MCP-1 -2518 A/G gene polymorphism is associated with blood pressure in ischemic heart disease asymptomatic subjects.

Monocyte chemoattractant protein-1 (MCP-1), one of the key inflammatory chemokines, plays an important role in the initiation of atherosclerosis, and represents a risk for coronary artery disease and myocardial infarction. A recent animal study showed that MCP-1 gene might be a candidate gene for salt-sensitive hypertension in Dahl salt sensitive rats. This effect has not been yet studied in asymptomatic humans. We tested the MCP-1 -2518 A/G single nucleotide polymorphism (SNP) in 66 hypertensive ischemic heart disease asymptomatic subjects. Inflammatory markers, classic risk factors and absolute cardiovascular risk (SCORE system) were also investigated in these subjects. Our results showed that both, systolic and diastolic values of blood pressure were associated with MCP-1 -2518 A/G SNP at the level of both, genotype and allele frequencies. Subjects with mutant G allele had higher levels of both values of blood pressure, systolic (p = 0.035) and diastolic (p = 0.040) than subjects with allele A. Statistically significantly higher levels of both values of blood pressure, systolic (p = 0.037) and diastolic (p = 0.021) were found also in IHD asymptomatic subjects with AG and GG genotypes. Subjects with AG and GG genotypes had also an increased absolute cardiovascular risk (1.62% vs 3.17%; p = 0.004) and an increasing trend for elevated plasma level of high-sensitive CRP (2.858 vs 2.062 mg/l; p = 0.076). We did not find any significant correlation between the serum level of MCP-1 and blood pressure. To our best knowledge, this is the first study concerning the association between MCP-1 polymorphism and arterial blood pressure in IHD asymptomatic subjects. These results indicate that the expression of MCP-1 may be increased before the onset of hypertension but further observations from larger cohorts are needed to confirm this finding (Tab. 6, Ref. 41).

The MCP-1 -2518 (A/G) single nucleotide polymorphism is associated with ischemic heart disease and myocardial infarction in men in the Slovak population.

We investigated the MCP-1 -2518 (A/G) single nucleotide polymorphism (SNP) in Slovak cohort of patients with ischemic heart disease (IHD). Our study comprised 270 patients with IHD, out of them 92 with myocardial infarction (MI). We found that the frequencies of the mutant GG genotype in Slovak patients with IHD (10.7%; p=0.019) and MI (12.0%; p=0.046) were significantly higher than those in the control subjects (5.8%). After subdividing the groups according to the sex, statistically significant difference was found only in men (IHD: p=0.013, MI: p=0.009). We also found a higher rate of GG homozygous genotype in patients with early (< or =50 years of age) MI (18.4%; p=0.004)--statistically significant again only in men (23.1%; p=0.002). The frequencies of G alleles in IHD male patients (30.3%, p=0.046) and in early MI male patients (38.5%, p=0.019) were also statistically significantly higher than in control group. Our results confirm that IHD and MI are linked to MCP-1 -2518 (A/G) single nucleotide polymorphism (Tab. 4, Ref. 34). Full Text (Free, PDF) www.bmj.sk.

Coronary vasomotion after percutaneous transluminal coronary angioplasty depends on the severity of the culprit lesion.

