Associations of symptomatic or asymptomatic peripheral arterial disease with all-cause mortality and cardiovascular mortality

AbstractBackgroundTo investigate the rate of all cause and cardiovascular mortality in patients with symptomatic or asymptomatic peripheral arterial disease (PAD) compared to those without PAD.Methods and resultsAll the subjects were inpatients at high risk of atherosclerosis and enrolled from February to November, 2006. A total of 320 were followed up until an end-point (death) was reached or until February 2010. The mean follow-up time was 37.7±1.5months. Compared with non-PAD, PAD patients had significantly higher rates of hypertension, diabetes mellitus, and smoking (P<0.01). Those with symptomatic and asymptomatic PAD had a much higher all cause (37.5% and 23.0% vs. 12.1%) and cardiovascular mortality (18.8% and 13.8% vs. 6.7%) compared to those without PAD (P<0.001). The symptomatic PAD patients were 1.831 times (95% CI: 1.222–2.741) as likely to die as those without PAD, and 1.646 times (95% CI: 1.301–2.083) in asymptomatic PAD patients after adjusting for other factors. Those with symptomatic or asymptomatic PAD were more than twice as likely to die of CVD as those without PAD (RR: 2.248, 95% CI: 1.366–3.698 and RR: 2.105, 95% CI: 1.566–2.831, respectively).ConclusionsPAD was associated with a higher all cause and cardiovascular mortality whether or not PAD is symptomatic

Conventional and segmental myocardial Tei indices measurement in patients with acute ST-segment elevation myocardial infarction: Is there a relation?

Background: Myocardial infarction (MI) results in impairment of left ventricular (LV) systolic and diastolic functions to various degrees. The tissue Doppler image derived Tei index (TDI-Tei index) has recently been used to assess LV function, and like the conventional Tei index, it was also found to be useful for global function. There are a small number of studies which apply TDI-Tei index to assess regional function and whether it varies according to the degree of changes in wall motion in various LV segments. Objectives: This study was conducted to assess the changes of segmental myocardial Tei index by TDI according to the degree of changes of wall motion in the patient with acute ST-segment elevation myocardial infarction (STEMI) and its correlation with Tei index derived by conventional Doppler. Patients and methods: This study was carried out on thirty patients with acute STEMI selected from Coronary Care Unit, Cardiology Department, Mansoura Specialized Hospital, Mansoura University, Egypt. The study group was subjected to clinical assessment, electrocardiography (ECG), routine laboratory profile and Doppler echocardiography (conventional and pulsed wave tissue Doppler imaging “PW-TDI”). Tei index was calculated from the sum of isovolumetric contraction time (IVCT) and isovolumetric relaxation time (IVRT), divided by ejection time (ET) which were measured from pulsed wave Doppler imaging of the trans-mitral inflow and LV outflow tracts. Myocardial velocities and TDI-Tei index were measured at basal and mid-segments of LV walts from apical 4, 2 and 5-chamber views using 16-segment model. Average values of myocardial velocities and TDI-Tei indices were obtained from normal, hypokinetic and akinetic segments then compared. Results: The mean values of left ventricular ejection fraction (LVEF), mitral E/A ratio and conventional Tei index were 51.83 ± 5.15%, 1.18 ± 0.15 and 0.63 ± 0.07 ms, respectively. Segmental myocardial TDI-Tei index was correlated positively with conventional Tei index (r = 0.648, P < 0.001). TDI-Tei indices were significantly higher in akinetic and hypokinetic segments than those of normal segments (0.70 ± 0.09, 0.64 ± 0.05 vs 0.63 ± 0.05, P < 0.001). Conclusions: Tei index (either conventional or TDI) is superior to EF in evaluation of LV performance in patients with acute STEMI. Tei index derived by myocardial segments by TDI is correlated with conventional Tei index. Segmental TDI-Tei index values differ according to the grade of dysfunctional wall motion

Assessment of left ventricular long axis contraction in patients with ischemic mitral regurgitation after acute myocardial infarction

The development of ischemic mitral regurgitation (MR) after myocardial infarction (MI) may impose hemodynamic load during a period of active left ventricular remodeling and promote heart failure (HF). The aim of our study was to evaluate left ventricular (LV) long axis contraction assessed by both mitral annular plane systolic excursion (MAPSE) and peak systolic velocity in patients with ischemic MR after acute MI. Methods: Thirty eight patients with a first attack of acute MI were classified into two groups. Group I comprised 18 patients with MI and ischemic MR, and group II comprised 20 patients with MI without ischemic MR. Twenty subjects without acute MI were considered as the control group (group III). Measurement of MAPSE from M-mode tracing of the mitral annulus from apical 4- and 2-chamber, and Pulsed wave tissue Doppler imaging (TDI) of the 4 sides of the mitral annulus for assessment of peak systolic (Sa) and diastolic (Ea and Aa) velocities were done. Results: Significant decrease of MAPSE in 4 sides in patients with acute MI with MR compared to MI without MR and control group (P  0.05). Significant correlation between MAPSE on anterior side of mitral annulus and LV EF (P < 0.001) in patients with ischemic MR after acute MI. Conclusion: mitral annular displacement is a useful parameter for assessment of longitudinal LV function in patients with ischemic MR after MI

