Raynaud's phenomenon

Raynaud's phenomenon (RP) is a major cause of pain and disability in patients with autoimmune connective tissue diseases (CTDs), particularly systemic sclerosis (SSc). The clinician must perform a comprehensive clinical assessment in patients with RP to differentiate between primary (idiopathic) and secondary RP, in particular (for rheumatologists), secondary to an autoimmune CTD, as both the prognosis and treatment may differ significantly. Key investigations are nailfold capillaroscopy and testing for autoantibodies (in particular, those associated with SSc). Patients with RP and either abnormal nailfold capillaroscopy or an SSc-specific antibody (and especially with both) have a high risk of transitioning to an autoimmune CTD. Both nailfold capillaroscopy and autoantibody specificity may help the clinician in predicting organ-based complications. The management of CTD-associated RP requires a multifaceted approach to treatment, including patient education and conservative (‘non-drug’) measures. Patients with CTD-associated RP often require pharmacological treatment, which in the first instance is usually a calcium channel blocker, although other agents can be used. There is an increasing tendency to use phosphodiesterase type 5 inhibitors early in the treatment of CTD-associated RP. Oral therapies are commonly associated with side effects (often due to systemic vasodilation) that may result in failure of dose escalation and/or permanent discontinuation. Intravenous prostanoid therapy and surgery (e.g., botulinum toxin injection and digital sympathectomy) can be considered in severe RP. Patients with CTD-associated RP can develop a number of ischaemic digital complications (primarily ulcers and critical ischaemia), which may be associated with significant tissue loss. Future research is required to increase the understanding of the pathogenesis and natural history of RP (to drive therapeutic advances), and to explore/develop drug therapies, including those that target the mechanisms mediating cold-induced vasoconstriction, and locally acting therapies free of systemic side effects.     

Raynaud's phenomenon

Raynaud's phenomenon (RP) is common, affecting approximately 5% of the population, and is important to the rheumatologist because it is often the presenting symptom of connective tissue disease, especially of systemic sclerosis (SSc)-spectrum disorders. RP therefore provides a window of opportunity for early diagnosis. When RP is associated with SSc it is particularly challenging to treat.This review begins with a discussion of some of the recent advances in our understanding of the pathogenesis of RP: it is through increased understanding of the complex pathophysiology of RP that we are most likely to develop new therapies. The following questions are then addressed (with three clinical scenarios demonstrating key principles of assessment and management):1. How can we predict underlying connective tissue disease in the patient presenting with Raynaud's?2. How can we measure severity of Raynaud's?3. What are the latest advances in treatment of connective tissue disease-related digital vasculopathy?     

Increased mean platelet volume in primary Raynaud's phenomenon

We hypothesized that mean platelet volume (MPV), a reliable marker of platelet activation, might be elevated in primary Raynaud's phenomenon (PRP) even if there was no thrombotic complication in our subjects. In this retrospective-cohort study, we examined the clinical value of MPV in 200 patients with PRP and 116 clinical controls, and measured MPV and platelet P-selectin (CD62P) in all study participants. We also evaluated the effect of age, gender, and disease duration on these platelet activation markers in PRP. MPV and CD62 positivities were significantly (p?<?0.001) elevated in patients with PRP compared with controls. These differences retained when patients and controls were analyzed according to age, gender, and the disease duration. In logistic regression analysis, MPV (OR: 15.8, 95% CI: 8.14–30.64, p?<?0.001) and CD62P (OR: 11.3, 95% CI: 4.85–26.12, p?<?0.001) were found to be independently associated with PRP. In conclusion, increased MPV is independently related to PRP, and its level was not influenced by age, gender, and the duration of PRP.     

