Angiology recent issues

Do Different Vascular Risk Factors Affect All Arteries Equally?

2008-08-20

Established vascular risk factors (ie, smoking, hypertension, diabetes mellitus, and dyslipidemia) play an important role in the development of vascular disease. Emerging evidence suggests that some of these risk factors may have a more intense effect on specific arterial beds, a finding that holds implications for a prognostic role for certain types of vascular disease.

Traditional Risk Factors Are Predictive on Segmental Localization of Coronary Artery Disease

2008-08-20

The aim of this study was to investigate the relationship between established risk factors and segmental localization of coronary artery disease. A total of 2760 patients who underwent coronary angiography were enrolled into the study. Coronary angiographic segmental evaluation was performed according to the scheme of American Heart Association. Patients were classified into 2 groups (group 1: normal coronary artery segments, group 2: coronary artery segments with coronary artery disease). Smoking was highly related with left main coronary artery disease (odds ratio = 7.5; P = .005). Diabetes mellitus and male sex increased the risk of atherosclerosis in all coronary vasculature (odds ratio = 2.7-2.2; P < .001-P < .001). Hypertension was correlated with distal coronary artery (odds ratio = 1.4; P < .001) and family history with distal circumflex lesions (odds ratio = 4.5; P = .005) High triglyceride levels were associated with right coronary artery lesions (odds ratio = 1.00; P =.03). The effect of advanced age was small (odds ratio = 1.08; P < .001). Risk factors may be predictive for segmental localization.

Improvement in Circulation and in Cardiovascular Risk Factors With a Proprietary Isotonic Bioflavonoid Formula OPC-3(R)

2008-08-20

This study investigated the efficacy of isotonic bioflavonoid supplementation, OPC-3 on 61 individuals presenting with risk factors meeting the criteria for metabolic syndrome. Subjects were supplemented with a proprietary isotonic bioflavonoid OPC-3 or placebo over 2 months. Plasma oxidative stress status was significantly lowered by 10.1% with OPC-3. All major cardiovascular risk factors were improved with blood pressure, total cholesterol, and fasting blood glucose lowered. OPC-3 significantly improved endothelial function as evaluated by increased vasorelaxation in reactive hyperemia and enhanced diastolic carotid artery flow. Cardiac ultrasound scanning revealed a significant increase of left ventricular ejection fraction. Skin microcirculation was enhanced, and better tissue perfusion led to significantly increased transcutaneous oxygen partial pressure and decreased pCO₂. With OPC-3 a dramatic and significant plasma C-reactive protein decrease by 52.1% occurred. Individuals may improve key cardiovascular risk factors by daily supplementation with the bioflavonoid OPC-3 as an important part of a healthier lifestyle.

The Right Atrial Thrombus: The Sword of Damocles With Real Risk of Massive Pulmonary Embolism

2008-08-20

Cases of 6 patients admitted at the intensive care unit for massive pulmonary embolism are reported. All patients presented with dyspnea, tachypnea, and tachycardia, and 4 were hypotensive and had syncope. Lung ventilation/ perfusion scans revealed perfusion defects in 4 patients. Transthoracic echocardiography (TTE) demonstrated acute cor pulmonale. It also revealed mobile right atrial thrombi in 5 patients, adherent thrombus in the right atrium in 1 patient and patent foramen ovale in 4 patients. Thrombolytic therapy was initiated in 4 patients, and 2 patients received heparin infusion only. Effects of thrombolysis were monitored using bedside TTE during the first 24 hours and in follow-up. The outcome of 4 patients who received thrombolytic therapy was good whereas other 2 patients, who received only heparin, died. Thrombotic mass disappeared 8 to 12 hours after initiation of therapy, and 10 weeks after discharge TTE showed normalized right ventricle dimensions and function in all 4 patients.

Augmentation Index and Pulse Wave Velocity as Indicators of Cardiovascular Stiffness

Nakae, I., Matsuo, S., Matsumoto, T., Mitsunami, K., Horie, M. — 2008-08-20

The authors examine the clinical significance of radial augmentation index (rAI) and brachial-ankle pulse wave velocity (baPWV). In 78 hypertensive patients, rAI correlates inversely with pulse rate (PR; r = –0.57, P < .001), but baPWV does not. A weak correlation between rAI and systolic blood pressure (SBP) is observed (r = 0.28, P < .05). rAI has no significant correlation with diastolic blood pressure (DBP). In contrast, baPWV correlates positively with both SBP (r = 0.54, P < .001) and DBP (r = 0.43, P < .001). In 56 of these patients, baPWV correlates with the diastolic parameters—the mitral E/A ratio (r = —0.35, P < .01), pulmonary vein S/D ratio (r = 0.41, P < .01), and deceleration time (r = 0.28, P < .05)—by echocardiography, but AI.P75 (rAI corrected for PR 75 bpm because of PR dependence) does not. Therefore, for detection of diastolic dysfunction, baPWV may be more sensitive than rAI.

Secondary Prevention of Arterial Disease in Very Elderly People: Results From a Prospective Registry (FRENA)

2008-08-20

There is little information on the effectiveness of secondary prevention interventions in very elderly patients. In this article, the incidence of major cardiovascular events during a 12-month follow-up period in a series of consecutive patients with coronary, cerebrovascular, or peripheral artery disease is analyzed. As of October 2006, 1264 patients had been enrolled. Of these, 324 (26%) were ≥75 years of age. Their incidence rate of 22 events per 100 patient-years (95% CI, 17-28) was over 2-fold the 7.9 (95% CI, 6.2-10) found in those <75 years of age. Among them, only chronic heart failure and diabetes were independently associated with an increased risk for major events, whereas the use of angiotensin II antagonists was associated with a lower risk. Patients ≥75 years of age had an over 2-fold higher incidence of major cardiovascular events. The use of angiotensin II antagonists was associated with a lower risk.

A-Wave Acceleration: A New Doppler Echocardiographic Index for Evaluation of Left Ventricular Diastolic Dysfunction in Elderly Patients

Abd El-Aziz, T. A. — 2008-08-20

Age alters Doppler indexes of left ventricular diastolic performance. Thus, the Doppler detection of left ventricular diastolic dysfunction in the elderly is difficult. The reliability of Doppler indexes in detecting left ventricular diastolic dysfunction in the elderly patients with cardiac diseases known to affect diastolic function were evaluated. Diastolic function using pulsed Doppler in 6 groups of 10 subjects each: elderly normal, young normal, and elderly with hypertrophic cardiomyopathy, aortic stenosis, coronary artery disease, and dilated cardiomyopathy was tested. The comparison of elderly normal with young normal showed that A-wave acceleration did not change significantly. Comparing elderly normal to elderly with diseases showed that all tested indexes except A-wave acceleration failed to separate normal elderly from diseased elderly. A-wave acceleration appears to be a useful index that can help in diagnosis of left ventricular diastolic dysfunction in elderly patients independent of age effects.

Racial Differences in Coronary Artery Lesions: A Comparison of Coronary Artery Lesions Between Mainland Chinese and Australian Patients

Jiang, S.-s., Lv, L., Juergens, C. P., Chen, S.-l., Xu, D.-j., Huang, Z.-y. — 2008-08-20

Aims: The purpose of this study was to compare coronary lesions in mainland Chinese and Australians using coronary angiography (CAG). Methods and results: 6251 suspected coronary heart disease (CHD) patients (3021 Chinese patients from Nanjing and 3230 Australian patients from Sydney) who underwent a CAG between January 1, 2001, and December 31, 2003, were studied. Of these, 69.4% Chinese and 75.5% Australians were diagnosed with CHD. The incidences of both left main coronary artery (LM) and left anterior descending branch (LAD) lesions in Australians were higher than that for Chinese of the same gender. In the same age range, above 40, Gensini scores of Australians were significantly higher than those of Chinese. Conclusion: In both Chinese and Australians, men had more severe coronary lesions than women. Comparison among different age ranges in the 2 ethnic groups shows that Australians typically have artery lesions more than 10 years earlier than mainland Chinese.

