Pseudoaneurysm formation in infective endocarditis.

Left ventricular pseudoaneurysms that develop in the setting of infective endocarditis are believed to result from remodeling of extravalvular abscesses. The high pressure generated by the left ventricle is thought to dissect into the abscess causing it to form a characteristic sac-like protuberance readily recognized echocardiographically. Left ventricular pseudoaneurysms most often arise from abscesses in the mitral-aortic intervalvular fibrosa and protrude external to the aorta. Less often, as described herein, they arise from abscesses external the posterior mitral annulus and project into the posterior interventricular groove. Perforation may result in camo-cameral or aorto-cameral fistula formation, as well as fistulous communication with the pericardial space.

Risk factor control for coronary artery disease secondary prevention in large randomized trials.

OBJECTIVES: This study evaluated data from 3 federally funded trials that focused on optimal medical therapy to determine if formalized attempts at risk factor control within clinical trials are effective in achieving guideline-driven treatment goals for diabetic patients with coronary artery disease (CAD). BACKGROUND: Despite clear evidence of benefit for CAD secondary prevention, the level of risk factor control in clinical practice has been disappointing. METHODS: We obtained data from the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) diabetes subgroup, (n = 766 of 2,287), the BARI 2D (Bypass Angioplasty Revascularization Investigation 2 Diabetes) trial (n = 2,368), and the FREEDOM (Comparison of Two Treatments for Multivessel Coronary Artery Disease in Individuals With Diabetes) trial (n = 1,900) to evaluate the proportion of patients achieving guideline-based, protocol-driven treatment targets for systolic blood pressure, low-density lipoprotein cholesterol, smoking cessation, and hemoglobin A1c. The primary outcome measure was the proportion of diabetic CAD patients meeting all 4 pre-specified targets at 1 year after enrollment. RESULTS: The pooled data include 5,034 diabetic patients. The percentages of patients achieving the 1-year low-density lipoprotein cholesterol targets compared with baseline increased from 55% to 77% in COURAGE, from 59% to 75% in BARI 2D, and from 34% to 42% in FREEDOM. Although similar improved trends were seen for systolic blood pressure, glycemic control, and smoking cessation, only 18% of the COURAGE diabetes subgroup, 23% of BARI 2D patients, and 8% of FREEDOM patients met all 4 pre-specified treatment targets at 1 year of follow-up. CONCLUSIONS: A significant proportion of diabetic CAD patients fail to achieve pre-specified targets for 4 major modifiable cardiovascular risk factors in clinical trials. We conclude that fundamentally new thinking is needed to explore approaches to achieve optimal secondary prevention treatment goals. (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation; NCT00007657) (Bypass Angioplasty Revascularization Investigation 2 Diabetes [BARI 2D]; NCT00006305) (Comparison of Two Treatments for Multivessel Coronary Artery Disease in Individuals With Diabetes [FREEDOM]; NCT00086450).

Biomarkers after risk stratification in acute chest pain (from the BRIC Study).

Current models incompletely risk-stratify patients with acute chest pain. In this study, N-terminal pro-B-type natriuretic peptide and cystatin C were incorporated into a contemporary chest pain triage algorithm in a clinically stratified population to improve acute coronary syndrome discrimination. Adult patients with chest pain presenting without myocardial infarction (n = 382) were prospectively enrolled from 2008 to 2009. After clinical risk stratification, N-terminal pro-B-type natriuretic peptide and cystatin C were measured and standard care was performed. The primary end point was the result of a clinical stress test. The secondary end point was any major adverse cardiac event at 6 months. Associations were determined through multivariate stratified analyses. In the low-risk group, 76 of 78 patients with normal levels of the 2 biomarkers had normal stress test results (negative predictive value 97%). Normal biomarkers predicted normal stress test results with an odds ratio of 10.56 (p = 0.006). In contrast, 26 of 33 intermediate-risk patients with normal levels of the 2 biomarkers had normal stress test results (negative predictive value 79%). Biomarkers and stress test results were not associated in the intermediate-risk group (odds ratio 2.48, p = 0.09). There were 42 major adverse cardiac events in the overall cohort. No major adverse cardiac events occurred at 6 months in the low-risk subgroup that underwent stress testing. In conclusion, N-terminal pro-B-type natriuretic peptide and cystatin C levels predict the results of stress tests in low-risk patients with chest pain but should not be substituted for stress testing in intermediate-risk patients. There is potential for their use in the early discharge of low-risk patients after clinical risk stratification.

Clustering of metabolic abnormalities among obese patients and mortality after percutaneous coronary intervention.

