Prevalence of Ischemia on Myocardial Perfusion Scintigraphy of Pre- and Postmenopausal Women

Background

In postmenopausal women, the presence of risk factors for coronary artery disease (CAD) increases. However, the difference in prevalence of ischemia between pre- and postmenopausal women with multiple risk factors for CAD has not been well established.

Objectives

To compare the prevalence of ischemia on Tc^99m-sestamibi myocardial perfusion scintigraphy (MPS) in pre-and postmenopausal women, and to evaluate whether menopause can be considered an independent risk predictor of ischemia in women with multiple risk factors for CAD.

Methods

This study retrospectively assessed 500 MPS of pre- and postmenopausal women with multiple risk factors for CAD. Statistical analysis was performed by using Fisher exact test and univariate and multivariate analysis, a p value ≤ 0.05 being considered significant.

Results

Postmenopausal women represented 55.9% of the sample; 83.3% were hypertensive; 28.9%, diabetic; 32.1%, smokers; 25%, obese; 61.2% had high cholesterol levels; and 34.3% had known CAD. Postmenopausal women were more often hypertensive, diabetic and dyslipidemic, and had lower functional capacity on exercise testing (p = < 0.005). The presence of ischemia on MPS did not significantly differ between the pre- and postmenopausal groups (p = 0.395). The only variable associated with ischemia on MPS was known CAD (p = 0.004).

Conclusion

The results suggest that, in women with multiple risk factors for CAD, menopause was not an independent predictor of ischemia on MPS. Those data support the idea that the investigation of ischemia via MPS in women with multiple risk factors for CAD should begin prior to menopause.     

Applicability of the Appropriate use Criteria for Myocardial Perfusion Scintigraphy

Background

Appropriateness Criteria for nuclear imaging exams were created by American College of Cardiology (ACC) e American Society of Nuclear Cardiology (ASNC) to allow the rational use of tests. Little is known whether these criteria have been followed in clinical practice.

Objective

To evaluate whether the medical applications of myocardial perfusion scintigraphy (MPS) in a private nuclear medicine service of a tertiary cardiology hospital were suitable to the criteria of indications proposed by the American medical societies in 2005 and 2009 and compare the level of indication of both.

Methods

We included records of 383 patients that underwent MPS, November 2008 up to February 2009. Demographic characteristics, patient''s origin, coronary risk factors, time of medical graduation and appropriateness criteria of medical applications were studied. The criteria were evaluated by two independent physicians and, in doubtful cases, defined by a medical expert in MPS.

Results

Mean age was 65 ± 12 years. Of the 367 records reviewed, 236 (64.3%) studies were performed in men and 75 (20.4%) were internee. To ACC 2005, 255 (69.5%) were considered appropriate indication and 13 (3.5%) inappropriate. With ACC 2009, 249 (67.8%) were considered appropriate indications and 13 (5.2%) inappropriate.

Conclusions

We observed a high rate of adequacy of medical indications for MPS. Compared to the 2005 version, 2009 did not change the results.     

Very Long-Term Prognostic Role of Admission BNP in Non-ST Segment Elevation Acute Coronary Syndrome

Background

BNP has been extensively evaluated to determine short- and intermediate-term prognosis in patients with acute coronary syndrome, but its role in long-term mortality is not known.

Objective

To determine the very long-term prognostic role of B-type natriuretic peptide (BNP) for all-cause mortality in patients with non-ST segment elevation acute coronary syndrome (NSTEACS).

Methods

A cohort of 224 consecutive patients with NSTEACS, prospectively seen in the Emergency Department, had BNP measured on arrival to establish prognosis, and underwent a median 9.34-year follow-up for all-cause mortality.

Results

Unstable angina was diagnosed in 52.2%, and non-ST segment elevation myocardial infarction, in 47.8%. Median admission BNP was 81.9 pg/mL (IQ range = 22.2; 225) and mortality rate was correlated with increasing BNP quartiles: 14.3; 16.1; 48.2; and 73.2% (p < 0.0001). ROC curve disclosed 100 pg/mL as the best BNP cut-off value for mortality prediction (area under the curve = 0.789, 95% CI= 0.723-0.854), being a strong predictor of late mortality: BNP < 100 = 17.3% vs. BNP ≥ 100 = 65.0%, RR = 3.76 (95% CI = 2.49-5.63, p < 0.001). On logistic regression analysis, age >72 years (OR = 3.79, 95% CI = 1.62-8.86, p = 0.002), BNP ≥ 100 pg/mL (OR = 6.24, 95% CI = 2.95-13.23, p < 0.001) and estimated glomerular filtration rate (OR = 0.98, 95% CI = 0.97-0.99, p = 0.049) were independent late-mortality predictors.

