Objective: To analyze subjective influence of pregnancy on lower limb lymphedema.

Method: Cross-sectional study on 49 affected women was conducted in a single lymphology department between January 2002 and December 2006. All women were asked whether their lymphedema had worsened during pregnancy.

Results: Mean age at lymphedema onset was 17 years, with no familial history of lymphedema. Lymphedema was unilateral for 30 women and bilateral for 19. Median age at the first delivery was 28 years. Eighteen women had only 1 pregnancy, 23 women had only 2, and 8 women had 3. For the first pregnancy, birth weight was 3.4 kg. Subjective lymphedema worsening was reported by 5 women after the first pregnancy compared to 44 women without worsening (P = .006) and after 10 (11%) of the 88 pregnancies (1 twin birth) involving 9 women. During the median 18 years since the first pregnancy, only a 14-year-old boy has developed bilateral lymphedema.

Conclusion: Pregnancy did not significantly exacerbate primary lower limb lymphedema.

Introduction: Computed tomography angiography (CTA) is the gold standard follow-up modality after endovascular aneurysm repair (EVAR). A potential alternative noninvasive and less expensive modality is duplex ultrasound scanning (DUS).

Methods: We studied 314 follow-up paired scans (DUS and CTA) in 59 patients with EVAR.

Results: Endoleak—Endoleak was detected in 23.7% patients. The sensitivity and specificity rates of DUS were 54% and 95.3%, respectively. All 9 endoleaks that needed secondary intervention were detected on DUS. Eight of those were identified within a year after EVAR. Sac size—The mean difference in maximum diameter between the DUS and CTA was ≤5 mm in 84.5% of cases and ≤10 mm in 97.1%. Graft patency—There was 100% agreement between CTA and DUS.

Conclusions: Duplex ultrasound scanning was reliable as it detected all the leaks that needed reintervention after EVAR. Duplex ultrasound scanning showed similar results to CTA in detecting sac size and patency.

Sjögren syndrome (SS) is a chronic autoimmune rheumatic disease characterized by a progressive lymphocytic infiltration of exocrine glands, especially salivary and lachrymal ones, leading to xerostomia, parotid gland enlargement, and xerophthalmia. The aim of this study is to describe the capillaroscopic pattern of the interdental papilla in patients with SS and to evaluate a possible correlation with periodontal disease.

Methods: A total of 25 patients affected by SS and 25 healthy controls were examined. The patients with conditions that compromise microcirculation, such as diabetes, hypertension, hyperlipidemia, or some pharmacological treatments, were not included in the study. All the patients were nonsmokers. Periodontal capillaroscopy has been used to investigate the features of microcirculation. Visibility, course, tortuosity, as well as the possible presence of microhemorrhage, the average caliber of the capillary loops, and the number of visible capillary loops per square millimeter were evaluated for each patient.

Results: The results show evident alterations to the capillaries and a typical conformation of the interdental papilla microcirculation in patients with SS; it was possible to observe a reduced caliber of capillaries, as well as a greater number and tortuosity of capillary loops.

Conclusion: This study shows that capillary alterations to patients with SS occur in gingival microcirculation.

Background: It is widely believed that venous ulcers result from venous insufficiency related to venous valve damages. To further investigate the pathogenesis of venous ulcers, we compared the influence of oxidative stress in venous valvular tissue on stasis ulcer formation in patients with venous ulcers secondary to superficial venous reflux disease.

Methods: Thirty-nine consecutive patients with superficial venous reflux who underwent saphenectomy were included in the study. Patients were divided into 2 groups: with healed venous ulcers (group 1, n = 15) and without ulcers (group 2, n = 24). All patients were preoperatively evaluated with duplex ultrasound scanning and their blood samples were obtained to examine leukocyte count, interleukin-6 (IL-6), tumor necrosis factor- (TNF-), and C-reactive protein (CRP) levels. All patients underwent standard above-knee saphenectomy. Extracted saphenous vein segments were from the saphenofemoral junction, the first valve along. The biochemical analysis of the valve tissues included matrix metalloproteinase (MMP)-9, MMP-2, IL-6, TNF-, superoxide dismutase (SOD), malondialdehyde (MDA), and nitric oxide (NO) studies.

Results: There was no significant difference between patients in terms of age, gender, hospital stay, and preoperative blood levels of leukocyte, IL-6, TNF-, and CRP (P > .05). Biochemical examination of valve tissue showed that the levels of MMP-9, MMP-2, IL-6, TNF-, SOD, MDA, and NO in patients with healing venous ulcer were higher than those of the second group.

Conclusion: A higher oxidative stress in the valvular tissue may contribute to venous stasis ulcer formation.

Atrial septal aneurysm (ASA) and patent foramen ovale (PFO) are not uncommon during routine echocardiographic scanning and were reported to be associated with stroke, transient ischemic attacks, and migrainous headache. To assess the prevalence of ASA and PFO according to ethnicity, we retrospectively studied 887 consecutive referrals to a General Cardiology and Hypertension clinics. All participants underwent transthoracic echocardiography (TTE). In some patients, the TTE was repeated using bubble contrast. Results: Atrial septal aneurysm was detected in 70 participants (7.9%) and PFO in 18 (2%). Atrial septal aneurysm, PFO, or their combination was detected in 12% of the Caucasian patients, 15% of the Afro-Caribbean, and 3.7% of the Indo-Asian patients. Conclusions: There was a lower prevalence of ASA and PFO and their combination in Indo-Asians and a higher rate in Afro-Caribbeans than in Caucasians. The higher prevalence in the Afro-Caribbean participants may contribute to the high incidence of stroke in black participants.

Patients with acute coronary syndromes (ACS) have a poor short- and long-term prognosis. We sought to examine the presence of established coronary risk factors in contemporary patients presenting with an ACS for the first time and no known coronary artery disease (CAD) in the past. The study was conducted in 3171 consecutive patients admitted with the diagnosis of ACS. Of these, 941 patients (30%) had the admission as the first occurrence of ACS and no prior history of CAD. We studied the degree to which these first presenters with ACS had 1 or more established risk factors. We found that 98% of patients presenting with an ACS for the first time and no previous CAD had at least 1 established risk factor. Current population-based screening efforts must be improved to allow more effective prevention strategies and more individualized risk prediction.

