RV in COPD - The complicated matters of the heart - Correlation of ECHO and biomarker with COPD severity and outcome.

BACKGROUND: Patients with chronic obstructive pulmonary disease (COPD) have an increased risk of cardiovascular involvement, which is among the leading causes of morbidity and mortality worldwide. Echocardiography (ECHO) could be a reliable, non-invasive tool for predicting the risk of cardiovascular modalities in patients with COPD. Combining the ECHO parameters with highly selective cardiac troponin could predict the severity and outcome of patients with COPD. METHODS: This prospective observational study was conducted at a tertiary care hospital in South India. All patients who met the criteria were included. Patients with other concomitant chronic lung diseases were excluded. An echocardiographic examination was performed, and blood samples for hs-Tnt were taken on admission for patients admitted with COPD. Categorical variables were analyzed using Pearson's Chi-square test, and the T-test was used to compare the means. One-way analysis of variance (ANOVA) followed by the Bonferroni multiple comparison tests was done to compare different echo parameters concerning COPD severity. RESULTS: The mean tricuspid annulus plane systolic excursion (TAPSE) and right ventricle (RV) fraction area change (FAC) values were lower with the increase in the disease severity (P < 0.001). There was a significant increase in the mean systolic pressures in the right atrium and ventricle in patients with severe COPD (P < 0.001). The mean hs-TnT values were significantly higher in patients with severe COPD (18.86 ± 18.12) and correlated well with the increase in the severity of the disease (P < 0.001). Changes in the echo parameters, such as mean TAPSE and RV FAC values, negatively correlated with COPD severity. There was an increase in systolic pressure in both atria and ventricles with the progression of COPD. Troponin helped predict mortality during hospitalization. CONCLUSION: Comprehensive echocardiographic parameters, such as TAPSE and RV FAC, help assess the disease's severity, predict mortality, and evaluate whether the proper ventricular function is reliable. Troponin is a valuable adjunct that is an independent and strong predictor of overall mortality in patients with COPD.

Basal hyperinsulinemia beyond a threshold predicts major adverse cardiac events at 1 year after coronary angiogram in type 2 diabetes mellitus: a retrospective cohort study.

BACKGROUND: There is a substantial reduction in cardiovascular related morbidity and mortality in the general population attributed to improved treatment of cardiac risk factors and disease, the same magnitude of benefit has not been observed in those with diabetes mellitus. The aim of the present study was to evaluate factors associated with the cardiac outcome at 1 year after coronary angiogram in patients with type 2 diabetes mellitus and to compare the outcomes with nondiabetics. METHODS: A retrospective cohort study was carried out in subjects who underwent coronary angiogram for an evaluation of CAD, with follow-up data available for period of 12 months. The data consisted of 208 type 2 diabetic and 75 non-diabetic patients. Clinical, anthropometric and other biochemical risk factors of the study participants were recorded. Univariate and multivariate cox proportional hazard regression analyses were performed to evaluate the relation between the cardiovascular risk factors and major adverse cardiac events (MACE). RESULTS: At 1 year, MACE was observed in 50 (24.04%) type 2 diabetic subjects, which included non-fatal myocardial infarction 24 (11.54%), target vessel revascularization 15 (7.21%) and death 11 (5.29%). The area under the curve for insulin in predicting MACE was found to be 0.81 (95% CI 0.73-0.88) with sensitivity and specificity of 88% (95% CI 0.71-0.96) and 74% (95% CI 0.65-0.81) respectively. After adjustment for potential confounders hyperinsulinemia (>20 µIU/ml) was significantly associated with MACE [adjusted hazard ratio (HR): 3.03, 95% CI 1.41-6.54, p = 0.005]. Interestingly, the MACE rate in type 2 diabetics with insulin levels <20 µIU/ml (10.2%) and non-diabetics (12%) (p = 0.676) appears to be same. CONCLUSIONS: In addition to severity of the CAD at the baseline, basal hyperinsulinemia beyond a threshold strongly predicts adverse cardiac events at 1 year in type 2 diabetes mellitus. Those below the threshold, appears to be having a risk equivalent to non-diabetics.

