Changing paradigm: atherosclerosis versus ischaemia.
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Coronary Angiography↗
Biomedical subjects
J J Bax
Publications and source records attributed to J J Bax.
Feasibility of trans-endocardial cell transplantation in chronic ischaemia.
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Aged↗
Myocardial damage in high-risk patients undergoing elective endovascular or open infrarenal abdominal aortic aneurysm repair.
OBJECTIVE: Dobutamine stress echocardiography (DSE) provides an objective assessment of the presence and extent of coronary artery disease. Therefore we compared cardiac outcome in patients at high-cardiac risk undergoing open or endovascular repair of infrarenal AAA using preoperative DSE results. METHODS: Consecutive patients with >or=3 cardiac risk factors (age >70 years, angina pectoris, myocardial infarction, heart failure, stroke, renal failure, and diabetes mellitus) undergoing infrarenal AAA repair were reviewed retrospectively. All underwent cardiac stress testing using DSE. Postoperatively data on troponin release and ECG were collected on day 1, 3, 7, before discharge, and on day 30. The main outcome measures were perioperative myocardial damage and myocardial infarction or cardiovascular death. RESULTS: All 77 patients (39 endovascular, 38 open) had a history of cardiac disease. The number and type of cardiac risk factors were similar in both groups. Also DSE results were similar: 55 vs 56%, 24 vs 28%, and 21 vs 18% had no, limited, or extensive stress induced myocardial ischemia respectively. The incidence of perioperative myocardial damage (47% vs 13%, p=0.001) and the combination of myocardial infarction or cardiovascular death (13% vs 0%, p=0.02) was significantly lower in patients receiving endovascular repair. CONCLUSION: In patients with similar high cardiac risk, endovascular repair of infrarenal aortic aneurysms is associated with a reduced incidence of perioperative myocardial damage.
Aged↗
Non-invasive anatomical and functional imaging for the detection of coronary artery disease.
Coronary artery disease (CAD) is still an important cause of morbidity and mortality in the Western world. The gold standard for assessing significant coronary artery stenosis is invasive coronary angiography. Several disadvantages of the technique in combination with the fact that a substantial number of patients referred for conventional angiography appear free from significant stenosis have led to the pursuit of non-invasive imaging modalities for the diagnosis of CAD. The traditional modalities for this purpose are gated single-photon emission computed tomography, position emission tomography, (contrast) stress echocardiography and cardiac magnetic resonance (CMR), and these techniques can be characterized as functional imaging techniques as they detect ischaemia. Although the presence of a flow-limiting stenosis can be adequately ruled out with these techniques, atherosclerosis cannot be visualized with functional techniques. For this purpose, non-invasive coronary angiography techniques (computed tomography and CMR) are currently under development. The purpose of this review is to provide the reader an overview of the currently used imaging modalities to detect CAD.
Coronary Artery Disease↗
[Diagnostic image (296). A woman with a cardiac murmur].
A 40-year-old woman presented with a diastolic cardiac murmur. Transthoracic echocardiography revealed a quadricuspid aortic valve with moderate regurgitation.
Adult↗
Increase of 1-year mortality after perioperative beta-blocker withdrawal in endovascular and vascular surgery patients.
OBJECTIVES: To assess the relation between beta-blocker use, underlying cardiac risk, and 1-year outcome in vascular surgery patients, including the effect of beta-blocker withdrawal. DESIGN: Prospective survey. MATERIALS: 711 consecutive peripheral vascular surgery patients from 11 hospitals in the Netherlands between May and December 2004. METHODS: Patients were evaluated for cardiac risk factors, beta-blocker use and 1-year mortality. Low and high risk was defined according to the Revised Cardiac Risk Index. Propensity scores for the likelihood of beta-blocker use were calculated and regression models were used to study the relation between beta-blocker use and mortality. RESULTS: 285 patients (40%) received beta-blockers throughout the perioperative period (continuous users). Only 52% of the 281 high risk patients received continuous beta-blocker therapy. Beta-blocker therapy was started in 29 and stopped in 21 patients, respectively. One-year mortality was 11%. After adjustment for potential confounders and the propensity of its use, continuous beta-blocker use remained significantly associated with a lower 1-year mortality compared to non-users (HR=0.4; 95%CI=0.2-0.7). In contrast, beta-blocker withdrawal was associated with an increased risk of 1-year mortality compared to non-users (HR=2.7; 95%CI=1.2-5.9). CONCLUSIONS: We demonstrated an under-use of beta-blockers in vascular surgery patients, even in high-risk patients. Perioperative beta-blocker use was independently associated with a lower risk of 1-year mortality compared to non-use, while perioperative withdrawal of beta-blocker therapy was associated with a higher 1-year mortality.
