Coronary Artery Disease

Coronary artery disease and its sequelae-ischemia, myocardial infarction, and heart failure-are leading causes of morbidity and mortality in man. Considerable effort has been devoted toward improving functional recovery and reducing the extent of infarction after ischemic episodes. As a step in this direction, it was found that the heart was significantly protected against ischemia -reperfusion injury if it was first preconditioned by brief ischemia or by administering a potassium channel opener. Both of these preconditioning strategies were found to require opening of a K ATP channel, and in 1997 we showed that this pivotal role was mediated by the mitochondrial ATP-sensitive K + channel (mitoK ATP ). This paper will review the evidence showing that opening mitoK ATP is cardioprotective against ischemiareperfusion injury and, moreover, that mitoK ATP plays this role during all three phases of the natural history of ischemia -reperfusion injury preconditioning, ischemia, and reperfusion. We discuss two distinct mechanisms by which mitoK ATP opening protects the heart-increased mitochondrial production of reactive oxygen species (ROS) during the preconditioning phase and regulation of intermembrane space (IMS) volume during the ischemic and reperfusion phases. It is likely that cardioprotection by ischemic preconditioning (IPC) and K ATP channel openers (KCOs) arises from utilization of normal physiological processes. Accordingly, we summarize the results of new studies that focus on the role of mitoK ATP in normal cardiomyocyte physiology. Here, we observe the same two mechanisms at work. In low-energy states, mitoK ATP opening triggers increased mitochondrial ROS production, thereby amplifying a cell signaling pathway leading to gene transcription and cell growth. In high-energy states, mitoK ATP opening prevents the matrix contraction that would otherwise occur during high rates of electron transport. MitoK ATP -mediated volume regulation, in turn, prevents disruption of the structure -function of the IMS and facilitates efficient energy transfers between mitochondria and myofibrillar ATPases. D

Background To determine whether waist-to-height ratio correlates with coronary artery disease (CAD) severity better, than the body mass index (BMI) as assessed by coronary angiography in Bangladeshi population. Methods This cross sectional study was done on patients in Department of Cardiology in DMCH and those referred in the cath-lab of the Department of Cardiology for CAG during November 2009 to October 2010 involving 120 patients. They were divided into group-A (with coronary score ≥7) and group-B (coronary score <7) depending on Gensisni score. Result There were no statistically significant difference regarding the distribution of age, sex and clinical diagnosis and parameters between the two groups. The mean age of patients was 51.7 ± 8.2 years and 48.8 ± 9.1 years in Group A and Group B respectively with a male predominance in both the groups. Patients in group A had higher BMI ≥25 and waist to height ratio (≥0.55) than Group B which showed a statistically significant asso...

Reimplantation of the right internal thoracic artery, as a free graft, into the left in situ internal thoracic artery (Y procedure) has enabled us to bypass more distant marginal vessels, which was not possible by the bilateral technique alone. This prospective study was aimed at evaluating the clinical state of the patients and the degree of patency of grafts within 16 months of follow-up. All 80 patients who underwent the Y procedure between January 1988 and January 1992 were included. This group represented 10% of the 840 patients having coronary bypass during the same period. A total of 202 coronary anastomoses were performed in this series. Early postoperative (30 days) complications included three deaths (3.75%), eight myocardial infarctions (10%), one case of phrenic nerve paralysis (1.25%), two cases of respiratory failure (2.5%), and six wound infections (7.5%). At 3 months' follow-up, 96% of patients were free of symptoms. During the follow-up period, four patients died of noncardiac causes (lung, pancreatic, and brain cancer and rupture of an abdominal aortic aneurysm). At 1 year, 71 patients were free of symptoms (97%). Sixty-one patients underwent coronary angiography between 12 and 24 months. Six patients with peripheral arterial disease were not suitable for coronary angiography, and six refused to be tested. These 12 patients had normal thallium test results in the bypassed area (stress or dipyridamole test). The patency rate of the left internal thoracic artery was 98.3% (n = 60), occlusion rate 1.6% (n = 1), and incidence of threadlike arteries 4.9% (n = 3). Thus the rate of perfect patency was 93.4%. The patency rate of the right internal thoracic artery as a free graft was 93.4% (n = 57), occlusion rate 6.5% (n = 4), and the incidence of threadlike arteries 8% (n = 5). Thus the rate of perfect patency was 85.2%. A total of 169 anastomoses were studied. The rate of patency of the anastomoses to the left anterior descending coronary artery was 96% (n = 58) and the occlusion rate, 4% (n = 2). The patency rate of sequential anastomoses (side to side) to diagonal arteries was 100% (n = 16). Patency rate of anastomoses to obtuse marginal arteries was 95% (n = 58) and the rate of occlusion, 4.9% (n = 3). The patency rate of anastomoses to the posterior descending artery or distal branches of the right coronary artery was 80% (n = 4/5). We conclude that the Y procedure is a ~safe technique with an acceptable morbidity and a good patency rate. This procedure can be used when the in situ technique is not possible because of far-reaching distal marginal coronary arteries. (J THORAC CARDIOVASC SURG 1995;109:1042-8)

