Intracoronary epinephrine versus adenosine in the management of refractory no-reflow phenomenon: a single-center retrospective cohort study.

BACKGROUND: The no-reflow phenomenon is associated with a considerable reduction in myocardial salvage in patients with ST elevation myocardial infarction (STEMI) treated by primary percutaneous intervention (PCI). There has been no head-to-head comparison of intra-coronary epinephrine to adenosine in the management of no-reflow phenomenon. OBJECTIVES: Evaluate the short- and long-term efficacy and safety of using intracoronary epinephrine versus adenosine for management of the catastrophic no-reflow phenomenon that may occur during primary PCI. DESIGN: Retrospective cohort. SETTING: Single center in Egypt. PATIENTS AND METHODS: The study included STEMI patients who developed refractory no-reflow phenomenon during primary PCI after failure of conventional treatments and received either intracoronary epinephrine or adenosine. MAIN OUTCOME MEASURES: No-reflow management measured through improvement of thrombolysis in myocardial infarction grade (TIMI flow), myocardial blush grade, TIMI frame count and major adverse cardiovascular events (MACE) at 1-year follow up. SAMPLE SIZE: 156 patients with refractory no-reflow phenomenon during primary PCI. RESULTS: Successful reperfusion was achieved in 74 of 81 (91.4%) of patients who received epinephrine and in 65 of 75 (86.7%) who received adenosine (P<.05). Fifty-six of 81 patients (69.1%) achieved TIMI III flow after epinephrine administration versus 39 of 75 patients (52.7%) in the adenosine group (P=.04). The incidence of heart failure after 1 year of follow up was lower in the epinephrine group compared to the adenosine group (6.3% vs. 19.2%, P<.017). MACE after 1 year of follow up was lower in patients who received epinephrine compared to those who received adenosine (11.3 % Vs. 26.7 %, P<.01). CONCLUSION: During primary PCI, intracoronary epinephrine is as effective as adenosine in successful management of refractory no-reflow phenomenon with a more favorable long-term prognosis compared to adenosine. LIMITATIONS: Retrospective design. CONFLICT OF INTEREST: None.

Relation between left atrial strain and exercise tolerance in patients with mild mitral stenosis: An insight from 2D speckle-tracking echocardiography.

BACKGROUND: Mild mitral stenosis (MS) is a progressive disease but unfortunately, its clinical course is still unclearly studied. We aimed to study the left atrial (LA) deformation in such patients and how it is related to exercise intolerance. METHODS: Seventy-five patients with mitral valve area of 1.81 ± 0.13 cm2 and 40 healthy control subjects were enrolled. All participants had sinus rhythm, and they underwent conventional echocardiography and LA strain analysis with speckle-tracking study. The following parameters were obtained: left atrial reservoir strain (LAS-s), LA conduit strain (LAS-e), and LA contraction strain (LAS-a). All participants underwent symptoms limited stress ECG using modified Bruce protocol. RESULTS: Comparing with control subjects, patients with mild MS had significant lower LAS-s value (P < .01) and LAS-e (<0.03). Patients with exercise intolerance (METs < 8) had lower LAS-s (P < .001), LAS-e (P < .01), and LAS-a (P < .05) values compared to those with METs ≥ 8. We found that METs was significantly related to LAS-s (P < .001), brain natriuretic peptide (P < .001), and Δ TAPSE (P < .03). Multivariate analysis showed that LAS-s was an independent predictor of reduced exercise capacity. With ROC analysis, LAS-s ≤ 26.5% was the optimal value for prediction of exercise intolerance in patients with mild MS. CONCLUSION: A significant percentage of patients with mild mitral stenosis had exercise intolerance. We found that LAS-s was significantly associated with exercise capacity in patients with mild MS. Hence, we thought that LA deformation could be of great value in the follow-up of patients with mild MS.

Relation of microvascular dysfunction and exercise tolerance in patients with heart failure with preserved ejection fraction.

