Uterine Fibroids and Hypertensive Disorders in Pregnancy: A Systematic Review and Meta-Analysis

Capsule

In this study the presence of uterine fibroids was significantly associated with an increased risk of development of hypertensive disorders of pregnancy even when accounting for age and BMI in meta-regression. This finding has potential implications for risk stratification and monitoring for hypertension during pregnancy in this population.

Objective

To examine the association between uterine fibroids and the development of hypertensive disorders in pregnancy.

Data sources

Cochrane, Embase, PubMed, MEDLINE, Scopus, and Web of Science databases were searched from inception through April 2023.

Study Selection and Synthesis

Cohort, case-control, or case series studies including uterine fibroid status and hypertensive disorders of pregnancy status were included. The comparison group was pregnant women without uterine fibroids. Inverse-variance weighted random effects models were used to pool RR and OR estimates separately. Age and BMI were explored as potential sources of heterogeneity using inverse-variance weighted meta-regression.

Main Outcomes

Hypertensive disorders of pregnancy (HDP) defined as gestational hypertension, pre-eclampsia, eclampsia, superimposed preeclampsia, or hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome.

Results

A total of 17 studies were included (Total N=1,374,395 participants, N=64,968 with uterine fibroids). Thirteen studies were retrospective cohorts and four were case-control studies. Women with uterine fibroids had a significantly higher risk of hypertensive disorders in pregnancy compared to women without uterine fibroids with RR 1.74 (95% CI 1.33-2.27, p<0.01), and OR 2.87 (95% CI 1.38-5.97, p<0.01), in cohort studies and case-control studies, respectively. In meta-regression analyses, age did not significantly change the positive association between uterine fibroids and hypertensive disorders in pregnancy.

Conclusion

Uterine fibroids were associated with an increased risk of hypertensive disorders of pregnancy when all available literature was synthesized, including when shared risk factors are examined in meta-regression analyses.

Relevance

If confirmed in future studies, investigations into the mechanisms of this association are needed as this finding potentially has implications for risk stratification and monitoring for hypertensive disorders of pregnancy in this population.

Trial Registration

PROSPERO, ID # 331528.

A Narrative Review on Spontaneous Clearance of Urogenital Chlamydia trachomatis: Host, Microbiome, and Pathogen-Related Factors

ABSTRACT

Chlamydia trachomatis (CT) is the most commonly reported sexually transmitted infection in the United States. Untreated urogenital infection in women can result in adverse sequelae such as pelvic inflammatory disease and infertility. Despite national screening and treatment guidelines, rates continue to rise; because most infections are asymptomatic, the actual prevalence of CT infection is likely significantly higher than reported. Spontaneous clearance of CT in women (in the absence of antibiotic treatment) has been described in multiple epidemiologic studies. Given the serious consequences and high prevalence of CT infection, there is growing interest in understanding this phenomenon and factors that may promote CT clearance in women. Spontaneous CT clearance is likely the result of complex interactions between CT, the host immune system, and the vaginal microbiota (i.e., the communities of bacteria inhabiting the vagina), which has been implicated in CT acquisition. Herein, we briefly review current literature regarding the role of each of these factors in spontaneous CT clearance, identify knowledge gaps, and discuss future directions and possible implications for the development of novel interventions that may protect against CT infection, facilitate clearance, and prevent reproductive sequelae.

Workplace interventions focusing on how to plan, organize and design the work environment in hospital settings: A systematic review

BACKGROUND

Occupational Health Service (OHS) is a service that should support employers and employees with their work environment. Previous research indicates the need for deeper knowledge about the effect of workplace interventions with a focus on planning, organizing and designing the workplace to improve work conditions in hospital settings.

OBJECTIVE

The aim was to evaluate the outcomes, workplace interventions and intervention strategies in hospital settings.

METHODS

A systematic literature review was conducted. CINAHL, MEDLINE, PsycInfo, Scopus, and Web of Science Core Collection were searched in September 2021. The Mixed Methods Appraisal Tool was used to evaluate the quality of the included studies. Study results are presented through a narrative synthesis. A protocol for this study was registered on the Open Science Framework.

RESULTS

Twenty-six studies, published between 2010 and 2021, were included. These included randomized controlled trials (RCTs), non-RCTs, and mixed methods reports with moderate to good quality. The results support the use of workplace interventions to improve work conditions, health, and well-being in hospital settings. Combinations of different interventions, tailored to the specific organization, were used. Important intervention strategies commonly used in the start-up, evaluation, and intervention of successful workplace interventions, were identified. Using a pragmatist complexity approach in workplace interventions can improve outcomes by providing clear intervention strategies and combinations of tailored interventions, related to context specific problems.

CONCLUSION

OHS support in workplace interventions with clear intervention strategies will contribute to improve work conditions, health and well-being in hospital settings.

Children with autism spectrum disorder in high technology medicine environments; a qualitative systematic review of parental perspectives

BACKGROUND

Children with autism spectrum disorders are frequent visitors to high technology environments, and their needs may differ from those of their typically developed peers. Procedures in high technology environments can constitute a challenge for these children and their parents since the environment presents many challenges relevant to the child's impairments. This systematic review aimed to explore the experiences of children with autism spectrum disorders and their parents during procedures in a high technology environment.

METHODS

The following sources were searched for this systematic review: Cochrane CENTRAL Trials, CINAHL, Dentistry and Oral Sciences Source, MEDLINE, PsycINFO, Scopus, and Web of Science Core Collection. The search terms included variants of the following concepts: (1) children with autism spectrum disorder and/or their parents and (2) anesthesia or radiographic departments. Publications were not limited by date or study design.

RESULT

Out of 13,389 bibliographic records, nine studies were eligible for synthesis. After another search in October 2022, one additional study was eligible for synthesis.None of the studies reported children's experiences, and all ten reported their parents' experiences. Only one study was conducted in a radiographic context. Parents' experiences were both positive and negative and were categorized into two main categories: (1) challenges in a new environment and (2) health care professionals' approaches.

CONCLUSION

Studies describing children's experiences with procedures in high technology environments are lacking. The parents described a need for health care professionals to work in structured ways with their child and to be able to make suitable adaptations.

SYSTEMATIC REVIEW REGISTRATION

This systematic review was registered in advance on the Open Science Framework, https://doi.org/10.17605/OSF.IO/5TXWJ .

