Imaging of myocardial dyssynchrony in congestive heart failure

Heart failure constitutes a major health problem in USA and Europe. Angiotensin converting enzyme inhibitors and _ blockers were shown to reduce morbidity and mortality in patients with CHF. Yet, their effectiveness is limited. A significant number of patients with heart failure manifest myocardial conduction abnormalities. Conduction abnormalities, especially in the form of left bundle branch block (LBBB) may be associated with abnormal mechanical function. Several studies demonstrated that these patients may gain benefit from biventricular (BiV) pacing in terms of improvement in exercise tolerance, heart failure morbidity and even decreased mortality. BiV pacing was also associated with improvement in ejection fraction, reduction in the extent of mitral regurgitation and a decrease in cardiac size (reverse remodeling). However, a significant number of patients do not gain benefit from biventricular pacing despite having conduction abnormalities. The underlying reason is that the electrical activity may not closely reflect mechanical activity. Several imaging modalities and techniques have been proposed to improve the selection of patients who may benefit from biventricular pacemakers. Of those, echo-Doppler, and especially, Tissue Doppler Imaging has been demonstrated as important tools for evaluating patients for cardiac resynchronization therapy (CRT) and following their response. The advantages of echo include accessibility, portability, its cost and a high temporal resolution. Yet, it is limited by its acoustic windows and scanning angles. MRI is a useful tool for evaluating patients for CRT by providing 3-D image of myocardial function. However, it is limited for follow-up after implantation due to its cost and a potential damage to the patients or pacemakers. Dyssnchrony imaging is a rapidly evolving field. New imaging techniques such as speckle tracking are promising and close update is needed to keep track of the developments and the changes in this exciting field.     

Electrocardiogram and clinical characteristics of patients referred for cardiac transplantation: implications for pacing in heart failure

BACKGROUND: Permanent pacing for the treatment of heart failure (HF) has been the subject of intense research over the past decade. Those with conduction abnormalities may benefit most from pacing. The incidence of these conduction abnormalities in patients referred for cardiac transplantation and its relationship to outcome has not been well described. HYPOTHESIS: This study sought to determine the incidence of these abnormalities and to correlate these findings to outcome in this patient population. METHODS: A review of 100 patients referred for transplantation was performed. Data were analyzed in two groups: those with QRS duration < 120 ms and those with a QRS duration > 120 ms. Times to transplantation or death were analyzed in these two groups. RESULTS: Of these patients, 34% had QRS duration > or = 120 ms and survival was inversely associated with QRS duration. Of those with QRS duration < 120 ms, 24% (16) went on to cardiac transplantation or died. Of those with a QRS duration > or = 120 ms, 55% (17) went on to transplantation or died (p = 0.0134). CONCLUSIONS: This suggests that in addition to a multi-drug regimen for heart failure, 34% of patients referred for transplantation may benefit from additional therapy with biventricular pacing.     

Unfavorable-risk cytogenetics in acute myeloid leukemia

Cytogenetic analysis at diagnosis is one of the most significant prognostic factors in acute myeloid leukemia (AML). AML patients with unfavorable-risk cytogenetic abnormalities account for 16-30% of younger adult patients and have poor response to standard treatment, with only 32-55% achieving a complete response. Overall survival is also extremely poor with only 5-12% patients alive at 5-10 years after diagnosis. Owing to the poor response in this subset of patients, risk-adapted treatment has been investigated. Allogeneic stem cell transplant has been shown to provide a survival benefit in patients with unfavorable-risk cytogenetic abnormalities in complement receptor 1. Other risk-adapted treatment strategies, such as reduced-intensity conditioning regimens prior to allogeneic stem cell transplant for older patients with AML, have also shown some survival benefit, without increasing treatment-related toxicities. Risk-stratification models that include cytogenetic abnormalities, as well as other molecular markers, are being developed to allow for individualized risk-adapted treatment for patients with AML. Prospective multicenter trials will be needed to validate these prognostic models.     

