[Home-based devices for the treatment of female urinary incontinence: A literature review]

OBJECTIVE

Literature review on the home-based options for the conservative management of stress urinary incontinence including biofeedback and weighted vaginal cones..

METHODS

Research was conducted in the Cochrane Library and Pubmed to find articles, published until March 2020, dealing with the conservative management of incontinence.

RESULTS

A total of 9 randomized controlled trials were included, 4 concerning biofeedback and 5 concerning vaginal cones. Most of them highlighted the superiority of these three methods compared to the absence of treatment but were not superior compared to the pelvic floor muscles training in the clinic setting.

CONCLUSION

Home-based devices for female stress urinary incontinence is a safe and effective treatment for female urinary incontinence. It has not shown superiority to physiotherapist-guided pelvic floor muscle reinforcement and needs more evidence to gain its place as a first line therapeutic option.

P612Multimodal cardiac imaging in patients with suspected ST-elevation myocardial infarction and no obstructive coronary arteries

Background

Patients with suspected ST-elevation myocardial infarction (STEMI) and normal coronary arteries comprise a heterogeneous group with various underlying causes of disease.

Purpose

To study pathophysiology and underlying diagnoses in patients with suspected STEMI and normal coronary arteries using multimodal cardiac imaging.

Methods

We consecutively included patients with suspected STEMI, normal coronary arteries on acute coronary angiography, and elevated troponin T levels at a tertiary heart center (2012–14). Patients were examined with echocardiography, cardiac magnetic resonance imaging, and 13NH3/82Rb and 18F-FDG positron emission tomography within one week from symptom onset.

Results

We included 42 patients (60% male, median age 58 (IQR 50–65) years. Median troponin T levels were 783 (IQR 566–1208) ng/l. Multimodal cardiac imaging findings are presented in Table 1. Multimodal cardiac imaging showed signs of cardiac involvement in all but one patient (98%). Underlying diagnoses were acute myocardial infarction (36%), Takotsubo cardiomyopathy (29%), perimyocarditis (10%), and cardiomyopathy (7%). The diagnosis was unclear in 19% of patients.

Echocardiography   Left ventricular ejection fraction <40%, n (%) 12 (29)   Moderate to severe left ventricular hypertrophy, n (%) 3 (7)   Moderate to severe valvular disease, n (%) 3 (7)   Pericardial effusion, n (%) 5 (12)   Apical thrombus, n (%) 1 (2) Magnetic resonance imaging   Left ventricular end diastolic volume, ml (IQR) 157 (125–185)   Left ventricular end systolic volume, ml (IQR) 75 (63–88)   Left ventricular stroke volume, ml (IQR) 73 (57–93)   Edema, n (%) 38 (91)   Late gadolinium enhancement, n (%) 22 (52) 13NH3/82Rb and 18F-FDG positron emission computer tomography   Myocardial perfusion defect, n (%) 29 (69)   Myocardial perfusion-metabolism mismatch, n (%) 12/30 (40)   Reduced myocardial viability, n (%) 6/30 (20)

Conclusion

The majority of patients with suspected STEMI and normal coronary arteries had signs of cardiac involvement by multimodal cardiac imaging and were diagnosed with cardiac disease.

Acknowledgement/Funding

The Danish Heart Foundation, the A.P. Møller Foundation, the Foundation of Reinholdt W. Jorck and Wife, Rigshospitalet's Research Foundation

P885Cardiovascular events in patients with suspected ST-elevation myocardial infarction and no obstructive coronary artery disease

Background

Patients with suspected ST-elevation myocardial infarction (STEMI) and no obstructive coronary artery disease (CAD) comprise a heterogeneous group with varying prognoses.

Purpose

To evaluate the prognostic value of cardiac troponin T (cTnT) in patients with suspected STEMI and no obstructive CAD.

Methods

Patients with suspected STEMI and no obstructive (<50% diameter stenosis) CAD were consecutively included from 2009–2014. Patients were classified as having normal cTnT, dynamic cTnT elevation, or stationary cTnT elevation. All patients were followed with respect to major adverse cardiovascular events (MACE), cardiovascular readmission, and repeat coronary procedures, until 1 year after discharge.

Results

The study included 502 patients with suspected STEMI and no obstructive CAD: 165 (33%) had normal cTnT, 293 (58%) had dynamic cTnT elevation and 44 (9%) had stationary cTnT elevation. Within one year after admission, 40 (8%) had MACE, 81 (16%) had cardiovascular readmission, and 8 (2%) underwent repeat coronary procedures. The risk of MACE was elevated in patients with stationary cTnT elevation compared with normal cTnT (OR 13.6, 95% CI 2.3–80.2, p=0.004). There was no statistically significant difference between those with dynamic cTnT elevation and normal cTnT (OR 2.9, 95% CI 0.6–14.0, p=0.189). Adding cTnT pattern to a conventional risk model, area under the receiver operating curve for predicting the 1-year risk of MACE improved significantly (80% vs. 85%, p=0.004, Figure 1).

Figure 1

Conclusion

In patients with suspected STEMI and no obstructive CAD, cTnT pattern during acute hospitalization is associated with the 1-year risk of MACE and improves risk prediction for the individual patient.

Acknowledgement/Funding

The Danish Heart Foundation, the A.P. Møller Foundation, the Foundation of Reinholdt W. Jorck and Wife, Rigshospitalet's Research Foundation

Deferred versus conventional stent implantation in patients with ST-segment elevation myocardial infarction (DANAMI 3-DEFER): an open-label, randomised controlled trial

BACKGROUND

Despite successful treatment of the culprit artery lesion by primary percutaneous coronary intervention (PCI) with stent implantation, thrombotic embolisation occurs in some cases, which impairs the prognosis of patients with ST-segment elevation myocardial infarction (STEMI). We aimed to assess the clinical outcomes of deferred stent implantation versus standard PCI in patients with STEMI.

METHODS

We did this open-label, randomised controlled trial at four primary PCI centres in Denmark. Eligible patients (aged >18 years) had acute onset symptoms lasting 12 h or less, and ST-segment elevation of 0·1 mV or more in at least two or more contiguous electrocardiographic leads or newly developed left bundle branch block. Patients were randomly assigned (1:1), via an electronic web-based system with permuted block sizes of two to six, to receive either standard primary PCI with immediate stent implantation or deferred stent implantation 48 h after the index procedure if a stabilised flow could be obtained in the infarct-related artery. The primary endpoint was a composite of all-cause mortality, hospital admission for heart failure, recurrent infarction, and any unplanned revascularisation of the target vessel within 2 years' follow-up. Patients, investigators, and treating clinicians were not masked to treatment allocation. We did analysis by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT01435408.

