Association of GDF-15, hs-cTnT and NT-proBNP with coronary artery disease in patients undergoing elective angiography

Aim: This study investigated the association between plasma levels of GDF-15, hs-cTnT and NT-proBNP and the presence of coronary artery disease (CAD) in stable patients referred for elective coronary angiography. Methods: The outcome of CAD was defined as an ordinal variable with 3 levels. The association between each biomarker and the outcome was tested using the Winell and Lindbäck method. Results: In unadjusted analysis of 252 patients, GDF-15 and hs-cTnT were associated with the presence and extent of CAD. In multivariate regression analysis including traditional risk factors, this association was no longer significant. Conclusion: NT-proBNP, GDF-15 and hs-cTnT plasma levels do not seem to improve the predictive ability of traditional risk factors for CAD in stable patients referred for coronary angiography.

Association of growth differential factor-15, hs-cardiac troponin T and N-terminal pro-brain natriuretic peptide with coronary artery disease in patients undergoing elective coronary angiography

Background

Although the importance of conventional risk factors is well established, a significant proportion of patients with coronary artery disease (CAD) lack any of these factors and many patients without CAD have one or more of them. Better tools are needed to improve risk stratification of patients.

Purpose

We aimed to investigate the association between plasma levels of growth differentiation factor 15 (GDF-15), a marker of stress and inflammation, high-sensitivity cardiac troponin T (hs-cTnT) and N-terminal pro-brain natriuretic peptide (NT-proBNP) with the presence of CAD in stable patients referred for elective coronary angiography.

Methods

Plasma levels of the three biomarkers were measured in 252 consecutive patients. Patients with known CAD, acute coronary syndrome, or with chronic inflammatory conditions were excluded. CAD was defined by the presence of at least one lesion causing >50% stenosis. The outcome was defined as an ordinal variable with 3 levels: no CAD, 1- or 2-vessel CAD and 3-vessel or left main CAD.

Results

Median age was 63 years (56–71), and 35% of patients were females. Among conventional risk factors, hypertension was the most prevalent (70%), followed by hyperlipidemia (69%), smoking (42%), diabetes (33%) and family history of CAD (32%). Of the 252 patients enrolled, 153 (61%) had no CAD, 81 (32%) 1- or 2-vessel CAD, and 18 (7%) 3-vessel or left main CAD. Plasma levels of GDF-15, hs-cTnT and NT-proBNP in each of the 3 groups of CAD are summarized in table 1. In unadjusted ordinal logistic regression analysis, GDF-15 and hs-cTnT were statistically significantly associated with the presence and extent of CAD, while NT-proBNP was not (table 1). However, in a multivariable analysis including age, sex and traditional risk factors, the association of GDF-15 and hs-cTnT with angiographic CAD was attenuated and no longer statistically significant. Age, male sex, family history of premature CAD and the presence of hyperlipidemia, were independent predictors of the presence and extent of CAD (table 2).

Conclusion

In stable patients referred for coronary angiography, plasma levels of GDF-15 and hs-cTnT could predict the presence of CAD when evaluated separately. However, that association was attenuated by clinical characteristics.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Roche Diagnostics International LtdForrenstrasse 26343 RotkreuzSwitzerland Table 1Table 2

Plasma PCSK9 levels increase following percutaneous coronary interventions

Background

Beside its role in cholesterol homeostasis, Proprotein Convertase Subtilisin/Kexin type 9 (PCSK9) has been associated with the processes of vascular inflammation and atherosclerosis. The protein is expressed in endothelial cells, smooth muscle cells and macrophages and it is detected inside the human atherosclerotic plaque.

Purpose

We aimed to investigate the effect of acute inflammation associated with plaque rupture and vascular injury during elective percutaneous coronary intervention (PCI) on plasma levels of PCSK9 in patients with coronary artery disease (CAD).

Methods

We measured PCSK9, C-reactive protein (CRP), Interleukin-6 (IL-6) and high-sensitivity cardiac Troponin T (hs-cTnT) plasma levels immediately before and 18–24 hours after PCI via the radial approach, in 68 consecutive patients with stable CAD referred for elective PCI of a de novo lesion in a native coronary artery. Patients with unstable coronary syndrome <3 months old, baseline inflammatory condition, malignancy, auto-immune disease or intervention via the femoral access, were excluded.

Results

All patients were treated with balloon angioplasty and implantation of a second-generation drug eluting stent (DES). Baseline plasma levels of PCSK9 were higher in women and in patients treated with statins. At 18–24 hours after the procedure, plasma levels of PCSK9, CRP, IL-6 and hs-cTnT increased significantly compared to baseline (table). The change (elevation) in CRP plasma levels was statistically correlated with that of IL-6 (r=0.33; p=0.006) and with that of hs-cTnT (r=0.28; p=0.023). However, there was no correlation between the change (elevation) in plasma PCSK9 levels and those of IL-6 (r=−0.09; p=0.47), CRP (r=0.01; p=0.9), and hs-cTnT (r=0.1; p=0.41).

Conclusions

Plasma levels of PCSK9 increased by 26% following PCI with DES. That elevation was however, not correlated with the degree of myocardial injury (hs-cTnT) or of inflammation (IL-6 and CRP). The mechanism underlying PCK9 elevation post PCI requires further investigation.

Funding Acknowledgement

Type of funding sources: None.

A Practical Approach for the Use of High-Sensitivity Cardiac Troponin Assays in the Evaluation of Patients With Chest Pain

Chest pain is a common clinical presentation, especially in the emergency department. Both rapid identification of patients with myocardial infarction as well as those with noncardiac chest pain is important in order to start therapy in the former and avoid unnecessary investigations and delay in discharge in the latter. Beside electrocardiogram, cardiac biomarkers are a key element in decision making. Conventional creatinine kinase and troponin assays are not sensitive enough and have to be repeated at least 6 to 12 hours after initial evaluation. New high-sensitivity cardiac troponin (hs-cTn) tests are currently available and if used appropriately can substantially improve management. Because of their high sensitivity and accuracy, these tests allow measurement of very low serum troponin levels, such as those present in healthy individuals and can detect small changes in troponin concentration within a short time frame. These tests are thus, very useful for the early diagnosis of myocardial infarction but can also be elevated in several other conditions that result in myocardial injury. A good understanding of the analytical characteristics of these assays is of uppermost importance for their appropriate use in clinical practice.