Conclusions

BNP measured at hospital admission in patients with NSTEACS is a strong, independent predictor of very long-term all-cause mortality. This study allows raising the hypothesis that BNP should be measured in all patients with NSTEACS at the index event for long-term risk stratification.     

Effects of intermittent and long-term glucose-insulin-potassium infusion in patients with systolic heart failure

BACKGROUND

Although single dose and short-term glucose-insulin-potassium (GIK) infusions are known to have positive cardiac effects, the effects of repeated and long-term GIK infusion on left ventricular (LV) systolic function and brain natriuretic peptide (BNP) levels are unknown.

OBJECTIVE

To investigate the effects of repeated and long-term GIK infusion on LV systolic function and BNP levels.

METHODS

Thirty-three patients diagnosed with ischemic cardiomyopathy were included in the study. Patients were divided into two groups: the GIK group (n=19) and the control group (n=14). GIK solutions (1000 mL 20% dextrose, 60 U insulin and 50 mmol/L KCl) were administered at 1 mL/kg/h for 24 h on the first, third and fifth days. The patients were examined by echocardiography at 24 h, one week and one month after the start of treatment. BNP levels were measured before and after GIK infusion.

RESULTS

In the GIK group, baseline ejection fraction (EF) was 29.2±10.3%. After one week, EF elevated to 40.8±10.8% (P=0.001). The EF after one month (37.1±10.9%) was less than the EF in the first week, but it was significantly higher than baseline in the GIK group (P=0.01). However, no significant changes in EF were observed after one week and one month in the control group (P=0.1 and P=0.2, respectively). BNP levels after GIK infusion was significantly lower than baseline level in the GIK group (P=0.01).

CONCLUSION

Intermittent and long-term GIK infusion has beneficial effects on LV systolic function in a short and intermediate amount of time. Decrease in BNP levels may indicate effective GIK treatment. Intermittent and long-term GIK infusion could be a promising treatment option in patients with systolic heart failure.     

Dipyridamole stress myocardial perfusion by computed tomography in patients with left bundle branch block

Background

Functional tests have limited accuracy for identifying myocardial ischemia in patients with left bundle branch block (LBBB).

Objective

To assess the diagnostic accuracy of dipyridamole-stress myocardial computed tomography perfusion (CTP) by 320-detector CT in patients with LBBB using invasive quantitative coronary angiography (QCA) (stenosis ≥ 70%) as reference; to investigate the advantage of adding CTP to coronary computed tomography angiography (CTA) and compare the results with those of single photon emission computed tomography (SPECT) myocardial perfusion scintigraphy.

Methods

Thirty patients with LBBB who had undergone SPECT for the investigation of coronary artery disease were referred for stress tomography. Independent examiners performed per-patient and per-coronary territory assessments. All patients gave written informed consent to participate in the study that was approved by the institution’s ethics committee.

Results

The patients’ mean age was 62 ± 10 years. The mean dose of radiation for the tomography protocol was 9.3 ± 4.6 mSv. With regard to CTP, the per-patient values for sensitivity, specificity, positive and negative predictive values, and accuracy were 86%, 81%, 80%, 87%, and 83%, respectively (p = 0.001). The per-territory values were 63%, 86%, 65%, 84%, and 79%, respectively (p < 0.001). In both analyses, the addition of CTP to CTA achieved higher diagnostic accuracy for detecting myocardial ischemia than SPECT (p < 0.001).

Conclusion

The use of the stress tomography protocol is feasible and has good diagnostic accuracy for assessing myocardial ischemia in patients with LBBB.     

Assessment of Myocardial Ischemia in Obese Individuals Undergoing Physical Stress Echocardiography (PSE)

Background

Physical stress echocardiography is an established methodology for diagnosis and risk stratification of coronary artery disease in patients with physical capacity. In obese (body mass index ≥ 30 kg/m²) the usefulness of pharmacological stress echocardiography has been demonstrated; however, has not been reported the use of physical stress echocardiography in this growing population group.