FINDINGS

Between March 1, 2011, and Feb 28, 2014, we randomly assigned 1215 patients to receive either standard PCI (n=612) or deferred stent implantation (n=603). Median follow-up time was 42 months (IQR 33-49). Events comprising the primary endpoint occurred in 109 (18%) patients who had standard PCI and in 105 (17%) patients who had deferred stent implantation (hazard ratio 0·99, 95% CI 0·76-1·29; p=0·92). Procedure-related myocardial infarction, bleeding requiring transfusion or surgery, contrast-induced nephopathy, or stroke occurred in 28 (5%) patients in the conventional PCI group versus 27 (4%) patients in the deferred stent implantation group, with no significant differences between groups.

INTERPRETATION

In patients with STEMI, routine deferred stent implantation did not reduce the occurrence of death, heart failure, myocardial infarction, or repeat revascularisation compared with conventional PCI. Results from ongoing randomised trials might shed further light on the concept of deferred stenting in this patient population.

FUNDING

Danish Agency for Science, Technology and Innovation, and Danish Council for Strategic Research.

Accessory articulation of elongated anterior transverse process: a rare anatomical variant of the cervical spine depicted with CT and post-processing techniques

There are several described anatomical variants of the cervical spine, ranging from common to extremely rare, which may have different clinical implications. We present the case of an extremely rare anatomical variant of the cervical spine, in a symptomatic patient, consisting of a unilateral accessory articulation between the 5th and 6th cervical vertebrae, due to elongated anterior transverse processes. Our search found only three cases in the English literature describing similar findings to the case here reported. Our case is, to our knowledge, the first report of this anatomical variant imaged with computed tomography including post-processing images (volume rendering technology and multiplanar reformations), which contribute greatly to a better understanding and depiction of the anatomical variant.

Short- and long-term cause of death in patients treated with primary PCI for STEMI

BACKGROUND

Short-term mortality has been studied thoroughly in patients undergoing primary percutaneous coronary intervention (PCI), whereas long-term cause of death in patients with ST-segment elevation myocardial infarction (STEMI) remains unknown.

OBJECTIVES

The goal of this study was to describe the association between time and cause of death in patients with STEMI undergoing primary PCI.

METHODS

A centralized civil registration system, patient files, and public disease and death cause registries with an accurate record linkage were used to trace time and cause of death in 2,804 consecutive patients with STEMI (age 63 ± 13 years, 72% males) treated with primary PCI.

RESULTS

Patients were followed up for a median of 4.7 years. During a total of 13,447 patient-years, 717 patients died. Main causes of death within the first 30 days were cardiogenic shock and anoxic brain injury after cardiac arrest. Age, culprit vessel size and flow, and the presence of heart failure and diabetes were independent predictors of mortality. After 30 days, the annual cardiac mortality rate was <1.5%. Causes of death beyond 30 days were noncardiac in 65% of cases (mainly malignancies and pulmonary diseases). The 30-day, 1-year, and 5-year all-cause (and cardiac) mortality rates were 7.9% (7.3%), 11.4% (8.4%), and 23.3% (13.8%), respectively.

CONCLUSIONS

Patients who survive the first month after an STEMI treated with primary PCI have an excellent prognosis, with a <1.5% annual risk of successive cardiac death. Noncardiac causes are responsible for the majority of later deaths in these patients.

Takotsubo cardiomyopathy, a two-stage recovery of left ventricular systolic and diastolic function as determined by cardiac magnetic resonance imaging

AIMS

Takotsubo cardiomyopathy (TTC) is an entity mimicking acute myocardial infarction, characterized by transient severe systolic heart failure. Echocardiographic studies suggest that diastolic dysfunction is present in TTC at presentation; however, no reports exist regarding the time course of left ventricular (LV) recovery. This study describes the recovery of LV systolic and diastolic function in TTC. We hypothesized that, in TTC, there is diastolic dysfunction at admission, and that recovery is delayed compared with systolic function.

METHODS AND RESULTS

We enrolled (consecutively 2010-12) 16 patients (mean age 66, range 39-84 years) diagnosed with TTC and 20 healthy matched controls. We performed cardiac magnetic resonance imaging (CMR) at admission, pre-discharge, and 3-month follow-up. Diastolic function was assessed by LV peak filling rate (LVPFR) and left atrial (LA) emptying volumes. At admission, LV ejection fraction was low, increased at pre-discharge (37 ± 6 vs. 58 ± 6%, P < 0.001), and normalized at follow-up (to 65 ± 5%, P = 0.01). LVPFR did not increase during hospitalization (80 ± 3 vs. 89 ± 4 mL/s/m(2), P = 0.21), but was normalized at follow-up (to 206 ± 19, P < 0.001; controls, 214 ± 13, P = 0.23). During hospitalization, LA passive emptying volume remained low (6 ± 2 vs. 8 ± 3 mL/m(2), P = 0.05) and LA active emptying volume remained high (17 ± 3 vs. 16 ± 3 mL/m(2), P = 0.71), whereas LA conduit volume increased (7 ± 3 vs. 23 ± 4 mL/m(2), P < 0.001). T2-weighted imaging demonstrated non-coronary distributed apical oedema without contrast enhancement.

CONCLUSION

Patients with TTC undergo fast systolic recovery. However, at discharge, profound diastolic dysfunction is demonstrated by CMR. At follow-up, both LV systolic and diastolic function is normalized in patients with recovered TTC.

Short-term hemodynamic effect of angiotensin-converting enzyme inhibition in patients with severe aortic stenosis: a placebo-controlled, randomized study

BACKGROUND

In patients with severe aortic stenosis (AS), treatment with angiotensin-converting enzyme inhibitors has previously been considered contraindicated. However, there is a lack of clinical evidence to confirm these potential hemodynamic risks and benefits.

METHODS

Forty-four patients with severe AS (aortic valve area <1 cm(2)) were randomized to treatment with trandolapril 22 mg daily/placebo (1:1). Right heart catheterization and echocardiography were performed at rest and during exercise at baseline and on day 3. Follow-up was performed before valve replacement or after a maximum of 8 weeks, when exercise echocardiography was repeated.

RESULTS

Compared with placebo, systolic blood pressure and systemic arterial compliance significantly changed at day 3 (-14 ± 11 vs -5 ± 13 mm Hg, P = .02, and 0.08 ± 0.16 vs -0.05 ± 0.86 mL/m(2) per mm Hg, P = .03, respectively). Changes in left ventricular end systolic volume (LVESV) was nonsignificant (-8 ± 9 vs -3 ± 11 mL, P = .17). At a median of 49 days of follow-up, changes in LVESV and N-terminal pro-brain natriuretic peptide were even lower revealing significant differences between the groups (-7.8 ± 2.6 vs -0.5 ± 2.5 mL, P = .04, and -19 ± 7 vs 0.8 ± 6 pmol/L, P = .04, respectively). No episodes of symptomatic hypotension were noted, and other hemodynamic parameters remained unchanged.