The increasing use of coronary computed tomography angiography (CCTA) requires the establishment of standards meant to ensure reliable practice methods and quality outcomes. The Society of Cardiovascular Computed Tomography Guidelines Committee was formed to develop recommendations for acquiring, interpreting, and reporting these studies in a standardized fashion. Indications and contraindications for specific services or procedures are not included in the scope of these documents. These recommendations

This study was designed to determine the predictive value of lipid hydroperoxide (LOOH) levels for adverse cardiovascular outcomes in patients with stable coronary artery disease (CAD). Oxidative modification of circulating lipids contributes to inflammation and endothelial dysfunction, which are hallmark features of atherosclerosis. A serum biomarker of oxidation is LOOH, which is a primary product of fatty acid peroxidation. Serum LOOH levels were measured and correlated with clinical events over a 3-year period in 634 patients with angiographic evidence of CAD. Baseline LOOH levels in the highest quartile were associated with hazard ratios of 3.24 (95% confidence interval [CI] 1.86 to 5.65; p = 0.0001) for nonfatal vascular events (n = 149), 1.80 (95% CI 1.13 to 2.88; p = 0.014) for major vascular procedures (n = 139), and 2.23 (95% CI 1.44 to 3.44; p = 0.0003) for all vascular events and procedures. Baseline LOOH levels correlated with serum levels of soluble intercellular adhesion molecule-1 (p = 0.001) and thiobarbituric acid reactive substances (p = 0.001) as well as the mean percent change in stenosis for large segments >50% stenosed (p = 0.048). A multivariate proportional hazards model, adjusted for traditional risk factors and inflammatory markers, showed an independent effect of LOOH on nonfatal vascular events, vascular procedures, and all events or procedures. Amlodipine treatment was associated with reduced cardiovascular events and changes in LOOH levels compared with placebo. Elevated LOOH levels were predictive of nonfatal vascular events and procedures in patients with stable CAD, independent of traditional risk factors and inflammatory markers.

Aims: To report the three-year clinical outcome of the Axxess™ stent, a nitinol self-expanding Biolimus A9™ eluting stent for treatment of de novo coronary bifurcation lesions. The Axxess stent is a new-generation drug-eluting stent that might offer advantages in terms of improved clinical outcomes and safety profile in bifurcation lesion stenting. Methods and results: The DIVERGE study was a multicentre, prospective, single-arm trial. The primary endpoint was the cumulative rate of major adverse cardiac events (MACE), a composite of all-cause death, myocardial infarction (MI), and ischaemia-driven target lesion revascularisation (TLR) at one, two and three years. Secondary safety endpoints were cumulative stent thrombosis (ST). A total of 302 patients were included across 14 sites: 77.4% had a true bifurcation lesion, with the left anterior descending/diagonal as target vessel in 80.8%. The Axxess stent was placed in 299 patients (99.0%) and scored as optimal in 93.0%. Two hundred and ninety-eight patients (98.7%) returned for the three-year follow-up. The MACE rate was 9.3% at one year, 14.0% at two years and 16.1% at three years. Individual components at three years were 10.1% for ischaemia-driven TLR, 3.0% for death (2.0% cardiac death), and 7.4% for MI. In the secondary safety endpoint at three years, a total of seven patients (2.3%) had ST with six (2.0%) definite and two (0.7%) probable ST events. Conclusions: The present large study of the Axxess stent reports a good cumulative MACE rate during three years of long-term follow-up. The Axxess stent offers a promising treatment strategy for bifurcation lesions.

Carotid artery intima–media thickness (IMT) is now widely used as a surrogate marker for atherosclerotic disease. Carotid IMT measured by ultrasound has been shown to be correlated with coronary artery disease as defined by angiography. However, the relation between carotid IMT and ...

The Society of Cardiovascular Computed Tomography (SCCT) and the Society of Thoracic Radiology (STR) have jointly produced this document. Experts in this subject have been selected from both organizations to examine subject-specific data and write this guideline in partnership. A formal literature review, weighing the strength of evidence has been performed. When available, information from studies on cost was considered. Computed tomography (CT) acquisition, CAC scoring methodologies and clinical outcomes are the primary basis for the recommendations in this guideline. This guideline is intended to assist healthcare providers in clinical decision making. The recommendations reflect a consensus after a thorough review of the best available current scientific evidence and practice patterns of experts in the field and are intended to improve patient care while acknowledging that situations arise where additional information may be needed to better inform patient care.