Objective

To assess the frequency of myocardial ischemia in obese and non-obese patients undergoing physical stress echocardiography and compare their clinical and echocardiographic differences.

Methods

4,050 patients who underwent treadmill physical stress echocardiography were studied according to the Bruce protocol, divided into two groups: obese (n = 945; 23.3%) and non-obese (n = 3,105; 76.6%).

Results

There was no difference regarding gender. Obese patients were younger (55.4 ± 10.9 vs. 57.56 ± 11.67) and had a higher frequency of hypertension (75.2% vs. 57, 2%; p < 0.0001), diabetis mellitus (15.2% vs. 10.9%; p < 0.0001), dyslipidemia (59.5% vs 51.9%; p < 0.0001), family history of coronary artery disease (59.3% vs. 55.1%; p = 0.023) and physical inactivity (71.4% vs. 52.9%, p < 0.0001). The obese had greater aortic dimensions (3.27 vs. 3.14 cm; p < 0.0001), left atrium (3.97 vs. 3.72 cm; p < 0.0001) and the relative thickness of the ventricule (33.7 vs. 32.8 cm; p < 0.0001). Regarding the presence of myocardial ischemia, there was no difference between groups (19% vs. 17.9%; p = 0.41). In adjusted logistic regression, the presence of myocardial ischemia remained independently associated with age, female gender, diabetes and hypertension.

Conclusion

Obesity did not behave as a predictor of the presence of ischemia and the physical stress echocardiography. The application of this assessment tool in large scale sample demonstrates the feasibility of the methodology, also in obese.     

Comparison of the effects of different magnesium administration times on infarct size

BACKGROUND:

The protection of high magnesium on infarct size remains controversial.

OBJECTIVE:

To examine the effects of magnesium administered before ischemia or early in reperfusion on infarct size in a rat model of global ischemia

METHODS:

Isolated rat hearts were submitted to 40 min of normothermic global ischemia and 2 h of reperfusion. After 20 min of stabilization, four protocols were performed: ischemic control (IC) hearts; 15 mM of magnesium chloride administered 15 min before ischemia (MgI); 15 mM of magnesium chloride administered during the first 15 min of reperfusion (MgR); or 15 mM magnesium plus 5 mM calcium (Mg+Ca) before ischemia. Infarct size was measured by triphenyltetrazolium staining. Contractile function was assessed by left ventricular developed pressure and the maximal velocity of rise of left ventricular presssure.

RESULTS:

The infarct size in IC hearts was 44±5%. In MgI and MgR hearts, the infarct diminished to 4.5±1.5% and 18±4%, respectively. In Mg+Ca hearts, the protection was also obtained (19±3%). Myocardial function also improved significantly by magnesium treatment. At the end of reperfusion, left ventricular developed pressure and maximal velocity of rise of left ventricular pressure values were 23±6% and 22±3% in MgI; and 10±3% and 9±2.6% in MgR versus 2±0.7% and 2.3±0.8% in IC hearts, respectively.

CONCLUSION:

The treatment with magnesium either before ischemia or early in reperfusion has an infarct size limiting effect in a model of global ischemia. This protective effect is partially due to its calcium antagonistic action.     

Effects of levosimendan versus dobutamine on left atrial function in decompensated heart failure

BACKGROUND:

Although the effects of levosimendan on the left ventricle (LV) have been studied, its effect on left atrial (LA) function is poorly understood, despite its key role in optimizing LV function.

OBJECTIVE:

To compare the effects of levosimendan and dobutamine on LA and LV function in patients with decompensated heart failure (DHF).

METHODS:

Seventy-four patients (mean [± SD] age 64±10 years) with DHF and an LV ejection fraction of 35% or lower were randomly assigned to receive levosimendan (n=37) or dobutamine (n=37). LA active emptying fraction, LA passive emptying fraction (PEF) and the ratio of mitral inflow early diastolic velocity to annulus velocity (E/e) were evaluated with pulsed wave and tissue Doppler imaging along with plasma B-type natriuretic peptide (BNP) level measurements before and after drug infusion.

