NT-Pro-BNP levels and their response to exercise in patients with slow coronary flow.

BACKGROUND: Natriuretic peptides are released by the heart in response to wall stress. OBJECTIVE: The NT-Pro-BNP concentrations in slow coronary flow (SCF) patients were assessed before and after the exercise test and compared with the values of healthy controls. METHODS: The study population was 34 patients with SCF [22 males (64.7%), aged 51.0 ± 6.2 years], and 34 normal subjects with normal coronary arteries [21 males (61.8%), aged 53.2 ± 6.6 years]. Coronary flow rates of all patients and control subjects were documented as Thrombolysis in Myocardial Infarction (TIMI) frame count. Blood samples were drawn at rest and after the exercise testing. RESULTS: The baseline NT-Pro-BNP concentrations of the SCF patients were higher than those of the control subjects (NT-Pro-BNP: 49.7 ± 14.2 pg/mL vs. 25.3 ± 4.6 pg/mL p<0.0001, respectively), and this difference increased after exercise test between the groups (NT-Pro-BNP: 69.5 ± 18.6 pg/mL vs. 30.9 ± 6.4 pg/mL p<0.0001). In SCF group after exercise, NT-Pro-BNP concentration in 15 patients with angina was higher than those without angina (76.8 ± 17.8 pg/mL vs. 63.8 ± 17.5 pg/mL p=0.041). NT-Pro-BNP concentration in 11 patients with ST depression was also higher than those without ST depression (82.4 ± 17.3 pg/mL vs. 63.3 ± 16.1 pg/mL p=0.004). Median post-exercise increases in NT-Pro-BNP (Δ NT-Pro-BNP) were higher in the SCF group than in the control group (Δ NT-Pro-BNP: 19.8 ± 7.7 pg/mL vs. 5.7 ± 4.5 pg/mL p<0.0001). CONCLUSION: The results of this study suggest that there may be an important pathophysiologic link between the severity of SCF (microvascular or epicardial coronary artery dysfunction) and the level of circulating NT-Pro-BNP in SCF patients.

Congenital heart defects in two siblings in an Axenfeld-Rieger syndrome family.

Axenfeld-Rieger syndrome is a genetically heterogeneous, autosomal dominant disorder characterized by anomalies of the anterior segment of the eye, face, teeth, and umbilicus. Many other extraocular findings, including congenital heart defects, have been reported in association with this syndrome. It has been suggested by some investigators that the coexistence of Axenfeld-Rieger syndrome and congenital heart defects is not a chance event but it represents a distinct entity. We report a family in which four members in three generations have typical ocular features of Axenfeld-Rieger syndrome. Two of them, who are siblings, also have congenital heart defects. The congenital heart defect was bicuspid aortic valve anomaly with severe stenosis and mild regurgitation in one sibling and ostium secundum atrial septal defect in the other. To our knowledge, the combination of congenital heart defects with Axenfeld-Rieger syndrome in siblings has not been reported previously. Our observation further strengthens the notion that Axenfeld-Rieger syndrome associated with congenital heart defects is not a chance event.

Admission levels of C-reactive protein and plasminogen activator inhibitor-1 in patients with acute myocardial infarction with and without cardiogenic shock or heart failure on admission.

Scarce data exist on the relationship of C-reactive protein (CRP) or plasminogen activator inhibitor-1 (PAI-1) to the occurrence of heart failure (HF) or cardiogenic shock (CS) after acute myocardial infarction (AMI) and on the relationship between these biomarkers and mortality in CS patients. Thus, we compared high-sensitivity CRP and PAI-1 antigen plasma levels on admission among 3 age- and gender-matched AMI patients groups (consisting of 60 patients with CS, 60 with HF, and 60 without HF on admission), after determining that PAI-1 levels did not vary significantly diurnally in these groups by comparing the data among subgroups which were divided according to admission time within the groups. For CS patients, we also conducted regression analyses to examine the relations of these biomarkers to mortality. CRP levels both in CS (P < 0.001) and HF (P < 0.05) patients were significantly higher compared to those without HF, PAI-1 levels in CS patients were significantly higher compared to both those with (P < 0.05) and without HF (P > 0.01), and CRP and PAI-1 were independent predictors of in-hospital (Odds ratio [OR] = 6.12, 95% confidence intervals [95%CI] = 1.47-25.54 and OR = 5.92, 95%CI = 1.31-26.77, respectively) and 1-year mortality (OR = 5.53, 95%CI = 1.21-25.17 and OR = 5.48, 95%CI = 1.09-27.52, respectively) in CS patients. In conclusion, at admission, CRP is associated with the occurrence of CS and HF and PAI-1 is associated with the occurrence of CS after AMI, and they are of prognostic value in CS complicating AMI.

Cutting balloon angioplasty for the treatment of in-stent restenosis in diabetics: A matched comparison of 6 months' outcome with conventional balloon angioplasty.