A prospective study of respiratory ciliary structure and function after stem cell transplantation

We prospectively investigated the morphological and ciliary function abnormalities in 19 consecutive Chinese patients undergoing hemopoietic stem cell transplantation (HSCT) and studied their relationship with pulmonary complications. The percentage of structural ciliary abnormalities preceding HSCT was comparable to normal controls, but increased up to 1-year post-HSCT. However, the abnormalities did not correlate with ciliary or pulmonary function. Ciliary beat frequency (CBF) for patients undergoing autologous and allogeneic SCT was lower than that of matched controls, with a further decline at one year. There was, however, no significant change in pulmonary function for the whole cohort. There was considerable variation in CBF and ciliary abnormalities in all cases during 3-month interval assessments. Regular ciliary assessment did not predict the only two patients who eventually suffered from bronchiolitis obliterans (BO). We conclude that structural and functional ciliary abnormalities are common in recipients of HSCT, and predict post-HSCT deterioration. However, there is no evidence to show that CBF monitoring may be of prospective benefit.     

Quantitative T-wave analysis predicts 1 year prognosis and benefit from early invasive treatment in the FRISC II study population.

AIMS: To investigate the prognostic value of T-wave abnormalities in patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS), and whether such ECG changes may predict benefit from an early coronary angiography. Although ST-segment changes are considered the most important ECG feature in NSTE-ACS, T-wave abnormalities are the most common ECG finding. We hypothesize that a new quantitative approach to T-wave analysis could improve the prognostic value of this ECG abnormality. METHODS AND RESULTS: Quantitative T-wave analysis was performed on the admission ECG in 1609 patients with NSTE-ACS. Nine different categories of T-wave abnormality were analysed for their prognostic value concerning clinical outcome in patients not randomized to early coronary angiography. Also, the presence of one category (i.e. T-wave abnormality in > or =6 leads) was analysed for its predictive value concerning benefit from early coronary angiography. The combined study endpoint was death or myocardial infarction at 1 year follow-up. Patients with > or =6 leads with abnormal T-waves and concomitant ST-segment depression had a higher risk when not receiving early coronary angiography (24 vs. 12%, respectively; P=0.003), but could be brought to the same level of risk as the remaining patients with this treatment. For non-invasively treated patients five different categories of T-wave abnormality were significantly associated with an adverse outcome. CONCLUSION: New quantitative T-wave analysis of the admission ECG gives additional predictive information concerning clinical outcome and identifies patients who benefit from early coronary angiography.     

Insulin resistance and hypertension. Patients in double jeopardy for cardiovascular disease

Essential hypertension is prevalent among older individuals, and approximately 50% of persons with hypertension can be considered to have insulin resistance and hyperinsulinemia. It appears likely that insulin resistance and hyperinsulinemia predispose to, rather than result from, hypertension. Insulin resistance is associated with abnormalities in lipoprotein metabolism, hypercoagulability, and endothelial function, which probably account in part for the increased cardiovascular risk among hypertensive patients. To identify this subset of patients, all hypertensive patients should be screened for diabetes and lipid abnormalities. The presence of impaired glucose tolerance, diabetes, or hypertriglyceridemia and low HDL suggest the presence of insulin resistance. Insulin resistant patients, in particular, will benefit from exercise and weight loss.     

Current considerations of the etiology of aplastic anemia

Aplastic anemia is a disorder characterized by marrow aplasia and pancytopenia. The pathogenetic mechanisms that lead to bone marrow aplasia have been intensively studied. Data obtained from these studies suggest that aplastic anemia is a heterogeneous disorder with regards to pathogenesis. Bone marrow aplasia may result from a number of abnormalities including qualitative or quantitative abnormalities of hematopoietic stem cells, abnormal interaction between bone marrow accessory cells (lymphocytes and macrophages) and hematopoietic stem cells, cytotoxic humoral inhibitors of hematopoiesis, and abnormalities of the bone marrow microenvironment. A number of new therapeutic options have improved the survival of patients with aplastic anemia. Allogeneic bone marrow transplantation has actually resulted in the cure of patients. Unfortunately, only a minority of patients have a suitable bone marrow donor and alternate modes of therapy have been sought. Encouraging results have been reported from several centers concerning the use of antilymphocyte serum in patients with aplastic anemia. Certainty of the ultimate long-term benefit of this type of immunosuppressive therapy is not possible until careful, randomized, prospective studies of its use are completed.     