RESULTS:

The ejection fraction was significantly increased in both groups. The levosimendan group had a greater decrease in BNP and a greater increase in active emptying fraction at 24 h compared with the dobutamine group. The PEF, E/e and deceleration time of the E wave were significantly improved in the levosimendan group, but not in the dobutamine group. Levosimendan-induced percentage change of BNP was significantly correlated with the percentage change of E/e and PEF (r=0.48 [P<0.005] and r=−0.38 [P<0.05], respectively).

CONCLUSIONS:

In patients with DHF, levosimendan and dobutamine both improve LV systolic function. However, levosimendan also improves LV diastolic function and LA performance in parallel with a greater improvement in neurohormonal activation compared with dobutamine.     

Acetylsalicylic acid use in patients with acute myocardial infarction and peptic ulcer bleeding

BACKGROUND:

Acetylsalicylic acid (ASA) is used in the treatment of acute myocardial infarction (AMI) but is also a risk factor for peptic ulcer disease (PUD) bleeding.

OBJECTIVE:

To determine the factors associated with continued ASA use in patients with AMI who develop PUD bleeding.

METHODS:

AMI patients who developed PUD bleeding during the same hospitalization at two tertiary care hospitals in Edmonton, Alberta, between January 1999 and December 2006, were evaluated retrospectively. Multivariate analysis was used to determine predictors of the primary outcome of continued ASA use during PUD bleeding.

RESULTS:

A total of 102 patients were analyzed. Thirty-eight patients (37%) were continued on ASA, while 64 (63%) had ASA discontinued during their hospitalization. On multivariate regression analysis, significant predictors of continued ASA use included low-risk ulcer stigmata on endoscopy (OR 3.7; 95% CI 1.4 to 10.2; P=0.01) and AMI requiring coronary intervention (OR 8.2; 95% CI 2.1 to 32.1; P=0.002). The mean (± SD) blood transfusion requirement was 3.9±3.6 units. The 30-day rebleeding and mortality rates were 14% and 14%, respectively.

CONCLUSIONS:

The continued use of ASA during AMI and PUD bleeding was variable. However, patients with low-risk ulcers and those who received coronary intervention were more likely to have ASA continued during PUD bleeding. Further studies evaluating the gastrointestinal risk of immediate ASA use in AMI with acute PUD bleeding are required.     

Relationship between Neutrophil-To-Lymphocyte Ratio and Electrocardiographic Ischemia Grade in STEMI

Background

Neutrophil-to-lymphocyte ratio (NLR) has been found to be a good predictor of future adverse cardiovascular outcomes in patients with ST-segment elevation myocardial infarction (STEMI). Changes in the QRS terminal portion have also been associated with adverse outcomes following STEMI.

Objective

To investigate the relationship between ECG ischemia grade and NLR in patients presenting with STEMI, in order to determine additional conventional risk factors for early risk stratification.

Methods

Patients with STEMI were investigated. The grade of ischemia was analyzed from the ECG performed on admission. White blood cells and subtypes were measured as part of the automated complete blood count (CBC) analysis. Patients were classified into two groups according to the ischemia grade presented on the admission ECG, as grade 2 ischemia (G2I) and grade 3 ischemia (G3I).

Results

Patients with G3I had significantly lower mean left ventricular ejection fraction than those in G2I (44.58 ± 7.23 vs. 48.44 ± 7.61, p = 0.001). As expected, in-hospital mortality rate increased proportionally with the increase in ischemia grade (p = 0.036). There were significant differences in percentage of lymphocytes (p = 0.010) and percentage of neutrophils (p = 0.004), and therefore, NLR was significantly different between G2I and G3I patients (p < 0.001). Multivariate logistic regression analysis revealed that only NLR was the independent variable with a significant effect on ECG ischemia grade (odds ratio = 1.254, 95% confidence interval 1.120–1.403, p < 0.001).

Conclusion

We found an association between G3I and elevated NLR in patients with STEMI. We believe that such an association might provide an additional prognostic value for risk stratification in patients with STEMI when combined with standardized risk scores.     

Left Ventricular Synchrony and Function in Pediatric Patients with Definitive Pacemakers

Background

Chronic right ventricular pacing (RVP) induces a dyssynchronous contraction pattern, producing interventricular and intraventricular asynchrony. Many studies have shown the relationship of RVP with impaired left ventricular (LV) form and function.