CONCLUSION

Angiotensin-converting enzyme inhibition in severe AS caused a decrease in LVESV and N-terminal pro-brain natriuretic peptide with other hemodynamic parameters preserved both at rest and during exercise implying hemodynamic improvement with left ventricular unloading.

Laparoscopic partial nephrectomy for endophytic hilar tumors: feasibility and outcomes

OBJECTIVE

To analyze feasibility and outcomes of laparoscopic partial nephrectomy (LPN) for endophytic hilar tumors in low-intermediate (ASA I-II) risk patients.

METHODS

This is a single centre retrospective study. From May 2009 to September 2011, 208 LPNs were performed at our institution. Overall 11 (5.2%) elective LPNs were for hilar tumors not visible on kidney surface. Hilar tumor was defined as a mass located in the renal hilum and in contact with a major renal vessel on preoperative imaging. Procedures were carried out by a single experienced surgeon (G.G.) via retroperitoneal approach by clamping the only main renal artery.

RESULTS

Mean (range) age of patients was 45.3 years (38.2-64.1), tumor size 1.6 cm (1.2-2.0), warm ischemia time 24 min (19-32), operative time 140 min (110-200) and estimated blood loss 270 ml (100-750). Two collecting system injuries were observed and repaired intraoperatively. No conversion to open surgery was required. Final pathological examination revealed 10 renal cell carcinomas and 1 oncocytoma. A negative surgical margin was obtained in 10/11 (91%) patients. Renal function and serum hemoglobin were nearly unaltered pre and post-surgery. No tumor recurrence was observed at mean (range) follow-up of 34 months (15-43).

CONCLUSIONS

In experienced hands, LPN represents a feasible, safe and effective treatment for selected patients diagnosed with endophytic hilar masses. A larger number of patients and longer follow-up are required to draw definitive conclusions.

Reperfusion delay in patients treated with primary percutaneous coronary intervention: insight from a real world Danish ST-segment elevation myocardial infarction population in the era of telemedicine

BACKGROUND

Reperfusion delay in ST-segment elevation myocardial infarction (STEMI) predicts adverse outcome. We evaluated time from alarm call (system delay) and time from first medical contact (PCI-related delay), where fibrinolysis could be initiated, to balloon inflation in a pre-hospital organization with tele-transmitted electrocardiograms, field triage and direct transfer to a 24/7 primary percutaneous coronary intervention (PPCI) center.

METHODS AND RESULTS

This was a single center cohort study with long-term follow-up in 472 patients. The PPCI center registry was linked by person identification number to emergency medical services (EMS) and National Board of Health databases in the period of 2005-2008. Patients were stratified according to transfer distances to PPCI into zone 1 (0-25 km), zone 2 (65-100 km) and zone 3 (101-185 km) and according to referral by pre-hospital triage. System delay was 86 minutes (interquartile range (IQR) 72-113) in zone 1, 133 (116-180) in zone 2 and 173 (145-215) in zone 3 (p<0.001). PCI-related delay in directly referred patients was 109 (92-121) minutes in zone 2, but exceeded recommendations in zone 3 (139 (121-160)) and for patients admitted via the local hospital (219 (171-250)). System delay was an independent predictor of mortality (p<0.001).

CONCLUSIONS

Pre-hospital triage is feasible in 73% of patients. PCI-related delay exceeded European Society of Cardiology (ESC) guidelines for patients living >100 km away and for non-directly referred patients. Sorting the PPCI centers catchment area into geographical zones identifies patients with long reperfusion delays. Possible solutions are pharmaco-invasive regiments, research in early ischemia detection, airborne transfer and EMS personnel education that ensures pre-hospital triage.

[Patients with acute critical pulmonary embolism should be evaluated and treated in a centre with medical and surgical possibilities]

Acute pulmonary embolism (PE) is a common and potential lifethreatening condition. Nevertheless the advancements in the patient visitation and treatment algorithms have been few and the mortality unchanged high. Acute high risk PE, which is the most serious subtype, is primary treated with trombolysis. This treatment is not always possible or sufficient. Recent studies have shown that surgical embolectomy is a relevant treatment offer with low mortalities of 6-8%. Patients with acute critical PE should be evaluated and treated in a multidisciplinary centre with medical and surgical possibilities.

Genetically elevated bilirubin and risk of ischaemic heart disease: three Mendelian randomization studies and a meta-analysis

BACKGROUND

Elevated plasma levels of bilirubin, an endogenous antioxidant, have been associated with reduced risk of ischaemic heart disease (IHD) and myocardial infarction (MI). Whether this is a causal relationship remains unclear.

OBJECTIVE

We tested the hypothesis that elevated plasma bilirubin is causally related to decreased risk of IHD and MI.

DESIGN

We used a Mendelian randomization approach and three independent studies from Copenhagen, Denmark. We measured bilirubin in 43 708 white individuals from the general population, and genotyped rs6742078 G>T in the uridine diphosphate glucuronosyltransferase 1A1 (UGT1A1) gene in 67 068 individuals, of whom 11 686 had IHD.

RESULTS

Third versus first tertile of baseline bilirubin levels was associated with 134% increased bilirubin levels, with sex- and age-adjusted hazard ratios (HRs) of 0.86 [95% confidence interval (CI), 0.76-0.98; P = 0.02] for IHD and 0.81 (95% CI, 0.66-0.99; P = 0.04) for MI, but with corresponding multifactorially adjusted HRs of 0.93 (95% CI, 0.82-1.06; P = 0.29) and 0.90 (95% CI, 0.73-1.12; P = 0.35). UGT1A1 rs6742078 TT versus GG genotype was associated with 95% increased bilirubin levels (P < 0.001); TT versus GG genotype was associated with odds ratios (ORs) of 1.03 (95% CI, 0.96-1.11; P = 0.73) for IHD and 1.01 (95% CI, 0.92-1.12; P = 0.68) for MI. Finally, in a meta-analysis of the present three studies and eight previous studies including a total of 14 711 cases and 60 324 controls, the random effects OR for ischaemic cardiovascular disease for genotypes with approximately 100% increased bilirubin levels versus reference genotypes was 1.01 (95% CI, 0.88-1.16).

CONCLUSION

These data suggest that plasma bilirubin is not causally associated with risk of IHD.

Genetically elevated non-fasting triglycerides and calculated remnant cholesterol as causal risk factors for myocardial infarction

AIMS

Elevated non-fasting triglycerides mark elevated levels of remnant cholesterol. Using a Mendelian randomization approach, we tested whether genetically increased remnant cholesterol in hypertriglyceridaemia due to genetic variation in the apolipoprotein A5 gene (APOA5) associates with an increased risk of myocardial infarction (MI).