Objective: Assess outcomes of ilio-politeal grafting for complex ilio-femoral atherosclerotic disease. Design:Retrospective review of patients undergoing ilio-popliteal grafting between January 1998 and January 2007. Methods: Patients were identified from our unit database. Case notes and radiology were retrieved. Data were extracted and entered into the database for analysis. Results: 19 grafts were undertaken in 19 patients. Primary graft patency was 45% at 1 year (95% CI, 22% - 68%). Secondary graft patency was 82.5% at one year (95% CI, 64% - 100%). 25 subsequent surgical and radiological interventions were undertaken in 12 patients. Lower limb amputation was rare; limb survival was 88% (95% CI, 72% - 100%) at one year and 73% (95% CI 44% - 100%) at 4 years. Conclusions: Ilio-popliteal grafts are rarely undertaken severe disease requiring their use is infrequently encountered. High mortality and low primary patency mean its use can only be advocated in exceptional circumstances.

Peripheral arterial disease (PAD) is an inflammatory process. The association between white blood cell (WBC) count and PAD in those with and without traditional risk factors is not clear. We examined data from the National Health and Nutrition Examination Survey (NHANES) 1999 to 2004. A total of 5260 participants were included. The result showed that the prevalence of PAD rose from 2.8% ± 0.5% in the lowest quartile of plasma WBC count to 8.0% ± 1.2% in the highest quartile. In subgroup analysis, the graded association between WBC count and PAD was significant in patients without hypertension, diabetes, smoking, chronic kidney disease (CKD), and in patients with or without hypercholesterolemia but not significant in patients with hypertension, smoking, diabetes, or CKD. In those without hypertension, diabetes, smoking, or CKD, the cutoff value for WBC count was 6.75 x 10⁹/L. We concluded that the positive association between WBC count and PAD can be demonstrated in this national survey.

Aim: Coronary artery disease (CAD) is the leading cause of morbidity and mortality in the elderly population. Atypical presentation, reduced activity levels, and comorbidity often confound the diagnosis. We studied the use of stress myocardial perfusion imaging (MPI) in octogenarians. Methods: We retrospectively reviewed the medical records of all patients with both MPI and coronary angiogram within 6 months from 1998 to 2008. Sixty veterans under the age of 60 years who underwent both cardiac procedures served as controls. Results: We evaluated 53 patients, predominantly men, with mean age of 85 ± 2.5 yrs. Chest pain (68%) was the most common reason for requesting the stress test. Risk factors included diabetes 44%, hypertension 93%, smoking 48%, hyperlipidemia 93%, and peripheral vascular disease 40%. All patients had an abnormal myocardial perfusion scan. Reversible defects were present in 91% with the following distribution: mild 26%, moderate 39%, severe 15% and multiple defects 11%. Fixed defects were present in 44% of the patients. Analysis of both studies in the 53 patients revealed complete (43), partial (7) and no correlation (3) between the MPI defects and culprit lesions identified on the coronary angiogram. Positive predictive value and accuracy of the myocardial perfusion scan in detection of the disease was 98%. Follow up ranged from 1 to 10 years during which 19 patients died, and 7 deaths were cardiac. Conclusion: Myocardial perfusion imaging in octogenarians is as accurate in diagnosing CAD as it is in younger people.

Renal insufficiency (RI) is a strong predictor of unfavorable outcomes after percutaneous coronary intervention (PCI). After PCI, stent thrombosis (ST) is a considerable concern. The risk of ST in RI has not been independently evaluated before. The mechanism of ST is frequently related to dual antiplatelet underuse. We reviewed the publications listed on Medline, Scopus, and EBSCO Host research database in the last two decades to identify the risk of ST in patients with RI. There are no enough data on the incidence of ST in RI patients. Platelet reactivity, appropriate period of dual antiplatelet therapy, coronary anatomy, selection of stent, and patient compliance are vital issues that warrant detailed evaluation in RI patients. Moreover, prospective trials and new therapeutic strategies are needed for proper assessment and management of ST in high-risk patients.

The etiology of abdominal aortic aneurysm (AAA) includes inflammation and endothelial dysfunction. To evaluate relations between these mechanisms and AAA growth, endothelin (ET)-1, tumor necrosis factor (TNF)-, interleukin (IL)-6, and CD40 ligand were related to yearly AAA growth for 2.9 ± 1.6 years (mean ± SD) in 178 patients with conservatively followed AAA. Total number of follow-up years was 491. Abdominal aortic aneurysm diameter increased by 3.3 ± 4.0 mm during the first year and by 4.9 ± 4.4 mm during the first 2 years. Median (range) growth was 2.5 (-1.0 to 30.6) mm/year. When patients with AAA growth above or below median were compared, initial AAA diameter (46.1 ± 5.8 vs 42.0 ± 8.3 mm; P < .0001), age (75 ± 7 vs 72 ± 8 years; P < .029), and initial ET-1 levels (1.31 ± 0.50 vs 1.13 ± 0.49 pg/mL; P < .0177) were higher in patients with growth above median. Endothelin 1 (P = .0230) and initial AAA diameter (P = .0019) predicted AAA growth above median in logistic regression. In conclusion, higher initial levels of ET-1 and initial AAA diameter independently predict AAA growth.

A total of 30 patients with chronic hepatitis C (HCV) thrombocytopenia (TP) and 20 healthy controls were studied. Both groups were subjected to complete medical history, clinical examination in addition to assessment of hepatitis markers: level of thrombopoietin (Tpo), Geimsa-stained bone marrow smears, and in vitro short-term megakaryocytic progenitors culture (CFU-MK). Serum Tpo level was significantly elevated in patients with TP HCV. Short-term CFU-MK showed an evident depression in the colony-forming unit–megakaryocyte (CFU-meg). There is a positive correlation between the number of CFU-meg and the platelet count and between serum Tpo level and prothrombin time, transaminase, albumin, and the Child Pugh score of liver disease; a negative correlation between serum Tpo level and the number of CFU-meg and between serum Tpo level and the platelet count. Thus, the level of Tpo could be an indicator of intact functional response of the hepatocytes.

