Cardiac, possible cardiac, and likely non-cardiac origin of chest pain : A hitherto underestimated parameter in German chest pain units

BACKGROUND

Current guidelines emphasize the diagnostic value of non-cardiac or possibly cardiac chest pain. The goal of this analysis was to determine whether German chest pain units (CPUs) adequately address conditions with "atypical" chest pain in existing diagnostic structures.

METHOD

A total of 11,734 patients from the German CPU registry were included. The analyses included mode of admission, critical time intervals, diagnostic steps, and differential diagnoses.

RESULTS

Patients with unspecified chest pain were younger, more often female, were less likely to have classic cardiovascular risk factors and tended to present more often as self-referrals. Patients with acute coronary syndrome (ACS) mostly had prehospital medical contact. Overall, there was no difference between these two groups regarding the time from the onset of first symptoms to arrival at the CPU. In the CPU, the usual basic diagnostic measures were performed irrespective of ACS as the primary working diagnosis. In the non-ACS group, further ischemia-specific diagnostics were rarely performed. Extra-cardiac differential diagnoses were not specified.

CONCLUSION

The establishment of broader awareness programs and opening CPUs for low-threshold evaluation of self-referring patients should be discussed. Regarding the rigid focus on the clarification of cardiac causes of chest pain, a stronger interdisciplinary approach should be promoted.

Phagocytosis of latex beads by a human monocytic Mono Mac 6 cell line and effects of low-frequency electromagnetic field interaction

Some studies have shown that electromagnetic fields (EMFs) may impact immune response cells and their functions. The first stage of the defense from pathogens is innate immunity encompassing phagocytosis and phagocytosis-related intracellular effects. Our work aimed to determine the influence of a low-frequency electromagnetic field (7 Hz, 30 mT_rms) on the phagocytosis process of latex beads (LBs), the production of reactive oxygen species (ROS), and viability changes in a human monocytic Mono Mac 6 (MM6) cell line as an experimental model of the phagocytosing cells in in vitro cell culture conditions. For these purposes, cells were firstly activated with infectious agents such as lipopolysaccharide (LPS), Staphylococcal enterotoxin B (SEB), or the proliferatory agent phytohaemagglutinin (PHA), and then a phagocytosis test was performed. Cell viability and range of phagocytosis of latex beads by MM6 cells were measured by flow cytometry, and the level of ROS was evaluated with the use of a cytochrome C reduction test. The obtained results revealed that applied EMF exposure mainly increased the necrosis parameter of cell death when they were pre-stimulated with SEB as an infectious factor and subsequently phagocytosed LBs (P=0.001). Prestimulation with other agents like LPS or PHA preceding phagocytosis resulted in no statistically significant changes in cell death parameters. The level of ROS depended on the used stimulatory agent, phagocytosis, and/or EMF exposure. The obtained effects for EMF exposure indicated only a slight decrease in the ROS level for cells phagocytosing latex beads and being treated with SEB or PHA, while the opposite effect was observed for LPS pre-stimulated cells (data not statistically significant). The results concerning the viability of phagocytosing cells, the effectiveness of the phagocytosis process, and the level of radical forms might result from applied EMF parameters like signal waveform, frequency, flux density, and especially single EMF exposure.

[Metabolic syndrome and atrial fibrillation]

Metabolic syndrome is defined by the simultaneous occurrence of the cardiovascular risk factors obesity, hypertension, diabetes and dyslipidemia. Overweight, in particular, is continuously increasing in many countries. In this respect, metabolic syndrome is a strong risk factor for atrial fibrillation. Only few data are available on the influence of obesity on antiarrhythmic drugs. Sodium channel blockers, in particular, appear to show a reduced effectiveness. Direct oral anticoagulants can be used for anticoagulation in obese patients. With a body weight > 140 kg, a plasma level measurement is recommended. Severe overweight reduces the chances of successful ablation treatment and leads to more complications. Consistent treatment of the metabolic syndrome, and in particular weight reduction, can significantly improve the risk and the frequency of atrial fibrillation, the associated symptoms and the success of treatment for maintaining cardiac rhythm.

Correlation of Walking Activity and Cardiac Hospitalizations in Coronary Patients for 1 Year Post Cardiac Rehabilitation: The More Steps, the Better!

Problem:

Reducing risk by improving fitness is one of the main objectives of cardiac rehabilitation (CR). To estimate how the number of steps/day post-CR affects coronary patients’ prognosis, we analyzed its correlation with the occurrence of death, hospitalizations, and heart complaints, and if and how other variables (ejection fraction (EF), gender, age) relate to those.

Methods:

One hundred eleven patients (male = 91, female = 20; average age ± standard deviation (SD): 61 ± 11 years) who had been in CR due to recent coronary revascularization or chronic coronary syndrome could be enrolled. Patients were advised to document their steps (daily), blood pressure (daily), weight (weekly) and occurrences of a cardiac event in a diary for 1 year post-CR. A Cox proportional hazard model was used to examine the influence of steps/day, EF, gender, and age until the occurrence of an event. Kaplan-Meier curves were generated to compare patients’ profiles.

Results:

Average steps/day of patients post-CR were 7333 (SD 4426). Increased walking activity reduced risk for cardiac hospitalization (constant steps/day: 5000 vs 7500, hazard rate (HR) reduction of 0.43; 10 000 vs 12 500, HR reduction of 0.20) and risk was higher in patients with an EF < 55% versus EF ⩾ 55% (HR increase of 2.88). Median follow-up time post-CR was 218 days. No patient died, 25 were hospitalized.

Discussion:

Monitoring the number of steps of coronary patients post CR could be valuable for estimating patients’ prognosis.