A Systematic Review of Autoimmune Oophoritis Therapies

Autoimmune primary ovarian insufficiency (POI) is a devastating disease with limited clinical guidance. The objective of this systematic review was to identify treatments for autoimmune POI and analyze their efficacy. A comprehensive search of CINAHL, Cochrane, Embase, PubMed, Scopus, and Web of Science was performed from inception to April 2022. English language publications that evaluated women with autoimmune POI after a documented intervention were included. Animal models of autoimmune POI were also included. Risk of bias was assessed with the SYRCLE's risk of bias tool for animal studies or the NIH Quality Assessment Tool for Case Series as appropriate. Twenty-eight studies were included in this review, with 11 RCTs, 15 case reports, and 2 case series. Seventeen studies were in humans, and 11 were in animal models. No completed RCTs, cohort studies, or case-control studies were identified in humans. In observational human studies, corticosteroids were effective in select patients. In many case reports, adequate treatment of comorbid autoimmune conditions resulted in return of menses, hormonal normalization, or spontaneous pregnancy. In terms of assisted reproductive technologies, there was case report evidence for both in vitro fertilization (IVF) and in vitro maturation (IVM) in women wishing to conceive with their own oocytes. Ovulation induction, IVF, and IVM resulted in a total of 15 pregnancies and 14 live births. In animal models, there was additional evidence for stem cell therapies and treatments used in traditional Chinese medicine, although this research may not be generalizable to humans. Furthermore, litter size was not evaluated in any of the animal studies. Additional research is needed to establish the efficacy of current treatments for autoimmune POI with a controlled experimental design and larger sample size. Additionally, there is a critical need to develop novel therapies for this condition, as understanding of its pathophysiology and  available tools to modulate the immune response have progressed.

A Systematic Review of Epigenetics of Endometriosis

Objective

To assess the current literature evaluating the epigenetics of endometriosis in humans.

Evidence Review

A systematic review was conducted in accordance with the PRISMA guidelines within PubMed, EBSCOhost, Cochrane Library, Embase, Scopus, and Web of Science Core Collection. A comprehensive search strategy was developed by a data informationist. Observational and interventional studies assessing epigenetics in humans published in English up to January 15th, 2023, were included. Two reviewers independently screened studies evaluating the role of epigenetics in endometriosis. The risk of bias was assessed using Cochrane RoB 2.0 tool and the Newcastle-Ottawa scale. Extracted data were analyzed descriptively.

Results

We identified 18.639 studies, of which 57 were included, comprising 1.623 patients with endometriosis and 1.243 controls. Among the 57 studies included, 50 (88%) were case-control studies, and 7 (12%) were cross-sectional. Fifty-nine percent of the studies were Asian, 25% were from America, 14% were European, and 2% were from Africa. Acetylation and methylation were the two main key histone modifications that were centered in this review. Accordingly, we classified the studies as those focusing on genome-wide methylation and those on histone acetylation. Several studies identified an association between endometriosis and hypermethylated genes, including the PGR-B, SF-1, and RASSF1A. The genes HOXA10, COX-2, IL-12B, and GATA6 were found to be hypomethylated in endometriotic tissue by several studies. In regards to histone modification, multiple studies reported that the acetylation levels of histones H3 and H4 affect multiple genes associated with endometriosis. In addition, HDAC2 was found to be elevated in endometriosis patients in two studies.

Conclusion

Several studies reported a significant difference between specific genes' methylation levels in endometrial biopsies and normal tissue, which suggests that DNA methylation may play an important role in the modulation of the genotype in endometriotic tissue. Acetylation and methylation are the two key histone modifications leading to differential gene expression in endometriotic tissues. The alterations in gene expression reported by the 57 studies can have direct implications on cell cycle growth, cell cycle arrest, and apoptosis and, therefore, might play a key role in the pathogenesis of endometriosis. This review offers insight that histone modifications need further research to evaluate their role as potential biomarkers and treatment targets for endometriosis. Although several key similarities were reported, there were some disagreements among the results, which might be attributable to the heterogeneity between studies. Further research with a more robust standardization is needed to validate the epigenetic changes in endometriosis.

Factors affecting women's participation in mammography screening in Nordic countries: A systematic review

INTRODUCTION

Mammography screening programs have been implemented in European countries as prevention tools aimed at reducing breast cancer mortality through early detection in asymptomatic women. Nordic countries (Denmark, Finland, Iceland, Norway, Sweden, the Faroe Islands, and Greenland) demonstrated high participation rates; however, breast cancer mortality could be limited by further optimizing screening. This review aimed to explore factors that affect women's participation in mammography screening in Nordic countries.

METHOD

A systematic review of segregated mixed research synthesis using a deductive approach was conducted. The following databases and platforms were searched to identify relevant studies: CINAHL with Full Text (EBSCOHost), MEDLINE (EBSCOHost), PsycInfo (ProQuest), Scopus (Elsevier) and Web of Science Core Collection (SCI-EXPANDED, SSCI, A&HCI, CPCI-S, CPCI-SSH, and ESCI). The Critical Appraisal Skills Program was used for quality assessment. The Health Promotion Model was applied to integrate findings from qualitative and qualitative research. All methodological steps followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

The final selection (16 articles) included studies from three Nordic countries: Denmark (four quantitative studies), Norway (one qualitative and four quantitative studies), and Sweden (three qualitative and seven quantitative studies). Sixty-three factors were identified as barriers, facilitators, or factors with no influence.

CONCLUSION

A substantial number of obtained factors, spread across a wide spectrum, describe (non-)participation in mammography screening as a versatile phenomenon.

IMPLICATIONS FOR PRACTICE

The findings of this review could benefit the mammography staff and providers regarding possible interventions aimed at improving screening participation rates.

A Systematic Review of Vitamin D and Fibroids: Pathophysiology, Prevention, and Treatment

Uterine fibroids are the most common tumor of reproductive-age women worldwide and cause significant morbidity in affected women. Vitamin D has emerged as a potential therapy for uterine fibroids based on experimental and epidemiologic evidence. The objective of this systematic review was to evaluate the role of vitamin D in the pathophysiology of uterine fibroids and its efficacy for prevention and treatment of fibroids. A comprehensive search was conducted of Cochrane Library, Embase, PubMed, Scopus, and Web of Science from inception to March 2022. English-language publications that evaluated vitamin D and uterine fibroids in humans, whether experimental or clinical, were considered. The search yielded 960 publications, and 89 publications met inclusion criteria: 23 preclinical studies, 25 clinical studies, and 41 review articles. Preclinical studies indicated that the vitamin D receptor was decreased in fibroid cells. Vitamin D treatment of fibroid cells decreased proliferation, extracellular matrix protein expression, and Wnt/β-catenin signaling. Fourteen clinical studies (n = 3535 participants) assessed serum vitamin D level in women with ultrasound-proven fibroids, and all found an inverse correlation between serum vitamin D level and presence of fibroids. Five clinical studies (n = 472 patients) evaluated treatment of fibroids with vitamin D. Four of five studies showed vitamin D significantly inhibited fibroid growth. One pilot study (n = 109 patients) of vitamin D for secondary prevention of fibroids demonstrated smaller recurrent fibroids in the treated group. These studies provide evidence for vitamin D as a therapy for uterine fibroids and underscore the need for well-designed, randomized, placebo-controlled clinical trials.

Mapping definitions of co-production and co-design in health and social care: A systematic scoping review providing lessons for the future

Objectives

This study aimed to explore how the concepts of co‐production and co‐design have been defined and applied in the context of health and social care and to identify the temporal adoption of the terms.

Methods

A systematic scoping review of CINAHL with Full Text, Cochrane Central Register of Controlled Trials, MEDLINE, PsycINFO, PubMed and Scopus was conducted to identify studies exploring co‐production or co‐design in health and social care. Data regarding date and conceptual definitions were extracted. From the 2933 studies retrieved, 979 articles were included in this review.