BENCHMARKING THE DOSE MAP SOFTWARE FOR CLINICAL IMPLEMENTATION AND ESTABLISHMENT OF A LOCAL FOLLOW-UP PROTOCOL FOR THE MANAGEMENT OF SKIN INJURES FOLLOWING COMPLEX INTERVENTIONAL CARDIOLOGY PROCEDURES

This paper aims to validate the accuracy of the peak skin dose (Dskin,max) computed by the Dose Map software (DMS)-general electric and establish a local follow-up protocol for the management of patient skin injuries following complex interventional cardiology procedures (ICPs). Dskin,max was computed by the DMS and was simultaneously measured by a dense mesh of 72 thermoluminescent dosemeters for 20 ICP. Measured and computed Dskin,max were compared using Lin's concordance coefficient (${\rho}_c$). The implementation of a local follow-up strategy was based on a computed Dskin,max of 2 Gy. After eliminating 2 outliers, the average deviation between the two methods was 6% (range: -36 to +40%). Concordance between the two methods was moderate with ${\rho}_c$ (confidence interval) of 0.9128 (0.8541-0.9486). DMS computes Dskin,max with an acceptable accuracy and can be used to setup an individual follow-up process for patients with high skin exposure and risks.

Lebanese students' motivation in medical school: does it change throughout the years? A cross-sectional study

BACKGROUND

Students entering medical school are driven by different types of motivation: autonomous motivation, controlled motivation, or amotivation. Motivation types can influence students' performance, outcome and well-being. To our knowledge, this topic has never been studied in Lebanese medical students. This study aims to identify students' motivation types in the first 5 years of medical school at two Lebanese universities (USJ and USEK). It also aims to determine the predominant motivation type of the whole sample. Results may be the first step towards raising awareness about this topic and implementing actions that enhance autonomous motivation.

METHODS

A cross-sectional study was performed between January and June 2017. A questionnaire was sent to medical students by e-mail. The students' academic motivation was assessed using the Academic Motivation Scale.

RESULTS

A higher mean autonomous motivation score was found in each academic year, as compared to the mean controlled motivation and amotivation scores. The highest mean autonomous motivation score was seen among second year students, whereas the lowest score was noted in fifth year students. The highest scores for controlled motivation and amotivation belonged to the fourth-year students, and the lowest to the first-year students. Students who were still satisfied with medical studies had a higher autonomous motivation score. Finally, USJ students who were satisfied with their second year training had a higher mean autonomous motivation score than those who were not.

CONCLUSION

This study showed high levels of autonomous motivation in the first five years of medical school. Autonomous motivation was the predominant type in the whole sample. The highest scores of controlled motivation and amotivation were noted in the fourth year. Moreover, high levels of self-determination were seen in students who enjoyed their early contacts with patients through trainings. Actions should be implemented in medical schools to enhance and maintain autonomous motivation, and consequently students' outcome and health-care quality.

Diabetes without Manifest Cardiovascular Disease: A Novel Approach in Risk Stratification and Treatment Selection

BACKGROUND

Cardiovascular disease (CVD), the main macro vascular complication of type 2 diabetes (T2D), increases the risk of death significantly in patients with T2D.

INTRODUCTION

Most of the patients with T2D do not have obvious CVD symptoms. Due to the paucity of data, CVD screening in asymptomatic patients with T2D remains highly controversial.

METHODS

This has driven a panel of experts to establish a novel consensus on how to approach patients with T2D at high CVD risk. The panel formulated a stepwise algorithm by which patients with T2D undergo initial risk stratification into low, intermediate and high risk using the ASCVD calculator. In patients with intermediate risk, coronary artery calcium measurement is used to further stratify those patients into new low and high-risk categories.

RESULTS AND CONCLUSION

The panel recommends using standard diabetes care in low risk patients and using SGLT2 inhibitors and GLP1 agonists with cardio protective effect, on top of standard care, in high risk individuals.

Quality of Life and Its Association With Treatment Satisfaction, Adherence to Medication, and Trust in Physician Among Patients With Hypertension: A Cross-Sectional Designed Study

OBJECTIVE

Patients with hypertension tend to have a lower health-related quality of life (HRQOL) compared to normotensive patients. This study's main objectives are to assess (1) HRQOL and factors that might impact it and (2) association between HRQOL and adherence to treatment, trust in physician, and treatment satisfaction among patients with hypertension.

METHODS

A cross-sectional study enrolled 196 patients from medical-care offices in Beirut, North and South Lebanon. Eligible patients signed a consent form and were asked to complete the Trust in Physician Scale, World Health Organization Quality of Life-brief (WHOQOL-brief) questionnaire, and Treatment Satisfaction Questionnaire (TSQM 1.4) as well as questions assessing medication adherence.

RESULTS

Better antihypertensive medication adherence was significantly and positively correlated with better HRQOL domains except general health where significance was not reached ( P = .089). Better adherence was also significantly related to better treatment satisfaction (side effects, convenience, and global satisfaction but not to effectiveness) and an increased trust in physicians ( P < .0001). Better treatment satisfaction (TSQM domains) was significantly and positively associated with a better overall HRQOL ( P ≤ .001). Increased trust in physician scores were significantly and positively correlated with a better psychological health, environment, and overall HRQOL domains ( P = .045, .005, and .006, respectively). Finally, TSQM effectiveness, convenience, and global satisfaction were significantly higher when trust in physician was greater ( P = .017, .035, and .002, respectively).

CONCLUSION

The results of this study revealed an association between increased adherence to treatment, a higher global satisfaction, and an increased quality of life. An increased patient satisfaction with their antihypertensive treatment and trust in their physician were also correlated with a greater adherence to treatment.