The case report of acute coronary episode caused by air embolism associated with the removal of central vascular access, published in "Anaesthesiology Intensive Therapy"1/2012 aroused much interest [1]. Iatrogenic gas emboli are rare, albeit dramatic complications of therapeutic interventions,which result in persistent neurological symptoms in over 40% of cases [2].

Background Real world cardiology is faced with a low diagnostic yield of coronary angiography (CXA) in patients presenting with ACC/AHA class II CXA indication. Our aim was to analyze the clinical implication of a Cardiac MR (CMR) protocol including adenosine stress perfusion in this patient population. We examined whether CMR could enhance appropriate CXA indication and thus reduce the rate of pure diagnostic CXA. In addition, we compared the relative impact of CMR exam components (perfusion, function and viability assessment) in achieving this target. Methods 176 patients were referred for CXA with class II indication. 171 underwent complete additional CMR exam in a 1.5-T whole body CMR-scanner for myocardial function, ischemia and viability prior to CXA. The routine protocol for assessment of CAD consisted of functional imaging (long and short axes), adenosine stress- and rest-perfusion in short axis orientation and “late enhancement” imaging in long and short axes. Images were analyzed by two independent and blinded investigators. Interobserver differences were resolved by a third reader. Results There was a high association between CMR results and subsequent invasive findings (chi square for CMR perfusion deficit and stenosis >70% in CXA: 113.7, p70%. Four (2.3%) patients had false negative CMR findings. In 58 patients (33.9%) no relevant coronary artery stenosis could be observed, correctly predicted by CMR in 48 cases; in 10 (5.8%) patients CMR provided false positive results. Sensitivity of CMR to detect relevant CAD (>70% luminal narrowing) was 0.96, specificity 0.83, positive predictive value 0.92 and negative predictive value 0.92. Of the CMR components, perfusion deficit was the strongest independent predictor (odds ratio 132.3, p Conclusion In a great number of patients being referred to cath lab with ACC/AHA class II indication for CXA, CMR provides a high accuracy for decision making regarding appropriateness of the invasive exam. CMR prior to CXA could substantially reduce pure diagnostic coronary angiographies in patients with intermediate probability for CAD, in our patient-cohort from approximately 34% to 6%. Further studies are warranted to identify rare false negative CMR results.

Background: Acute anterior myocardial infarction (MI) caused by proximal occlusion of the left anterior descending coronary artery (LAD), is associated with unfavourable outcome and should be recognized by simple noninvasive methods like the 12-lead electrocardiogram (ECG). Methods: In a prospective post-hoc DANAMI-2 substudy we compared two pre-specified ECG patterns to determine the level of LAD occlusion. The ECG findings were correlated to coronary angiography from the acute phase. The impact on clinical outcome of ECG and angiographic signs of proximal versus distal LAD occlusion was studied. Results: In 146 patients without confounding factors on the ECG, either ST-elevation ≥ 0.5 mm in lead aVL or any ST-elevation in lead aVR in association with precordial ST-segment elevation in at least two contiguous leads (including V 2 , V 3 or V 4 ) had a sensitivity of 94%, specificity of 49%, positive predictive value of 85% and negative predictive value of 71% to predict a proximal LAD lesion. Surprisingly, ECG or angiographic signs of lesion proximality were not associated with worse outcome at 30 day or 2.7 year follow-up. Conclusions: The site of occlusion in the LAD could be reliably predicted by 12-lead ECG in patients with acute anterior MI. The prognostic significance of the level of occlusion in the LAD in the modern era of acute ST-elevation MI treatment should be reassessed.