Coronary Collateral Circulation: Any Effect on P-Wave Dispersion?

2008-08-20

Coronary collateral circulation determines the severity of ischemic myocardial damage. Increased P-wave dispersion is an independent predictor for atrial fibrillation. Consistent evidence is little about the relation between coronary collateral circulation and arrhythmia risk. In this article, the effect of coronary collateral circulation on P-wave dispersion was evaluated. Collateral grade and P-wave dispersion were ascertained in 100 patients with ≥85% diameter stenoses in left anterior descending or right coronary arteries. Left ventricular function score was also determined in all patients. Coronary collateral circulation was absent in 32 patients, whereas 68 patients had coronary collateral circulation. Patients with collateral grade ≥1 had greater left ventricular function score than did patients with collateral grade 0 (P = .048). However, there was no significant difference between P-wave dispersion of patients with and without coronary collateral circulation (P = .45). The presence of coronary collateral circulation failed to exert a beneficial decreasing effect on P-wave dispersion.

Age-Related Differences in Arterial Compliance Are Independent of Body Mass Index

Fjeldstad, A. S., Montgomery, P. S., Gardner, A. W. — 2008-08-20

The aim of this study is to examine the effect of age on large and small arterial compliance in apparently healthy adults, and to determine whether this effect is independent of body mass index. The subjects consisted of 126 men and women, aged 45 years and above. The subjects rested supine while pulse contour analysis was measured from the radial artery to evaluate large and small arterial compliance. Large (12.0 ± 4.2 mL/mm Hg x 10, mean ± standard deviation) and small (3.3 ± 1.9 mL/mm Hg x 100) arterial compliance were lower in the oldest group (P = .007, P = .002, respectively) compared with the youngest group (15.2 ± 4.6 mL/mm Hg x 10 and 5.0 ± 2.5 mL/mm Hg x 100, respectively). After adjusting for body mass index, large and small arterial compliance remained lower in the oldest group. Large and small arterial compliance are decreased with advancing age, independent of body mass index.

Effects of Atrial Fibrillation on Arterial Stiffness in Patients With Hypertension

Lee, S.-H., Choi, S., Jung, J.-H., Lee, N. — 2008-08-20

Arterial stiffness is significantly correlated with cardiovascular risk in patients with hypertension. Although arterial stiffness increases with age and other vascular risk factors, the effect of heart rhythm on arterial stiffness is uncertain. The aim of this study was to determine whether the presence of atrial fibrillation is associated with arterial stiffness, as determined by heart to femoral pulse wave velocity, in patients with hypertension. Heart to femoral pulse wave velocity was measured, and comprehensive transthoracic echocardiography was performed in 68 subjects (35 subjects with sinus rhythm, 33 subjects with atrial fibrillation). Potential determinants of heart to femoral pulse wave velocity were identified by univariate and multivariate analyses. Individuals with atrial fibrillation had higher heart to femoral pulse wave velocity than those with sinus rhythm (1028 ± 222 vs 923 ± 110 cm/s, P = .03). Age, the presence of atrial fibrillation, systolic blood pressure, and pulse pressure were found to be significantly correlated with heart to femoral pulse wave velocity. After adjusting for possible con-founders, multivariate analysis identified systolic blood pressure (P = .003) and the presence of atrial fibrillation (P = .007) as independent determinants of heart to femoral pulse wave velocity. The presence of atrial fibrillation was significantly correlated with a higher pulse wave velocity, independently of age or blood pressure in patients with hypertension.

Myocardial Perfusion in Patients With a Totally Occluded Left Anterior Descending Coronary Artery Reinjected by a Normal Right Coronary Artery: The Role of Collateral Circulation

2008-08-20

In this article, myocardial perfusion in patients with a totally occluded left anterior descending artery reinjected by a normal right coronary artery is assessed using stress single photon emission computed tomography (SPECT). In all, 20 patients, with a totally occluded left anterior descending artery reinjected by normal right coronary artery, underwent myocardial single photon emission computed tomography imaging within 60 days of angiography. All patients had abnormal perfusion single photon emission computed tomography results and 70% had reversible defects. Perfusion defects at rest were present in 75% of patients, with perinecrotic residual ischemia in 45% of patients whereas for 30% of patients, no viable myocardium was detected in the collateral-dependent segments. In all, 25% of patients had no resting perfusion defects but all are presented with stress-induced ischemia. Collaterals are not protective against stress-induced ischemia, but they can preserve myocardial viability. This conclusion is highly supported by the presence of residual ischemia in the collateral-dependent segments.

In-Stent Stenosis: Potential Role of Increased Oxidative Stress and Glutathione-Linked Detoxification Mechanisms

Misra, P., Reddy, P. C., Shukla, D., Caldito, G. C., Yerra, L., Aw, T. Y. — 2008-08-20

This study was designed to determine whether red-cell oxidative stress status and antioxidant enzyme levels can serve as markers in patients predisposed to in-stent stenosis. Blood was collected from patient groups undergoing coronary angiography for chest pain evaluation, namely, group A (without coronary artery disease), group B (previous coronary stents without in-stent stenosis), and group C (previous coronary stents with in-stent stenosis). Thiobarbituric acid reactive substances (measure of lipid peroxidation), glutathione-linked detoxification enzymes, catalase, and superoxide dismutase were determined. Compared with group A, patients in group C showed increased lipid peroxidation products and glutathione-S-transferase but decreased glutathione peroxidase and glutathione reductase activities. Results in group B patients were intermediate between those of groups A and C with significant decreases in glutathione peroxidase versus controls. In-stent stenosis is associated with significant increase in lipid peroxidation and attenuated glutathione-linked detoxification enzymes, consistent with oxidative stress.

Crush Stenting With Paclitaxel-Eluting or Sirolimus-Eluting Stents for the Treatment of Coronary Bifurcation Lesions

2008-08-20

Two hundred forty-six patients with 252 bifurcation lesions were enrolled into a prospective, nonrandomized study to use paclitaxel-eluting or sirolimus-eluting stent for crush stenting in the treatment of coronary bifurcation lesions. Compared with the sirolimus-eluting stent group, the paclitaxel-eluting stent group had significantly higher mean late lumen and binary angiographic restenosis rates. Sirolimus-eluting stent versus paclitaxel-eluting stent recipients had significantly lower in-segment restenosis in the entire main vessel (15.7% vs 3.1%, P = .004), and simultaneous side branch and main vessel restenoses were solely detected in the paclitaxel-eluting stent group (11.9% vs 0%, P = .03). Target-lesion vessel revascularization and cumulative major adverse cardiac events rates were significantly higher in the paclitaxel-eluting versus the sirolimus-eluting stent group (17.99% vs 8.41%, P = .01; 19.4 vs 9.3%, P = .01; 23.6 vs 11.2%, P = .03). In this study with crush stenting, use of sirolimus-eluting stent, compared with paclitaxel-eluting stent, yielded significantly lower late lumen loss, restenosis, and revascularization rates, with comparable safety by 8-month follow-up.

Surrogate Markers for Atherosclerosis in Overweight Subjects With Atherogenic Dyslipidemia: The GEMS Project

2008-08-20

Metabolic syndrome is a constellation of major risk factors for cardiovascular disease. In affected individuals with this syndrome, the independent contribution of low high-density lipoprotein—cholesterol and increased triglyceride levels to the development of atherosclerosis remains to be clarified. We assessed the relationship between these 2 parameters and several surrogate markers for atherosclerosis. One hundred and twenty overweight cases, defined as having high-density lipoprotein—cholesterol (≤25 age- and gender-specific percentile in general population) and high triglyceride values (≥75 percentile) were compared with 120 discordant overweight controls defined on lipid values (high-density lipoprotein—cholesterol ≥50 percentile and triglycerides ≤50 percentile). Case-control pairs were matched for age and gender. Carotid and femoral arteries were examined to determine carotid intima-media thickness and the presence of atherosclerotic plaque(s). Endothelial function was assessed by laser Doppler flowmetry in the skin microvasculature. Daytime ambulatory blood pressure monitoring was performed for each subject. Cases had higher prevalence of atherosclerotic plaques (mean 1.50 ± 0.15 vs 0.80 ± 0.15, P < .001), increased carotid intima-media thickness (mean 0.66 ± 0.15 vs 0.61 ± 0.15, P < .01), and a significantly reduced temperature-induced and postischemic endothelial vasodilation compared with controls. In conclusion, low high-density lipoprotein—cholesterol and high triglycerides levels are major contributors to peripheral atherosclerosis and are associated with an increase in intima-media thickness and impaired microvascular endothelial function in overweight individuals.