Ranging from 24% to 55%, angiographic in-stent restenosis (ISR) rates in diabetics are higher than the 17% to 28% rates observed in nondiabetics. There are controversies regarding optimal treatment for ISR. Recently, cutting balloon angioplasty (CBA) emerged as a tool in management. The authors assessed the hypothesis that CBA has advantages over conventional percutaneous transluminal balloon angioplasty (PTCA) in treatment of ISR in diabetics. CBA or PTCA was applied to 165 diabetics (267 ISR lesions) in their institution. With a computer algorithm, an attempt was made to match each lesion in the CBA group with a corresponding lesion in the PTCA group. The lesion pairs should match with respect to the patients' age and gender, type of target vessel and stent, reference vessel diameter, and baseline minimal lumen diameter (MLD). Following the matching process, 55 ISR lesion pairs were identified. Baseline patient characteristics were similar among the groups (p = NS). There was no difference in the in-hospital major adverse cardiac events (MACE) between the groups, whereas MACE at follow up was significantly lower in the CBA group compared to the PTCA group (CBA, 20.0% vs PTCA, 43.6%, p<0.05). The recurrent ISR rate was significantly lower in the CBA group compared to the PTCA group (CBA, 27.3% vs PTCA, 49.1%; p < 0.05). Also, a diffuse pattern of recurrence was more common in lesions treated with PTCA, whereas a focal pattern of recurrence was more common in the CBA group. The minimal luminal diameter at follow-up, the acute gain, and net gain were significantly higher in the group of lesions treated with CBA than in the PTCA group. In addition, a significantly higher late loss and loss index at follow-up were observed in the PTCA group compared to the CBA group. CBA has advantages over PTCA in treatment of diabetic patients with ISR, with better immediate and follow-up angiographic outcomes, and better follow-up clinical outcome.

Impact of invasive strategy for the management of patients with cardiogenic shock after acute myocardial infarction.

OBJECTIVE: This study evaluates the influence of early revascularization (with percutaneous transluminal coronary angioplasty (PTCA) and coronary surgery) on short- and long-term survival in patients with cardiogenic shock complicating acute myocardial infarction (AMI). METHODS AND RESULTS: In-hospital and 6-month survival were retrospectively determined on day 193 (65-270, median +/- 25th and 75th percentiles) in 87 patients who either underwent early invasive reperfusion (group A, n=60) or those who were treated conservatively (group B, n=27). In-hospital mortality was 37% in group A and 56% in group B (P=0.192). Six-month mortality was statistically lower in group A than in group B (30 patients (50%) compared with 25 patients (93%), P=0.005). Being a woman and older age were found to be factors increasing mortality. Lower mortality in the long term was strongly associated with revascularization (odds ratio=0.08, 95% confidence interval=1.54-109). PTCA was found to be an independent predictor of long-term survival (odds ratio= 0.22, 95% confidence interval=0.049-1.00, P=0.050), by multiple logistic regression. CONCLUSIONS: In conclusion, this study suggests that early revascularization improves long-term survival of patients with cardiogenic shock complicating AMI, even after adjustment for baseline differences between patients who underwent early revascularization and those who did not.

A comparison of 1-month and 6-month clopidogrel therapy on clinical and angiographic outcome after stent implantation.

In this study, we aimed to disclose the net effect of long-term (6-month) clopidogrel treatment as compared to that of short-term (1-month) treatment in the poststenting period. A total of 278 patients with successful stent implantation were involved in the study. After preloading with 300 mg of clopidogrel orally (p.o.) 24 h prior to the procedure, randomly selected patients were given either 75 mg p.o. for 1 month (group A) or 75 mg p.o. for 6 months (group B). The patients were followed up clinically and underwent control angiography at 6 months regardless of their clinical status to delineate the coronary anatomy and assess quantitative computer-assisted (QCA) analysis. In 140 (50.4%) patients (group A), 244 (50.6%) stents were used to treat 237 coronary lesions, and in 138 patients (group B), 238 (49.4%) stents were used to treat 238 coronary lesions. There was no difference between the groups with respect to any of the clinical characteristics, intracoronary thrombus, antiaggregant therapy, the type of lesion, vessel score index, and baseline QCA parameters. In 62 patients binary in-stent restenosis (ISR) was determined with no statistical difference between the groups (group A: 20.7% vs group B: 23.9%, P = not significance). There was also no difference between the two groups at 6 months regarding QCA parameters. Thirty-seven of the 62 patients with restenosis have developed major adverse coronary events such as death, myocardial infarction, and target vessel revascularization (group A: 12.9% vs group B: 13.8%, P = not significant). In patients with chronic coronary syndrome, in the poststenting period, 6-month clopidogrel use as an adjunct to aspirin has shown no benefit over 1 month use with respect to clinical outcome and angiographic outcome, such as restenosis rate, follow-up, minimal luminal diameter, late loss, lost index, and net gain.