Results

A network map of the sixty most common definitions and—through exploration of citations—eight definition clusters and a visual representation of how they interconnect and have informed each other over time are presented. Additional findings were as follows: (i) an increase in research exploring co‐production and co‐design in health and social care contexts; (ii) an increase in the number of new definitions during the last decade, despite just over a third of included articles providing no definition or explanation for their chosen concept; and (iii) an increase in the number of publications using the terms co‐production or co‐design while not involving citizens/patients/service users.

Conclusions

Co‐production and co‐design are conceptualized in a wide range of ways. Rather than seeking universal definitions of these terms, future applied research should focus on articulating the underlying principles and values that need to be translated and explored in practice.

Patient and Public Contribution

The search strategy and pilot results were presented at a workshop in May 2019 with patient and public contributors and researchers. Discussion here informed our next steps. During the analysis phase of the review, informal discussions were held once a month with a patient who has experience in patient and public involvement. As this involvement was conducted towards the end of the review, we agreed together that inclusion as an author would risk being tokenistic. Instead, acknowledgements were preferred. The next phase involves working as equal contributors to explore the values and principles of co‐production reported within the most common definitions.

Development and validation of a sensitive MEDLINE search strategy to identify literature relevant to limb prostheses

BACKGROUND

Researchers and clinicians may find it challenging to identify relevant articles about limb prostheses in online databases. Searches may be improved by using standardized strategies, also known as filters or hedges.

OBJECTIVES

To develop and validate a highly sensitive MEDLINE (EBSCOHost) search strategy for limb prostheses.

STUDY DESIGN

Search strategy development/validation.

METHODS

A gold standard (GS) list of peer-reviewed articles on the topic of limb prostheses was created using a relative recall method. This involved identifying and including relevant systematic reviews/meta-analyses and then adding articles that were included in the analysis section of these reviews. Possible terms for the search strategy were identified through brainstorming and exploration of medical subject headings in MEDLINE (MeSH) and standards from the International Organization for Standardization (ISO). Concepts were grouped using relevant Boolean operators (e.g. AND and OR) and database record search fields (i.e. MeSH terms, title, and abstract). Part of the GS was used to refine the search strategy and reduce the number of records retrieved in total. The remaining GS set was used to validate and calculate sensitivity of the search strategy. Performance of the search strategy was compared against searches using only relevant MeSH terms.

RESULTS

After screening, the final GS totaled 853 records. The developed search strategy was highly sensitive (99.80%) and performed with higher relative recall than searches with relevant MeSH terms.

CONCLUSIONS

This study provides a highly sensitive search strategy that can be used by clinicians and researchers when searching for relevant literature on limb prostheses in MEDLINE (EBSCOHost).

Information Literacies of PhD Students in the Health Sciences: A Review of Scholarly Articles (2009 - 2018)

Abstract Objective – Doctoral studies offer a unique phase in the development and legitimization of researchers, in which PhD students shift from the consumption to the production of knowledge. If librarians are to support this process in an evidence based manner, it is essential to understand the distinct practices of this user population. While recent reviews exist concerning the information behaviours of graduate students and researchers, there is little knowledge synthesis focused on the information literacies of PhD students in specific disciplines. The aim of this article is to explore the depth and breadth of recent evidence which describes the information literacies of students pursuing a doctoral degree in the health sciences. Methods – Strategic searches were performed in databases, hand-searched key journals, and reference lists. Records were screened independently by both authors based on pre-determined criteria. General trends within the literature were mapped based on the extraction of the following data: geographic location, population, study aims, and method of investigation. Further analysis of the articles included charting the academic disciplines represented, summarizing major findings related to PhD students in health sciences, and which databases indexed the relevant articles. Results – Many studies fail to treat doctoral studies as a unique process. PhD students are often grouped together with other graduate students or researchers. Studies tend to be based on small populations, and the number of PhD students involved is either unclear or only equals a few individuals within the entire group of study. In addition, of the limited number of studies which focus exclusively on PhD students, few conduct explicit examination of information practices in the health sciences. The result is that this user group is underrepresented within recent journal publications. Conclusion – This review highlights the need for more primary, in-depth research on the information literacies of PhD students in the health sciences. In addition, librarians are encouraged to share their knowledge in scholarly publications which can reach beyond their own professional circles.

Epstein-Barr virus is not detected in mucosal lichen planus

Background

Lichen planus (LP) is a chronic inflammatory, immunological, mucocutaneous disease can affect skin, genital and oral mucosa. Oral lichen planus (OLP) is the most common noninfectious, chronic inflammatory oral disease affecting 1-2% of the general adult population. World Health Organization (WHO) classifies OLP as a potentially malignant disorder. Epstein Barr virus or human herpesvirus-4, is a member of the herpes virus family and one of the most ubiquitous viruses known to human, infecting approximately 90% of the world’s adult population. The virus often infects B lymphocytes resulting in a wide spectrum of mucocutaneous and systemic diseases, ranging from mild lesions to aggressive malignancies. The aim of this study was to investigate expression of the EBV encoded RNAs EBER1 and EBER2 in oral and genital lichen planus and compare results with normal tissues in situ hybridization which is considered the golden standard for detection of EBER.

Material and Methods

A total of 68 biopsies, 25 oral LP, 26 genital LP, 10 oral controls and finally 7 genital controls were analysed using situ hybridization.

Results

All samples had RNA as shown by the control slide, whereas no case contained neither EBER1 nor EBER2.

Conclusions

Based on results from our study EBV is not involved in aetiology of lichen planus.

Key words:Mucosal lichen planus, Epstein - Barr virus.

Increased expression of p16 in both oral and genital lichen planus

Background

Lichen Planus, LP, is an inflammatory disease of possible autoimmune origin affecting mainly oral and genital mucosa and skin. According to the WHO oral LP is considered a potentially malignant disorders. The p16 tumour suppressor protein can act as an inhibitor of cyclin dependent kinases 4 and 6 and thus down regulate cell cycle progression. Since the discovery of p16 several studies have evaluated its expression in various forms of human cancers. The aim of this study was to evaluate and compare the expression of p16 in oral and genital LP and corresponding healthy mucosa.

Material and Methods

A total of 76 cases of oral LP (OLP), 34 cases of genital LP (GLP), 12 cases of healthy oral and 9 cases of healthy genital mucosa were analysed by the use of immunohistochemistry.

Results

Data showed p16 to be highly expressed in both oral and genital LP, higher than in oral (p=0.000), and genital controls (p=0.002).

Conclusions

Results suggest that the over-expression of p16 seen in LP play a part in the histopathology of the disease.

Key words:p16, inflammation, oral, genital, lichen planus, malignant risk.

Vascular characteristics in young women-Effect of extensive endurance training or a sedentary lifestyle

AIM

To explore whether high-level endurance training in early age has an influence on the arterial wall properties in young women.

METHODS

Forty-seven athletes (ATH) and 52 controls (CTR), all 17-25 years of age, were further divided into runners (RUN), whole-body endurance athletes (WBA), sedentary controls (SC) and normally active controls (AC). Two-dimensional ultrasound scanning of the carotid arteries was conducted to determine local common carotid artery (CCA) geometry and wall distensibility. Pulse waves were recorded with a tonometer to determine regional pulse wave velocity (PWV) and pulse pressure waveform.

