Use of B-type natriuretic peptide to predict blood pressure improvement after percutaneous revascularisation for renal artery stenosis.

OBJECTIVES: The purpose of this study was to evaluate the utility of B-type natriuretic peptide (BNP) to predict blood pressure (BP) response in patients with renal artery stenosis (RAS) after renal angioplasty and stenting (PTRA). METHODS: In 120 patients with RAS and hypertension referred for PTRA, 24-h ambulatory BP recordings were obtained before and 6 months after intervention. BNP was measured before, 1 day and 6 months after PTRA. RESULTS: BP improved in 54% of patients. Median BNP levels pre-intervention were 97 pg ml(-1) (interquartile range (IQR) 35-250) and decreased significantly within 1 day of PTRA to 62 pg ml(-1) (IQR 24-182) (p < 0.001), remaining at 75 pg ml(-1) (IQR 31-190) at 6 months. The area under the receiver operating curve for pre-intervention BNP to predict BP improvement was 0.57 (95% confidence interval (CI) 0.46-0.67). Pre-intervention BNP >50 pg ml(-1) was seen in 79% of patients with BP improvement compared with 56% in patients without improvement (p = 0.01). In a multivariate logistic regression analysis, BNP >50 pg ml(-1) was significantly associated with BP improvement (odds ratio (OR) 4.0, 95% CI 1.2-13.2). CONCLUSIONS: BNP levels are elevated in patients with RAS and decrease after revascularisation. Although BNP does not seem useful as a continuous variable, pre-interventional BNP >50 pg ml(-1) may be helpful to identify patients in whom PTRA will improve BP.

B-type natriuretic peptide and C-terminal-pro-endothelin-1 for the prediction of severely impaired peak oxygen consumption.

OBJECTIVE: To assess the utility of B-type natriuretic peptide (BNP) and C-terminal-pro-endothelin-1 (CT-proET-1) to predict a severely impaired peak oxygen consumption (peak VO(2), < 14 mL kg(-1) min(-1)) in patients referred for cardiopulmonary exercise testing. DESIGN: Cross-sectional study. SETTING: Tertiary care center. METHODS: Peak VO(2), BNP and CT-proET-1 were assessed in 141 consecutive patients referred for cardiopulmonary exercise testing. RESULTS: B-type natriuretic peptide [median (interquartile range) 48 (38-319) vs. 33 (15-86) pg mL(-1); P = 0.002] and CT-proET-1 [87 (76-95) vs. 60 (52-74) pmol L(-1); P < 0.001] were higher in patients with a peak VO(2) < 14 mL kg(-1) min(-1) (n = 30) than in those with a peak VO(2) > or = 14 mL kg(-1) min(-1) (n = 111). CT-pro-ET-1 had a higher area under the receiver-operator-characteristics curve (AUC) to predict a peak VO(2) < 14 mL kg(-1) min(-1) than BNP (0.79 vs. 0.68; P = 0.04). The optimal BNP cut-off of 37.2 pg mL(-1) had a sensitivity of 80% and a specificity of 56%. The optimal CT-proET-1 cut-off of 74.4 pmol L(-1) had a sensitivity of 80% and specificity of 76%. A five-item score composed of body mass index, diabetes, forced expiratory volume within the first second, alveolo-arterial oxygen pressure difference, and BNP had an AUC of 0.88 to predict a peak VO(2) < 14 mL kg(-1) min(-1). Adding CT-proET-1 to the score resulted in an AUC of 0.92. CONCLUSIONS: C-terminal-pro-endothelin-1 is superior to BNP for the prediction of a peak VO(2) < 14 mL kg(-1) min(-1) in patients referred for CPET. A score incorporating body mass index, diabetes status, spirometry, blood gases, BNP and CT-proET-1 improves the prediction of a peak VO(2) < 14 mL kg(-1) min(-1) based on single biomarkers.

Long-term prognostic value of B-type natriuretic peptide in cardiac and non-cardiac causes of acute dyspnoea.

BACKGROUND: B-type natriuretic peptide (BNP) levels significantly predict increased risk of death in heart failure. The predictive role of BNP levels in patients with non-cardiac causes of acute dyspnoea presenting to the emergency department is not well characterized. MATERIALS AND METHODS: The B-type natriuretic peptide for Acute Shortness of Breath EvaLuation (BASEL) study enrolled consecutive patients with acute dyspnoea. RESULTS: Cumulative mortality was 14.8%, 33.1% and 51.9% in 452 patients (age: 19-97 years; 58% male) within low (< 100 pg mL(-1)), intermediate (100-500 pg mL(-1)) and high (> 500 pg mL(-1)) BNP plasma levels at 18 months of follow-up. BNP classes (point estimate: 1.55, 95%CI: 1.19-2.03, P = 0.001) in addition to age, increased heart rate and diuretic use emerged as significant predictors for long-term mortality in multivariable Cox regression analyses. The BNP concentration alone had an area under the receiver operating characteristic curve of 0.71 (95%CI: 0.66-0.76; P < 0.001) for predicting 18 months mortality. BNP plasma levels independently predicted long-term risk of death in patients with non-cardiac (point estimate: 1.72, 95%CI: 1.16-2.56; P = 0.007) and with cardiac causes of acute dyspnoea (point estimate: 2.21, 95%CI: 1.34-3.64; P = 0.002). CONCLUSIONS: BNP levels are strong and independent predictors for long-term mortality in unselected dyspnoeic patients presenting to the emergency department independent from the cause of dyspnoea.