Objective

The aim of this study was to evaluate LV synchrony and function in pediatric patients receiving RVP in comparison with those receiving LV pacing (LVP).

Methods

LV systolic and diastolic function and synchrony were evaluated in 80 pediatric patients with either nonsurgical or postsurgical complete atrioventricular block, with pacing from either the RV endocardium (n = 40) or the LV epicardium (n = 40). Echocardiographic data obtained before pacemaker implantation, immediately after it, and at the end of a mean follow-up of 6.8 years were analyzed.

Results

LV diastolic function did not change in any patient during follow-up. LV systolic function was preserved in patients with LVP. However, in children with RVP the shortening fraction and ejection fraction decreased from medians of 41% ± 2.6% and 70% ± 6.9% before implantation to 32% ± 4.2% and 64% ± 2.5% (p < 0.0001 and p < 0.0001), respectively, at final follow-up. Interventricular mechanical delay was significantly larger with RVP (66 ± 13 ms) than with LVP (20 ± 8 ms). Similarly, the following parameters were significantly different in the two groups: LV mechanical delay (RVP: 69 ± 6 ms, LVP: 30 ± 11 ms, p < 0.0001); septal to lateral wall motion delay (RVP: 75 ± 19 ms, LVP: 42 ± 10 ms, p < 0.0001); and, septal to posterior wall motion delay (RVP: 127 ± 33 ms, LVP: 58 ± 17 ms, p < 0.0001).

Conclusion

Compared with RV endocardium, LV epicardium is an optimal site for pacing to preserve cardiac synchrony and function.     

Accuracy of the long-axis area-length method for the measurement of left ventricular volumes and ejection fraction using multidetector computed tomography

BACKGROUND:

Multidetector computed tomography (MDCT) is useful for assessing left ventricular (LV) volumes and function. Validation has mainly been carried out using Simpson’s method of summing up consecutive short-axis areas. Because the latter method is time-consuming, many users prefer using a quicker method, based on a single view or a pair of views.

OBJECTIVES:

To evaluate the accuracy of the long-axis area-length method (AL), which has not been validated for MDCT, using Simpson’s method as the gold standard, as well as right anterior oblique LV angiography as a clinical standard.

METHODS:

Twenty-three patients admitted with acute chest pain were clinically evaluated with electrocardiogram-gated MDCT and invasive LV angiography. MDCT-based end-diastolic, end-systolic and stroke volumes, and ejection fraction (EF) were calculated using Simpson’s method, biplane AL and single-plane AL. For LV angiography, EF was calculated using single-plane AL.

RESULTS:

A Bland-Altman analysis showed a close agreement between biplane AL and Simpson’s method for EF, with 1% underestimation, 95% CI of ±11% and a correlation of 0.89. For end-diastolic, end-systolic and stroke volumes, overestimations of 7 mL, 4 mL and 2 mL, and 95% CI of ±27 mL, ±15 mL and ±26 mL, respectively were found. Correlation coefficients were 0.95, 0.97 and 0.82, respectively. Comparisons with LV angiography were considerably weaker. The vertical long-axis AL method by MDCT correlated better with both LV angiography and Simpson’s method than the horizontal long-axis AL method.

CONCLUSIONS:

The biplane AL method gives results for EF, which correspond closely with the more cumbersome Simpson’s method, although volumes are slightly overestimated.     

3D Echo Pilot Study of Geometric Left Ventricular Changes after Acute Myocardial Infarction

Background

Left ventricular remodeling (LVR) after AMI characterizes a factor of poor prognosis. There is little information in the literature on the LVR analyzed with three-dimensional echocardiography (3D ECHO).

Objective

To analyze, with 3D ECHO, the geometric and volumetric modifications of the left ventricle (VE) six months after AMI in patients subjected to percutaneous primary treatment.

Methods

Prospective study with 3D ECHO of 21 subjects (16 men, 56 ± 12 years-old), affected by AMI with ST segment elevation. The morphological and functional analysis (LV) with 3D ECHO (volumes, LVEF, 3D sphericity index) was carried out up to seven days and six months after the AMI. The LVR was considered for increase > 15% of the end diastolic volume of the LV (LVEDV) six months after the AMI, compared to the LVEDV up to seven days from the event.