Association Between Adherence to Statins, Illness Perception, Treatment Satisfaction, and Quality of Life among Lebanese patients

OBJECTIVES

The main objective of this study was to evaluate treatment adherence to statin and health-related quality of life (QOL) in Lebanese patients with dyslipidemia. Secondary objectives were to examine associations between treatment adherence, QOL, treatment satisfaction, and illness perception.

METHODS

This cross-sectional study, conducted in 20 community pharmacies from all districts of Lebanon between August 2016 and April 2017, enrolled 247 adult patients taking any statin.

RESULTS

The mean age of the participants was 52.63 ± 11.92 years (57.5% males); the mean duration of treatment with a statin was 59.72 months. A significant association was found between adherence and marital status ( P < .0001), educational level ( P = .001), cigarette smoking ( P < .0001), and alcohol drinking ( P < .0001). A negative but significant correlation was found between the adherence score and the duration of dyslipidemia ( r = -0.199). A significant but negative correlation was also found between the side effect score and age ( r = -0.137). The monthly salary, the marital status, the educational level, smoking cigarettes or waterpipes, and drinking alcohol were all associated with the Illness Perception Questionnaire scores ( P < 0.0001 for all variables). Secondary level of education (β = 13.43), smoking more than 3 waterpipes per week (β = 14.06), global satisfaction score (β = 0.32), convenience score (β = 0.29), and effectiveness score (β = 0.27) would significantly increase the adherence score. Smoking more than 15 cigarettes per day (β = -11.15) and a divorced status (β = -14.81) would however significantly decrease the adherence score. Significant associations were found between the illness perception score, the QOL domains, and the satisfaction domains ( P < .05 for all variables).

CONCLUSION

This study showed that global satisfaction with treatment, convenience, and effectiveness are important factors that increase treatment adherence. Patient adherence results in patient satisfaction and improved QOL and is an important criterion for achieving desired therapeutic outcomes.

Snuggle T and protrusion (S-TAP) technique for coronary bifurcation stenting: A step-by-step angiographic and illustration demonstration

T and small protrusion (TAP) is a stenting technique that is utilized for the management of coronary bifurcation lesions when using a two-stent strategy. This technique is also useful whenever stenting of a main vessel (MV) jeopardizes a side branch (SB) or when a sub-optimal result is encountered in a daughter vessel after starting with one-stent approach. The conversion from one-stent strategy to TAP could be achieved smoothly and often leads to good results. Technically, optimal positioning of the SB stent to achieve the required protrusion into the lumen of the MV remains a challenge. Toward that goal we propose an added step that involves inflating a balloon in the MV to serve as an anvil with simultaneous pullback of the SB stent, to be followed by stent deployment. We refer to this approach as the snuggle T and protrusion (S-TAP) technique owing to close contact between the SB stent and the MV balloon during simultaneous inflation. In this manuscript, we detail this interventional technique and provide a demonstrative case study.

Association between adherence, treatment satisfaction and illness perception in hypertensive patients

The relationship between adherence to antihypertension medications, treatment satisfaction and illness perception has not been studied so far. The primary objective of this study was to examine the association between adherence to medication, treatment satisfaction and illness perception in Lebanese hypertensive patients. The relation between medication adherence and blood pressure (BP) control was also assessed. In this cross-sectional study, patients were recruited from the physician's practice offices and community pharmacies in Beirut. Patients who had been treated for hypertension for at least 3 months were invited to participate in the study; they completed three questionnaires: the 8-item Morisky Medication Adherence Scale (MMAS-8), the Treatment Satisfaction Questionnaire for Medication (TSQM-4) and the Brief Illness Perception Questionnaire (BIPQ). BP was also measured and recorded. A total of 117 subjects were included, of whom 29.1% had poor adherence to their antihypertension treatment (MMAS-8 scores<6). The odds of having well-controlled hypertension was 3.5 times higher in patients with high adherence compared with patients with poor adherence (P=0.010). Treatment satisfaction was significantly greater in patients with good adherence (P<0.001). Neither socio-demographic, disease- nor drug-related characteristics of the participants were significantly associated with medication adherence. As for illness perception, even though the mean BIPQ score of adherent participants was lower than the mean score of non-adherent participants, this difference did not reach statistical significance. In conclusion, treatment satisfaction was found to be a predictor of adherence. Studies are needed to determine whether interventions to increase satisfaction can improve adherence and BP control.

[The percutaneous treatment of pulmonary atresia with intact ventricular septum]

OBJECTIVE

Describe a mechanical method of perforation-dilatation of the pulmonary valve in pulmonary atresia with intact interventricular septum (PA-IVS), with or without stenting the patent ductus arteriosus (PDA) and medium-term results.

METHOD

Since 2007, all patients with PA-IVS and a right ventricle adequate for biventricular repair, benefited from a transcatheter attempt to perforate-dilate the valve with or without stenting the PDA, and were included in this retrospective study.

TECHNIQUE

A catheter was percutaneously introduced through the femoral vein and positionned in front of the atretic pulmonary valve. A lasso catheter was introduced through the femoral artery to the other side of the pulmonary valve. The tip of a rigid guidewire was then pushed through the atretic valve and taken with the lasso, creating a loop that allowed for balloon valvuloplasty. If the child remained ductal dependant following PGE1 withdrawal, a stent is placed in the ductus arteriosus.

RESULTS

Five patients were included in this series. Four patients were successfully dilated, and two patients necessitated stents. The procedure had to be interrupted in one patient.

FOLLOW-UP

One patient with a patent stent was operated at the age of one year and died in the postoperative period. The other patient with a stent is now 16 months old with a patent stent and an oxygen saturation of 98%. The two remaining patients without stent are now 3- and 18-month-old with oxygen saturation of 85% and 96% respectively.

CONCLUSION

The percutaneous treatment of PA-IVS is feasible and avoids early high risk surgery. Stenting the ductus arteriosus may replace a Blalock shunt. However, the prognosis is still related to the severity of the anomaly.

