Effects of verapamil and adenosine in an adjunct to tirofiban on resolution and prognosis of noreflow phenomenon in patients with acute myocardial infarction.

AIM: We aimed to investigate the effects of verapamil and adenosine in an adjunct to intravenous tirofiban on management and prognosis of no-reflow phenomenon during primary percutaneous coronary intervention (PPCI) and to compare their efficacies on reversing of no-reflow phenomenon and short and midterm survival. METHODS: We included 46 patients with acute ST-segment elevation myocardial infarction (STEMI) and occurrence of no-reflow phenomenon after PPCI. All patients received intravenous tirofiban and then randomized into one of the following 3 groups: intracoronary adenosine (N.=16), intracoronary verapamil (N.=15) or placebo (N.=15). RESULTS: Intracoronary verapamil therapy had significant effect in restoring impaired coronary blood flow by decreasing thrombolysis in myocardial infarction (TIMI) frame count from 73±44 to 52±48 (P=0.024). However, adenosine and serum physiologic administration were not found to be so effective in decreasing TIMI frame count (from 81±35 to 71±46, P=0.084; from 74±32 to 71±37, P=0.612, respectively). In-hospital and 6-month survival rates were similar among groups. CONCLUSION: In conclusion, intracoronary verapamil restored the impaired coronary blood flow more effectively than adenosine or placebo. However, none of them has changed the clinical course in the first 6 months.

Comparison between nebivolol and ramipril in patients with hypertension and left ventricular hypertrophy: a randomized open blinded end-point (PROBE) trial.

AIMS: To compare the effects of nebivolol and ramipril on left ventricular hypertrophy in hypertensive patients. MATERIALS AND METHODS: The study was conducted with a pre-randomised blinded endpoint (PROBE) design in which 106 patients with mild-to-moderate hypertension and left ventricular hypertrophy were randomised to ramipril (n = 52) or to nebivolol (n = 54) and treated for 39 weeks. The doses of ramipril and nebivolol were 2.5 and 5 mg/day, respectively. After 4-8 weeks, in patients with not normalised diastolic blood pressure, a thiazide diuretic was added (indapamide 2.5 mg or hydrochlorothiazide 12.5 mg/day). In the ramipril group, thiazide diuretic was added in 97% of subjects and in nebivolol group in 92%. The effect of treatment on left ventricular mass was assessed by two-dimensional guided M-mode transthoracic echocardiography, at baseline and at the end of the treatment. Left ventricular mass index (LVMI) was calculated and indexed to body surface area (g/m2) and height2.7 (g/height2.7). Blood pressure (BP) was measured at baseline, after 4, 8, 12, 24 and 39 weeks with a standard mercury sphygmomanometer. RESULTS: Both left ventricular mass (LVM) and mass index (LVMI) decreased significantly after treatment with ramipril (LVMI -14.8 g/m2, -7.3 g/height2.7; p < 0.001), and after treatment with nebivolol (LVMI -31.9 g/m2, -15.6 g/height2.7; p < 0.001). The difference between ramipril and nebivolol (-17.1 g/m2, -8.3 g/height2.7) with regards to reduction of LVMI was statistically significant (p < 0.001). No differences were observed between the two groups in terms of normalization of LVMI. Both drugs decreased BP similarly after 39 weeks of treatment CONCLUSIONS: The present study shows that both nebivolol and ramipril decrease LVMI. Nebivolol 5 mg/daily treatment reduced LVMI significantly more than ramipril 2.5 mg/daily. Both drugs similarly decreased BP during the treatment.

The effect of lipoprotein-a on thrombolytic therapy and spontaneous reperfusion in acute myocardial infarction. A comparative study.

