Predicting clinically unrecognized coronary artery disease: use of two- dimensional echocardiography

<p>Abstract</p> <p>Background</p> <p>2-D Echo is often performed in patients without history of coronary artery disease (CAD). We sought to determine echo features predictive of CAD.</p> <p>Methods</p> <p>2-D Echo of 328 patients without known CAD performed within one year prior to stress myocardial SPECT and angiography were reviewed. Echo features examined were left ventricular and atrial enlargement, LV hypertrophy, wall motion abnormality (WMA), LV ejection fraction (EF) < 50%, mitral annular calcification (MAC) and aortic sclerosis/stenosis (AS). High risk myocardial perfusion abnormality (MPA) was defined as >15% LV perfusion defect or multivessel distribution. Severe coronary artery stenosis (CAS) was defined as left main, 3 VD or 2VD involving proximal LAD.</p> <p>Results</p> <p>The mean age was 62 ± 13 years, 59% men, 29% diabetic (DM) and 148 (45%) had > 2 risk factors. Pharmacologic stress was performed in 109 patients (33%). MPA was present in 200 pts (60%) of which, 137 were high risk. CAS was present in 166 pts (51%), 75 were severe. Of 87 patients with WMA, 83% had MPA and 78% had CAS. Multivariate analysis identified age >65, male, inability to exercise, DM, WMA, MAC and AS as independent predictors of MPA and CAS. Independent predictors of high risk MPA and severe CAS were age, DM, inability to exercise and WMA.</p> <p>2-D echo findings offered incremental value over clinical information in predicting CAD by angiography. (Chi square: 360 vs. 320 p = 0.02).</p> <p>Conclusion</p> <p>2-D Echo was valuable in predicting presence of physiological and anatomical CAD in addition to clinical information.</p

Effects of Combined Therapy with Ezetimibe Plus Simvastatin After Drug-Eluting Stent Implantation in a Porcine Coronary Restenosis Model

The aim of this study was to examine the anti-proliferative and anti-inflammatory effects of ezetimibe/simvastatin (E/S) after drug-eluting stent (DES) implantation in a porcine coronary restenosis model. Pigs were randomized into two groups in which the coronary arteries (23 pigs) had DES. Stents were deployed with oversizing (stent/artery ratio 1.3:1) in porcine coronary arteries. Fifteen pigs were taken 10/20 mg of E/S and eight pigs were not taken E/S. Histopathologic analysis was assessed at 28 days after stenting. In neointima, most inflammatory cells were lymphohistiocytes. Lymphohistiocyte count was not different between two groups (337±227 vs. 443±366 cells, P=0.292), but neointima area was significantly smaller (1.00±0.49 mm2 vs. 1.69±0.98 mm2, P=0.021) and percent area stenosis was significantly lower (23.3±10% vs. 39±19%, P=0.007) in E/S group compared with control group. There were no significant differences in fibrin score (1.99±0.79 vs. 1.81±0.88, P=0.49), endothelial score (1.75±0.66 vs. 1.80±0.59, P=0.79), and the percent of endothelium covered lumen (43±21% vs. 45±21%, P=0.84) between E/S group and control group. Combined therapy with ezetimibe and simvastatin inhibits neointimal hyperplasia, but does not inhibit inflammatory infiltration and arterial healing after DES implantation in a porcine coronary restenosis model

HIV/HCV Co-infection: Pathogenesis, Clinical Complications, Treatment, and New Therapeutic Technologies