Comparison of the effects of combination atorvastatin (40 mg) + ezetimibe (10 mg) versus atorvastatin (40 mg) alone on secretory phospholipase A2 activity in patients with stable coronary artery disease or coronary artery disease equivalent

Secretory phospholipase A2 (sPLA2) is an enzyme that plays an important role in the pathogenesis of atherosclerosis and of adverse cardiovascular events. It is currently the target of emerging therapeutic agents. Our study was designed to investigate the effect of aggressive lowering of low-density lipoprotein (LDL) cholesterol with ezetimibe and atorvastatin on sPLA2 activity. We randomized 100 patients with stable coronary artery disease (CAD) or CAD equivalent (diabetes, stroke, or peripheral vascular disease) to receive ezetimibe 10 mg/day in association with atorvastatin 40 mg/day (combination therapy group) versus atorvastatin 40 mg/day and placebo (monotherapy group). Patients on statin therapy before inclusion were allowed to enter the study as long as the potency of the statin was lower than atorvastatin 40 mg/day. Lipid profile, high-sensitivity C-reactive protein (hs-CRP), and sPLA activity were measured at baseline and after 8 weeks of therapy. The decrease in LDL cholesterol was more significant in the combination therapy group, but the decrease in hs-CRP was similar. sPLA2 activity significantly decreased in the ezetimibe/atorvastatin group from 29 U/ml (interquartile range 23 to 35) to 26 U/ml (23 to 29, p = 0.001) but remained similar in the placebo/atorvastatin group (23 U/ml, 19 to 32, vs 22 U/ml, 19 to 28, p = NS). In a multivariate stepwise linear regression model, change in sPLA2 correlated with change in hs-CRP (p <0.001), baseline LDL cholesterol level (p = 0.001), body mass index (p = 0.003), diabetes mellitus (p = 0.04) and combination therapy with ezetimibe/atorvastatin (p = 0.05). In conclusion, this study demonstrates that coadministration of ezetimibe and atorvastatin decreases sPLA2 activity.

Myocardial extraction of intracellular magnesium and atrial fibrillation after coronary surgery

BACKGROUND

The effects of magnesium loading on the incidence of atrial fibrillation following coronary artery bypass graft surgery (CAGB) are equivocal. None of the previous studies assessed the influence of myocardial extraction of magnesium in these settings. The current trial aims to elucidate whether the incidence of atrial fibrillation following CABG is affected by the preoperative rate of myocardial extraction of magnesium.

METHODS

The ethical committee approved the study protocol. 113 patients (94 male, mean age 63 ± 11 years) planned for elective CABG surgery under normothermic cardiopulmonary bypass were prospectively included. Preoperative independent variables included preoperative treatment, electrocardiographic abnormalities, left ventricular ejection fraction estimation, left atrial size, creatinine clearance and assays of plasma and intracellular magnesium, calcium, albumin, potassium and ionized calcium, drawn preoperatively from the coronary sinus and the aortic root. The covariates - including the rate of myocardial extraction of magnesium - were entered in a logistic regression model to predict the odds of atrial fibrillation.

RESULTS

The incidence of post operative atrial fibrillation was 16%. A rate of myocardial extraction of intracellular magnesium ≥ 7% increases fivefold the multivariate risk of postoperative atrial fibrillation (p < .01). Advanced age was also significantly associated to postoperative atrial fibrillation.

CONCLUSIONS

This study suggests that a preoperative rate of myocardial extraction of intracellular magnesium ≥ 7% could be a new and a potent predictive factor for postoperative atrial fibrillation.

Effect of high bolus dose tirofiban on the inflammatory response following percutaneous coronary intervention

BACKGROUND

Tirofiban at the bolus dose of 10 microg/kg does not suppress the inflammatory response following percutaneous coronary intervention (PCI). This may be due to less than optimal inhibition of platelet aggregation. High bolus dose tirofiban (25 microg/kg) allows better inhibition of platelet aggregation but its anti-inflammatory effect remains unknown.

HYPOTHESIS

High bolus dose tirofiban exhibits anti-inflammatory activity.

METHODS

A total of 100 patients referred for PCI were randomized to receive high bolus dose tirofiban followed by a 24-h infusion or a bolus and an infusion of saline. Patients with elevated troponin or with thrombus in the culprit lesion were excluded. Inflammatory markers were measured at baseline and at 24 h.

RESULTS

Levels of soluble CD40 ligand (sCD40L) were not affected by PCI while those of interleukin-6 (IL-6) and of high sensitivity C-reactive protein (hs-CRP) significantly increased. Despite inhibiting platelet's aggregation by > 90%, tirofiban did not suppress the rise of IL-6 and hs-CRP. Median (interquartile range) elevation of IL-6 was 0.6 pg/mL (-1.5-3.6) versus 0.4 pg/mL (-0.7-1.8) and that of hs-CRP was 2.1 mg/L (0.7-5.2) versus 2.4 mg/L (1-4.7) in the tirofiban and the control groups, respectively (p = ns). However, in patients with diabetes mellitus, tirofiban significantly suppressed the rise of hs-CRP by 65% (p = 0.01), but did not significantly affect the rise of IL-6.

CONCLUSION

In low-risk patients undergoing PCI, tirofiban did not attenuate the rise of inflammatory markers. However, the significant effect in diabetics suggests that tirofiban may have anti-inflammatory activity in higher risk patients.

Tako-Tsubo Cardiomyopathy Triggered by Misdirection

Tako-Tsubo cardiomyopathy (TTC), also known as transient left ventricular apical ballooning syndrome or stress-induced cardiomyopathy, is a novel reversible cardiomyopathy mimicking acute myocardial infarction without epicardial coronary artery disease. The exact physiopathology of TTC remains unclear. It is usually precipitated by acute physical or emotional stress and it most commonly affects postmenopausal women. The growing number of clinical cases of TTC have demonstrated a wide field of possible etiologies beyond the emotional stress. We report a case of a 67-year-old postmenopausal woman who was being supplemented by enteral feeding via a nasogastric tube and who developed TTC due to misdirection, probably favored by the mechanical blockade by the nasogastric tube, while swallowing the drug pills.