Botulinum toxin in the management of primary and secondary Raynaud's phenomenon

Raynaud's phenomenon (RP) is common in rheumatic diseases. In the setting of systemic sclerosis (SSc), it can be complicated by digital ischemia that includes ulceration and gangrene. Systemic adverse effects may preclude the use of oral or topical vasodilators for the treatment of RP and its complications. In this article, we review effectiveness/efficacy of botulinum toxin injection in primary and secondary RP. We discuss botulinum toxin formulations, dosage, sites of administration, and adverse effects. The evidence for botulinum toxin in the treatment of primary and SSc-associated RP is promising. Consistency across patient populations, treatment options (botulinum serotype, dose, and injection site), and outcome measures will be essential for further research.     

急性心肌梗死介入术后心肌水平无再流的危险因素

目的:探讨急性心肌梗死(AMI)直接冠状动脉介入治疗(PCI)术后发生心肌水平无再流的危险因素.方法:58例因首次AMI接受直接PCI治疗的患者,在术后48 h接受心肌声学造影(MCE)检查,评价心肌水平血流灌注.比较发生心肌无再流和有再流的患者在临床和冠状动脉造影资料上的差异,采用Logistic多因素分析方法确定心肌水平无再流的危险因素.结果:17例(29.3%)判断为心肌水平无再流.与心肌水平有再流的患者比较,发生心肌水平无再流者前壁心肌梗死的比例显著较高,入院时血糖水平显著较高,肌酸激酶(CK)峰值显著较高,单支血管病变的比例较高,球囊扩张后罪犯血管血流达到TIMI 3级的比例较低,有梗死前心绞痛的比例较低,长期使用他汀类药物的比例也较低.多因素分析示缺乏梗死前心绞痛、入院时血糖水平高、CK峰值高是发生心肌水平无再流的独立危险因素.结论:缺乏梗死前心绞痛、入院时血糖高、CK峰值高的AMI患者是直接PCI术后发生心肌水平无再流的高危人群.     

Lower serum magnesium level after exposure to cold in women with primary Raynaud's phenomenon

Serum levels of magnesium (s-Mg), calcium (s-Ca), potassium (s-K) and sodium (s-Na) were measured in 80 women with primary Raynaud's phenomenon (RP) and in 24 age-matched female controls recruited from a population survey. The blood samples were taken after a 40-min standardized whole body cooling test. The mean s-Mg level in the group with RP was significantly lower than in the controls (0.81 +/- 0.05 vs. 0.86 +/- 0.07 mmol l-1, P less than 0.05). One year later, 66 members of the RP group and 22 members of the control group were investigated further, but without any exposure to cold. No differences in mean s-Mg values were found between the groups. The mean s-Mg level was significantly higher in the blood samples taken later without cold exposure than at the initial examinations after exposure to cold in the RP group, but not in the controls. The s-Mg level was lower after exposure to cold in 82% of the women with RP, compared to 45% of the controls (P less than 0.001). No differences in the other electrolytes were found. It is concluded that exposure to cold under standardized conditions may decrease the s-Mg level in women with primary RP. Further studies of the role of magnesium in patients with RP are required.     

Paroxysmal Dysarthria and Raynaud's Phenomenon in the Tongue

Abstract Three patients suffering from systemic scleroderma and Raynaud's phenomenon in the digits as well as the tongue are reported. Following exposure to cold, a vasospasm was observed in the digits and the tongue accompanied by severe dysarthria. These striking oral symptoms had been overlooked for years in the medical ward. It is recommended to question all patients with Raynaud's phenomenon about visceral manifestations during the digital attacks.     

Paroxysmal Dysarthria and Raynaud's Phenomenon in the Tongue

ABSTRACT Three patients suffering from systemic scleroderma and Raynaud's phenomenon in the digits as well as the tongue are reported. Following exposure to cold, a vasospasm was observed in the digits and the tongue accompanied by severe dysarthria. These striking oral symptoms had been overlooked for years in the medical ward. It is recommended to question all patients with Raynaud's phenomenon about visceral manifestations during the digital attacks.     

Treatment of slow/no-reflow phenomenon with intracoronary nitroprusside injection in primary coronary intervention for acute myocardial infarction.