Results

Eight (38%) patients have presented LVR. Echocardiographic measurements (n = 21 patients): I- up to seven days after the AMI: 1- LVEDV: 92.3 ± 22.3 mL; 2- LVEF: 0.51 ± 0.01; 3- sphericity index: 0.38 ± 0.05; II- after six months: 1- LVEDV: 107.3 ± 26.8 mL; 2- LVEF: 0.59 ± 0.01; 3- sphericity index: 0.31 ± 0.05. Correlation coefficient (r) between the sphericity index up to seven days after the AMI and the LVEDV at six months (n = 8) after the AMI: r: 0.74, p = 0.0007; (r) between the sphericity index six months after the AMI and the LVEDV at six months after the AMI: r: 0.85, p < 0.0001.

Conclusion

In this series, LVR has been observed in 38% of the patients six months after the AMI. The three-dimensional sphericity index has been associated to the occurrence of LVR.     

New Exercise-Dipyridamole Combined Test for Nuclear Cardiology in Insufficient Effort: Appropriate Diagnostic Sensitivity Keeping Exercise Prognosis

Background

Myocardial perfusion scintigraphy (MPS) in patients not reaching 85% of the maximum predicted heart rate (MPHR) has reduced sensitivity.

Objectives

In an attempt to maintain diagnostic sensitivity without losing functional exercise data, a new exercise and dipyridamole combined protocol (EDCP) was developed. Our aim was to evaluate the feasibility and safety of this protocol and to compare its diagnostic sensitivity against standard exercise and dipyridamole protocols.

Methods

In patients not reaching a sufficient exercise (SE) test and with no contraindications, 0.56 mg/kg of dipyridamole were IV administered over 1 minute simultaneously with exercise, followed by 99mTc-MIBI injection.

Results

Of 155 patients, 41 had MPS with EDCP, 47 had a SE test (≥ 85% MPHR) and 67 underwent the dipyridamole alone test (DIP). They all underwent coronary angiography within 3 months. The three stress methods for diagnosis of coronary lesions had their sensitivity compared. For stenosis ≥ 70%, EDCP yielded 97% sensitivity, SE 90% and DIP 95% (p = 0.43). For lesions ≥ 50%, the sensitivities were 94%, 88% and 95%, respectively (p = 0.35). Side effects of EDCP were present in only 12% of the patients, significantly less than with DIP (p < 0.001).

Conclusions

The proposed combined protocol is a valid and safe method that yields adequate diagnostic sensitivity, keeping exercise prognostic information in patients unable to reach target heart rate, with fewer side effects than the DIP.     

Long-term outcome of infrapopliteal catheter-based intervention for critical limb ischemia

CONTEXT:

Percutaneous treatment of tibioperoneal occlusive disease is associated with decreased morbidity compared with bypass surgery. The long-term patency and limb salvage rates are not well documented.

AIMS:

To evaluate the long-term outcome of endoluminal interventions for tibioperoneal lesions.

METHODS:

A retrospective study was performed to determine the outcomes of patients undergoing infrapopliteal catheter-based intervention for critical limb ischemia. Collected data included demographics, comorbidities, clinical presentation, pre- and postintervention noninvasive vascular measurements (segmental pressure and waveforms, and ankle-brachial index [ABI]), type of intervention, limb loss rate, patient follow-up and need for surgical revascularization. Statistical analysis was performed with the two-tailed t test. P<0.05 was considered significant; results were reported as mean ± SD. Cox regression analysis and Kaplan-Meier limb survival analysis were performed to demonstrate freedom from amputation over time.

RESULTS:

Thirty-five patients underwent intervention from 2003 to 2008; technical success was achieved in 26 patients (75%). Arterial segmental pressure studies revealed a significant increase in ABI – preprocedure ABI was 0.62±0.24 versus a postintervention ABI of 0.81±0.29 (P=0.02). The limb salvage rate was 63% during the follow-up period. Limb salvage was better for patients who underwent isolated infrapopliteal intervention versus combined above and below the knee intervention.

CONCLUSION:

Percutaneous interventions for tibioperoneal occlusive disease offer an acceptable limb salvage rate and may be the preferred initial treatment for critical limb ischemia.     