RESULTS

Carotid-radial PWV was lower in WBA than in RUN (P < .05), indicating higher arterial distensibility along the arm. Mean arterial pressure was lower in ATH than in CTR and in RUN than in WBA (P < .05). Synthesized aortic augmentation index (AI@75) was lower among ATH than among CTR (-12.8 ± 1.6 vs -2.6 ± 1.2%, P < .001) and in WBA than in RUN (-16.4 ± 2.5 vs -10.7 ± 2.0%, P < .05), suggesting a diminished return of reflection waves to the aorta during systole. Carotid-femoral PWV and intima-media thickness (IMT), lumen diameter and radial distensibility of the CCA were similar in ATH and CTR.

CONCLUSION

Elastic artery distensibility and carotid artery IMT are not different in young women with extensive endurance training over several years and in those with sedentary lifestyle. On the other hand, our data suggest that long-term endurance training is associated with potentially favourable peripheral artery adaptation, especially in sports where upper body work is added. This adaptation, if persisting later in life, could contribute to lower cardiovascular risk.

Autoantibodies and decreased expression of the transcription factor ELF-3 together with increased chemokine pathways support an autoimmune phenotype and altered differentiation in lichen planus located in oral mucosa

BACKGROUND

The pathogenesis of oral lichen planus (OLP), a chronic inflammatory disease, is not fully understood. It is known that OLP has autoimmune features, and it is suggested to be an autoimmune disease. ELF-3 is involved in differentiation of keratinocytes and deregulated in different tumours and inflammatory diseases. CXCR-3 and its ligands CXCL-10 and CXCL-11 are increased in autoimmune diseases and linked to Th-1 immune response.

OBJECTIVES

To analyse and compare expression of ELF-3, CXCR-3, CXCL-10 and CXCL-11 in OLP lesions and controls in whole and microdissected epithelium.

METHODS

Tissue biopsies from 20 patients clinically and histologically diagnosed with OLP and 20 healthy controls were studied using whole tissues or microdissected epithelium. By the use of qRT-PCR, mRNA levels of ELF-3, CXCR-3, CXCL-10 and CXCL-11 were studied. Western blot was used for analysis of ELF-3 protein expression. Sera from 19 OLP patients and 20 controls were analysed with ELISA in search for autoantibodies. Results  The upregulation of CXCR-3, CXCL-10 and CXCL-11 found in OLP is similar to previous findings showing an autoimmune phenotype in lichen planus (LP) and lichen sclerosus. Decreased expression of the differentiation-related transcription factor ELF-3 was also seen in OLP lesions, and we further demonstrate presence of circulating autoantibodies against the ELF-3 protein in sera from 3 of 19 (16%) LP patients tested.

CONCLUSIONS

On the basis of these findings, we confirm that OLP shows features of an autoimmune disease and suggest deregulated differentiation of keratinocytes to be one of the causes of the disease phenotype.

Asking about condom use: a key to individualized care when screening for chlamydia

Chlamydia trachomatis (CT) infection has been a target for both selective and national screening programmes, and Sweden has an opportunistic approach. A national plan of action states that risk groups should be identified and offered risk reduction counselling. Patients attending a drop-in sexually transmitted infection (STI) clinic reception at the University Hospital, Umeå, Sweden, were invited to complete a questionnaire regarding sociodemographic characteristics, symptoms and sexual risk behaviour; all had a CT test taken. A total of 1305 patients were included, 58% men, mean age 27.8 years. CT prevalence was 11%; 51% of those with CT were ≥25 years old. Only 5% used a condom during the entire sexual intercourse with their last new/temporary partner. Sexually active inconsistent condom users comprised 62% of the study population and contributed to 81% of the chlamydia infections. Asking whether a condom was used could quickly triage patients into groups with a ‘higher risk’ (none or inconsistent use of condoms and at least one new/temporary partners), and ‘lower risk’ (with more consistent condom use, although not always accurate) allowing for individualized care and counselling when screening for chlamydia. Evaluating whether a condom was used throughout the sexual intercourse did not add any useful information.

Long-term efficacy of flecainide in paroxysmal atrial fibrillation

The efficacy and safety of flecainide for long-term prevention of paroxysmal atrial fibrillation (AF) were studied in an open trial. Twenty patients with very frequent attacks (mean 13 per month) of paroxysmal AF for many years (mean 8 years) participated. Before inclusion, the patients had unsuccessfully been treated with an average of 3.3 antiarrhythmic drugs. Efficacy was jugded from a carefully kept diary in which the patients made daily notes of any AF attacks and possible side-effects from 1 month before treatment until the end of a follow-up period of 6 months. Twelve patients (60%) were completely free from AF and 11 of these are still successfully treated with flecainide after 11-38 months (mean 24 months). Flecainide plasma levels did not differ between responders and non-responders. Eleven patients (55%) had adverse effects but these were usually mild and well tolerated, necessitating withdrawal or dose reduction resulting in relapse of AF only in three patients (15%). No proarrhythmic events were seen.

The effects of metoprolol and captopril on heart rate variability in patients with idiopathic dilated cardiomyopathy

BACKGROUND

The effects of treatment with captopril or metoprolol on heart rate variability (HRV) were investigated in 38 patients (29 men and 9 women) with mild to moderate symptoms of heart failure due to idiopathic dilated cardiomyopathy (DCM).

HYPOTHESIS

The aim of the study was to investigate and compare the effects of the angiotensin-converting enzyme inhibitor captopril with those of the selective beta-adrenergic receptor blocker metoprolol on HRV in patients with idiopathic DCM.

METHODS

Heart rate variability was analyzed in the time and frequency domains from 18th of Holter monitoring before randomized treatment was started, after 6 months of therapy, and 1 month after therapy was stopped.

RESULTS

Captopril treatment increased HRV expressed as total power and low-frequency power in the frequency domain. There was no change in the time domain. In the metoprolol group, there was a pronounced increase in both time- and frequency-domain indices of HRV. The increase in total power was partly maintained 1 month after therapy was stopped in both treatment groups.

CONCLUSION

Treatment with captopril and metoprolol increases HRV in patients with DCM. This effect seems to be maintained for at least 1 month after therapy is stopped. The increase in HRV seems to be more pronounced with metoprolol, and the two different pharmacologic approaches may have additive effects that are of prognostic importance in patients with heart failure.

Sudden cardiac death in young athletes: time for a Nordic approach in screening?

In 2005, the European Society of Cardiology published recommendations for cardiovascular screening in athletes. Discussion on whether screening is beneficial is ongoing. Recently, the first prospective results on effectiveness of screening in preventing sudden deaths were published from Italy. The results were supportive of screening, but did not provide conclusive evidence. Our suggestion for a Nordic approach on this issue is a directed cardiovascular examination initially involving elite athletes, because this is feasible with respect to the Nordic health care systems and the organization and logistics of elite competitive sports, but also because of the negative aspects of screening large populations. This directed cardiovascular examination would include personal and family history, clinical examination, and electrocardiography (ECG). Further examinations should thereafter be carried out in athletes with suggestive findings in the initial evaluation. The directed cardiovascular examination should be voluntary. It should be conducted at least once, with information on alarming symptoms (syncope, chest pain or dizziness during exercise) and heredity (sudden cardiac death or hereditary heart disease in near relatives) stressed to the athlete as indications for necessary check-ups in the future. The examination would also provide the athlete with an ECG recording, which is valuable as a reference at a later time.