METHODS AND RESULTS

We resequenced the core promoter and coding regions of APOA5 in individuals with the lowest 1% (n = 95) and highest 2% (n = 190) triglyceride levels in the Copenhagen City Heart Study (CCHS, n = 10 391). Genetic variants which differed in frequency between the two extreme triglyceride groups (c.-1131T > C, S19W, and c.*31C > T; P-value: 0.06 to <0.001), thus suggesting an effect on triglyceride levels, were genotyped in the Copenhagen General Population Study (CGPS), the CCHS, and the Copenhagen Ischemic Heart Disease Study (CIHDS), comprising a total of 5705 MI cases and 54 408 controls. Genotype combinations of these common variants associated with increases in non-fasting triglycerides and calculated remnant cholesterol of, respectively, up to 68% (1.10 mmol/L) and 56% (0.40 mmol/L) (P < 0.001), and with a corresponding odds ratio for MI of 1.87 (95% confidence interval: 1.25-2.81). Using APOA5 genotypes in instrumental variable analysis, the observational hazard ratio for a doubling in non-fasting triglycerides was 1.57 (1.32-2.68) compared with a causal genetic odds ratio of 1.94 (1.40-1.85) (P for comparison = 0.28). For calculated remnant cholesterol, the corresponding values were 1.67(1.38-2.02) observational and 2.23(1.48-3.35) causal (P for comparison = 0.21).

CONCLUSION

These data are consistent with a causal association between elevated levels of remnant cholesterol in hypertriglyceridaemia and an increased risk of MI. Limitations include that remnants were not measured directly, and that APOA5 genetic variants may influence other lipoprotein parameters.

Nonfasting glucose, ischemic heart disease, and myocardial infarction: a Mendelian randomization study

OBJECTIVES

The purpose of this study was to test whether elevated nonfasting glucose levels associate with and cause ischemic heart disease (IHD) and myocardial infarction (MI).

BACKGROUND

Elevated fasting plasma glucose levels associate with increased risk of IHD, but whether this is also true for nonfasting levels and whether this is a causal relationship is unknown.

METHODS

Using a Mendelian randomization approach, we studied 80,522 persons from Copenhagen, Denmark. Of those, IHD developed in 14,155, and MI developed in 6,257. Subjects were genotyped for variants in GCK (rs4607517), G6PC2 (rs560887), ADCY5 (rs11708067), DGKB (rs2191349), and ADRA2A (rs10885122) associated with elevated fasting glucose levels in genome-wide association studies.

RESULTS

Risk of IHD and MI increased stepwise with increasing nonfasting glucose levels. The hazard ratio for IHD in subjects with nonfasting glucose levels ≥11 mmol/l (≥198 mg/dl) versus <5 mmol/l (<90 mg/dl) was 6.9 (95% confidence interval [CI]: 4.2 to 11.2) adjusted for age and sex, and 2.3 (95% CI: 1.3 to 4.2) adjusted multifactorially; corresponding values for MI were 9.2 (95% CI: 4.6 to 18.2) and 4.8 (95% CI: 2.1 to 11.2). Increasing number of glucose-increasing alleles was associated with increasing nonfasting glucose levels and with increased risk of IHD and MI. The estimated causal odds ratio for IHD and MI by instrumental variable analysis for a 1-mmol/l (18-mg/dl) increase in nonfasting glucose levels due to genotypes combined were 1.25 (95% CI: 1.03 to 1.52) and 1.69 (95% CI: 1.28 to 2.23), and the corresponding observed hazard ratio for IHD and MI by Cox regression was 1.18 (95% CI: 1.15 to 1.22) and 1.09 (95% CI: 1.07 to 1.11), respectively.

CONCLUSIONS

Like common nonfasting glucose elevation, plasma glucose-increasing polymorphisms associate with increased risk of IHD and MI. These data are compatible with a causal association.

Surgical treatment of acute pulmonary embolism--a 12-year retrospective analysis

OBJECTIVES

Surgical embolectomy for acute pulmonary embolism (PE) is considered to be a high risk procedure and therefore a last treatment option. We wanted to evaluate the procedures role in modern treatment of acute PE.

DESIGN

All data on patients treated with surgical embolectomy for acute PE were retrieved from our clinical database. The mortality was extracted from the Danish mortality register.

RESULTS

From October 1998 to July 2010, 33 patients underwent surgical embolectomy. All procedures were done through a median sternotomy and extracorporeal circulation. Twenty-six patients were diagnosed with a high risk PE and 7 with an intermediate risk PE and intracardial pathology. Six patients had been insufficiently treated with thrombolysis. Thirteen patients had contraindication for thrombolysis. Six patients were brought to the operating theatre in cardiogenic shock, 8 needed ventilator support, and 1 was in cardiac arrest. The postoperative 30-day mortality was 6% and during the 12-year follow-up the cumulative survival was 80% with 4 late deaths.

CONCLUSION

Surgical pulmonary embolectomy can be performed with low mortality although the treated patients belong to the most compromised part of the PE population. The results support surgical embolectomy as a vital part of the treatment algorithm for acute PE.

Genetic variation in ABCG1 and risk of myocardial infarction and ischemic heart disease

OBJECTIVE

ATP binding cassette transporter G1 (ABCG1) facilitates cholesterol efflux from macrophages to mature high-density lipoprotein particles. Whether genetic variation in ABCG1 affects risk of atherosclerosis in humans remains to be determined.

METHODS AND RESULTS

We resequenced the core promoter and coding regions of ABCG1 in 380 individuals from the general population. Next, we genotyped 10 237 individuals from the Copenhagen City Heart Study for the identified variants and determined the effect on lipid and lipoprotein levels and on risk of myocardial infarction (MI) and ischemic heart disease (IHD). g.-376C>T, g.-311T>A, and Ser630Leu predicted risk of MI in the Copenhagen City Heart Study, with hazard ratios of 2.2 (95% confidence interval: 1.2-4.3), 1.7 (1.0-2.9), and 7.5 (1.9-30), respectively. These results were confirmed for g.-376C>T in a case-control study comprising 4983 independently ascertained IHD cases and 7489 controls. Expression levels of ABCG1 mRNA were decreased by approximately 40% in g.-376C>T heterozygotes versus noncarriers (probability values: 0.005-0.009). Finally, in vitro specificity protein 1 (Sp1) bound specifically to a putative Sp1 binding site at position -382 to -373 in the ABCG1 promoter, and the presence of the -376 T allele reduced binding and transactivation of the promoter by Sp1.

CONCLUSIONS

This is the first report of a functional variant in ABCG1 that associates with increased risk of MI and IHD in the general population.

Heterozygosity for R1141X in ABCC6 and risk of ischemic vascular disease

BACKGROUND

Pseudoxanthoma elasticum (PXE) is an autosomal recessive disease caused by loss-of-function mutations in ABCC6 and characterized by elastic calcification leading to dermal, ocular, and ischemic vascular disease. We tested the hypothesis that heterozygosity for R1141X, the most frequent PXE-causing mutation in Caucasians, associated with risk of ischemic vascular disease, as previous studies suggested 4- to 11-fold risk of ischemic heart disease (IHD) in heterozygotes.