OBJECTIVES: This study sought to evaluate coronary vasomotor response to percutaneous transluminal coronary angioplasty (PTCA) and its influence on proximal and distal vessel diameters with regard to stenosis severity and coronary blood flow. BACKGROUND: Coronary vasoconstriction of the distal vessel segment has been reported after PTCA. This vasoconstrictive effect was thought to be due to balloon-induced injury of the vessel wall, with release of local vasoconstrictors or stimulation of the sympathetic system with release of catecholamines, or both. METHODS: Thirty-nine patients were prospectively studied before and after PTCA. Patients were classified into two groups according to the severity of the culprit lesion: group 1 = > or = 70% to < or = 85% diameter stenosis (n = 23); and group 2 = > 85% to < or = 95% diameter stenosis (n = 16). The coronary vessel diameter of the proximal and distal vessel segments as well as the minimal lumen diameter were determined by quantitative coronary angiography. In a subgroup of 16 patients, basal and maximal coronary flow velocity was measured before and after PTCA with the Doppler FloWire system. RESULTS: The groups were comparable with regard to age, gender, serum cholesterol levels and medical therapy. The proximal vessel segment remained unchanged after PTCA in group 1 ([mean +/- SD] 0.9 +/- 3.5%, p = 0.8) but showed vasodilation in group 2 (+13.7 +/- 3.6%, p < 0.05). However, the distal segment showed vasoconstriction in group 1 (-6.7 +/- 2.0%, p < 0.01) and vasodilation in group 2 (+31 +/- 8.0%, p < 0.01). A significant correlation was found between the change in distal vessel diameter after PTCA and stenosis severity (r = 0.61, p < 0.0001). Changes in blood flow were directly correlated to stenosis severity (r = 0.85, p < 0.002); that is, rest flow increased after PTCA in narrow lesions but remained unchanged in moderate lesions. The diameter changes in the distal vessel segment after PTCA were significantly related to flow changes (r = 0.90, p < 0.0001). Coronary distending pressure of the distal vessel segment increased significantly in both groups; however, this increase was significantly greater in group 2 than in group 1 (55 +/- 4 vs. 14 +/- 3 mm Hg, p < 0.0001). CONCLUSIONS: Coronary vasomotion of the proximal and distal vessel segments after PTCA depends on the severity of the culprit lesion; that is, vasoconstriction of the distal segment is found in patients with moderate lesions and vasodilation in those with severe lesions. Thus, vasomotion of the post-stenotic vessel segment depends on the severity of the culprit lesion and is influenced by changes in coronary flow or distending pressure, or both.

Hemodynamic benefit of atrioventricular synchrony: prediction from baseline Doppler-echocardiographic variables.

The purpose of this study was to determine if baseline Doppler-echocardiographic variables of systolic or diastolic function could predict the hemodynamic benefit of atrioventricular (AV) synchronous pacing. Twenty-four patients with a dual chamber pacemaker were studied. Baseline M-mode and two-dimensional echocardiograms were obtained and Doppler-echocardiographic measurements of mitral inflow and left ventricular outflow were made in VVI mode (single rate demand) and in VDD (atrial synchronous, ventricular inhibited) and DVI (AV sequentially paced) modes at AV intervals ranging from 50 to 300 ms. Forward stroke volume and cardiac output were determined in each mode at each AV interval from the left ventricular outflow tract flow velocities, and the percent increase in cardiac output over VVI mode was determined. M-mode measurements, including left ventricular end-diastolic dimension, shortening fraction and left atrial size and Doppler measurement of diastolic filling, including peak early velocity and percent atrial contribution, did not correlate with the percent increase in cardiac output during physiologic pacing. The stroke volume in VVI mode correlated significantly with the percent increase in cardiac output during physiologic pacing (r = -0.61, p less than 0.005 for VDD mode and r = -0.55, p less than 0.05 for DVI mode). Five of the 15 patients with VVI stroke volume less than 50 ml but none of the 9 patients with stroke volume greater than 50 ml had ventriculoatrial (VA) conduction.(ABSTRACT TRUNCATED AT 250 WORDS)

The hemodynamic benefit of differential atrioventricular delay intervals for sensed and paced atrial events during physiologic pacing.

The ability to program different atrioventricular (AV) delay intervals for paced and sensed atrial events is incorporated in the design of some newer dual chamber pacemakers. However, little is known regarding the hemodynamic benefit of differential AV delay intervals or the magnitude of difference between optimal AV delay intervals for paced and sensed P waves in individual patients. In this study, Doppler-derived cardiac output was used to examine the optimal timing of paced and sensed atrial events in 24 patients with a permanent dual chamber pacemaker. The hemodynamic effect of utilizing separate optimal delay intervals for sensed and paced events compared with utilizing the same fixed AV delay interval for both was determined. The optimal delay interval during DVI (AV sequential) pacing and VDD (atrial triggered, ventricular inhibited) pacing at similar heart rates was 176 +/- 44 and 144 +/- 48 ms (p less than 0.002), respectively. The mean difference between the optimal AV delay intervals for sensed (VDD) and paced (DVI) P waves was 32 ms and was up to 100 ms in some individuals. The difference between optimal AV delay intervals for sensed and paced atrial events was similar in patients with complete heart block and those with intact AV node conduction. At the respective optimal AV delay intervals for sensed and paced P waves, there was no significant difference in the cardiac output during VDD compared with DVI pacing. However, cardiac output significant declined during VDD pacing at the optimal AV delay interval for a paced event and during DVI pacing at the optimal interval for a sensed event.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of ventricular function on the exercise hemodynamics of variable rate pacing.

