Large paradoxical embolus through a patent foramen ovale following arteriovenous graft thrombectomy.

An 86-year-old man with end-stage renal disease on hemodialysis with an arteriovenous fistula in his left upper extremity presented to his hemodialysis session with thrombosis of his arteriovenous fistula. The patient underwent surgical thrombectomy. The patient later showed evidence of peripheral embolization and livedo reticularis. Transthoracic and transesophageal echocardiograms revealed a large thrombus (5 × 2 cm) in the right atrium prolapsing to the left atrium via a patent foramen ovale and another thrombus adherent to the apical wall of the right ventricle. The thrombus in the left atrium was intermittently crossing the mitral valve and entering the left ventricle.

Acute effects of waterpipe smoking on blood pressure and heart rate: a real-life trial.

BACKGROUND: Waterpipe smoking is becoming a popular way of tobacco use in the world. Its acute effects on the cardiovascular system are not well investigated. MATERIALS AND METHODS: This is a trial designed to evaluate the acute effects of waterpipe smoking on blood pressure (BP) and heart rate (HR) in healthy adults. Individuals who ordered waterpipe in 6 Lebanese restaurants were enrolled (cases) and were compared to controls who consisted of subjects who were sitting at the same table of smokers but who did not smoke (passive smokers) and of subjects who were sitting in nonsmoking sections (nonsmokers). BP and HR were measured immediately before and 15 min after smoking or at baseline and 15 min later in controls. RESULTS: A total of 194 subjects were enrolled: 101 waterpipe smokers, 51 passive smokers, and 42 nonsmokers. Systolic and diastolic BP and HR significantly increased after 15 min of smoking in cases (mean 3.1 mm Hg (95% CI 0.8-5.5; p = 0.009) for systolic BP, 2.1 mm Hg (95% CI 0-4.2; p = 0.053) for diastolic BP, and 6.3 beats/minute (95% CI 4.3-8.3; p < 0.001) for HR, but did not change in controls. CONCLUSIONS: Waterpipe smoking for duration as short as 15 min has acute hemodynamic effects and significantly increases systolic BP and HR.

Stroke in hemodialysis patients and its association with CHA2DS2-VASC and HAS-BLED scores: a retrospective study.

Background: In the general population, the CHA2DS2-VASC and the HAS-BLED scores are helpful to predict cerebrovascular events and hemorrhage in patients with atrial fibrillation (AF). However, their predictive value remains controversial in the dialysis population. This study aims to explore the association between these scores and cerebral cardiovascular events in hemodialysis (HD) patients. Methods: This is a retrospective study including all HD patients treated between January 2010 and December 2019 in two Lebanese dialysis facilities. Exclusion criteria are patients younger than 18 years old and patients with a dialysis vintage less than 6 months. Results: A total of 256 patients were included (66.8% men; mean age 69.3 ± 13.9 years). The CHA2DS2-VASc score was significantly higher in patients with stroke (P = .043). Interestingly, this difference was significant in patients without AF (P = .017). Using receiver operating curve analysis, CHA2DS2-VASc score had an area under the curve (AUC) of 0.628 [95% confidence interval (CI): 0.539-0.718) and the best cut-off value for this score was 4. The HAS-BLED score was also significantly higher in patients with a hemorrhagic event (P < .001). AUC for HAS-BLED score was 0.756 (95% CI: 0.686-0.825) and the best cut-off value was also 4. Conclusions: In HD patients, CHA2DS2-VASc score can be associated with stroke and HAS-BLED score can be associated with hemorrhagic events even in patients without AF. Patients with a CHA2DS2-VASc score ≥4 are at the highest risk for stroke and adverse cardiovascular outcomes, and those with a HAS-BLED score ≥4 are at the highest risk for bleeding.

Association of GDF-15, hs-cTnT and NT-proBNP with coronary artery disease in patients undergoing elective angiography.

Aim: This study investigated the association between plasma levels of GDF-15, hs-cTnT and NT-proBNP and the presence of coronary artery disease (CAD) in stable patients referred for elective coronary angiography. Methods: The outcome of CAD was defined as an ordinal variable with 3 levels. The association between each biomarker and the outcome was tested using the Winell and Lindbäck method. Results: In unadjusted analysis of 252 patients, GDF-15 and hs-cTnT were associated with the presence and extent of CAD. In multivariate regression analysis including traditional risk factors, this association was no longer significant. Conclusion: NT-proBNP, GDF-15 and hs-cTnT plasma levels do not seem to improve the predictive ability of traditional risk factors for CAD in stable patients referred for coronary angiography.