Right bundle branch block and long-term mortality in patients with acute congestive heart failure.

OBJECTIVES: Risk stratification in acute congestive heart failure (ACHF) is poorly defined. The aim of the present study was to assess the impact of right bundle brunch block (RBBB) on long-term mortality in patients presenting with ACHF. METHODS AND RESULTS: The initial 12-lead electrocardiogram was analysed for RBBB in 192 consecutive patients presenting with ACHF to the emergency department. The primary endpoint was all-cause mortality during 720-day follow-up. This study included an elderly cohort (mean age 74 years) of ACHF patients. RBBB was present in 27 patients (14%). Age, sex, B-type natriuretic peptide levels and initial management were similar in patients with RBBB when compared with patients without RBBB. However, patients with RBBB more often had pulmonary comorbidity. A total of 84 patients died during follow-up. Kaplan-Meier analysis revealed that mortality at 720 days was significantly higher in patients with RBBB when compared with patients without RBBB (63% vs. 39%, P = 0.004). In Cox proportional hazard analysis, RBBB was associated with a two-fold increase in mortality (hazard ratio 2.18, 95% CI 1.26-3.66; P = 0.003). This association persisted after adjustment for age and comorbidity. CONCLUSIONS: RBBB is a powerful predictor of mortality in patients with ACHF. Early identification of this high-risk group may help to offer tailored treatment in order to improve outcome.

Coronary artery disease and outcome in acute congestive heart failure.

OBJECTIVES: To quantify the prognostic impact of coronary artery disease (CAD) on patients with acute heart failure (HF). DESIGN: Prospective cohort study of 217 consecutive patients presenting with acute HF to the emergency department. Treatment, hospitalisation, the use of revascularisation procedures, and survival were observed during follow up of up to three years. RESULTS: CAD was present in 153 patients (71%). Patients with and without CAD were similar with respect to age and sex. Although adequate HF treatment was initiated more rapidly among patients with CAD, their initial outcomes including hospitalisation rate, time to discharge, and total treatment cost were significantly worse. Moreover, despite higher use of angiotensin converting enzyme inhibitors and beta blockers during follow up, patients with CAD had a significantly lower survival rate. Cumulative survival at 720 days was 48.7% of patients with CAD as compared with 76.4% of patients without CAD (p = 0.0004). In Cox regression analysis the presence of CAD increased the risk of death by more than 250% (hazard ratio 2.57, 95% confidence interval 1.50 to 4.39, p = 0.001). This strong association persisted after multivariate adjustments. The use of coronary angiography and coronary revascularisation procedures was low, both at initial presentation and during follow up. CONCLUSION: CAD is a strong and independent predictor of mortality among patients with acute HF. Whether, for example, less restrictive use of revascularisation procedures in this elderly HF population can improve the outcome for patients with CAD warrants further study.

Transmyocardial laser revascularization: histopathological findings.

Transmyocardial laser revascularization (TMLR) is a new surgical technique clinically tested in patients with advanced severe coronary arteriosclerosis when classic routine treatment by medicaments, percutaneous transluminal coronary angioplasty (PTCA), or aorto-coronary bypass surgery does not improve symptoms of ischemic heart disease. During the procedure high-energy CO 2 laser performs 35-40 transmyocardial channels via left-sided thoracotomy. Channels are drilled from the epicardial side of the heart through the myocardium into the left ventricle cavity. Impulses are synchronized with EKG (diastole), the channel diameter is about 1 mm. Transmural laser penetration is confirmed by intraoperative transesophageal echocardiography (TEE). This technique is based on a theory that channels allow blood supply from left ventricle directly into the intramyocardial vessels (possibly capillaries) and so improve oxygenation of ischemic myocardium. Presented are gross and microscopic findings in a 75-year-old woman who suffered from classic class IV angina with shortness of breath. She had a history of an inferior myocardial infarct, ventricular tachyarrhythmia, aorto-coronary bypass, and mitral valvuloplasty. Her ejection fraction by echocardiography was 25%. Angiographically, she had multiple occlusions of native coronary arteries and diffuse distal stenosis in the graft of the left internal mammary artery (LIMA) to the left anterior descending coronary artery (LAD). Thirty six of forty laser pulses were confirmed by TEE as transmural. The patient died suddenly of ventricular fibrillation 5 days after TMLR surgery. The autopsy was performed 6 hours after death. After cross-sectioning of the heart all the laser-bored channels were found partially or completely filled by fibrin and cell infiltrate composed mainly of polymorphonuclear leukocytes. Patent channels were found within myocardial scars, channels performed through viable myocardium appeared to be partially collapsed and occluded.