Association Between Abnormal Uterine Artery Doppler Flow Velocimetry, Risk of Preeclampsia, and Indices of Arterial Structure and Function: A Pilot Study

2008-08-20

Preeclampsia increases the risk of future cardiovascular disease. The association between abnormal uterine artery Doppler flow velocimetry, risk of preeclampsia, and indices of arterial structure and function is investigated in this study. The carotid intima-media thickness of 34 pregnant women with normal uteroplacental flow was compared with 30 women with abnormal uterine artery Doppler analysis during the transvaginal assessment of the uterine arteries at the routine anomaly scan (20-23 weeks of gestation). Women with abnormal uterine artery Doppler results had a greater mean internal (but not common) carotid intima-media thickness (0.58 ± 0.06 vs 0.53 ± 0.08, respectively, P = .005) and risk of developing preeclampsia (6 of 30 vs 0 of 34 or 20% vs 0%, respectively, P = .0079) compared with those with normal uteroplacental flow. Women with abnormal uterine artery Doppler results may be at increased risk not only for developing subsequent preeclampsia but also for future cardiovascular disease.

Dynamic Nutcracker-Like Compression ofAu Saphenous Vein Graft by Adjacent Stents

Chen, J. P., Herring, T. — 2008-08-20

Systolic compression of coronary flow is a rare angiographic finding and usually results from intramyocardial bridging. In this article, the first reported case of iatrogenic dynamic saphenous vein graft compression by adjacent stents is presented. The cyclic movements of the stents resemble the action of a nutcracker with the involved segment at the fulcrum. Previous angiography 4 months prior showed no evidence of such flow impairment, thereby excluding intramyocardial bridging as a potential etiology. Progressive scarring and fibrosis may result in adhesion of a noncoronary conduit to a stationary mediastinal structure. Thus, conceptually, such vessels would be more prone to systolic compression and torsion, as they do not move with the cardiac cycle. Although the stent deployment may be beneficial in some scenarios, complications of vessel rupture and stent collapse can occur. The pathophysiology, natural history, and treatment of dynamic vessel compression are briefly reviewed.

Imaging Investigation of a Giant Splenic Artery Aneurysm

2008-08-20

Splenic artery aneurysms represent approximately 60% of visceral arterial aneurysms. Their incidence at autopsy is 0.02 — 2 % in all age groups and rises to 10.4% above the age of 60. Although splenic artery aneurysms are the most common visceral aneurysms, giant splenic artery aneurysms >10 cm in diameter have rarely been reported. A recent review of the literature came up with 12 true giant splenic artery aneurysms >10 cm. A case of 12-cm splenic artery aneurysms is presented in this study and the imaging findings are described.

Left Ventricular Pseudoaneurysm With Infective Pericarditis: A Rare Cause of Intractable Hemoptysis

2008-08-20

A 52-year-old man with diabetes presented with recurrent, massive hemoptysis following pericardiectomy for pyopericardium secondary to Streptococcus viridans infection. Chest radiograph and bronchoscopic examinations revealed no bronchial cause. Computed tomography of the chest and echocardiography showed a pseudoaneurysm of the left ventricle. Surgical exploration confirmed that the pseudoaneurysm communicated with the left lung parenchyma and was the cause of recurrent intractable hemoptysis.

Inferior Vena Cava Agenesia and a Massive Bilateral Iliofemoral Venous Thrombosis

Vucicevic, Z., Degoricija, V., Alfirevic, Z., Sharma, M. — 2008-08-20

The absence of the inferior vena cava is a rare congenital anomaly and represents a modest risk for deep-venous thrombosis. When associated with genetic polymorphism or other hypercoagulable states, the risk can increase several times. A case of young man with the inferior vena cava agenesia and deep-venous thrombosis of both legs triggered by the physical effort is reported. The view that the congenital inferior vena cava malformation represents a predisposition to deep-venous thrombosis in spite of well-developed collateral circulation is supported. In these circumstances, various external triggers (physical effort, hormonal contraception etc) may precipitate thrombosis. Because the patient had no other convincing and permanent risk factors for thrombosis, the lifelong anticoagulant therapy was not recommended.

Splenic Vein Thrombosis Following Abdominal Compression and Vibration: A Case Report

2008-08-20

The authors describe a 46-year-old man with isolated splenic vein thrombosis (SVT) that developed after concrete drilling, which caused significant compression and vibration of the abdominal wall. Methyltetrahydrofolate reductase (MTHFR) deficiency-related hyperhomocysteinemia, which was subsequently diagnosed, predisposed him to this event. To the best of the knowledge of authors, this is the first report of isolated splenic vein thrombosis caused by compression and vibration of the abdomen. Relevant aspects of isolated post-traumatic splenic vein thrombosis in this context are discussed.

Catastrophic Antiphospholipid Syndrome Presenting With Multiorgan Failure and Gangrenous Lesions of the Skin

Antonelli Incalzi, R., Gemma, A., Moro, L., Antonelli, M. — 2008-08-20

A 38-year-old woman with a 20-year history of systemic lupus erythematosus and positive anticardiolipin antibodies developed anuria and hypotension. 20 days before, she had discontinued 25 mg prednisone, but not warfarin, on medical advice. 3 days before admission, she developed extensive necrosis and blisters involving both arms and legs and a multiorgan failure. She improved after immunosuppressive and antibiotic therapy, 3 sessions of dialysis and 5 sessions of plasmapheresis. It was decided that she could be discharged after 45 days. Her skin lesions were complicated by several abscesses requiring surgical drainage and finally healed almost completely within 9 months. Catastrophic antiphospholipid syndrome is a distinctly rare dramatic condition characterized by widespread thrombosis of small vessels, which in the present case was likely triggered by the abrupt withdrawal of steroid therapy. It should be borne in mind in cases of multiorgan failure, which does not recognize a well-defined etiology.

Erratum

2008-08-20

Effects of Policosanol (10 mg/d) Versus Aspirin (100 mg/d) in Patients With Intermittent Claudication: A 10-Week, Randomized, Comparative Study

2008-06-10

Antiplatelet therapy, including aspirin, is recommended to lower the vascular risk in patients with intermittent claudication. Policosanol has increased walking distances in these patients, probably because of its antiplatelet effects, but the effect of shorter treatment has not been studied. This double-blind study compared the effects of policosanol 10 mg/d and aspirin 100 mg/d for 10 weeks on walking distances in claudicants. Thirty-nine patients were randomized to policosanol or aspirin. Walking distances on a treadmill were assessed before and after treatment. Policosanol significantly increased the initial and absolute claudication distances, while aspirin changed neither variable. Policosanol, not aspirin, significantly lowered serum low-density lipoprotein-cholesterol and total cholesterol while raising high-density lipoprotein-cholesterol. In conclusion, treatments of policosanol, not aspirin, for 10 weeks significantly increased walking distances, but modestly, in contrast with previous results. Therefore, the duration of treatments at the doses tested was too short for meaningful effects on the treadmill test.

Does Gender Influence the Patency of Infrainguinal Bypass Grafts?