[Electromagnetic interference : Pacemakers, cardiac resynchronization therapy devices, implantable cardioverter-defibrillator]

Patients with cardiac pacemakers, implantable cardioverter-defibrillators (ICDs), and cardiac resynchronization therapy devices (CRT) are exposed to different types of electromagnetic interference (EMI) at home and at work. Due to the constantly increasing role of electrically active appliances in daily use and the introduction of new therapy concepts such as the leadless cardiac pacemaker and the subcutaneous defibrillator, this topic is of great relevance. The further development of the implanted devices and the almost complete use of bipolar leads has reduced the overall risk of EMI. This review article provides information about the current status of possible interference in the private environment and how to avoid it. In addition, information is provided on how to deal with occupational sources of interference.

Food for all: designing sustainable and secure future seafood systems

Food from the sea can make a larger contribution to healthy and sustainable diets, and to addressing hunger and malnutrition, through improvements in production, distribution and equitable access to wild harvest and mariculture resources and products. The supply and consumption of seafood is influenced by a range of 'drivers' including ecosystem change and ocean regulation, the influence of corporations and evolving consumer demand, as well as the growing focus on the importance of seafood for meeting nutritional needs. These drivers need to be examined in a holistic way to develop an informed understanding of the needs, potential impacts and solutions that align seafood production and consumption with relevant 2030 Sustainable Development Goals (SDGs). This paper uses an evidence-based narrative approach to examine how the anticipated global trends for seafood might be experienced by people in different social, geographical and economic situations over the next ten years. Key drivers influencing seafood within the global food system are identified and used to construct a future scenario based on our current trajectory (Business-as-usual 2030). Descriptive pathways and actions are then presented for a more sustainable future scenario that strives towards achieving the SDGs as far as technically possible (More sustainable 2030). Prioritising actions that not only sustainably produce more seafood, but consider aspects of access and utilisation, particularly for people affected by food insecurity and malnutrition, is an essential part of designing sustainable and secure future seafood systems.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s11160-021-09663-x.

Food for all: designing sustainable and secure future seafood systems

Food from the sea can make a larger contribution to healthy and sustainable diets, and to addressing hunger and malnutrition, through improvements in production, distribution and equitable access to wild harvest and mariculture resources and products. The supply and consumption of seafood is influenced by a range of 'drivers' including ecosystem change and ocean regulation, the influence of corporations and evolving consumer demand, as well as the growing focus on the importance of seafood for meeting nutritional needs. These drivers need to be examined in a holistic way to develop an informed understanding of the needs, potential impacts and solutions that align seafood production and consumption with relevant 2030 Sustainable Development Goals (SDGs). This paper uses an evidence-based narrative approach to examine how the anticipated global trends for seafood might be experienced by people in different social, geographical and economic situations over the next ten years. Key drivers influencing seafood within the global food system are identified and used to construct a future scenario based on our current trajectory (Business-as-usual 2030). Descriptive pathways and actions are then presented for a more sustainable future scenario that strives towards achieving the SDGs as far as technically possible (More sustainable 2030). Prioritising actions that not only sustainably produce more seafood, but consider aspects of access and utilisation, particularly for people affected by food insecurity and malnutrition, is an essential part of designing sustainable and secure future seafood systems.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s11160-021-09663-x.

Unexpected high level of severe events even in low-risk profile chest pain unit patients

AIMS

Early heart attack awareness programs are thought to increase efficacy of chest pain units (CPU) by providing live-saving information to the community. We hypothesized that self-referral might be a feasible alternative to activation of emergency medical services (EMS) in selected chest pain patients with a specific low-risk profile.

METHODS AND RESULTS

In this observational registry-based study, data from 4743 CPU patients were analyzed for differences between those with or without severe or fatal prehospital or in-unit events (out-of-hospital cardiac arrest and/or in-unit death, resuscitation or ventricular tachycardia). In order to identify a low-risk subset in which early self-referral might be recommended to reduce prehospital critical time intervals, the Global Registry of Acute Coronary Events (GRACE) score for in-hospital mortality and a specific low-risk CPU score developed from the data by multivariate regression analysis were applied and corresponding event rates were calculated. Male gender, cardiac symptoms other than chest pain, first onset of symptoms and a history of myocardial infarction, heart failure or cardioverter defibrillator implantation increased propensity for critical events. Event rates within the low-risk subsets varied from 0.5-2.8%. Those patients with preinfarction angina experienced fewer events.

CONCLUSIONS

When educating patients and the general population about angina pectoris symptoms and early admission, activation of EMS remains recommended. Even in patients without any CPU-specific risk factor, self-referral bears the risk of severe or fatal pre- or in-unit events of 0.6%. However, admission should not be delayed, and self-referral might be feasible in patients with previous symptoms of preinfarction angina.

Ticagrelor monotherapy versus aspirin in patients undergoing multiple arterial or single arterial coronary artery bypass grafting: insights from the TiCAB trial

OBJECTIVES

We evaluated the effect of ticagrelor monotherapy on outcomes after multiple arterial grafting (MAG) or single arterial grafting (SAG) in coronary artery bypass grafting (CABG).

METHODS

In a post hoc, non-randomized analysis of the TiCAB (Ticagrelor in CABG; ClinicalTrials.gov NCT01755520) trial, we compared event rates for ticagrelor versus aspirin in patients undergoing MAG and SAG. Primary outcome was the composite of cardiovascular death, non-fatal myocardial infarction (MI), stroke or repeat revascularization 1 year after CABG. Secondary outcomes included individual components of the primary end point, all-cause death and bleeding.