Although current literature demonstrates metabolic abnormalities are associated with mortality, obese patients who tend to have more metabolic abnormalities paradoxically have lower overall mortality rates compared to their normal-weight counterparts. In this study, we examined the prevalence of metabolic abnormality clustering and its relation to mortality in obese and normal-weight patients after percutaneous coronary intervention (PCI). Patients (n = 9,673) undergoing elective PCI from October 2003 through December 2006 at a single urban hospital were categorized by body mass index (BMI) levels of 18.5 to 24.9, 25.0 to 29.9, 30.0 to 34.9, and ≥35 kg/m(2) and by number of metabolic abnormalities possessed (hypertension, impaired fasting glucose/diabetes, triglycerides ≥150 mg/dl, high-density lipoprotein cholesterol < 40 mg/dl, and C-reactive protein ≥2.0 mg/L). All-cause mortality was assessed through June 30, 2007. Mean age of patients was 65.9 years and 66% were men. Prevalences of 4 or 5 metabolic abnormalities were 12%, 18%, 24%, and 31% in patients with BMI levels of 18.5 to 24.9, 25.0 to 29.9, 30 to 34.9, and ≥35 kg/m(2), respectively. In patients with BMI of 30.0 to 34.9 kg/m(2), hazard ratios (95% confidence intervals) for mortality associated with 2, 3, and 4 to 5 metabolic abnormalities versus 0 to 1 metabolic abnormality were 1.31 (0.79 to 2.17), 1.42 (0.83 to 2.43), and 2.39 (1.24 to 4.59), respectively. Analogous hazard ratios for patients with BMI ≥35 kg/m(2) were 1.94 (0.90 to 4.20), 1.44 (0.63 to 3.28), and 2.17 (0.91 to 5.18). All-cause mortality rates per 1,000 person-years were 55.5, 33.7, 28.3, and 33.8 in patients with BMI levels of 18.5 to 24.9, 25 to 29.9, 30 to 34.9, and ≥35 kg/m(2), respectively. In conclusion, BMI levels of 25.0 to 29.9 and 30 to 34.9 kg/m(2) were associated with lower all-cause mortality after PCI. However, an increased number of metabolic abnormalities translated into increased all-cause mortality.

Platelet perturbations in diabetes: implications for cardiovascular disease risk and treatment.

The prevalence of Type 2 diabetes mellitus (DM) continues to increase globally and brings with it a parallel increase in the associated cardiovascular disease complications. Despite advances in evidence-based therapies for cardiovascular disease risk modification, many of which are especially effective among patients with DM, there remains a residual degree of cardiovascular disease risk associated with DM, yielding opportunity for continued clinical advances. Given the myriad perturbations of platelet function associated with DM, improvements in antiplatelet therapies hold particular promise for this high-risk population of patients, with emerging data from ex vivo assessments and clinical outcomes trials providing a basis of support for this concept.

Cardiomyopathy in type 2 diabetes: update on pathophysiological mechanisms.

Type 2 diabetes mellitus (DM) is associated with increased risk for developing heart failure (HF) and worse outcomes once HF is present. While the exact mechanisms underpinning these observations remain poorly understood, several metabolic perturbations associated with DM have been implicated as contributors to the HF risk, including alterations of cardiomyocyte metabolic substrate switching between free fatty acid (FFA) and glucose metabolism; increased FFA exposure and cellular accumulation; and alterations in peroxisome proliferator-activated receptor-(PPAR-)alpha activity, among others. The commonly coincident conditions of left ventricular hypertrophy and ischemic heart disease likely confound the metabolic derangements further increasing HF risk. Continued investigation into these mechanistic connections is necessary to better understand the pathophysiology and ideally inform the pursuit of novel therapeutic targets and strategies to intervene on the HF associated with DM.

Drug eluting stents for below the knee lesions in patients with critical limb ischemia : long-term follow-up.

OBJECTIVES: The purpose of this study was to assess the long-term limb preservation and/or healing of ulcers in patients with critical limb ischemia (CLI) and severe infrapopliteal atherosclerotic disease treated with drug eluting stents (DES). BACKGROUND: Percutaneous revascularization has become an effective treatment for CLI in patients with infrapopliteal atherosclerotic disease. Recent reports using DES in patients with CLI have documented excellent short-term infrapopliteal vessel patency. Higher primary patency rates in infrapopliteal vessels treated with DES could translate into better long-term clinical outcomes and improved limb salvage rates. METHODS: Twenty-four consecutive patients with CLI (defined as rest pain, nonhealing ulcers, or gangrene) because of severe infrapopliteal disease were treated with DES from August 2004 to June 2006. RESULTS: Procedural success was achieved in 96% (27/28) of targeted lesions. There were no procedure-related deaths, acute vessel thrombosis events, or need for urgent surgical intervention. There was one case of distal embolization. Clinical follow up, ranging 8-34 months, is available for 100% of patients of which 83% (20/24) achieved limb preservation and healing. Angiographic and/or sonographic follow up, ranging 6-34 months, is available in 79% (19/24) of patients of which 95% (18/19) had patent target vessels. CONCLUSIONS: DES is a safe and effective long-term option for CLI due to severe infrapopliteal arterial disease. Long-term vascular patency led to a high rate of limb preservation and low amputation rate. A multicenter trial should further elucidate the role of DES in the treatment of CLI.