This study aimed to look at a possible association between blood levels of three molecules (GDF-15, hs-cTnT and N-terminal pro B-type natriuretic peptide [NT-proBNP]) and the presence of coronary artery disease (CAD) in stable patients referred for coronary angiography. Three CAD degrees of severity were identified: no CAD, 1- or 2-vessel CAD and 3-vessel or left main CAD. The association between each of the three blood molecules and CAD was studied using a specific statistical method. In the 252 consecutive patients enrolled, the two molecules GDF-15 and hs-cTnT were significantly associated with the presence and extent of CAD, while NT-proBNP was not. However, when the statistical analysis was adjusted for the traditional risk factors of CAD (age, gender, smoking, diabetes, etc.), the association of GDF-15 and hs-cTnT with CAD was no longer significant. NT-proBNP, GDF-15 and hs-cTnT blood levels do not seem to be independent predictive tools for CAD in stable patients referred for coronary angiography.

Benefit and tolerability of the coadministration of ezetimibe and atorvastatin in acute coronary syndrome patients.

BACKGROUND AND AIM: The effect of ezetimibe-statin combination on inflammatory markers in acute coronary syndrome is unknown. The aim of our study is to evaluate the effect of this combination on the lipid profile, the CRP hs and the sCD40 ligand levels in acute coronary syndrome (ACS) patients. METHODS: This is a randomized, double-blind study including 93 patients admitted for ACS randomized in 2 groups, ezetimibe 10 mg + atorvastatin 10 mg vs atorvastatin 20 mg + placebo, for 12 weeks follow-up; blood samples were collected for lipid profile, ALT, AST, CRP and sCD40L at baseline, 12 hours, 4 weeks, and 12 weeks. RESULTS: There was no significant difference in total cholesterol levels, HDL, LDL, CRP, but there was a significant decrease in sCD40L levels in the ezetimibe combination group, with less side effects in the combination group, mainly myalgia (p = 0.012). CONCLUSION: Ezetimibe combination with low dose statin in patients in acute coronary syndrome could be a safe, potent therapy to reduce LDL level with antiinflammatory effect.

A Practical Approach for the Use of High-Sensitivity Cardiac Troponin Assays in the Evaluation of Patients With Chest Pain.

Chest pain is a common clinical presentation, especially in the emergency department. Both rapid identification of patients with myocardial infarction as well as those with noncardiac chest pain is important in order to start therapy in the former and avoid unnecessary investigations and delay in discharge in the latter. Beside electrocardiogram, cardiac biomarkers are a key element in decision making. Conventional creatinine kinase and troponin assays are not sensitive enough and have to be repeated at least 6 to 12 hours after initial evaluation. New high-sensitivity cardiac troponin (hs-cTn) tests are currently available and if used appropriately can substantially improve management. Because of their high sensitivity and accuracy, these tests allow measurement of very low serum troponin levels, such as those present in healthy individuals and can detect small changes in troponin concentration within a short time frame. These tests are thus, very useful for the early diagnosis of myocardial infarction but can also be elevated in several other conditions that result in myocardial injury. A good understanding of the analytical characteristics of these assays is of uppermost importance for their appropriate use in clinical practice.

Antithrombotic treatment pattern in newly diagnosed atrial fibrillation patients and 2-year follow-up results for dabigatran-treated patients in the Africa/Middle-East Region: Phase II results from the GLORIA-AF registry program.

BACKGROUND: Data on the epidemiology and treatment of atrial fibrillation in the Africa/Middle East region are limited, and the use of novel oral anticoagulants and their effectiveness in real-world clinical practice has not been evaluated. METHODS AND RESULTS: This study used prospectively collected data from the Global Registry on Long-Term Oral Antithrombotic Treatment in Patients With Atrial Fibrillation (GLORIA-AF) to describe anticoagulant use and outcomes in Africa and the Middle East. Baseline characteristics of patients newly diagnosed with nonvalvular atrial fibrillation from Lebanon (242 patients, 40.3%), Saudi Arabia (236 patients, 39.3%), United Arab Emirates (87 patients, 14.5%), and South Africa (35 patients, 5.8%) were described, and clinical outcomes were investigated for all patients in this region who received dabigatran.In newly diagnosed patients (having a diagnosis within the last three months) with nonvalvular atrial fibrillation in Africa and the Middle East, the observed uptake of non-vitamin K oral anticoagulants was high in the first years following their availability; dabigatran was the most commonly used antithrombotic agent (314/600 patients), and only 1.5% of patients did not receive any antithrombotic therapy. Use of dabigatran was associated with a high persistence rate (>88% at 24 months) and low incidence rates of stroke, myocardial infarction, major bleeding, and all-cause mortality after 2 years of follow-up. CONCLUSIONS: Data from GLORIA-AF reveal a change in the landscape for stroke prevention in the AME region, and the results were consistent with those observed in the global GLORIA-AF registry, as well as those of randomized clinical trials.Clinical Trial Registration: NCT01937377 (https://clinicaltrials.gov/ct2/show/NCT01937377).

