Infective endocarditis caused by Gemella haemolysans in a patient with bicuspid aortic valve: A case report.

Gemella haemolysans is a gram-positive coccus, and commensal of the upper respiratory tract and oral mucosa. In rare cases, it has been identified as an opportunistic pathogen in the development of endocarditis. Here, we describe a case of Gemella haemolysans endocarditis in a patient with bicuspid aortic valve. A 14-year-old male presented to our hospital with a 1-month history of intermittent fever. Gemella haemolysans was isolated from the patient's blood cultures. Transesophageal echocardiography revealed severe aortic stenosis and a pseudoaneurysm of the mitral-aortic intervalvular fibrosa. The patient underwent aortic valve replacement with pseudoaneurysm of the mitral-aortic intervalvular fibrosa repair and remained symptom-free during follow-up. This case highlights the importance of considering atypical pathogens as causative agents of infective endocarditis.

Ventricular Septal Defect and Right-Sided Infective Endocarditis.

Right-sided infective endocarditis (IE), which represents a small but not negligible percentage of IE cases, can be observed in patients with congenital heart diseases. We discuss the case of a young woman with unrepaired perimembranous ventricular septal defect and repeated episodes of right ventricle and tricuspid valve IE with septic embolism.

Never too Grown-Up for a Congenital Heart Disease: Diagnosis of Transitional Atrioventricular Canal in a 50-Year-Old Male.

Transitional atrioventricular (AV) septal defects are uncommon congenital heart defects, and diagnosis is usually made in childhood. We present the case of intermediate AV canal diagnosed in a man referring to cardiological examination for the first time in his life at the age of fifty for exertional dyspnea. The absence of medical examination or execution of electrocardiogram or echocardiogram in childhood or in youth and the very late appearance of symptoms lead to a late diagnosis of this congenital heart disease (CHD). This case underlines the importance of including CHD in the differential diagnosis of symptoms such as chronic dyspnea, also in adulthood.

Surgical management of a free-floating thrombus in the ascending aorta.

The ascending aorta is an uncommon site of noninfective thrombus. We describe the case of a 63-year-old woman who was admitted to our department with acute myocardial infarction. Coronary angiography showed occlusion of a small diagonal vessel, likely related to a distal embolization event. A transthoracic echocardiogram revealed a free-floating mass in the proximal ascending aorta. Two-and 3-dimensional transesophageal echocardiography studies were performed, and after a multidisciplinary heart team discussion, surgical removal of the mass was planned and successfully performed through a median sternotomy on cardiopulmonary bypass.

Is the definition of daytime and nighttime blood pressure prognostically relevant?

OBJECTIVES: Although the prognostic value of the day-night blood pressure (BP) changes is well established, the most appropriate method for definition of daytime and nighttime BP is still undefined. In a recent guidelines document of the European Society of Hypertension, there is no clear position in favor of one definition over other. METHODS: In the setting of the Progetto Ipertensione Umbria Monitoraggio Ambulariale study, we analyzed the prognostic impact of the day-night BP changes by using three widely used different definitions of day and night (large fixed-clock intervals, narrow fixed-clock intervals, diary) in 2934 initially untreated participants with essential hypertension. RESULTS: Three hundred and fifty-six cardiovascular events and 176 deaths over a median follow-up period of 7 years were observed. Nondippers showed a higher risk of total cardiovascular events and all-cause mortality than dippers regardless of the definition of day and night. Furthermore, the area under a receiver-operated characteristic curve analysis did not differ among the different definitions of day and night (large fixed-clock intervals, narrow fixed-clock intervals, diary) for total cardiovascular events and all-cause mortality (all P=NS). CONCLUSION: The data suggest that the prognostic value of the diurnal BP changes is comparable when day and night are defined using large fixed-clock intervals, narrow fixed-clock intervals, or actual time spent in and out of bed.

Effects of barnidipine on blood pressure and left ventricular diastolic function in patients with hypertension and metabolic syndrome: A 12-week, open-label noncomparison study.