Purpose: To investigate the relationship between left coronary bifurcation and dimensional changes and development of coronary artery disease using multislice CT angiography. Materials and methods: 30 patients (18 men, 12 women, mean age, 56 years ± 8) suspected of coronary artery disease undergoing 64-and 256-slice CT angiography were included in the study. Left bifurcation angle and left coronary diameter were measured to determine the relationship between angulation and plaque formation and subsequent dimensional changes. Results: Plaques were present in the left coronary artery in 22 patients with variable angulations and dimensional changes. The mean bifurcation angle between left anterior descending and left circumflex arteries was measured 89.1 • ± 13.1 • (range, 55.3 • , 134.5 • ) among all patients. The mean bifurcation angle measured in patients with normal and diseased left coronary artery was 75.5 • ± 19.8 • (range, 60 • , 96.1 • ), and 94 • ± 19.7 • (range, 55.3 • , 134.5 • ), respectively, with significant difference between these two groups (p = 0.02). Similarly, there is a significant difference in the mean diameters of left anterior descending and left circumflex between patients with normal and diseased left coronary artery (p < 0.001), which were measured 2.8 ± 0.3 mm (range, 2.2, 3.2 mm) and 2.1 ± 0.4 mm (range, 1.9, 2.9 mm) for the normal left coronary arteries, 4.0 ± 0.8 mm (range, 2.5, 6.1 mm) and 2.9 ± 0.5 mm (range, 1.6, 3.9 mm) for the diseased left coronary arteries, respectively. Conclusion: There is a direct correlation between left bifurcation angle and dimensional changes and formation of plaques. Multislice CT angiography can be used to provide relevant features of left coronary atherosclerosis.

As doenças cardiovasculares são as principais causas de morbidade e mortalidade no Brasil e no mundo. Atualmente é possível avaliar o risco cardiovascular individual com base em estudos observacionais. Assim, aliando o elevado risco cardiovascular atual à possibilidade de se prever a ocorrência de eventos, realizou-se neste estudo a avaliação dos fatores de risco e o desenvolvimento de Doença Arterial Coronariana (DAC) em 10 anos em pacientes do município de São Caetano do Sul, com o objetivo de determinar o risco cardiovascular dos mesmos com base no Escore de Framingham e relacionar o risco encontrado com outras variáveis que caracterizam a Síndrome Metabólica (SM). Pôde-se observar uma baixa prevalência de DAC nos 63 pacientes analisados, já que 47,6% encontravam-se em grupos de baixo risco, 36,5% em médio risco e apenas 15,9% em alto risco. Entretanto, esse quadro inicialmente favorável não se confirmou quando relacionado à SM, pois 23,3% dos pacientes com baixo risco para DAC tiveram diagnóstico positivo para SM. Concluiuse que, o baixo risco resultante da avaliação dos pacientes baseada apenas nos critérios de Framingham, não significa que os mesmos estão isentos de risco cardiovascular, pois podem apresentar outros fatores que não estão incluídos neste escore de predição clínica. A abordagem que possui maior respaldo na análise detalhada das evidências disponíveis consiste em estimar o risco cardiovascular total não pela elevação de fatores isolados e sim pela soma de risco decorrente de múltiplos fatores, estimada pelo risco absoluto global em cada indivíduo.

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Good aerobic fitness is associated with favorable cardiovascular outcomes. However, it is not well known whether aerobic fitness correlates to the degree of coronary atherosclerosis, which affects cardiovascular prognosis. The aim of the present study was to investigate the relation between aerobic fitness and coronary atherosclerosis. A total of 8,565 apparently healthy men underwent routine health screening, including both cardiopulmonary function testing and coronary calcium scoring. The subjects with clinical cardiovascular disease or abnormal exercise electrocardiographic findings were excluded. A treadmill exercise test was done using the modified Bruce protocol, and the Agatston coronary artery calcium (CAC) score was measured using multidetector computed tomography. Advanced CAC was defined as a score >75th percentile according to the age group. The mean age was 51 ؎ 7 years, the average maximum oxygen uptake was 32 ؎ 5 ml/kg/min, and 34% had a positive CAC score. On univariate analysis, age, blood pressure, lipid profile, body mass index, hemoglobin A1c, fasting glucose, calculated 10-year risk for coronary disease, and maximum oxygen uptake were significantly associated with advanced CAC. In the multiple logistic regression model, the subjects in the highest quartile of the maximum oxygen uptake for age were less likely to have advanced CAC for age compared to those in the lowest quartile (odds ratio 0.60, 95% confidence interval 0.48 to 0.73), with adjustment for age, hypertension, hemoglobin A1c, current smoking, body mass index, and regular exercise habit. In conclusion, greater aerobic fitness was associated with less prevalent advanced coronary atherosclerosis in an asymptomatic male population. The degree of subclinical coronary artery disease might be 1 of the mechanisms connecting aerobic fitness and cardiovascular outcome.

Background Little is known about the incremental value of real-time myocardial contrast echocardiography (MCE) as an adjunct to pharmacologic stress testing. This study was performed to evaluate the diagnostic value of MCE to detect abnormal myocardial perfusion by technetium Tc 99m sestamibi-single photon emission computed tomography (SPECT) and anatomically significant coronary artery disease (CAD) by angiography.