Adrenergic beta-Antagonists↗
Abdominal aortic aneurysm screening using non-imaging hand-held ultrasound volume scanner--a pilot study.
BACKGROUND: Screening for abdominal aortic aneurysms (AAA) is cost-effective and timely repair improves outcome. Using standard ultrasound (US) an AAA can be accurately diagnosed or ruled-out. However, this requires training and bulk equipment. AIM: To evaluate the diagnostic potential of a new hand-held ultrasound bladder volume indicator (BVI) in the setting of AAA screening. METHODS: In total, 94 patients (66 +/- 14 years, 67 men) referred for atherosclerotic disease were screened for the presence of AAA (diameter > 30 mm using US). All patients underwent both examinations, with US and BVI. Using the BVI, aortic volume was measured at 6 pre-defined points. Maximal diameters (US) and volumes (BVI) were used for analyses. RESULTS: In 54 (57%) patients an AAA was diagnosed using US. The aortic diameter by US correlated closely with aortic volume by BVI (r = 0.87, p < 0.0001). Using a cut-off value of > or = 50 ml for the presence of AAA by BVI, sensitivity, specificity, positive and negative predictive value of BVI in detection of AAA were 94%, 82%, 88% and 92%, respectively. The agreement between the two methods was 89%, kappa 0.78. CONCLUSION: The bladder volume indicator is a promising tool in screening patients for AAA.
Aged↗
Outcome after redo coronary artery bypass grafting in patients with ischaemic cardiomyopathy and viable myocardium.
BACKGROUND: Repeat coronary artery bypass grafting (redo-CABG) in patients with ischaemic cardiomyopathy is associated with high perioperative risk and worse long-term outcome compared with patients undergoing their first CABG. OBJECTIVE: To assess whether patients with viable myocardium undergoing redo-CABG have a better outcome. METHODS: 18 patients with ischaemic cardiomyopathy underwent redo-CABG and 34 underwent their first CABG; all had substantial viability (> or =25% of the left ventricle) on dobutamine stress echocardiography (DSE). Left ventricular ejection fraction (LVEF) and heart failure symptoms were assessed before and 9-12 months after revascularisation. Cardiac event rate was assessed during the follow-up period (median 4 years, 25-75th centile 2.8-4.9 years). RESULTS: The extent of viable myocardium on DSE was comparable in the two groups (11.3 (3.9) segments in patients who underwent redo-CABG v 12.8 (3.0) in patients who underwent their first CABG; p = NS). LVEF improved from 32% (9%) to 39% (12%); p = 0.01, in patients who underwent redo-CABG and from 30% (7%) to 36% (7%); p<0.01, in those who underwent their first CABG; New York Heart Association class improved from 2.5 (1.1) to 1.9 (0.8); p = 0.03, and from 2.7 (1.0) to 1.8 (0.70); p<0.01, respectively. In patients who underwent redo-CABG, the perioperative mortality was 0, post-surgery inotropic support was needed in 11% of the patients and mid-term (4-year) survival was 100%, with a total event rate of 28%. All these variables were not statistically different from patients who underwent their first CABG (p = 0.50, 0.90, 0.08 and 0.81, respectively). CONCLUSION: Patients with ischaemic cardiomyopathy and substantial viability undergoing redo-CABG benefit from revascularisation in terms of improvement in LVEF, heart failure symptoms, angina and mid-term prognosis.
Aged↗
Assessment of left ventricular volumes and ejection fraction with 16-slice multi-slice computed tomography; comparison with 2D-echocardiography.
BACKGROUND: In recent years, multi-slice computed tomography (MSCT) has emerged as a rapidly expanding modality for non-invasive assessment of coronary artery disease. Simultaneously, left ventricular (LV) function can be evaluated although this is not yet a routine component of an MSCT examination. Accordingly, the purpose of the present study was to validate assessment of LV function with MSCT using 2D-echocardiography in a large cohort of patients. METHODS: In 70 patients (57 male, 13 female), 16-slice MSCT was performed (Toshiba Aquilion 16, Japan) followed by retrospective analysis of global LV function. For these measurements, 2D-echocardiography served as the standard of reference. RESULTS: For LV volumes, excellent correlations for both end-diastolic volume (EDV) (r=0.97) and end-systolic volume (ESV) (r=0.98) were obtained by linear regression analysis. At Bland-Altman analysis, mean differences (+/-standard deviations) of -1.4 ml+/-11.3 ml and -3.0 ml+/-7.7 ml were observed between MSCT and 2D-echocardiography for LV EDV and LV ESV respectively. As a result, LV EF was slightly overestimated with MSCT (1.7%+/-4.9%, P<0.05). Correlation between the two techniques was excellent (r=0.91). CONCLUSION: In a large cohort of patients, an excellent correlation was observed between 16-slice MSCT and 2D-echocardiography in the evaluation of LV volumes and EF. The addition of LV function analysis to the anatomical MSCT data may potentially enhance the diagnostic and prognostic value of the technique.
