Reduced visfatin levels in aortic stenosis increase after aortic valve replacement and may contribute to reverse left ventricular remodelling

AIM

Visfatin may play a part in reverse left ventricular remodelling. Using a mouse model of reversible left ventricle pressure overload, we examined if visfatin was altered in the myocardium. Furthermore, we addressed this issue in patients with aortic stenosis (AS) and examined whether visfatin levels are related to reverse remodelling following aortic valve replacement (AVR).

METHODS

Myocardial visfatin was analysed after aortic banding (AB) and debanding (DB) in mice and compared to sham operated animals. Myocardial visfatin was measured in biopsies from patients undergoing AVR and compared to controls. Serum visfatin was measured before and after AVR in patients with AS and correlated with echocardiographic measurments of cardiac morphology and function.

RESULTS

Four weeks after AB, myocardial visfatin protein was reduced by 50% compared to sham. Three days after DB, myocardial protein levels increased significantly. Myocardial visfatin and serum visfatin levels were reduced by 23% and 64%, respectively, in patients with AS compared to controls. Twelve months after AVR, serum visfatin levels increased compared to preoperative values and correlated negatively with degree of left ventricular hypertrophy.

CONCLUSION

Myocardial visfatin and serum visfatin levels are reduced by cardiac pressure overload. Visfatin levels increase after correction of pressure overload and may play a part in postoperative reverse remodelling.

Osteoprotegerin levels predict mortality in patients with symptomatic aortic stenosis

OBJECTIVES

To examine the prognostic value of osteoprotegerin (OPG) levels in relation to all-cause mortality in patients with symptomatic severe aortic stenosis (AS).

DESIGN

We measured plasma OPG levels in 136 patients with symptomatic severe AS and investigated associations with transvalvular gradients, valve area, valve calcification (using ultrasonic backscatter analysis as an estimate) and measures of heart failure. Then, we assessed the prognostic value of elevated plasma OPG in determining all-cause mortality (n = 29) in these patients.

RESULTS

Elevated OPG was poorly correlated with the degree of AS but was associated with increased backscatter measurements and impaired cardiac function. Furthermore, OPG was associated with all-cause mortality in patients with symptomatic AS, even after adjustment for conventional risk markers. The strongest association was obtained by using a combination of high levels of both OPG and N-terminal pro-brain natriuretic peptide (NT-proBNP), suggesting that these markers may reflect distinct pathways in the development and progression of AS.

CONCLUSION

The level of circulating OPG is significantly associated with all-cause mortality alone and in combination with NT-proBNP in patients with severe symptomatic AS.

Prosthetic heart valve thrombosis during dicloxacillin therapy

A 76-year-old woman receiving warfarin after aortic valve replacement experienced prosthetic valve thrombosis during dicloxacillin therapy. Successful thrombolysis was achieved with tissue plasminogen activator. The international normalized ratio (INR) on admission was reduced to 1.4 and an increased warfarin dosage was required for three weeks following discontinuation of dicloxacillin treatment in order to maintain therapeutic INRs. Careful monitoring of INRs and titration of the warfarin dosage is recommended when dicloxacillin is prescribed to patients receiving warfarin.

Panic disorder in chest pain patients referred for cardiological outpatient investigation

OBJECTIVES

The aims of the study were to: (i) determine the prevalence of panic disorder (PD) in patients referred to cardiological outpatient clinics for evaluation of chest pain; (ii) compare psychiatric comorbidity, psychological distress, pain characteristics and suicidal ideation in PD and non-PD patients: (iii) compare the prevalence of coronary risk factors and medical comorbidity in PD and non-PD patients; and (iv) describe current PD treatment and need for PD treatment as expressed by PD patients.

DESIGN

A cross-sectional study based on psychiatric and cardiological investigation.

SETTING

Four cardiological outpatient clinics in Oslo, Norway.

SUBJECTS

One-hundred and ninety-nine consecutive patients without known heart disease referred to out-patient clinics for investigation of chest pain.