PURPOSE: We aimed to investigate the association of coronary flow reserve (CFR) with exercise tolerance (ET) in subjects with heart failure with preserved ejection fraction (HFpEF). MATERIALS AND METHODS: Seventy-seven patients with HFpEF were recruited for the study and compared with 30 healthy matched age and sex controls. All subjects underwent comprehensive echocardiographic evaluation. Exercise tolerance was assessed using 6-minute walking test (6 MWT). CFR was calculated with adenosine stress transthoracic Doppler echocardiography. RESULTS: Out of 77 patients with HFpEF, 51 (66%) had CFR < 2.0. Patients with CFR < 2.0 had lower 6 MWT distance (P < .001), increased E/e' ratio (P < .001), when compared to HFpEF patients with CFR ≥ 2.0 and controls. In subjects with HFpEF, CFR was significantly correlated with 6 MWTD (P < .001) and inversely correlated with E/e" (P < .01). With univariate analysis, the results showed that left ventricular mass index, left atrial volume index, E/e', and CFR were independent predictors for reduced exercise tolerance, whereas at multivariate analysis, reduced CFR was the only independent predictor (P < .001) for both reduced exercise tolerance in patients with HFpEF. CONCLUSION: The current study demonstrated that reduced CFR was an independent predictor for reduced exercise tolerance in patients with HFpEF. We supposed that microvascular dysfunction has an important role in pathogenesis and clinical course in subjects with HFpEF.

Right ventricular mechanics and exercise capacity in patients with microvascular angina: The impact of microvascular function.

OBJECTIVES: We planned to assess the right ventricular mechanics in subjects with typical chest pain and angiographically normal coronary arteries (microvascular angina [MVA]) and to search for an association between right ventricular mechanics, coronary flow reserve, and exercise tolerance. METHODS: Seventy-one patients with MVA (mean age of 48.5 ± 7.9 years, 63% female) and 30 healthy control subjects were recruited. Right ventricular mechanics were calculated utilizing speckle tracking imaging. The exercise capacity was assessed by metabolic equivalents (METs). Coronary flow reserve (CFR) was calculated as the ratio between hyperemic (in response to intravenous adenosine) diastolic peak flow velocity and the basal diastolic peak velocity. RESULTS: Coronary flow reserve (a surrogate marker of microvascular dysfunction) was diminished in MVA patients compared with the control group (2.41 ± 0.35 vs 3.35 ± 0.5; P < .03). Patients with lower right ventricular global longitudinal strain (RVGLS) and right ventricular global longitudinal strain rate (RVGLSr) had a considerably lower CFR (P < .001) and a significantly lower MET (P < .001) than patients with normal RV mechanics. Right ventricular global longitudinal strain and RVGLSr were significantly correlated with both CFR and METs in subjects with MVA. Receiver operating characteristic (ROC) curve analysis demonstrated that RVGLS ≤ -14.5 was the best cutoff value for the prediction of impaired exercise tolerance in patients with MVA. CONCLUSION: We suggested that impaired right ventricular mechanics in subjects with microvascular angina was associated with reduced exercise capacity. Moreover, right ventricular mechanics is significantly correlated with coronary flow reserve. Henceforth, right ventricular mechanics might be of value for both risk stratification and follow-up in cases with microvascular dysfunction.

Mean platelet volume as a predictor of pulmonary hypertension in patients with stable COPD.

Background: Pulmonary hypertension (PH) is one of the most common complications developed during the course of chronic obstructive pulmonary disease (COPD). Platelet activation plays an important role in its pathophysiology, and mean platelet volume (MPV) is considered a respectable index of platelet activation. The aim of this work is to assess the ability of MPV in predicting PH secondary to COPD as well as its severity. Methods: A cross-sectional study was conducted on 228 stable COPD patients. CBC, echocardiography, and pulmonary function tests were performed. Results: The prevalence of PH in stable COPD patients was high (63%), and the majority of patients had a mild degree (33%). There was no significant association between PH presence with different COPD grade, but, in very severe COPD, severe PH was significantly presented. MPV in COPD patients with PH was significantly higher than those without (9.02±1.14 vs 7.11±0.98, P<0.001). Moreover, a significant statistical rising of MPV with increased severity of PH. Multivariate regression analysis of predictors of PH demonstrated that; MPV is a real predictor of PH in such patients. The likelihood probability of PH increased up to 7-times with increasing one unit of MPV; (OR=6.7). A cut-off value of MPV >7.25 had 96% sensitivity and 76% specificity in predicting PH. Conclusion: MPV was higher in COPD patients with PH and positively correlated with PH severity. If the data are to be confirmed, MPV may be taken into consideration in decision-making and management of COPD patients.

Association between fragmented QRS and exercise intolerance in hypertensive patients: the relation with coronary flow.

