QRS dispersion: an electrocardiographic index of systolic left ventricular dysfunction in patients with left bundle branch block

The presence of complete left bundle branch block (LBBB) in patients with congestive heart failure has been proposed to be a factor that negatively affects left ventricular (LV) systolic function. The aim of this study was to evaluate the relative predictive value of QRS dispersion (QRSD) and QRS duration (QRSd) in relation to systolic performance of the left ventricle. The ejection fraction of 130 consecutive patients with LBBB was evaluated by standard echocardiographic methods, whereas QRSd and QRSD were measured. It was demonstrated that QRSD in patients with complete LBBB is strongly related to LV contractility. We, therefore, suggest that this simple electrocardiographic index may serve as a useful screening test for detection of patients with LV systolic dysfunction.     

Efficacy of antithrombotic therapy in chronic heart failure: the HELAS study

BACKGROUND: It is not clear if long-term antithrombotic treatment has a beneficial effect on the incidence of thromboembolism in chronic heart failure (CHF). The HELAS study (Heart failure Long-term Antithrombotic Study) is a multicentre, randomised, double-blind, placebo-controlled trial to evaluate antithrombotic treatment in patients with CHF. METHODS: 197HF patients (EF <35%) were enrolled. Patients with Ischaemic Heart Disease were randomised to receive either aspirin 325mg or warfarin. Patients with Dilated Cardiomyopathy (DCM) were randomised to receive either warfarin or placebo. RESULTS: Analysis of the data from 312 patient years showed an incidence of 2.2 embolic events per 100 patient years, with no significant difference between groups. The incidence of myocardial infarction, hospitalisation, exacerbation of heart failure, death and haemorrhage were not different between the groups. No peripheral or pulmonary emboli were reported. Echocardiographic follow-up for 2years showed an overall increase in left ventricular ejection fraction from 28.2+/-6 to 30.3+/-7 p<0.05, which was most obvious in patients with DCM taking warfarin (EF 26.8+/-5.3 at baseline, 30.7+/-10 at 2 years, p<0.05). CONCLUSIONS: (1) Overall embolic events are rare in heart failure regardless of treatment. (2) Treatment does not seem to affect outcome.     

Communication between left main stem trunk and proximal segment of left anterior descending coronary artery rescues left ventricular ejection fraction of a patient with three-vessel disease

The well-known congenital anomalies of the left main stem refer mainly to its anomalous origin from the pulmonary artery or the right aortic sinus. We present a patient with a large communication between the left main stem trunk and the proximal segment of the left anterior descending coronary artery which preserves the left ventricular systolic performance in the setting of significant three-vessel disease.     

Association between passive cigarette smoking and the risk of developing acute coronary syndromes: the CARDIO2000 study

Although the effect of smoking on human health has been established as a major risk factor, the effect of passive smoking is controversial. The purpose of this study was to investigate the association between passive smoking and the risk of acute coronary syndromes (ACS) among nonsmokers. Eight hundred and forty-eight patients with the first event of ACS and 1078 cardiovascular disease-free matched controls completed a detailed questionnaire regarding their exposure to environmental smoke. Two hundred and ninety-seven (35%) of the patients and 259 (24%) of the controls were defined as nonsmokers and passive smokers, respectively. After controlling for several potential confounders, the results showed that nonsmokers exposed to cigarette smoke increased the risk of ACS by 51% (odds ratio = 1.51, 95% confidence interval 1.21–2.99) compared with nonsmokers not exposed to smoke. It was estimated that 34 coronary events per 134 subjects would occur as a result of passive smoking during their lifetime. Consequently, this study supports the hypothesis that passive smoking increases the risk of developing acute coronary syndromes. Given the high prevalence of cigarette smoking in many developing societies, the public health consequences of passive smoking with regard to coronary heart disease may be important. Received: November 19, 2001 / Accepted: January 25, 2002     

Plasma level changes of fibrinopeptide a after uncomplicated coronary angioplasty