Manipal diabetes coronary artery severity score.

AIMS: To develop a risk score, for identifying severe and complex CAD in patients with type 2 diabetes mellitus. METHODS: In this cross sectional study, 179 patients with type 2 diabetes mellitus undergoing coronary angiogram for the evaluation of suspected coronary artery disease (CAD) were recruited at a tertiary-care hospital. Patients were divided into developmental (n=124) and validation (n=55) cohorts. Biochemical and anthropometric parameters were analysed. Predictors of severe and complex CAD (SYNTAX Score>22) were identified by multiple logistic regression analysis. RESULTS: Insulin resistance>3.4 (OR: 21.26, 95% CI: 5.71-79.09), duration of diabetes>5years (OR: 13.50, 95% CI: 3.13-58.25), total cholesterol/HDL-C ratio>5 (OR: 2.75, 95% CI: 0.66-11.55) and waist circumference>96cm (OR: 5.08, 95% CI: 1.27-20.42) were independent predictors of severe and complex CAD, and Manipal Diabetes Coronary Artery Severity Score was developed. CONCLUSIONS: The prediction of severe and complex CAD was achieved with this simple score, and thus enabling effective identification of patients beforehand, who are not likely to be suitable for angioplasty.

Severity of coronary artery disease in type 2 diabetes mellitus: Does the timing matter?

AIM: The aim of our study was to compare the angiographic changes in 53 nondiabetic patients, 54 type 2 diabetic patients of less than 5 years of duration, 41 patients with 5-10 years of diabetes, and 27 with more than 10 years of diabetic duration. METHODS: In this cross-sectional study, 175 patients, who underwent coronary angiogram for the evaluation of the coronary artery disease (CAD), were recruited. Based on the angiographic findings, syntax score, vessel score, and coronary collaterals grading were analyzed. The biochemical analysis was done by using the auto analyzer. RESULTS: A significant increase in the mean syntax score (p=0.019), vessel score (p=0.007), and coronary collateral grade (p=0.008) was observed in the patients with 5-10 years of diabetes when compared to those with less than 5 years of diabetic duration. There was no significant difference in the mean syntax score (p=0.979), vessel score (p=0.299), and collateral grade (p=0.842) between the patients with 5-10 years and more than 10 years of diabetes. The difference in the mean syntax score (p=0.791), vessel score (p=0.098), and collateral grade (p=0.661) between the nondiabetic and the patients with less than 5 years of diabetes was not significant. CONCLUSION: A significant structural change in the coronary arteries was found among the patients with 5-10 years of diabetes.

Inadvertent subclavian artery cannulation: endovascular repair using a collagen closure device-report of two cases and review of the literature.

Inadvertent line insertion into the subclavian artery is an uncommon complication of subclavian venous catheterisation, and its timely recognition is vital to minimise risk of harm to the patient. We describe the radiographic, computed tomographic (CT), and angiographic findings in two patients and illustrate the subsequent endovascular management using collagen vascular closure devices.

Arteriovenous fistula of a colic branch of the superior mesenteric artery: endovascular therapy.

Arteriovenous fistulae (AVF) of the superior mesenteric artery and its branches are exceedingly rare. We report an unusual case of a patient who was found to be symptomatic from such an AVF, with diarrhea and terminal ileal thickening. We describe the findings from magnetic resonance imaging, computed tomography and catheter angiography and discuss the endovascular management.

Spontaneous subclavian artery dissection causing ischemia of the arm: diagnosis and endovascular management.

Spontaneous subclavian artery dissections are rare, with very few cases described in the literature. We report an unusual case of a 62-year-old female who presented with ischemia of the left arm secondary to spontaneous dissection of the first part of the left subclavian artery. We describe the imaging findings on both aortic arch angiogram and CT angiogram and discuss management by endovascular means.

Primary cutting balloon angioplasty for treatment of venous stenoses in native hemodialysis fistulas: long-term results from three centers.