Alpagut, U., Ugurlucan, M., Banach, M., Mikhailidis, D. P., Dayioglu, E. — 2008-06-10

Infrainguinal revascularization is an effective method of treatment for femoropopliteal/tibial occlusive diseases. However, these bypass grafts are prone to stenosis. In this retrospective study, the authors investigate the association of gender with patency of infrainguinal bypass grafts. The outcomes for consecutive 375 male and 200 female patients who underwent infrainguinal bypass surgery for arterial occlusive disease are compared, and associations with characteristics of the patients, surgical procedure, and graft stenosis are determined. It is found that several demographic, biochemical, and etiological factors could influence the patency of bypass procedures in different genders. However, infrainguinal arterial reconstruction procedures performed in women have a worse outcome when compared with that in men.

Bilateral Transit Time Assessment of Upper and Lower Limbs as a Surrogate Ankle Brachial Index Marker

Foo, J. Y. A. — 2008-06-10

Ankle brachial index is useful in monitoring the pathogenesis of peripheral arterial occlusive diseases. Sphygmomanometer is the standard instrument widely used but frequent prolonged monitoring can be less comfortable for patients. Pulse transit time is known to be inversely correlated with blood pressure and a ratio-based pulse transit time measurement has been proposed as a surrogate ankle brachial index marker. In this study, 17 normotensive adults (9 men; aged 25.4 ± 3.9 years) were recruited. Two postural change test activities were performed to induce changes in the stiffness of the arterial wall of the moved periphery. Results showed that only readings from the limbs that adopted a new posture registered significant blood pressure and pulse transit time changes (P < .05). Furthermore, there was significant correlation between the ankle brachial index and pulse transit time ratio measure for both test activities (R² ≥ 0.704). The findings herein suggest that pulse transit time ratio is a surrogate and accommodating ankle brachial index marker.

Age and Blood Pressure Levels Modify the Functional Properties of Central but Not Peripheral Arteries

2008-06-10

The effect of age and blood pressure on the carotid and the radial artery distensibilities was investigated. Patients referred to the outpatient clinic of the Department of Internal Medicine and Geriatric Medicine were asked to participate in the study. The carotid and radial artery distensibility coefficients were measured. Linear regression analyses were performed to investigate the associations between determinants and arterial distensibility. The mean age of the participants was 72.3 years, and 41.5% were men. Carotid distensibility decreased with age in adjusted models (β = –0.317; 95% confidence interval [CI], –0.241, –0.055), whereas the radial distensibility did not decrease. Levels of systolic blood pressure and mean arterial pressure were associated with decreasing levels of carotid distensibility, whereas the diastolic blood pressure and pulse pressure were not associated (β = –0.571; 95% CI, –0.404, –0.007; β = –0.410; 95% CI, –0.308, –0.101, respectively). In conclusion, age and blood pressure levels are associated with the distensibility of the central arteries but not with that of the peripheral arteries.

Doppler Ultrasound Compared With Strain Gauge for Measurement of Systolic Ankle Blood Pressure

Joensen, J.B., Juul, S., Abrahamsen, J., Henneberg, E.W., Lindholt, J. S. — 2008-06-10

This study assesses measurement variation in the measurement of ankle systolic blood pressure (ABP) when measured with Doppler ultrasound and with the strain gauge method. Ninety-seven patients were included. ABP was measured with Doppler ultrasound and with the strain gauge method. The methods were compared graphically by scatterplots and analyzed by paired t test, analysis of variance, and Pitman's paired variance ratio test. ABP was measured by strain gauge in all extremities, whereas no Doppler signal was obtainable in 7 limbs (4%). There was no systematic difference in measurements between the means of the two measurements. However, a substantial difference of more than 25 mm Hg was found in 15% of limbs and more than 20 mm Hg in 20%. In the majority of patients, measurements of ABP by Doppler ultrasound and the strain gauge method give similar results, but for a minority the discrepancy is substantial.

Acute Posttraumatic Ischemia of the Limbs: Algodystrophy or Related Syndrome? A Prospective Study on a Series of 25 Patients

Pistorius, M.-A., Connault, J., Kalassy, C., Goueffic, Y., Planchon, B. — 2008-06-10

The aim of this study was to present clinical and paraclinical features of a rarely studied vascular syndrome that usually occurs after a minor traumatic injury. The prospective study of 25 patients identified a group of young subjects, mainly women, generally with history of vascular hyperactivity to cold, showing disseminated pain in a limb always combined with vasospasm, consecutive to a minor traumatic injury in general, and simulating acute ischemia of a limb. The patients' arterial and microcirculatory flows were restored after warming, which proved that they were suffering from intense, reversible but pathological vasospasm, because of its duration, diffusion, intensity, and disproportion as to the triggering event. The symptoms may recur, but they respond to physiotherapy. Patients' follow-up showed that microcirculatory function remains abnormal sometime after the initial episode with, in particular, an exacerbation of the venoarteriolar reflex.

Assessment of Left Ventricular Functions in Patients With Isolated Coronary Artery Ectasia by Conventional and Tissue Doppler Imaging

2008-06-10

The authors sought to determine left ventricular functions by conventional and tissue Doppler imaging in patients with isolated coronary artery ectasia and controls. Peak early (E) and late (A) mitral inflow velocity, E/A ratio, E deceleration time, and isovolumetric relaxation time were obtained. Peak systolic velocity (Sm), diastolic early (Em), and late (Am) velocities were measured by tissue Doppler imaging. Interventricular septum velocities, including peak systolic (Ss), diastolic early (Es), and late (As) velocities, were recorded. Peak early (E) velocity, E/A ratio, and E deceleration time were different in both groups. Isovolumetric relaxation time was prolonged in patients with coronary artery ectasia than controls. Em and Em/Am ratio were lower in patients with coronary artery ectasia than controls. Diastolic early and Es/As velocities were lower in patients with coronary artery ectasia compared with controls. The authors showed that mitral inflow-lateral annulus and interventricular septum velocities were lower in patients with coronary artery ectasia than controls indicating left ventricular diastolic dysfunction.

Effect of Acute Cigarette Smoking on Left and Right Ventricle Filling Parameters: A Conventional and Tissue Doppler Echocardiographic Study in Healthy Participants

2008-06-10

Acute effects of smoking on left and right ventricular function is determined by conventional and tissue Doppler imaging methods in this study. Pulsed-wave Doppler indices of the left and right ventricle diastolic function, including mitral and tricuspid inflow peak early and late velocity and their ratio were obtained from 20 healthy subjects by conventional Doppler and tissue Doppler imaging. Echocardiographic indices of left and right ventricles, including isovolumetric relaxation time, deceleration time, isovolumetric contraction time, ejection time, and myocardial performance index of right ventricle were measured before and 30 minutes after smoking a cigarette. Mitral and tricuspid inflow parameters and right ventricular myocardial performance index significantly altered after smoking a cigarette. Among the tissue Doppler imaging parameters, mitral and tricuspid lateral annulus diastolic, but not systolic, velocities altered after smoking a cigarette. Acute cigarette smoking alters left and right ventricular diastolic functions in healthy nonsmokers.

Diverse Effects of Oxygen Inhalation on the Regional Myocardial Functions Related to the Degree of Coronary Artery Stenosis

Arat, N., Altay, H., Ilkay, E., Sabah, I. — 2008-06-10

In patients with stable coronary artery disease, the effect of oxygen (O₂) inhalation to regional myocardial functions and its relation to the degree of the coronary artery stenosis is still unclear. This article investigates the effect of O₂ therapy on regional myocardial functions in patients with coronary atherosclerosis according to the severity of stenosis. Myocardial segments were evaluated via tissue velocities, strain, strain rate, and tissue tracking. While O₂ inhalation improves late diastolic myocardial velocity and tissue tracking in normally perfused myocardial regions, a negative effect was observed on systolic and diastolic parameters of myocardial segments, which are perfused by insignificantly stenotic coronary arteries. Although nasal O₂ treatment has unfavorable effects on regional myocardial functions in patients with coronary artery disease, this effect remains subclinic with short-term inhalation. However, it is reasonable to pursue the effects of longer-term O₂ inhalation on myocardial function especially in patients with insignificant coronary stenosis.