Aim  The aim of the study was to assess the influence of physical activity on the components of metabolic syndrome (MS) in an urban south Indian population in Chennai.Methods  The Chennai Urban Population Study (CUPS) is an epidemiological study involving two residential areas in Chennai in South India. Of the total of 1399 eligible subjects (age ≥ 20 years), 1262 individuals participated in the study. MS was diagnosed based on modified Adult Treatment Panel (ATP) III guidelines. Details about the physical activity were collected using questionnaire, which included job-related and leisure-time activities, and specific questions on exercise. Study individuals were then graded as light, moderate and heavy using a scoring system. We assessed the relationship between the grades of physical activity and the components of MS and coronary artery disease (CAD). Insulin resistance was calculated using the homeostasis assessment model (HOMA-IR).Results  Prevalence of most of the components of MS (diabetes P < 0.001, obesity P = 0.003, abdominal obesity P < 0.001 and hypertension P < 0.001) and MS per se (P < 0.001) increased significantly with decrease in physical activity. Among non-diabetic subjects, HOMA-IR was significantly higher in subjects who did light-grade activity compared with heavy-grade activity (P = 0.041). Logistic regression analysis revealed physical activity to be significantly associated with MS [heavy activity: reference, moderate activity, odds ratio (OR) 1.639, (P = 0.017); light activity: OR 2.289, (P < 0.001)]. Subjects in the light-grade activity group also had higher odds of CAD (OR 2.42, 95% confidence interval 1.40, 4.24, P = 0.011), compared with the heavy-grade activity group.Conclusion  Physical inactivity is associated with the components of MS and CAD in this urban south-Indian population. Lifestyle changes focusing on increasing physical activity could help to prevent the exploding epidemic of MS and CAD in India.

Background: Atrial fibrillation (AF) is the commonest sustained cardiac arrhythmia, which confers a high risk of mortality and morbidity from stroke and thromboembolism. Altered platelet activation and platelet-dependent thromboembolism have been associated with the pathogenesis of cardiovascular or thromboembolic disorders, which include atherosclerosis, coronary disease and cerebrovascular disease. Platelet adhesion and activation are mediated by human platelet alloantigens (HPAs), a complex of platelet membrane glycoproteins (Gp) and other cellbound Factors. By altering platelet receptor sensitivity, polymorphisms in platelet Gp directly impact platelet susceptibility to activating stimuli, which is linked with an increased risk of atherothrombotic events, including acute myocardial infarction. We wanted to investigate HPA-1 polymorphism in patients with AF who have had a stroke than in healthy controls. Methods: The HPA-1 polymorphism was analysed in 70 patients with nonvalvuler AF who have had a stroke and 65 healthy individuals with no documented episode of AF matched for age, race and sex. Because ethnic differences have been reported for HPA-1. The HPA-1 gene polymorphism was identified by polymerase chain reaction (PCR) method. Distribution of the HPA-1 gene polymorphism alles (allel 1a, allel 1b) genotypes (1a1a, 1a1b and 1b1b) were determined in study population. Demographic characteristics and risk factors for AF and stroke were evaluated in the study groups. Results: There was no significant difference with respect to age and gender between groups. Genotype and allel distribution of AF patients who have had a stroke and control groups shown in the table. The frequency of 1a1a genotype of HPA-1 polymorphism was significantly lower in patients with AF patients who have had a stroke group compared with control group (49 (70%) vs 57 (87.7%), p¼0.012). The frequency of 1a1b genotype heterozygous genotype was significantly higher in AF patients who have had a stroke group than control (18 (25.7%) vs 6 (9.2%), p¼0.012). Between the two groups were compared according to the dominant genetic model (1a1b + 1b1b vs. 1a1a), The number of patients carrying at least one 1b mutant allele (1a1b + 1b1b) was significantly higher in AF patients who have had a stroke group than control (21 (30%) vs 7 (10.8%), p¼0.006). With respect to allelic distribution (1a vs 1b, additive model), the frequency of the 1b allele was significantly higher in AF patients who have had a stroke (24 (17.1%) vs 8 (6.1%), p¼0.009). Conclusıons: In this study, our data suggest that the HPA-1 gene polymorphisms may be associated with AF patients who have had a stroke from other clinical risk factors, but this should be confirmed in a much larger series of patients. Screening for this mutation may help in identifying patients at risk and in deciding the antithrombotic strategy.