Comparative study of galectin-3 and B-type natriuretic peptide as biomarkers for the diagnosis of heart failure

Background Heart failure （HF） is a common disease with complex pathophysiological causes. The diagnosis of HF commonly relies on comprehensive analyses of medical history and symptoms, and results from echocardiography and biochemical tests. Galectin-3, a rela-tively new biomarker in HF, was approved by the US Food and Drug Administration in 2010 as a marker in the stratification of risk for HF. We assessed galectin-3 as a biomarker for HF diagnosis in patients with preserved ejection fraction （pEF） and compared its performance with that of B-type natriuretic peptide （BNP）. Methods Thirty-five pEF patients with HF （HFpEF group） and 43 pEF patients without HF （control group） were enrolled. Plasma levels of galectin-3 and BNP in HFpEF and control subjects were determined. Sensitivity, specificity, pre dictive values, and accuracy of galectin-3 and BNP as markers for HF diagnosis were calculated and compared. Results Levels of galec- tin-3 and BNP were 23.09 ±6.97 ng/mL and 270.46 ± 330.41 pg/mL in the HFpEF group, and 16.74 ± 2.75 ng/mL and 59.94 ± 29.93 pg/mL in the control group, respectively. Differences in levels of galectin-3 and BNP between the two groups were significant （P 〈 0.01）. As a bio- marker for HF diagnosis in study subjects, galectin-3 showed sensitivity and specificity of 94.3% and 65.1%, respectively, at a cutoff value of 17.8 ug/mL. BNP showed sensitivity and specificity of 77.1% and 90.7%, respectively, at a cutoff value of 100 pg/mL. Galectin-3 was a significantly more sensitive （P 〈 0.05） but less specific （P 〈 0.01） biomarker compared with BNP. Differences in positive predictive value, negative predictive value, and accuracy between galectin-3 and BNP markers were not significant （P 〉 0.05）. Areas under the receiver operating characteristic curve （95% confidence interval） were 0.891 （0.808-0.974） and 0.896 （0.809-0.984） for galectin-3 and BNP, respec- tively, with no significant difference between the two values （P 〉 0.05）. Conclusions The level of galectin-3 is significantly elevated in patients with HF. Galectin-3 and BNP are useful biomarkers for the diagnosis of HF in patients with pEF.     

Clinical Coronary In-Stent Restenosis Follow-Up after Treatment and Analyses of Clinical Outcomes

Background

Clinical in-stent restenosis (CISR) is the main limitation of coronary angioplasty with stent implantation.

Objective

Describe the clinical and angiographic characteristics of CISR and the outcomes over a minimum follow-up of 12 months after its diagnosis and treatment.

Methods

We analyzed in 110 consecutive patients with CISR the clinical presentation, angiographic characteristics, treatment and combined primary outcomes (cardiovascular death, nonfatal acute myocardial infarction [AMI]) and combined secondary (unstable angina with hospitalization, target vessel revascularization and target lesion revascularization) during a minimal follow-up of one year.

Results

Mean age was 61 ± 11 years (68.2% males). Clinical presentations included acute coronary syndrome (ACS) in 62.7% and proliferative ISR in 34.5%. CISR was treated with implantation of drug-eluting stents (DES) in 36.4%, Bare Metal Stent (BMS) in 23.6%, myocardial revascularization surgery in 18.2%, balloon angioplasty in 15.5% and clinical treatment in 6.4%. During a median follow-up of 19.7 months, the primary outcome occurred in 18 patients, including 6 (5.5%) deaths and 13 (11.8%) AMI events. Twenty-four patients presented a secondary outcome. Predictors of the primary outcome were CISR with DES (HR = 4.36 [1.44–12.85]; p = 0.009) and clinical treatment for CISR (HR = 10.66 [2.53–44.87]; p = 0.001). Treatment of CISR with BMS (HR = 4.08 [1.75–9.48]; p = 0.001) and clinical therapy (HR = 6.29 [1.35–29.38]; p = 0.019) emerged as predictors of a secondary outcome.

Conclusion

Patients with CISR present in most cases with ACS and with a high frequency of adverse events during a medium-term follow-up.     

Value of QT dispersion in evaluating spatial dispersion of ventricular repolarization during acute myocardial ischemia

OBJECTIVES:

To study the value of epicardial QT interval dispersion in predicting ischemia-induced heterogeneity of ventricular repolarization.