Effect of carvedilol on diastolic function in patients with diastolic heart failure and preserved systolic function. Results of the Swedish Doppler-echocardiographic study (SWEDIC)

AIM

The purpose of this study was to investigate the effects of carvedilol on diastolic function (DF) in heart failure patients with preserved left ventricular (LV) systolic function and abnormal DF.

PATIENTS AND METHODS

We randomised 113 patients with diastolic heart failure (DHF) (symptomatic, with normal systolic LV function and abnormal DF) into a double blind multi-centre study. The patients received either carvedilol or matching placebo in addition to conventional treatment. After uptitration, treatment was continued for 6 months. Two-dimensional and Doppler echocardiography were used for quantification of LV function at baseline and at follow-up. Four different DF variables were evaluated by Doppler echocardiography: mitral flow E:A ratio, deceleration time (DT), isovolumic relaxation time (IVRT) and the ratio of systolic/diastolic pulmonary venous flow velocity (pv-S/D). Primary endpoint was change in the integrated quantitative assessment of all four variables during the study.

RESULTS

Ninety-seven patients completed the study. A mitral flow pattern reflecting a relaxation abnormality was recorded in 95 patients. There was no effect on the primary endpoint, although a trend towards a better effect in carvedilol treated patients was noticed in patients with heart rates above 71 beats per minute. At the end of the study, there was a statistically significant improvement in E:A ratio in patients treated with carvedilol (0.72 to 0.83) vs. placebo (0.71 to 0.76), P<0.05.

CONCLUSIONS

Treatment with carvedilol resulted in a significant improvement in E:A ratio in patients with heart failure due to a LV relaxation abnormality. E:A ratio was found to be the most useful variable to identify diastolic dysfunction in this patient population. This effect was observed particularly in patients with higher heart rates at baseline.

A novel method to assess systolic ventricular function using atrioventricular plane displacement - a study in young healthy males and patients with heart disease

Analysis of atrioventricular plane displacement (AVPD) is a well established method for assessment of both systolic and diastolic ventricular function. For several years, AVPD has been a clinical tool and there are many current, as well as potential, areas of application. However, clinical work has shown that the traditional method for evaluation of systolic ventricular function, called total AVPD, does not temporally reflect true systole. Systolic AVPD is a new approach for measuring AVPD to assess ventricular systolic function. We wished to apply this new model in healthy subjects and in patients with different common heart diseases. Twenty-eight young healthy males and 30 patients (aortic stenosis, left sided regurgitant lesions, postmyocardial infarction) were enrolled. AVPD was obtained at the four standard sites by M-mode. Total AVPD was measured in the conventional way and systolic AVPD by identifying true systole, by means of mitral- and aortic valve closure respectively. Ventricular volumes were calculated according to biplane Simpson's rule. The systolic AVPD measurements were significantly lower than the total measurements, at both atrioventricular planes in all groups (P<0.001). This discrepancy was greater at the mitral than at the tricuspid annulus in the patients 24.2% vs. 15.5% (P<0.001), but did not differ in the healthy subjects. At the mitral annulus, this discrepancy also seemed to be more pronounced in the patients than in the healthy subjects 24.2% vs. 10.7%. When assessing ventricular systolic function by AVPD, the conventional method overestimates the amplitude in relation to true systolic function in both patients with heart disease and in young healthy males. Thus, there are uncertainties regarding earlier estimations of AVPD in terms of expression of systolic function and regarding previously presented reference values. We recommend the proposed methodology.

Contribution of mitral annular excursion and shape dynamics to total left ventricular volume change

The mitral annulus (MA) has a complex shape and motion, and its excursion has been correlated to left ventricular (LV) function. During the cardiac cycle the annulus' excursion encompasses a volume that is part of the total LV volume change during both filling and emptying. Our objective was to evaluate the contribution of MA excursion and shape variation to total LV volume change. Nine healthy subjects aged 56 +/- 11 (means +/- SD) years underwent transesophageal echocardiography (TEE). The MA was outlined in all time frames, and a four-dimensional (4-D) Fourier series was fitted to the MA coordinates (3-D+time) and divided into segments. The annular excursion volume (AEV) was calculated based on the temporally integrated product of the segments' area and their incremental excursion. The 3-D LV volumes were calculated by tracing the endocardial border in six coaxial planes. The AEV (10 +/- 2 ml) represented 19 +/- 3% of the total LV stroke volume (52 +/- 12 ml). The AEV correlated strongly with LV stroke volume (r = 0.73; P < 0.05). Peak MA area occurred during middiastole, and 91 +/- 7% of reduction in area from peak to minimum occurred before the onset of LV systole. The excursion of the MA accounts for an important portion of the total LV filling and emptying in humans. These data suggest an atriogenic influence on MA physiology and also a sphincter-like action of the MA that may facilitate ventricular filling and aid competent valve closure. This 4-D TEE method is the first to allow noninvasive measurement of AEV and may be used to investigate the impact of physiological and pathological conditions on this important aspect of LV performance.

Unspecific elevation of plasma troponin-T and CK-MB after coronary surgery

OBJECTIVE

Biochemical markers of myocardial injury are frequently elevated after cardiac surgery. It is generally accepted that release unrelated to permanent myocardial damage explains a proportion of these elevations. However, little is known about the magnitude and temporal characteristics of this diagnostic noise. One way to address this issue would be to study a group without permanent myocardial injury.

DESIGN

The unique release kinetics of troponin-T (permanent myocardial injury causes a sustained release of structurally bound troponin) were used to identify patients with no or minimal permanent myocardial injury. Blood was sampled from patients undergoing coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB) before surgery, 3 and 8 h after unclamping the aorta, and each morning until postoperative day 4, for analysis of enzymes and troponin-T. From 302 consecutive patients a subgroup was identified that fulfilled the following criteria: (a) normalized troponin-T levels < or = postoperative day 4; (b) no ECG changes indicating myocardial injury.

RESULTS

Seventy-seven patients fulfilled the criteria above and in this subgroup troponin-T (2.08 +/- 1.42 microg/l; range 0.35-8.99 microg/l) peaked at the 3 h recording and creatine kinase monobasic (CK-MB) (28.6 +/- 11.3 microg/l; range 11.9-86.0 microg/l) peaked at the 8 h recording after unclamping the aorta.

CONCLUSION

Substantial early elevations of plasma CK-MB and troponin-T occurred in patients with no or minimal permanent myocardial injury after CABG. Unspecific release was most pronounced during the timeframe that is usually studied to evaluate myocardial protective strategies or to compare revascularization procedures.

Chest pain and ischaemic heart disease in primary care

BACKGROUND

Chest pain is the main symptom of first presentation with ischaemic heart disease (IHD). Little is known about the incidence of IHD among patients consulting the general practitioner (GP) for chest pain.