OBJECTIVE: We aimed to investigate the relation between the presence of fragmented QRS (FQRS) and exercise intolerance as assessed by 6 minute walking test (6MWT) and its association with coronary flow reserve (CFR). METHODS: One hundred and twenty patients with hypertension (age: 47.3 + 6.9) who were never treated and without left ventricular hypertrophy underwent 6MWT. Echocardiographic examination was obtained for all patients. CFR was calculated as the hyperemic to baseline mean velocity ratio (hyperemia was induced by intravenous adenosine 0.14 mg/kg/min). Patients were stratified into one group with FQRS and another group without FQRS. Forty-eight normotensive subjects with a mean age of 45.7 + 5.3 were recruited and served as a control group. RESULTS: The frequency of FQRS was 49% in hypertensive patients versus 2% in control subjects. Patients with FQRS had higher systolic blood pressure (p < .05; <.01), a significant lower 6MWTD (p < .001), increased LAVI (p <.05), increased E/e' ratio (p < .01) and lower CFR (p < .001) compared with those without FQRS and controls. FQRS was inversely correlated with CFR (-0.531; p < .001) and 6 MWTD (-0.415; p < .001) and positively correlated with E/e' (0.352, p < .02) and LAVI (0.296; p < .05). By a multivariate regression analysis, FQRS (OR = 6.13; p < .001) and CFR (OR = 3.28; p < .001) were the only two independent predictors for decreased 6 MWTD in hypertensive patients. Importantly the ≥3 cutoff number of leads was found to be the best predictor of CFR < 2.0 in hypertensive patients. CONCLUSION: FQRS is frequent and an independent predictor of reduced exercise tolerance in hypertensive patients. More so, it is significantly associated with decreased CFR and left ventricular diastolic dysfunction. In light of these findings, fragmented QRS might be considered a simple marker for risk stratification of hypertensive patients.

Determinants and impact of masked hypertension in offspring of patients with diabetes: relation with coronary flow and cardiac function.

OBJECTIVE: We aimed to evaluate the prevalence, determinants and clinical impact of masked hypertension in offspring of patients with diabetes. Masked hypertension was defined according to guidelines as daytime ambulatory blood pressure monitoring "ABPM" ≥135/85 mmHg and clinic BP <140/90 mmHg. METHODS: 100 nondiabetic offspring of patients with diabetes and 60 offspring of healthy people were enrolled; 24-h ABPM was applied to evaluate mean 24-h systolic/diastolic blood pressure "BP", daytime, nighttime and night dipping readings. Left ventricular parameters and coronary flow reserve of the left anterior descending artery (induced by adenosine 0.14 mg/kg/min) was calculated in all offspring. RESULTS: 29% of offspring of patients with diabetes had masked hypertension compared to only 3.3% offspring in healthy people (p < 0.001). Compared with those without masked hypertension, offspring with masked hypertension had a significantly reduced coronary flow reserve (p < 0.001), significantly higher E/e' (p < 0.01), [a surrogate marker of left ventricular filling pressure], more microalbuminuria (p < 0.01), and higher values of high-sensitive C-reactive protein "CRP" (p < 0.001). Multivariate regression analysis showed that, fasting blood glucose, and high-sensitive CRP, were independently associated with masked hypertension, whilst daytime systolic BP and non-dipping systolic BP were the strongest predictors for masked hypertension. Logistic regression analysis revealed that masked hypertension was independently associated with reduced coronary flow reserve (p < 0.0001) and diastolic dysfunction (p < 0.001). CONCLUSION: Masked hypertension is prevalent in offspring of patients with diabetes and significantly associated with reduced coronary flow reserve and left ventricular diastolic dysfunction. These findings suggest that offspring of patients with diabetes constitute a high risk group and deserve close follow up, mainly with the use of ABPM.

Interatrial septal fat thickness and left atrial stiffness are mechanistic links between nonalcoholic fatty liver disease and incident atrial fibrillation.

