Sequential Activation of Vulnerable Plaques Endorsing the Inflammatory Hypothesis of Atherosclerosis

A case of sequential activation of vulnerable plaques in two different coronary vessels over the course of 2 days is being presented probably related to inflammation inciting these acute coronary events. Rhythmos 2017;12(4): 69-70

Cardiogoniometry compared to fractional flow reserve at identifying physiologically significant coronary stenosis: The Cardioflow Study

Cardiogoniometry (CGM) is method of 3-dimensional electrocardiographic assessment which has been shown to identify patients with angiographically defined, stable coronary artery disease (CAD). However, angiographic evidence of CAD, does not always correlate to physiologically significant disease. The aim of our study was to assess the ability of CGM to detect physiologically significant coronary stenosis defined by fractional flow reserve (FFR). In a tertiary cardiology centre, elective patients with single vessel CAD were enrolled into a prospective double blinded observational study. A baseline CGM recording was performed at rest. A second CGM recording was performed during the FFR procedure, at the time of adenosine induced maximal hyperaemia. A significant CGM result was defined as an automatically calculated ischaemia score < 0 and a significant FFR ratio was defined as < 0.80. Measures of diagnostic performance (including sensitivity and specificity) were calculated for CGM at rest and during maximal hyperaemia. Forty-five patients were included (aged 61.1 ± 11.0; 60.0% male), of which eighteen (40%) were found to have significant CAD when assessed by FFR. At rest, CGM yielded a sensitivity of 33.3% and specificity of 63.0%. At maximal hyperaemia the sensitivity and specificity of CGM was 71.4 and 50.0% respectively. The diagnostic performance of CGM to detect physiologically significant stable CAD is poor at rest. Although, the diagnostic performance of CGM improves substantially during maximal hyperaemia, it does not reach sufficient levels of accuracy to be used routinely in clinical practice

Transradial primary angioplasty of anomalous right coronary artery from the left sinus of Valsalva

Percutaneous coronary intervention (PCI) of congenitally anomalous coronary arteries may be a technically challenging procedure. There is general belief that femoral approach is associated with better chances of coronary engagement and better guide support during PCI of anomalous coronary arteries. The following case supports that radial access is effective for PCI of an aberrant right coronary artery from the left sinus of Valsalva, even in an acute setting

