Reappraisal of Ischemic Heart Disease: Fundamental Role of Coronary Microvascular Dysfunction in the Pathogenesis of Angina Pectoris

In recent years, it has become apparent that coronary microvascular dysfunction plays a pivotal pathogenic role in angina pectoris. Functional and structural mechanisms can affect the physiological function of the coronary microvasculature and lead to myocardial ischemia in people without coronary atheromatous disease and also in individuals with obstructive coronary artery disease. Abnormal dilatory responses of the coronary microvessels, coronary microvascular spasm, and extravascular compressive forces have been identified as pathogenic mechanisms in both chronic and acute forms of ischemic heart disease. The condition characterized by anginal symptoms and evidence of myocardial ischemia triggered by coronary microvascular dysfunction, in the absence of obstructive coronary disease, is known as microvascular angina. The concept of microvascular angina, however, may extend further to include patients with obstructive coronary artery disease and individuals with angina after coronary revascularization or heart transplantation because coronary microvascular dysfunction contributes to myocardial ischemia in many such patients. Patients with microvascular angina constitute a sizeable proportion of all cases of stable angina undergoing diagnostic coronary angiography and of those with persisting angina after successful coronary revascularization. Coronary microvascular dysfunction is also often responsible for angina in individuals with cardiomyopathy and heart valve disease as well as acute coronary syndrome cases such as Takotsubo syndrome and myocardial infarction with no obstructive coronary artery disease. Patients with stable microvascular angina present typically with effort or rest chest pain and a reduced coronary flow reserve or microvascular spasm. This condition, which affects women and men, can markedly impair quality of life and prognosis and represents a substantial cost burden to healthcare systems and individuals alike. In recent years, progress in the diagnosis of myocardial ischemia and the use of tests to investigate functional and structural causes for a reduced coronary flow reserve and microvascular spasm have allowed the identification of an increased number of cases of microvascular angina in everyday clinical practice. Although some of the available anti-anginal drugs may be helpful, treatment of coronary microvascular dysfunction remains a major challenge. The present article discusses the fundamental role that coronary microvascular dysfunction plays in the pathogenesis of ischemic heart disease, the clinical characteristics of patients presenting with microvascular angina, and possible diagnostic and therapeutic strategies

Naming the Body: A Translation with Commentary and Interpretive Essays of Three Anatomical Works Attributed to Rufus of Ephesus.

Often cast in the shadow of his successor Galen, Rufus of Ephesus adds a large and wide-ranging corpus to the surviving body of ancient medical texts. His anatomical treatises, particularly his Names of the Parts of the Body, provide a window into his cultural assumptions and his self-situation in the medical and scientific community. In naming the parts of the human body, Rufus reveals that what constitutes “human” is limited to what is most like him: Greek, male, free-born, and distinct from other animal species. Women; eunuchs; slaves; and the old and young are all imperfect deviations from the norm. Because of various cultural limitations, including prohibitions against human dissection and the impossibility of displaying nude Greek males, Rufus must use a slave and a monkey in his demonstrations. Nonetheless, his use of these substitutes betrays a real sense of disappointment. Rufus’ prejudices about humanness extend into his process of naming. The most suitable words are those which are Greek. And the most appropriate metaphors are those which draw from the distinctly human realm. In presenting this information to his audience, Rufus shows himself to be an early player in the Second Sophistic movements. His lecture involves props and is an obviously rehearsed performance. Yet Rufus lacks the polemical self-assertiveness of the other iatrosophists. And in many ways, this reticence keeps his contribution to ancient medical literature largely overlooked.PHDClassical StudiesUniversity of Michigan, Horace H. Rackham School of Graduate Studieshttp://deepblue.lib.umich.edu/bitstream/2027.42/95946/1/cgersh_1.pd

Impact of socioeconomic status, ethnicity, and urbanization on risk factor profiles of cardiovascular disease in Africa

Africa is a continent characterized by marked ethnic, sociodemographic, and economic diversity, with profound changes in many regions over the past 2 decades. This diversity has an impact on cardiovascular disease presentation and outcomes. Within Africa and within the individual countries, one can find regions having predominantly communicable diseases such as rheumatic heart disease, tuberculous pericarditis, or cardiomyopathy and others having a marked increase in noncommunicable disease such as hypertension and hypertensive heart disease. Ischemic heart disease remains rare in most countries. Difficulties in the planning and implementation of effective health care in most African countries are compounded by a paucity of studies and a low rate of investment in research and data acquisition. The fiduciary responsibilities of companies working in Africa should include the effective and efficient use of natural resources to promote the overall health of populations

Outcome of Patients With Hypertrophic Cardiomyopathy and a Normal Electrocardiogram