RESULTS

Among 1753 patients, 998 patients underwent MAG and 755 patients underwent SAG. There was no significant difference in the 1-year primary composite outcome for ticagrelor versus aspirin with MAG [7.2% vs 7.9%; hazard ratio (HR) 0.90, 95% confidence interval (CI) 0.57-1.43; P = 0.66] or SAG (12.3% vs 8.6%; HR 1.47, 95% CI 0.93-2.31; P = 0.10). Event rates for cardiovascular death, MI, stroke, repeat revascularization and all-cause death were similar for both treatment groups with MAG and SAG. No significant difference in major bleeding was observed for ticagrelor versus aspirin with MAG (2.6% vs 2.7%; HR 0.95, 95% CI 0.44-2.05; P = 0.90) or SAG (5.8% vs 4.0%; HR 1.49, 95% CI 0.77-2.89; P = 0.24).

CONCLUSIONS

In patients undergoing either MAG or SAG in the TiCAB trial, ticagrelor monotherapy compared with aspirin did not affect the rate of cardiovascular death, non-fatal MI, stroke or repeat revascularization, or the rate of bleeding, at 1 year after CABG.

Clinical outcomes of complete versus incomplete revascularization in patients treated with coronary artery bypass grafting: insights from the TiCAB trial

OBJECTIVES

In this post hoc analysis of the Ticagrelor in coronary artery bypass grafting (CABG) trial, we aimed to analyse patients treated with CABG receiving either complete revascularization (CR) or incomplete revascularization (ICR) independent from random allocation to either ticagrelor or aspirin.

METHODS

Of 1859 patients enrolled in the Ticagrelor in CABG trial, 1550 patients (83.4%) received CR and 309 patients (16.6%) ICR. Outcomes were evaluated regarding all-cause mortality, cardiovascular death, myocardial infarction (MI), repeat revascularization, stroke and bleeding within 12 months after CABG.

RESULTS

Baseline parameters revealed significant differences regarding clinical presentation (stable angina pectoris: CR 68.9% vs ICR 71.2%, instable angina pectoris: 14.1% vs 7.8%, non-ST elevation MI: 17.0% vs 21.0%, P ˂ 0.01), lesion characteristics (chronic total occlusion: CR 91.3% vs ICR 96.8%, P ˂ 0.01), operative technique [off-pump coronary artery bypass surgery (OPCAB): CR 3.0% vs ICR 6.1%, P ˂ 0.01] and number of utilized grafts (total number of grafts: 2.69/patient vs 2.49/patient, P ˂ 0.001). ICR patients displayed a significantly increased risk of repeat revascularization [hazard ratio (HR) 1.91, 95% confidence interval (CI) 1.16-3.16; P < 0.01] and percutaneous coronary intervention (HR 1.95, 95% CI 1.13-3.35; P < 0.05) within 12 months after CABG. Higher risk for repeat revascularization in ICR patients was independent from random allocation to either ticagrelor or aspirin and persisted after adjustment for baseline imbalances.

CONCLUSIONS

Patients with ICR presented more stable at the time of admission, but received less grafts, highly likely due to a higher rate of chronic total occlusion lesions and performed OPCAB. Although mortality presented no difference between groups, our results suggest that patients benefit from CR with regard to prevention of repeat revascularization.

Decreased layer specific longitudinal strain in myocardial segments supplied by stenosed LAD coronary artery: analysis for baseline, peak and recovery phase of stress echocardiography

Background

Despite wide utility of global longitudinal strain in the assessment of left ventricular function up to now little is known about layer specific quantification of myocardial function during stress tests and its potential for ischemia detection.

Purpose

To investigate diagnostic utility of layer specific LS during stress echocardiography using marker segments in patients with established Left Anterior Descending (LAD) coronary artery status.

Methods

We retrospectively analyzed 63 patients (mean age 62.5±9.9 years, 62% males) with suspected coronary artery disease, who had performed dobutamine stress echocardiography (DSE). Layer specific speckle tracking LS analyses were performed during rest, maximal stress and recovery. As a marker for LAD (segment most probably supplied by this artery) we used mid-anterior left ventricle segments. LAD status were established with coronary angiography or angioCT and consider as significant if ≥70% stenosis was present.

Results

In our study group 14 patients had significantly stenosed LAD (group 1) and 24 had normal coronaries (group 2). We detected significantly lowered absolute values of strain in endocardial and mid-myocardial layers of segments supplied by stenosed LAD at rest for endocardium −8.6% (group 1) vs −13.4% (group 2); p=0.045; and mid-myocardium −7.3% (group 1) vs −11.2% (group 2); p=0.044. Moreover, we observed similar trend at recovery, however without reaching statistical significance.

Conclusions

Longitudinal strain analysis focused on segments supplied by assessed coronary artery my provide quantitative data confirming ischemia in the settings of rest and stress echocardiography. Our pilot study suggest that for inotropic agents like dobutamine the potential ischemic dysfunction may be however masked at peak stage of the test.

Funding Acknowledgement

Type of funding source: None

Ticagrelor-based antiplatelet regimens in patients treated with coronary artery bypass grafting: a meta-analysis of randomized controlled trials

OBJECTIVES

The optimal antiplatelet strategy in patients undergoing CABG remains unclear. This is the first meta-analysis investigating the clinical outcomes associated with ticagrelor-based antiplatelet regimens in patients receiving CABG.

METHODS

Relevant scientific databases were searched for studies investigating antiplatelet regimens after CABG from inception until April 1, 2019. Studies which randomly assigned CABG patients to either ticagrelor-based or control antiplatelet regimens were eligible. The primary outcome of this analysis was all-cause death. The main secondary outcome was MI. Other outcomes of interest were cardiac death, major adverse cardiac events, stroke and bleeding. This study is registered with PROSPERO, number CRD42019122192.