METHODS AND RESULTS

We studied 10,276 persons from the general population, including 1985 with IHD and 989 with ischemic cerebrovascular disease (ICVD). We examined 45,603 individuals from a cross-sectional general population study, of whom 3738 had IHD and 2335 had ICVD. Finally, we compared 4851 patients with IHD and 625 patients with ICVD with, respectively, 4851 and 625 matched control subjects. We genotyped participants in all studies for ABCC6 R1141X. The frequency of R1141X was 0.6% in all populations studied. ABCC6 R1141X genotype was not associated with an increased risk of IHD, myocardial infarction, ICVD, or ischemic stroke. Furthermore, R1141X genotype did not interact with age on risk of the largest end point, IHD. Finally, R1141X genotype did not associate with variation in plasma levels of high-sensitivity C-reactive protein, fibrinogen, blood pressure, or lipid and lipoproteins in the general population.

CONCLUSIONS

In 4 studies including 66 831 participants and 13 642 cases with ischemic vascular events, heterozygosity for ABCC6 R1141X did not associate with risk of IHD, myocardial infarction, ICVD, or ischemic stroke.

Copy Number Variation in Glutathione S-Transferases M1 and T1 and Ischemic Vascular Disease

Background—

Glutathione S-transferases (GSTs) M1 and T1 detoxify products of oxidative stress and may protect against atherosclerosis and ischemic vascular disease (IVD). We tested the hypothesis that copy number variation (CNV) in GSTM1 and GSTT1 genes, known to be associated with stepwise decreases in catalytic activity, predict risk of IVD.

Methods and Results—

We included 23 059 Danes from 2 general population studies and 2 case-control studies, of whom 4930 had ischemic heart disease (IHD) and 2086 had ischemic cerebrovascular disease. A real-time polymerase chain reaction method genotyped for the exact number of GSTM1 and GST T1 gene copies. We also performed meta-analyses, including our own and former studies, totaling 13 196 IHD cases and 33 228 controls. CNV in GSTM1 or GSTT1 or genotype combinations were not associated with an increased risk of IHD, myocardial infarction, ischemic cerebrovascular disease, ischemic stroke, or any ischemic vascular event in studies individually or combined or in the meta-analyses. Furthermore, genotypes did not interact with smoking on risk of disease end points. Finally, GST genotypes did not associate with markers of inflammation and oxidation or interact with smoking on markers of inflammation in the general population. In contrast, we observed the well-established association between CNV in GSTM1 and risk of bladder cancer.

Conclusions—

In studies including 6557 IVD cases and 16 502 controls and in meta-analyses of 13 196 cases and 33 228 controls, CNV in GSTM1 and GST T1 genes did not associate with risk of IVD or with markers of inflammation. These observations were independent of smoking exposure.

Mutation in APOA1 predicts increased risk of ischaemic heart disease and total mortality without low HDL cholesterol levels

OBJECTIVES

To determine whether mutations in APOA1 affect levels of high-density lipoprotein (HDL) cholesterol and to predict risk of ischaemic heart disease (IHD) and total mortality in the general population.

BACKGROUND

Epidemiologically, risk of IHD is inversely related to HDL cholesterol levels. Mutations in apolipoprotein (apo) A-I, the major protein constituent of HDL, might be associated with low HDL cholesterol and predispose to IHD and early death.

DESIGN

We resequenced APOA1 in 190 individuals and examined the effect of mutations on HDL cholesterol, risk of IHD, myocardial infarction (MI) and mortality in 10 440 individuals in the prospective Copenhagen City Heart Study followed for 31 years. Results were validated in an independent case-control study (n = 16 035). Additionally, we determined plasma ratios of mutant to wildtype (WT) apoA-I in human heterozygotes and functional effects of mutations in adenovirus-transfected mice.

RESULTS

We identified a new mutation, A164S (1 : 500 in the general population), which predicted hazard ratios for IHD, MI and total mortality of 3.2 [95% confidence interval (CI): 1.6-6.5], 5.5 (95% CI: 2.6-11.7) and 2.5 (95% CI: 1.3-4.8), respectively, in heterozygotes compared with noncarriers. Mean reduction in survival time in heterozygotes was 10 years (P < 0.0001). Results for IHD and MI were confirmed in the case-control study. Furthermore, the ratio of mutant S164 to WT A164 apoA-I in plasma of heterozygotes was reduced. In addition, A164S heterozygotes had normal plasma lipid and lipoprotein levels, including HDL cholesterol and apoA-I, and this finding was confirmed in adenovirus-transfected mice.

CONCLUSIONS

A164S is the first mutation in APOA1 to be described that predicts an increased risk of IHD, MI and total mortality without low HDL cholesterol levels.

Genetically elevated apolipoprotein A-I, high-density lipoprotein cholesterol levels, and risk of ischemic heart disease

CONTEXT

Epidemiologically, levels of high-density lipoprotein (HDL) cholesterol and its major protein constituent, apolipoprotein A-I (apoA-I), are inversely related to risk of ischemic heart disease (IHD).

OBJECTIVE

We tested whether common genetic variation in the apolipoprotein A1 gene (APOA1) contributes to apoA-I and HDL cholesterol levels and risk of IHD in the general population.

DESIGN

We resequenced the regulatory and coding regions of APOA1 in 190 individuals from the Copenhagen City Heart Study with the lowest 1% (n=95) and highest 1% (n=95) apoA-I levels. Two single-nucleotide polymorphisms (SNPs) were subsequently genotyped in the Copenhagen City Heart Study (n=10,273) and in 2361 cases with IHD (the Copenhagen Ischemic Heart Disease Study).

RESULTS

In total, 13 genetic variants were identified. Three SNPs, g.-560A→C, g.-151C→T, and *181A→G, determined a haplotype that differed between high and low apoA-I groups (6 vs. 1%, P=0.002). Genotype combinations of two SNPs, the g.-560A→C (tagging the g.-560A→C/g.-151C→T/*181A→G haplotype) and g.-310G→A (situated near a potential functional promoter site), were associated with increases in apoA-I and HDL cholesterol levels of up to 6.6 and 8.5%, respectively, resulting in theoretically predicted reductions in risk of 9 and 8% for IHD and 14 and 12% for myocardial infarction (MI). Despite this, these same genotype combinations were not associated with decreased risk of IHD or MI.

CONCLUSION

Common genetic variation in APOA1 associated with increased apoA-I and HDL cholesterol levels did not associate with decreased risk of IHD or MI.

TRIB1 and GCKR polymorphisms, lipid levels, and risk of ischemic heart disease in the general population

OBJECTIVE

The goal of this study was to test whether TRIB1-rs2954029 and GCKR-rs1260326 associate with lipid levels and risk of ischemic heart disease (IHD) and myocardial infarction (MI) in the general population.