Genetic risk identifies multiple myeloma patients who do not benefit from autologous stem cell transplantation

Genetic aberrations have emerged as major prognostic factors for patients with multiple myeloma (MM). We evaluated 126 MM patients for t(4;14) or t(11;14), 13q or p53 deletions and correlated the number of genetic aberrations with patient's clinical outcome following undergoing autologous stem cell transplantation. We demonstrate the significance of genetic-based risk classification that clearly segregate patients into low (no genetic abnormalities or only t(11;14)), intermediate (any one of the genetic abnormalities other than t(11;14)) and high-risk groups (any two or more of the genetic abnormalities other than t(11;14)). High-risk patients do not benefit from stem cell transplant and should be offered alternative therapies.     

Osteomalacia in rheumatoid arthritis.

Fifty-four patients with rheumatoid arthritis and severe osteomalacia were found to have considerable bone and general deficiency problems. In 46 of them 14 stress fractures occurred and 32 minimal trauma fractures necessitating admission to hospital. Radiological abnormalities of absorption were found in nearly 25% of the total, implying that dietary factors alone are not always responsible for osteomalacia in patients with rheumatoid arthritis. A high index of suspicion is necessary in the diagnosis of osteomalacia in patients with rheumatoid arthritis, so they may benefit from treatment.     

Branched chain amino acids in the management of chronic liver disease. Facts and fantasies

The liver plays a central role in protein and amino acid metabolism. It processes dietary amino acids and reprocesses amino acids released from muscle protein degradation. It utilises amino acids for protein synthesis and gluconeogenesis, regulates the supply of amino acids to peripheral tissues and converts excess amino acids to urea. In patients with liver disease the liver's ability to control both plasma and tissue amino acid fluxes may be seriously disturbed. The resultant changes in amino acid metabolism may be implicated in the genesis of the neuropsychiatric abnormalities and the deterioration in nutritional status commonly observed in patients with hepatic failure. Thus, on theoretical grounds, amelioration of these amino acid abnormalities might benefit patients with liver disease who have hepatic encephalopathy or are malnourished. However, there is, at present, no consensus as to the efficacy, practicality or cost-effectiveness of 'amino acid therapy' in patients with liver disease.     

Arrhythmias in Pulmonary Arterial Hypertension

Cardiac arrhythmias are important contributors to morbidity and mortality in patients with pulmonary arterial hypertension (PAH). Such patients manifest a substrate resulting from altered autonomics, repolarization abnormalities, and ischemia. Supraventricular arrhythmias such as atrial fibrillation and flutter are associated with worsened outcomes, and maintenance of sinus rhythm is a goal. Sudden death is a relatively common issue, though the contribution of malignant ventricular arrhythmias versus bradyarrhythmias differs from non-PAH patients. Congenital heart disease patients with PAH benefit from catheter ablation of medically refractory arrhythmias. Clinical studies of defibrillator/pacemaker therapy for primary prevention against sudden death in PAH patients are lacking.     

Eosinophilic fasciitis

Two patients with clinical and pathologic features of eosinophilic fasciitis manifested serologic and systemic abnormalities that raised the question of the fundamental nature and relationship of eosinophilic fasciitis to scleroderma. In addition to the characteristic features of eosinophilic fasciitis, both patients exhibited arthritis, a predominantly mononuclear cell infiltration of muscles with normal serum muscle enzyme levels, weakly positive serum antinuclear factor, IgA deficiency, and abnormalities of pulmonary function. In addition, one patient had wide-mouthed colonic diverticulae and synovial deposits consistent with amyloid; the second patient had bone marrow hypoplasia. Although corticosteroid therapy was of benefit, hydroxychloroquine and potassium para-aminobenzoate were of further help in controlling the disorder. Biopsies from the two patients revealed inflammatory lesions to be heaviest deep in the skeletal muscle; fascia was only minimally inflamed with mild fibrosis. The findings suggest that striking fibroinflammatory lesions noted in the fascia in some patients with eosinophilic fasciitis may derive largely from spillover of lesions in neighboring skeletal muscle.     

Sarcoidosis of the Heart

Myocardial involvement in sarcoidosis occurs in about 27% of patients. Clinical manifestations include ventricular arrhythmias, conduction abnormalities, and sudden death. Diagnosis requires clinical suspicion and may be supported by electrocardiography, echocardiography, thallium imaging, gallium-67 scanning, and myocardial biopsy. Steroids seem to be beneficial in the treatment of myocardial sarcoidosis. Those who do not respond to medical treatment may benefit from cardiac transplantation.     