RESULTS

Five trials comprising 3996 patients (2002 assigned to ticagrelor-based and 1994 to control antiplatelet regimens) were eligible for quantitative synthesis. The median follow-up was 12 months. Control antiplatelet regimens consisted of either aspirin or clopidogrel or both. As compared to control, ticagrelor-based regimens reduced the risk of all-cause death [0.61 (0.43-0.87); P = 0.007], cardiac death [0.58 (0.39-0.86); P = 0.007] and major adverse cardiac events [0.79 (0.63-0.98); P = 0.03], without difference in the risk of MI [0.76 (0.50-1.18); P = 0.22], stroke [0.99 (0.56-1.78); P = 0.98] or bleeding [1.04 (0.95-1.14); P = 0.41]. There was a treatment effect modification for the primary outcome associated with trials enrolling predominantly patients with acute coronary syndrome (P for interaction = 0.038).

CONCLUSIONS

In patients receiving CABG, ticagrelor-based regimens reduce mortality and major adverse cardiac events without excess bleeding risk as compared with aspirin monotherapy or the combination of aspirin and clopidogrel. The benefit of ticagrelor-based regimens is more relevant in those studies enrolling predominantly patients with acute coronary syndrome. These findings require further confirmation in randomized trials focused on this subset of patients and powered for clinical outcomes.

[Travelling with a pacemaker or implanted defibrillator]

There are no guidelines for patients travelling with implanted pacemakers or defibrillators. Only few publications deal with specific problems that this patient group might face. In this article different aspects of travelling with implanted electric devices are summarized. Patients with pacemakers and implanted defibrillators have nearly no limits when travelling. An exception to that rule is scuba diving, which mostly is limited because of the device. In general it is the underlying heart disease or arrhythmia that limits patients' travel activities. It is reasonable to travel after implantation only after wound healing is complete because arm movement on the implant site is limited and the risk of wound infection and lead dislocation is elevated in the early phase. However, if necessary, flying is possible 2 days after an uncomplicated implantation if pneumothorax can be excluded. Security checks can be passed safely by patients with pacemakers/defibrillators. Only repetitive movement of a handheld metal detector over the device should be avoided. When travelling to different time zones it might be reasonable to deactivate a programmed sleep rate (Medtronic, Biotronik). Patients at risk for ventricular arrhythmia (mainly patients with an implantable cardioverter-defibrillator) must make sure to take all possible preventive measures to avoid travelers' diarrhea. In case of infection early replacement of fluids and electrolytes is essential.

Herzschrittmacher- und ICD-Infektionen

Die Infektion von Herzschrittmachern und implantierbaren Defibrillatoren stellt ein zunehmendes Problem dar, da immer mehr komplexe Systeme bei multimorbiden Patienten implantiert werden. Wesentlich sind die Kenntnis der Risikofaktoren für eine Aggregatinfektion und die konsequente Prävention, u. a. durch eine perioperative Antibiotikaprophylaxe. Die Diagnostik kann, gerade bei latenten Infektionen, schwierig sein. Sie umfasst neben Blutkulturen die transthorakale und transösophageale Echokardiografie zur Abklärung von Vegetationen der Elektroden und/oder einer Endokarditis. In aller Regel ist neben einer verlängerten Antibiotikagabe die komplette Systemexplantation erforderlich. Die Indikation zur Reimplantation muss kritisch überprüft werden. Diese erfolgt nach vollständiger Ausheilung sofern möglich kontralateral. Alternativen können eine epikardiale Implantation oder elektrodenlose Systeme sein.

Walking activity during ambulant cardiac rehabilitation is related to maximum working capacity, age, and smoking behavior

BACKGROUND

A total of 6,500 to 8,000 steps per day are recommended for cardiovascular secondary prevention. The aim of this research was to examine how many steps per day patients achieve during ambulant cardiac rehabilitation (CR), and if there is a correlation between the number of steps and physical and cardiological parameters.

METHODS

In all, 192 stable CR patients were included and advised for sealed pedometry. The assessed parameters included maximum working capacity and heart rate, body mass index (BMI), New York Heart Association (NYHA) class, ejection fraction (EF), coronary artery disease status, beta-blocker medication, age, sex, smoking behavior, and laboratory parameters. A regularized regression approach called least absolute shrinkage and selection operator (LASSO) was used to detect a small set of explanatory variables associated with the response for steps per day. Based on these selected covariates, a sparse additive regression model was fitted.

RESULTS

The model noted that steps per day had a strong positive correlation with maximum working capacity (P=0.001), a significant negative correlation with higher age (P=0.01) and smoking (smoker: P<0.05; ex-smoker: P=0.01), a positive correlation with high-density lipoprotein (HDL), and a negative correlation with beta-blockers. Correlation between BMI and walking activity was nonlinear (BMI 18.5-24: 7,427±2,730 steps per day; BMI 25-29: 6,448±2,393 steps/day; BMI 30-34: 6,751±2,393 steps per day; BMI 35-39: 5,163±2,574; BMI >40: 6,077±1,567).

CONCLUSION

Walking activity during CR is reduced in patients who are unfit, older, smoke, or used to smoke. In addition to training recommendations, estimated steps per day during CR could be seen as a baseline orientation that helps patients to stay generally active or even to increase activity after CR.

Experimental infection by Yersinia ruckeri O1 biotype 2 induces brain lesions and neurological signs in rainbow trout (Oncorhynchus mykiss)

Pathological manifestations in rainbow trout (Oncorhynchus mykiss) following experimental waterborne infection with Yersinia ruckeri serotype O1 biotype 2 (strain 07111224) were investigated. Rainbow trout were exposed to 8 × 10⁷  CFU/ml of Y. ruckeri by bath for 6 hr, and mortality was then monitored for 22 days post-infection (dpi). Organs were sampled at 3 dpi and also from moribund fish showing signs of severe systemic infection such as bleeding, exophthalmia or erratic swimming behaviour. Y. ruckeri was observed in the meninges and diencephalon of the brain, and lamina propria of olfactory organ at 3 dpi. At 12 dpi, Y. ruckeri had spread throughout the brain including cranial connective tissues and ventricles and the infection was associated with haemorrhages and an infiltration with leucocytes. Y. ruckeri infection and associated with leucocyte infiltration were observed at 13 dpi. In conclusion, Y. ruckeri strain 07111224 causes encephalitis in the acute phase of infection, which could explain why Y. ruckeri-affected fish show exophthalmia and erratic swimming known as signs of ERM.