BACKGROUND AND AIM: Recently, a clear evidence suggests that nonalcoholic fatty liver disease (NAFLD) is associated with an increased risk of incident atrial fibrillation (AF). Yet, the underlying pathogenesis is speculative. Thereby, we aimed to investigate the hypothesis that, interatrial thickness (IAST) and left atrial stiffness (LASt) might have mechanistic links between NAFLD and AF. METHODS: Echocardiography and speckle-tracking assessment of left atrial function, transient elastography (TE) of the liver, basal ECG, and Holter monitoring were performed in 180 patients with (NAFLD) and 80 subjects without NAFLD. RESULTS: Patients with NAFLD had higher values of IAST (P < 0.001), LASt (<0.001), and E/e' ratio (<0.003) compared with controls. IAST was correlated with LASt (r = 0.413; P < 0.001). 15.6% of patients with NAFLD had AF. More so, patients with increased IAST/LASt had a higher incidence of AF (25%) vs 3.8% in those with normal IAST/LASt. The LASt and IAST increased significantly in those with AF compared with those without (P < 0.001). Patients who experienced AF had higher values (P < 0.01) of TE (kPa). The degree of liver stiffness TE (kPa) was correlated with both IAST and LASt (r = 461, r = 0.535; P < 0.001). Furthermore, multivariate regression analysis showed that LASt and IAST were independent predictors of incident AF in subjects with NAFLD. CONCLUSIONS: Our data suggest that increased IAST and LASt index are independently associated with incident atrial fibrillation in patients with NAFLD. Increased IAST and LASt index might provide mechanistic links between NAFLD and incident atrial fibrillation.

Coronary flow reserve in mitral stenosis before and after percutaneous balloon mitral valvuloplasty.

We aimed to evaluate the coronary flow reserve (CFR) before and after percutaneous balloon mitral valvuloplasty (PBMV) in patients with mitral stenosis (MS) and its association to clinical events. A prospective study included 45 patients with mitral stenosis candidate for PBMV (age 38 ± 19 years, 27 were females) and 20 with matched age and sex, healthy controls were included in the study. Noninvasive CFR was measured using transthoracic echocardiography and utilizing adenosine stress echocardiography (0.14 mg/kg/min) before PMBV, and one weak post PBMV using multi-tract balloon valvuloplasty technique. CFR was significantly lower in patients with MS compared to controls (P < 0.001). Moreover the CFR was significantly increased post-PBMV (P < 0.001) associated with significant increase in LVEF% (P < 0.05), decrease in systolic pulmonary artery pressure (P < 0.001), significant increase in TAPSE (P < 0.001). CFR was significantly correlated with the degree of change (Δ) in MVA, TAPSE, LVEF%, mean mitral PG and sPAP (r = 0.77, P < 0.001, r = 0.63; P < 0.001; r = 0.42; P < 0.05; r = -0.81; P < 0.001 and r = -0.65; P < 0.001). Mitral valve stenosis was associated with significantly impaired coronary flow reserve that significantly improved after PMBV. The improved CFR values were significantly correlated with the gain in the MVA and the improvement in the functions of both left and right ventricles.

Longitudinal function and ventricular dyssynchrony are restored in children with pulmonary stenosis after percutaneous balloon pulmonary valvuloplasty.

The aim of this study was to evaluate the impact of balloon pulmonary valvuloplasty on longitudinal ventricular dysfunction and cardiac dyssynchrony in children with congenital moderately severe pulmonary stenosis (PS). Forty-eight children with congenital moderately severe valvular pulmonary stenosis and 36 age-matched normal children were included. Successful percutaneous balloon pulmonary valvuloplasty was performed for children with PS. Longitudinal Cardiac function and myocardial synchrony was assessed by echocardiography with tissue Doppler imaging (TDI). Mitral annular plane excursion (MAPSE), tricuspid annular plane excursion (TAPSE), left ventricular systolic wave (LVs), right ventricular systolic wave (RVs) and myocardial synchrony was assessed by echocardiography with TDI. TAPSE, RVs, TAPSE/MAPSE ratio and RVs/LVs ratio were significantly lower in children with PS compared to control subjects: (P < 0.001, P < 0.001, P < 0.001 and P < 0.001). All these parameters were significantly improved after balloon valvuloplasty in children with PS. Intra& inter-ventricular dyssynchrony were significantly increased in PS patients than in control group, (P < 0.03, <0.001 and 0.02 respectively). All these variables were significantly reduced after pulmonary valvuloplasty. In children with valvular PS, balloon valvuloplasty restored longitudinal function and cardiac Synchrony. This gives good insights for the importance of early intervention in children with PS to prevent the progression for cardiac deformation.

The relation between coronary tortuosity and calcium score in patients with chronic stable angina and normal coronaries by CT angiography.