Management of arrythmias

The management of arrhythmias in elderly patients with congestive heart failure, including atrial fibrillation, ventricular tachyarrhythmias, and bradyarrhythmias, is described. Patients with atrial fibrillation can be treated with rate control anticoagulation for stroke prevention or by attempt at cardioversion and maintenance of sinus rhythm. Elderly patients remaining in atrial fibrillation benefit from anticoagulation provided that no contraindication exists. In patients surviving malignant ventricular arrhythmias, defibrillator implantation is beneficial in elderly patients with heart failure. Prognosis and treatment of nonsustained arrhythmias depends on the presence of underlying cardiac abnormalities. In the healthy elderly population, treatment is not indicated. In patients with coronary artery disease, decreased ejection fraction, and nonsustained ventricular tachycardia, electrophysiology can further stratify risk, and defibrillator implantation can improve survival if arrhythmias are induced. This benefit is as great in elderly patients as in younger patients. Symptomatic bradycardias are increasingly common with advancing age. Symptoms are improved with pacing, with maximum benefit from physiologic rather than ventricular pacing. Although the elderly population poses a unique challenge when faced with arrhythmias, an active approach not only saves lives but also reduces morbidity.     

Post-myocardial infarction beta-blocker therapy: the bradycardia conundrum. Rationale and design for the Pacemaker & beta-blocker therapy post-MI (PACE-MI) trial

Multiple clinical trials have demonstrated beta-blockers improving survival after myocardial infarction (MI). Patients with "bradycardia-related" contraindications to beta-blockers, such as those with asymptomatic bradycardia or AV conduction abnormalities, have been excluded from clinical trials of beta-blockers and continue to be excluded from post-MI beta-blocker therapy in routine clinical practice. These patients tend to be elderly and have a high 1-year mortality. If beta-blockers provide benefit to the post-MI patient independent of their heart rate-lowering effect, then these patients could benefit substantially from initiation of beta-blocker therapy. However, in this particular group of patients, beta-blockers can be safely initiated only if more severe or significant bradycardia can be prevented by pacemaker implantation. It is unclear whether adverse effects related to pacemaker implantation could also negate some or all of the hypothesized benefit of beta-blocker therapy. Although beta-blockers are particularly effective in the elderly, the benefit of beta-blocker therapy in patients with bradycardia-related contraindications to beta-blockers has not been established. The PACE-MI trial is a randomized controlled trial that will address whether beta-blocker therapy enabled by pacemaker implantation is superior to no beta-blocker and no pacemaker therapy after MI in patients with rhythm contraindications to beta-blockers or in those who have developed symptomatic bradycardia due to beta-blockers. The trial will randomize 1124 patients to standard therapy (not to include beta-blockers as patients must have a contraindication to be enrolled) or standard therapy plus pacemaker implantation and beta-blocker. The primary end point is the composite end point of total mortality plus nonfatal reinfarction.     

The thrombophilias: well-defined risk factors with uncertain therapeutic implications

Discovery of the factor V Leiden and prothrombin G20210A mutations has greatly increased the percentage of patients in whom venous thrombosis can be attributed to hereditary thrombophilia. The first step in the diagnostic approach to all patients with venous thrombosis consists of a careful history and physical examination combined with routine laboratory testing to characterize the severity of the thrombotic condition and determine the presence of any of the acquired causes of hypercoagulability. The second step is to consider screening for the causes of hereditary and acquired thrombophilia in selected subsets of patients. The selection of patients for testing, the choice of tests to perform, and the timing of the testing are important and challenging issues to consider. Routine testing would be warranted if the identification of abnormalities led to an alteration in the type or duration of initial anticoagulant therapy or the use of long-term prophylactic anticoagulation. The available data, however, do not yet indicate that most patients with defined thrombophilic states should be managed any differently than patients without identifiable abnormalities. On the basis of relative prevalences of the various thrombophilias, patients can be classified as "strongly" or "weakly" thrombophilic depending on their thrombotic histories. Management considerations and guidelines are offered for patients who are found to have one or more defined abnormalities, hereditary or otherwise. The future identification of additional laboratory abnormalities predisposing patients to thrombosis, coupled with prospective clinical trials, should enable us to better identify patients at high risk for recurrence who will benefit from prolonged anticoagulant prophylaxis.     