Assessment of right ventricular function by myocardial performance index in diabetic patients

Background: Assessment of right ventricular (RV) function remains difficult because of the RV complex shape. Data regarding RV performance in patients with diabetes are incomplete The aim of this study was to assess the feasibility of pulsed wave tissue Doppler imaging and myocardial performance index (MPI) for the assessment of right ventricular function in diabetic patients without coronary artery disease. Methods: The study included 20 diabetic patients, 20 diabetic hypertensive and 20 gender and age matched healthy subjects underwent standard echocardiography with tissue Doppler imaging (TDI) to assess RV function. Patients with myocardial ischemia, impaired left ventricular systolic function, valvular heart disease or other diseases which could alter the right ventricular performance were excluded. Results: Myocardial performance index was significantly higher in diabetes compared to control group (0.41 ± 0.05 versus 0.27 ± 0.04, p = 0.001). Peak myocardial systolic velocity (Sa), early diastolic myocardial velocity (Ea), and late diastolic myocardial velocity (Aa) were significantly lower in patients with diabetes mellitus (DM) compared to the control group (p = 0.0001). Isovolumetric relaxation time (IVRT) was significantly higher in DM group compared to control group (p = 0.003). MPI was significantly higher in diabetic hypertensive group versus DM alone group (0.46 ± 0.050 versus 0.41 ± 0.05, p = 0.01). There was no correlation between MPI and blood glucose level and duration of diabetes. Conclusion: Myocardial performance index is a useful noninvasive tool for the detection of early right ventricular systolic and diastolic dysfunction in diabetic patients, regardless of coexisting hypertension

Does isolated myocardial bridge really interfere with coronary blood flow?

Background: Myocardial bridge (MB) is defined as a segment of a major epicardial coronary artery the “tunneled artery” that goes intramurally through the myocardium beneath the muscle bridge. Multiple methods have been proposed to assess coronary flow rate among which thrombolysis in acute myocardial infarction frame count was a relatively new semiquantitative method. Objectives: Our goal was to determine incidence of MB in the patients undergoing coronary angiography in Mansoura Specialized Hospital, Cardiac Catheterization Laboratory, also to investigate the hypothesis that slow coronary flow rate may be linked to angina or angina like symptoms in patients with MB without stenotic lesions in epicardial coronary arteries using TFC. Patients and methods: Fifteen patients with MB (group I) were retrospectively collected from Mansoura Specialized Hospital, Cardiac Catheterization Laboratory, we review 3000 cases referred to diagnostic coronary angiography to exclude significant coronary artery disease. Fifteen patients with normal coronary angiography served as control (group II). We review the clinical presentations, risk factors, echocardiographic data for both test and control groups. TFC was calculated using a simple continuous index. Results: The incidence of MB in our study was 0.5%. CTFC in LAD was significantly higher in the patients with MB compared with control. No significant correlation between TFC and echocardiographic parameters. Conclusions: Myocardial bridging must be considered especially in patients at low risk for coronary atherosclerosis but with angina like chest pain or established myocardial ischemia. We suggest that coronary blood flow is decreased in the patients with MB compared with the patients having normal coronary

Assessment of left ventricular long axis contraction in patients with ischemic mitral regurgitation after acute myocardial infarction

Introduction: The development of ischemic mitral regurgitation (IMR) after myocardial infarction (MI) may impose hemodynamic load during a period of active left ventricular remodeling and promote heart failure (HF). The aim of our study was to evaluate left ventricular (LV) long axis contraction assessed by both mitral annular plane systolic excursion (MAPSE) and peak systolic velocity (Sa) in patients with ischemic MR after acute MI. Methods: Thirty-eight patients with a first attack of acute MI were classified into two groups. Group I comprised 18 patients with MI and ischemic MR, and group II comprised 20 patients with MI without IMR. Twenty age-matched subjects were considered as the control group (group III). Measurement of MAPSE from M-mode tracing of the mitral annulus in apical 4- and 2-chamber view, and pulsed wave tissue Doppler imaging (PW-TDI) of the 4 sides of the mitral annulus for assessment of the Sa velocity were done. Results: A significant decrease of MAPSE was observed in 4 sides in patients with acute MI with IMR compared to MI without IMR and control group (P < 0.05). Peak systolic velocity (Sa) in septal, anterior, and inferior sides of mitral annulus was significantly decreased in MI patients compared to control group (P < 0.05). A significant correlation between MAPSE on anterior side of mitral annulus and LV ejection fraction (P < 0.001) in patients with ischemic MR after acute MI was found. Conclusion: Mitral annular plane systolic excursion is a useful and superior parameter over peak Sa for assessment of longitudinal LV function in patients with ischemic MR after MI

Does the Serum Testosterone Level Have a Relation to Coronary Artery Disease in Elderly Men?