Acute effects of ace-inhibition on endothelial function in hypertensive patients

Introduction: The acute effects of the angiotensin-converting enzyme (ACE) inhibitors may be important in some clinical settings, such as at the onset of a myocardial infarction or during a surgical procedure. Recent evidence suggests that tissue affinity of ACE inhibitors is an important characteristic that may influence the efficacy of these drugs in such acute conditions. Aim of the present study was to evaluate the acute effects of different inhibitors of the renin-angiotensin system on arterial function, which is an important determinant of cardiovascular function and a predictor of the corresponding risk. Methods: In the present randomized, double-blind, placebo-controlled study, we assessed the acute effects of captopril 25 mg (an old, low tissue affinity ACE inhibitor), quinapril 20 mg (a newer ACE inhibitor with presumed high tissue affinity properties) and telmisartan 80 mg (an angiotensin receptor blocker with PPARγ stimulating properties) on arterial function of 100 patients with essential hypertension, which may be regarded as a model of endothelial dysfunction. Central (aortic) blood pressure and augmentation index (AIx, a measure of wave reflections), as well as flow-mediated dilatation (FMD) of the brachial artery and forearm blood flow (FBF) (measures of conduit and resistance artery endothelial function respectively), were evaluated before and 2 hours after oral drug administration. Results: Compared to placebo, captopril and quinapril decreased central systolic (by 7.5 mmHg, P<0.05 and by 12.3 mmHg, P<0.001) and diastolic blood pressure (by 5.0 mmHg, P<0.01 and by 8.4 mmHg, P<0.001), whereas telmisartan had no significant effect (P=NS). Additionally, AIx was reduced significantly after quinapril (absolute decrease of 7.2%, P<0.01) and marginally after captopril (decrease of 4.7%, P=0.07). Only quinapril led to a beneficial change of FMD (absolute increase of 2.7%, P<0.001). No treatment was related to significant changes of resting, peak hyperemic or 3-min hyperemic FBF. In adjusted (multivariable) analyses, all the favourable alterations induced by quinapril were independent of potential confounding haemodynamic factors. Conclusions: Our data indicate that acute ACE inhibition with the high tissue affinity quinapril (20 mg) may be more beneficial in terms of arterial function and central hemodynamics compared to ACE inhibition with the low tissue affinity captopril (25 mg) or compared to angiotensin receptor blockade with telmisartan (80 mg). These findings have potential clinical implications, considering that arterial function is a predictor of cardiovascular risk.Εισαγωγή: Οι οξείες ή βραχυπρόθεσμες δράσεις των αναστολέων του μετατρεπτικού ενζύμου της αγγειοτασίνης (Α-ΜΕΑ) ενδέχεται να έχουν ιδιαίτερη κλινική σημασία σε ορισμένες κλινικές καταστάσεις, όπως είναι η οξεία φάση του εμφράγματος του μυοκαρδίου ή το περιεγχειρητικό διάστημα. Πρόσφατα δεδομένα υποδηλώνουν ότι η ιστοεκλεκτικότητα των Α-ΜΕΑ αποτελεί σημαντική ιδιότητα των φαρμάκων αυτών, καθώς ενδέχεται να επηρεάζει την αποτελεσματικότητά τους σε τέτοιες οξείες καταστάσεις. Ο σκοπός της παρούσας μελέτης ήταν να αξιολογηθούν οι οξείες δράσεις αναστολέων του συστήματος ρενίνης-αγγειοτασίνης στην αρτηριακή λειτουργία, η οποία προσδιορίζει τη συνολική καρδιαγγειακή λειτουργία και αποτελεί προγνωστικό δείκτη του αντίστοιχου κινδύνου. Μέθοδοι: Στην παρούσα τυχαιοποιημένη, διπλή τυφλή, ελεγχόμενη με εικονικό φάρμακο (placebo) μελέτη, εξετάσαμε την οξεία επίδραση 25 mg καπτοπρίλης (που είναι παλαιότερος Α-ΜΕΑ χαμηλής ιστοεκλεκτικότητας), 20 mg κιναπρίλης (που είναι νεότερος Α-ΜΕΑ με θεωρητικά υψηλή ιστοεκλεκτικότητα) και 80 mg τελμισαρτάνης (που αποτελεί ανταγωνιστή υποδοχέων της αγγειοτασίνης-ΙΙ και επιπλέον διεγείρει τους υποδοχείς ΡΡΑRγ) στην αρτηριακή λειτουργία 100 ασθενών με ιδιοπαθή αρτηριακή υπέρταση, η οποία θεωρείται μοντέλο ενδοθηλιακής δυσλειτουργίας. Οι κεντρικές (αορτικές) πιέσεις και ο κεντρικός δείκτης ενίσχυσης (ΑΙx, δείκτης των ανακλώμενων κυμάτων), όπως επίσης η ενδοθηλιοεξαρτώμενη αγγειοδιαστολή της βραχιονίου αρτηρίας (FMD) και η αιματική ροή του αντιβραχίου (FBF) (δείκτες της ενδοθηλιακής λειτουργίας των αρτηριών-αγωγών και των μικρών αρτηριών αντίστασης αντίστοιχα), εκτιμήθηκαν πριν και 2 ώρες μετά από τη λήψη των φαρμάκων της μελέτης. Αποτελέσματα: Συγκριτικά με το εικονικό φάρμακο, η καπτοπρίλη και η κιναπρίλη μείωσαν την κεντρική συστολική πίεση (κατά 7,5 mmHg, Ρ<0,05 και κατά 12,3 mmHg, Ρ<0,001) και την κεντρική διαστολική πίεση (κατά 5,0 mmHg, Ρ<0,01 και κατά 8,4 mmHg, Ρ<0,001), ενώ αντιθέτως η τελμισαρτάνη δεν προκάλεσε σημαντικές μεταβολές (P=NS). Επιπλέον, ο δείκτης ΑΙx ελαττώθηκε σημαντικά με την κιναπρίλη (απόλυτη μείωση κατά 7,2%, Ρ<0,01) και οριακά με την καπτοπρίλη (μείωση κατά 4,7%, Ρ=0,07). Μόνο η κιναπρίλη βελτίωσε την τιμή του FMD της βραχιονίου αρτηρίας (απόλυτη αύξηση κατά 2,7%, Ρ<0,001). Κανένα από τα 3 ενεργά φάρμακα δεν προκάλεσε μεταβολή (P=NS) στη ροή του αντιβραχίου FBF σε ηρεμία, σε μέγιστη υπεραιμία ή καθ’ όλη τη διάρκεια της υπεραιμικής περιόδου. Μετά από πολυπαραγοντική ανάλυση, παρατηρήθηκε ότι όλες οι ευνοϊκές μεταβολές που προκάλεσε η κιναπρίλη ήταν ανεξάρτητες από τις συνοδές μεταβολές διαφόρων δυνητικά συγχυτικών παραγόντων. Συμπεράσματα: Τα αποτελέσματα της παρούσας μελέτης υποδηλώνουν ότι η οξεία αναστολή του ΜΕΑ με τον υψηλής ιστοεκλεκτικότητας Α-ΜΕΑ κιναπρίλη (20 mg) προκαλεί πιο ευνοϊκές μεταβολές στην περιφερική ενδοθηλιακή λειτουργία, στις κεντρικές πιέσεις και στα ανακλώμενα κύματα συγκριτικά με τον χαμηλής ιστοεκλεκτικότητας Α-ΜΕΑ καπτοπρίλη (25 mg) ή τον ανταγωνιστή υποδοχέων αγγειοτασίνης τελμισαρτάνη (80 mg). Τα ευρήματα αυτά έχουν δυνητική κλινική σημασία, καθώς η αρτηριακή λειτουργία αποτελεί σημαντικό προγνωστικό δείκτη του καρδιαγγειακού κινδύνου