[Epidemiology of cardiac tumors in adults in Lebanon]. / Epidémiologie des tumeurs cardiaques des adultes au Liban.

Primary cardiac tumors are rare but potentially fatal. No studies have discussed this issue yet on the national level. We describe the epidemiology of cardiac tumors in adults in Lebanon. The data were taken from the hospitals, the patients and/or their doctors by means of a questionnaire. Fifty-seven cases of cardiac tumors were found, mainly myxomas in the left atrium. Dyspnea was the most frequent symptom. Transthoracic echocardiography was the main diagnostic tool. Transesophageal echocardiography was inconstantly made, scanner and MRI rarely while contrast echocardiography has never been used. Almost half of the patients had a follow-up and none had a familial screening. The collected data urged us to propose a unique and homogenous strategy for diagnosis, treatment and follow-up of cardiac tumors in Lebanon.

Effects of clopidogrel on soluble CD40 ligand and on high-sensitivity C-reactive protein in patients with stable coronary artery disease.

BACKGROUND: Antiplatelet therapy with clopidogrel decreases ischemic complication especially in patients with acute coronary syndromes or after percutaneous coronary interventions. Our study was designed to test the effects of clopidogrel on soluble CD40 ligand (sCD40l) and on high-sensitivity C-reactive protein (hs-CRP) in patients with stable coronary artery disease (CAD). METHODS: This is a randomized, double-blind, placebo-controlled study. A total of 73 patients with stable CAD for > 6 months were randomized to receive either clopidogrel (loading dose 300 mg followed by 75 mg/d) for 8 weeks or placebo. Soluble CD40 ligand and hs-CRP were measured at baseline and at completion of the study. RESULTS: All patients were on aspirin therapy, and 74% were on statins. Median and interquartile ranges (IQR) of sCD40l decreased from 64 pg/mL (43-99) at baseline to 53 pg/mL (35-77) at 8 weeks (P = .03) in the clopidogrel group and remained unchanged in the placebo group (59 pg/mL, IQR 35-77 vs 55 pg/mL, IQR 35-78) (P = non significant). Levels of hs-CRP were not affected by therapy and remained unchanged in both groups. CONCLUSIONS: In patients with stable CAD, clopidogrel inhibits the release of sCD40l by platelets, which may contribute to the clinical benefit provided by this drug. This, however, does not translate in a reduction of subclinical inflammation, as measured by hs-CRP.

[Control of blood pressure morning surge in a Lebanese hypertensive population]. / Contrôle du pic matinal de la pression artérielle par telmisartan chez une population libanaise hypertendue.

OBJECTIVE: The primary endpoint of this prospective clinical study is to ascertain the degree of blood pressure control in the early-morning hours after 8 weeks of treatment with Telmisartan in hypertensive patients using home blood pressure measurements. METHODS: Two hundred forty Lebanese patients with uncontrolled hypertension are enrolled in the study. The blood pressure is measured at the initial visit, then at week 4 of follow-up (optional visit) and after the 8 weeks period, by the physician at his office (with pulse rate) and by the patient at home in the morning. RESULTS: The blood pressure measured by the patient at home in the morning has a mean value of 129.7/79.1 mmHg, significantly less than 135/85 mmHg (P < 10(-1)), and it is reduced by 31.9/13.5 mmHg (P < 10(-5)). At the physician's office, the reduction is 34.8/16 mmHg (P < 10(-4)). Heart rate is decreased by 4.7+/-0.5 bpm (P < 10(-5)). The drug was well tolerated. CONCLUSION: This study has demonstrated that Telmisartan, by his long half-life, protects the patients against the early-morning hours blood pressure surge, period during which coronary and cerebral events are the most frequent.

Duration of abnormal SPECT myocardial perfusion imaging following resolution of acute ischemia: an angioplasty model.