Slow/no-reflow phenomenon is a serious problem complicating primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) and is associated with a poor prognosis. From January 2002 to November 2002, 11 of the 70 consecutive patients with ST elevation AMI who were subjected to primary PCI using balloon angioplasty and/or stenting developed slow/no-reflow phenomenon (TIMI 1 flow in 2, TIMI 2 in 8, and TIMI 2.5 in 1). They were 10 men and 1 woman, aged 64 +/- 11 years (range, 46-81). The culprit vessels were six in the left anterior descending coronary artery, three in the right coronary artery, one in the left circumflex coronary artery, and one in saphenous vein graft. Multiple bolus doses (100 microg) of nitroprusside were injected into the index artery through the guiding catheter using a 3 ml syringe until the TIMI flow grade improved by at least one grade or the systolic pressure decline below 80 mm Hg (one patient). The total drug dose varied from 100 to 700 microg. Following the drug treatment, angiographic TIMI flow grade improved by at least one grade in 9 (82%) of the 11 patients (P = 0.007). The TIMI frame counts significantly decreased from 36 +/- 17 frame counts to 16 +/- 11 frame counts (P = 0.012). All patients were discharged without major adverse cardiovascular events. Intracoronary bolus injection of nitroprusside using a 3 ml syringe appears to be a feasible, safe, and effective technique for the management of slow/no-reflow phenomenon complicating primary PCI.     

Beta-endorphins in acute myocardial infarction

The endogenous peptide B-endorphin (B-EP) is closely connected with different aspects of homeostasis, behavior, and in particular with the perception of pain. The purpose of this study was to investigate the correlation between: the level of plasma B-EP and the intensity of pain in acute myocardial infarction (AMI); and the B-EP and specific enzymes for AMI serum glutamic oxolo-acetic transferase, lactate dehydrogenase, and creatine phosphokinase and some stress hormones (cortisol, growth hormone). Twenty-six patients hospitalized in the CCU for acute MI were studied during the first 72 hours from the onset of symptoms. Seven normal subjects served as controls. Blood was taken for hormone and B-EP evaluation before treating the patients by opiates. Plasma B-EP levels were determined using the protocol of the Immunonuclear Corporation (Stillwater, MN). Statistical analysis of the results showed: Nonsignificant differences between B-EP levels of all MI patients and control group. Unaltered B-EP levels in patients with acute MI suffering from moderate pain. Significant differences in drop of B-EP in the group with most severe pain (p less than 0.025). A tendency toward decreased B-EP in patients suffering from more prolonged pain (greater than 6 hours). Significant negative correlation was shown between B-EP and chest pain intensity (0-4 graduation) (r = 0.8, p less than 0.01); lactate dehydrogenase (r = 0.7, p less than 0.01); serum glutamic oxolo-acetic transferase (r = 0.6, p less than 0.01); creatine phosphokinase (r = 0.6, p less than 0.05; plasma cortisol level (r = 0.5, p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)     

Relation of stent overexpansion to the angiographic no-reflow phenomenon in intravascular ultrasound-guided stent implantation for acute myocardial infarction