This experimental study investigates the effects of hypothyroidism on the descending thoracic aorta. Hypothyroidism was induced in 20 male Wistar rats by administering 0.05% of 6-n propyl 2-thiouracil (PTU) in their drinking water for 8 weeks. Euthyroid rats were used as controls. Animals were sacrificed and longitudinal strips of the descending aorta were subjected to various preselected levels of stress in a uniaxial tensile-testing device. Analysis of stress–strain, elastic modulus–strain curves disclosed significant differences between groups, indicative of stiffer aortas in hypothyroid animals at the upper physiologic and higher levels of pressure. Remodeling of the aortic wall of hypothyroid animals revealed significant histological changes. The thoracic aorta of hypothyroid rats compared with that of euthyroid ones became stiffer at high strains, including the upper physiologic range, loosing part of its distensibility. Hypothyroidism was also associated with diameter enlargement and substantial lengthening of the aorta.

This article is being retracted because another article was published using the same data, but under a different title, in Microvascular Research.

Objective: To evaluate the relationship between microalbuminuria (MA) and the presence and extent of coronary artery disease (CAD). Methods: Four hundred and two consecutive patients were divided into 4 groups based on the presence of diabetes mellitus (DM) and MA: DM(+)/MA(+), DM(+)/MA(-), DM(-)/MA(+), and DM(-)/MA(-). Severity of CAD was assessed by the Gensini scoring system. Results: The Gensini score was 57 ± 38.2 vs 16.5 ± 19.5 (P < .001) in the DM(+)/MA(+) and DM(+)/MA(-) groups and 45 ± 39.8 vs 9.9 ± 16.6 (P < .001) in the DM(-)/MA(+) and DM(-)/MA(-) groups. Spearman correlation analysis demonstrated a positive relation between urine albumin/creatinine ratio (ACR) and extent of CAD both in the diabetic and nondiabetic patients (r = .584, P = .001; r = .545, P = .001). Microalbuminuria was found to be an independent predictor for the presence (OR for MA: 3.728; 95% CI, 1.931–7.196; P < .001) and severity of CAD (P < .001, β = .563). Conclusion: A strong relationship between MA and the severity of CAD was reported.

We characterized the age-related change in large and small artery compliance in 137 healthy participants between 9 and 77 years of age. Large artery compliance, measured by diastolic pulse contour analysis, had a sharp positive linear trend (0.89 mL x mm Hg^-1 x year^-1) highly correlated with age in participants younger than 30 years (r = .76, p <.0001), had a slight negative trend (-0.10 mL x mm Hg^-1 x year^-1) not significantly associated with age (r = -.11, p = .532) in middle-aged participants, and had a sharper negative trend (-0.19 mL x mm Hg^-1 x year^-1) significantly associated with age (r = -.30, p =.023) in participants beyond 50 years. Similar results were found for small artery compliance. Large and small artery compliance increase in children, adolescents, and young adults, reach plateaus near age 30, and then decline beyond 30 years of age in those free of cardiovascular disease and risk factors.

Background: The genetic risk factors that contribute to the risk of developing abdominal aortic aneurysm (AAA) are poorly understood. We assessed the association of endothelial nitric oxide synthase (eNOS) gene polymorphism with AAA. Methods: eNOS gene polymorphism of 61 patients with AAA and 62 control participants were analyzed by polymerase chain reaction (PCR)-restriction technique. Results: eNOS G894 homozygote T/T genotype polymorphism and 894T allele frequency in patients with AAA were significantly higher than those of the control participants (P = .01, P = .03). Among patients with AAA, the eNOS G894 T/T polymorphism and 894T allele frequency were associated with larger AAAs. Conclusion: The current study, in a small group of participants, showed a relationship between eNOS G894T polymorphism and AAA.

Renal artery stenting is a widely performed procedure for atherosclerotic renal artery stenosis. It is very important to identify patients that will benefit from this procedure as this may involve potential risk and complications. Our study is a retrospective analysis aimed at evaluation of mid-pole renal cortical thickness at the time of stenting and correlating with renal function and blood pressure after the procedure. A total of 48 procedures were done on 31 patients evaluated in this study. The change in SBP was greater for the abnormal group compared to the normal group (-1.49 mmHg vs. -0.98 mmHg, P = 0.7813). The change in DBP was greater for the abnormal group compared to the normal group (-0.68 mmHg vs. 0.04 mmHg, P = 0.3809). The change in odds of having a GFR in higher categories was greater for the abnormal group compared to the normal group (OR =1.23 vs. 1.05, P = 0.3085). Our study did not show a significant association of renal cortical thickness and outcomes of BP and GFR following stenting of atherosclerotic renal artery stenosis. However, we did find a greater improvement in BP and GFR in patients with abnormal cortical thickness compared to those with normal cortical thickness.

Objective: This study was designed to describe the characteristics and clinical outcome of patients diagnosed with plantar vein thrombosis. Methods: Patients presenting with sudden pain and/or swelling of the foot were evaluated by duplex scanning of the affected leg. All the main foot veins were imaged with high resolution multi-linear array transducers. The location and extent of thrombosis was recorded in detail. All patients were scheduled for clinical and ultrasound follow-up within a week from the diagnosis and at various intervals thereafter. Results: Acute thrombosis was found in the plantar veins in 11 patients of whom 7 were females. Pain was presented in all patients, swelling in 8 and the left foot was involved in 7. From the risk factors evaluated, the most common were recent surgery 4, use of contraceptive pills 3, followed by malignancy, airplane travel, HIV-AIDS infection, and past history of DVT in one each. Plantar veins were exclusively affected in 8, with lower segment of the posterior tibial veins in 2 and the great saphenous vein in 1. In the follow up, there was evidence of thrombosis extension in 3 patients. At six months partial recanalization was found in 9 and complete in 2. Conclusions: Pain and swelling of the foot can be caused by plantar vein thrombosis. Complete or partial recanalization occurs in these patients by 6 months. Thrombi in the plantar veins can progress more proximally with the possibility of postthrombotic events.

