Percutaneous Techniques for the Treatment of Patients with Functional Mitral Valve Regurgitation.

Percutaneous approaches to mitral regurgitation remain largely investigational. In the last decade, novel percutaneous strategies have opened new options in the treatment of valvular heart disease. Several studies are currently underway to determine the benefits of transcatheter mitral valve repair therapy. Transcatheter chordal procedures are being developed, including chordal cutting and chordal implantation. Transcatheter valve implantation in the mitral position might offer a desirable alternative in selected patients and has been accomplished in a compassionate fashion on rare occasions in patients who are not candidates for surgical valve repair or replacement.

Effects of optimal medical treatment with or without coronary revascularization on angina and subsequent revascularizations in patients with type 2 diabetes mellitus and stable ischemic heart disease.

BACKGROUND: In the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial, an initial strategy of coronary revascularization and optimal medical treatment (REV) compared with an initial optimal medical treatment with the option of subsequent revascularization (MED) did not reduce all-cause mortality or the composite of cardiovascular death, myocardial infarction, and stroke in patients with type 2 diabetes mellitus and stable ischemic heart disease. In the same population, we tested whether the REV strategy was superior to the MED strategy in preventing worsening and new angina and subsequent coronary revascularizations. METHODS AND RESULTS: Among the 2364 men and women (mean age, 62.4 years) with type 2 diabetes mellitus, documented coronary artery disease, and myocardial ischemia, 1191 were randomized to the MED and 1173 to the REV strategy preselected in the percutaneous coronary intervention (796) and coronary artery bypass graft (377) strata. Compared with the MED strategy, the REV strategy at the 3-year follow-up had a lower rate of worsening angina (8% versus 13%; P<0.001), new angina (37% versus 51%; P=0.001), and subsequent coronary revascularizations (18% versus 33%; P<0.001) and a higher rate of angina-free status (66% versus 58%; P=0.003). The coronary artery bypass graft stratum patients were at higher risk than those in the percutaneous coronary intervention stratum, and had the greatest benefits from REV. CONCLUSIONS: In these patients, the REV strategy reduced the occurrence of worsening angina, new angina, and subsequent coronary revascularizations more than the MED strategy. The symptomatic benefits were observed particularly for high-risk patients. CLINICAL TRIAL REGISTRATION: URL: http://www.ClinicalTrials.gov. Unique identifier: NCT00006305.

The prevalence and predictors of an abnormal ankle-brachial index in the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial.

OBJECTIVE: To examine ankle-brachial index (ABI) abnormalities in patients with type 2 diabetes and coronary artery disease (CAD). RESEARCH DESIGN AND METHODS: An ABI was obtained in 2,240 patients in the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) Trial. ABIs were classified as: normal, 0.91-1.3; low, ≤ 0.9; high, >1.3; or noncompressible artery (NC). Baseline characteristics were examined according to ABI and by multivariate analysis. RESULTS ABI was normal in 66%, low in 19%, and high in 8% of patients, and 6% of patients had NC. Of the low ABI patients, 68% were asymptomatic. Using normal ABI as referent, low ABI was independently associated with smoking, female sex, black race, hypertension, age, C-reactive protein, diabetes duration, and lower BMI. High ABI was associated with male sex, nonblack race, and higher BMI; and NC artery was associated with diabetes duration, higher BMI, and hypertension. CONCLUSIONS: ABI abnormalities are common and often asymptomatic in patients with type 2 diabetes and CAD.

Predictive value of high sensitivity C-reactive protein in the diagnosis and outcomes of acute aortic syndromes.