OBJECTIVES: This study was designed to determine how long nuclear myocardial perfusion imaging (MPI) remains abnormal following transient myocardial ischemia. BACKGROUND: Acute rest MPI identifies myocardial ischemia with a high sensitivity when the radionuclide is injected during chest pain. However, the sensitivity of this technique is uncertain when the radionuclide is injected following the resolution of symptoms. METHODS: Forty patients undergoing successful coronary angioplasty were randomized into four equal groups. Tc-99m sestamibi was injected intravenously during the last balloon inflation (acute MPI) in 30 patients and then reinjected 1, 2, or 3 h later (delayed MPI). In a fourth group, the radiopharmaceutical was injected at 15 min following balloon deflation (delayed MPI). A final injection was performed at 24 to 48 h (late MPI) in 37 patients (93%). RESULTS: A perfusion defect was detected in all 30 acute MPI studies; in 7/10 patients (70%) injected at 15 min; in 11/30 patients (37%) injected at 1, 2, or 3 h; and in 7/37 patients (19%) injected at 24 to 48 h. Perfusion scores were 13.0 +/- 9.2 on acute MPI, 5.1 +/- 2.8 at 15 min (p < 0.001 vs. acute MPI); 2.6 +/- 3.0 at 1, 2, and 3 h (p < 0.001 vs. acute MPI); and 1.3 +/- 2.4 at 24 to 48 h (p < 0.001 vs. acute MPI; p < 0.03 vs. delayed MPI). CONCLUSIONS: Myocardial perfusion imaging may remain abnormal for several hours following transient myocardial ischemia even when normal flow is restored in the epicardial coronary artery.

Effects of tirofiban and statins on high-sensitivity C-reactive protein, interleukin-6, and soluble CD40 ligand following percutaneous coronary interventions in patients with stable coronary artery disease.

This study assessed the effects of tirofiban and statins on high-sensitivity C-reactive protein, interleukin-6, and soluble CD40 ligand after percutaneous coronary intervention in patients who had stable coronary artery disease. Tirofiban insignificantly limited the increase of soluble CD40 ligand after revascularization, especially in patients who had high levels of this marker at baseline (p = 0.06), whereas statins significantly inhibited increases in interleukin-6 and, to a lesser extent, high-sensitivity C-reactive protein without affecting the soluble CD40 ligand.

Pravastatin does not affect insulin sensitivity and adipocytokines levels in healthy nondiabetic patients.

BACKGROUND: The effect of statins on insulin resistance is controversial and poorly studied in nondiabetic subjects. In addition, the effect of statins on leptin and adiponectin has never been studied. METHODS: Forty healthy nondiabetic volunteers (22 men and 18 women) aged 28 to 72 were randomized either to placebo or pravastatin 40 mg daily for a 12-week period. Insulin resistance, assessed using the Quantitative Insulin Sensitivity Check Index (QUICKI), as well as serum leptin and adiponectin levels, was measured at baseline and at the end of therapy. RESULTS: Pravastatin treatment decreased total cholesterol, low-density lipoprotein cholesterol, and triglycerides levels by 24%, 32%, and 14%, respectively ( P < .05 for all), but did not affect glucose and insulin levels, the (QUICKI) index, and adiponectin and leptin levels. When stratification was performed according to QUICKI index or sex, no significant differences were observed in the prevalues and postvalues of leptin, adiponectin, or QUICKI index in the pravastatin group. Adiponectin, leptin, and QUICKI index were statistically higher in women than in men ( P < .001 for both variables). Adiponectin was negatively correlated with body mass index (BMI; r = -0.39, P < .05) and positively correlated with the QUICKI index ( r = 0.54, P < .001) and with high-density lipoprotein cholesterol ( r = 0.50, P < .01). The relation between adiponectin and QUICKI index remained significant after adjustment for sex and BMI ( P = .005 and P = .007, respectively). Leptin was only related to BMI ( r = 0.57, P < .001) and to sex ( P < .001) with no significant correlations with lipid parameters or QUICKI index. Both sex and BMI are independent predictors of leptin ( P < .001 and P < .001). CONCLUSION: A 12-week treatment with pravastatin 40 mg/d does not change the QUICKI index and leptin and adiponectin levels in healthy volunteers. In addition, our results emphasize the importance of sex and BMI in the determination of both adiponectin and leptin. Adiponectin was also related to QUICKI index, whereas this relation was not found with leptin.

[Management of acute transmural myocardial infarction: a study on 200 patients admitted to a tertiary care medical center]. / Prise en charge de l'infarctus du myocarde transmural à la phase aiguë: Etude de 200 patients admis dans un hôpital de soins tertiaires.