Aged↗
[Intramyocardial injection of autologous bone-marrow stem cells in a 74-year-old man with untreatable angina pectoris and demonstrated myocardial ischaemia].
For a 74-year-old man with angina pectoris and demonstrated myocardial ischaemia, optimal medical treatment was insufficient. He was ineligible for coronary revascularization. To improve myocardial perfusion, autologous bone-marrow stem cells were injected into the ischaemic myocardium. During the months following the injection, the frequency of angina attacks decreased and myocardial perfusion and cardiac function improved.
Aged↗
The future of cardiovascular imaging and non-invasive diagnosis: a joint statement from the European Association of Echocardiography, the Working Groups on Cardiovascular Magnetic Resonance, Computers in Cardiology, and Nuclear Cardiology, of the European Society of Cardiology, the European Association of Nuclear Medicine, and the Association for European Paediatric Cardiology.
Advances in medical imaging now make it possible to investigate any patient with cardiovascular disease using multiple methods which vary widely in their technical requirements, benefits, limitations, and costs. The appropriate use of alternative tests requires their integration into joint clinical diagnostic services where experts in all methods collaborate. This statement summarises the principles that should guide developments in cardiovascular diagnostic services.
Biomedical Research↗
[Cardiovascular nuclear medicine 1976/'06: 30 years representation in clinical cardiology].
Over the past 30 years, cardiovascular nuclear medicine has become an important diagnostic tool in patients with known and suspected coronary artery disease. Myocardial perfusion scintigraphy is indicated in: patients with suspected coronary artery disease and an intermediate likelihood of disease to detect myocardial ischemia, patients with a sustained myocardial infarction to assess myocardial viability, patients following revascularization for risk stratification, and coronary patients to assess prognosis. Gated SPECT myocardial perfusion imaging offers the potential of assessing left ventricular function and myocardial perfusion simultaneously. Information on left ventricular function and volumes significantly improves the diagnostic accuracy of myocardial perfusion imaging. The gated SPECT technique is a valuable tool for risk stratification because it offers the potential of assessing left ventricular function and volumes, which are both important prognostic parameters.
Cardiovascular Diseases↗
Comprehensive cardiac assessment with multislice computed tomography: evaluation of left ventricular function and perfusion in addition to coronary anatomy in patients with previous myocardial infarction.
OBJECTIVE: To evaluate a comprehensive multislice computed tomography (MSCT) protocol in patients with previous infarction, including assessment of coronary artery stenoses, left ventricular (LV) function and perfusion. PATIENTS AND METHODS: 16-slice MSCT was performed in 21 patients with previous infarction; from the MSCT data, coronary artery stenoses, (regional and global) LV function and perfusion were assessed. Invasive coronary angiography and gated single-photon emission computed tomography (SPECT) served as the reference standards for coronary artery stenoses and LV function/perfusion, respectively. RESULTS: 236 of 241 (98%) coronary artery segments were interpretable on MSCT. The sensitivity and specificity for detection of stenoses were 91% and 97%. Pearson's correlation showed excellent agreement for assessment of LV ejection fraction between MSCT and SPECT (49 (13)% v 53 (12)%, respectively, r = 0.85). Agreement for assessment of regional wall motion was excellent (92%, kappa = 0.77). In 68 of 73 (93%) segments, MSCT correctly identified a perfusion defect as compared with SPECT, whereas the absence of perfusion defects was correctly detected in 277 of 284 (98%) segments. CONCLUSIONS: MSCT permits accurate, non-invasive assessment of coronary artery stenoses, LV function and perfusion in patients with previous infarction. All parameters can be assessed from a single dataset.
Coronary Angiography↗
Mitral regurgitation and left ventricular dyssynchrony: implications for treatment.
Cardiac resynchronisation therapy may provide an alternative treatment for mitral regurgitation in patients unsuitable for surgery.