Coagulation factor XII (FXII) plays a key role in both coagulation and fibrinolysis and has been associated with cardiovascular disease in some studies. Plasma FXIIa levels are strongly determined by a common functional polymorphism in the promoter of the FXII gene (F12-4C>T). To investigate the potential association of this polymorphism with peripheral arterial disease (PAD), we performed a case-control study including 668 patients with PAD and 762 controls participants without cardiovascular disease. F12 genotype frequencies were not significantly different between patients with PAD and control participants. After adjustment for classical risk factors, the odds ratio of carriers of a F12 -4T allele for PAD was 1.06 (95% confidence interval 0.86—1.32). F12 genotypes were associated with a modest increase of the mean-activated partial thromboplastin time but not with PAD stage or severity. We conclude that the functional F12-4C>T polymorphism is not associated with PAD.

Objectives: Does thrombin activation seen in patients with abdominal aortic aneurysms (AAA) relate to the thrombus surface area or volume within the aneurysm? Patients and methods: A total of 130 patients with AAA were analyzed regarding levels of the complex between activated protein C-protein C inhibitor (APC-PCI) and AAA morphology. Analysis of APC-PCI complex was made using a sandwich immunofluorometric method. Results: Increased APC-PCI concentrations were seen in patients with AAA (0.44 µg/L; P < .001 compared with controls). The correlations of APC-PCI values were r = .13, P = .13 for aneurysm size, r = .08, P = .35 for thrombus surface area, and r = .13, P = .14 for thrombus volume. APC-PCI values elevated to 0.45 µg/L in 10 patients with AAA having no or very little thrombus mass. Conclusion: Disappointingly, no correlation was found between thrombus surface area or volume and levels of the APC-PCI complex. Mechanisms other than the AAA-sac thrombus must be evaluated as cause of thrombin activation in patients with AAA.

Risk factors for pulmonary embolism (PE) have been identified among populations in Western countries but have not been well characterized in Japan. A hospital-based case-control design employed cases with PE, which diagnosed by standard imaging techniques; controls were individuals drawn by systematic random sampling from the hospital admission register. A total of 100 (38 males and 62 females) and 199 controls were identified. Patients with PE were younger (56.5 vs 60.9 years) and more likely to be female. The odds ratio ([OR] adjusted for other factors) and 95% confidence interval (CI) for risk of PE was elevated for the following: female gender, prolonged immobilization, history of prior venous thromboembolism (VTE), lower extremity varicose veins, body mass index (BMI) ≥ 25 kg/m², extremity paralysis, and gout/hyperuricemia. Inherited thrombophilia was found in 14 patients with PE (14%). Risk factors for PE in Japan are comparable in magnitude to those in Western countries; only one third of PE cases had received VTE prophylaxis.

Purpose: To evaluate the prevalence of significant coronary artery disease (CAD) and nondiagnostic studies in patients referred for clinically indicated coronary angiography performed by 128 multidetector computed tomography (MDCT). Methods: We examined patients referred for coronary computed tomography (CT) angiography for the presence of CAD. The analysis included 438 studies classified as normal, with nonsignificant CAD, with significant CAD, or nondiagnostic. Results: Of the 438 cases evaluated, 121 (27.6%) cases were reported as normal, 184 (42%) were classified as nonsignificant CAD, 92 (21%) as significant CAD, and 41 (9.3%) were inconclusive. Therefore, 69.7% of the study population most probably did not require conventional coronary angiography. Conclusion: Among patients referred for computed tomography angiography (CTA) for appropriate indications, 69.6% had either normal coronary arteries or nonobstructive disease. Given the high negative predictive value of coronary CTA, these patients most likely would not require invasive coronary angiography. Selective cardiac CTA may substantially decrease unnecessary diagnostic cardiac catheterizations.

Aim: To describe the outcomes of treating patients with angioplasty who are older than 40 years with symptomatic/labile/refractory hypertension (HTN). Methods: Between1999 and 2005, 28 patients underwent angioplasty for renal fibromuscular dysplasia (FMD). Patients were excluded if they had concomitant atherosclerotic renal artery stenosis (n = 4) or less than 1 month follow-up (n = 8). Results: The study group included 16 Caucasians (21 procedures; mean age 65.5 ± 10.8 years; females = 88%). The cardiovascular risk factors include HTN (n = 13), smoking (n = 1), diabetes (n = 2), dyslipidemia (n = 8). The HTN was characterized as refractory (n = 15, 12 were symptomatic) and new-onset in 1 patient. The technical success rate was 100%. Over a median period of 12.8 months (range: 1.0-85.8), 18 (95%) procedures "failed," of which 8 (42%) within 1 month and the rest in 1 year. Conclusions: Angioplasty in symptomatic renal FMD in patients >40 years is associated with poor outcomes possibly due to early restenosis.

Statins possess several pleiotropic effects and have been shown in vitro and in vivo to inhibit the expression of inflammatory mediators and downregulate molecules involved in extracellular matrix (ECM) degradation. Recent observational studies in humans suggest that statins may have a role in abdominal aortic aneurysm (AAA) prevention or may even inhibit aneurysm expansion. In this review, we summarize the effects of statins on the vessel wall of aneurysmal aortas and currently available data concerning their inhibitory effects on aneurysm progression.

This pilot study assessed the effects of hyperemia on carotid-radial pulse wave velocity (PWV) in 39 normotensive (NT) and 23 hypertensive (HT) participants using applanation tonometry. Pulse wave velocity was measured at 1- and at 2-minute intervals. Baseline PWV was similar between the groups (P = .59). At 1 minute, PWV decreased (8.5 ± 1.2 to 7.1 ± 1.4 m/s, P < .001) in NT but not in HT (P = .83). Hyperemic PWV (PWV) response differed between the groups (-16% vs + 1.0%, P < .001). On multivariate analysis, HT, not age or blood pressure was independently related to PWV (R² = .43, P < .01). Among patients with cardiovascular risk factors/disease, PWV was inversely related to flow-mediated dilation (FMD; R² = .43, P < .003). Conclusion: hyperemia decreases PWV_1min in NT but not in HT. PWV is inversely related to FMD. Blunted hyperemic PWV response may represent impaired vasodilatory reserve.

