The Echocardiographic "Spike and Dome"--Obstruction It Is But Where?

Spectral Doppler interrogation of the descending thoracic and abdominal aorta provides valuable information regarding cardiac and vascular hemodynamics. An abnormal aortic Doppler profile is encountered in pathological conditions that affect the aorta and its branches, the aortic valve, the left ventricle, and the pericardium. Characteristic findings on Doppler interrogation of the aorta are often noted in individuals with obstructive atherosclerotic disease of the aorto-iliac system including severe stenosis or occlusion of the distal aorta and/or iliac arteries. In this manuscript, we highlight the findings on spectral Doppler that led to the identification of occlusive disease in the distal aorta.

Short term effects of milrinone on biomarkers of necrosis, apoptosis, and inflammation in patients with severe heart failure.

INTRODUCTION: Inotropes are associated with adverse outcomes in heart failure (HF), raising concern they may accelerate myocardial injury. Whether biomarkers of myocardial necrosis, inflammation and apoptosis change in response to acute milrinone administration is not well established. METHODS: Ten patients with severe HF and reduced cardiac output who were to receive milrinone were studied. Blood samples were taken just before initiation of milrinone and after 24 hours of infusion. Dosing was at the discretion of the patient's attending physician (range 0.25-0.5 mcg/kg/min). Plasma measurements of troponin, myoglobin, N-terminal-pro-BNP, interleukin-6, tumor necrosis factor-alpha, soluble Fas, and soluble Fas-ligand were performed at both time points. RESULTS: Troponin was elevated at baseline in all patients (mean 0.1259 +/- 0.17 ng/ml), but there was no significant change after 24 hours of milrinone (mean 0.1345 +/- 0.16 ng/ml, p = 0.44). There were significant improvements in interleukin-6, tumor necrosis factor-alpha, soluble Fas, and soluble Fas-ligand (all p < 0.05) indicative of reduced inflammatory and apoptotic signaling compared to baseline. CONCLUSION: In conclusion, among patients with severe HF and low cardiac output, ongoing myocardial injury is common, and initiation of milrinone did not result in exacerbation of myocardial injury but instead was associated with salutary effects on other biomarkers.

Delay in invasive risk stratification of women with acute coronary syndrome is associated with worse outcomes.

BACKGROUND: Invasive risk stratification in patients with acute coronary syndromes (ACS) has been shown to improve outcomes. There is paucity of data on women undergoing invasive risk stratification. We investigated whether the time to coronary angiography affects survival of female patients admitted with ACS. METHOD: Female patients admitted to the coronary intensive care unit with ACS between 1/1/97 and 12/31/00 and undergoing coronary angiography during same hospitalization were divided into three groups based on the time to angiography: same day, 1-2 days and >2 days. The baseline clinical features, angiography results and outcomes were compared between the angiography groups. RESULTS: Of the total 350 female patients who fulfilled the inclusion criteria, 63% underwent angiography within two days of presentation. Three year mortality rates in women undergoing angiography on the same day, 1-2 days and >2-days were 7%, 7% and 22% respectively (p = 0.001). Using multivariate analysis, angiography beyond 2 days was a significant predictor of mortality among women (OR 2.6, 95% CI 1.3-5.0, p = 0.006) after adjusting for confounding variables. CONCLUSION: Later invasive risk stratification after 2 days of presentation in women with ACS is associated with worse survivial. Gender should not be a reason to defer early coronary angiography in these patients.

Predictors and outcomes associated with gastrointestinal bleeding in patients with acute coronary syndromes.

BACKGROUND: Potent antiplatelet and anticoagulant agents along with early revascularization are increasingly used in patients hospitalized with acute coronary syndromes (ACS). An important complication associated with these therapies is gastrointestinal bleeding (GIB); yet, the predictors, optimal management, and outcomes associated with GIB in ACS patients are poorly studied. METHODS: We investigated the incidence, predictors, pathological findings, and clinical outcomes associated with GIB in patients with ACS hospitalized at a United States tertiary center between 1996 and 2001. RESULTS: Three percent (80/3,045) of ACS patients developed clinically significant GIB. Predictors of GIB were older age, female gender, non-smoking status, peak troponin I, and prior heart failure, diabetes, or hypertension. Patients with GIB were more critically ill with lower blood pressure and higher heart rates. GIB was associated with an increased need for transfusion, mechanical ventilation, and inotropes/pressors. In-hospital mortality was significantly higher in ACS patients with versus without GIB (36% vs. 5%, P < 0.001). Thirty patients (38%) with GIB underwent endoscopy with no procedural complications of death, arrhythmia, urgent ischemia, or hemodynamic deterioration. CONCLUSION: In patients with ACS, GIB is associated with older age, female sex, peak troponin I, non-smoking status, diabetes, hypertension, and heart failure. Hospital mortality is increased eightfold when ACS patients experience GIB. More studies are needed to establish the safety of and optimal timing of endoscopy in these patients.