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PubMed1982

Recurrent primary coronary artery dissecting aneurysm (hematoma).

A 40-year-old man with recurrent spontaneous (non-iatrogenic) primary coronary artery dissecting aneurysm (hematoma) apparently survived long enough to permit spontaneous healing of the first coronary arterial lesion, as well as the myocardial infarct that accompanied it. Death was due to a recent myocardial infarct, located at a different site than the first one, and caused by a recent coronary artery dissection, involving a different coronary artery. The nature of the coronary artery disease was not identified until the time of necropsy. It was not related to coronary atherosclerosis, or demonstrable systemic vascular disease. Spontaneous primary coronary artery dissecting aneurysm is a rare condition. Survival, with complete healing, without the aid of surgical therapeutic intervention, has not yet been reported. The finding of a healed myocardial infarct, in the presence of grossly normal appearing coronary arteries, indicates a necessity for extremely careful histologic examination, including use of special staining procedures of the arteries supplying the areas of infarction.

Adult↗
PubMed1994

[Primary antiphospholipid syndrome and cardiac involvement. Description of a clinical case of right atrial thrombosis].

Antiphospholipid syndrome is a well-defined clinical and serological entity characterized by venous and arterial thrombosis, recurrent abortion and thrombocytopenia. The immunological feature shows the presence of anticardiolipin antibodies and lupus anticoagulant. Cardiac involvement includes pericardial effusion, myocardial dysfunction, valvular disease, coronary artery occlusion. The literature reports only a few cases of intracardiac thrombosis associated with primary antiphospholipid syndrome. Here we describe a case of a 54 year-old woman with thrombocytopenia and history of recurrent abortions. When she was 51 she presented a left deep iliac venous thrombosis, followed by recurrent pulmonary embolism; a caval filter was placed in the inferior vena cava. Transthoracic and transoesophageal echocardiogram showed 3 masses in the right atrium: the first one was connected with the atrial wall, hyperechogenic and extending to the right ventricle in diastole: th second was connected with the interatrial septum and less echogenic; the third was in connection with septum-tricuspid valve junction and it was floating in the atrium. The immunological feature showed the presence of lupus anticoagulant and antiphospholipid antibodies; the histological examination of the masses, surgically removed, proved they were thrombi coated by endothelial cells. The case reported is very uncommon and offers the opportunity to emphasize the difficulty of diagnostic differentiation of intracardiac masses using echocardiographic imaging: thrombotic masses may present similar characteristics of seat, morphology and echogenicity of other cardiac masses. For these reasons it can be useful to look for antiphospholipid antibodies and lupus anticoagulant in such clinical conditions.

Antiphospholipid Syndrome↗
PubMedDate not supplied

A case of primary hypoparathyroidism complicated by heart failure.

We report a case of hypocalcemic heart failure without underlying myocardial disease. Two-dimensional and Doppler echocardiography revealed dilatation and impaired contraction of the left ventricle, but did not show any valvular dysfunction. Cardiac catheterization showed a normal coronary artery, and cardiac muscle biopsy showed morphological changes in mitochondoria and endoplasmic reticulum, which may be due to metabolic changes. This patient was asymptomatic after the serum calcium concentration was normalized.

Aged↗
PubMed2005

Who is sensitive to extremes of temperature?: A case-only analysis.

BACKGROUND: Extremes of temperature are well known to be associated with excess mortality. Less is known about the characteristics of persons that put them at higher risk, particularly the role of medical conditions. METHODS: To investigate these effects, I used a case-only approach to analyze 160,062 deaths in Wayne County, Michigan, among persons who were 65 years of age or older, who were covered by Medicare, and who had a previous hospital admission for heart and lung disease. Using their unique Medicare identification number, I traced deaths through Medicare hospital admission records to identify primary and secondary diagnoses for all admissions before death. I investigated the role of diabetes, myocardial infarction, congestive heart failure, chronic obstructive pulmonary disease, and pneumonia as modifiers of the risk of dying on an extreme temperature day. Hot days were defined as those greater than the 99th percentile of all days and cold days as those less than the 1st percentile. I also examined the role of sex, age (85 years of age and older), and nonwhite race as modifiers. RESULTS: I found that patients with diabetes had a higher risk of dying on hot days than other subjects (odds ratio=1.17; 95% confidence interval=1.04-1.32). Persons with chronic obstructive pulmonary disease had elevated risks of dying on cold days (1.19; 1.07-1.33). Nonwhites had greater risks on both hot (1.22; 1.09-1.37) and cold (1.25; 1.12-1.40) days, and women had elevated risks on cold days (1.14; 1.02-1.26). The other conditions conveyed no higher risks than average. CONCLUSIONS: Sociodemographic characteristics and medical conditions can increase the likelihood of death associated with temperature extremes.