N-terminal Prohormone Brain Natriuretic Peptide Plasma Levels in Heart Failure Are Affected Both Directly and Indirectly by Carvedilol

Kallistratos, M. S., Dritsas, A., Laoutaris, I. D., Cokkinos, D. V. — 2008-06-10

N-terminal prohormone brain natriuretic peptide (NT Pro BNP) is a sensitive marker of left ventricular function in patients with heart failure. The influence of carvedilol on NT Pro BNP plasma levels was analyzed in 21 heart failure patients. Blood samples were taken before administration and after 12 months of treatment with low-dose carvedilol. Peak oxygen consumption did not change after carvedilol treatment, left ventricular ejection fraction improved (P < .005) in 11 patients (52%), did not change in 9 (43%), and decreased in 1 (5%). In patients where left ventricular ejection fraction improved, NT Pro BNP tended to decrease; however, in patients without improvement, NT Pro BNP increased at follow-up. A correlation exists between magnitude of change in BNP and magnitude of improvement in ventricular function during carvedilol therapy. Patients without noticeable changes in left ventricular ejection fraction with a low to moderate carvedilol dosage show an increase in NT Pro BNP plasma levels.

Impact of Percutaneous Transluminal Septal Myocardial Ablation on Refractory Paroxysmal Atrial Fibrillation in Patients With Hypertrophic Obstructive Cardiomyopathy

Hosokawa, Y., Takano, H., Ohno, T., Takayama, M., Takano, T. — 2008-06-10

Atrial fibrillation is commonly observed in patients with hypertrophic obstructive cardiomyopathy. Episodes of paroxysmal atrial fibrillation are often torturous and limit the quality of life by causing congestive heart failure, transient hypotension, or bradycardia. Control of paroxysmal atrial fibrillation in patients with hypertrophic obstructive cardiomyopathy is considered to be important for symptomatic improvement and prevention of the development to chronic atrial fibrillation. The authors report on 3 patients with hypertrophic obstructive cardiomyopathy who suffered from paroxysmal atrial fibrillation despite receiving medical treatment using antiarrhythmic agents. However, after undergoing percutaneous transluminal septal myocardial ablation, the incidence of episodes became significantly less frequent. Percutaneous transluminal septal myocardial ablation is normally performed for attenuating left ventricular obstruction by reducing the systolic anterior motion of the mitral leaflet. However, in these patients, this procedure was also effective in preventing supraventricular arrhythmia, probably by improving left ventricular diastolic dysfunction, smooth blood inflow into the left ventricular, and decreasing the pressure stress against the left atrial wall.

Risk Stratification of Apolipoprotein B, Apolipoprotein A1, and Apolipoprotein B/AI Ratio on the Prevalence of the Metabolic Syndrome: the ATTICA Study

2008-06-10

We investigated the association of apolipoproteins AI and B in relation to the prevalence of metabolic syndrome in a random sample of cardiovascular disease— free adults from the ATTICA study (1,514 men, aged 18-87 y; 1,528 women, aged 18-89 y). Metabolic syndrome was defined according to the National Cholesterol Education Program Adult Treatment Panel III criteria. The prevalence of metabolic syndrome was 25% in men and 15% in women (P < .001). Using the area under the Receiver Operation Characteristic curve, apolipoprotein B/AI was the best diagnostic marker of metabolic syndrome, the optimal discriminating cut-off value of this ratio was 0.72 (sensitivity 74%, specificity 67%), and individuals with apolipoprotein B/AI ratio greater than 0.74 had 3.29 times higher odds of having metabolic syndrome (95% confidence interval: 2.56-4.21) after adjusting for potential confounders.

Endovascular Embolization of Intracranial Aneurysms

Guan, Y.-S., Wang, M.-Q. — 2008-06-10

Intracranial aneurysm (ICA) is a common condition but with a high mortality rate when rupture occurs. The treatment of ruptured or unruptured ICA, especially with an endovascular approach, has been evolving rapidly. The current generally accepted opinion suggests that endovascular embolization is an effective technique for preventing the recurrence of aneurysm rupture, but the rebleeding rate after endovascular embolization is found to be higher than that after surgical clipping. In addition, long-term follow-up data are required for the evaluation of the effectiveness of endovascular treatment in unruptured ICA. This review presents the current understanding of ICA, the selection of optimal treatment approaches, and in particular, the advances in endovascular embolization in the treatment of ICA, including embolic materials, therapeutic and assisting techniques, long-term effectiveness, and limitations.

Randomized, Double Blind, Placebo-Controlled Clinical Trial to Evaluate the Lymphagogue Effect and Clinical Efficacy of Calcium Dobesilate in Chronic Venous Disease

Flota-Cervera, F., Flota-Ruiz, C., Trevino, C., Berber, A. — 2008-06-10

The aims of the present study were to investigate the effect of calcium dobesilate on lymph flow and lymphovenous edema in patients with chronic venous disease. It was a randomized, placebo-controlled, double-blind clinical trial. Patients received 1 capsule of 500 mg calcium dobesilate every 8 hours (1.5 g/day) or placebo by 49 days. By the end of the treatment period, only the patients treated with calcium dobesilate had normalization of lymphogammagraphy (capture index and speed of lymph flow; 80 and 78%, respectively). Only patients treated with calcium dobesilate had statistically significant reduction in the perimeter of leg, calf, and ankle. Twenty-two out of 25 (88%) calcium dobesilate—treated patients presented clinical improvement versus 5 out of 24 (20.8%) in the placebo group. One patient on calcium dobesilate developed rash and one patient on placebo complained of vomiting. In the present study, calcium dobesilate normalized lymph physiology and improved symptoms in patients with chronic venous disease.

Endothelial Dysfunction in Chronic Obstructive Pulmonary Disease

2008-06-10

Background: Cardiovascular diseases are prevalent in people with chronic obstructive pulmonary disease (COPD). We hypothesized that endothelial dysfunction could be a marker of the proatherogen status in COPD. Methods and results: We measured endothelial dysfunction by flow-mediated dilation (FMD) and after sublingual administration of nitroglycerin (nitrate-mediated dilation: NMD) in 44 COPD patients and 48 controls. Compared with controls COPD patients had worse mean FMD (5.4% vs 8.2%, P < .001) and NMD (12.0% vs 13.9%, P = .007). FMD was inversely related to FEV1/VC ratio (r = –0.327, P = .030). The negative association between COPD and FMD was confirmed after correction for potential confounders in a multiple linear regression model (β = –0.019, P = .002). In the same model NMD (β = 0.396, P < .001) was positively associated with FMD. Conclusions: Endothelial-dependent and, to a lesser extent, endothelial-independent dilations are significantly impaired in COPD, and the impairment is proportional to the severity of bronchial obstruction.

Acute Pancreatitis Mimicking Acute Inferior Myocardial Infarction

2008-06-10

A 56-year-old man presented with acute pancreatitis and electrocardiographic abnormalities, suggesting acute inferior myocardial infarction. An emergent coronary angiogram showed normal coronary arteries. The clinical significance and therapeutic implications of this rare finding are discussed.

Successful Treatment of Primary Cardiac Angiosarcoma With Docetaxel and Radiotherapy

2008-06-10

A 49-year-old man was admitted for primary cardiac angiosarcoma with a cardiac tamponade. Transthoracic echocardiography and contrast-enhanced computed tomography scan demonstrated a large mass in the right atrium and thickening of the right ventricular wall. ¹⁸F-labeled deoxyglucose (FDG) positron emission tomography (PET) scan showed increased FDG uptake in the mediastinum and over the heart. The patient responded to combination therapy with docetaxel and radiotherapy and tolerated the treatment well, except for radiation esophagitis, which required a soft diet and resolved 1 month after treatment. This combination therapy resulted in a minimal response with slight regression in the tumor size, but FDG-PET initially showed an increase in FDG uptake by the tumor that was no longer seen after combination therapy. There is no evidence of progression or metastasis even at 12 months after diagnosis.