To determine the effect of ventricular function on the exercise hemodynamics of variable rate pacing, 16 selected patients underwent paired, double-blind, randomized exercise tests in single rate demand (VVI) or variable rate (VVIR) pacing modes. Ejection fraction and cardiac index were determined by two-dimensional and Doppler echocardiography at baseline and during peak exercise. Baseline ejection fraction ranged from 14 to 73% and was less than 40% in 6 patients (Group 1) and greater than or equal to 40% in 10 patients (Group 2). Duration of exercise was longer during the VVIR mode (502 s) than during the VVI mode (449 s) (p less than 0.01) and unrelated to baseline ejection fraction. Heart rate during exercise increased 9% in the VVI mode and 35% in the VVIR mode (p less than 0.005). Cardiac index increased 49% in the VVI mode and 83% in the VVIR mode. Analysis of variance for repeated measures showed a significant effect of pacing mode (p less than 0.01) and exercise (p less than 0.001), but not baseline ejection fraction, on cardiac index. Baseline ejection fraction did not correlate with the increase in cardiac index in either pacing mode or with the difference in increase between modes. There was no significant difference between Groups 1 and 2 in exercise duration, peak heart rate-blood pressure (rate-pressure) product, baseline or peak heart rate or baseline or peak cardiac index. Therefore, in selected patients, VVIR pacing during exercise results in an increase in heart rate, duration of exercise and cardiac index that is unrelated to the degree of baseline left ventricular dysfunction.(ABSTRACT TRUNCATED AT 250 WORDS)

Hemophilus influenzae pericarditis in adults.

We saw an unusual case of spontaneous Hemophilus influenzae purulent pericarditis in an adult. Counterimmunoelectrophoresis (CIE) of the pericardial fluid may be used to make an early, accurate diagnosis. Treatment should include pericardectomy and immediate use of both ampicillin sodium and chloramphenicol sodium succinate, until the sensitivity of the organism is known.

Effect of conduction defects on the signal-averaged electrocardiographic determination of late potentials.

To determine the effect of cardiac conduction defects on the signal-averaged electrocardiogram (ECG) and on its ability to noninvasively identify patients predisposed to ventricular tachycardia (VT), standard 12-lead ECGs and signal-averaged ECGs were obtained in 213 patients with normal conduction and 186 patients with various conduction defects. Sustained VT was induced by programmed stimulation or occurred spontaneously in 122 patients. Two-way analysis of variance showed that conduction defects and VT were associated with changes in 3 signal-averaged ECG parameters: duration of the filtered QRS, duration of the terminal QRS under 40 microV and the mean amplitude of the terminal 40 ms of the QRS. Stepwise multiple logistic regression identified 3 variables that distinguished the patient with VT with a sensitivity of 62%, a specificity of 63% and a positive predictive accuracy of 63%. These 3 variables, listed in order of importance, were conduction defect score, duration of the filtered QRS and mean amplitude of the terminal 40 ms of the QRS. These data indicate that conduction defects have systematic effects on signal-averaged ECG parameters independent of those seen in patients predisposed to VT. These effects mandate the adjustment of the definitions of late potentials in the presence of conduction defects.

Signal-averaged electrocardiography in the time and frequency domains.

The noninvasive signal-averaged electrocardiographic detection of late potentials correlates with the spontaneous occurrence of sustained ventricular tachycardia (VT). Frequency analysis of the electrocardiographic signal from the terminal QRS and ST segment also correlates with sustained VT. This study was designed to compare these 2 methods by analysis of signals recorded from the same hardware system. Signals were recorded from 234 patients with prior myocardial infarctions with a commercially available signal-averaging system. Patients were classified into 2 groups: group 1 consisted of 84 patients with VT and group 2 consisted of 150 patients without VT. In the frequency domain, magnitude and energy area ratios and peak ratios of the spectral plot from 20 to 50 Hz over 0 to 20 Hz were calculated for a 140-ms interval starting 60 ms after the beginning of the QRS. In the time domain, the duration of the filtered QRS was 121 +/- 29 ms for group 1 and 110 +/- 25 ms for group 2 (p less than 0.002). The duration of the terminal QRS less than 40 microV was 45 +/- 21 ms in group 1 and 36 +/- 18 ms in group 2 (p less than 0.001). The root-mean-square amplitude of the terminal 40 ms of the QRS was 25 +/- 24 microV in group 1 and 36 +/- 33 microV in group 2 (p less than 0.004).(ABSTRACT TRUNCATED AT 250 WORDS)

Independent value of signal-averaged electrocardiography and left ventricular function in identifying patients with sustained ventricular tachycardia with coronary artery disease.