MAIN OUTCOME MEASURES

Psychiatric state diagnosis (axis I); scores on self-assessment rating scales of psychological factors and pain modalities; cardiological diagnosis.

RESULTS

Thirty-eight per cent of the patients met criteria for current panic disorder (PD). Panic disorder was associated with psychological distress, comorbid psychiatric disorders, medical disorders and significantly higher prevalence of coronary risk factors (P<0.05). Furthermore. the results suggest that these patients were not identified and appropriately treated for panic disorder prior to cardiological investigation. The results indicate that the patients are positive to screening for psychiatric disorder and communicate a need for treatment early in the investigation process.

CONCLUSION

PD commonly occurs in this chest pain population. Thus, there is a need to educate physicians caring for these patients about PD identification and treatment.

[Surgical treatment of infective endocarditis]

Patients operated on for infective endocarditis (n = 69) at two regional hospitals between 1988 and 1994 are reviewed. 70% had a known valvular heart disease and 16% had prosthetic valve endocarditis. In 28% the offending microorganism was Staphylococcus aureus; in 26% Streptococcus viridans. Therapy was intended to be a six-week antibiotic course before operating, but 55% of the patients had to be operated on earlier. The postoperative course was uncomplicated in 59%, mortality was 16% and one-year survival 81%. Increased risk of death was associated with operating before the six-week course of antibiotics was completed (p = 0.005), with preoperative renal failure (p = 0.006) or lung failure (p = 0.008), with the growth of microorganisms from tissue samples extirpated during the operation (p = 0.01), with additional surgical procedures concomitant to valvular replacement (p = 0.02), S. aureus endocarditis (p = 0.03), and with the presence of paravalvular abscesses or intracardial fistulas (p = 0.03). The study shows that infective endocarditis is a serious disease. Wherever clinically feasible, all patients should be given antibiotics for six weeks before evaluating surgery. However, close surveillance of infection and haemodynamics is necessary to allow for the possibility of acute surgery before the development of organ failure. Special attention must be paid to cases of S. aureus endocarditis.

[Infectious endocarditis at Ullevål hospital 1988-94. Echocardiographic investigation]

During a seven-year period (1998-94) 68 patients with infectious endocarditis were diagnosed at a university hospital. Staphylococcus aureus was the most common etiological agent (38%), followed by Streptococcus viridans (21%). In seven patients the diagnosis infectious endocarditis was first made during autopsy, all seven of them had the clinical diagnosis septicaemia. Surgery was performed on 41% of the patients. Case fatality was 34%. Case fatality was significantly higher for S aureus endocarditis than for S viridans endocarditis, 48% vs. 7% (p = 0.01). The advantages of transthoracic and transoesophageal echocardiography in the diagnosis and follow up of patients with infectious endocarditis is emphasized. In spite of these new diagnostic tools a definitive clinical diagnosis of infectious endocarditis was not made for 23% of the patients.

[Poisoning with Jimson weed. Five cases treated with physostigmine]

During the autumn of 1995, the National Poisons Information Centre was contacted about several cases of poisoning with Jimson weed (Datura stramonium). Five cases are described here. Upon admission to hospital the patients had moderate to severe anticholinergic symptoms, such as mydriasis, sinus tachycardia, agitation, dry mouth, urine retention, fever, hypertension, hallucinations and seizures. Owing to their agitated behaviour, gastrointestinal decontamination was impossible. Repeated doses of physostigmine (2-3 mg) administered intravenously reversed the anticholinergic features without side-effects. In the most severe case, physostigmine was needed for 18 hours (total dose; 25.5 mg). The patients recovered in a day or two, but mydriasis persisted in many cases.

[Eosinophilia in malignant tumors]

The article presents two cases of malignant tumour and eosinophilia and reviews the literature on this condition. It is associated with disseminated disease and indicates a poor prognosis. Current knowledge supports the view that eosinophilia in malignant tumours is caused by a tumour-produced ectopic hormone-like substance which directly stimulates the growth of the eosinophilic granulocytes in the bone marrow.