Aged↗
PubMed2005

Gender differences in the outcome of cardiac interventions.

I. The actual data base on the decision-making process of indication for revascularization reveals that angiographic severity of coronary artery disease (CAD) is the primary determinant of referral to coronary interventional procedures. Several recent studies demonstrated that after an acute myocardial infarction, women undergo cardiac catheterization to a lesser extent than men. Data of the MITI study and of the Cooperative Cardiovascular Project suggested that during acute treatment of myocardial infarction a somewhat less aggressive therapy is performed in women as compared to men. II. With respect to sex-related differences in the early and late outcome after elective PCI, the main problem is the small, limited amount of data due to the lack of randomized clinical studies including a larger number of women. The vast majority of data was obtained in patients with PTCA and stents. All the older studies and registers until 1993 revealed a three times higher periprocedural complication rate and in-hospital mortality in women. In recent studies such as BARI, after successful PCI women have an excellent long-term prognosis comparable or even better than in men. III.1. Several studies on the effect of interventional strategies in patients with unstable angina or non-ST elevation myocardial infarction NSTEMI) revealed superiority of an early invasive versus a more conservative, noninvasive approach. However, the data of the FRISC II and RITA-3 trials indicated that an early intervention strategy resulted in a beneficial effect only in men which was not seen in women. On the other hand, two studies (e.g., the TACTICS-TIMI- 18 study) showed an improved outcome of women with acute coronary syndrome after early invasive therapy. III.2. In numerous investigations, a higher early mortality after acute ST elevation myocardial infarction (STEMI) has been observed in women compared to men. Although placebo-controlled randomized trials of thrombolytic therapy have demonstrated a 25-30% reduction in early mortality, in-hospital survival has remained consistently lower for women than men after thrombolytic reperfusion. -- In our clinic, prospective studies on clinical events during the early phase (30 days) and during long-term follow-up for 4 years after direct (primary) PTCA for acute STEMI were performed in women. Data were obtained in 204 consecutive and unselected women; results in women were compared with those of 577 consecutive and unselected men who had undergone direct angiography/primary PTCA for acute STEMI in the same time span. PTCA of the infarct-related artery was equally successful in both sexes (women 95%, men 94%). In the group of patients with acute STEMI who had been treated with primary infarct PTCA, no difference of early (30 days) mortality was detected in women versus men. Total cumulative mortality during 4 years of follow-up was 12.5%, 14.5%, 18% and 23% in women, respectively, versus 9%, 10.5%, 12% and 15%, respectively, in men. The general trend for a higher postdischarge mortality in women became apparent after 3 years and reached significance after 4 years. After multivariate analysis, female gender was no independent risk factor of increased mortality. Thus, direct (primary) coronary angiography and PCI eliminate significant gender-specific differences in survival early after acute myocardial infarction. Long-term follow-up (4 years) also revealed no sex-related differences in mortality and cardiac morbidity after direct (primary) PCI for acute ST elevation myocardial infarction.

Angioplasty, Balloon, Coronary↗
PubMed2000

Aspirin for the primary prevention of stroke and other major vascular events: meta-analysis and hypotheses.

BACKGROUND: Aspirin therapy reduces stroke by about 25% for persons with atherosclerotic vascular disease, but the effect in those without clinically apparent vascular disease is distinctly different. OBJECTIVE: To define the effect of aspirin use on stroke and other major vascular events when given for primary prevention to persons without clinically recognized vascular disease. DATA SOURCES AND EXTRACTION: Systematic review of randomized clinical trials and large prospective observational cohort studies examining the relation between aspirin use and stroke in persons at low intrinsic risk. Studies were identified by a computerized search of the English-language literature. DATA SYNTHESIS: Five randomized trials of primary prevention included 52 251 participants randomized to aspirin doses ranging from 75 to 650 mg/d; the mean overall stroke rate was 0.3% per year during an average follow-up of 4.6 years. Meta-analysis revealed no significant effect on stroke (relative risk = 1.08; 95% confidence interval, 0.95-1.24) contrasting with a decrease in myocardial infarction (relative risk = 0.74; 95% confidence interval, 0.68-0.82). The lack of reduction of stroke by aspirin for primary prevention was incompatible with its protective effect against stroke in patients with manifest vascular disease (P = .001). Intracranial hemorrhage was increased by the regular use of aspirin (relative risk = 1.35; P = .03), similarly for both primary and secondary prevention. In 4 large observational studies, self-selected use of aspirin was consistently associated with higher rates of stroke. CONCLUSIONS: The effect of aspirin therapy on stroke differs between individuals based on the presence or absence of overt vascular disease, in contrast with the consistent reduction in myocardial infarction by aspirin therapy observed in all populations. We hypothesize that the effect of aspirin therapy on stroke for persons with major risk factors for vascular disease may be intermediate between a substantial decrease for those with manifest vascular disease and a possible small increase for healthy persons due to accentuated intracranial hemorrhage. When aspirin is given for primary prevention of vascular events, available data support using 75 to 81 mg/d.