The value of preoperative screening investigations in otherwise healthy individuals

To assess the value of routine screening preoperative investigations in an otherwise healthy surgical population, the charts of 2570 patients undergoing cholecystectomy in two university teaching hospitals were reviewed. Of these, 1010 patients who were believed to be free of active disease other than cholelithiasis were selected for further study. Preoperative screening investigations were assessed in terms of frequency of use and abnormalities detected. The predictive values of these tests were analyzed and compared with information obtained from the history and physical examination. The frequency with which action was taken because of abnormal test results was also determined. Of the 5003 preoperative screening tests performed, abnormal results were obtained in 225. Of these, 104 were of potential importance. Action resulting from these abnormalities occurred in 17 cases. In only four patients could a conceivable benefit have arisen from a preoperative screening test. When compared with the results of the history and physical examination, routine preoperative investigations provided little further information that altered management in otherwise healthy surgical patients undergoing cholecystectomy.     

Improving the sensitivity of the American College of Rheumatology classification criteria for systemic sclerosis

OBJECTIVE: A large proportion of patients with limited systemic sclerosis (SSc) do not meet the current American College of Rheumatology (ACR) classification criteria for SSc. We undertook this study to determine whether the addition of easily available clinical variables, namely nailfold capillary abnormalities identified using a dermatoscope and visible telangiectasias, could improve the sensitivity of the current ACR classification criteria for patients with limited SSc. METHODS: Patients in the Canadian Scleroderma Research Group Registry with skin involvement distal to the metacarpophalangeal joints were identified and divided into two groups according to whether they fulfilled the current ACR classification criteria for SSc or not. Sensitivity of the criteria was calculated. Regression tree analysis was performed to determine whether the addition of nailfold capillary abnormalities identified using a dermatoscope and visible telangiectasias could improve the sensitivity of the criteria. RESULTS: One hundred and one (101) patients were included, in majority women with a mean age of 59 (+/- 13). Of these, 68 (67%) met the ACR classification criteria. The sensitivity of the criteria increased from 67% to 99% with the addition of nailfold capillary abnormalities identified using a dermatoscope and visible telangiectasias. CONCLUSIONS: The SSc research community would benefit from having better classification criteria to identify patients with limited SSc. The current classification criteria for SSc may be significantly improved by the inclusion of easily identified clinical variables including nailfold capillary abnormalities using a dermatoscope.     

急性颅脑损伤患者心电图异常情况分析

目的分析急性颅脑损伤患者心电图异常的情况。 方法选择2015年2月至2017年4月于皖南医学院弋矶山医院就诊的118例急性颅脑损伤患者为研究对象。所有患者均于治疗前后接受心电图检查,并针对心电图检查结果进行具体分析。 结果经心电图检查后,118例患者中存在心电图异常的达到97例(82.20%),类似急性心肌梗死29例(24.58%);心电图异常主要表现为ST－T改变、心律失常、病理性Q波、QRS波振幅增高等;治疗后有82例(84.54%)患者心电图明显改善,差异有统计学意义(P<0.05)。 结论急性颅脑损伤患者多伴有不同程度的心电图异常改变,临床需进行联合诊断,并加强心电图连续监测,提高诊断准确率,利于临床治疗及预后评估。     

Successful treatment of massive pulmonary embolism by combined mechanical and thrombolytic therapy

In two patients with massive pulmonary embolism and cardiogenic shock requiring mechanical ventilation and prolonged external cardiac massage, occluded pulmonary arteries were recanalized by primary mechanical fragmentation of thrombi using a percutaneously inserted catheter followed by fibrinolytic therapy. The hemodynamic and respiratory parameters rapidly and greatly improved. Pulmonary angiography before discharge revealed normal results in both patients. No central neurological abnormalities were detected. It is concluded that patients with cardiogenic shock due to massive pulmonary embolism may benefit from immediate mechanical thrombus fragmentation followed by fibrinolysis when thrombolysis or surgical embolectomy are strictly contraindicated or not available.