Percutaneous Thrombin Injection for Treatment of Iatrogenic Femoral Artery Pseudoaneurysms: A Case for Caution

Ohlow, M.-A., Secknus, M.-A., von Korn, H., Weiss, R., Lauer, B. — 2008-06-10

The case of a patient who developed a femoral artery pseudoaneurysm following cardiac catheterization is described. After 2 failed attempts of ultrasound-guided compression repair, the patient underwent percutaneous thrombin injection with, beside of complete closure of the pseudoaneurysm, a severe limb ischemia due to distal thrombin migration with consecutive clot formation finally resulting in thigh amputation of the affected leg. Indications, advantages, and disadvantages of various options for the treatment of iatrogenic femoral artery pseudoaneurysms (vascular surgery, ultrasound-guided compression, percutaneous thrombin injection, and other nonsurgical treatment modalities), as well as risk factors for distal migration of liquid thrombin after percutaneous injection, are discussed in this report.

Acute Myocardial Infarction in a Young Man Using Anabolic Steroids

Wysoczanski, M., Rachko, M., Bergmann, S. R. — 2008-06-10

Anabolic-androgenic steroids are used worldwide to help athletes gain muscle mass and strength. Their use and abuse is associated with numerous side effects, including acute myocardial infarction (MI). We report a case of MI in a young 31-year-old bodybuilder. Because of the serious cardiovascular complications of anabolic steroids, physicians should be aware of their abuse and consequences.

Intracoronary Administration of Isosorbide Dinitrate Induced Severely Slow Flow and Transient ST-Segment Elevation

Yamashita, K., Tasaki, H. — 2008-06-10

Nitroglycerin is one of the most widely used drugs in the treatment of angina. However, nitroglycerin fails to relieve angina in patients with syndrome X who have microvessel dysfunction. Microvessel function is impaired in several diseases. In this article, the authors report that despite normal coronary angiograms at control, intracoronary administration of isosorbide dinitrate induced severe coronary slow flow and transient ST-segment elevation with mild chest pain in a patient with congestive heart failure. The authors speculated that functional stenosis and a delay in the dilatation of microvessels less than 100 µm in diameter because of their dysfunction resulted in a severely slow flow after intracoronary administration of isosorbide dinitrate.

Spontaneous Coronary Artery Dissection Mimicking Acute Aortic Dissection

2008-06-10

Spontaneous coronary artery dissection is a rare cause of acute coronary syndrome or sudden cardiac death, occurring predominantly in the female sex without cardiovascular risk factors. Although the etiology and pathogenesis remain uncertain, hypertension has not appeared to be one of the most important factors. This case report describes a patient with spontaneous coronary artery dissection in proximal Right coronary artery who presented the signs and symptoms of acute aortic dissection. The authors postulate that hypertension may have been an important factor for the pathogenesis of the spontaneous coronary artery dissection.

Erratum

2008-06-10

Effect of Statins on Serum Apolipoprotein J and Paraoxonase-1 Levels in Patients With Ischemic Heart Disease Undergoing Coronary Angiography

2008-04-10

It has been proposed that apolipoprotein J (apo J) and paraoxonase-1 (PON1) correlate with the extent and severity of ischemic heart disease (IHD). This article compares apo J and PON1 serum concentrations, PON1 activity, and the apo J/PON1 ratio in 138 IHD patients (64 statins users and 74 statin nonusers) referred for angiography and possible percutaneous coronary intervention. The effect of statin treatment on apo J and PON1 concentrations, PON1 activity, and the degree of coronary artery stenosis were evaluated. In both groups, apo J levels were increased, whereas PON1 concentration and activity decreased. IHD patients on statins had significantly lower apo J concentration and higher PON1 concentration and activity. Patients on statins had less coronary artery stenosis. High apo J levels, low PON1 levels, low PON1 activity, and a high apo J/PON1 ratio were associated with IHD. Statin treatment reverses these changes, probably by multiple beneficial actions.

Intracoronary Autologous Bone Marrow-Derived Mononuclear Cell Transplantation Improves Coronary Collateral Vessel Formation and Recruitment Capacity in Patients With Ischemic Cardiomyopathy: A Combined Hemodynamic and Scintigraphic Approach

2008-04-10

This study investigated the effects of intracoronary autologous bone marrow–derived mononuclear cell (BMC) transplantation on coronary microcirculation. Fifteen patients with ischemic cardiomyopathy were treated by intracoronary infusion of BMCs via the patent infarct-related artery. The thermodilution-derived coronary flow reserve, index of microvascular resistance, pressure-derived collateral flow index, and coronary wedge pressure were measured at baseline and at 6 months. Successive balloon inflations during BMC transplantation were performed to observe the recruitment in pressure-derived collateral flow index and coronary wedge pressure, and the percentage changes between baseline and 6 months were calculated. The mean (SD) coronary flow reserve increased from 1.3 (0.4) to 2.1 (0.5), and the mean (SD) index of microvascular resistance decreased from 44.9 (24.4) to 21.2 (14.1) (P = .001 for both). The mean (SD) improvement in pressure-derived collateral flow index (from 0.14 [0.05] to 0.22 [0.08]) was also statistically significant (P = .001). Similarly, the percentage improvements in pressure-derived collateral flow index and coronary wedge pressure were statistically significant (P = .01 for both). The percentage improvement in perfusion assessed by single-photon emission computed tomography strongly correlated with the percentage changes in pressure-derived collateral flow index (r = 0.88, P = .001) and coronary wedge pressure (r = 0.69, P = .01). These results demonstrate for the first time (to our knowledge) that intracoronary autologous BMC transplantation improves coronary collateral vessel formation and recruitment capacity in human subjects.

Hierarchical Analysis of Cardiovascular Risk Factors in Relation to the Development of Acute Coronary Syndromes, in Different Parts of Greece: The CARDIO2000 Study

Panagiotakos, D. B., Pitsavos, C., Chrysohoou, C., Stefanadis, C. — 2008-04-10

During 2000 to 2002, 700 men (59 ± 10 years) and 148 women (65 ± 9 years) patients with first event of an ACS were randomly selected from cardiology clinics of Greek regions. Afterwards, 1078 population-based, age-matched and sex-matched controls were randomly selected from the same hospitals. The frequency ratio between men and women in the case series of patients was about 4:1, in both south and north Greek areas. Hierarchical classification analysis showed that for north Greek areas family history of coronary heart disease, hypercholesterolemia, hypertension, diabetes (explained variability 35%), and less significantly, dietary habits, smoking, body mass index, and physical activity status (explained variability 4%) were associated with the development of ACS, whereas for south Greek areas hypercholesterolemia, family history of coronary heart disease, diabetes, smoking, hypertension, dietary habits, physical activity (explained variability 34%), and less significantly body mass index (explained variability <1%), were associated with the development of the disease.

Relation of Serum Uric Acid Levels With the Presence and Severity of Angiographic Coronary Artery Disease

Gur, M., Yilmaz, R., Demirbag, R., Aksoy, N. — 2008-04-10

The aim of this study is to investigate the association between uric acid level and severity of coronary artery disease. Consecutive 495 patients with coronary artery disease and 356 individuals with normal coronary angiograms were included in the study. Severity of coronary artery disease was evaluated using the Gensini score index. For both groups, conventional risk factors, the levels of uric acid, and other biochemical markers were assessed. The mean uric acid levels of the patient group were significantly higher than those of the control group (P = .002). Mean uric acid levels were higher in men than in women (P < .001). In the coronary artery disease group, there was no significant correlation between uric acid levels and Gensini score in both sexes. Thus, it can be concluded that uric acid level is associated with the presence but not with the severity of coronary artery disease.