ANIMALS AND METHODS:

Ischemia was produced by total occlusion of the obtuse branch of the circumflex coronary artery in seven open-chest sheep. A 64-channel electrocardiogram (ECG) was acquired from the epicardium before and after coronary artery occlusion. Wavelet transformation was used to determine the characteristic points of the epicardial ECGs, and to measure the QT interval and activation-recovery interval (ARI) and their dispersions.

RESULTS:

The average QT interval and ARI from the epicardial ECG were not changed by acute myocardial ischemia (P=0.07 and P=0.13, respectively). QT dispersion remained unchanged during ischemia (P=0.17), whereas ARI dispersion was significantly increased by acute ischemia (59.9±24.0 ms versus 126.3±32.1 ms, P<0.001).

CONCLUSIONS:

These findings indicate that epicardial QT dispersion is less sensitive than ARI dispersion in estimating repolarization heterogeneity induced by acute myocardial ischemia.     

Short and Long-Term Outcome of Stress-Induced Cardiomyopathy: What Can We Expect?

Background

Stress-induced/Takotsubo cardiomyopathy (TC) is an increasingly recognized diagnostic entity.

Objective

This study was aimed to assess the prevalence and clinical predictors of short and long-term outcome of patients (pts) diagnosed with TC.

Methods

We included all consecutive pts admitted in our department, from November 2006 to August 2011, who met the Mayo Clinic criteria for TC diagnosis.

Results

We evaluated 37 pts (35 women) with a mean age of 63 ±13 years. TC was precipitated by a stressful emotional event in the majority (57%) and chest pain was the most common symptom (89%). Twelve pts (32%) had ST-segment elevation and 15 pts (41%) had T-wave inversion on the electrocardiogram at admission. Severe left ventricular (LV) dysfunction was found in 16 pts (43%) and the mean troponin I level was 2.6±1.8 ng/mL. The in-hospital complication rate was 30%, with cardiogenic shock being the most common situation. Physical stress, severe LV systolic dysfunction and peak brain natriuretic peptide (BNP) were predictors of acute complications. On the other hand, we found no association between peak troponin I and electrocardiographic presentation. Thirty-five pts were followed for a mean time of 482 ± 512 days, without clinic recurrence.

Conclusion

In our cohort of pts, TC was associated with a high in-hospital complications rate. Physical stress, LV dysfunction and peak BNP could predict acute adverse outcomes.     

Cardiac work-up protocol for liver transplant candidates: Experience from a single liver transplant centre

BACKGROUND:

Ischemic cardiac events can cause significant morbidity and mortality postliver transplantation; however, no validated protocols to screen patients before transplantation exist.

OBJECTIVES:

To report the introduction of a noninvasive cardiac screening protocol used at the Liver Unit, University of Calgary (Calgary, Alberta); to determine whether the protocol decreases use of coronary angiograms; and to compare cardiac outcomes using the new protocol with an appropriately matched historical control group.

METHODS:

A new cardiac screening protocol was introduced into the program in 2005, which uses perfusion scintigraphy to screen high-risk cardiac patients, reserving coronary angiograms for abnormal results. Transplanted patients screened using this protocol were compared with matched historical controls. Electronic charts were reviewed for cardiac outcomes intra- and postliver transplantation.

RESULTS:

A total of 396 patients were screened between April 2005 and February 2009. Eighty-two were transplanted by February 2009 and included in the study. Eighty-one patients were successfully matched according to age, sex, cardiac history and presence of diabetes. Twelve of 82 (14.6%) and 11 of 81 (13.6%) in the study and control groups, respectively, underwent coronary angiograms (P=0.85). Coronary artery disease was found in six of 12 (50.0%) study patients and three of 11 (27.3%) control patients who underwent coronary angiography (P=0.27). The mean (± SD) length of the follow-up period was 1.87±0.91 years and 4.45±1.89 years in the study and control groups, respectively. One of 81 in the control group and zero of 82 in the study group experienced an acute coronary syndrome event postoperatively.

CONCLUSIONS:

Coronary events are infrequent in liver transplant recipients. The described protocol is an effective method of coronary artery disease screening before liver transplant but does not reduce the number of cardiac investigations performed.