Although takotsubo cardiomyopathy is a rare entity, it is an important differential in patients presenting with symptoms, signs, and electrocardiographic changes suggestive of an acute myocardial infarction. Since it was first recognized in 1991, it has gained increasing attention worldwide; however, its etiology and consequently the optimal management still remains unclear. Here, the authors provide a review of the current literature accompanied with images of a typical case from our department.

Objectives: To investigate the long-term impact of right ventricular myocardial involvement (RVI) after acute inferior ST-segment elevation myocardial infarction (STEMI). Methods: A total of 1208 consecutive patients, who survived to discharge after hospitalization for acute inferior STEMI, were studied. Patients were divided into those with (n = 459) or without (n = 749) of RVI involvement, defined as ST-segment elevation ≥1 mm in V4R. Cardiac death by 3 years was the primary study end point. Results: By the end of follow-up, 207 (17.1%) patients had died. Patients with RVI were at similar risk for death at 3 years than those without (17.6% vs 16.8%, hazard ratio 1.1, 95% confidence interval 0.8-1.4, P = .79). By multivariate Cox analysis, several variables, but not RVI, were associated with the incidence of 3 years cardiac death. Conclusions: Right ventricular myocardial involvement does not portend any increased risk for long-term mortality, in patients who survived to discharge after hospitalization for acute inferior STEMI.

Background: Increasing evidence suggests that erythrocytes may participate in atherogenesis. We sought to investigate the relationship between total cholesterol content in erythrocyte membranes (CEM) and coronary atheroma burden in patients with coronary artery disease (CAD). Methods: We prospectively enrolled 28 participants: 11 patients with angiographically significant CAD and 17 controls. Intravascular ultrasound (IVUS) and 3-dimensional reconstruction of coronary arteries was performed in the patient subgroup. Results: Cholesterol content of erythrocyte membranes was higher in patients compared to controls (P < .01). Cholesterol content of erythrocyte membranes correlated with total atheroma volume (r = .82, P < .01) and with percentage plaque area at the vessel site with minimal lumen area (r = .75, P < .05). On multivariate analysis, CEM was the only variable independently predicting total atheroma volume (P = 05). Conclusions: This pilot study is the first to demonstrate a significant relation between CEM and coronary atherosclerotic burden, suggesting a possible role of erythrocyte membrane–derived lipids in the expansion of atheromata. The results merit validation in larger studies.

Aim: To determine the impact of stages of renal dysfunction on mortality after percutaneous coronary intervention (PCI) in patients with acute coronary syndrome (ACS). Patients and Methods: A total of 449 patients (mean age 63 ± 11.9 years) with ACS after PCI were included. Serum creatinine was determined and creatinine clearance was calculated using the Modification of Diet in Renal Disease (MDRD) formula. Results: The prevalence of chronic kidney disease (CKD) defined as glomerular filtration rate (GFR) <60 mL/min per 1.73 m² was 26.3%. After up to 787 days of follow-up, 40 patients had died. Kaplan-Meier survival analysis showed progressively higher risk for cardiovascular death from stage 1 to stage 4 of renal dysfunction. In an adjusted Cox model, gender (P < .009), age (P < .0001), total cholesterol level (P < .01), and stage of renal dysfunction (P < .04) were predictors of mortality. Conclusions: In patients with ACS after PCI, a higher stage of renal dysfunction was directly associated with higher mortality of these patients.

Introduction: The saphenous vein is one of the indispensible grafts for coronary revascularization despite the advantages of arterial grafts over veins. It can be used in different configurations with different anastomosis (eg, sequential, composite, or Y-graft) techniques. Our aim was to investigate early and mid-term results of Y-type anastomosis of saphenous vein grafts for complete coronary revascularization.

Material and methods: Coronary artery bypass grafting (CABG) with Y-graft technique was performed in 512 patients between February 1998 and June 2007. In total, 608 saphenous Y coronary anastomoses were performed. These anastomoses were on first and second obtuse marginal arteries (n: 323), first diagonal and first obtuse marginal arteries (n: 187), posterolateral and posterior descending artery (n: 79), and right coronary artery and posterior descending artery (n: 19). Endareterectomy was performed in 28 patients with severely calcified coronary arteries. Patients were evaluated for early and late survival, newly developing cardiac events, recurring angina, and reinterventions.

Results: In the early postoperative period, new myocardial infarction (MI) occurred in 27 (5.2%) patients and mortality in 13 (2.5%). Follow-up included the results of 487 (98%) patients. Mean follow-up duration was 56 ± 24 months. Late mortality occurred in 36 (7.3%) patients, and in 13 (2.6%) patients new MI developed in the remote follow-up. Overall survival including all deaths at 3, 5, and 7 years was 94 ± 0.6%, 86 ± 1.3%, and 83 ± 2.1%, respectively, and actuarial freedom from angina recurrence at 3, 5, and 7 years was 95.2 ± 2.5%, 86.4 ± 3%, and 84.7 ± 4.6%, respectively. Among long-term survivors, 116 patients (25.7%), 49 being symptomatic, with 123 saphenous Y-type anastomoses having undergone angiography studies. Saphenous vein Y grafts were completely patent in 94 anastomoses (76.4%).

Conclusions: Saphenous vein Y-type anastomosis technique can safely be used in patients with multivessel coronary artery disease (CAD) with successful long-term outcomes. As with sequential anastomosis, the safety of the technique may be attributed to the distribution of inflow from aorta into multiple vessels.