Position paper nuclear cardiology: Update 2008

Nuclear cardiology is well established in clinical diagnostic algorithms for many years. This is an update 2008 of the first common position paper of the German Association of Nuclear Medicine and the German Association of Cardiology, Heart and Circulation Research published in 2001 aiming at an overview of state-of-the-art scintigraphic methods.

Optimizing ventilation-perfusion lung scintigraphy: Parting with planar imaging

Aim of the study was to introduce and verify a ventilation-perfusion (V/Q) acquisition protocol that incorporates new developments in scintigraphy in order to allow for a more balanced comparison with other diagnostic procedures. Methods: In 103 patients suspect of having pulmonary embolism, V/Q scans were acquired exclusively with SPECT technique. Ventilation was done with ultrafine aerosol. Planar images in eight directions were reconstructed through addition of three consecutive SPECT projections. Three referees examined the scans in regard to type, localization, and extent of V/Q defects. Results: Using this protocol, significantly more defects, especially of subsegmental size, were detected (p <0.Q1). Sensitivity, and diagnostic accuracy were also significantly improved (p <0.01) to 0.96, and 0.99, respectively. Furthermore, kappa values were increased up to 0.82 - a relevant enhancement in the ability to precisely localize V/Q defects. Conclusion: In conclusion this protocol provides high-resolution tomographic scans as well as high-quality planar images within a short acquisition time. Due to the significant increase in lesion detection, sensitivity, diagnostic accuracy, and anatomical localization of defects, it is a substantial improvement in the diagnosis of pulmonary embolism that will put V/Q scintigraphy on a par with other tomographic methods.

Combined image interpretation of computed tomography and hybrid PET in head and neck cancer

Aim: Evaluation of potential synergistic effects of combined image interpretation of FDG PET using a gamma camera modified for coincidence detection (hybrid PET) and computed tomography (CT) and comparison of the diagnostic accuracy of hybrid PET and dedicated PET in patients with head and neck cancer. Methods: Forty-two patients with suspected primary or recurrent cancer were included. Twenty-four patients underwent dedicated PET in addition to attenuationcorrected hybrid PET using a one-day protocol. Results: Sensitivity, specificity and accuracy for detection of primary or recurrent head and neck cancer were 74, 73, and 74% for hybrid PET, 52, 82, and 60% for CT and 77, 82, and 79% for combined reading. With the combination of CT and hybrid PET all cases of recurrent disease were detected. The largest tumour not detected was 1.7 cm in diameter. Sensitivity, specificity and accuracy for the detection of neck sides with lymph node metastases were 69, 88, and 85% for hybrid PET, 62, 88, and 84% for CT, 69, 99, and 94% for combined image interpretation. With combined interpretation four involved neck sides were missed including two cases of microscopic metastases. Hybrid PET revealed concordant results to dedicated PET in all patients with respect to the detection of primary or recurrent tumour and in 45 of 48 neck sides (94%) with the same number of false negative findings. Conclusion: The combination of functional information of hybrid PET and morphological information of CT by the simple approach of combined image interpretation improves the sensitivity for the detection of primary/recurrent head and neck cancer and increases the specificity of lymph node staging compared to CT alone. The accuracy of hybrid PET and dedicated PET was almost identical.

An approach for comparative quantification of myocardial blood flow (0-15-H2O-PET), perfusion (Tc-99m-tetrofosmin-SPECT), and metabolism (F 18-FDG-PET)

Aim: In the present study a new approach has been developed for comparative quantification of absolute myocardial blood flow (MBF), myocardial perfusion, and myocardial metabolism in short-axis slices. Methods: 42 patients with severe CAD, referred for myocardial viability diagnostics, were studied consecutively with 0-15-H2O PET (H2O-PET) (twice), Tc-99m-Tetrofosmin 5PECT (TT-SPECT) and F-18-FDG PET (FDG-PET). All dato sets were reconstructed using attenuation correction and reoriented into short axis slices. Each heart was divided into three representative slices (base, rnidventricular, apex) and 18 ROIs were defined on the FDG PET images and transferred to the corresponding H2O-PET and TT-SPECT slices. TT-SPECT and FDG-PET data were normalized to the ROI showing maximum perfusion. MBF was calculated for all left-ventricular ROIs using a single-compartment-model fitting the dynamic H2O-PET studies. Microsphere equivalent MBF (MBF_micr) was calculated by multiplying MBF and tissue-fraction, a parameter which was obtained by fitting the dynamic H2O-PET studies. To reduce influence of viability only well perfused areas (>70% TT-SPECT) were used for comparative quantification. Results: First and second mean global MBF values were 0.85 ml × min-1 × g-1 and 0.84 ml × min-1 × g1, respectively, with a repeatability coefficient of 0.30 ml ÷ min-1 × gl. After sectorization mean MBF_micr was between 0.58 ml × min1 ÷ ml"1 and 0.68 ml × min-1 × ml"1 in well perfused areas. Corresponding TT-SPECT values ranged from 83 % to 91 %, and FDG-PET values from 91 % to 103%. All procedures yielded higher values for the lateral than the septal regions. Conclusion: Comparative quantification of MBF, MBF_micr, TT-SPECT perfusion and FDG-PET metabolism can be done with the introduced method in short axis slices. The obtained values agree well with experimentally validated values of MBF and MBF_micr.