Malignant tumors arising in endometriosis: clinical-pathological study and flow cytometry analysis.

BACKGROUND: Malignant transformation to endometriosis is a well documented phenomenon that occurs most commonly in the ovaries with cancer arising in extra-ovarian endometriosis being a rare event. METHODS: A retrospective clinical-pathological evaluation of eleven cases with malignant tumors arising in endometriosis was performed to evaluate the prognostic impact of various factors. Nuclear DNA content (ploidy) was assessed through flow cytometric study. RESULTS: Ovarian origin was identified in eight cases and three were associated with extra-ovarian endometriosis. Histologic type was endometrioid carcinoma in ten patients. The eleventh case had high grade endometrial stromal sarcoma. All tumors were diploid with no relation to stage, grade, or clinical outcome. The S-phase fraction (SPF) was analyzed in nine patients and no correlation could be demonstrated with any histologic parameters or clinical outcome. CONCLUSIONS: The DNA content seems to have no association with the classical prognostic parameters in these cases.

True aneurysm of the saphenous vein graft stump associated with CABG in a cardiac transplant patient.

Aneurysm of a saphenous vein graft after coronary artery bypass requires surgical resection because of its potential for rupture. This report describes a case of aneurysm formation in a 55-year-old man who underwent coronary artery bypass operation in 1977 and orthotopic heart transplantation 7 years later. A proximal vein graft remnant that had been ligated at the time of transplantation developed into a 5-cm aneurysm. In patients who have undergone previous coronary artery bypass operation, we recommend that the entire vein graft stump be excised and oversewn at the aortosaphenous anastomosis at the time of transplantation.

Iatrogenic stress fractures. / Iatrogenní zlomeniny z pretezování.

The author treated since 1982 85 fractures caused by overloading, incl. 19 which were associated with surgical, manipulation and medicamentous treatment. These iatrogenic influences altered statics and had a bearing on the locomotor stereotype causing deterioration of mechanical properties of osseous tissue and as a result of external rhythmic force during manipulation. Analysis of the causes makes it possible to draw preventive conclusions.

Case report 680. Intraosseous meningioma of the sphenoid bone.

Two cases of intraosseous meningioma of the calvaria with hyperostosis are presented and compared with the appearance on plain films and CT of en plaque meningioma, metastatic disease from such primary sites as prostatic cancer, and fibrous dysplasia. It is emphasized that intraosseous meningioma in the calvaria is relatively uncommon, occurring most often in the sphenoid bone (probably because of its numerous articulations). The relationship of the development of intraosseous meningioma to the entrapment of dura containing arachnoid cells is discussed in considering the cause of such lesions, and it is stressed that calvarial fractures and cranial sutures may contribute to the entrapment of arachnoidal tissue and later the formation of a meningioma.

[Early radiologic signs of stress fractures]. / Casné rentgenologické príznaky zlomenin z pretezování.

The authors present a retrospective evaluation of radiograms of 57 fractures from skeleton overload dealing with lower extremities. Three kinds of symptoms detected in the first radiological examination are presented. In addition to periostosis and sclerosis there is also a clearing as an expression of interrupted bone in a form of infraction, fissure or fracture. The symptoms may occur in combination.

Maternal malignancy metastatic to the products of conception: a review.

Documented reports of maternal malignancy metastatic to the placenta and fetus are rare. From 1866 until the present there have been 52 cases reported in the Western literature. We report a case of maternal large-cell carcinoma of the lung metastatic to the maternal brain and the placenta without fetal involvement.

Rare primary sarcomas of the heart.

Three patients with primary malignant cardiac neoplasms are described. All tumors were intracavitary myxomatous masses of the left atrium. Preoperative clinical diagnostic techniques did not indicate malignancy, but suggested mitral stenosis, cor triatriatum, and cardiac myxoma. Grossly, the tumors were sessile rather than pedunculated, and they invaded the underlying structures. Microscopically, although the tumors resembled benign cardiac myxomas, they exhibited mitotic activity and areas of necroses. Ultrastructural examination revealed a spectrum of differentiated mesenchymal cells that lacked the maturation features of cardiac myxoma cells. These gross, microscopic, and ultrastructural features, which suggested the tumors' malignant potential, should help in the early recognition and management of similar tumors.

Asymptomatic cavitary pneumonitis due to amiodarone pulmonary toxicity.

A 52-year-old woman presented with ventricular tachycardia after receiving amiodarone for the previous 18 months. The chest roentgenogram revealed evidence of multiple pleural-based cavitary nodules despite the absence of respiratory disease on clinical examination. The nodules were attributed to amiodarone because of histologic changes noted at open-lung biopsy. The cavitating nodules cleared with the discontinuation of amiodarone.