A reduction in arterial compliance in patients with autoimmune diseases such as rheumatoid arthritis and systemic lupus erythematosus has been previously reported. It is caused by the effect that systemic inflammation has on the cardiovascular system. Multiple sclerosis (MS), an immune-mediated disease that exclusively affects the central nervous system (CNS), has a significant inflammatory component that is limited to that compartment. The potential effects of its inflammatory mediators in the cardiovascular system are largely unknown. Purpose: To examine large (C1) and small arterial compliance (C2) in patients with MS and compare them with healthy age-matched controls. To also determine whether any differences in C1 and C2 indices between participants diagnosed with relapsing remitting MS (RR-MS), secondary progressive MS (SP-MS), and controls exist. Methods: A total of 26 men and women between the ages of 18 and 64 diagnosed with MS and 25 healthy controls volunteered for this study. Arterial compliance was measured by using pulse contour analysis (PCA), which records and analyzes the blood pressure waveform data from the Arterial Pulse Wave Sensors. Results: Significant differences in C1 and C2 were found between young RR-MS and healthy young controls (P < .05), with the MS group showing lower arterial C1 and C2 compliance. No significant differences (P > .05) were seen for C1 or C2 values between older RR-MS, SP-MS, and healthy controls. Conclusion: Arterial compliance is significantly compromised in young individuals with MS, compared with age-matched controls, but not for older individuals, suggesting a systemic effect of an inflammatory process that predominantly affects the CNS.

Peripheral arterial disease (PAD) is associated with significant morbidity and mortality and is an important marker of systemic atherosclerosis. However, little is known about the associated risk factors for PAD in patients on maintenance hemodialysis (HD). We collected the basic data and possible risk factors associated with PAD for 277 patients on maintenance HD. Furthermore, we measured ankle-brachial blood pressure index (ABI) in these patients. PAD was defined as an ABI value less than 0.90. The prevalence of PAD in our HD center was 22.8% (61/268). Advanced age (P = 0.006), longer history of HD (P < 0.001), diabetes (P = 0.002) and presence of PAD symptoms (P < 0.001) were independent predictors of PAD. PAD patients with diabetes had shorter history of HD (P = 0.001). 2-vessel PAD had higher serum cholesterol in HD patients (≥ 200 vs < 200 mg/dL; Odds ratio, 12.12, 95% confidence interval, 2.199-67.79; P < 0.004).

Objectives Chronic inflammatory diseases are associated with an accelerated atherosclerotic process. Recent studies have discussed whether inflammatory bowel diseases (IBDs) can predict early atherosclerosis. We investigated this possibility. Methods: The study consisted of IBD cases (group 1, n = 40) and healthy persons (group 2, n = 40). The IBD group was selected so as not to have vascular disease or the presence of established major cardiovascular risk factors. Results: Group 1 cases showed a significant increase in carotid intima media thickness (cIMT; P = .01). Carotid artery stiffness was impaired in group 1 (P = .03) and high-sensitivity C-reactive protein (hsCRP), homeostasis model assessment of insulin resistance (HOMA-IR), and homocysteine (Hyc) were higher in group 1 patients (P = .02, P = .03, P = .05). Conclusions: Inflammatory bowel disease patients have an increased risk of early atherosclerosis as shown by greater values of cIMT, carotid artery stiffness, Hyc, hsCRP, and insulin resistance.

The purpose of the current study was to investigate a novel measure of oxidative stress in patients with acute coronary syndrome (ACS) using a pro-oxidant–antioxidant balance (PAB) assay, which is simple and rapid. Blood samples were taken from 94 patients admitted with ACS. Pro-oxidant–antioxidant balance values were determined in the first and second 12 hours after the onset of symptoms and compared with values for 81 age- and sex-matched controls. The mean PAB values in the first and second 12-hour samples of patients were both significantly higher than that of controls (P < .001). Among patients, PAB values were also significantly higher in the second samples compared with the first samples (P < .001). These findings indicate a heightened state of oxidative stress following ACS and suggest that the PAB value may be considered as a cardiovascular risk predictor to estimate the extent of oxidative stress.

Background Coronary artery bypass graft surgery is standard treatment for unprotected left main coronary artery disease. Recently, drug-eluting stents have been used to treat unprotected left main coronary artery disease. Objective: To analyze data for consecutive patients treated at a single center with drug-eluting stents for unprotected left main coronary artery disease. Results: Seventy-three patients underwent elective percutaneous coronary intervention of unprotected left main coronary artery disease. Twenty-one (30%) of the patients had disease involving the ostium or midshaft of the left main, while the remaining 52 (70%) patients had distal bifurcation disease. The group consisted of high-risk patients with an average European System for Cardiac Operative Risk Evaluation of 9% (range 0.9%-54%). After 1 year follow-up, 3 (4%) patients died; 8 patients (11%) had target vessel revascularization; 4 with repeat percutaneous coronary intervention; and 4 with coronary artery bypass graft surgery. All the events occurred in the distal bifurcation group. Conclusion: These results from a single-center registry suggest the safety of performing percutaneous coronary intervention with drug-eluting stents in unprotected left main coronary artery disease with low major adverse cardiac events (MACE) rates at 1 year.

In this prospective study, we aimed to document the rate and localization of deep venous thromboses in patients with spinal cord injuries. Patients with paraplegia or tetraplegia were screened by a serial color duplex sonography protocol for deep venous thrombosis within the first 36 hours after admission, at day 7, and at day 21. Sonography was performed by a complete scan including the veins below the knee. A total of 139 patients were included (19-90 years, 63.5% male). Cumulative rate of deep venous thrombosis after 3 duplex scans was 45.3% (n = 63). In 71.4% (n = 45), thromboses were localized below the knee. Because of the relevant number of distal vein thromboses, inclusion of the calf veins during screening scans is suggested. Further studies are needed to analyze the clinical benefit of diagnosing and treating distal vein thromboses.

Background Although, metabolic syndrome and obesity are cardiovascular risk factors, little systematically collected community-based data are available from the Arabian Gulf region. Methods: We report a nationwide cross-sectional study from Kuwait. A random sample was selected. Demographic and clinical data were collected. Blood tests including fasting blood glucose, high-density lipoprotein cholesterol, and triglycerides were collected. Metabolic syndrome was defined according to International Diabetes Federation criteria. Overweight and obesity were defined as body mass index ≥25, and body mass index ≥30, respectively. Results: Prevalence of overweight, obesity, and metabolic syndrome in adult Kuwaiti population were 80.4%, 47.5%, and 36.2%, respectively. Overweight and obesity rates were higher in women 81.9% and 53% compared to men 78% and 39.2%, respectively (P = .02, P > .001). MetS was equally distributed between men and women at 36.2% and 36.1%. Conclusions: Prevalence of overweight, obesity, and metabolic syndrome is alarmingly high in Kuwait. This requires urgent and active community-based public health intervention.