Adult↗
PubMed1993

Antiplatelet therapy--Part II.

We summarize current information about aspirin and other antiplatelet drugs in patients with cardiac and vascular disease. For each indication, we briefly summarize the rationale for the use of antiplatelet therapy and describe the findings of relevant clinical trials. We propose recommendations for the use of these agents in clinical practice. In Part 2, we discuss the use of antiplatelet agents in coronary angioplasty, atrial fibrillation, artificial cardiac valves, stroke, and peripheral vascular disease. In Part 1, we reviewed the use of antiplatelet therapy for the primary and secondary prevention of myocardial infarction, in conjunction with coronary thrombolysis, in patients with unstable and chronic stable angina, and following coronary artery-saphenous vein bypass grafting.

Cardiovascular Diseases↗
PubMedDate not supplied

[Polycythemia vera, complicated by myocardial infarction].

In an autopsied female primary polycythemia was definitely diagnosed only after histological examination. A classical form of Vaquez-Osler disease was characterized by pronounced normo-, granulo- and megakaryocyte hyperplasia of the bone marrow, spleen and liver myelosis with an admixture of atypical megakaryocytes and splenomegaly. There was a complication in the form of two coronary arteries thrombosis. Lethal outcome resulted from myocardial infarction.

Aged↗
PubMed1998

[Clinical picture and therapy of hypertrophic cardiomyopathy].

Hypertrophic cardiomyopathy is defined as a primary, sometimes familial and genetically fixed myocardial hypertrophy. In the obstructive form of the disease (HOCM) a dynamic outflow tract obstruction of the left, occasionally also the right ventricle can be found. HOCM is the most frequent cause of stress-induced syncope or sudden cardiac death in younger patients. An individual estimation of prognosis is difficult although several risk factors have been identified. In addition to standard therapy of symptomatic patients (medical treatment with betablockers and calcium-antagonists of verapamil-type as well as surgical myotomy/myectomy) DDD-pacemaker implantation and percutaneous transluminal septal myocardial ablation (PTSMA) by alcohol-induced septal branch occlusion have been introduced. After PTSMA significant outflow tract gradient reduction can be achieved in > 90% of patients. Due to remodeling after circumscribed myocardial necrosis further gradient reduction has been observed during follow-up. Optimization of ablated septal area by echocardiographic monitoring resulted in reduction of the most important complication (trifascicular block with need of permanent pacemaker implantation) and improvement of acute and follow-up results. Long-term follow-up and comparison with established treatment options are necessary to evaluate the definitive importance of the promising new treatment.

Cardiomyopathy, Hypertrophic↗
PubMed1987

Report on the Lipid Research Clinic trials.

The Lipid Research Clinic Coronary Primary Prevention Trial was a randomized, double-blind, placebo-controlled intervention trial performed in 3806 hypercholesterolaemic (greater than 265 mg dl-1) but asymptomatic men aged 35-59 at entry. The bile acid sequestrant cholestyramine was used to achieve the cholesterol differential in the treatment group. Both groups received a modest low cholesterol-low fat diet. All subjects were followed for at least seven years (mean duration 7.4 years) during which time a mean fall of 8% and 12% in plasma total cholesterol and LDL cholesterol levels respectively relative to levels in placebo controls were achieved and maintained. The cholestyramine group experienced a 19% reduction in risk (P greater than 0.05) of the primary end point-definite coronary heart disease death and/or definite non-fatal myocardial infarction. In addition, the incidence rates for new positive exercise tests, angina, and coronary bypass surgery were all significantly reduced by 25%, 20% and 21%, respectively, in the cholestyramine group. In the treated group, risk reduction was related directly to reduction in total and LDL cholesterol. In a similar but considerably smaller double blind, placebo-controlled, secondary prevention trial where coronary artery lesion change as determined by serial coronary angiography was the end point (The NHLBI Type II Intervention Trial), cholestyramine treatment significantly delayed the progression of atherosclerotic lesions. Plaque progression related directly to both a fall in low density lipoprotein and a rise in high density lipoprotein.