Background. The low serum level of testosterone in the elderly subjects may contribute to coronary artery disease (CAD). Our aim is to study serum levels of free testosterone in elderly men with CAD. Subjects and Methods. This study was conducted on 100 elderly males with CAD, one half of them was presented with ACS (with mean age 69.6±2.44 year), and the other half was presented with stable CAD (with mean age 69.42±2.14 year), in addition to 50 apparently healthy elderly males (with mean age 69.06±1.64 year) as a control group. We detected the levels of serum free testosterone, cortisol, fibrinogen, plasminogen activator inhibitor-1(PAI-1), high sensitive C-reactive protein(hsCRP), interleukin-6(IL-6). Results. Cases with CAD had significant lower values of free testosterone and HDL-c, but they had significant higher values of cortisol, fibrinogen, PAI-1, IL-6, hsCRP, in comparison to control group. Cases with ACS had significant higher values of cortisol, hsCRP, IL-6, fibrinogen, PAI-1, total cholesterol and BMI more than those with stable CAD. The free testosterone had significant negative correlation with fibrinogen, PAI-1, hsCRP and IL-6 in both groups of patients. Conclusion. The lower value of serum free testosterone in elderly male subjects may contribute to CAD

Corrected QT dispersion as a predictor of the frequency of paroxysmal tachyarrhythmias in patients with Wolff–Parkinson–White syndrome

Background: Patients with Wolff–Parkinson–White (WPW) syndrome are prone to develop a variety of tachyarrhythmias which may lead to unpleasant, disabling symptoms and in extreme, sudden cardiac death (SCD). The aim of our study was to evaluate the clinical significance of corrected QT dispersion (QTcd) as a noninvasive predictor of paroxysmal tachyarrhythmias in patients with WPW syndrome. Patients and methods: The study population comprised 40 patients with WPW syndrome presented to the emergency department by paroxysmal tachyarrhythmias. They were classified into 3 groups; group I: 18 patients presented with regular narrow QRS complex tachycardia, group II: 10 patients presented with regular wide QRS complex tachycardia, group III: 12 patients presented with irregular wide QRS complex tachycardia. All patients were subjected to clinical evaluation, 12-lead electrocardiography (ECG) analysis during the attack of paroxysmal tachyarrhythmia to define its type and after reversion to sinus rhythm for the measurement of QTcd, echocardiography, laboratory investigations and 24-h ambulatory electrocardiographic monitoring. Results: There was a significant increase of QTcd, QTmax, QTmin, Delta wave duration, QRS duration, and QRS amplitude in patients with group III compared to either group I and group II (P < 0.05). There was a significant increase in QTcd when compared to patients with WPW syndrome with frequent attacks of tachyarrhythmias with those with infrequent attacks (93.08 ± 14.68 versus 67.47 ± 7.03, P < 0.001). Conclusion: Calculation of QTcd in patients with WPW syndrome presented with paroxysmal tachyarrhythmias is a simple noninvasive clinical test for risk stratification of those patients and hence detecting patients at higher risk for frequent and recurrent tachyarrhythmias

Carriage of beta-lactamase-producing Enterobacteriaceae among nursing home residents in north Lebanon

Background: Multidrug-resistant (MDR) Enterobacteriaceae can cause severe infections with high morbidity, mortality, and health care costs. Individuals can be fecal carriers of these resistant organisms. Data on the extent of MDR Enterobacteriaceae fecal carriage in the community setting in Lebanon are very scarce. The aim of this study was to investigate the fecal carriage of MDR Enterobacteriaceae among the elderly residents of two nursing homes located in north Lebanon. Methods: Over a period of 4 months, five fecal swab samples were collected from each of 68 elderly persons at regular intervals of 3–4 weeks. Fecal swabs were subcultured on selective media for the screening of resistant organisms. The phenotypic detection of extended-spectrum beta-lactamase (ESBL), AmpC, metallo-beta-lactamase (MBL), and Klebsiella pneumoniae carbapenemase (KPC) production was performed using the beta-lactamase inhibitors ethylenediaminetetraacetic acid, phenylboronic acid, and cloxacillin. A temocillin disk was used for OXA-48. Multiplex PCRs were used for the genotypic detection of ESBL and carbapenemase genes, and sequencing was performed to identify CTX-M-15. The medical records of each subject were reviewed on a regular basis in order to assess the risk factors associated with MDR Enterobacteriaceae fecal carriage. Results: Over the study period, 76.5% of the recruited elderly persons were at least one-time carriers. A total of 178 isolates were obtained. Phenotypic testing revealed that 91.5% of them were ESBL producers, 4% were AmpC producers, 2.8% were co-producers of ESBL and AmpC, and 1.7% were co-producers of OXA-48 and ESBL. Recent antibiotic intake was found to be the only independent risk factor associated with the fecal carriage of MDR Enterobacteriaceae. Conclusions: The high prevalence of MDR Enterobacteriaceae detected in this study and the emergence of carbapenem resistance is alarming. Efficient infection control measures and antibiotic stewardship programs are urgently needed in these settings in order to limit the spread of resistant strains