Characterization of radioiodine therapy failures in Graves’ disease

Aim of this study was a characterization of radioiodine therapy (RIT) failures in Graves’ disease without simultaneous Carbimazole. Method: 226 patients with a confirmed diagnosis of Graves’ disease received 686.8 ± 376.4 MBq of iodine-131 orally for thyroid ablation. Target dose was 250 Gy. All patients were followed up for 6 months. Therapy failures were compared with successes regarding possible influencing variables initial thyroid volume, thyroid function, immune activity (TRAb), 1-131 uptake, effective half-life, absorbed energy dose, age and gender. Results: 212 of 226 patients (93.8%) were treated successfully, 14 (6.2%) showed a hyperthyroidism relapse within 6 months which required a second radioiodine therapy. A success rate of 92.5% (62/67) could also be achieved with 67 patients who were hyperthyroid at the time of RIT. Compared to the therapy successes, the 14 failures achieved significantly lower absorbed doses (223.8 ±76.6 Gyvs. 285.2 ±82.1 Gy, ρ <0.005), but with no significant differences regarding age, thyroid volume, function or TRAb (all ρ >0.2). Of the 14 failures, η = 8 reached an absorbed dose <200 Gy and η = 1 a dose <250 Gy, although 5 of the failures reached an absorbed dose of >250 Gy. Stepwise logistic regression revealed only absorbed energy dose as a variable significantly influencing therapy success (p <0.005), but no influence of initial thyroid volume, function, TRAb value, age (all ρ >0.2) or gender (p = 0.13). Two-tailed Fisher’s exact test showed no significant influence of gender on success rates (failures/successes: male 1 /36, female 13/176, ρ = 0.48). Conclusions: Except for the absorbed energy dose, no other significant variable influencing the outcome of radioiodine therapy in Graves’ disease without simultaneous Carbimazole could be found. It should be noted, though, that 5 therapy failures (2.2%) reached an absorbed energy dose of >250 Gy.

Quantification of left ventricular volumes and ejection fraction from 16- and rebinned 8-frame gated 99mTc-tetrofosmin SPECT

Aim: Using 8-frames/cardiac cycle with gated SPECT underestimates end-diastolic volumes (EDV) and ejection fractions (LVEF), and overestimates end-systolic volumes (ESV). However, using 16-frames/cardiac cycle significantly decreases the signal-to-noise-ratio. We analyzed 16-frames and rebinned 8-frame gated SPECT data using common 4D-MSPECT and QGS algorithms. Patients, methods: 120 patients were examined using gated SPECT on a Siemens Multispect 3 (triple-head gamma camera) 60 minutes after intravenous administration at rest of about 450 MBq (two-day protocol) or about 750 MBq (one-day protocol) 99mTc-tetrofosmin. Reoriented short axis slices (16-frames) were summed framewise (1+2,3+4, etc.) yielding 8-frame data sets. EDV, ESV and LVEF were calculated for both data sets using 4D-MSPECT and QGS. Results: QGS succeeded with 119, 4D-MSPECT with 117 patients. For the remaining 116 patients, higher EDV (+0.8ml/+3.8ml) and LVEF (+1.5%/+2.6%; absolute) and lower ESV (–1.7ml/–0.9ml) (4D-MSPECT/QGS) were found for 16-frame runs. Bland-Altman limits were smaller for QGS than 4D-MSPECT [EDV 32/12ml, ESV 21/10ml, LVEF 17/7% (4D-MSPECT/QGS)]. Conclusion: Both algorithms showed the expected effects. Contour finding using QGS failed with only one data set, whereas contour finding using 4D-MSPECT failed with three data sets. Since the effects observed between the 8– and the 16-frame studies are relatively small and quite predictable, 8-frame studies can be employed in clinical routine with hardly any loss at all, plus contour finding appears less susceptible to error.

Stunning in radioiodine therapy of benign thyroid disease

In radioiodine therapy of benign thyroid disease, a reduction of radioiodine uptake is known for consecutive administrations of 131I, which needs to be considered in therapy planning. Aim: Analysis of uptake reduction with regard on the time interval between radioiodine administration and the delivered dose to the thyroid tissue. Patients, methods: 200 patients were enrolled in the study and distributed into two groups (matched for diagnoses), each containing 32 patients with Graves' disease (target dose 250 Gy), 24 with focal (400 Gy), 44 with disseminated thyroid autonomy (150 Gy). In one group, a second fraction of radioiodine was given after 48 h (2d) due to an unexpected low radioiodine uptake or effective half-life, whereas in the other group the second fraction was given after 96 h (4d). Results: There was no significant difference between delivered doses due to the first fraction after four days: 2d: 86 ± 48 Gy (extrapolated) vs. 4d: 87 ± 41 Gy, p > 0.05. In 2d, delivered dose at time of second administration was significantly lower (51 ± 29 Gy) than in 4d (p < 0.01). The radioiodine uptake of the second fraction relative to the initial uptake was significantly lower in the 4d (4d: 63 ± 25% vs. 2d: 82 ± 24%, p < 0.01). In addition, a correlation between uptake reduction and delivered dose and an influence of the time interval between radioiodine administrations could be shown. Conclusions: Relative uptake of subsequent radioiodine fractions decreases with time after first administration and with increasing delivered dose to the thyroid. If a second fraction of 131I is given at an earlier time, the same therapeutic effect can be reached using lower amounts of activity, minimising radiation exposure and increasing efficiency of radioiodine therapy.