Thienopyridine Therapy Influences Late Outcome After Coronary Stent Implantation

2008-04-10

Clinical significance of resistance to aspirin and thienopyridine therapy is poorly defined. The authors aimed to evaluate whether more effective antiplatelet therapy is associated with better outcome in patients on dual-antiplatelet treatment. Using optical aggregometer, maximal platelet aggregation values were measured with induction of adenosine diphosphate, collagen, and adrenaline 30 ± 5 days after coronary stent implantation in 134 patients. Markers of platelet activation were also analyzed with fluorescent immunoassay in 57 patients. After 10 months of follow-up, 33 patients reached the composite endpoint of cardiovascular death, myocardial infarction, and revascularisation. Adenosine diphosphate-induced maximal aggregation values were in significant relationship with the development of major adverse cardiac events (P < .01). Level of soluble P-selectin proved to be an independent risk factor of adverse outcome (P < .05). As efficacy of thienopyridine therapy showed significant relation with clinical outcome, the authors conclude that interindividual variability in response to adenosine diphosphate-receptor antagonists may be of substantial clinical importance.

Assessment of Early Changes in the Segmental Functions of the Left and the Right Ventricles After Biventricular Pacing in Heart Failure: A Study With Tissue Doppler Imaging

2008-04-10

Tissue Doppler imaging allows assessment of systolic and diastolic regional ventricular function. The aim of this study was to assess early changes in regional systolic and diastolic functions and differences in transition time to contraction between the ventricles after cardiac resynchronization therapy. Fourteen patients were included, who underwent echocardiography before and 1 month after resynchronization. The difference between transition time to contraction of left and right ventricles decreased to 24.4 ± 10.7 milliseconds from 65.3 ± 18.2 milliseconds after resynchronization therapy (P = .001). There was a significant relation between the decrease in difference between transition time and increase in ejection fraction (r = 0.80, P = .002). Early or late diastolic myocardial motion increased in 7 segments of left and 2 segments of right ventricles. Systolic myocardial motion increased in 7 segments of left and in all segments of right ventricles. Resynchronization therapy improved systolic and diastolic functions in both ventricles. The difference between transition time to contraction of ventricles might be helpful in estimating optimal resynchronization.

Transient Left Ventricular Apical Ballooning Syndrome: The First Series in Taiwanese Patients

2008-04-10

Previously thought as exclusive in Japanese patients, cases of transient left ventricular apical ballooning from other countries have also been reported. The cause remains unknown. From January 1997 to December 2005, 25 patients presenting with signs and symptoms of acute myocardial infarction with normal coronary arteries were analyzed. In all, 10 patients fulfilled all the criteria for transient left ventricular apical ballooning. In all, 6 patients had chest pain and diaphoresis, 5 patients had ST segment elevation, 7 had T wave inversions, and 5 had QT prolongation; 6 patients had normal coronary arteries and 4 had insignificant stenosis. In all, 2 patients died of sepsis, whereas the rest recovered. This is the first series in Taiwanese patients. Our series showed male preponderance, and most patients recovered with supportive treatment. Without any delineating preangiographic feature differentiating it from acute myocardial infarction, any patient should be treated as a case of myocardial infarction until proven otherwise.

Fate of Incidental, Asymptomatic Lesions Discovered During Percutaneous Coronary Intervention

Caymaz, H. O., Yuksel, G. — 2008-04-10

The authors aimed to determine the incidence and angiographic features associated with plaque progression requiring nontarget lesion percutaneous coronary intervention after culprit lesion percutaneous coronary intervention. Of 945 consecutive percutaneous coronary interventions reviewed, 100 patients who required nontarget lesion percutaneous coronary intervention in the following year of the index percutaneous coronary intervention were found and compared with 100 consecutive patients who did not require nontarget lesion percutaneous coronary intervention. Patients with restenosis were excluded. Incidence of clinical plaque progression leading to additional nontarget lesion percutaneous coronary intervention in the year after an index percutaneous coronary intervention was found to be 10.5%. In multivariable logistic regression analyses, the predictors of plaque progression were multivessel disease, unstable angina pectoris, diabetes mellitus, prior percutaneous coronary intervention, and lack of statin use. Initially, lesions that lead to repercutaneous coronary intervention were mostly nonsignificant. Clinical presentation of plaque progression was mostly acute coronary syndrome. Results emphasize the need for further study to refine the methods to identify potentially vulnerable but clinically silent plaques.

Prevalence of Metabolic Syndrome in Patients With Clinically Advanced Peripheral Vascular Disease

Qadan, L. R., Ahmed, A. A., Safar, H. A., Al-Bader, M. A., Ali, A. A. — 2008-04-10

The aim of this cross-sectional study was to determine the prevalence of metabolic syndrome (MetS) and its components among 100 patients with progressive peripheral arterial disease (PAD) referred for diagnostic angiography in preparation for a revascularization procedure. The prevalence of MetS was more than 95%. Diabetes mellitus was the most prevalent component followed by hypertension and low high-density lipoprotein. Almost half the patients aggregated in the highest metabolic score category. A direct relationship was identified between the number of MetS components and serum uric acid (P = .001) and C-reactive protein (P = .826), whereas an inverse relationship was seen between the clustering of components and androgen levels in men (P < .001). For PAD, which could have a benign clinical course, early screening for MetS might identify those at greater risk of failing conservative therapy and progressing to a more aggressive atherosclerotic disease typically associated with high morbidity and mortality.

Association Between Lower-Extremity Function and Arterial Compliance in Older Adults

Nickel, K. J., Acree, L. S., Montgomery, P. S., Gardner, A. W. — 2008-04-10

The purpose was to identify the association between lower-extremity function and arterial compliance in older men and women. Participants included 46 healthy men (n = 18) and women (n = 28) 60 years of age or older. Lower-extremity functional performance was assessed by the summary performance score (SPS) that includes tests of 5 timed repeated chair rises, standing balance, and 4-meter walking velocity. Arterial compliance and arterial pressure were analyzed through pulsewave analysis. Small arterial compliance (3.74 ± 2.14; mean ± SD) was related (r = 0.34, P = .028) to SPS (11.09 ± 1.19) after adjusting for body surface area, hyperlipidemia, and hypertension. Systolic blood pressure (138 ± 14) also was related to SPS (r = –0.314, P = .040). These results suggest diminished lower-extremity function is associated with decreased small arterial compliance and elevated arterial pressure in older men and women.

The Role of Antiendothelial Cell Antibodies in the Development and Follow-up of Coronary and Peripheral Arterial Diseases

2008-04-10

Occlusive lesions in the arterial endothelium are often caused by formation of intimal hyperplasia and fibrinoid necrosis. The objective of this study was to investigate the association between antiendothelial cell antibodies (AECAs) and the development of coronary artery disease (CAD) and peripheral artery disease (PAD). In this study, 94 patients with CAD or PAD and 94 healthy volunteers serving as control subjects were examined. Frozen sections of human umbilical vein endothelial cells and primate smooth muscle cells were used to detect the presence of AECAs, which were found in 52 of 94 patients (55%) and in 15 of 94 controls (16%) (P < .001). Endothelial structure tissue damage is a major factor in arterial diseases. In the present study, a statistically significant relationship was found between AECAs and the development of CAD and PAD. The presence of AECAs has been identified as a risk factor for these diseases. According to this study, AECAs are reliable prognosticators for the development of CAD and PAD. Further studies with large numbers of serum samples are under way.

Treatment of End-Stage "Trash Feet" With the End-Diastolic Pneumatic Boot

Filip, J. R., Dillon, R. S. — 2008-04-10

This study reassessed the clinical effect of Circulator Boot (CB) therapy in patients with cholesterol embolization syndrome (CES) of the lower extremities. The medical records were reviewed of 27 patients consecutively referred to the Bryn Mawr Wound Care and Vascular Center with CES who had not responded to previous therapies. All patients with CES referred from January 1, 1997, to September 19, 2005, were followed up and included in the study. The alternate therapy offered for most patients at the time of referral was limb amputation. The median age of the patients was 65 years (age range, 46-84 years) at the time of diagnosis. Healing of CES was observed after a median interval of 11 months (range, 3-32 months) following the initiation of CB therapy. The total number of legs treated was 41. Of 41 legs, 33 (81%) were totally healed, 6 (15%) improved, and 2 (5%) were amputated. After an initial period of improvement, one patient died a month later of causes unrelated to CES or CB therapy. Another patient improved and discontinued treatment before he was totally healed. Cholesterol embolization syndrome is seen predominantly in patients following cardiac or vascular procedures but may occur spontaneously. The CB seems to be the only effective noninvasive therapy for CES. Early initiation of therapy is essential to minimize tissue loss and patient discomfort.