AIMS

To estimate the occurrence of IHD among patients consulting for chest pain, to study the results of the bicycle exercise test, and to estimate the incidence of IHD in the population.

DESIGN OF STUDY

Prospective descriptive study.

SETTING

Three primary health centres in south-eastern Sweden.

METHOD

All patients without a current IHD diagnosis, aged 20 to 79 years, and consulting for a new episode of chest pain, were included consecutively. The outcome was classified as IHD, possible IHD or not IHD, according to the results of a postal questionnaire, an exercise test or hospital care. Data from the hospital registry on patients with a diagnosis of IHD were analysed retrospectively.

RESULTS

Out of 38,075 GP consultations, 577 (1.5%) were for chest pain. IHD was diagnosed in 41 (8%) of the chest pain patients, in 441 (83%) the diagnosis was excluded, and in 50 (9%) the diagnosis was judged as being uncertain. Even though the diagnostic criteria were strict, the exercise tests led to a diagnostic conclusion in 77% of the cases, most frequently a normal test result. Combining data from primary and hospital care, the yearly incidence of IHD was 6.5 diagnosed per 1000 inhabitants (aged 20 to 79 years old).

CONCLUSION

The incidence of a new episode of chest pain bringing the patients to the GP was low. Eight per cent of the patients received an IHD diagnosis, and in 9% further investigation or clinical assessment is needed.

Early identification of permanent myocardial damage after coronary surgery is aided by repeated measurements of CK-MB

OBJECTIVE

ECG diagnosis of myocardial infarction after cardiac surgery is associated with major pitfalls and enzyme diagnosis is interfered by unspecific elevation unrelated to permanent myocardial injury. Sustained release of troponin-T is a marker of permanent myocardial injury if renal function is maintained. However, early identification of perioperative myocardial infarction is desirable and therefore the usefulness of creatine kinase monobasic (CK-MB) kinetics to detect myocardial injury early after coronary surgery was investigated.

DESIGN

Two hundred and eighty-six patients undergoing coronary surgery were studied with respect to release of enzymes and troponin-T preoperatively and postoperatively 3 and 8 h after unclamping the aorta, and every morning postoperative days 1-4.

RESULTS

CK-MB peak was found at 3 h (n = 145), 8 h (n = 103) and 16-20 h after unclamping (n = 38). Depending on when the CK-MB peak was recorded different demographic and perioperative characteristics were found. A sustained release of troponin-T was characteristic for the group with the CK-MB peak at 16-20 h after unclamping.

CONCLUSION

If CK-MB is measured only once it may be advisable to do it on the first postoperative morning as these measurements provided the best discrimination between patients with and without sustained elevation of troponin-T. However, repeated sampling provides additional information that aids in the early identification of permanent myocardial injury particularly in patients with borderline elevations of CK-MB.

Adaptation of cardiac morphology and function to endurance and strength training. A comparative study using MR imaging and echocardiography in males and females

Left ventricular (LV) dimensions and function and maximal oxygen uptake (VO(2)max) were measured in endurance-trained (10 male, m, 10 female, f), strength-trained athletes (8 m, 10 f) and untrained subjects (9 m, 10 f). LV dimensions were measured using magnetic resonance imaging (MRI) and echocardiography and the results were equal irrespective of method. Endurance-trained m and f had significantly higher LV volumes and mass than both strength-trained and controls. No VO(2)max or dimensional differences were seen between strength-trained and untrained subjects. In endurance-trained males, LV volumes and mass/kg bw were higher than in endurance-trained females. There was no significant gender difference for strength-trained or untrained subjects regarding body weight-related heart dimensions. It is concluded that LV dimensions and volumes are strongly dependent on oxygen transport capacity in normal subjects practising different modes of training, and that the gender differences, if LV dimensions are related to aerobic work capacity, are smaller than previously reported.

Atrioventricular plane displacement correlates closely to circulatory dimensions but not to ejection fraction in normal young subjects

AIMS

Mitral atrioventricular plane displacement (AVPD) provides information about left ventricular systolic function. M-mode of systolic annulus amplitude or tissue Doppler imaging of systolic annulus velocity are the current methods of evaluating AVPD. A correlation to ejection fraction (EF) has been demonstrated in patients with coronary artery disease and left ventricular dysfunction. Our aim was (i) to investigate the mitral AVPD of normal subjects with different physical work capacities and (ii) to further evaluate AVPD as an index of left ventricular systolic function.

METHODS AND RESULTS

Twenty-eight healthy men mean age 28 years (20-39) were included: endurance trained (ET) (n=10), strength trained (ST) (n=9) and untrained (UT) (n=9). The systolic AVPD was recorded at four sites, septal, lateral, anterior and posterior, using M-mode. Left ventricular volumes were calculated according to Simpson's rule. Systolic AVPD was higher in endurance trained, 16.9 +/- 1.5 mm, as compared with both strength trained, 13 +/- 1.6 (P<0.001) and untrained, 14 +/- 1.6 (P<0.001). Left ventricular systolic AVPD correlated strongly with end-diastolic volume (r=0.82), stroke volume (r=0.80) and maximal oxygen consumption per body weight (r=0.72). The correlation between AVPD and EF was poor (r=0.22).

CONCLUSION

In the subjects studied, with a range of normal cardiac dimensions, AVPD correlated to stroke volume, end-diastolic volume and maximal oxygen consumption per body weight, but not to EF. On theoretical grounds, it also seems reasonable that a dimension like AVPD is related to other cardiac dimensions and volumes, rather than to a fraction, like EF. AVPD is one parameter that is useful for evaluation of left ventricular systolic function but is not interchangeable with other measurements such as EF.

Vectorcardiography is superior to conventional ECG for detection of myocardial injury after coronary surgery

OBJECTIVE

The reliability of conventional scalar ECG for diagnosis of perioperative myocardial infarction (PMI) in cardiac surgery has been questioned. For the diagnosis of myocardial infarction in general vectorcardiography (VCG) is superior to ECG. Therefore, the usefulness of conventional VCG and computerized analysis of spatial VCG changes for diagnosis of PMI were studied.

DESIGN

VCG registrations were obtained from 218 patients undergoing coronary surgery. The spatial QRS vector loop area of each VCG registration was calculated and the loop area before surgery compared with the loop area after surgery. Conventional VCG criteria for myocardial infarction and set values for loop area reduction were related to sustained elevation of plasma troponin-T and clinical course.

RESULTS

Both conventional VCG criteria and spatial changes translated better than Q-waves on scalar ECG into elevation of biochemical markers of myocardial injury and impaired clinical course.

CONCLUSION

VCG appears superior to conventional ECG as regards detection of myocardial injury in coronary surgery. Computerized programs have facilitated the registration and the interpretation of VCG and this methodology deserves further evaluation in cardiac surgery.

Aortic valve replacement with pericardial valves in patients with small aortic roots. Clinical results in a consecutive series of patients receiving 19 and 21 mm prostheses

OBJECTIVE

To determine how second generation pericardial valves perform in patients with small aortic roots.

