Circadian blood pressure variability in normo and hypertensive diabetic patients

Diabetic patients have a higher prevalence of non-dipping pattern in blood pressure [BP] than general population. Non-dipping arterial pressure pattern is associated with increased cardiovascular risk. The objective of this study was to investigate the association between the clinical and paraclinical characteristics of the diabetic patients with circadian BP variability. This cross-sectional study included 114 diabetic patients [more than 18 years old] recruited by consecutive sampling. The patients were divided into two groups according to the results of systolic blood pressure dipping from day to night. Mean age was 58.3 +/- 9.6 years; and 63% of the study population was male. Also, 80.7%, 78.1%, and 78.9% of the patients had non-dipper patterns in systolic, diastolic, and mean BP respectively. The dipping pattern did not have any significant association with baseline or clinical characteristics of the patients [p > 0.05]. The characteristics of the patients do not assist finding diabetic persons who are more likely to have non-dipping arterial pressure pattern. As such, ABPM is an essential tool for proper risk stratification in diabetic patients

Thrombolytic-plus-anticoagulant therapy versus anticoagulant-alone therapy in submassive pulmonary thromboembolism [TVASPE study]: a randomized clinical trial

The use of thrombolytic agents in the treatment of hemodynamically stable patients with acute submassive pulmonary embolism [PTE] remains controversial We, therefore, conducted this study to compare the effect of thrombolytic plus anticoagulation versus anticoagulation alone on early death and adverse outcome following submassive PTE. We conducted a study of patients with acute pulmonary embolism and pulmonary hypertension or right ventricular dilatation/dysfunction but without arterial hypotension or shock. The patients were randomly assigned in a single-blind fashion to receive an anticoagulant [Enoxaparin [1 mg/kg twice a day]] plus a thrombolytic [Alteplase [100 mg] or Streptokinase [1500000 u/2 hours]] or an anticoagulant [Enoxaparin [1 mg/kg twice a day]] alone. The primary endpoint was in-hospital death or clinical deterioration requiring an escalation of treatment. The secondary endpoints of the study were major bleeding, pulmonary hypertension, right ventricular dilatation at the end of the first week, and exertional dyspnea at the end of the first month. Of 50 patients enrolled, 25 patients were randomly assigned to receive an anticoagulant plus a thrombolytic and the other 25 patients were given an anticoagulant alone. The incidence of the primary endpoints was significantly higher in the anticoagulant-alone group than in the thrombolytic-plus-anticoagulant group [p value = 0.022]. At the time of discharge, pulmonary artery pressure was significantly higher in the anticoagulant-alone group than in the thrombolytic-plus-anticoagulant group [p value = 0.018]; however, reduction in the right ventricular size or normalization of the right ventricle showed non-significant differences between the two groups. There was no significant difference regarding the New York Heat Association [NYHA] functional class between the two groups at the end of the first month [p value = 0.213]. No fatal bleeding or cerebral bleeding occurred in the patients receiving an anticoagulant plus a thrombolytic. When given in conjunction with anticoagulants, thrombolytics may improve the clinical course of stable patients who have acute submassive pulmonary embolism and prevent clinical deterioration

Could mean platelet volume predicts impaired reperfusion and in-hospital major adverse cardiovascular event in patients with primary percutaneous coronary intervention after ST-elevation myocardial infarction?

Due to the positive relation between platelet size and platelet reactivity, a high value of the mean platelet volume [MPV] is an independent risk factor to predict acute myocardial infarction [AMI] and its adverse outcome. Few data are available to determinate the prognostic value of MPV in ST-elevation myocardial infarction [STEMI] patients treated with percutaneous coronary intervention [PCI]. The primary purpose of this study was to evaluate the clinical value of MPV to predict impaired reperfusion and in-hospital major adverse cardiovascular events [MACE] in acute STEMI treated with primary PCI. This study included 203 STEMI patients referring for blood sampling before primary PCI to estimate MPV and determine the thrombolysis in myocardial infarction [TIMI] flow grade, corrected TIMI frame count [CTFC], and in-hospital MACE. The frequency of in-hospital MACE in the group of patients with a high MPV [>/= 10.3 ng/dl] was significantly more than that of the group with a low MPV [<10.3 ng/dl] [37.8% vs. 4.4%, P < 0.001]. The no-reflow phenomenon was more frequent in the patients with a high MPV than that of the patients with a low MPV [17.8% vs. 1.9%, P < 0.001]. The mean MPV in the group of patients with CTFC >/= 40 was significantly more than that of the group of patients with CTFC < 40 [10.9 +/- 0.92 vs. 9.45 +/- 0.85, P = 0.001]. After adjustment for baseline characteristics, a high MPV remained a strong independent factor to predict the no-reflow phenomenon [Odds Ratio [OR]=2.263, 95% Confidence Interval [CI] = 1.47 to 5.97; P < 0.002], in-hospital MACE [OR = 2.49, 95% CI = 1.34 to 4.61; P < 0.004], and CTFC >/= 40 [OR=2.09, 95% CI = 1.22 to 3.39; P < 0.003]. These findings confirmed that not only could admission MPV predict impaired reperfusion and in-hospital MACE in acute STEMI patients treated with PCI, but also it could be considered a practical way to determine higher-risk patients