BACKGROUND: Barnidipine is one of a new generation of dihydropyridine calcium-channel blockers. Despite evidence of favorable effects on blood pressure (BP) and insulin sensitivity, this drug has rarely been tested in hypertensive patients with metabolic syndrome (MS). OBJECTIVE: The aim of this study was to evaluate the effects of barnidipine on BP and left ventricular (LV) diastolic function in patients with hypertension and MS. METHODS: Consecutive subjects aged 18 to 75 years with systolic BP (SBP) of 140 to 179 mm Hg and/or diastolic BP (DBP) of 90 to 109 mm Hg and MS (based on Adult Treatment Panel III criteria) were assessed for inclusion in the study. Lifestyle changes according to current guidelines were recommended and barnidipine monotherapy 10 mg daily was initiated. All patients entered a 2-week run-in period. After a 6-week treatment period, the daily dosage was doubled for the remainder of the study in patients whose BP remained uncontrolled (≥140/≥90 mm Hg). We assessed the glycolipidic profile and LV structure and function using standard Doppler and tissue Doppler imaging (TDI) echocardiography before and after 12 weeks of treatment. Ambulatory BP records and electrocardiographic and echocardiographic tracings were coded and shipped to a central laboratory for blinded analysis. Possible adverse events (AEs) were recorded at predetermined intervals throughout the follow-up period and at unplanned intervals whenever an AE became known to the investigators. RESULTS: Thirty-four consecutive patients were assessed for inclusion. Thirty consecutive patients (20 men, 10 women; mean {SD| age, 55.9 {10.3| years; 5 current smokers) were included in the study. At study entry, mean office SBP was 146 mm Hg, DBP was 87 mm Hg, and heart rate was 72 beats/min. At the study end, mean office SBP/DBP was <140/90 mm Hg in 20 patients (66.7%). From baseline to study end, 24-hour ambulatory BP decreased significantly by 12 and 8 mm Hg for SBP and DBP, respectively (both, P = 0.001). The smoothness index was 0.92 for SBP and 0.82 for DBP. Fasting plasma glucose concentration decreased significantly from 110 to 104 mg/dL (P = 0.001). Total cholesterol, high-density lipoprotein cholesterol, and low-density lipoprotein cholesterol concentrations did not change significantly. From baseline to study end, there were no significant changes in LV structure or systolic function (LV mass, 50.7 vs 50.6 g/ht(2.7); LV diastolic/systolic diameters, 47.50/29.80 vs 48.40/30.76 mm; wall motion score index, 1.0 vs 1.0; ejection fraction, 61% vs 60%), while the peak E/A velocity ratio on TDI increased from 1.078 to 1.245 (P = 0.009). No AEs (including AEs reflected by chemistry values) either unrelated or related to treatment were noted during the 12-week duration of the study. CONCLUSIONS: In these hypertensive patients with MS, a 12-week treatment period with barnidipine in addition to lifestyle modifications was associated with significant reductions in 24-hour BP and BP variability, reduction in plasma glucose concentration, and improvement in LV diastolic relaxation. No significant changes in lipid concentrations, LV structure, or systolic function were found.

The clinical significance of white-coat and masked hypertension.

OBJECTIVE: Self-measured blood pressure (BP) and 24-hour ambulatory blood pressure (ABP) monitoring are used to define the arbitrary clinical categories of masked hypertension (MH) and white-coat hypertension (WCH). Severity of target organ damage and incidence of major cardiovascular events are greater in patients with MH than in patients whose BP is normal both inside and outside the doctor's office. METHODS: We reviewed studies that addressed the prognostic impact of MH and WCH. RESULTS: Overall, WCH was associated with a better outcome and MH to a poor outcome. We, however, need the criteria to identify the clinically normotensive patients at elevated pretest probability of MH in whom a broad use of self-measured home BP and 24-hour ambulatory BP as screening tests may be appropriate and cost effective. Clinical management of patients with MH should continue to be based on current guidelines and mostly related to target organ damage and associated clinical conditions because of the normal values of clinic BP in these patients. WCH is generally defined by the coexistence of persistently high office BP with normal daytime or 24-hour ABP. Daytime ABP normalcy has been defined by values<135/85 mmHg. Data, however, suggest that incidence of cardiovascular events tends to increase consistently above the cut-off value of 130/80 mmHg for daytime BP. CONCLUSION: The long-term outcome of patients with WCH remains uncertain. Data suggesting an increased risk of stroke need to be confirmed in wide-scale studies.

Validation of the A&D wrist-cuff UB-511 (UB-512) device for self-measurement of blood pressure.