DESIGN

Ninety patients who underwent isolated aortic valve replacement (AVR) with 19 or 21 mm Mitroflow or Carpentier-Edwards (Perimount) valves between 1989 and 1996 were studied. Mean age was 78 years. Concomitant coronary bypass surgery was performed in 41%.

RESULTS

Thirty-day mortality was 5.6%. Ninety-seven percent had acceptable transprosthetic mean pressure gradients (25 mmHg or less) 1 week after surgery. Follow-up was 100% complete and 76% of the patients were alive after a mean of 5 years. There was no structural valve failure or valve thrombosis. One patient required reoperation for perivalvular leak. Four patients had transient ischemic attacks and seven had strokes. These figures are, however, within the expected range for the age.

CONCLUSION

Second generation pericardial valves perform well in elderly patients with small aortic roots. Postoperative hemodynamics are acceptable, valve durability of up to 8 years adequate, and the clinical results good, considering the age of the patients.

Management of patients with end-stage heart disease treated with an implantable left ventricular assist device in a nontransplanting center

OBJECTIVE

To describe the setup of a left ventricular assist device (LVAD) program in a nontransplanting center.

DESIGN

A prospective study from February 1993 to June 1999.

SETTING

A university hospital.

PARTICIPANTS

Ten patients, 6 men, with a mean age of 44 years (range 16 to 63 years) and with end-stage heart failure resulting from dilated cardiomyopathy (n = 7) or ischemic heart disease (n = 3).

INTERVENTIONS

The patients received the TCI (Thermo Cardiosystems Inc, Woburn, MA) Heart Mate implantable assist device. Five patients had a pneumatic device, and 5 had an electric device. All except 1 patient with an electric device had the pump for an extended period.

MEASUREMENTS AND MAIN RESULTS

Median time on the ventilator was 6.2 days, and median time in the ICU was 14 days. Significant hemodynamic improvement was observed by echocardiography and invasive monitoring. Milrinone and epinephrine supplemented by prostaglandin E1 were the most commonly used drugs to avoid right-sided heart failure. Nine patients were transplanted after pump therapy of 241 days (median) (range, 56 to 873 days). One patient died because of endovascular infection and septicemia. Infectious complications were frequent, especially when the pump time was extended.

CONCLUSIONS

The introduction of an LVAD program in a nontransplanting center can be achieved with good results. Intense collaboration with a transplant center is mandatory. The complication rate increased when treatment times were extended.

The value of repeated echocardiographic evaluation in patients with idiopathic dilated cardiomyopathy during treatment with metoprolol or captopril

Serial echocardiographic investigations were carried out on patients with idiopathic dilated cardiomyopathy, to evaluate treatment effects on left ventricular (LV) performance during therapy with either metoprolol or captopril. Thirty-two patients (23 males and 9 females) with mild to moderate symptoms of heart failure (NYHA II-III) and a mean age of 49 years were included in the investigation. The patients were investigated with Doppler echocardiography before treatment, after 3 and 6 months of treatment (either metoprolol or captopril) and 1 month after withdrawal of treatment. Intra- and inter-investigator reproducibility was acceptable, with a coefficient of variation of less than 5% for LV dimensions. A reduction in LV dimensions was seen in both treatment groups. In the metoprolol group there was also an increase in LV stroke volume and fractional shortening. The non-invasive data were in accordance with invasive measurements of stroke volume and LV filling pressure. In patients with idiopathic dilated cardiomyopathy and mild to moderate symptoms of heart failure, echocardiography seemed to be sufficiently reproducible to be used for determination of treatment effects in a longitudinal heart failure study. Both metoprolol and captopril were well tolerated and had favourable effects on LV performance.

[Diagnosis and treatment of heart failure in primary health care. Low correlation between Pro-ANF and heart failure]

Three eastern Swedish primary care clinics serving a predominantly rural clientele monitored for 13 months all patients under 80 years of age with a diagnosis based on clinical signs alone of heart failure (n = 56) or suspected incipient heart failure (n = 62). Echocardiography was performed on all patients. For 64% of the former group, the putative diagnosis matched echocardiography findings. Results showed a purely diastolic disorder in one-fifth of all 118 patients, and a hemodynamically significant, hitherto unknown heart defect in about as many. Pro-ANF assays correlated poorly with manifest heart failure. Pharmacological treatments were registered, and at 6-month follow-up, 82% of patients with systolic failure were receiving ACE-inhibition.

The circulating renin-angiotensin system during treatment with metoprolol or captopril in patients with heart failure due to non-ischaemic dilated cardiomyopathy

OBJECTIVE

To investigate the effects of beta-blocker (metoprolol) or angiotensin-converting enzyme inhibitor (captopril) treatment on neurohormonal function in a randomized prospective study on patients with heart failure due to dilated cardiomyopathy.

PATIENTS

Fifty-four patients (42 men and 12 women, mean age 50 years) were studied. There were three patients in NYHA (New York Heart Association) functional class I, 32 patients in class II and 19 patients in class III.

METHODS

Measurements of plasma renin activity (PRA). plasma angiotensin II (A II) concentration and plasma atrial natriuretic peptide (ANP) concentration were made at rest and also in a subgroup (n = 32) during exercise. The urinary excretion of aldosterone was also determined. Investigations were performed at baseline, and after 3 and 6 months. Therapy was then stopped and the patients were re-investigated 1 month thereafter.

RESULTS

The mean level of PRA was normal at baseline, reduced during therapy with metoprolol, and increased during therapy with captopril. The mean plasma concentration of A II was reduced during exercise and there was a trend towards a reduction even at rest in the metoprolol group, but not in the captopril group. The urinary excretion of aldosterone decreased in both groups. The mean plasma concentration of ANP was elevated at baseline and declined during exercise in the metoprolol group.

CONCLUSION

In patients with dilated cardiomyopathy and only a partly activated renin-angiotensin system, both metoprolol and captopril reduced urinary excretion of aldosterone. Furthermore, metoprolol suppressed the exercise-induced increase in ANP, suggesting a favourable effect on ventricular performance.

Are electrocardiographic Q-wave criteria reliable for diagnosis of perioperative myocardial infarction after coronary surgery?

OBJECTIVE

A major assumption in cardiovascular medicine is that Q-waves on the electrocardiogram indicate major myocardial tissue damage. The appearance of a new Q-wave has therefore been considered the most reliable criterion for diagnosis of perioperative myocardial infarction (PMI) in cardiac surgery. In a study, originally intended to evaluate troponin-T as a marker of PMI, analysis of our data aroused the need to address the reliability of Q-wave criteria for diagnosis of PMI.

METHODS

In 302 consecutive patients undergoing coronary surgery, Q-wave and other electrocardiogram (ECG) criteria were compared with biochemical markers of myocardial injury and the postoperative course. All ECGs were analysed by a cardiologist blinded to the biochemical analyses and the clinical course.

RESULTS

The incidence of positive Q-wave criteria was 8.1%. Combined biochemical (CK-MB > or = 70 microg/l) and Q-wave criteria were found in 1.0%. Patients with new Q-waves did not have CK-MB or troponin-T levels significantly different from those without Q-waves. More than 25% of the Q-waves were associated with plasma troponin-T below the reference level (< 0.2 microg/l) on the fourth postoperative day. Q-wave criteria alone did not influence the postoperative course. In contrast, biochemical markers correlated with clinical outcome.