Objective: Epicardial adipose tissue (EAT) has been implicated in the pathogenesis of coronary atherosclerosis. The association of EAT volume with type of coronary artery plaque on computed tomography angiography (CTA) is not known. Methods: Coronary artery calcium (CAC) scoring and EAT volume measurement were performed on 214 consecutive patients (mean age 54 ± 14 years) referred for coronary CTA. CAC was performed on noncontrast images, while EAT volume, the severity of luminal stenoses, and plaque characterization were assessed using contrast-enhanced CTA images. EAT volume was also indexed to body surface area (EAT-i). Results: EAT volume correlated with age, height, body mass index (BMI), and CAC score. EAT volume increased significantly with the severity of luminal stenosis (p < 0.001), and in patients with no plaques, calcified, mixed, and non-calcified plaques (62 ± 33 mL, 63 ± 22 mL, 98 ± 47 mL, and 99 ± 36 mL, respectively, p < 0.001). The EAT volume was significantly larger in patients with mixed or non-calcified plaques compared to patients with calcified plaques or no plaques (all p < 0.01 or smaller). The trend remained significant after adjustment for traditional risk factors for coronary artery disease. In adjusted models EAT was an independent predictor of CAC [exp(B) = 3.916, p < 0.05], atherosclerotic plaques of any type [exp(B) = 4.532, p < 0.01], non-calcified plaques [exp(B) = 3.849, p < 0.01], and obstructive CAD [exp(B) = 3.824, p < 0.05]. The above results were unchanged after replacing EAT with EAT-i. Conclusion: EAT volume was larger in the presence of obstructive CAD and non-calcified plaques. These data suggest that EAT is associated with the development of coronary atherosclerosis and potentially the most dangerous types of plaques.

-type natriuretic peptide (BNP) is a natriuretic peptide released primarily by ventricular myocytes in response to various physiological and pathological stimuli. In addition to its established diagnostic role in patients with heart failure, a growing body of evidence suggests that raised levels of BNP in the absence of heart failure can indicate myocardial ischaemia. This appears to be the case in patients with symptomatic, and even asymptomatic coronary artery disease (CAD). In this review, we discuss the current evidence supporting the role of BNP as a simple marker of cardiac ischaemia and CAD. We also propose some therapeutic interventions that may be useful when BNP detects silent myocardial ischaemia. Br J Diabetes Vasc Dis 2010;10:78-82

Currently used coronary artery disease (CAD) risk scores estimate CAD-related event risk rather than the presence or the absence of CAD. Newer statistical methods such as neural network systems are rarely used in this context. They could help to diagnose/exclude CAD based on easily available patient data thereby reducing the need of unnecessary tests and related costs. We applied such a memetic pattern based algorithm (MPA) to data of 2 separate patient cohorts using simple clinical variables to determine the diagnostic accuracy and compare it to the Framingham risk score.

Objective: Free fatty acid inhibition with trimetazidine (TMZ) improves myocardial metabolism and myocardial ischemia in patients with coronary artery disease (CAD). Because of its effect on myocardial glucose utilization TMZ may represent a therapeutic option in diabetic patients with CAD. Aim of the present study was to evaluate whether the metabolic effect of TMZ may improve episodes of myocardial ischemia in diabetic patients with CAD. Research design and methods: We assessed the effect of TMZ on 24 h ambulatory ECG monitoring (AEM) in 30 patients (22 males and 8 females, mean (SE) age 67 ± 6.5 years) with NIDDM and ischemic cardiomyopathy. Patients were randomized to receive on top of standard therapy either TMZ (20 mg, tds) or placebo (tds) and were evaluated at baseline and after 6 months. Results: Patients randomized to TMZ or placebo were comparable regarding demographic data, distribution of CAD, and glicated haemoglobin levels. TMZ significantly reduced the number of episodes of transient myocardial ischemia (−24% compared to baseline, p b 0.01; − 27% compared to placebo, p b 0.01), and Total Ischemic Burden (− 28% compared to baseline, p b 0.01; −29% compared to placebo, p b 0.01). TMZ also significantly reduced the number of silent episodes of myocardial ischemia (−42% compared to baseline and −39% compared to placebo, p b 0.01) and the time of silent myocardial ischemia/24 h (−37% compared to baseline and − 35% compared to placebo, p b 0.01). No significant changes in heart rate were detected between baseline, placebo and TMZ evaluations. Conclusions: TMZ is effective in reducing silent and symptomatic episodes of transient myocardial ischemia in diabetic patients with CAD on standard anti-anginal therapy.

In patients with acute myocardial infarction (AMI), little is known about the correlation between prognostic variables and aspects of ruptured plaque at the coronary angiography. Five hundred patients with acute myocardial infarction were studied in a consecutive and prospective manner; of these, 264 patients were excluded mainly because of the presence of an occluded culprit coronary artery. The remaining 236 patients were divided according to the presence (113, 52%) or absence (126, 48%) of angiographic aspects suggestive of ruptured plaque, and correlated with 49 clinical, electrocardiographic, in-hospital complications, procedures, and other angiographic prognostic variables. The variables that correlated significantly and independently with angiographic aspects of ruptured plaque were: presence of thrombi and higher degree of residual stenosis at the culprit coronary artery, as well as white ethnic group.