Introduction: Varied reasons existed for not offering reperfusion therapy in ST elevation myocardial infarction and results in poor outcomes, and if related factors could be delineated, corrective measures can be attempted. Method: We compared variables between participants not receiving reperfusion therapy and those receiving single reperfusion therapy. Multivariate analysis examined the contribution of non-reperfusion therapy to death and factors related to it. Results: Non-reperfusion therapy was older and had a lower frequency of typical chest pain, but more dyspnea, and post cardiac resuscitation. They had more heart failure and death. Non-reperfusion therapy was an independent factor related to cardiac death, and factors related to non-reperfusion therapy were age, type of hospital, presenting features on admission (dyspnea and post cardiac resuscitation), lack of typical chest pain, and not being referred to. Conclusion: Non-reperfusion therapy had 2 to 3 times higher in-hospital mortality. Factors related to not offering reperfusion therapy, aside from age, appeared to be amendable to better management.

In segments of human varicose veins, endothelial function was assessed by measuring relaxation induced by acetylcholine in noradrenaline-precontracted preparations. In addition, concentration-response curves to acetylcholine were obtained before and after incubation with the arterial endothelium protectant agents captopril, losartan, troglitazone, pravastatin, or simvastatin. The antivaricose agent escin was also tested. Mean acetylcholine-induced relaxation of varicose venous rings was about 13%, approximately one third of that reported for control saphenous veins. Concentration-response curves to acetylcholine were "u" shaped, the result of endothelium-mediated relaxation at low concentrations, superseded by subsequent smooth muscle contractile responses. Relaxation was enhanced by the endothelium-protecting agents and by escin, troglitazone being the least, and simvastatin the most effective. It was concluded that endothelial dysfunction is present in varicose veins, that this anomaly can be reverted by cardiovascular protecting agents, and that it can play a role in the pathogenesis and treatment of chronic venous insufficiency.

The cardiomyopathies were previously defined as "heart muscle diseases of unknown cause" and were differentiated from specific heart muscle disease with known cause. With increasing understanding of etiology and pathogenesis, the difference between cardiomyopathy and specific heart muscle disease has become indistinct. The term specific cardiomyopathies are used to describe heart diseases that are associated with specific cardiac or systemic disorders. These were previously defined as specific heart muscle diseases. They included ischemic cardiomyopathy, valvular cardiomyopathy, hypertensive cardiomyopathy, inflammatory cardiomyopathy, metabolic cardiomyopathy, general system disease, muscular dystrophies, sensitivity and toxic reactions, and peripartal cardiomyopathy. The cardiomyopathies are therefore classified by the dominant pathophysiology or, if possible, by etiological/pathogenetic factors. Topol in 1985 described a syndrome called hypertensive hypertrophic cardiomyopathy that included severe concentric cardiac hypertrophy, a small left ventricular cavity, and supernormal indexes of systolic function without concurrent medical illness or ischemic heart disease. The aim of this review was to highlighted this syndrome from pathophysiological, clinical, diagnostical view and clear all the possible correlations with genetic, inflammatory, and other markers.

Endurance training has been shown to increase arterial compliance; however, the effect of resistance training is unclear. Purpose: The purpose of this study was to examine the effect lower body resistance training on arterial compliance in healthy premenopausal women. Methods: Thirty-two women were assigned to a resistance training group (n = 21) or a control group (n = 11). Large (C1) and small (C2) arterial compliance (Pulse Contour Analysis) were measured at baseline and after twelve weeks of training. Results: Two-way (group x time) repeated measured ANOVA did not detect significant group, time effects or group x time interactions for small arterial compliance (P > 0.05). There was a significant time effect for large arterial compliance (P < 0.05), which increased in both groups. Conclusions: In contrast to previous studies in men, which found decrease in arterial compliance with resistance training, no decrease in arterial compliance was observed.

Introduction:Advanced glycation end products (AGEs) engagement of a monocyte surface receptor (RAGE) induces atherosclerosis. AGEs also act as CD36 ligands. We studied reactive oxygen species (ROS) and CD36 expression after siRNA inhibition of RAGE expression in human monocytes. Methods: We isolated monocytes from: a) 10 type 2 diabetics, and b) 5 age- and sex-matched healthy individuals. CD36 expression and ROS production were evaluated before and after RAGE knockdown. Results: After incubation of monocytes with AGE + bovine serum albumin (BSA), CD36 expression and intracellular ROS increased significantly in all groups. In RAGE-knockdown monocytes, AGE-induced CD36 expression and ROS generation were also significantly inhibited. Conclusions: Blocking RAGE expression using siRNA in human monocytes led to a significant inhibition of CD36 expression and ROS production, suggesting a positive interaction between RAGE, CD36 expression and ROS generation in monocytes.

Osteoprotegerin is a secretory glycoprotein. Recent experimental findings have suggested that osteoprotegerin may protect against vascular calcification and/or atherosclerosis. In humans, osteoprotegerin levels are positively correlated with the presence and severity of coronary artery disease and the progression of atherosclerosis. However, it is unclear how osteoprotegerin levels are regulated. Statins are known to have beneficial pleiotropic effects against atherosclerosis beyond their lipid-lowering effects. In this study, we examined whether treatment with pravastatin can alter osteoprotegerin levels in patients with hypercholesterolemia and type 2 diabetes. Osteoprotegerin levels were significantly increased from 6.64 ± 2.18 pmol/L at baseline to 7.08 ± 2.29 pmol/L (P = .024) after 3-month treatment with pravastatin. These increases in osteoprotegerin levels remained after 6 months of treatment (7.05 ± 2.22 pmol/L, P = .026). These findings suggest that pravastatin may exert its pleiotropic effects in part through alteration of osteoprotegerin levels.

Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers are thought to possess cardioprotective, cerebroprotective, and nephroprotective properties. Both classes of agents can prevent or reverse endothelial dysfunction and atherosclerosis, thereby potentially reducing the risk of cardiovascular events. Such a reduction has been shown with angiotensin-converting enzyme inhibitors in patients with coronary artery disease, but no such data are scarce with angiotensin receptor blockers (Valsartan in Acute Myocardial Infarction study). Both angiotensin-converting enzyme inhibitors and angiotensin receptor blockers have been shown to reduce damage in target organs, such as the heart and kidney, and to decrease cardiovascular mortality and morbidity in patients with congestive heart failure. These drugs (especially angiotensin receptor blockers) may successfully prevent atrial fibrillation and play a protective role in metabolic syndrome. In some clinical settings, combined therapy angiotensin-converting enzyme inhibitors with angiotensin receptor blocker (double blockade of the renin–angiotensin–aldosterone system) may appear the most effective.

Introduction. The aim of our study was to investigate whether collagen degradation is altered in participants with masked hypertension and whether this alteration could be related to disturbances in the matrix metalloproteinases plasma concentration and to compare the findings with those participants with normal blood pressure levels matched for age, sex, and body mass index.

Methods. Twenty-four (11 men, 13 women) participants with masked hypertension [mean age 46 ± 7 years and body mass index 25.9 ± 2.1 kg/m² (group A)] and 106 healthy normotensives (49 men, 57 women) with normal blood pressure [mean age 44 ± 6 years and body mass index 25.5 ± 2.4 kg/m² (group B)].

Results. The plasma levels of matrix metalloproteinase-9 were significantly higher, while the levels of tissue inhibitors of metalloproteinases-1 and -4 were significantly lower in group A compared with group B (matrix metalloproteinase-9: 569 ± 135 vs. 282 ± 117 ng/mL, TIMP-1: 169 ± 42 vs. 230 ± 37 ng/mL, P < .01, and TIMP-4: 2.1 ± 1.3 vs. 4.2 ± 1.98 ng/mL, P < .04, respectively).

Conclusions. Patients with masked hypertension had significantly increased matrix metalloproteinase-9 plasma levels and significantly decreased plasma levels of tissue inhibitors of metalloproteinases-1 and -4 compared with participants with normal blood pressure. These findings need further investigation.

Objective: The aim of this study was to assess the relationship between ankle brachial pressure index and pulse wave velocity in patients with peripheral arterial disease.

Methods: Brachial-knee and brachial-ankle pulse wave velocity were measured by pneumoplethysmography using cuffs in a standard technique. Correlation between pulse wave velocity and Doppler-ankle brachial pressure index was assessed by Spearman correlation and receiver operating curves.

Results: A total of 133 claudicants were assessed. Analysis by developing receiver operating curves for ankle brachial pressure index and pulse wave velocity showed that patients with ankle brachial pressure index over 0.6 were more likely to have a bk-pulse wave velocity over 9.2 m/s and ba-pulse wave velocity over 9.5 m/s.

Conclusion: These results show for the first time that nondiabetic vascular patients may have measurable significant arterial stiffness independent of an impaired ankle brachial pressure index. These data suggest that pulse wave velocity may be valuable in screening and evaluating the severity of peripheral arterial disease.

Background: There is controversy on the influence of renal artery stenosis on outcome in patients with peripheral artery disease. Patients and Methods: The 12-month impact of renal artery stenosis on declining renal function, control of hypertension, and incidence of major cardiovascular events in 100 consecutive patients undergoing angiography for peripheral artery disease was evaluated. Results: A total of 60 patients had renal artery stenosis: 32 mild, 16 moderate, and 12 severe stenosis. There were no significant differences in either the decline of renal function (2.7 ± 18% vs 0.9 ± 16%), control of hypertension (139 ± 16 vs 139 ± 22 mm Hg) or number of antihypertensive drugs (1.8 ± 1.0 vs 1.6 ± 0.8). Patients with renal artery stenosis had an increased incidence of major cardiovascular events (odds ratio: 2.3; 95% confidence interval: 1.03-5.4), but on multivariate analysis its influence disappeared. Conclusions: Patients with peripheral artery disease having renal artery stenosis had similar decline of renal function and control of hypertension. They had an increased incidence of major cardiovascular events, but it may be explained by the confounding effect of additional variables.

Background: Diabetes mellitus is associated with a higher incidence of acute myocardial infarction. Objective: To study the prevalence and outcome of patients with diabetes among patients with acute myocardial infarction. Methods: Retrospectively, patients who presented with acute myocardial infarction in a 10-year period were identified from the coronary care unit database. Results: A total of 1598 Qatari patients were admitted with acute myocardial infarction, 863 (54%) of them had diabetes mellitus (females 68.5% vs males 48.3%; P < .001). In-hospital mortality rate was non-significantly higher in diabetic patients (18% vs 15% P = .15). Aspirin (odds ratio 2.39, 95% confidence interval 1.96-2.90, P = .003] and β-blocker use (odds ratio 1.75, 95% CI 1.21-2.52, P = .0001) were independently associated with reduced mortality risk. Conclusions: The prevalence of diabetes mellitus among patients with acute myocardial infarction in a geographically defined population in the developing world is high with a trend for poor outcomes. However, mortality was not significantly higher in diabetes mellitus than non-diabetes mellitus patients.

Objectives: To determine the relationship between endothelial function by means of brachial artery flow-mediated dilation (BAFMD) and the clinical severity of peripheral arterial disease (PAD).

Methods and Results: We examined the brachial artery diameter by ultrasound, before and after ischemia of the arm in 3 groups of participants—group A: healthy individuals under 30 years, without cardiovascular risk factors (n = 30); group B: patients with PAD and ischemic claudication (n = 30); and group C: patients with critical leg ischemia (n = 20). There were no differences between groups B and C, in regard to age, sex, and main cardiovascular risk factor. The BAFMD was 9.9% in group A compared with 5.5% in the pooled patients group (B + C; P<.001). Significant differences were absent between groups B and C (P > .05). Correlation coefficient of ankle-brachial index/BAFMD was r = .1; P = .49.

Conclusions: Patients with PAD present endothelial dysfunction, but this does not seem to determine the severity of the disease.