Prevalence of and risk factors of renal artery stenosis in patients with resistant hypertension.

Renal artery stenosis (RAS) is a common cause of secondary hypertension. Renal artery angiography is the gold standard for diagnosing RAS. The aim of this study is to report (1) the prevalence of RAS in patients with resistant hypertension and (2) the association of RAS with peripheral vascular disease (PVD) and diabetes mellitus (DM). We studied 285 consecutive patients (mean age: 72.5 years) with resistant hypertension (systolic blood pressure >140 mm Hg despite administration of at least 3 antihypertensive drugs) who underwent renal artery angiography at Baylor Heart and Vascular Hospital from January 2006 to December 2010. Sixty-nine cases of RAS were identified (incidence: 24.2%). The propensity-adjusted analysis (controlling for clinical and nonclinical risk factors) showed a strong and significant association between RAS and PVD (odds ratio 5.15, 95% confidence interval 2.68 to 9.89, p <0.0001). However, the association between RAS and DM, a previously defined risk factor for RAS, was not significant in this cohort (odds ratio 0.63, 95% confidence interval 0.34 to 1.19, p = 0.16). In conclusion, results from this study define the prevalence of RAS in patients with resistant hypertension. Patients with PVD were found to be 5 times more likely to experience RAS than patients without PVD, whereas DM did not confer any increased risk.

Massive bloody pericardial effusion as an initial manifestation of chronic kidney disease.

We describe a 35-year-old man with a massive bloody pericardial effusion, which was his initial manifestation of chronic kidney disease. Pericardiocentesis and hemodialysis restored cardiac function and relieved the associated massive anasarca.

Three-year outcomes and cost analysis in patients receiving 64-slice computed tomographic coronary angiography for chest pain.

Sixty-four slice computed tomographic coronary angiography (CTCA) is being used more often in the evaluation of patients with chest pain. The strength of this test is its high specificity and negative predictive value in exclusion of coronary artery disease (CAD). Its use remains controversial because there are theoretical risks of radiation, additional costs of the test, and no long-term data to suggest that excluding CAD by use of this test results in positive patient outcomes. A total of 436 patients underwent 64-slice CTCA because of chest pain thought to be anginal. Cardiac computed tomography was ordered by the primary physician or cardiologist based on a low to intermediate pretest probability of flow-limiting CAD. A smaller subset of patients initially underwent stress testing but had equivocal findings or continued symptoms that warranted further evaluation. Of the total patient cohort, 376 had "no significant CAD" based on computed tomographic coronary angiographic results. Of the 60 patients who were believed on computed tomographic coronary angiogram to have "flow-limiting" CAD, 34 (57%) ended up having percutaneous coronary intervention or coronary artery bypass grafting. The remaining 26 patients (43%) did not have true flow-limiting disease on coronary catheterization and were treated medically. With follow-up of 36 months, 376 of those patients (100%) with minimal or no disease by CTCA were free of events or intervention. In conclusion, in a real-world, clinical setting, the negative predictive value of low-risk CTCA is very high and exceptionally helpful in predicting freedom from events for up to 3 years. By avoiding further invasive treatments, there is a significant potential cost savings in patients who are sent for noninvasive coronary angiography rather than invasive angiography.

Echocardiographic findings in professional hockey players.

Tissue Doppler imaging was used to evaluate the physiological and morphological response in athletes whose cardiac system must not only adapt to intense cardiovascular demands but also support sudden, transient changes in cardiac output. A total of 45 professional hockey players with a mean age of 24 years underwent a baseline transthoracic echocardiographic protocol after a typical morning workout; 12 healthy age- and gender-matched controls were evaluated as a means of comparison. The athletes in this study possessed larger left ventricular diastolic and systolic dimensions than the control group (5.5 ± 0.4 vs 4.9 ± 0.4 cm and 3.9 ± 0.4 vs 3.3 ± 0.4 cm, P < 0.0001). The increase in athletes' septal and posterior wall thickness was not substantial, nor was there a significant difference in left ventricular ejection fraction. The athletes demonstrated consistently larger left ventricular end-diastolic volume (196 ± 34 vs 136 ± 23 mL, P < 0.001) and end-systolic volume (87 ± 20 vs 57 ± 12 mL, P < 0.0001). They also had lower annular septal and lateral early diastolic and systolic tissue Doppler velocities compared with the control group. Thus, characteristic myocardial changes previously reported in elite athletes were also represented in professional hockey players. The lower left ventricular tissue Doppler velocities was a relatively unique finding and probably a consequence of lower postexertion preload levels compared with controls who were measured at rest.

Current role of medical treatment and invasive management in carotid atherosclerotic disease.

As a significant known risk factor for the development of ischemic stroke, carotid atherosclerosis is a potentially preventable and treatable disease process. The progression of improved diagnostic modalities, including magnetic resonance and computed tomography angiography, has provided enhanced plaque detection and characterization. The management of carotid artery stenosis has also continued to evolve from an aggressive, early surgical approach with the advent of the carotid endarterectomy to the initiation of progressive medical management options and the development of advanced percutaneous intervention. Carotid endarterectomy continues to be the clear treatment of choice in symptomatic patients with >70% carotid stenosis. However, strict risk factor modification, including improved antihypertensive therapy, lipid management, smoking cessation, and antiplatelet therapy, have led to less-compelling indications for immediate surgery in asymptomatic populations. In recent years, the evolution of improved percutaneous techniques and the development and approval of carotid stents have expanded the role of intervention. Several randomized trials have studied the efficacy of carotid artery stenting versus carotid endarterectomy in asymptomatic and symptomatic patients to help define the role of invasive therapy. The primary objective of this review is to summarize the current evidence and standards for the advanced diagnostic and management strategies used in asymptomatic and symptomatic patients with carotid artery stenosis.

The ectopic adrenocorticotropic hormone syndrome in carcinoid tumors.

Ectopic production of adrenocorticotropic hormone by carcinoid tumors is relatively uncommon and may not be recognized by physicians. This report describes a woman who had Cushing syndrome from the ectopic secretion of adrenocorticotropic hormone by a carcinoid tumor. Her cause of death was a pneumonia that may have been secondary to her untreated hypercortisolism. There are threeinstructive elements of this case: 1) the recognition of Cushing syndrome, 2) the association of Cushing syndrome with low-grade (carcinoid tumors) as well as with high-grade (small cell carcinoma) neuroendocrine tumors, and 3) the need to treat the hypercortisolism as well as the tumor.