Background: Abdominal aortic operations have the highest perioperative cardiac risk. To test the impact of preoperative coronary artery revascularization (PR) in this high-risk subset, a post hoc analysis was performed in patients undergoing aortic surgery within the Coronary Artery Revascularization Prophylaxis (CARP) trial. Methods: The study cohort was a subset of 109 CARP patients with myocardial ischemia on nuclear imaging randomized to a strategy of PR (N 5 52) or no PR (N 5 57) before their scheduled abdominal aortic vascular operation. The clinical indications for vascular surgery were an expanding aneurysm (N 5 62) or severe claudication (N 5 47). The composite end-point of death and nonfatal myocardial infarction (MI) was determined by an intention-to-treat analysis following randomization. Results: The median time (Interquartiles) from randomization to vascular surgery was 56 (40, 81) days in patients assigned to PR and 19 (10, 43) days in patients assigned to no PR (P < 0.001). At 2.7 years following randomization, the probability of remaining free of death and nonfatal MI was 0.65 with PR and 0.55 with no PR [unadjusted P 5 0.08, odds ratio 5 1.67, 95% confidence interval (0.93, 2.99)]. Using a Cox proportional hazard model, predictors of the composite of death and nonfatal MI (odds ratio; 95% confidence interval) were no PR (1.90; 1.06-3.43; P 5 0.03) and anterior ischemia on preoperative imaging (1.79; 0.99-3.23; P 5 0.07). Conclusions: In patients with an abnormal cardiac imaging before abdominal aortic vascular surgery, PR was associated with a reduced risk of death and nonfatal MI while anterior ischemia was an identifier of poor outcome independent of the revascularization status. V C 2010 Wiley-Liss, Inc.

Seismocardiography (SCG) is a useful method for the detection of exercise-induced changes in cardiac muscle contractility which may occur during myocardial ischemia. The aim of this study was to compare the diagnostic accuracy of SCG with electrocardiographic exercise test (ETT) for diagnosis of ischemia in patients with angiographically proved coronary artery disease (CAD). Seventy-seven male patients with CAD without myocardial infarction (MI), mean age 51+/-9 years, were subjected to SCG and ETT. A gender-matched control group consisted of 30 healthy volunteers aged 34+/-7 years. SCG was done simultaneously with resting supine 12-lead electrocardiography before and immediately after a symptom-limited ETT. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) of SCG were compared with ETT. Moreover, the diagnostic accuracy of both the methods was compared, with coronary angiography being the reference for the analysis. SCG was more sensitive (61.1% vs 44.2%, P&amp;amp;amp;amp;amp;amp;amp;lt;0.05) and accurate (70% vs 61%, P&amp;amp;amp;amp;amp;amp;amp;lt;0.05) method for detecting ischemia caused by coronary stenosis&amp;amp;amp;amp;amp;amp;amp;gt;or=50%, at least in one coronary artery compared to the ETT. However, ETT had better specificity than SCG (82.4% vs 76%, P&amp;amp;amp;amp;amp;amp;amp;lt;0.05). The PPV and NPV of SCG were significantly better than those obtained with ETT (77.9% vs 76%, P&amp;amp;amp;amp;amp;amp;amp;lt;0.05 and 63.4% vs 53.8%, P&amp;amp;amp;amp;amp;amp;amp;lt;0.05, respectively). Moreover, the concordant results of SCG and ETT improved the diagnostic accuracy of both methods. SCG appeared to be more sensitive for detecting ischemia caused by more than&amp;amp;amp;amp;amp;amp;amp;gt;or=50% stenosis of the main coronary artery compared to an electrocardiographic stress test. SCG was a useful ETT adjunct for selecting patients requiring coronary angiography.

Plasma and tissue concentrations of the angiotensin-I converting enzyme (ACE) have been shown to be associated with the ACE insertion/deletion (I/D) polymorphism. The purpose of this study was to examine the relation of ACE levels in atherosclerotic plaques to the ACE I/D polymorphism and to restenosis after balloon angioplasty and directional atherectomy (DCA). The study included 104 patients who underwent DCA and received angiographic follow-up at 12 to 18 months. The amount of ACE protein in various morphologically defined plaque components (fibrous, atheromatous, and complicated lesions) of the atherectomy specimens was determined by qualitative and semiquantitative immunohistochemistry. ACE levels were related to the ACE genotype, to plaque morphology and to the risk of restenosis. Sequential staining revealed that pathologic ACE overexpression of the atherosclerotic lesions occurred in intimal smooth muscle cells, fibrocytes/fibroblasts and macrophage/foam cells. The ACE content of the whole plaques and of the single plaque components was not associated with the I/D polymorphism, but with restenosis after coronary interventions. In addition, ACE levels in the atherosclerotic lesions correlated with the severity of vessel wall damage. The ACE phenotype might serve as an indicator for the risk of restenosis after coronary interventions.

