Thrombomodulin, a protective marker against coronary artery disease

1] To compare the serum thrombomodulin levels between apparently healthy subjects and patients with myocardial infarction and unstable angina 2] To assess, whether it may be identified as a protective marker for determining the incidence of coronary artery disease The controls and patients were taken by convenient sampling. A total of 32 control [healthy] subjects were compared with 32 consecutive patients with history of myocardial infarction, [M.I.] and 32consecutive patients with history of unstable angina [U.A.] respectively. The diagnosis of myocardial infarction [M.I.] and unstable angina was made on the basis of history, E.C.G. and Trop. I levels. Serum thrombomodulin and serum lipid profile of each subject were determined by ELISA Kit methods. One way analysis of variance [ANOVA] was conducted for comparison of serum thrombomodulin level among healthy, Myocardial infarction [M.I.] and unstable angina [U.A.] patients. Serum Thrombomodulin levels were significantly higher in controls when compared to patients of myocardial infarction and unstable angina. Serum L.D.L. cholesterol and total cholesterol levels were significantly higher in diseased group in comparison with control Incur study healthy population had increased Thrombomodulin levels as compared to patients of coronary artery disease [C.A.D.]

Pro-brain natriuretic peptide plasma levels, left ventricular dimensions and ejection fraction in acute dyspnoea

To determine the association of the pro-brain natriuretic peptide [NT-proBNP] plasma levels with two dimensional echocardiographic determination of left ventricular dimensions and ejection fraction [EF] in acute dyspneic patients. An observational cross-sectional study. Tabba Heart Institute, Karachi, from January to June 2010. One hundred patients were selected by consecutive purposive non-probability sampling who had presented with acute dyspnoea. NT-proBNP levels were assessed by commercial tests [Roche Diagnostics]. The clinical diagnosis of congestive heart failure [CHF], echocardiographic assessment of left ventricular dimensions and function were compared with NT-proBNP levels. Receiver operating characteristic [ROC] curve was estimated for NT-proBNP and compared. The chi-square test was applied for categorical and student's t-test for numerical data at 0.05 levels of significance were used to compare patients with and without heart failure. Further comparative analysis between groups on the basis of ejection fraction was done by one way ANOVA test. Seventy-nine patients [79%] had CHF as a cause of their dyspnoea. Patients with CHF were older [61.9 +/- 14 years vs. 58.6 +/- 14 years, p=0.368], had a lower EF [36.9% vs. 61%, p < 0.0001], had a higher LV dimensions, left ventricular end diastolic dimension - LVEDD [49.94 +/- 5.6 vs. 42 +/- 7.9 mm, p < 0.0001], left ventricular end systolic dimension - LVESD [37.31 +/- 6 vs. 29.21 +/- 10.9 mm, p < 0.0001] and a higher NT-proBNP [10918 +/- 1228 vs. 461 +/- 100 pg/mL, p < 0.0001] than patients without CHF. NT-proBNP values increased with the severity of ventricular impairment. Significant differences were found between patients with LVEF < 25% and patients with moderate ventricular impairment [LVEF = 26 - 40%] and mild ventricular impairment [LVEF = 41-60%, p < 0.001]. The group of patients with LV dilation, had significantly higher BNP levels than those with normal LVEDD [12416 +/- 1060 pg/ml vs. 6113 +/- 960, p = 0.009] and LVESD [10416 +/- 1160 vs. 4513 +/- 960 pg/ml, p = 0.008]. Area under ROC curve for the diagnosis of CHF was significantly higher for NT-proBNP [AUC 0.99, p < 0.003]. The sensitivity of NT-proBNP value of > 300 pg/mL for the diagnosis of CHF was 100% and specificity was 42%. A cut-point of 300 pg/mL NT-proBNP had 100% negative predictive value to exclude acute CHF. NT-proBNP is strongly associated with two-dimensional echocardiographic determination of left ventricular dimensions and EF in identifying CHF in patients with acute dyspnoea