Primary percutaneous coronary intervention in patients with acute myocardial infarction

Primary percutaneous coronary intervention [primary PCI] is the method of choice in establishing reperfusion in acute myocardial infarction [AMI] patients. The aim of this study was to determine the success rate of primary PCI in a university medical center in Iran with a view to promoting it as a first-line therapy in patients with AMI, especially in centers with established catheterization labs across the country. All cases of AMI admitted between September 2001 and September 2005 underwent primary PCI. The achieved thrombolysis in myocardial infarction [TIMI] flow was recorded, and the patients were followed during the hospital admission for major adverse cardiac events [MACE]. A total of 180 patients, consisting of 36 females and 144 males, with a mean age of 56 +/- 2.1 years were included in the study. The target vessel was the left anterior descending artery in 66.1%, right coronary artery in 27.2%, and left circumflex artery in 6.7% of the cases. The respective rate of anatomical and procedural success was 94.4% and 90%. The rates of mortality, coronary artery bypass grafting [CABG], and reinfarction were 6.7%, 1.1%, and 2.2%, respectively. Most patients were discharged with no complications in less than a week. Anatomical success in patients < 65 years old was 95% versus 92.5% for those >/= 65 years of age. Procedural success in patients < 65 years of age was 93.6% versus 77.5% for those >/= 65 years old [P < 0.05]. No significant relation was detected between the success rate and sex, target vessel, or major coronary artery disease risk factors. More patients in the mortality group had a longer door-to-balloon [DTB] time compared to the surviving group [P < 0.05]. In light of the results of this study, primary PCI may also be practiced as the therapy of choice for AMI patients in centers with established equipment in our region with acceptable rates of MACE and complications. Better procedural success rates are achieved in younger patients and in those with a shorter DTB time

combined approach to severe multi-organ atherosclerosis

Severe coronary artery disease often coexists with peripheral vascular atherosclerosis. The assessment of the supra-aortic circulation is, therefore, of clinical relevance. We herein describe a case of coronary artery disease treated with surgical revascularization using the internal mammary artery and thereafter the progressive atherosclerotic disease of the native coronary arteries as well as the left subclavian and left renal arteries. We also describe and discuss the clinical presentation, the diagnostic procedures, and the therapeutic approach with respect to the percutaneous transluminal angioplasty of the subclavian, renal, and right coronary arteries

Potential role of thermal therapy as an adjunct treatment in congestive heart failure

The clinical and economic importance of heart failure is widely recognized. The incidence of heart failure is on the increase, particularly with the aging of the population around the world. It is time for a paradigm shift in heart failure management. Alternative non-pharmacological strategies to remodel the failing ventricle will shape a major portion of heart failure therapy in the decade ahead. Exposure to heat is widely used as a traditional therapy in many cultures. In this paper, we will review recent data that suggest thermal therapy may be helpful as an adjunctive non-pharmacological treatment for heart failure

Coronary artery perforation after guidewire removal

Coronary artery perforation is a rare, but potentially serious, complication of percutaneous coronary intervention and is associated with a high incidence of death, Q-wave myocardial infarction, and emergency coronary bypass surgery. Management is different but requires prompt recognition and treatment. We describe a case of coronary perforation only after guidewire removal and also review the management of vessel rupture and perforation

Randomized, blinded trial comparing enoxparin with unfractionated heparin in patients undergoing contemporary percutaneous coronary intervention

This study was designed to examine a unique and low dose use of intravenous enoxaparin in elective percutaneous coronary intervention [PCI] that would be applicable to an unselected population regardless of age, weight, and renal function. There is limited experience in anticoagulation using intravenous low-molecular-weight heparin in PCI. A total of 100 consecutive patients undergoing elective PCI were treated with a single IV bolus of enoxaparin [0.5mg/kg] in group A of patients [n=50] or with unfractionated heparin in group B of patients [n=50]. Sheaths were removed immediately after the procedure in patients treated with enoxaparin and some hours later in those treated with unfractionated heparin. In group A, ACT was 124.6 +/- 9.3 before PCI and 149.2 +/- 17.1 after that [P<0.05]. In group B, one patient [2.9%] developed groin hematoma. No deaths, MI, or urgent target vessel revascularization were reported. Low- dose [0.5 mg/kg] IV enoxaparin allows a target level of anticoagulation in patients undergoing PCI, appears to be safe and effective, allows immediate sheath removal, and does not require dose adjustment