Effect of ezetimibe/atorvastatin combination on oxidized low density lipoprotein cholesterol in patients with coronary artery disease or coronary artery disease equivalent

Ezetimibe is effective in providing additional low-density lipoprotein (LDL) cholesterol lowering when coadministered with statins, but its effect beyond LDL cholesterol lowering is unknown. Oxidized LDL (ox-LDL) is a better predictor of adverse cardiovascular events than standard lipid parameters. The objective of this study was to investigate the effect of ezetimibe on ox-LDL. A total of 100 patients with coronary artery disease or coronary artery disease equivalent were randomized to atorvastatin 40 mg/day and ezetimibe 10 mg/day or to atorvastatin 40 mg/day and placebo. LDL cholesterol, LDL cholesterol subfractions, and ox-LDL were measured at baseline and after 8 weeks of therapy. The ezetimibe group had a larger reduction in total LDL cholesterol compared to placebo. This was due mainly to a larger reduction in large buoyant LDL (24% vs 10%, p = 0.008). Ox-LDL level did not change in the placebo group (50 +/- 13 vs 51 +/- 13 U/L), while it decreased in the ezetimibe group, from 51 +/- 13 to 46 +/- 10 U/L (p = 0.01 vs baseline and p = 0.02 vs final level in placebo). The change in ox-LDL correlated significantly with those in total LDL and in large buoyant LDL (r = 0.6 and r = 0.5, respectively, p <0.01 for both), but not with that of small dense LDL, high-density lipoprotein, or very low density lipoprotein. In conclusion, this study demonstrates that ezetimibe decreases ox-LDL cholesterol through reductions in total LDL cholesterol and in large buoyant LDL cholesterol.

Cerebellar hematoma complicating 600 mg loading dose of clopidogrel in combination with tirofiban

A patient admitted for coronary angioplasty received a loading dose of Clopidogrel 600 mg, in combination with an infusion of Tirofiban and one prophylactic dose of Enoxaparin. He developed massive cerebellar hemorrhage and underwent urgent surgery. Recovery was fortunately complete and reintroduction of antiplatelet agents was guided by platelet aggregation inhibition test.

[Epidemiology of cardiac tumors in adults in Lebanon]

Primary cardiac tumors are rare but potentially fatal. No studies have discussed this issue yet on the national level. We describe the epidemiology of cardiac tumors in adults in Lebanon. The data were taken from the hospitals, the patients and/or their doctors by means of a questionnaire. Fifty-seven cases of cardiac tumors were found, mainly myxomas in the left atrium. Dyspnea was the most frequent symptom. Transthoracic echocardiography was the main diagnostic tool. Transesophageal echocardiography was inconstantly made, scanner and MRI rarely while contrast echocardiography has never been used. Almost half of the patients had a follow-up and none had a familial screening. The collected data urged us to propose a unique and homogenous strategy for diagnosis, treatment and follow-up of cardiac tumors in Lebanon.

Inhibition of microsomal triglyceride transfer protein in familial hypercholesterolemia

BACKGROUND

Patients with homozygous familial hypercholesterolemia have markedly elevated cholesterol levels, which respond poorly to drug therapy, and a very high risk of premature cardiovascular disease. Inhibition of the microsomal triglyceride transfer protein may be effective in reducing cholesterol levels in these patients.

METHODS

We conducted a dose-escalation study to examine the safety, tolerability, and effects on lipid levels of BMS-201038, an inhibitor of the microsomal triglyceride transfer protein, in six patients with homozygous familial hypercholesterolemia. All lipid-lowering therapies were suspended 4 weeks before treatment. The patients received BMS-201038 at four different doses (0.03, 0.1, 0.3, and 1.0 mg per kilogram of body weight per day), each for 4 weeks, and returned for a final visit after a 4-week drug washout period. Analysis of lipid levels, safety laboratory analyses, and magnetic resonance imaging of the liver for fat content were performed throughout the study.

RESULTS

All patients tolerated titration to the highest dose, 1.0 mg per kilogram per day. Treatment at this dose decreased low-density lipoprotein (LDL) cholesterol levels by 50.9% and apolipoprotein B levels by 55.6% from baseline (P<0.001 for both comparisons). Kinetic studies showed a marked reduction in the production of apolipoprotein B. The most serious adverse events were elevation of liver aminotransferase levels and accumulation of hepatic fat, which at the highest dose ranged from less than 10% to more than 40%.

CONCLUSIONS

Inhibition of the microsomal triglyceride transfer protein by BMS-201038 resulted in the reduction of LDL cholesterol levels in patients with homozygous familial hypercholesterolemia, owing to reduced production of apolipoprotein B. However, the therapy was associated with elevated liver aminotransferase levels and hepatic fat accumulation.

Percutaneous coronary intervention increases leptin and decreases adiponectin levels

OBJECTIVE

The study was designed to examine the effect of percutaneous coronary intervention (PCI) on adiponectin and leptin levels. We have previously demonstrated that PCI triggers a systemic inflammatory response. We hypothesized that inflammation participates in the pathogenesis of diabetes mellitus and the metabolic syndrome by modulating levels of adiponectin and leptin.

DESIGN

Prospective study in which inflammation was induced by PCI.

PATIENTS

Forty-eight patients with stable coronary artery disease and without diabetes mellitus.

MEASUREMENTS

High-sensitivity C-reactive protein (hs-CRP), interleukin-6 (IL-6), leptin and adiponectin were measured at baseline and 48 h after the procedure.

RESULTS

Following PCI, hs-CRP increased by 211%, IL-6 by 87% and leptin by 19%, while adiponectin decreased by 14% (P < 0.001 for all). The change in IL-6 correlated with that in hs-CRP (rho = 0.32; P = 0.027), as did the changes in IL-6 and leptin (rho = 0.31; P = 0.03). The change in adiponectin, however, did not correlate with the change in any of the other markers.

CONCLUSION

This study demonstrates that PCI affects the levels of adiponectin and leptin within 48 h. These effects may be secondary to the inflammatory response triggered by PCI.