Role of serum troponin-l in identifying left ventricular ejection fraction of

To determine the serum levels of troponin-l in identifying left ventricular ejection fraction [LVEF] of 63.5 ng/ml predicted LVEF of <40% with a sensitivity of 94% and specificity of 97% in patients receiving streptokinase, whereas in patients undergoing primary PCI, troponin-l levels of > 87.5 ng/ml predicted LVEF < /=40% with a sensitivity of 86% and specificity of 100%. Troponin-l concentration of > 63.5 ng/ml and > 87.5 ng/ml can predict LVEF

Biatrial myxoma

A female, 32 years of age, presented with complaint of easy fatigability and exertional dyspnoea for the last one year. She had no previous history of cardiac disease. On clinical examination, there was a diastolic murmur at apex. Transthoracic echocardiography and subsequently a transesophageal echocardiogram was performed, which showed biatrial pedunculated masses, suggestive of cardiac myxoma. The left atrial mass was 28 x 15 mm and right atrial mass was 35 x 25 mm in dimension and both appeared attached with interatrial septum. On surgical excision and histopathological examination, findings were consistent with cardiac myxoma

Acute myocardial infarction with left bundle branch block [LBBB]: significance of sgarbossa criteria

A middle aged female presented in emergency department with chest discomfort. Her old electrocardiogram [EKG] showed left bundle branch block [LBBB] signs. EKG performed in the emergency room revealed left bundle branch block with 4-6 mm discordant ST segment elevation in leads VI-V3 and 1mm concordant ST segment elevation in lead V4. Diagnosis of acute anterior wall STEMI was made based on Sgarbossa criteria. She underwent angiography which showed total occlusion of proximal left anterior descending artery which was stented. She had uneventful post-stenting course in hospital and was discharged. The case highlights the significance of Sgarbossa criteria which can be applied to diagnose acute myocardial infarction in the presence of LBBB so that prompt thrombolytic or primary angioplasty can be preformed

Myocardial viability- assessment and clinical relevance

The assessment of myocardial viability is an important indication for noninvasive imaging in patients with coronary artery disease and chronic ischemic left ventricular dysfunction. Left ventricular function is a major determinant of survival in coronary artery disease. The goal of myocardial viability assessment is to differentiate patients with potentially reversible from irreversible left ventricular dysfunction9. In patients with chronic coronary artery disease and left ventricular dysfunction, there exists an important subpopulation in which revascularization may significantly improve regional or global left ventricular function, as well as symptoms and hence therapeutic and prognostic benefits in selected patients. The underlying pathophysiology involves reversible myocardial dysfunction [hibernation or stunning] which may exist independently or may coexist within the same patient. Stunned myocardium refers to the state of persistent regional dysfunction after a transient period of ischemia followed by reperfusion, most commonly present in acute coronary syndromes. Hibernating myocardium refers to a condition of chronic sustained abnormal contraction due to chronic underperfusion in patients with coronary artery disease in whom revascularization causes recovery of function. These states of potentially reversible left ventricular dysfunction commonly have preserved cell membrane integrity and metabolic activity to maintain cellular functions in the absence of normal myocyte contractility secondary to resting ischemia. Stunned myocardium improves its function early post revascularization, whereas hibernating myocardium may need longer time to fully recover in function. Furthermore, exercise capacity improved in patients with viable myocardium, and long term prognosis appeared favorable if patients with viable myocardium underwent revascularization. Viable myocardium has unique characteristics and these form the basis for the different imaging modalities that are currently available for the assessment of myocardial viability. A number of diagnostic techniques have emerged for differentiating viable from non viable myocardium in dysfunctional regions. These include evaluation of regional perfusion, cell membrane integrity, and metabolism using nuclear techniques with various radionuclide tracers; contractile reserve using dobutamine echocardiography or magnetic resonance imaging. More conventional approaches of identifying scarred and necrotic myocardium including presence of occluded coronary artery, regional contractile dysfunction, Q waves on electrocardiogram have been shown to be less accurate. New modalities include use of metabolic tracers with single photon emission tomography [SPECT], precise quantitative metabolic evaluation with positron emission tomography [PET], assessment of microvascular integrity with contrast echocardiography and use of magnetic resonance imaging [MRI]. Most of these techniques are reasonably accurate in predicting myocardial viability