OBJECTIVE: To verify if the management of acute transmural myocardial infarction in a university hospital, follows the international guidelines of the ACC/AHA. DESIGN: This is a retrospective study on 200 consecutive patients admitted with an acute transmural myocardial infarction. Data were obtained by review of medical records. RESULTS: 20.5% of patients were treated with primary angioplasty, 44% received thrombolytic therapy and 35.5% a conventional medical treatment. Mean age was 62 +/- 11.64 years and 72% of the patients were males. Risk factors were: smoking 62%, hyperlipidemia 46%, hypertension 43.5%, diabetes 33.5%, obesity 13.5%, and a family history of coronary artery disease 25%. 17.5% of patients had a prior history of myocardial infarction and 4.5% had prior coronary artery bypass graft surgery. The mean delay between onset of symptoms and arrival to the hospital was 12 hours. Chest pain was the main symptom and was present in 88% of patients. Cardiac arrest was observed in 7% of patients upon arrival to the emergency department. Administration of thrombolytic therapy followed the established criteria in all cases. Angioplasty was mainly performed in cases of cardiogenic shock, and as a rescue for failed thrombolytic therapy and for pain recurrence. The two reperfusion modalities were given equally to elderly patients, patients with prior coronary artery bypass surgery and to those with anterior wall myocardial infarction. Coronary angiography was done in 94% of patients, coronary angioplasty was subsequently performed on 30.1%, and bypass surgery on 27%. Mortality rate was 11.2%, and it was significantly higher in patients treated conventionally by comparison with thrombolysis and/or PTCA. Major arrhythmias were observed in 13.5% of cases and infections in 3.5%. Mean length of stay was 2.85 +/- 3.1 days in the intensive care unit and 8.9 +/- 6.7 days in the hospital. Treatment on discharge followed the international recommendations; aspirin was given to 87.5% of patients, beta-blockers to 63.3%, ACE inhibitors to 59% and statines to 32%. CONCLUSION: The management of acute transmural myocardial infarction at our institution follows the international guidelines. However, the delay between the onset of symptoms and arrival to the hospital needs to be shortened. Public awareness campaigns should be useful for that purpose. In addition, the treatment on discharge should be improved.

[Coronary angioplasty for primary cardiogenic shock following acute myocardial infarction]. / L'angioplastie à la phase aiguë de l'infarctus du myocarde compliqué d'un choc cardiogénique primaire.

BACKGROUND: In the setting of acute myocardial infarction (AMI), several investigators have demonstrated that emergency coronary angioplasty (PTCA) reduces in-hospital mortality of primary cardiogenic shock (CS) from 90% to less than 50% ; however, few studies have focused on the current outcome of non selected patients in whom the onset of AMI is immediately complicated by CS. PURPOSE OF THE STUDY: To evaluate in-hospital mortality of the patients admitted to our institution for Q wave AMI presented in CS. MATERIAL AND METHOD: Between 05/93 and 05/03, 30 consecutive pts, 26 men and 4 women, in CS following AMI were treated with direct PTCA, 26 without thrombolysis and 4 as rescue after failed streptokinase. AMI was defined by prolonged chest pain and > or =1 mm ST segment elevation in > or =2 contiguous peripheral leads or > or =2 mm for precordial leads on the admission ECG. The diagnosis of CS was based on the combination of systolic blood pressure of <90 mm Hg, unresponsive to volume expansion, signs of acute circulatory failure (cyanosis, cold extremities, restlessness, mental confusion or coma) and congestive heart failure secondary to myocardial dysfunction. In 40% of cases the diagnosis of CS was only clinical and in 60% of cases was confirmed by a Swan Ganz catheter. Mean age was 62.3 +/- 12.3 years, 7 had triple vessel disease, 14 a double vessel disease, 8 a single vessel disease and in one case a left main disease. The AMI was anterior in 22 pts (73%), inferior in 8 (27%). Intraaortic balloon was used in 3 pts, CPR in 16 (47%), transitory pacemaker in 1 pt, inotropes in 25 pts, emergency coronary artery bypass grafting (CABG) in 1 pt. RESULTS: Success for PTCA with a residual stenosis < 50% and a TIMI flow III was obtained in 26 pts (87%). Mean time between CS and revascularization was 219 +/- 302 minutes. 19 pts (63%) survived and 11 pts (37%) died while at the hospital, 6 from intractable shock, 4 from multiple organ failure and in 1 case from pulmonary hemorrhage. Mean time of revascularization for the surviving was 190 +/- 329 min, and for the dead 295 +/- 212 min. Hospital mortality for inferior infarction is 12.5% after successful angioplasty. Comparison of surviving and non surviving number of patients according to revascularization time showed a significant difference of these groups whether the revascularization was accomplished before or after 120 minutes. [table: see text] CONCLUSION: Direct PTCA for AMI immediately complicated by CS, can be achieved with a high success rate, and can significantly reduce in-hospital mortality; this improvement of survival is most evident if revascularizarion is performed early.