[Control of blood pressure morning surge in a Lebanese hypertensive population]

OBJECTIVE

The primary endpoint of this prospective clinical study is to ascertain the degree of blood pressure control in the early-morning hours after 8 weeks of treatment with Telmisartan in hypertensive patients using home blood pressure measurements.

METHODS

Two hundred forty Lebanese patients with uncontrolled hypertension are enrolled in the study. The blood pressure is measured at the initial visit, then at week 4 of follow-up (optional visit) and after the 8 weeks period, by the physician at his office (with pulse rate) and by the patient at home in the morning.

RESULTS

The blood pressure measured by the patient at home in the morning has a mean value of 129.7/79.1 mmHg, significantly less than 135/85 mmHg (P < 10(-1)), and it is reduced by 31.9/13.5 mmHg (P < 10(-5)). At the physician's office, the reduction is 34.8/16 mmHg (P < 10(-4)). Heart rate is decreased by 4.7+/-0.5 bpm (P < 10(-5)). The drug was well tolerated.

CONCLUSION

This study has demonstrated that Telmisartan, by his long half-life, protects the patients against the early-morning hours blood pressure surge, period during which coronary and cerebral events are the most frequent.

[Coronary angioplasty for primary cardiogenic shock following acute myocardial infarction]

BACKGROUND

In the setting of acute myocardial infarction (AMI), several investigators have demonstrated that emergency coronary angioplasty (PTCA) reduces in-hospital mortality of primary cardiogenic shock (CS) from 90% to less than 50% ; however, few studies have focused on the current outcome of non selected patients in whom the onset of AMI is immediately complicated by CS.

PURPOSE OF THE STUDY

To evaluate in-hospital mortality of the patients admitted to our institution for Q wave AMI presented in CS.

MATERIAL AND METHOD

Between 05/93 and 05/03, 30 consecutive pts, 26 men and 4 women, in CS following AMI were treated with direct PTCA, 26 without thrombolysis and 4 as rescue after failed streptokinase. AMI was defined by prolonged chest pain and > or =1 mm ST segment elevation in > or =2 contiguous peripheral leads or > or =2 mm for precordial leads on the admission ECG. The diagnosis of CS was based on the combination of systolic blood pressure of <90 mm Hg, unresponsive to volume expansion, signs of acute circulatory failure (cyanosis, cold extremities, restlessness, mental confusion or coma) and congestive heart failure secondary to myocardial dysfunction. In 40% of cases the diagnosis of CS was only clinical and in 60% of cases was confirmed by a Swan Ganz catheter. Mean age was 62.3 +/- 12.3 years, 7 had triple vessel disease, 14 a double vessel disease, 8 a single vessel disease and in one case a left main disease. The AMI was anterior in 22 pts (73%), inferior in 8 (27%). Intraaortic balloon was used in 3 pts, CPR in 16 (47%), transitory pacemaker in 1 pt, inotropes in 25 pts, emergency coronary artery bypass grafting (CABG) in 1 pt.

RESULTS

Success for PTCA with a residual stenosis < 50% and a TIMI flow III was obtained in 26 pts (87%). Mean time between CS and revascularization was 219 +/- 302 minutes. 19 pts (63%) survived and 11 pts (37%) died while at the hospital, 6 from intractable shock, 4 from multiple organ failure and in 1 case from pulmonary hemorrhage. Mean time of revascularization for the surviving was 190 +/- 329 min, and for the dead 295 +/- 212 min. Hospital mortality for inferior infarction is 12.5% after successful angioplasty. Comparison of surviving and non surviving number of patients according to revascularization time showed a significant difference of these groups whether the revascularization was accomplished before or after 120 minutes. [table: see text]

CONCLUSION

Direct PTCA for AMI immediately complicated by CS, can be achieved with a high success rate, and can significantly reduce in-hospital mortality; this improvement of survival is most evident if revascularizarion is performed early.

[Prevention and treatment of atrial fibrillation after cardiac surgery]

The incidence of postoperative atrial fibrillation in cardiac surgery is still high despite major advances in anesthetic, pharmacological and surgical techniques. Its precise mechanism is still totally unknown. Postoperative atrial fibrillation increases length of stay as well as hospital costs. Rate of postoperative atrial fibrillation spontaneous conversion is high. Several protocols have been developed for prevention and/or treatment of postoperative atrial fibrillation. Beta-blockers, amiodarone and atrial pacing reduce.atrial fibrillation incidence as compared to placebo. On the other hand, amiodarone and propafenone achieve a high conversion rate of installed postoperative atrial fibrillation. However, among many pharmacological options, the best treatment is still to be defined.

[Three-dimensional renal angiography]

The usefulness of three-dimensional angiography is not fully established except for neurovascular diseases. We report a case of significant renal artery stenosis not shown on conventional angiography because of its orientation along the axial plane, where 3D imaging allowed complete analysis of the lesion leading to endovascular treatment.

Effects of tirofiban and statins on high-sensitivity C-reactive protein, interleukin-6, and soluble CD40 ligand following percutaneous coronary interventions in patients with stable coronary artery disease

This study assessed the effects of tirofiban and statins on high-sensitivity C-reactive protein, interleukin-6, and soluble CD40 ligand after percutaneous coronary intervention in patients who had stable coronary artery disease. Tirofiban insignificantly limited the increase of soluble CD40 ligand after revascularization, especially in patients who had high levels of this marker at baseline (p = 0.06), whereas statins significantly inhibited increases in interleukin-6 and, to a lesser extent, high-sensitivity C-reactive protein without affecting the soluble CD40 ligand.