OBJECTIVE: The purpose of this study was to determine whether high-sensitivity C-reactive protein (hsCRP) levels differ among patients with acute aortic syndromes (AAS) and if hsCRP could predict their long-term outcomes. DESIGN: Retrospective observational study. SETTING: Cleveland Clinic Hospital, Cleveland, Ohio. PATIENTS: 115 consecutive patients with AAS admitted to the cardiac intensive care unit. INTERVENTIONS: HsCRP and other laboratory data were measured within 24 h of admission. Demographic, imaging and laboratory data were obtained at the time of presentation. For the long-term survival analysis, the social security death index was used to determine all-cause mortality. MAIN OUTCOME MEASURES: HsCRP levels among AAS patients. RESULTS: Hospital mortality was 4.3% for AAS patients. HsCRP levels differed significantly among AAS; the median hsCRP was higher in the aortic dissection group (49 mg/l) than in those with penetrating aortic ulcer (28 mg/l), symptomatic aortic aneurysm (14 mg/l), and intramural haematoma (10 mg/l); (p=0.02). In multivariable analysis, aortic dissection patients had higher hsCRP levels than intramural haematoma (p=0.03) and symptomatic aortic aneurysm (p=0.04) patients, after adjusting for age and gender. Multivariable Cox regression analyses showed that elevated hsCRP levels at presentation were associated with a higher long-term mortality (p=0.007). CONCLUSIONS: Among patients with AAS, those with aortic dissection have the highest hsCRP levels at presentation. Elevated hsCRP independently predicted a higher long-term mortality in AAS patients.

Clinical characteristics of tako-tsubo cardiomyopathy.

Tako-tsubo cardiomyopathy (TTC) is increasingly diagnosed in the United States, especially in the Caucasian population. To evaluate the clinical features and outcome of patients with TTC, we evaluated 34 patients (32 women and 2 men) 22 to 88 years of age (mean 66 +/- 14) who fulfilled the following criteria: (1) akinesia or dyskinesia of the apical and/or midventricular segments of the left ventricle with regional wall motion abnormalities that extended beyond the distribution of a single epicardial vessel and (2) absence of obstructive coronary artery disease. Twenty-five patients (74%) presented with chest pain, 20 patients (59%) presented with dyspnea, and 8 patients (24%) presented with cardiogenic shock. Twenty-two patients (65%) had ST-segment elevation and 14 patients (41%) had T-wave inversion on presentation. Twenty-five patients (74%) reported a preceding stressful event. Cardiac biomarkers were often mildly increased, with a mean troponin I (peak) of 13.9 +/- 24. Mean +/- SD left ventricular ejection fractions were 28 +/- 10% at time of presentation and 51 +/- 14 at time of follow-up (p <0.0001). Two patients (6%) died during the hospital stay. Average duration of hospital stay was 6.6 +/- 6.2 days. In conclusion, TTC is common in postmenopausal women with preceding physical or emotional stress. It predominantly involves the apical portion of the left ventricle and patients with this condition have a favorable outcome with appropriate medical management. The precise cause remains unclear.

Type 2 diabetes and coronary heart disease: focus on myocardial infarction.

Individuals with type 2 diabetes are more likely to experience a myocardial infarction and have worse outcomes compared with nondiabetic individuals. The underlying pathophysiology of the atherosclerotic process is accentuated but not significantly different in patients with type 2 diabetes. In addition, the prothrombotic state associated with diabetes may also contribute to the higher incidence of and worse prognosis after myocardial infarction. Difficulties of re-establishing vessel patency by thrombolytic or mechanical means due to diffuse coronary disease, altered vessel structure, and prothrombotic state can contribute to the high morbidity and mortality in these patients. The concurrent metabolic dysfunction contributes to impair compensatory mechanisms, which can increase infarct size and cause more impairment of left ventricular function. Aggressive medical therapy and careful modulation of glucose metabolism in the acute and follow-up phase of a myocardial infarction may favorably influence outcome.

Interindividual variation in serum sodium and longitudinal blood pressure tracking in the Framingham Heart Study.

BACKGROUND: Recent cross-sectional studies have suggested that higher serum sodium levels may be a marker of elevated blood pressure. It is unclear whether serum sodium levels are related to the risk of developing hypertension in the community. METHODS: We investigated the association of serum sodium with longitudinal blood pressure tracking and incidence of hypertension in 2172 nonhypertensive Framingham Offspring Study participants (mean age 42 years, 54% women). We defined an increase in blood pressure as an increment of at least one category (as defined by the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure), and incident hypertension as a systolic blood pressure of at least 140 or a diastolic blood pressure of at least 90 mmHg, or use of antihypertensive medications. Serum sodium was analyzed as a continuous variable, and as categories. RESULTS: Cross-sectionally, serum sodium was not associated with systolic or diastolic blood pressure (P exceeded 0.10). On follow-up (mean 4.4 years), 805 participants (37%, 418 women) progressed by at least one blood pressure category, and 318 (15%, 155 women) developed new-onset hypertension. In multivariable logistic regression analyses (adjusting for age, sex, baseline blood pressure, diabetes, BMI, weight gain and smoking), serum sodium was not associated with blood pressure progression (odds ratio per SD increment 0.93, 95% confidence interval 0.85-1.03), or with hypertension incidence (odds ratio per SD increment 0.94, 95% confidence interval 0.82-1.08). CONCLUSION: In our large community-based sample, serum sodium was not associated with blood pressure cross-sectionally, or with blood pressure tracking or hypertension incidence longitudinally.