Fibrinopeptide A (FPA) is a small polypeptide cleaved from fibrinogen by thrombin, has a short half-life, and is considered a sensitive biochemical marker of thrombin activity, fibrin generation, and ongoing thrombosis. Increased plasma levels of FPA have been reported in various procoagulable and thrombotic medical and cardiovascular disorders, including acute myocardial infarction, unstable angina, and sudden cardiac death. However, activation of thrombosis by the arterial injury incurred during coronary angioplasty has not been systematically examined with use of plasma FPA measurements. To detect and monitor activation of thrombosis by coronary angioplasty, plasma levels of FPA were obtained by venipuncture and measured by radioimmunoassay before, immediately after, 24 to 48 h later, and 1 and 3 months after uncomplicated coronary angioplasty. From December 1990 through June 1991, FPA was measured in 30 patients (28 men and 2 women, aged 54 ± 9 years) with coronary artery disease who were undergoing coronary angioplasty. The mean left ventricular ejection fraction was 55 ± 7%. The dilated vessel was the left anterior descending coronary artery in 20 patients (together with a second vessel in 2), the right coronary artery in 9, and the left circumflex in 1. The procedure was successful and free of major complications in all patients. Before angioplasty the FPA levels averaged 6.50 ± 1.18 ng/ml. Shortly after angioplasty they rose to 20.20 ± 7.91 ng/ml (p = 0.08) despite intravenous heparin. At 24 to 48 h and after heparin had been discontinued for at least 4 h, the mean FPA levels were significantly higher (32.33 ± 10.86 ng/ml) compared with baseline values (p = 0.025 ). At 1 month after the procedure, the FPA levels measured in 22 patients were lower but still elevated (20.25 ± 9.29 ng/ml), albeit nonsignificantly, compared with baseline values, and at 3 months they had fallen to baseline values (4.84 ± 2.20 ng/ml, n = 11). No patient developed restenosis during the study period of 1 to 3 months, during which all patients were receiving aspirin. We conclude that, as reflected by increased FPA levels, angioplasty, most likely due to arterial injury incurred, activates thrombin and generates ongoing coronary thrombosis, which is not suppressed by heparin or aspirin and appears to extend at least through the first month after the procedure.     

Impaired clearance of apoptotic cells leads to HMGB1 release in the bone marrow of patients with myelodysplastic syndromes and induces TLR4-mediated cytokine production

Excessive pro-inflammatory cytokine production in the bone marrow has been associated with the pathogenesis of myelodysplastic syndromes. We herein investigated the involvement of toll-like receptors and their endogenous ligands in the induction/maintenance of the inflammatory process in the marrow of patients with myelodysplastic syndromes. We evaluated the expression of toll-like receptors in marrow monocytes of patients (n=27) and healthy controls (n=25) by flow-cytometry and also assessed the activation of the respective signaling using a real-time polymerase chain reaction-based array. We measured the high mobility group box-1 protein, a toll-like receptor-4 ligand, in marrow plasma and long-term bone marrow culture supernatants by an enzyme-linked immunosorbent assay and we performed cross-over experiments using marrow plasma from patients and controls in the presence/absence of a toll-like receptor-4 inhibitor to evaluate the pro-inflammatory cytokine production by chemiluminescence. We assessed the apoptotic cell clearance capacity of patients’ macrophages using a fluorescence microscopy-based assay. We found over-expression of toll-like receptor-4 in patients’ marrow monocytes compared to that in controls; this over-expression was associated with up-modulation of 53 genes related to the respective signaling. Incubation of patients’ monocytes with autologous, but not with normal, marrow plasma resulted in over-production of pro-inflammatory cytokines, an effect that was abrogated by the toll-like receptor-4 inhibitor suggesting that the pro-inflammatory cytokine production in myelodysplastic syndromes is largely mediated through toll-like receptor-4. The levels of high mobility group box-1 protein were increased in patients’ marrow plasma and culture supernatants compared to the levels in controls. Patients’ macrophages displayed an impaired capacity to engulf apoptotic cells and this defect was associated with excessive release of high mobility group box-1 protein by dying cells. A primary apoptotic cell clearance defect of marrow macrophages in myelodysplastic syndromes may contribute to the induction/maintenance of the inflammatory process through aberrant release of molecules inducing toll-like receptor-4 such as high mobility group box-1 protein.     