Adult↗
PubMed1984

Alterations in regional myocardial metabolism, perfusion, and wall motion in Duchenne muscular dystrophy studied by radionuclide imaging.

Studies at necropsy have shown that the cardiomyopathy of Duchenne muscular dystrophy selects the posterobasal and contiguous lateral left ventricular (LV) walls as initial and primary sites of myocardial dystrophy in the absence of small-vessel coronary artery disease in these areas. The present investigation was designed chiefly to determine whether a myocardial metabolic abnormality could be identified in these same areas during a patient's life. Positron emission computed tomography was used to study regional LV metabolism with 18F 2-fluorodeoxyglucose, and metabolism and/or perfusion was studied with 13NH3. In addition, all subjects had the following performed: thallium-201 scans, technetium-99m multiple-gated equilibrium blood pool imaging, electrocardiograms, vectorcardiograms, and M mode and two-dimensional echocardiograms. 18F 2-fluorodeoxyglucose activity was selectively increased in the posterobasal and posterolateral walls of the left ventricle in 11 of 12 patients with technically adequate images, indicating accelerated regional exogenous glucose utilization. 13NH3 activity was selectively decreased in the same areas in 13 of 15 patients, indicating either a regional metabolic alteration in uptake and trapping, a reduction in regional blood flow, or both. These data identify a myocardial metabolic abnormality concentrated in specific segments of the LV free wall in living patients with Duchenne dystrophy.

Adolescent↗
PubMed2005

[The importance of microcirculation and tissue perfusion in hypertension].

The importance of abnormalities observed in the microcirculation of hypertensive subjects is being increasingly recognised. These microvascular changes may be central to the development of end-organ damage brought about by hypertension, including ischaemic heart disease. The primary function of the microcirculation is to supply oxygen and nutrients to myocardial tissue, and it also has an important role in regulating coronary blood flow. Some 70-90% of the overall peripheral resistance of the circulatory system arises at the level of the microcirculation. In hypertension, thickening of the microvascular walls occur, with narrowing of the lumen, so that eventually the vessel is functionally occluded. The result is a reduction in the number of arterioles or capillaries in a given vascular bed. Such changes have been seen in the structure and density of the microvasculature of heart muscle, the conjunctiva and retina, and in the kidneys. In hypertension a vicious circle occurs, with an increase in blood pressure producing a rise in resistance in the microcirculation, leading to further elevation of blood pressure. New techniques for exploring the coronary microcirculation have shown that microvascular damage results in reductions of coronary vasodilator reserve, an important predictor of clinical deterioration and death. With studies showing that impairment of microcirculation occurs early in patients with hypertension, there would seem to be a need for new therapeutic perspectives in hypertension, concentrating on preventing or reversing changes to the microvasculature of affected organs.

Blood Flow Velocity↗
PubMed1996

Sex differences in the features of coronary artery disease of patients undergoing coronary angiography.

OBJECTIVE: To examine sex differences in the features of coronary artery disease (CAD) of patients who have undergone coronary angiography. DESIGN: Retrospective study which reviewed clinical and angiographic results from eligible patients who underwent coronary angiography under one cardiologist during a consecutive period. SETTING: Tertiary referral women's health centre. PATIENTS: 515 patients (167 women, 348 men) who underwent coronary angiography for suspected CAD, excluding those with previously known primary valvular disease, valvular replacement, congenital heart disease, nonischemic cardiomyopathy, history of cocaine-induced myocardial ischemia or infarction, and those who had previously undergone coronary angiography, coronary artery bypass graft or percutaneous transluminal coronary angioplasty. MAIN RESULTS: Overall, females and males presented at similar ages and with similar prevalences of smoking, diabetes, hypertension, and family histories of premature CAD, albeit women were less likely than men to have a prior history of myocardial infarction. The observed age difference between females and males with coronary disease was less than expected (3.3 +/- 2.3 years, 95% confidence limits). At angiography, women were three times more likely than men to have normal coronary arteries. Yet, in patients found to have coronary disease, there was no sex difference in either the severity or the distribution of the disease. Women were twice as likely as men to have normal left ventricular function on catheterization. However, when all cases of normal angiograms were excluded, multivariate logistic regression analysis showed that, after controlling for other important confounding factors, females were as likely as males to have significant CAD and left ventricular dysfunction on angiography. CONCLUSIONS: Women can develop serious ischemic heart disease that is similar to that in men and at a relatively younger age than previously described. The vulnerability to ischemic heart disease in nonelderly women needs to be emphasized.

