Plaque regression and improved clinical outcomes following statin treatment in atherosclerosis.

3-hydroxy-3-methylglutaryl-coenzymeA reductase inhibitors, or statins, represent an important class of agents that improve clinical outcomes in atherosclerotic cardiovascular disease. Aside from lowering total and low density lipoprotein cholesterol, statins have important pleiotropic effects that include anti-inflammatory, antioxidant, antithrombotic actions as well as mobilization of endothelial progenitor cells and modification of plaque cholesterol crystallization. These combined effects lead to atherosclerotic plaque stabilization that is both quantitative (slowing of plaque progression or plaque volume regression) as well as qualitative (reduced inflammation and amount of lipid rich necrotic plaque) in nature. Statins have been shown to reduce overall mortality when used for either primary or secondary prevention of cardiovascular disease in multiple randomized clinical trials, but such trials involve a large sample size, long treatment duration and enormous financial cost. Imaging of change in plaque burden by various means such as coronary angiography, intravascular and B mode ultrasound and magnetic resonance imaging represents a means of measuring surrogate endpoints by directly assessing statin effects on plaque regression. Multiple imaging studies have demonstrated plaque stabilization or regression with statin treatment that paralleled improvement in lipid profile and clinical outcomes, although it is unlikely that imaging modalities can replace hard clinical outcomes in assessing treatment efficacy.

Case report: Delayed enhancement on cardiac MRI in a patient with multiple myeloma without amyloidosis.

We report the first observation of diffuse subendocardial and myocardial delayed enhancement on cardiac MRI in a 50-year-old patient with recurrent multiple myeloma but without evidence of amyloidosis. She presented with advanced heart failure and severe restrictive cardiomyopathy. Myocardial biopsy revealed endomyocardial fibrosis. The case was associated with development of multiple arterial and venous thromboses and a fatal course. Because of the fatal outcome, the prognostic significance of delayed enhancement on MRI in multiple myeloma patients may need to be further investigated.

End-systolic volume index at 90 to 180 minutes into reperfusion therapy for acute myocardial infarction is a strong predictor of early and late mortality. The Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries (GUSTO)-I Angiographic Investigators.

BACKGROUND: Left ventricular remodeling is an important sequela of myocardial infarction (MI). Although remodeling occurs soon after MI, the effect of early left ventricular dilatation on outcome is not established and may be useful for early risk stratification. We assessed whether end-systolic volume index (ESVI) at 90 to 180 minutes into thrombolytic therapy for MI is associated with adverse outcomes. METHODS AND RESULTS: In the Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries (GUSTO)-I study, 41021 patients with evolving MI received one of four thrombolytic regimens. At 90 or 180 minutes into reperfusion therapy, 1300 patients underwent left ventriculography. ESVI was measured and correlated with adverse outcomes: 30-day and 1-year mortality and in-hospital congestive heart failure, shock, and reinfarction. Clinical variables were also tested in a stepwise logistic regression analysis to determine predictors of left ventricular dilatation. ESVI was directly related to all adverse outcomes with univariate analysis. ESVI of > or = 40 mL/m2 was independently associated with mortality (adjusted odds ratio [95% confidence interval]: 30-day, 3.4 [2.0 to 5.9]; 1-year, 4:1 [2.6 to 6.2], both P < .001). Male sex, prior angina or MI, weight of < 70 kg, heart rate of > or = 80 bpm, systolic blood pressure of < 110 mm.Hg, and anterior infarction were independent predictors of an ESVI of > or = 40 mL/m2. CONCLUSIONS: Left ventricular ESVI early into reperfusion therapy for MI strongly predicts adverse outcomes, including early and late mortality. The study establishes the role of very early left ventricular dilatation on outcome in MI and may be useful in identifying high-risk patients who might benefit from aggressive treatment, including the early use of ACE inhibitors.

Deep tissue infections caused by Scopulariopsis brevicaulis: report of a case of prosthetic valve endocarditis and review.

Scopulariopsis brevicaulis is a saprophytic fungus that commonly causes onychomycosis but rarely causes deep tissue infection. To the best of our knowledge, this is the first reported case of endocarditis caused by S. brevicaulis. The infection persisted despite two aortic valve replacements, debridement, and prolonged therapy with several antifungal agents. The patient eventually died due to an acute myocardial infarction caused by ongoing prosthetic valve endocarditis. We review case reports of deep tissue infections due to Scopulariopsis species.