To determine if the signal-averaged electrocardiographic detection of late potentials is an independent marker of sustained ventricular tachycardia (VT) in patients with documented chronic coronary artery disease (CAD), 57 patients underwent signal-averaged electrocardiography. Mean ejection fraction was 47 +/- 13% in the 14 patients with sustained VT and 56 +/- 19% in the 43 patients without VT (difference not significant). The sensitivity, specificity and accuracy of late potentials for detecting patients with VT were 64% (9 of 14), 79% (34 of 43), and 75% (43 of 57), respectively. Univariate analysis and stepwise logistic regression of angiographic and electrocardiographic variables identified late potentials as an independent marker of the patient with sustained VT. The odds ratio for late potentials to detect patients with prior sustained VT was 2.6. Six-month follow-up revealed a cardiac mortality rate of 11% and an arrhythmia event rate of 22% in patients with late potentials vs a cardiac mortality rate of 3% and an arrhythmia event rate of 13% in patients without late potentials. Thus, signal-averaged electrocardiographic detection of late potentials is useful in identifying patients with prior sustained VT independent of left ventricular function.

Utility of ambulatory electrocardiography in detecting pacemaker dysfunction in the early postimplantation period.

The value of ambulatory electrocardiography (AECG) in detecting pacemaker dysfunction before hospital discharge was assessed in 100 patients a mean of 1.2 days after pacemaker implantation. The incidence of permanent pacemaker dysfunction detected by AECG in the early postimplantation period, the frequency that pacemaker dysfunction detected by AECG was not detected by telemetric monitoring and the frequency that results of AECG led to pacemaker reprogramming before hospital discharge were determined. AECG detected at least 1 type of pacemaker dysfunction in 35% of patients and routine telemetry identified the abnormality in only 8% (p less than 0.001). Pacemaker dysfunction occurred in 42% of patients with dual-chamber devices and 27% of those with single-chamber devices (difference not significant). In the 35 patients who had pacemaker malfunction, a total of 50 instances of pacemaker dysfunction were detected. Failure of atrial capture occurred in 2% of patients, failure of atrial sensing in 9%, failure of atrial output in 1%, failure of ventricular capture in 8%, failure of ventricular sensing in 14%, failure of ventricular output due to myopotential inhibition in 11% and pacemaker-mediated tachycardia in 5%. The results of the AECG led to a clinical intervention in 22 patients (pacemaker reprogramming in 21 patients and lead repositioning in 1 patient) in whom no pacemaker dysfunction was suspected on the basis of telemetry or clinical symptoms. In conclusion, AECG provides additional benefit beyond that of routine telemetry monitoring in identifying pacemaker dysfunction in the early period after implantation.

Natural history of potentially lethal ventricular arrhythmias in patients treated with long-term antiarrhythmic drug therapy.

To examine the natural history of long-term anti-arrhythmic therapy in patients with benign and potentially lethal ventricular premature complexes (VPCs), 28 patients with initial efficacy with moricizine (greater than 75% suppression of baseline mean VPCs/hr and greater than 90% suppression of repetitive VPCs) were prospectively followed for 1 to 56 (mean +/- standard deviation 25 +/- 17) months. Patients were examined during baseline placebo, anti-arrhythmic drug therapy and intermittent pulsed-placebo reexamination periods. The mean VPCs of all patients at baseline entry were 233 +/- 47 VPCs/hr, and after moricizine therapy 14 +/- 4 VPCs/hr. Follow-up demonstrated that antiarrhythmic efficacy decreased to 75% at 12 months and to 62% at 24 months. Loss of antiarrhythmic drug efficacy most commonly occurred as a "transient" event (10 patients [36%]), and efficacy was spontaneously reestablished without a change in antiarrhythmic therapy. In contrast, increased dose titration of moricizine was necessary to reestablish antiarrhythmic suppression efficacy in 4 patients (14%), and 4 patients (14%) lost antiarrhythmic drug responsiveness during follow-up. Spontaneous decrease in baseline VPCs resulted in discontinuation of antiarrhythmic therapy in 3 patients, and increase in baseline VPCs was associated with a loss of antiarrhythmic response in 2 patients. Late proarrhythmic effects (2 patients, 7%), delayed side effects necessitating drug withdrawal (6 patients, 21%) and medical events (4 patients, 14%) occurred during 56 months of follow-up. Individual serum moricizine levels remained in the therapeutic range throughout the study and did not correlate with changes in antiarrhythmic efficacy.(ABSTRACT TRUNCATED AT 250 WORDS)