Prediction of cardiovascular events and all-cause mortality with central haemodynamics: a systematic review and meta-analysis

To calculate robust quantitative estimates on the predictive value of central pressures and derived central haemodynamic indices for cardiovascular (CV) outcomes and all-cause mortality by meta-analysis of longitudinal studies. We meta-analysed 11 longitudinal studies that had employed measures of central haemodynamics and had followed 5648 subjects for a mean follow-up of 45 months. The age- and risk-factor-adjusted pooled relative risk (RR) of total CV events was 1.088 (95% CI 1.040-1.139) for a 10 mmHg increase of central systolic pressure, 1.137 (95% CI 1.063-1.215) for a 10 mmHg increase of central pulse pressure (PP), and 1.318 (95% CI 1.093-1.588) for a 10% absolute increase of central augmentation index (AIx). Furthermore, we found that a 10% increase of central AIx was associated with a RR of 1.384 (95% CI 1.192-1.606) for all-cause mortality. When compared with brachial PP, central PP was associated with marginally but not significantly higher RR of clinical events (P = 0.057). Central haemodynamic indexes are independent predictors of future CV events and all-cause mortality. Augmentation index predicts clinical events independently of peripheral pressures, while central PP has a marginally but not significantly (P = 0.057) better predictive ability when compared with peripheral PP

Prediction of Cardiovascular Events and All-Cause Mortality With Arterial Stiffness A Systematic Review and Meta-Analysis

Objectives The purpose of this study was to calculate robust quantitative estimates of the predictive value of aortic pulse wave velocity (PWV) for future cardiovascular (CV) events and all-cause mortality by meta-analyses of longitudinal studies. Background Arterial stiffness is increasingly recognized as a surrogate end point for CV disease. Methods We performed a meta-analysis of 17 longitudinal studies that evaluated aortic PWV and followed up 15,877 subjects for a mean of 7.7 years. Results The pooled relative risk (RR) of clinical events increased in a stepwise, linear-like fashion from the first to the third tertile of aortic PWV. The pooled RRs of total CV events, CV mortality, and all-cause mortality were 2.26 (95% confidence interval: 1.89 to 2.70, 14 studies), 2.02 (95% confidence interval: 1.68 to 2.42, 10 studies), and 1.90 (95% confidence interval: 1.61 to 2.24, 11 studies), respectively, for high versus low aortic PWV subjects. For total CV events and CV mortality, the RR was significantly higher in high baseline risk groups (coronary artery disease, renal disease, hypertension) compared with low-risk subjects (general population). An increase in aortic PWV by 1 m/s corresponded to an age-, sex-, and risk factor-adjusted risk increase of 14%, 15%, and 15% in total CV events, CV mortality, and all-cause mortality, respectively. An increase in aortic PWV by 1 SD was associated with respective increases of 47%, 47%, and 42%. Conclusions Aortic stiffness expressed as aortic PWV is a strong predictor of future CV events and all-cause mortality. The predictive ability of arterial stiffness is higher in subjects with a higher baseline CV risk. (J Am Coll Cardiol 2010; 55: 1318-27) (C) 2010 by the American College of Cardiology Foundatio

Statins in Stroke

Background: Stroke is a major cause of mortality and disability in modem societies. Statins are effective medications in decreasing cardiovascular events through lipid lowering and pleiotropic effects. Objective: To summarize current evidence regarding the role of statins in the prevention and management of stroke. Methods: A narrative review of current evidence regarding the effect of statins in stroke management. Electronic searches of MEDLINE, EMBASE and Cochrane Databases were performed. Results: In primary prevention of stroke in patients with risk factors but no established cardiovascular disease, potent statins such as atorvastatin and rosuvastatin have shown some benefits, but the clinical relevance of this effect is questionable. In populations at higher risk of stroke, such as patients with established coronary heart disease, the majority of relevant studies have shown a beneficial effect of statins in preventing stroke. Similarly, in patients with a previous cerebrovascular event, there is a clear benefit of statins for the prevention of recurrent events. The use of statins is not associated with an increased risk of intracranial bleeding in primary prevention studies. There may be an increased incidence of non-fatal hemorrhagic stroke with high dose statins in patients with a previous cerebrovascular event. Patients who experience a stroke while on statins should not discontinue statins. In addition, statins are associated with better survival and improved functional outcome when administered during the acute phase of stroke in statin-naive patients. In contrast, statins do not confer any benefit in patients with acute ischemic stroke who receive thrombolysis. Conclusion: Treatment with statins prevents ischemic stroke, especially in patients with high cardiovascular risk and established atherosclerotic disease. It seems that both lipid lowering and pleiotropic effects contribute to these effects