Health status and health care use of Massachusetts women reporting partner abuse

BACKGROUND: Studies indicate that women abused by their intimate partners are at increased risk for a number of health problems and have increased rates of health care utilization. However, these findings are based mainly on studies using clinic or health plan populations. In this study, we examined the association between intimate partner abuse (IPA) and health concerns and health care utilization in a population-based sample of adult women. METHODS: We analyzed data on 2043 women aged 18 to 59 who participated in the 1998 Massachusetts Behavioral Risk Factor Surveillance System (BRFSS), a population-based health survey that included questions on IPA. IPA was defined as experiencing physical violence by, fear of, or control by an intimate partner. Consequences of IPA and self-rated health status and health care utilization of women experiencing IPA were examined. RESULTS: A total of 6.3% of Massachusetts women aged 18 to 59 reported IPA during the past year. Women experiencing IPA were more likely than other women to report depression, anxiety, sleep problems, suicidal ideation, disabilities, smoking, unwanted pregnancy, HIV testing, and condom use. Women experiencing IPA were less likely to have health insurance, but received routine health care at similar rates as other women. CONCLUSIONS: These results indicate that women in the general population experiencing IPA are at increased risk for several serious emotional and physical health concerns. Most of these women are in routine contact with health care providers. These findings also suggest that the BRFSS may provide a valuable mechanism for tracking state-based IPA prevalence rates over time.     

Increased cortisol concentrations in the cord blood of newborns whose mothers smoked during pregnancy

AIM: To investigate the effect of tobacco smoke on cord blood cortisol concentrations. METHODS: Cortisol concentrations were measured in cord blood from 211 term newborns of smoking and 211 term newborns of nonsmoking mothers; 48 and 36 newborns were delivered by cesarean section, respectively. In 16 cases, in addition to cord blood, maternal venous blood was obtained at delivery. RESULTS: The median cord blood cortisol concentration in neonates of the smoking and the nonsmoking mothers was 23 and 13 microg/dL, respectively (P<0.0001). Cortisol concentrations were greater in the newborns whose mothers smoked, when compared to corresponding controls, whether they were delivered vaginally or by cesarean section. In the newborns delivered by cesarean section, there was a positive correlation between number of cigarettes smoked/day and cortisol concentrations, as well as a negative correlation between cortisol concentrations and neonatal length. There was no significant correlation between cortisol concentrations and birth weight or head circumference. Cortisol concentrations in the cord blood of neonates whose mothers were smokers and nonsmokers were by 29% and 45% lower from those measured in their mothers, respectively. CONCLUSIONS: Although a causal relationship between maternal smoking and high cortisol concentrations in cord blood was not established, the findings are in accordance with previous reports indicating elevated stress-hormones in newborns whose mothers smoked during pregnancy.     

Relevance of the restoration of humeral length and retroversion in hemiarthroplasty for humeral head fractures

Sixteen patients, with a fracture of the upper humerus treated with hemiarthroplasty, were followed-up for 45.7 +/- 15.1 (20-72) months after surgery. The results were assessed using the Constant-Murley scale. The mean score was 75.8 +/- 15.7 (54-96) points out of a possible maximum of 100. At the time of their last follow-up they underwent CT of the fractured and contralateral humerus. Humeral length and retroversion were measured and evaluated. A very good final outcome (Constant score more than 71) was achieved in patients with a difference in retroversion less than 10 degrees and a difference in length less than 14 mm, between fractured and sound humerus. The mean difference in retroversion was 8.7 degrees and the mean difference in length was 0.65 cm, between fractured and sound humerus. We attribute the very good clinical outcome in our series to the quality of the anatomical reconstruction that was performed.