ObjectivesThis study sought to clarify the frequency, clinical phenotype, and prognosis of those patients with hypertrophic cardiomyopathy (HCM) who present with a normal electrocardiogram (ECG).BackgroundHypertrophic cardiomyopathy is the most common cause of sudden death in young people. Screening advocates have recommended a 12-lead ECG for the early detection of HCM in athletes, yet the clinical outcomes of those presenting with a normal ECG remains to be fully delineated.MethodsBaseline characteristic and echocardiographic data were collected on all patients with HCM who initially presented to our institution with a diagnostic echocardiogram but a normal ECG. Follow-up was obtained and compared with the prognosis of HCM patients who presented with abnormal ECGs.ResultsWe compared 135 HCM patients with a normal ECG with 2,350 HCM patients with an abnormal ECG. The latter group was more likely to have worse symptoms, have higher gradients, and a greater degree of septal wall thickness than the patients with a normal ECG. Severe obstructive symptoms requiring surgical myectomy and implantation of an implantable cardioverter-defibrillator were more common in patients with abnormal ECGs. Cardiac survival was significantly better in the group with a normal ECG at presentation—none of these patients had a cardiac death at follow-up.ConclusionsAlmost 6% of patients presenting with demonstrable echocardiographic evidence of HCM had a normal ECG at the time of diagnosis. This subset of patients with normal ECG-HCM appears to exhibit a less severe phenotype with better cardiovascular outcomes

Influence of coronary artery disease on morbidity and mortality after abdominal aortic aneurysmectomy: A population-based study, 1971–1987

AbstractThe prognostic importance of coronary artery disease at the time of elective abdominal aortic aneurysmectomy was evaluated among 131 residents of Olmsted County, Minnesota who underwent elective aneurysmectomy from 1971 to 1987 and were followed up to 1988 for death and cardiac events (cardiac death, myocardial infarction, coronary bypass surgery and angioplasty). Before aneurysmectomy, 75 patients (Group 1) had no clinically recognized coronary disease, 47 patients (Group 2) had suspected or overt uncorrected coronary artery disease (history of prior myocardial infarction, angina or a positive stress test) and 9 patients (Group 3) had undergone coronary artery bypass grafting or coronary angioplasty.The 30 day operative mortality rate was 3% (2 of 75) in Group 1 and 9% (4 of 47) in Group 2 (p = 0.15). According to Kaplan-Meier analysis, estimated survival 8 years after aneurysmectomy was 59% (expected rate 68%, p = 0.29) in Group 1 versus 34% (expected rate 61%, p = 0.01) in Group 2. The cumulative incidence rate of cardiac events at 8 years was 15% and 61%, respectively, for patients without and with suspected/overt coronary artery disease (p < 0.01). Using multivariable proportional hazards analysis, uncorrected coronary artery disease was associated with a nearly twofold increased risk of death (hazard ratio 1.79, 95% confidence interval 1.06 to 3.00) and a fourfold increased risk of cardiac events (hazard ratio 3.71, 95% confidence interval 1.79 to 7.69).These population-based data support an aggressive lifelong approach to the management of coronary artery disease in patients undergoing abdominal aortic aneurysmectomy

Referral for coronary artery revascularization procedures after diagnostic coronary angiography: Evidence for gender bias?

AbstractObjectives. We sought to determine whether there is a gender bias in the selection of patients for coronary revascularization once the severity of the underlying coronary artery disease has been established with angiography.Background. It has been suggested that women with coronary artery disease are less likely to be referred for coronary angiography and coronary artery bypass surgery than men. Whether such a referral bias for revascularization procedures, including coronary angioplasty, is present once angiography has been performed is not clear.Methods. We retrospectively analyzed 22,795 patients with suspected coronary artery disease who underwent coronary angiography between 1981 and 1991 and compared the numbers of women and men who underwent either coronary artery bypass surgery or coronary angioplasty within 30 days of coronary angiography.Results. Angiography revealed significant (one-vessel or more) disease in 15,455 patients (52% of women, 76% of men). Despite worse symptoms, women had less extensive coronary disease than men as judged by the number of vessels diseased. Women were also more likely to have other co-morbid diseases. An equal proportion of women (54%) and men underwent revascularization procedures. After adjustment for baseline differences and age, differences in the two individual revascularization strategies were very small: More women tended to have coronary angioplasty ([absolute difference ± 1 SD] + 3.3 ± 0.7%, p < 0.0001), but fewer had coronary artery bypass surgery than men (−2.5 ± 0.8%, p = 0.003). When the two revascularization strategies were considered together, there was no significant gender difference in overall adjusted use of revascularization (+0.8 ± 0.9%, p = 0.41).Conclusions. Once diagnostic coronary angiography had been performed, no major differences in the overall utilization of revascularization procedures were noted for women compared with men

Electrodynamics of Media

Contains reports on four research project.Joint Services Electronics Program (Contract DAAB07-71-C-0300)U. S. Army - Research Office - Durham (Contract DAHCO4-72-C-0044