METHODS AND RESULTS

We genotyped >71 000 individuals. Lipid levels were studied cross-sectionally. Risk of IHD and MI was examined prospectively, cross-sectionally, and in a case-control study, and a metaanalysis was performed. TRIB1 TA (50%) and AA (27%) versus TT (23%) genotypes were associated with increased levels of triglycerides (total increase, +0.16 mmol/L; trend, P<0.001), remnant cholesterol (+0.07 mmol/L; P<0.001), apolipoprotein B (+5.7 mg/dL; P<0.001), and low-density lipoprotein cholesterol (+0.11 mmol/L; P<0.001) and with decreased levels of high-density lipoprotein cholesterol (-0.04 mmol/L; P<0.001). In metaanalyses of the 3 studies combined, TRIB1 TA and AA versus TT genotypes were associated with 13% (95% CI, 5% to 20%) and 15% (7% to 23%) increased risk of IHD, and 11% (1% to 21%) and 17% (6% to 30%) increased risk of MI, respectively. Although GCKR CT (46%) and TT (14%) versus CC (40%) genotypes had effects on triglycerides (+0.17 mmol/L; trend, P<0.001), remnant cholesterol (+0.07 mmol/L; P<0.001), and apolipoprotein B (+4.6 mg/dL; P<0.001) similar to those of TRIB1, GCKR did not influence low-density lipoprotein cholesterol levels or risk of IHD or MI. Risks of IHD were similar after stratification for gender, age, body mass index, hypertension, diabetes mellitus, smoking, statin use, alcohol intake, and physical activity.

CONCLUSIONS

In the general population, both TRIB1-rs2954029 and GCKR-rs1260326 were associated with lipid levels, whereas TRIB1 was also associated with increased risk of IHD and MI.

PCSK9 R46L, low-density lipoprotein cholesterol levels, and risk of ischemic heart disease: 3 independent studies and meta-analyses

OBJECTIVES

The aim of this study was to examine the effect of PCSK9 R46L on low-density lipoprotein cholesterol (LDL-C), risk of ischemic heart disease (IHD), and mortality.

BACKGROUND

The 46L allele has been associated with reductions in LDL-C and risk of IHD, but results vary between studies.

METHODS

We determined the association of R46L genotype with LDL-C, risk of IHD, myocardial infarction (MI), and mortality in the prospective CCHS (Copenhagen City Heart Study) (n = 10,032) and validated the results in: 1) the cross-sectional CGPS (Copenhagen General Population Study) (n = 26,013); and 2) the case-control CIHDS (Copenhagen Ischemic Heart Disease Study) (n = 9,654). We also performed meta-analyses of present and previous studies (n = 66,698).

RESULTS

In carriers (2.6%) versus noncarriers, the 46L allele was associated with reductions in LDL-C of 0.35 to 0.55 mmol/l (11% to 16%) from 20 to 80+ years in the general population (CCHS and CGPS; p values <0.0001). Observed risk reductions for IHD in 46L allele carriers were: 6% in the CCHS study (hazard ratio [HR]: 0.94; 95% confidence interval [CI]: 0.68 to 1.31), 46% in the CGPS study (odds ratio [OR]: 0.54; 95% CI: 0.39 to 0.77), 18% in the CIHDS study (OR: 0.82; 95% CI: 0.55 to 1.21), and 30% in the studies combined (OR: 0.70; 95% CI: 0.58 to 0.86). In the CCHS study, HR for mortality was 1.18 (95% CI: 0.93 to 1.50). In meta-analyses, 46L allele carriers had a 12% (0.43 mmol/l) reduction in LDL-C and a 28% reduction in risk of IHD (HR: 0.72; 95% CI: 0.62 to 0.84), similar to results in the CCHS, CGPS, and CIHDS studies combined. However, the observed 12% (0.43 mmol/l) reduction in LDL-C theoretically predicted an only 5% reduction in risk of IHD (HR: 0.95; 95% CI: 0.92 to 0.97).

CONCLUSIONS

The PCSK9 46L allele was associated with reductions in LDL-C from 20 to 80+ years in the general population. The reduction in risk of IHD was larger than predicted by the observed reduction in LDL-C alone. This could be because genotype is a better predictor of lifelong exposure to LDL-C than LDL-C measured in adult life.

Long-term effects of invasive treatment in patients with a post-thrombolytic Q-wave myocardial infarction

OBJECTIVES

The aim of the present study was to assess the effect of a deferred invasive treatment strategy on long-term outcome in patients with a post-thrombolytic Q-wave myocardial infarction and inducible myocardial ischemia.

DESIGN

Patients (N=751) with post-thrombolytic Q-wave myocardial infarction and inducible ischemia (angina pectoris or silent myocardial ischemia) were randomized to a deferred invasive treatment (balloon angioplasty or coronary bypass surgery) or medical treatment. Vital status and non-fatal cardiac events defined as hospitalization caused by acute cardiac events were recorded for a median of 11.4 years.

RESULTS

Survival was significantly improved in patients receiving invasive treatment compared to patients treated medically (hazard ratio 0.85 (95% confidence limits 0.73-0.99), p=0.034). Subgroup analysis showed a reduction of non-fatal cardiac events and improved survival among the patients with post-infarction angina pectoris and not among the patients with silent myocardial ischemia.

CONCLUSIONS

A deferred invasive treatment strategy improves survival compared to medical treatment in patients with inducible myocardial ischemia after a post-thrombolytic Q-wave myocardial infarction.

Usefulness of pregnancy-associated plasma protein A in patients with acute coronary syndrome

To investigate whether pregnancy-associated plasma protein-A (PAPP-A) is a prognostic marker in patients admitted with high-risk acute coronary syndrome. In patients admitted with high-risk non-ST-segment elevation acute coronary syndrome (NSTE-ACS) and ST-segment elevation myocardial infarction (STEMI), risk stratification is primarily determined by the markers of myocardial necrosis and known demographic risk profiles. However, it has recently been proposed that the presence and extent of vulnerable plaques might influence the prognosis significantly. A marker for the vulnerable plaque could identify patients at high risk who would potentially benefit from intensive treatment and surveillance. Two populations of consecutive patients admitted with high-risk NSTE-ACS (n = 123) and STEMI (n = 314) were evaluated with serial measurements of PAPP-A. The incidence of mortality and nonfatal myocardial infarction was prospectively registered for 2.66 to 3.47 years. In the patients with high-risk NSTE-ACS, PAPP-A was related to the risk of nonfatal myocardial infarction (p = 0.02) and death (p = 0.03). This result was consistent on multivariate analysis of the combination of mortality or nonfatal myocardial infarction (odds ratio 2.65, 95% confidence interval 1.40 to 5.03) but not for mortality alone (p = NS). In patients with STEMI, PAPP-A was related to the risk of death (p = 0.01) but not the composite outcome of myocardial infarction and death. This was also true after adjustment for other univariate predictors of death (odds ratio 2.19, 95% confidence interval 1.16 to 4.16). In conclusion, PAPP-A seems to be valuable in predicting the outcomes of patients admitted with high-risk NSTE-ACS or STEMI.