Cardiac Pacing, Artificial↗
['Migraine and a hole in the heart': causal relationship between migraine and patent foramen ovale not established].
The relationship between patent foramen ovale (PFO) and migraine is controversial. A common genetic background seems possible, but there is no evidence for a causal relationship. Despite the lack of evidence, PFO closure is recommended in many countries as a remedy for migraine. At present, PFO closure for migraine should only be carried out under strictly controlled clinical trial conditions.
Genetic Predisposition to Disease↗
Uncontrolled acromegaly is associated with progressive mitral valvular regurgitation.
INTRODUCTION: Recent cross-sectional studies have documented an association between acromegaly and regurgitant valvular heart disease. The aim of this study was to evaluate the change in prevalence of valvular heart disease in relation to the clinical activity, because the natural history of valvular changes in acromegaly is unknown. PATIENTS AND METHODS: Valvular regurgitation was assessed in 37 acromegalic patients (18 patients with active disease, and 19 with controlled disease) by conventional two-dimensional and Doppler echocardiography before and after an interval of 1.9 years (range 1.5-3.0 years). RESULTS: At baseline, valvular regurgitation (mitral and aortic sites combined) was present in 46% of the patients and increased to 67% at follow-up (P=0.008). Mitral regurgitation increased significantly from 32% to 60% (P=0.002), but no change was noted for the aortic valve (27% vs. 31%, NS). In patients with active disease, valvular regurgitation increased significantly from 56% at baseline to 88% at follow-up (P=0.031) due to a significant increase of mitral regurgitation from 39% to 78% at follow-up (P=0.016). In contrast, no increase in valvular regurgitation was found in patients with controlled disease. CONCLUSION: The prevalence of mitral, but not aortic, valvular regurgitation increased in patients with active acromegaly during follow-up. Patients with acromegaly require adequate cardiac evaluation and follow-up to establish the extent and progression of valvular involvement.
Acromegaly↗
[Screening of asymptomatic individuals for coronary disease using CT-calcium measurement in the coronary arteries].
Coronary calcification is a specific marker for coronary atherosclerosis. It is therefore reasonable to assume that the risk ofcardiac events can be assessed by the quantification of the extent of coronary calcium. Until now, the predictive value of coronary calcium and its advantage over conventional risk factors has not been proven by any of the available prospective cohort studies. It is particularly likely that assessment of coronary atherosclerosis will help in the decision to initiate or discard a specific therapy in patients with an intermediate risk for cardiac events. Recently it has been suggested that the Framingham risk score (FRS) be replaced by a score corrected by assessing the amount of coronary calcium, which can be obtained by multislice spiral computed tomography (MSCT). To this end, the Commission Law Population Investigation has approved a study proposal to evaluate the effects of coronary-calcium screening in 4000 asymptomatic individuals with an intermediate likelihood of coronary artery disease. Based on the amount of calcium (calcium score > 100) obtained by MSCT, different treatment strategies will be initiated over a period of 5 years. Hard endpoints will be myocardial infarction, stroke and mortality due to cardiovascular disease.
Biomarkers↗
Statins are associated with a reduced infrarenal abdominal aortic aneurysm growth.
OBJECTIVE: To evaluate the effect of statins on aneurysm growth in a group of consecutive patients under surveillance for infrarenal aortic aneurysms (AAA). MATERIALS AND METHODS: All patients (59 statin users, 91 non-users) under surveillance between January 2002 and August 2005 with a follow-up for aneurysm growth of at least 12 months and a minimum of three diameter evaluations were retrospectively included in the analysis. Multiple regression analysis, weighted with the number of observations, was performed to test the influence of statins on AAA growth rate. RESULTS: During a median period of 3.1 (1.1-13.1) years the overall mean aneurysm growth rate was 2.95+/-2.8 mm/year. Statin users had a 1.16 mm/year lower AAA growth rate compared to non-users (95% CI 0.33-1.99 mm/year). Increased age was associated with a slower growth (-0.09 mm/year per year, p = 0.003). Female gender (+1.82 mm/year, p = 0.008) and aneurysm diameter (+0.06 mm/year per mm, p = 0.049) were associated with increased AAA growth. The use of non-steroidal anti-inflammatory drugs, chronic lung disease, or other cardiovascular risk factors were not independently associated with AAA growth. CONCLUSIONS: Statins appear to be associated with attenuation of AAA growth, irrespective of other known factors influencing aneurysm growth.
Aged↗