The angiographic no-reflow phenomenon is observed in some patients during stent implantation for acute myocardial infarction (AMI). We attempted to clarify the influence of stent overexpansion and plaque morphology on the angiographic no-reflow phenomenon in AMI patients who underwent intravascular ultrasound (IVUS)-guided stent implantation. We assessed the thrombolysis in myocardial infarction (TIMI) flow grade in the coronary angiographic findings, and quantitative and qualitative IVUS findings, in a total of 90 patients who underwent IVUS-guided stenting for AMI. The patients were divided into two groups according to the stent-to-artery ratio: overexpansion group (ratio 1.2) and non-overexpansion group (ratio <1.2). Angiographic no-reflow (defined as TIMI flow grade <3) in stent implantation was observed in 15 patients (17%). Angiographic no-reflow was more frequently observed in the overexpansion group than in the non-overexpansion group (32% vs 11%, P = 0.0312). Patients with no-reflow had more lipid pool-like images or fissure/dissection than those without. In the overexpansion group, a lipid pool-like image and fissure/dissection were more frequently observed in patients with no-reflow. The rate of target lesion revascularization (TLR) in the overexpansion group was significantly lower than that in the non-overexpansion group during the follow-up period (10% vs 18%, P = 0.0476), but the incidence of pump failure in the overexpansion group was higher than that in the non-overexpansion group during the hospital course (28% vs 14%, P = 0.0358). Stent overexpansion in AMI patients is related to a higher incidence of angiographic no-reflow, especially if the lesion has a lipid pool-like image or fissure/dissection, although there is a tendency for lower TLR.     

Clinical significance of intra-aortic balloon pumping on no-reflow phenomenon of primary percutaneous coronary intervention for acute myocardial infarction

Background Percutaneous coronary intervention(PCI) is used as a treatment for acute myocardial infarction(AMI),and one of its major complications is the angiographic no-reflow phenomenon(NR).Although intra-aortic balloon pumping(IABP) is sometimes used in such patients to increase the diastolic coronary blood flow,there is little available information regarding the effects of IABP on the angiographic no-reflow phenomenon.Method Twenty-two AMI patient with NR were performed primary PCI between January 2006 a...     

急诊经皮冠状动脉介入治疗冠状动脉造影无复流的相关因素

目的　探讨急诊经皮冠状动脉介入治疗 (percutaneouscoronaryinterventions,PCI)冠状动脉(冠脉 )造影无复流现象的相关因素。方法　自 1999年 1月至 2 0 0 2年 10月 ,回顾性分析 4 97例急诊PCI病人的临床和冠脉造影资料 ,冠脉造影无复流病人 5 8例 ,由其余的 4 39例急诊PCI冠脉前向血流TIMI 3级的病人中随机抽取 6 0例 ,为正常血流组。运用Logistic回归分析无复流的相关因素。结果　无复流的发生率为 12 6 %。单因素分析表明 :糖尿病、症状开始到再灌注的时间、梗死前心绞痛、Kil lip心功能分级、Q波计数、室壁运动积分差异有显著性。而多因素Logistic回归分析表明 :症状开始到再灌注的时间、梗死前心绞痛、Killip心功能分级、Q波计数是无复流的相关因素。结论　大面积心肌坏死、严重的心肌损害、心功能不全和症状开始到再灌注的时间长 ,可能会促使无复流的形成 ;梗死前心绞痛可能减少无复流的发生。而冠心病的危险因素与无复流没有相关性。     

Viral and bacterial infections in patients with acute myocardial infarction

The association of both viral and bacterial infections with acute myocardial infarction was investigated in a case-control study involving 40 consecutive patients with an acute myocardial infarction, 41 random controls and 30 patients with chronic coronary heart disease. All individuals were males aged 50 years or less. A rise in enterobacterial common antigen antibodies (15/40) and a recent influenza-like illness (11/40) were significantly more common among patients with acute myocardial infarction compared with the other groups. No differences were observed between the groups in the occurrence of antibodies against eight other bacterial antigens or 16 viruses.     

Chemotherapy-induced myocardial infarction in a young man with Hodgkin's disease.

A 32-year-old male with stage IIIA nodular sclerosing Hodgkin's disease and no cardiac risk factors presented with chest pain after receiving chemotherapy consisting of multiple drugs, including vinca alkaloids. He completed an uncomplicated anterior wall myocardial infarction. Coronary angiography documented the absence of significant coronary artery disease. Exercise stress testing with gated scan confirmed loss of anterior wall motion and a decreased left ventricular ejection fraction. Vascular toxicity, including, rarely, myocardial infarction, has been reported following antineoplastic regimens containing vinca alkaloids. Hypercoagulable states, cardiac invasion by tumor, and coronary artery spasm are possible etiologies. Of these, coronary artery spasm appears most likely. Management should include discontinuation of the offending drug and supportive care.     