Aged↗
PubMed1995

A comparison of the costs of and quality of life after coronary angioplasty or coronary surgery for multivessel coronary artery disease. Results from the Emory Angioplasty Versus Surgery Trial (EAST).

BACKGROUND: The Emory Angioplasty Versus Surgery Trial (EAST) is a randomized trial that compares, by intention to treat, the clinical outcome and costs of percutaneous transluminal coronary angioplasty (PTCA) and coronary surgery for multivessel coronary artery disease. METHODS AND RESULTS: The primary end point was a composite of death, Q-wave myocardial infarction, and a large reversible thallium defect at 3 years. Multiple measures of quality of life also were made. Charges were assessed from the hospital UB-82 bills; professional charges were assessed from the Emory Clinic. Hospital charges were reduced to cost through step-down accounting methods. All costs and charges were deflated to 1987 dollars. Costs were assessed for the initial hospitalization and the cumulative costs of the initial hospitalization and additional revascularization procedures for up to 3 years. There was no difference in mortality or the primary end point. Mean initial hospital charges were $12,654 for the PTCA group and $20,214 for the surgery group (P < .0001). Professional charges were 4538 for PTCA and $9426 for surgery (P < .0001). Three-year hospital charges were $19,047 for PTCA and $21,174 for coronary surgery (P < .0001). Three-year professional charges were $6412 for PTCA and $9861 for surgery (P < .0001). Three-year total charges were $25,458 for PTCA and $31,033 for surgery (P < .0001). Total 3-year costs were $23,734 for PTCA and $25,310 for coronary surgery (P < .0001). There were more hospitalizations for angina and more antianginal medications used in the PTCA group, which would further narrow the differences in cost. CONCLUSIONS: There was no difference in the primary end point or its components at 3 years. Although the primary procedural costs of coronary surgery are more than for coronary angioplasty, this cost advantage is largely, although probably not completely, lost by 3 years because of more frequent additional procedures and other resource consumption after a first revascularization by PTCA.

Angioplasty, Balloon, Coronary↗
PubMed1985

Endomyocardial biopsy.

Endomyocardial biopsy is an accepted, useful invasive tool for the analysis of human endomyocardium at the cellular and subcellular levels. It is applicable in the evaluation of specific diseases including cardiac allograft rejection, myocarditis, anthracycline cardiotoxicity, and infiltrative cardiomyopathies. The procedure can be performed in a cardiac catheterization room on an outpatient basis. The technique is quite safe when performed by trained cardiologists. Left ventricular biopsies are also safe but require systemic heparinization to prevent thromboembolization. The clinical indications for performing an endomyocardial biopsy include routine followup and suspected rejection of cardiac allograft, suspected myocarditis, monitoring or diagnosis of suspected anthracycline cardiotoxicity, and suspected secondary cardiomyopathies. Left ventricular endomyocardial biopsy is indicated for diseases that predominantly involve the left side of the heart, including left heart irradiation, cardiac fibroelastosis in infants, endomyocardial fibrosis, and scleroderma heart disease, and when right ventricular biopsy is unsuccessful. Endomyocardial biopsy is increasingly being used for research in the areas of tissue biochemistry, primary and valvular cardiomyopathies, immunology, beta receptor enzymology, drug interactions, and myocardial fibrosis. Endomyocardial biopsy has not been shown to be clinically useful in the evaluation of primary, dilated, hypertrophic, or alcoholic cardiomyopathies. These disease processes all lack pathognomomic microscopic abnormalities, and subclassification has neither been successful nor therapeutically useful. In addition, this technique is limited in diagnosing any cardiac abnormality that is not diffuse, inasmuch as only a few samples of the endomyocardial layer are obtained for evaluation. Therefore, a negative biopsy result is not 100 percent specific in excluding certain diseases. A further limitation of this technique is the need for an experienced cardiac pathologist who is well versed in interpretation of biopsy specimens. Finally, there should be a sufficiently large case load to train and to maintain skilled practitioners so that the procedure can be performed with little risk. The role of endomyocardial biopsy will continue to expand as research continues to find more uses for the technique and as more clinicians become skilled in its use.

Antibiotics, Antineoplastic↗