OBJECTIVES: To determine the accuracy of the A&D UB-511 (UB-512) oscillometric wrist-cuff device for self-measurement of blood pressure, the only difference between the two devices being the size of storage memory. METHODS: Device evaluation was performed according to the modified British Hypertension Society protocol released in 1993. Eighty-five study participants with characteristics outlined in the British Hypertension Society protocol were recruited among those attending our out-patient clinic. The device was evaluated according to the various steps of the protocol. The non-dominant arm was used for blood pressure measurement. To maintain the wrist at cardiac level during validation, the arm was kept horizontal at the mid-sternum level and supported by a soft table. The wrist was kept extended. Sequential readings were taken for the main validation test. Outcome was classified according to the criteria of the British Hypertension Society recommendations, which are based on four strata of accuracy differing from the mercury standard by 5, 10 and 15 mmHg, or more. RESULTS: The device achieved a British Hypertension Society grade B for systolic and a grade B for diastolic blood pressure. The device tended to overestimate arm blood pressure, the mean difference (+/-1 SD) between device and observers being 4.3+/-8.7 mmHg for systolic blood pressure and 3.7+/-8.1 mmHg for diastolic blood pressure for observer 2, and 4.4+/-8.6 mmHg for systolic blood pressure and 3.8+/-7.9 mmHg for diastolic blood pressure for observer 1. In a logistic regression analysis, age was the sole predictor of an achieved difference between device and mercury column by 5 mmHg or less (hazard ratio 1.020; 95% confidence interval 1.003-1.04; P=0.024). CONCLUSIONS: These data show that the A&D UB-511 (UB-512) device satisfies the British Hypertension Society recommendations with a grade B/B. The device tends to overestimate cuff blood pressure and its accuracy increases with age.

Day-to-day variability of electrocardiographic diagnosis of left ventricular hypertrophy in hypertensive patients. Influence of electrode placement.

OBJECTIVE: Although electrocardiography (ECG) is recommended in all subjects with hypertension, no information is available on the influence exerted by random changes in the placement of electrodes on the day-to-day variability of ECG criteria for diagnosis of left ventricular hypertrophy (LVH). METHODS: In a multicentre, randomized study, two standard 12-lead ECG were recorded, 24 h apart, from 276 consecutive hypertensive patients (mean age 65 +/- 12 years, 49.6% men). Overall, 142 patients were randomized to ECG with the position of electrodes marked on the skin using a dermographic pen and 134 to traditional ECG without marking the position of electrodes. Day-to-day variability of ECG criteria for LVH was compared between the two groups. RESULTS: Coefficients of variation (SD of the difference between paired voltage measurements divided by the mean value) varied consistently among subjects randomized to ECG without dermographic pen, ranging from 30% (R wave in lead I) to 81% (R wave in lead V5). Dermographic pen led to a lesser variability of ECG voltages with consequent reduction in the coefficients of variation, which ranged from 26% (R-wave amplitude in lead I) to 43% (R-wave amplitude in lead V5). The proportion of subjects who changed classification status for LVH ('reclassification rate') from the first to the second ECG session (LVH present in session 1 and absent in session 2, or vice versa) decreased for effect of dermographic pen from 11 to 4% (P = 0.040) with the Cornell voltage, from 19 to 11% (P = 0.029) with the Sokolow-Lyon voltage, and from 18 to 7% with the Romhilt-Estes criterion (P = 0.018), but not with other criteria. In particular, the typical strain and the Cornell strain were associated with the lowest reclassification rates regardless of dermographic pen. CONCLUSIONS: Random changes in the position of ECG electrodes strongly impair the day-to-day reproducibility of Cornell voltage, Sokolow-Lyon and Romhilt-Estes criteria for LVH. The typical strain and Cornell strain criteria showed a lesser spontaneous day-to-day variability.

Regression of left ventricular hypertrophy and prevention of stroke in hypertensive subjects.

BACKGROUND: Left ventricular hypertrophy (LVH) is a risk marker for stroke and its regression confers protection from stroke. The relationship between serial LVH changes and risk of stroke has never been investigated in a mixed population of hypertensive subjects with and without LVH. METHODS: In this study, 880 initially untreated hypertensive subjects (mean age 48 years, office blood pressure (BP) 155/98 mm Hg; 24-h BP 137/87 mm Hg) underwent tests including echocardiography and 24-h ambulatory BP monitoring at entry and after a median of 3.5 years, still in the absence of cardiovascular events. RESULTS: Months or years after the follow-up study, 34 of these subjects developed a first cerebrovascular event (stroke in 21, transient ischemic attack in 13). Event rate (x 100 patients per year) was 0.25 among the subjects who never developed echocardiographic LVH or with regression of LVH, versus 1.16 among the subjects with lack of regression or new development of LVH (log-rank test: P = .00001). Serial electrocardiogram (ECG) changes failed to define groups at different risk. In a Cox analysis, the risk of cerebrovascular events was 2.8 times higher (95% CI: 1.18-6.69) in the subset with lack of regression or new development of LVH than in that with LVH regression or persistently normal LV mass. Such effect was independent of age (P = .001) and 24-h systolic BP (P = .003). CONCLUSIONS: In a mixed hypertensive population with and without LVH at entry, serial changes in the echocardiographic indexes of LVH predict subsequent cerebrovascular events independently of office and ambulatory BP and other individual risk factors.