Genetically reduced soluble epoxide hydrolase activity and risk of stroke and other cardiovascular disease

BACKGROUND AND PURPOSE

The development of stroke has been linked to lowered levels of epoxyeicosatrienoic acids in the cerebral microvasculature. These substances are metabolized by the enzyme-soluble epoxide hydrolase encoded by the EPHX2 gene. We tested whether genetically reduced soluble epoxide hydrolase activity is associated with risk of ischemic stroke, myocardial infarction, and ischemic heart disease.

METHODS

We genotyped participants from the Copenhagen City Heart Study (n=10 352), the Copenhagen General Population Study (n=26 042), the Copenhagen Carotid Stroke Study (n=398 cases+796 control subjects), and the Copenhagen Ischemic Heart Disease Study (n=4901 cases+9798 control subjects) for the R103C, R287Q, and Arg(402-403ins) variants in the EPHX2 gene and recorded hospital admissions due to ischemic stroke, myocardial infarction, and ischemic heart disease.

RESULTS

The hazard/odds ratio for ischemic stroke did not differ from 1.0 for any of the EPHX2 genotypes or genotype combinations in the Copenhagen City Heart Study (P for trend=0.15 to 0.76), in the Copenhagen General Population Study (P for trend=0.75 to 0.95), and the Copenhagen Carotid Stroke Study (P for trend=0.08 to 1.00). Similar results were obtained for myocardial infarction and ischemic heart disease in the 3 studies.

CONCLUSIONS

Our results show with significant power that genetically reduced soluble epoxide hydrolase activity is not a major risk factor for ischemic stroke, myocardial infarction, or ischemic heart disease in the Danish population. This suggests that the relationship between the EPHX2 gene and risk of ischemic stroke and other cardiovascular disease does not exist or its effect size is likely to be quite small.

Effects of statin therapy according to plasma high-sensitivity C-reactive protein concentration in the Controlled Rosuvastatin Multinational Trial in Heart Failure (CORONA): a retrospective analysis

BACKGROUND

We examined whether the antiinflammatory action of statins may be of benefit in heart failure, a state characterized by inflammation in which low cholesterol is associated with worse outcomes.

METHODS AND RESULTS

We compared 10 mg rosuvastatin daily with placebo in patients with ischemic systolic heart failure according to baseline high sensitivity-C reactive protein (hs-CRP) <2.0 mg/L (placebo, n=779; rosuvastatin, n=777) or > or = 2.0 mg/L (placebo, n=1694; rosuvastatin, n=1711). The primary outcome was cardiovascular death, myocardial infarction, or stroke. Baseline low-density lipoprotein was the same, and rosuvastatin reduced low-density lipoprotein by 47% in both hs-CRP groups. Median hs-CRP was 1.10 mg/L in the lower and 5.60 mg/L in the higher hs-CRP group, with higher hs-CRP associated with worse outcomes. The change in hs-CRP with rosuvastatin from baseline to 3 months was -6% in the low hs-CRP group (27% with placebo) and -33.3% in the high hs-CRP group (-11.1% with placebo). In the high hs-CRP group, 548 placebo-treated (14.0 per 100 patient-years of follow-up) and 498 rosuvastatin-treated (12.2 per 100 patient-years of follow-up) patients had a primary end point (hazard ratio of placebo to rosuvastatin, 0.87; 95% confidence interval, 0.77 to 0.98; P=0.024). In the low hs-CRP group, 175 placebo-treated (8.9 per 100 patient-years of follow-up) and 188 rosuvastatin-treated (9.8 per 100 patient-years of follow-up) patients experienced this outcome (hazard ratio, 1.09; 95% confidence interval, 0.89 to 1.34; P>0.2; P for interaction=0.062). The numbers of deaths were as follows: 581 placebo-treated (14.1 per 100 patient-years of follow-up) and 532 rosuvastatin-treated (12.6 per 100 patient-years) patients in the high hs-CRP group (hazard ratio, 0.89; 95% confidence interval, 0.79 to 1.00; P=0.050) and 170 placebo-treated (8.3 per 100 patient-years) and 192 rosuvastatin-treated (9.7 per 100 patient-years) patients in the low hs-CRP group (hazard ratio, 1.17; 95% confidence interval, 0.95 to 1.43; P=0.14; P for interaction=0.026).

CONCLUSIONS

In this retrospective hypothesis-generating study, we found a significant interaction between hs-CRP and the effect of rosuvastatin for most end points whereby rosuvastatin treatment was associated with better outcomes in patients with hs-CRP > or = 2.0 mg/L.

CLINICAL TRIAL REGISTRATION INFORMATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00206310.

Cardiac troponin I degradation in serum of patients with hypertrophic obstructive cardiomyopathy undergoing percutaneous septal ablation

INTRODUCTION

Troponin has become the most important marker for diagnosing acute myocardial infarction, yet knowledge is scarce regarding appearance of specific degradation fragments in the blood. We have recently described the appearance of intact cardiac troponin I (cTnI) and 7 degradation products in patients suffering from ST-elevation myocardial infarction (STEMI) using Western blot analysis. However, the time resolution in STEMI patients is hampered by the rather vague time point 'onset of pain'. We therefore sought to utilize a time-wise more reliable model of human myocardial necrosis: percutaneous transluminal septal myocardial ablation (PTSMA) of hypertrophic obstructive cardiomyopathy (HOCM). Here the iatrogenic induction of myocardial necrosis occurs in vivo, allowing us to investigate degradation of cTnI by the second.

METHODS

Blood samples were obtained from 8 patients with HOCM just prior to initiation of PTSMA and up to 50 h following the procedure. Western blot analysis was performed with subsequent analysis of relative intensities of the bands as compared to the degradation of cTnI in STEMI patients from the ASSENT-2 troponin substudy.

RESULTS

We demonstrate intact cTnI and 9 degradation products [molecular weight (MW) 12.0-23.5 kDa]. The bands were comparable in MW to degradation fragments in STEMI. Their early rise in intensity, occurring within few minutes after the alcohol injection, emphasizes how susceptible troponin bands are to chemical/ischemic insults. Moreover, two additional bands were visible in the PTSMA population.

CONCLUSION

This work describes the degradation products of troponin I in HOCM patients undergoing PTSMA. The detected bands appear fast and are similar to degradations following STEMI. This model contributes to our knowledge of the degradation patterns of troponin in disease states, and may thus play a role in the interpretation of elevated troponin levels.

[Thrombolytic therapy in pregnant woman with pulmonary embolism]

A 33-year-old pregnant woman suffered a massive pulmonary embolism at 29 weeks of gestation. The diagnosis was confirmed by spiral computed tomography, and she was successfully treated with recombinant tissue plasminogen activator and LMWH.