PURPOSE: Coronary tortuosity (CorT) is a phenomenon often noticed by cardiologists and may be associated with stable angina even without significant lesion. We aim to determine the relationship between CorT and coronary artery calcium (CAC) scoring in patients with chronic stable angina and normal or near normal coronaries detected by computed tomography (CT) angiography. METHODS: This is a cross sectional retrospective study included all patients with stable angina underwent CT coronary angiography and calcium scoring that reveals normal or non-significant coronary artery lesion. The presence of CorT was revised. CorT is defined as a fixed ≥ 3 bends during both systole and diastole, with each bend ≥ 45°. RESULTS: The study involved 83 patients. CT angiography revealed 31 patients (37.3%) with tortuous one or more coronary arteries and 52 patients (62.7%) without any CorT. The patients were divided into 2 groups; those patients with tortuous coronary arteries (CorT group) and those without coronary tortuosity (N CorT group). There was no significant difference between both groups regarding age, presence of DM, and dyslipidemia. However, there was a highly significant difference between both groups regarding hypertension with more hypertension among the CorT group (p value < 0.001). There was a significant difference between both groups in CAC score with high CAC score in the CorT group (p value < 0.05). There was significant correlation between CorT and CAC score (unadjusted p = 0.06); if adjusted for co-variated affecting CorT (p = 0.022). CONCLUSION: CorT is associated with subclinical atherosclerosis and increased CAC score even in the absence of significant obstructive lesion.

Can we predict the presence of coronary lesions from blood pressure measurement? A new clinical method.

The roles of arterial function and structure in cardiovascular physiology have expanded with the development of a variety of parameters that evaluate arterial stiffness. Markers of arterial stiffness have been correlated with cardiovascular outcomes. We aimed to find a simple, clinical, noninvasive method to predict atherosclerosis that leads to the development of coronary artery disease (CAD). We aimed to find a simple, clinical, noninvasive method to predict atherosclerosis that leads to the development of CAD. We included 100 cases that underwent coronary angiography in our center owing to different indications. The blood pressure in all cases was measured by two different observers. The oscillatory systolic blood pressure (OSBP) was defined as the point at which the mercury began to oscillate to a minimum level of 1 mm Hg. The auscultatory systolic blood pressure (AUSBP) was defined as the first Korotkoff sound. The difference between OSBP and AUSBP was calculated and called the oscillatory gap (OG). The correlation between the OG and the presence of coronary lesion in coronary angiography was statistically calculated. The study populations had a mean age of 57.3±9 years. The mean±s.d. OG was 14.44±10.44. There was a highly significantly positive correlation between the OG and the presence of coronary artery lesions (r=0.399 and P-value <0.000). There was also a significantly positive correlation between the presence of hypertension and the OG (r=0.376 and P-value <0.000). The difference between OSBP and AUSBP could be used as a simple method to detect atherosclerotic arterial changes. This method could indicate the degree of arterial stiffness. There was a significantly positive correlation between this new indicator of arterial stiffness and the presence of CAD. Any patient with a wide gap between OSBP and AUSBP should be treated early with antihypertensive drugs and statins before the development of CAD.

Is it ever possible to treat left ventricular free wall rupture conservatively?

A best evidence topic was written according to a structured protocol. The question addressed was whether conservative or surgical management would result in better outcomes in patients presenting with left ventricular free wall rupture (LVFWR) following acute myocardial infarction. Surgical techniques involved were infarctectomy + patch repair, suturing of an overlay patch to the defect, patch-and-glue repair and so on, on or off cardiopulmonary bypass. A total of 210 papers were found using the reported searches, of which 10 represented the best evidence to answer the clinical question. The authors, date, journal, study type, population, main outcome measures and results were tabulated. The studies found analysed the outcome related to conservative and surgical approaches plus the effects of cardiopulmonary bypass circuit and systemic heparinization on bleeding around the peri-infarct myocardial tissue in the surgical group. Most of the data available were either case reports or retrospective analysis of the cohort using the 2 techniques and showed that ruptures present in different sites and sizes. Patients with a milder form of LVFWR can be managed conservatively, but the irony is that it is difficult to identify these patients, because a small oozing-type rupture can increase in size and lead to large defect with sudden arrest of the patient and most probably death. More recently with patch-and-glue techniques, avoiding cardiopulmonary bypass, short- and mid-term survival rates have improved to 60-80% in studies of consecutive patients' series, which illustrates real-life experiences.