Asymptomatic left ventricular systolic dysfunction in essential hypertension: prevalence, determinants, and prognostic value.

Prevalence, determinants, and prognostic value of asymptomatic left ventricular systolic dysfunction (LVSD) in uncomplicated subjects with essential hypertension are still incompletely known. We studied 2384 initially untreated subjects with hypertension, no previous cardiovascular disease, and no symptoms or physical signs of congestive heart failure (CHF). These subjects were studied at entry and followed for up to 17 years (mean 6.0). Asymptomatic LVSD (ALVSD), defined by an echocardiographic ejection fraction <50%, was found in 3.6% of subjects. Cigarette smoking (P=0.013), increased left ventricular (LV) mass (P=0.001), and higher 24-hour heart rate (P=0.014) were independent correlates of ALVSD. During follow-up, a first cardiovascular event occurred in 227 subjects, and 24 of these events were hospitalizations for symptomatic CHF. Incidence of CHF per 100 persons per year was 0.12 in patients without and 1.48 in patients with ALVSD (log-rank test P=0.0001). In a Cox model, after adjustment for age (P=0.0001), LV mass (P=0.0001), and cigarette smoking (P=0.039), LVSD conferred a markedly increased risk for CHF (odds ratio, 9.99; 95% confidence interval, 3.67 to 27.2). Incidence of coronary (0.84 versus 0.62x100 person years) and cerebrovascular (0.80 versus 0.62x100 person years) events did not differ (all P=NS) between subjects with and without ALVSD. ALVSD is a potent and early marker of evolution toward severe CHF requiring hospitalization in subjects with essential hypertension.

White-coat hypertension in adults.

White-coat hypertension is defined by the coexistence of persistently high office blood pressure (BP) with normal self-measured or ambulatory blood pressure. The prognostic impact of white-coat hypertension is a subject of debate. Cardiovascular morbidity seems to be lower in white-coat hypertension than in ambulatory hypertension, and, according to some but not all studies, is not dissimilar between white-coat hypertension and clinical normotension. In a large collaborative study including individual data from four prospective cohort studies, the incidence of stroke tended to increase in the white-coat hypertension group in the long run, crossing the hazard curve of the ambulatory hypertension by the ninth year of follow-up. These data raise the hypothesis, to be tested in future studies, that white-coat hypertension might not be a benign condition for stroke in the long term. Further studies are needed in order to: (1) test whether white-coat hypertension is really a benign condition for stroke in the long term; (2) compare, in patients with white-coat hypertension, a regimen based on life-style measures without drugs and a standard regimen consisting of life-style measures with the possible addition of drugs. On the basis of current evidence, it is reasonable to suggest a treatment based on life-style measures in the low-risk stratum of patients with white-coat hypertension under the conditions of correct definition, absence of comorbid conditions and target-organ damage, and adequate follow-up

Effects of acute myocardial ischemia on QT dispersion by dipyridamole stress echocardiography.

Increased dispersion of the QT interval has been observed during pacing or exercise stress testing in patients with coronary artery disease (CAD). It has not been established whether this phenomenon is a consequence of ischemia. Therefore, we sought to evaluate whether dipyridamole-induced myocardial ischemia, as directly detected by echocardiographic monitoring of regional contractile function, would affect QT dispersion. Twenty-four patients with nonsignificant and 34 patients with significant CAD but no previous myocardial infarction underwent dipyridamole stress echocardiography while not taking medications. QT dispersion was measured on a 12-lead electrocardiogram at baseline and at various times after dipyridamole infusion. Dipyridamole infusion did not influence QT dispersion in patients without CAD. QT dispersion was similarly unaffected in patients with CAD in whom dipyridamole did not induce wall motion abnormalities. In contrast, in patients with positive dipyridamole stress test findings, QT dispersion increased from 60 +/- 17 ms at baseline to 94 +/- 25 ms during peak infusion (p <0.0001), with a time course mirroring that of development of contractile abnormalities. QT dispersion returned to 63 +/- 25 ms upon relief of ischemia by administration of aminophylline. The increase in QT dispersion was significantly related to the extent of contractile dysfunction induced by dipyridamole. Although ST-segment depression occurred in only 40% of patients with positive dipyridamole stress test findings, 88% of such patients had an increase in QT dispersion. Analysis of the receiver-operating characteristic curve showed that a QT dispersion increase of > or =20 ms identified positive findings for dipyridamole stress echocardiography with 68% sensitivity and 91% specificity. Thus, QT dispersion is acutely affected by myocardial ischemia induced by the administration of dipyridamole. Measurement of QT dispersion may improve detection of stress-induced ischemia on surface electrocardiograms.