[C-reactive protein and risk of ischaemic vascular and cerebrovascular disease--secondary publication]

Elevated levels of C reactive protein (CRP) are associated with increased risk of ischaemic vascular disease. We tested whether this is a causal association. CRP > 3 vs < 1 mg/l were associated with an increased risk of ischaemic heart- and cerebrovascular disease of 1.6 and 1.3, respectively. Four CRP polymorphisms were associated with a 64% increase in CRP levels, resulting in a theoretically predicted increased risk of 32% and 25% for ischemic heart- and ischemic cerebrovascular disease, respectively. However, these genotype combinations were not associated with an increased risk of ischaemic vascular disease.

Leukotriene C4 synthase and ischemic cardiovascular disease and obstructive pulmonary disease in 13,000 individuals

Ischemic cardiovascular disease and obstructive pulmonary disease involve inflammation. Leukotrienes may be important pro-inflammatory mediators. We tested the hypothesis that the (-1072)G > A and (-444)A > C promoter polymorphisms of leukotriene C4 synthase confer risk of transient ischemic attack (TIA), ischemic stroke, ischemic heart disease (IHD), asthma, and chronic obstructive pulmonary disease (COPD). We genotyped individuals from the Danish general population, the Copenhagen City Heart Study, and Danish patients with IHD/coronary atherosclerosis, the Copenhagen Ischemic Heart Disease Study. We used prospective (n = 10,386), cross-sectional (n = 10,386), and case-control (n = 2392 + 5012) designs. Allele frequency was 0.07 for (-1072)A and 0.29 for (-444)C. Cumulative incidence for TIA was higher for (-1072)AA versus GG genotype (log-rank: p < 0.001), and lower for (-444)CC versus AA genotype (log-rank: p = 0.03). Cumulative incidence for ischemic stroke was also lower for (-444)CC versus AA genotype (log-rank: p = 0.04). Multifactorially adjusted hazard ratios for TIA were 5.2(95% CI:1.9-14) for (-1072)AA versus GG genotype, and 0.4(0.2-1.0) for (-444)CC versus AA genotype. Corresponding values were 1.9 (0.7-5.2) and 0.7 (0.5-1.0) for ischemic stroke, and 0.8 (0.4-1.6) and 1.0 (0.9-1.2) for IHD. In the case-control study, corresponding multifactorially adjusted odds ratios for IHD/coronary atherosclerosis were 0.5 (0.2-1.3) and 1.2 (1.0-1.5). These genotypes were not associated with risk of asthma or COPD. Leukotriene C4 synthase promoter genotypes influence risk of TIA and ischemic stroke, but not risk of IHD/coronary atherosclerosis, asthma, or COPD.

Enzyme activities in serum after extensive exercise, with special reference to creatine kinase MB

It is well documented that elevations of serum enzymes used as criteria in establishing the diagnosis of acute myocardial infarction (AMI) often show a pattern of AMI after physical exercise without other clinical signs of myocardial damage. Since a clinical condition resembling AMI sometimes appears after strenuous physical exercise, this study was designed to show if the new, almost heart-specific, isoenzyme creatine kinase MB (CK-MB) would solve the diagnostic problems. Ten well trained volunteers took part in a 26 km jogging race. None of them had any cardiovascular symptoms, but the 'old' cardiac enzymes rose in some of them above the discriminatory levels, whereas CK-MB was below these levels in all cases. It is concluded that CK-MB determination is a valuable diagnostic tool, also in patients who have recently exercised extensively.

Relationship between serum CK-MB-estimated acute myocardial infarct size and clinical complications

The relationship between acute myocardial infarct (AMI) size and morbidity and mortality was estimated in 317 patients followed for one year or until death. Infarct size was estimated from serum creatine kinase (CK)-MB levels measured thrice daily. The incidence of ventricular arrhythmias, congestive heart failure, cardiogenic shock, and the cardiac performance during exercise were studied during hospitalization. Hospital mortality and one-year mortality were registered. A positive correlation was found between serum CK-MB-estimated infarct size and the incidence of ventricular arrhythmias (p less than 0.05). Patients with congestive heart failure and patients with cardiogenic shock had significantly larger infarct size than patients without (p less than 0.05-0.01), although there was a substantial overlap. During exercise test the rise in systolic blood pressure correlated negatively and the rise in heart rate correlated positively to estimated infarct size (p less than 0.01). Both hospital mortality and one-year mortality were significantly related to estimated infarct size (p less than 0.01). Thus the infarct size, as estimated from serum CK-MB, seems to be of importance for development of the most common and serious complications after AMI.

Left ventricular filling pressure estimation at rest and during exercise in patients with severe aortic valve stenosis: comparison of echocardiographic and invasive measurements

BACKGROUND

The Doppler index of left ventricular (LV) filling (E/e') is recognized as a noninvasive measure for LV filling pressure at rest but has also been suggested as a reliable measure of exercise-induced changes. The aim of this study was to investigate changes in LV filling pressure, measured invasively as pulmonary capillary wedge pressure (PCWP), at rest and during exercise to describe the relation with E/e' in patients with severe aortic stenosis.

METHODS

Twenty-eight patients with an aortic valve areas<1 cm(2) performed a multistage supine bicycle exercise test until exhaustion. PCWP, E/e'(septal), and E/e'(lateral) were determined simultaneously by echocardiography at rest and at maximal tolerated workload.

RESULTS

PCWP increased significantly from 18+/-8 mm Hg at rest to 39+/-10 mm Hg at peak exercise (P < .0001). E, e'(septal), and e'(lateral) increased with exercise, whereas E/e'(septal) remained unchanged (19+/-6 vs 19+/-6; P=NS), and only minimal changes were observed in E/e'(lateral) (14+/-4 vs 15+/-4; P=.05). E/e'(septal) and E/e'(lateral) were significantly correlated with PCWP at rest (r=0.72, P < .0001, and r=0.67, P < .0001, respectively) as well as at peak exercise (r=0.66, P=.0003, and r=0.47, P=.02, respectively), with nearly similar slopes of the linear regression lines. The intercepts, however, increased by 18 mm Hg (P=.01) and by 19 mm Hg (P=.01) at peak exercise, respectively. Changes in E/e'(septal) and E/e'(lateral) were not related to changes in PCWP with exercise (P=NS). Instead, the ratio of E velocity during exercise to e'(septal) at rest (E(exercise)/e'(septal, rest)) was correlated with PCWP during exercise (r=0.61, P=.001), and furthermore, E(exercise)-E(rest)/e'(septal, rest) was related to changes in PCWP (r=0.45, P=.02). The results for the lateral side were r=0.50 (P=.01) and r=0.44 (P=.03), respectively.

CONCLUSIONS

E/e' is well correlated with PCWP at rest. However, E/e' cannot be used to detect exercise-induced changes in PCWP in patients with severe aortic stenosis. Using the ratio of E during exercise to e' at rest may result in a better estimate of the increase in PCWP during exercise.