Optical Coherence Tomography (OCT) is an imaging technique offering a non-invasive alternative to the traditional analysis of artworks by means of sampling. A cross-section photomicrograph of a sample collected from a painting has its own limitations, mostly due to the restricted number of samples it is possible to collect. There is a need, therefore, for non-invasive

BACKGROUND Cardiovascular magnetic resonance imaging (CMR) has been utilized for diagnosis in various cardiovascular diseases and most of those were performed on a 1.5 Tesla CMR system. Recently, a 3.0 Tesla magnetic resonance imaging system has been introduced into clinical practice, however the clinical experience on cardiovascular examination using this system is limited. Therefore, the authors&#39; institution has integrated a team for developing a CMR program on this 3.0 Tesla system. OBJECTIVE To describe the authors&#39; experience on the 3.0 Tesla CMR system. MATERIAL AND METHOD The data on patients referred to the authors&#39; CMR unit between August 2004 and October 2005 were reviewed. RESULTS One hundred patients were referred for CMR examination. The mean age was 56 years (2 month - 85 years) and 65 patients were male. The most common indication was to assess coronary artery disease (64 patients). The performed examination was divided into cardiac structure and function ...

Coronary calcified plaque (CP) is both an important marker of atherosclerosis and major determinant of the success of coronary stenting. Intracoronary optical coherence tomography (OCT) with high spatial resolution can provide detailed volumetric characterization of CP. We present a semiautomatic method for segmentation and quantification of CP in OCT images. Following segmentation of the lumen, guide wire, and arterial wall, the CP was localized by edge detection and traced using a combined intensity and gradient-based level-set model. From the segmentation regions, quantification of the depth, area, angle fill fraction, and thickness of the CP was demonstrated. Validation by comparing the automatic results to expert manual segmentation of 106 in vivo images from eight patients showed an accuracy of 78 ± 9%. For a variety of CP measurements, the bias was insignificant (except for depth measurement) and the agreement was adequate when the CP has a clear outer border and no guide-wire overlap. These results suggest that the proposed method can be used for automated CP analysis in OCT, thereby facilitating our understanding of coronary artery calcification in the process of atherosclerosis and helping guide complex interventional strategies in coronary arteries with superficial calcification.

Background: Major depression is characterized by a decreased antioxidant status, an induction of the inflammatory and oxidative and nitrosative (IO&NS) pathways and inflammatoryneurodegenerative (I&ND) pathways. This study examines two markers of oxidative stress in depression, i.e. plasma peroxides and serum oxidized LDL (oxLDL) antibodies. Methods: Blood was sampled in 54 patients with major depression (mean ± SD age = 43.5 ± 11.6 years) and 37 normal volunteers (43.6 ± 11.1 years). The severity of illness was measured by means of the Hamilton Depression Rating Scale. The Fibromyalgia and Chronic Fatigue Syndrome Rating Scale was used to measure severity of "psychosomatic" symptoms in depression. Results: We found significantly higher plasma peroxides (p = 0.002) and serum oxLDL antibodies (p = 0.0002) in depressed patients as compared to normal controls. There was no significant correlation between both markers and both independently from each other predicted major depression. There were significant correlations between the oxLDL antibodies and the scores on two items of the FF scale, i.e. gastro-intestinal symptoms and headache. Discussion: The results show that major depression is accompanied by increased oxidative stress and lipid peroxidation. These results further extend the IO&NS pathophysiology of major depression. Since increased peroxides and oxLDL antibodies are predictors of coronary artery disease (CAD) and neurodegeneration, our findings suggest that IO&NS pathways are involved in the increased incidence of both CAD and neurodegeneration in depression.

A high fasting glucose level may be a marker not only for microvascular complications, but also for macrovascular complications. We evaluated the clinical significance of a high fasting glucose level (Ն110 mg/dL), detected either at baseline or during follow-up, in the Bezafibrate Infarction Prevention (BIP) study.

This study evaluates the impact of obesity on coronary endothelial function in patients with normal or mild coronary artery disease. BACKGROUND The American Heart Association (AHA) has recently classified obesity as a modifiable risk factor for coronary heart disease.