Changes in U937 cell viability induced by stress factors - possible role of calmodulin

Current studies were aimed to elucidate influence of magnetic field (MF) stimulation on cell viability and its effect on expression of calmodulin (CaM) and Hsp70 protein which plays a role of cell stress indicator and is a Ca²⁺-dependent CaM-binding protein. For the experimental model we have chosen U937 cell line exposed to chemical- and/or physical stress factors. Puromycin (PMC) was used as a chemical apoptosis inducer. Alternating (AC) (6.5_rms mT, 35 Hz) magnetic field combined with 6 mT static (DC) component, or pulsed electromagnetic field (45 ± 5)mT, 50 Hz (PEMF) acted as physical stressors. Cell viability was assessed by flow cytometry, and the Western blot analysis was carried out for CaM and Hsp70 levels in cytosolic extracts of U937 cells. Cell viability in samples exposed to MF alone did not differ from sham sample, for both types of MF exposure systems. Simultaneous action of MF and PMC influenced cell viability in type of MF stimulation-dependent manner. In contrast to PEMF + PMC stimulated samples, combination of ACDCMF with PMC enhanced cell death compared to PMC control. The observed changes in cell viability were correlated with changes in level of CaM and Hsp70 proteins. Immunoblots have shown, that cytosolic content of both CaM and Hsp70 proteins was enhanced in PMC-treated sample, and further elevated for ACDCMF + PMC. For PEMF + PMC stimulated samples, level of CaM was reduced compared to PMC-treated sample. The results suggest that the changes in expression of CaM and CaM-dependent proteins might modulate effectiveness of cell death under stimulation with MF and/or cytotoxic agents.

Is mortality a useful parameter for public reporting in pacemaker implantation? Results of an obligatory external quality control programme

AIMS

To evaluate if public reporting of pacemaker implantation-associated mortality is meaningful in a large contemporary patient cohort.

METHODS AND RESULTS

The database of the obligatory external quality control programme in the Federal State of Hessen, Germany, of patients undergoing permanent pacemaker (PPM) implantation was evaluated retrospectively. We compared the baseline features of patients who died compared with those who did not during hospitalization after PPM. Of 5079 patients who underwent PPM implantation in 2009, 74 (1.5%) died during the hospital stay. Cause of death was available in 70/74 patients (94.6%) who died. Deceased patients were older (79.6 ± 8.7 vs. 76.3 ± 9.9 years, P = 0.006), had worse American Society of Anesthesiologists (ASA) physical status (P < 0.001), lower ejection fraction (P < 0.001), a greater prevalence of high-degree atrioventricular-block (44.3 vs. 35.0%, P = 0.001), and were more likely to receive single-chamber devices (41.4 vs. 25.0%, P < 0.002). Perioperative complications were similar in both cohorts. Death was not attributable directly to PPM procedure in any patients but was related to (i) non-device-related infections (28.6%), (ii) heart failure (25.7%), (iii) extracardiac diseases (21.4%), (iv) multiorgan failure (8.6%), (v) previous resuscitation with hypoxic brain damage (8.6%), and (vi) arrhythmogenic death (7.1%).

CONCLUSION

Mortality associated with PPM implantation in vast majority of cases was not related to the procedure, but to comorbidities and other existing diseases at the time of PPM implantation. Thus, PPM implantation in-hospital mortality should not be chosen for public reporting comparing hospital quality, even after adjusting for baseline risk.

Changes in viability of rat adipose-derived stem cells isolated from abdominal/perinuclear adipose tissue stimulated with pulsed electromagnetic field

Previous experiments demonstrated that low-frequency electromagnetic field (LF-EMF) may activate cellular death pathways in proliferating cells. Therefore, we hypothesized that LF-EMF may also influence viability of highly proliferating undifferentiated adipose-derived stem cells. Obesity is classified as a civilization disease; its etiopathogenesis is presumed to include both genetic predisposition and influence of modified environmental factors, such as unbalanced diet with excess calories and/or too low physical activity. Obesity may lead to a number of metabolic disorders, including type 2 diabetes mellitus, cardiovascular diseases (associated with atherosclerosis) related to primary hypertension and ischemic heart disease, myocardial infarction and other complications. The aim of this study was to verify if LF-EMF alters viability parameters of adipose-derived stem cells (ADSCs) isolated from rats, cultured in vitro and exposed to pulsed electromagnetic field (PEMF; 7 Hz, 30 mT). ADSCs were obtained from healthy rats and animals with experimentally-induced obesity, both males and females, pups and adults. The animals were fed with chow with either low (LF diet) or high fat content (HF diet) for 21 days. Then, ADSCs were isolated from extracted adipose tissue and used to establish cell cultures. ADSCs from the first passage were exposed to PEMF three times, 4 hours per exposure, at 24-h intervals (experimentally developed protocol of PEMF stimulation). 24 hours after the last exposure to PEMF, viability parameters of ADSCs were analyzed by flow cytometry (FCM). The study demonstrated that LF diet exerted a protective effect on PEMF-exposed ADSCs, especially in the case of male and female pups. In turn, the proportion of early apoptotic cells in PEMF-treated ADSC cultures from adult female rats maintained on HF diet turned out to be significantly higher than in other experimental groups.

Implantable cardioverter/defibrillators for primary prevention in dilated cardiomyopathy post-DANISH: an updated meta-analysis and systematic review of randomized controlled trials

BACKGROUND

Sudden cardiac death (SCD) is frequent in patients with heart failure due to dilated cardiomyopathy (DCM). Implantable cardioverter/defibrillator (ICD) device therapy is currently used for primary prevention. However, publication of the DANISH trial has recently given reason for doubt, showing no significant improvement in all-cause mortality in comparison to contemporary medical therapy.

METHODS

We performed a meta-analysis of all randomized controlled trials comparing ICD therapy to medical therapy (MT) for primary prevention in DCM. The primary outcome was all-cause mortality; secondary analyses were performed on sudden cardiac death, cardiovascular death and non-cardiac death.

RESULTS

Five trials including a total of 2992 patients were included in the pooled analysis. Compared to contemporary medical treatment there was a significant mortality reduction with ICD device therapy [odds ratio (OR) 0.77, 95% confidence interval (CI) 0.64-0.93; p = 0.006]. SCD was decreased significantly (OR 0.43, CI 0.27-0.69; p = 0.0004), while cardiovascular death and non-cardiac death showed no differences. Sensitivity analyses showed no influence of amiodarone therapy on overall results. Analysis of MT details revealed the DANISH population to adhere the most to current guideline recommendations. In addition, it was the only study including a substantial amount of CRT devices (58%).