AIM: To evaluate the technical success and patency rates following primary cutting balloon angioplasty for venous stenoses in native dialysis fistulas. METHODS: Forty-one patients (26 men, 15 women; age range 26-82 years, average age 59 years) underwent 50 (repeat procedures in 9 patients) primary cutting balloon (PCB) angioplasty procedures in three institutions by three primary operators. The indication was primary stenosis in 21 patients, recurrent lesions in 15, and immature fistulas in 5. A PCB was used alone in 17 cases, but was followed by a larger standard balloon in 33 cases. Follow-up included ultrasound, flow analysis and urea reduction ratio, and ranged from 2 to 30 months (mean 14 months). RESULTS: The technical success rate was 98%. All procedures were relatively painless. Two PCBs burst and 4 leaked, but without causing any morbidity. Nineteen fistulas were still working at last follow-up. Primary patency rates at 6, 12, and 24 months using Kaplan-Meier analysis were 88%, 73%, and 34%, respectively, and the primary assisted patencies were 90%, 75%, and 50%, respectively. CONCLUSION: PCB angioplasty has high technical success and low complication rates. The long-term patency rates are favorable for PCB angioplasty and compare favorably with other series.

Cutting balloon angioplasty versus standard balloon angioplasty for failing infra-inguinal vein grafts: comparative study of short- and mid-term primary patency rates.

PURPOSE: To evaluate the results of a recent change in practice in our institution using cutting balloon angioplasty instead of standard balloon angioplasty as the primary treatment for failing infra-inguinal vein bypass grafts. METHODS: In this nonrandomized cohort study with a historical control, failing infra-inguinal vein grafts were identified at duplex surveillance or clinical examination. Patients had confirmatory arteriography and balloon angioplasty at the same attendance. Interventions proximal or distal to the graft itself and prosthetic grafts were not included. Patients were entered into a duplex graft surveillance program. Initial assessment of technical success was duplex or improvement 4-6 weeks after the primary angioplasty. RESULTS: Twenty-seven consecutive patients were treated with standard balloon angioplasty, then 11 consecutive patients were treated with cutting balloon angioplasty. Initial technical success was 74% for the standard balloon versus 82% for the cutting balloon. The primary patency rate at 6 months was 16/26 (62%) for standard balloon angioplasty and 8/10 (80%) for cutting balloon angioplasty (p = 0.44). The primary patency rate at 12 months was 9/25 (36%) for standard balloon angioplasty and 5/10 (50%) for cutting balloon angioplasty (p = 0.47). CONCLUSION: The use of cutting balloons for primary angioplasty of infra-inguinal vein grafts offers no definite advantage over standard balloon angioplasty in this institution or compared with patency rates after standard balloon angioplasty reported elsewhere. Larger multicenter studies would be required to demonstrate whether there was any real difference between the two techniques.

Regulation of human airway epithelial cell IL-8 expression by MAP kinases.

Recent studies indicate that maximal IL-8 protein expression requires activation of NF-kappaB as well as activation of the MAP kinases ERK, JNK, and p38. However, the precise relationship between NF-kappaB transactivation and MAP kinase activation remains unclear. We examined the requirements of NF-kappaB, ERK, JNK, and p38 for TNF-alpha-induced transcription from the IL-8 promoter in a human bronchial epithelial cell line. Treatment with TNF-alpha induced activation of all three MAP kinases. Using a combination of chemical and dominant-negative inhibitors, we found that inhibition of NF-kappaB, ERK, and JNK, but not p38, each decreased TNF-alpha-induced transcription from the IL-8 promoter. Inhibition of JNK signaling also substantially reduced TNF-alpha-induced NF-kappaB transactivation, whereas inhibition of ERK and p38 had no effect. On the other hand, ERK was required and sufficient for TNF-alpha-induced activation of activator protein (AP)-1 promoter sequences, which together function as a basal level enhancer. JNK activation was also required for AP-1 transactivation. Finally, inhibition of p38 attenuated IL-8 protein abundance, suggesting that p38 regulates IL-8 expression in a posttranscriptional manner. We conclude that, in human airway epithelial cells, MAP kinases may regulate IL-8 promoter activity by NF-kappaB-dependent (in the case of JNK) and -independent (ERK) processes, as well as by posttranscriptional mechanisms (p38).