Myocardial glucose transport and utilization: a target for therapeutic intervention.

Patients with type 2 diabetes mellitus (T2DM) have a 2-fold to 4-fold greater risk of cardiovascular mortality than nondiabetic individuals. The overall mortality rate of patients with T2DM is approximately twice that of people without diabetes. The excess in-hospital mortality of these patients is primarily due to an increased risk of congestive heart failure. Reduced compensatory ability of the noninfarcted myocardium and an underlying abnormality in the myocardial substrate metabolism (referable to the diabetic state) may also contribute to poor outcomes. Insulin resistance (IR) is a significant predictor of cardiovascular mortality and morbidity across a spectrum of glucose tolerance. Cardiac mass increases across the range of IR in subjects without diabetes, as well as across the range of glucose intolerance in subjects with diabetes. In one study, elevated fasting plasma glucose was an independent predictor of hospitalization for heart failure. Optimization of cardiac metabolism could become a new target for therapeutic intervention in patients with ischemic heart disease and diabetes.

Congestive heart failure and cardiovascular death in patients with prediabetes and type 2 diabetes given thiazolidinediones: a meta-analysis of randomised clinical trials.

BACKGROUND: The overall clinical benefit of thiazolidinediones (TZDs) as a treatment for hyperglycaemia can be difficult to assess because of the risk of congestive heart failure due to TZD-related fluid retention. Since prediabetic and diabetic patients are at high cardiovascular risk, the outcome and natural history of such risks need to be better understood. We aimed to examine the risk of congestive heart failure and of cardiac death in patients given TZDs. METHODS: We used a search strategy to identify 3048 studies. 3041 were excluded, and we did a systematic review and meta-analysis of the seven remaining randomised double-blind clinical trials of drug-related congestive heart failure in patients given TZDs (either rosiglitazone or pioglitazone). We calculated pooled random-effects estimates of the risk ratios for development of congestive heart failure in patients given TZDs compared with controls. The main outcome measures were development of congestive heart failure and the risk of cardiovascular death. FINDINGS: 360 of 20 191 patients who had either prediabetes or type 2 diabetes had congestive heart failure events (214 with TZDs and 146 with comparators). Results showed no heterogeneity of effects across studies (I2=22.8%; p for interaction=0.26), which indicated a class effect for TZDs. Compared with controls, patients given TZDs had increased risk for development of congestive heart failure across a wide background of cardiac risk (relative risk [RR] 1.72, 95% CI 1.21-2.42, p=0.002). By contrast, the risk of cardiovascular death was not increased with either of the two TZDs (0.93, 0.67-1.29, p=0.68). INTERPRETATION: Congestive heart failure in patients given TZDs might not carry the risk that is usually associated with congestive heart failure which is caused by progressive systolic or diastolic dysfunction of the left ventricle. Longer follow-up and better characterisation of such patients is needed to determine the effect of TZDs on overall cardiovascular outcome.

Transcatheter closure of atrial septal defects in adults using two devices: an angiographic overview.

Atrial septal defects are a common congenital cardiac abnormality in adults. lndividuals with atrial septal defects carry the risk to develop cardiac problems such as right ventricle volume overload, pulmonary hypertension, atrial fibrillation, and more rarely paradoxical embolic events. Surgery was the standard treatment for symptomatic patients with atrial septal defects for decades. More recently, percutaneous transcatheter closure of atrial septal defects in adults using a closure device has become an alternative to surgery in selected patients.