World-wide, hepatitis C virus (HCV) accounts for approximately 130 million chronic infections, with an overall 3% prevalence. Four to 5 million persons are co-infected with HIV. It is well established that HIV has a negative impact on the natural history of HCV, including a higher rate of viral persistence, increased viral load, and more rapid progression to fibrosis, end-stage liver disease, and death. Whether HCV has a negative impact on HIV disease progression continues to be debated. However, following the introduction of effective combination antiretroviral therapy, the survival of coinfected individuals has significantly improved and HCV-associated diseases have emerged as the most important co-morbidities. In this review, we summarize the newest studies regarding the pathogenesis of HIV/HCV coinfection, including effects of coinfection on HIV disease progression, HCV-associated liver disease, the immune system, kidney and cardiovascular disease, and neurologic status; and effectiveness of current anti-HIV and HCV therapies and proposed new treatment strategies

Diabetic cardiomyopathy

Diabetic cardiomyopathy is a distinct primary disease process, independent of coronary artery disease, which leads to heart failure in diabetic patients. Epidemiological and clinical trial data have confirmed the greater incidence and prevalence of heart failure in diabetes. Novel echocardiographic and MR (magnetic resonance) techniques have enabled a more accurate means of phenotyping diabetic cardiomyopathy. Experimental models of diabetes have provided a range of novel molecular targets for this condition, but none have been substantiated in humans. Similarly, although ultrastructural pathology of the microvessels and cardiomyocytes is well described in animal models, studies in humans are small and limited to light microscopy. With regard to treatment, recent data with thiazoledinediones has generated much controversy in terms of the cardiac safety of both these and other drugs currently in use and under development. Clinical trials are urgently required to establish the efficacy of currently available agents for heart failure, as well as novel therapies in patients specifically with diabetic cardiomyopathy

Eccentric Hypertrophy Predicts Adverse Events in Patients Undergoing Percutaneous Coronary Intervention for Acute Coronary Syndrome

INTRODUCTION: The effect of the type of left ventricular hypertrophy in patients presenting with an acute coronary syndrome (ACS) on long-term outcomes is ill-defined. The purpose of this study was to investigate the prognostic effect of concentric (CH) or eccentric hypertrophy (EH) on adverse outcomes in patients presenting with ACS undergoing percutaneous coronary intervention (PCI). MATERIAL AND METHODS: We analyzed 1-year follow-up data from a single-institution, retrospective, observational study that enrolled 1,153 patients who presented with ACS and were treated with PCI, for whom echocardiographic data were available. RESULTS: Normal geometry was observed in 718 (62.3%) patients, while 27.2% had CH and 10.5% had EH. The primary endpoint of all-cause death ( CONCLUSIONS: The presence of eccentric hypertrophy in ACS patients undergoing PCI is an independent predictor of adverse outcomes at 1 year

The Effect of Cardiac Geometry Variation According to Sex and Race on Outcomes in Patients with Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention

INTRODUCTION: The prevalence and long-term consequences of differences in baseline cardiac geometry (as a result of hypertension) in patients undergoing percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS) are ill-defined. The primary purpose of this study was to clarify whether there were differences among sexual and racial groups in echocardiographic findings reflecting cardiac geometry and adaptation in patients undergoing PCI for ACS and whether this could explain the differences in outcomes seen between these groups. MATERIAL AND METHODS: We analyzed 1-year follow-up data from a single institution, a retrospective, observational study that enrolled 1,153 patients who presented with ACS and were treated with PCI, for whom echocardiographic data were available. RESULTS: Normal, concentric hypertrophy, and eccentric hypertrophy in males vs. females were observed as follows: 29% vs. 19% ( CONCLUSIONS: Females undergoing PCI for ACS are at higher risk for worse outcomes because they are more likely to express the eccentric hypertrophy phenotype; however, it did not account for the difference in adverse outcomes observed between sexes

Relation of Left Ventricular Hypertrophy Subtype to Long-Term Mortality in Those With Subclinical Cardiovascular Disease (From the Multiethnic Study of Atherosclerosis [MESA])