CONCLUSIONS

Our meta-analysis of all available randomized evidence shows a survival benefit of ICD therapy for primary prevention in DCM. DANISH results suggest an attenuation of this ICD advantage when compared to contemporary medical and cardiac resynchronization therapy. Until larger trials have confirmed this finding, ICD therapy should remain the recommendation for primary prevention of SCD in DCM.

Unique properties of silver and copper silica-based nanocomposites as antimicrobial agents

The paper reports a new route for the fabrication and determination of physicochemical properties and biological activity, of metallic silica-based nanostructure (Ag/SiO₂, Cu/SiO₂).

Carvedilol Improves Myocardial Contractility Compared With Metoprolol in Patients With Chronic Hibernating Myocardium After Revascularization

Background: We tested the hypothesis of whether carvedilol delays morphologic degeneration and improves functional outcome compared with metoprolol tartrate in patients with hibernating myocardium undergoing surgical revascularization. We have previously shown that patients with chronic hibernating myocardium undergo progressive cellular degeneration and fibrosis.

Methods: Twenty patients with multivessel coronary artery disease revascularization and hibernating myocardium as assessed by technetium-99m perfusion scintigraphy and fluorine-18-fluorodeoxyglucose positron emission tomography were randomized to receive either carvedilol or metoprolol tartrate for at least 2 months before surgery, and this was continued for 7 months postoperatively. Left ventricular ejection fraction and regional wall motion abnormalities were assessed by left ventriculography at baseline and 7 months postoperatively. Intraoperative transmural needle biopsy samples were obtained for microscopic analysis.

Results: Postoperatively, the ejection fraction increased from 31% ± 5% to 44% ± 4% ( P < .005) in the carvedilol group (n = 10), and from 30% ± 6% to 40% ± 6% in the metoprolol tartrate group ( P < .05 vs preoperatively and vs carvedilol). Wall motion abnormalities in the carvedilol group improved from -2.1 ± 0.4 to -0.6 ± 0.5 ( P < .05) and from -2.3 ± 0.5 to -1.6 ± 0.6 in the metoprolol tartrate group ( P < .05 vs preoperatively and vs carvedilol). Microscopic analysis after 72 ± 18 days of either treatment showed mild cardiomyocyte degeneration and moderate-to-severe fibrosis (28% ± 7%) in the carvedilol group compared with moderate cardiomyocyte degeneration and moderate-to-severe fibrosis (33% ± 6%) in the metoprolol tartrate group. Apoptosis, as assessed by the terminal deoxynucleotidyl transferase nick end labeling method, was observed in only 1 patient in each group.

Conclusions: Carvedilol treatment of hibernating myocardium results in improved functional recovery after revascularization compared with metoprolol tartrate, and this might partially be related to reduced cardiomyocyte degeneration.

Incidence and characteristics of phrenic nerve palsy following pulmonary vein isolation with the second-generation as compared with the first-generation cryoballoon in 360 consecutive patients

AIMS

The second-generation cryoballoon (CB2) with increased surface cooling has recently become available. The aim was to investigate the incidence and characteristics of phrenic nerve palsy (PNP) during pulmonary vein isolation (PVI) using the CB2 as compared with the first-generation balloon (CB1).

METHODS AND RESULTS

A total of 360 consecutive patients with atrial fibrillation underwent PVI with the CB1 (106 patients) or the CB2 (254 patients). Right PN function was monitored by continuous stimulation and palpation during septal PV ablation. Persistent PNP (present at discharge) occurred in 2.8 and 1.9% (P = 0.63) of patients, transient PNP (full recovery before discharge) in 5.9 and 3.8% (P = 0.41) of patients in the CB2 and CB1 group, respectively. Phrenic nerve palsy during ablation at the right inferior PV was observed in 0% (CB1) and 4.3% (CB2, P = 0.03) of patients. Using the CB2, a trend of reduced incidence of persistent PNP over quartiles of consecutive patients was observed [4.8% (Q1) vs. 0% (Q4); P = 0.077]. At the culprit PV, PNP occurred after 3.5 ± 2.1 (CB1) and 1.1 ± 0.4 applications (CB2; P = 0.036). Complete recovery of PN function occurred after 29 ± 11 (CB1) and 259 ± 137 days (CB2; P = 0.004).

CONCLUSIONS

The rate of transient/persistent PNP associated with the use of the CB2 was 5.9 and 2.8%, respectively. Time to restitution of PN function was longer using the CB2.

Filling the gap: interventional occlusion of incompletely ligated left atrial appendages

AIMS

Patients undergoing heart surgery and with history of atrial fibrillation are often treated with intraoperative left atrial appendage (LAA) ligation. Incomplete LAA ligation is often described and can be associated with thrombo-embolic complications. To describe a case series of percutaneous LAA occlusion in patients previously treated with surgical LAA ligation.

METHODS AND RESULTS

Over 179 patients treated with implantation of an LAA-occluder system at our centre, 3 (1.6%) were previously treated with a surgical LAA suture exclusion (2 males, age 74 ± 3 years). Patients 1 and 3 presented a 'hammerhead' LAA morphology with an open neck and were successfully treated with an AGA Cardiac Plug (ACP-St Jude Medical) Device. Patient 2 had a conic monolobar LAA with a small neck, and the occlusion could be performed using a Watchman (Boston Scientific) device. After discharge on dual antiplatelet therapy, all the patients could be switched to single aspirin (ASA) therapy after a 6-week transoesophageal echocardiography control.

CONCLUSION

Left atrial appendage occlusion in patient with incomplete surgical ligation using percutaneous LAA occluder devices appears to be feasible, and studies including a larger number of patients are needed.