Role of Cytochrome P450 Metabolites of Arachidonic Acid in Hypertension

Considerable evidence has accumulated over the last decade implicating a role of cytochrome P450 (CYP)-dependent metabolites of arachidonic acid (AA) in the pathogenesis of hypertension. Indeed, 20-hydroxyeicosatetraenoic acid (20-HETE) is produced by vascular smooth muscle (VSM) cells and is a potent vasoconstrictor that depolarizes VSM by blocking large conductance Ca+-activated K2+ channels. In contrast, epoxyeicosatrienoic acids (EETs) are synthesized by the vascular endothelium and have opposite effects on VSM (hyperpolarization and vasodilatation). Inhibition of the synthesis of 20-HETE attenuates myogenic tone and autoregulation of blood flow and modulates vascular responses to vasodilators (NO and CO) and vasoconstrictors (angiotensin II, endothelin). In the kidney, 20-HETE inhibits sodium transport in the proximal tubule by blocking Na+-K+-ATPase activity. In the thick ascending limb of the loop of Henle, 20-HETE inhibits Na+-K+-2Cl- transport, in part, by blocking a 70 pS apical K+ channel. EETs are produced in the proximal tubule where they inhibit Na+-H+ exchange and in the collecting duct where they inhibit sodium and water transport. Numerous studies have established that the formation of EETs and 20-HETE and the expression of CYP enzymes are altered in the kidney in many genetic and experimental animal models of hypertension and in some forms of human hypertension. However, the functional significance of these changes remains to be determined. Given the importance of this pathway in the control of renal function and vascular tone, it is likely that alterations in the renal formation of CYP-dependent metabolites of AA will be shown to participate in the development of hypertension in many of these models.

Gadolinium-based coronarography in a patient with renal failure: first clinical report

This article reports the use of gadolinium to perform a coronarography in a patient with renal insufficiency, unstable angina, and peripheral vascular disease. The examination was well tolerated and the images obtained of good quality. Cathet Cardiovasc Intervent 2001;54:68-69.

[Hydatid cyst of the heart simulating coronary ischemia]

Cardiac echinococcosis is rare despite endemic occurrence of echinococcosis in some regions of the world. Clinical presentation can vary and may be misleading. Diagnosis is facilitated by new imaging techniques. Surgery is mandatory to avoid serious complications. We report a case of cardiac echinococcosis with pseudo, ischemic clinical and electrical presentation.

Hormone replacement therapy in postmenopausal women: endometrial hyperplasia and irregular bleeding

BACKGROUND

The decline in circulating oestrogen around the time of the menopause often induces unacceptable symptoms that affect the health and well being of women. Hormone replacement therapy (both unopposed oestrogen and oestrogen and progestogen combinations) is an effective treatment for these symptoms. In women with an intact uterus, unopposed oestrogen may induce endometrial stimulation and increase the risk of endometrial hyperplasia and carcinoma. The addition of progestogen reduces this risk but may cause unacceptable symptoms, bleeding and spotting which can affect adherence to therapy.

OBJECTIVES

The objective of this review is to assess which hormone replacement therapy regimens provide effective protection against the development of endometrial hyperplasia and/or carcinoma with a low rate of abnormal vaginal bleeding.

SEARCH STRATEGY

Electronic searches for relevant randomised controlled trials of the Cochrane Menstrual Disorders and Subfertility Group Register of Trials, MEDLINE, EMBASE, PsychLIT, Current Contents, Biological Abstracts, Social Sciences Index and CINAHL were performed. Attempts were also made to identify trials from citation lists of review articles and drug companies were contacted for unpublished data. In most cases, the corresponding author of each included trial was contacted for additional information.

SELECTION CRITERIA

The inclusion criteria were randomised comparisons of unopposed oestrogen therapy, combined continuous oestrogen-progestogen therapy and sequential oestrogen-progestogen therapy with each other and placebo administered over a minimum treatment period of six months. Trials had to assess which regimen was the most protective against the development of endometrial hyperplasia/carcinoma and/or caused the lowest rate of irregular bleeding.

DATA COLLECTION AND ANALYSIS

Twenty three RCTs were identified and five were excluded. The reviewers assessed the eighteen included studies for quality, extracted the data independently and odds ratios for dichotomous outcomes were estimated. Outcomes analysed included frequency of endometrial hyperplasia or carcinoma, frequency of irregular bleeding and unscheduled biopsies or dilation and curettage, and adherence to therapy.

MAIN RESULTS

Unopposed moderate or high dose oestrogen therapy was associated with a significant increase in rates of endometrial hyperplasia with increasing rates at longer duration of treatment and follow up. Odds ratios ranged from 5.4 (1. 4-20.9) for 6 months of treatment to 16.0 (9.3-27.5) for 36 months of treatment with moderate dose oestrogen (in the PEPI trial, 62% of those who took moderate dose oestrogen had some form of hyperplasia at 36 months compared to 2% of those who took placebo). Irregular bleeding and non adherence to treatment were also significantly more likely under these unopposed oestrogen regimens with greater effects with higher dose therapy. There was no evidence of increased hyperplasia rates, however, with low dose oestrogen. The addition of progestogens, either in continuous combined or sequential regimens, helped to prevent the development of endometrial hyperplasia and improved adherence to therapy (odds ratios of 3.7 for sequential therapy and 6.0 for continuous therapy). Irregular bleeding, however, was more likely under a continuous than a sequential oestrogen-progestogen regimen (OR = 2.3, 95% CI 2.1-2.5) but at longer duration of treatment, continuous therapy was more protective than sequential therapy in preventing endometrial hyperplasia (OR = 0.3, 95% CI 0.1-0.97). There was evidence of a higher incidence of hyperplasia under long cycle sequential therapy (progestogen given every 3 months) compared to monthly sequential therapy (progestogen given every month). No increase in endometrial cancer was seen in any of the treatment groups during the limited duration (maximum of 3 years) of these trials. (ABSTRACT TRUNCATED)

[Renovascular arterial hypertension in the framework of von Recklinghausen's neurofibromatosis. Apropos of a case]

Arterial hypertension in patients with neurofibromatosis is most often due to an associated pheochromocytoma. In rare cases the etiology of arterial hypertension is renovascular. Surgical treatment is mandatory when the stenosis is located in the proximal segment of the vessel. Angioplasty is hazardous in this setting due to the fibrotic nature of the culprit lesion. The authors report a case of ostial narrowing of the right renal artery in a 16-year-old girl with severe arterial hypertension and neurofibromatosis. The operation consisted of resection of the culprit lesion and reimplantation of the renal artery on the aorta. Postoperatively her blood pressure returned to normal.