CONCLUSIONS

The majority of Q-waves appearing after coronary surgery were not associated with major myocardial tissue damage, and according to troponin-T one-fourth of the Q-waves were not associated with myocardial necrosis. Furthermore, the appearance of Q-waves had little influence on short term clinical outcome. Therefore, the use of Q-wave criteria as the gold standard for diagnosis of PMI may have to be questioned.

Quantitative digital evaluation of myocardial exercise thallium-201 single-photon emission tomography in post-menopausal women

Quantitative computerized analysis of data from myocardial thallium-201 (201Tl) single-photon emission tomography (SPET) may improve the diagnostic accuracy of coronary heart disease. The reference ranges for post-menopausal women are, however, limited and obtained mainly from patients. To compare reference values from healthy post-menopausal women and to improve the quantitative analysis, 20 women (10 patients with coronary heart disease and previous infarction and 10 age-matched healthy volunteers) were examined immediately post exercise and after a delay. A nine-segment 'bull's-eye' model was used for analysis. At visual evaluation, reproducibility was high (93%), no false-positive results were obtained and in 70% of the patients the SPET was interpreted as abnormal. Using reported reference values for quantitative analysis, all the healthy women had an abnormal result. New reference values based on three different methods of 'normalization' were calculated: the relative activity of segment 3 set to 100%, the segment with the highest activity set to 100% and a least-squares method. They all differed significantly from those that had previously been reported. The frequencies of agreement between visual and quantitative analysis were 84-92% and were highest when segment 3 was used as a reference, but in this case only 40% of the patients with coronary heart disease had an abnormal SPET. Using the least-squares method for handling digital information, the SD of the normal values decreased and 90% of the patients with coronary heart disease were accurately diagnosed. These results provide quantitative digital reference values for healthy post-menopausal women. They verify that quantitative analysis is in diagnostic agreement with visual evaluation, stress the need for local verification of reference ranges and suggest a least-square normalization method for the analysis.

More favourable haemodynamic effects from metoprolol than from captopril in patients with dilated cardiomyopathy

AIM

The object of this study was to investigate and compare the haemodynamic effects of treatment with a beta receptor blocker (metoprolol) or an angiotensin-converting-enzyme inhibitor (captopril) in 54 patients with idiopathic dilated cardiomyopathy.

METHOD

All patients had cardiac catheterization performed at rest and during exercise, before and after 3 months of treatment.

RESULTS

The mean dose of metoprolol was 135 mg.day-1 and of captopril 98 mg.day-1. After treatment there was a significant reduction in left ventricular filling pressure both at rest (from 16 to 12 mmHg) and during exercise (from 27 to 20 mmHg) in the metoprolol group. In the captopril group a significant reduction was seen only during exercise (25 to 20 mmHg), compared to baseline. The stroke volume increased significantly after 3 months of therapy in the metoprolol group, both at rest (53 to 70 ml) and during exercise (56 to 79 ml). In the captopril group the increase reached significance only during exercise (72 to 79 ml). Cardiac output was maintained in both groups.

CONCLUSION

There were positive effects on left ventricular function in the metoprolol group as well as in the captopril group. Metoprolol reduced left ventricular filling pressure at rest and increased stroke volume both at rest and during exercise significantly more than captopril.

Aortic valve replacement for aortic stenosis in patients with small aortic root

BACKGROUND AND AIMS OF THE STUDY

Patients with aortic stenosis and small aortic ostia are getting more and more common in our practice. They now constitute a third of our aortic valve replacement (AVR) material. The patients are usually elderly women with small heart and body dimensions, sometimes making it difficult to implant sufficiently large valve prostheses.

MATERIALS AND METHODS

We describe a non-selected series of 254 patients from a geographically defined area who underwent AVR during a six year period (1989-1995) and who were considered to have small aortic annulus, defined as patients receiving 19 and 21 mm prostheses. Mean age was 71 years, 42% were over the age of 75, 88% were women and 32% underwent concomitant coronary artery bypass grafting (CABG). Fifty-nine (23%) required pericardial patch enlargement of the aortic root to accommodate sufficiently large prostheses. Prostheses used included Björk-Shiley Monostrut (n = 54), CarboMedics (n = 58), St. Jude (n = 74), Sorin Bicarbon (n = 2), Mitroflow pericardial (n = 26) and Carpentier-Edwards pericardial valve (n = 40). Pericardial valves were usually employed in patients 75 years and older.

RESULTS

Operative mortality was 3.1%. There was no mortality in patients undergoing isolated AVR. Late mortality, after a mean observation period of two years, was 4.9%. At Doppler echocardiography one week postoperatively, 95% had a gradient across the prosthesis that was considered to be within acceptable limits (resting mean gradient < 30 mmHg). In the remaining patients higher gradients indicated some degree of prosthesis-patient mismatch.

CONCLUSIONS

To avoid this mismatch the surgical considerations include choosing a prosthesis with a large effective orifice area, using an optimal valve implantation technique (partly or completely supra-annular placement of the prosthesis) and, if this is not enough, enlarging the annulus with an outflow patch.

Biplane transoesophageal echocardiography, transthoracic Doppler, and magnetic resonance imaging in the assessment of coarctation of the aorta

This study compared flow-sensitive magnetic resonance imaging with biplane transoesophageal echocardiography in combination with continuous wave Doppler from the suprasternal notch in patients with native coarctation or after surgical repair. Twenty patients (mean age 33 years, range 17-60) were investigated, of whom 15 had undergone surgery at mean age 13 years, range 5-43. Peak and mean flow in the ascending and descending aorta as well as coarctation peak velocity were determined with the magnetic resonance imaging phase contrast technique. Coarctation peak velocity was also measured by Doppler from the jugulum. Magnetic resonance imaging axial sections as well as biplane transoesophageal echocardiography were used to measure the smallest diameter of the constricted segment. Sixteen healthy volunteers, mean age 36 years, range 22-63, provided reference values for magnetic resonance imaging determined volume of flow in the aorta. Peak flow in the descending aorta was 9.2 +/- 3.7 l. min-1 (reference 13.0 +/- 2.5, P < 0.01) and mean flow 3.1 +/- 0.9 l. min-1 (reference 3.4 +/- 0.8, P > 0.05). The ratio of descending-to-ascending peak flow was 0.54 +/- 0.17 (reference 0.69 +/- 0.10, P < 0.01) and mean flow 0.68 +/- 0.15 (reference 0.69 +/- 0.08, P > 0.05). The coarctation velocity was slightly higher with Doppler than with magnetic resonance imaging (+0.24 +/- 0.44 m. s-1, 95% confidence interval +0.45 to +0.02 m. s-1, P = 0.05). The coarctation diameter was slightly larger with magnetic resonance imaging than with transoesophageal echocardiography (1.4 +/- 3.5 mm, 95% confidence interval +3.1 to -0.3 mm, P = 0.11). Both methods are suitable for the assessment and follow-up of coarctation of the aorta. Flow assessment with magnetic resonance imaging provides a hitherto unavailable measure with which to assess the severity of obstruction.