The clinical and biochemical profile of differing Left ventricular hypertrophy phenotypes and its effect on long-term outcomes is ill-defined. The study investigated the differences in risk profiles and prognostic effect of concentric (CH) and eccentric hypertrophy (EH) on long-term adverse outcomes in a contemporary, ethnically diverse cohort. We analyzed follow-up data over 15 years from the Multiethnic Study of Atherosclerosis study. A total of 4,979 participants with cardiac magnetic resonance performed at baseline enrollment were included. Descriptive statistics, Kaplan-Meier curves, and regression models were applied. Independent variables associated with CH were black and Hispanic race/ethnicity, systolic blood pressure, and metabolic syndrome. Independent variables associated with EH were systolic blood pressure and urine creatinine, whereas serum creatinine had an inverse association. The primary end point of all-cause death (n = 1,137, 22.8%) occurred in 21.7%, 47.4%, and 56.6% of participants with no, CH, or EH, respectively (p- \u3c 0.001). Age (hazard ratio [HR] per year = 1.10 [1.09 to 1.11], p \u3c0.001), male gender (HR = 1.48 [1.29 to 1.69], p \u3c0.001), black race (HR = 1.17 [1.005 to 1.36], p = 0.04), fasting glucose (HR = 1.005 [1.003 to 1.007], p \u3c0.001), baseline creatinine (HR per mg/100 ml = 1.29 [1.15 to 1.46], p \u3c0.001), left ventricular ejection fraction (HR per 1% = 0.98 [0.98 to 0.99], p = 0.005), IL-6 (HR per pg/ml = 1.17 [1.12 to 1.22], p \u3c0.001), CH (HR = 1.84 [1.41 to 2.41], p \u3c0.001), and EH (HR = 2.58 [1.77 to 3.76], p \u3c0.001) were significant predictors of all-cause mortality. In conclusion, CH and EH are 2 distinct clinical phenotypes of left ventricular hypertrophy with differing gender and racial predisposition, both of which are associated with worse long-term adverse outcomes

Clinical Variables for Predicting Type-1 and Type-2 Non-ST Segment Elevation Myocardial Infarction in Those Presenting With Ischemic Symptoms

INTRODUCTION: The accuracy of detecting myocardial infarction (MI) has greatly improved with the advent of more sensitive assays, and this has led to etiologic subtyping. Distinguishing between type 1 and type 2 non-ST-segment elevation myocardial infarction (NSTEMI) early in the clinical course allows for the most appropriate advanced diagnostic procedures and most efficacious treatments. The purpose of this study was to investigate the predictive effect of demographic and clinical variables on predicting NSTEMI subtypes in patients presenting with ischemic symptoms. MATERIAL AND METHODS: We performed a single institution retrospective cohort study of patients who presented to the emergency department (ED) with ischemic signs and symptoms consistent with non-ST-segment myocardial infarction, for whom results of coronary angiography were available. We analyzed demographic, laboratory, echocardiography and angiography data to determine predictors of NSTEMI sub-types. RESULTS: Five hundred and forty-six patients were enrolled; 426 patients were found on coronary angiography to have type 1 acute MI (T1AMI), whereas 120 patients had type 2 acute MI (T2AMI). Age (OR per year = 1.03 (1.00, 1.05), = 0.03), prior MI (OR = 3.50 (1.68, 7.22), = 0.001), L/H \u3e 2.0 (OR = 1.55 (1.12, 2.13), = 0.007), percentage change in troponin I \u3e 25% (OR = 2.54 (1.38, 4.69), = 0.003), and regional wall motion abnormalities (RWMA) (OR = 3.53 (1.46, 8.54), = 0.004) were independent predictors of T1AMI, whereas sex, race, body mass index, hypertension, end-stage renal disease (ESRD), heart failure, family history (FH) of coronary artery disease (CAD), HbA, and left ventricular ejection fraction (LVEF) were not. CONCLUSIONS: Key clinical variables such as age, prior MI, L/H ratio, percentage change in troponin I, and presence of RWMA on echocardiogram may be utilized as significant predictors of T1AMI in patients presenting with ischemic symptoms to the ED