Changing pattern of expression of the epidermal growth factor receptor and transforming growth factor alpha in the progression of prostatic neoplasms

The autocrine/paracrine interaction of the epidermal growth factor receptor (EGFr) and transforming growth factor alpha (TGF-alpha) has been implicated in prostate cancer cell growth and proliferation. To evaluate the role of EGFr and TGF-alpha in prostate cancer progression, we studied the immunohistochemical staining pattern of EGFr and TGF-alpha in malignant primary and hormone-independent metastatic prostate lesions. The specimens evaluated included 37 primary carcinomas (34 hormone-naive and 3 hormone-refractory tumors) and 22 metastases. For each specimen, the pattern of expression was evaluated and staining reactivities graded from 0-3, with 0 representing no staining and 3 representing homogeneous and intense staining. Primary malignant prostate epithelial cells in areas with discrete gland formation showed strong EGFr immunostaining, while stromal cells were generally nonreactive. In untreated primary tumors, TGF-alpha expression was primarily in the stroma, while epithelial cells were weakly positive in several cases. Malignant epithelial cells adjacent to neural elements that stained positive for TGF-alpha was frequently observed. A homogeneous staining pattern for EGFr was noted in 17 (89%) of 19 evaluable androgen-independent-refractory metastases, while TGF-alpha expression was found in 14 (78%) of 18 evaluable cases. Overall, 14 of 18 androgen-independent metastases coexpressed the receptor and the ligand. These results suggest that, unlike primary prostate tumors where a paracrine relationship between EGFr and TGF-alpha appears to predominate, the potential for autocrine stimulation may exist in the majority of metastatic androgen-independent tumors. Furthermore, the changing pattern of expression as the disease evolves from the localized hormone-naive to metastatic androgen-independent condition suggests that strategies aimed at blocking this growth factor pathway may be of therapeutic importance for androgen-independent disease.

Neoadjuvant chemotherapy for invasive bladder cancer: prognostic factors for survival of patients treated with M-VAC with 5-year follow-up

PURPOSE

To determine survival in patients with muscle-invasive bladder cancer treated with neoadjuvant chemotherapy and to analyze prechemotherapy and postchemotherapy factors for prognostic significance.

PATIENTS AND METHODS

The survival of 111 patients with T2-4N0M0 bladder cancer treated with neoadjuvant methotrexate, vinblastine, doxorubicin, and cisplatin (M-VAC) was assessed. Prechemotherapy and postchemotherapy factors were analyzed for correlation with survival. Factors found to be significant on univariate analysis were subjected to multivariate analysis using Cox's proportional hazards model.

RESULTS

The median follow-up duration was 5.3 years. Initial tumor (T) stage (P = .0001), presence of ureteral obstruction (P = .0074), and presence of a palpable mass (P = .0039) were the only pretreatment factors found to be significant on univariate analysis. Postchemotherapy surgery was performed in 81 patients. In these cases, postchemotherapy clinical stage and pathologic stage were significant factors on univariate analysis. In the multivariate analysis, the initial prechemotherapy T stage and the postchemotherapy pathologic stage (pT stage) were the only two factors to demonstrate independent significance. An association between downstaging postchemotherapy and survival was observed for patients with extravesical disease (T < or = 3B) at the start of treatment. In this subset, the 5-year survival rate was 54% for patients with downstaging versus 12% for those without downstaging. This association was not observed for patients with bladder-confined disease (T < or = 3A) at presentation.

CONCLUSION

The stage of bladder cancer at presentation and at postchemotherapy pathologic staging are independent prognostic factors for long-term survival in patients treated with neoadjuvant chemotherapy. Downstaging after neoadjuvant chemotherapy was associated with improved survival in patients with muscle-invasive bladder cancers, but only for those with extravesical disease (T > or = 3B) pretreatment. Randomized comparisons will be required to assess the impact of chemotherapy on overall survival.

Spontaneous cholesterol embolization. A rarely reported entity

Cholesterol embolization sometimes occurs after invasive procedures involving manipulation of the aorta or its major branches, and less commonly occurs after thrombolytic therapy for acute myocardial infarction. Rarer still is spontaneous cholesterol embolization, a case of which we now report. Our patient experienced peripheral embolization, the origin of which was traced to the infrarenal aortic segment and the common iliac vessels. Aortoiliac reconstruction was successful; we believe that surgical management of this condition should be performed in selected cases.

Severe phenytoin-induced bone marrow depression and agranulocytosis treated with human recombinant granulocyte-macrophage colony-stimulating factor. Case report

An unusual instance of severe and potentially lethal depression of the bone marrow is described as a result of the administration of phenytoin for seizure prophylaxis. The patient was treated successfully by prompt cessation of phenytoin and intravenous administration of human recombinant granulocyte-macrophage colony-stimulating factor.

Percutaneous embolization of an arteriovenous fistula of the internal mammary pedicle following sternal wire insertion

A case of traumatic arteriovenous fistula and false aneurysm of the internal mammary artery was encountered following sternal wire insertion during cardiac surgery. The diagnosis was suspected by echo-doppler and confirmed by arteriography allowing percutaneous embolization using cyanoacrylate in the same setting.

Isolated extracardiac unruptured sinus of Valsalva aneurysms

Reports concerning unruptured, isolated aneurysms of one sinus of Valsalva are rare. These aneurysms usually protrude inside the heart and are very rarely extracardiac. We report 4 cases of isolated, unruptured extracardiac aneurysms of the noncoronary sinus of Valsalva. Clinical symptoms were nonspecific. Operation was performed by patch reconstruction of the dilated aortic sinus without replacement of the ascending aorta. Microscopic examination of the diseased aortic wall revealed absence of medial elastic fibers. Late follow-up in all 4 cases revealed a normal ascending aorta with no dilatation of the aortic root and no aortic regurgitation.