Incidence of systemic thromboembolic lesions in acute myocardial infarction

In a series of 1277 cases of acute myocardial infarction, 30 episodes of systemic, noncerebral, thromboembolic lesions in 22 patients have been detected. Locations most frequently involved were the extremities (60%), kidneys (16.6%), spleen (13.3%), and mesentery (10%). The incidence of thromboembolism has been higher in patients over the age of 60. In the great majority of cases, the myocardial infarction has been anterolateral, often with a superimposed pump failure. Mortality has been very high (54.5%), perhaps in relation to the advanced age of the patients and to the extension of the infarction. Embolism at the extremities has been well treated with Fogarty's catheter. Among patients whose postmortem examination has been performed a high incidence of ventricular aneurysm (3 of 7) and mural thrombosis (5 of 7) has resulted. In the cases of ventricular aneurysm, episodes of atrial fibrillation have always occurred.     

Probable triggers of onset of acute myocardial infarction

Three cases of acute myocardial infarction are presented in which a probable triggering mechanism can be identified. The presence of triggering physical and mental stresses is consistent with recent documentation of a morning increase in frequency of acute myocardial infarction. This documentation suggests that the onset of acute myocardial infarction is not a random event. Recent advances in knowledge of the pathophysiology of acute myocardial infarction provide a background to the understanding of the probable triggering mechanism in these three cases. Further prospective study of patients with acute myocardial infarction in whom detailed information is collected sufficient to identify triggering activities may provide important insight into the pathophysiology of myocardial infarction and improved strategies for prevention.     

Ecstasy induced acute myocardial infarction

A 23 year old man presented with a clinical history and ECG compatible with acute myocardial infarction, having taken a single tablet of ecstasy (3,4-methylenedioxymetamphetamine) 18 hours previously. He was treated with aspirin and thrombolytic therapy; however, cardiac catheterisation showed angiographically normal coronary arteries and left ventricular function. Sympathomimetic drugs are freely available and widely abused in Britain, but there is little evidence of the mechanisms or management of cardiac complications. In such cases the use of standard treatment for acute myocardial infarction is recommended with agents such as glyceryl trinitrate and phentolamine to reduce coronary artery spasm. Early coronary angiography may help to determine the relative contribution of spasm, thrombus, and underlying atherosclerotic disease.


Keywords: ecstasy; 3,4-methylenedioxymetamphetamine; acute myocardial infarction     

老年急诊经皮冠状动脉介入术后无复流的危险因素分析

【】目的：探讨老年急性心肌梗死患者急诊经皮冠状动脉介入(PCI)术后出现无复流的相关危险因素。方法：302例行急诊PCI术的老年急性心肌梗死患者根据PCI术后TIMI血流分级分为无复流组和正常血流组,比较两组患者临床基线资料,造影结果及手术相关资料的差异,应用logistic逐步回归分析老年急诊PCI术后出现无复流的影响因素。结果：老年急诊PCI术后无复流发生率为24.8%(75/302),两组患者间的症状至PCI时间,既往糖尿病人数,术前心功能Killip分级,术前收缩压,术前TIMI血流≤1级人数,病变长度,球囊扩张次数,高血栓负荷人数比较差异有统计学意义(P<0.05)。logistic多元逐步回归分析显示：症状至PCI时间>6h(OR=2.119,P=0.018),高血栓负荷(OR=1.941,P=0.022),术前TIMI血流≤1级(OR=1.718,P=0.009),球囊扩张次数(OR=1.071,P=0.015)是老年急诊PCI术后发生无复流的独立危险因素。结论：可根据老年急性心肌梗死患者临床、造影及手术时的情况来预测急诊PCI术后是否发生无复流现象。