Exposure to Passive Smoking: A Test to Predict Endothelial Dysfunction and Atherosclerotic Lesions

Leone, A., Balbarini, A. — 2008-04-10

Acute exposure to environmental tobacco smoke (ETS) is considered to adversely influence atherogenesis. The aim of this article was to assess whether brachial ultrasonography in subjects with endothelial dysfunction after ETS exposure is associated with atherosclerotic lesions. Never smoker healthy volunteers (n = 18) and subjects with a previous myocardial infarction (MI; n = 10) were studied. Healthy volunteers were 12 men (66%) and 6 women (34%) with a mean age of 34 ± 9 years. Post-MI subjects were men with a mean age of 53.8 ± 4.8 years. After assessing endothelial function (by brachial ultrasonography) at rest, study subjects underwent brachial ultrasonography twice: in a smoke-free environment and then in the same environment polluted by cigarette combustion (35 ppm carbon monoxide concentration). Carboxyhemoglobin concentration was measured before and after ETS exposure. Baseline brachial-artery diameter, diameter during reactive hyperemia, and diameter after sublingual nitroglycerin (GTN) administration (endothelium-independent vasodilator) were measured at rest and in both smoke-free and smoking environments. Each study subject acted as their own control. No comparison was made between the two groups. A strong correlation between ETS exposure and endothelial dysfunction was observed in both groups. Post-MI subjects also showed endothelium-independent vasodilation worsening, which is usually due to arterial wall alterations. After ETS exposure, mean flow-mediated vasodilation after GTN was significantly (P < .01) reduced only in post-MI subjects (P < .01). Carboxyhemoglobin concentration increased in both groups (P < .01). ETS exposure may be an effective test to identify endothelial dysfunction and arterial wall alterations by using brachial ultrasonography.

The Roles of Oxidized Low-Density Lipoprotein and Interleukin-6 Levels in Acute Atherothrombotic and Lacunar Ischemic Stroke

2008-04-10

The role of circulating, oxidized low-density lipoprotein and interleukin-6 levels in acute ischemic stroke considering the primary-vessel disease was investigated. The study consisted of 28 patients with acute ischemic stroke and 23 control subjects. Patients were subdivided into large-vessel (n = 12) and small-vessel (n =16) disease stroke groups according to the Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria. The means of oxidized low-density lipoprotein and interleukin-6 levels of patients with acute ischemic stroke were higher than controls (P < .01, P < .05). Mean oxidized low-density lipoprotein level was higher in the large-vessel disease group than in the small-vessel disease group (P < .01). The mean of inteleukin-6 levels was higher in the small-vessel disease group (P < .01). The results of the present study showed that oxidative stress promotes large-vessel disease rather than small-vessel disease stroke, and inflammation may play important an role in the development of small-vessel disease stroke.

Comparison of Monotherapy Versus Combination Antihypertensive Therapy in Elderly Patients With Essential Hypertension

2008-04-10

Authors sought to compare the efficacy of monotherapy versus combination antihypertensive therapy in elderly patients. Patients in this study, aged 65 to 85 years, were divided into 4 groups and entered an 8-week treatment period. First group: 22 patients, amlodipine 5 mg/d increasing to 10 mg; second: 20 patients, eprosartan 600 mg/d increasing to 600 mg twice a day; third: 21 patients, amlodipine 5 mg/d and indapamide 2.5 mg/d, increasing amlodipine to 10 mg/d; fourth: 23 patients, imidapril 10 mg/d and indapamide 2.5 mg/d, imidapril doubled to 20 mg/d. A greater drop in systolic and in diastolic blood pressure was obtained by combination of amlodipine and indapamide compared with amlodipine or eprosartan monotherapy. Imidapril and indapamide showed similar efficacy compared with eprosartan monotherapy but not with amlodipine monotherapy. Amlodipine and indapamide appeared more effective than imidapril and indapamide in diastolic blood pressure. Combination treatment with amlodipine and indapamide or imidapril and indapamide effectively reduces blood pressure in elderly patients with essential hypertension.

Progression of Nonculprit Plaque Stenosis Following Successful Percutaneous Intervention

Bunch, T. J., Rihal, C. S., Gumina, R. J., Cooper, L., Caplice, N. M. — 2008-04-10

Despite percutaneous intervention after an acute coronary syndrome, patients remain at high risk for recurrent events in the first year. Prior studies have shown that a plaque rupture can occur not only at a single culprit lesion site but also in other atherosclerotic plaques throughout the coronary vasculature in patients with stable angina, silent myocardial ischemia, and during acute coronary syndromes. A 71-year-old man who presented with exertional angina and who had a successful stent in a culprit right coronary artery is described in this article. After 4 weeks, he represented with accelerated angina. A prior lesion in the obtuse marginal artery, remote from the site of the index lesion, had progressed from a 30% to 90% stenosis. This case report demonstrates the systemic nature of acute coronary syndromes, highlights the inherent instability of coronary artery disease, and supports the notion of aggressive secondary prevention in these patients.

Endovascular Embolization of a Giant Renal Artery Aneurysm With Preservation of Renal Parenchyma

Gutta, R., Lopes, J., Flinn, W. R., Neschis, D. G. — 2008-04-10

Renal artery aneurysm is a rare condition that has an unclear etiology. Although some patients present with symptoms of hypertension, pain, hematuria, or rupture, the majority are asymptomatic. Traditional surgical repair of renal artery aneurysms is often complex and may require ex vivo repair and reimplantation of the kidney if branch vessels are involved. Very large aneurysms made require nephrectomy. More recently, reports have described endovascular approaches to renal artery aneurysms, including coil embolization and stent graft coverage. This report describes successful endovascular treatment of a 10-cm renal artery aneurysm with preservation of renal mass.

Coronary Steal Due to Bilateral Internal Mammary Artery--Pulmonary Artery Fistulas: A Rare Cause of Chest Pain After Coronary Artery Bypass Grafting

2008-04-10

A 54-year-old man with a history of coronary artery bypass grafting (CABG) presented with chest pain and was found to have non—ST-segment elevation myocardial infarction. Left heart catheterization with coronary angiography demonstrated 100% occlusion of the right internal mammary artery (IMA) to the right coronary artery graft in its midsegment and a patent left IMA to the left anterior descending graft. An unusually large extensive fistulous collateral formation was observed between the right IMA and the left IMA to the pulmonary arterial system, causing left to right shunting. His angina was attributed to substantial coronary steal caused by the shunt. The patient refused any further intervention or surgery and opted for medical treatment. As a complication of CABG, IMA to pulmonary artery (PA) fistulas are rare. Thus far, more than 20 cases have been reported; most have been unilateral. This is the second reported case to date of bilateral IMA-PA fistula formation after CABG. An IMA-PA fistula should be considered in the differential diagnosis of patients presenting with chest pain after CABG and can be diagnosed by selective angiography of IMA grafts.

Central Venous Thrombosis in Behcet's Disease

Abou-Raya, A., Abou-Raya, S. — 2008-04-10

Behçet's disease is a systemic inflammatory disorder characterized by vasculitis, which affects all types and sizes of blood vessels. A thrombotic tendency with a predilection for the venous side of the vasculature is well known for Behçet's disease. However, central vein involvement is a rare complication. The authors report an unusual case of complete thrombosis of the supraazygos superior vena cava, brachiocephalic veins, as well as right internal jugular vein in a patient who is a young woman with Behçet's disease.