Reperfusion arrhythmias during coronary reperfusion therapy in man. Clinical and angiographic correlations.

We hypothesized that patients suffering acute myocardial infarction who have reperfusion arrhythmias (RPA) during intracoronary streptokinase infusion (ICSK) would have different clinical and angiographic characteristics and a larger infarction size than those who achieved reperfusion without RPA. Of 35 patients who received intracoronary streptokinase, 27 had successful reperfusion documented by angiography. Successful reperfusion was accompanied by RPA in eight patients and no RPA in 19 patients. RPA included episodes of ventricular tachycardia in one, idioventricular rhythm in four, junctional bradycardia in one, or AV block in two patients which occurred at the time of reperfusion. Myocardial infarction size was calculated using creatine kinase-MB (CK-MB) isoenzyme time activity curves using standard methods. The mean CK-MB g equivalents (eq) for those with RPA was 71 +/- 25 (+/- 1 SD) and for those with no RPA was 45 +/- 24 (p less than .04). In patients with RPA, ejection fraction rose 5 +/- 14 percentage points before discharge, but fell 10 +/- 13 points in those with RPA (p less than .03). There was no difference between groups in total dose of streptokinase, final degree of stenosis of the affected vessel, reocclusion rate, or time from onset of symptoms to reperfusion. We conclude that patients suffering acute myocardial infarction who have RPA during ICSK in most cases have a larger infarction site or a more "stunned myocardium," as indicated by greater CK-MB release and fall in ejection fraction which is not due to increased time of ischemia.

Embolus to the right atrium simulating myxoma.

A space-occupying mass of the right atrium was found by two-dimensional echocardiography and angiography in a 68-year-old woman whose clinical diagnosis indicated multiple pulmonary emboli. Since right heart myxomas frequently cause pulmonary thromboembolism, the patient was initially diagnosed by noninvasive and invasive techniques as having a right atrial myxoma. Surgery, however, revealed the pathologic findings of large thrombi of the right atrium, femoral and iliac veins, and pulmonary arteries. This case vividly demonstrates that deep venous thrombosis may embolize and lodge in the right atrial cavity simulating a right atrial myxoma.

Emergency catheter ablation of refractory ventricular tachycardia.

Catheter ablation, in extreme cases, can be used successfully as emergency therapy for VT in the CCU. In the hands of a physician experienced in electrophysiologic procedures, catheter ablation may prove to be an alternative to surgical or pharmacologic therapy in acutely ill patients with refractory ventricular arrhythmias.

Science and religion.

Religion and science have often been in conflict throughout human history. There are many who think that they can never be reconciled. In this essay, it will be argued that religion and science are in harmony, and, in fact, they are both necessary for the advancement of human civilization. In essence, religion and sciences represent to pathways in the search for truth. In general, religion deals with spiritual matters and science with physical matters. In some cases they overlap. The very word, "science" has had different meanings throughout the centuries. The sciences studied in the ancient world, such as alchemy, would have no meeting today. It is likely that some sciences, which are considered very important today, will in future centuries become irrelevant. (Ref. 15.).

Inappropriate implantable cardioverter defibrillator shocks secondary to sensing lead failure: utility of stored electrograms.

The Ventritex Cadence is a fourth generation implantable cardioverter defibrillator that provides for retrieval of stored electrograms related to therapy. In two patients, this feature enabled us to troubleshoot sensing lead problems, in one instance before it became clinically apparent. This may be an important consideration in selecting an appropriate device.