BACKGROUND: To evaluate the role of serum lipoprotein-a (Lp-a) levels on the success of thrombolytic therapy (TT) in patients with acute myocardial infarction (MI). PATIENTS: 56 patients randomly allocated into 2 groups (A and B) with an approximately 1 to 2 ratio. Group A consisted of 18 patients who received 1,5 million IU streptokinase. Group B: 38 patients receiving 100 mg t-PA totally and Group C: 22 patients who did not received any TT as controls. All patients had undergone coronary angiography in the first 7 days and the degree of TIMI flow was determined in the infarct related artery with TIMI-0 and I being considered as unsuccessful perfusion, whereas TIMI-II and III as successful. Lp-a level gs;30 mg/dl was considered as high Lp-a level. RESULTS: Patency rates were similar in Group A and B, in cases with high or low Lp-a levels (p>0.05 for both). In Group C patency rate was found significantly higher in patients with high Lp-a level compared to patients with low Lp-a (p<0.01). Lp-a level in Group C was similar with Group A and B (p>0.05). The time interval for coronary angiography was similar in all groups (p>0.05 for all). CONCLUSIONS: Lp-a level does not effect the reperfusion outcome of TT in patients with MI. However in those patients who not received TT, spontaneous reperfusion rate was found significantly higher in patients with low Lp-a level compared to those with high Lp-a level.

Estimation of left ventricular end-diastolic pressure by color M-mode Doppler echocardiography and tissue Doppler imaging.

OBJECTIVES: The aim of this study was to estimate left ventricular end-diastolic pressure (LVEDP) noninvasively by tissue Doppler imaging and color M-mode echocardiography. MATERIAL AND METHODS: We studied 3 groups of patients who were proven by angiography to be free of significant coronary artery lesions (<40% stenosis) with an LVEDP < 10 mm Hg (group A: n = 24; 16 men, 18 women; mean age +/- SD = 55 +/- 13 years), an LVEDP of 10 to 15 mm Hg (group B: n = 21; 17 men, 4 women; mean age 56 +/- 11 years), or an LVEDP > 15 mm Hg (group C: n = 35; 20 men, 15 women; mean age 58 +/- 9 years). Tissue Doppler imaging of the lateral mitral annulus and color M-mode imaging of the mitral valve in the apical 4-chamber view were obtained with an echocardiographic system. Early and late diastolic velocities (Em and Am, respectively), Em deceleration time (EmDT), Am time (Am-t), and mitral propagation velocity time delay (VpDT) were measured in each patient. RESULTS: In group A, sensitivity and specificity for EmDT < or = 100 ms, Am-t < or = 90 ms, Em/Am > or = 1, and VpDT < or = 45 ms were found to be 0.57 and 0.89, 0.66 and 0.88, 0.86 and 0.92, and 0.73 and 0.89, respectively. In group B, sensitivity and specificity for EmDT 100 to 120 ms, Am-t 90 to 110 ms, Em/Am 1 to 0.5, and VpDT 45 to 60 ms were found to be 0.57 and 0.84, 0.69 and 0.82, 0.66 and 0.75, and 0.55 and 0.83, respectively. In group C, sensitivity and specificity for EmDT > 120 ms, Am-t > 110 ms, Em/Am < 0.5, and VpDT > 60 ms were found to be 0.88 and 0.81, 0.71 and 0.80, 0.86 and 0.72, and 0.78 and 0.86, respectively. CONCLUSION: The EmDT, Am-t, Em/Am, and VpDT measurements obtained noninvasively by left ventricular tissue Doppler imaging and mitral flow propagation velocity were found to be useful in the estimation of LVEDP.

Resolution of a spontaneous coronary artery thrombus with a new antiplatelet agent.

A thrombus was observed in the left anterior descending coronary artery in a 47 year-old woman who presented with acute anterior myocardial infarction. On a coronary angiogram in the right oblique cranial position, the thrombus appeared as an eccentric, solid and homogeneous mass with a 22 mm maximal length and 1.9 mm maximal diameter. The thrombotic segment and the rest of the coronary tree was free of atherosclerosis. Due to the inappropriate coronary structure and length of the thrombus, coronary angioplasty and/or stent procedures were not performed. The patient refused coronary artery by-pass. She was given the glycoprotein IIb/IIIa inhibitor tirofiban 0.4 microg x kg(-1) x min(-1) bolus over 30 minutes followed by 0.1 microg x kg(-1) x min(-1) for 24 hours, orally acetylsalicylic acid 300 mg per day, nytroglicerin 40 mg per day and warfarine with INR being in a range of 2-2.5 times. A control coronary angiography performed two months later showed total dissolution of the coronary thrombus and clearance of the culprit vessel.

A recurrent right heart thrombus in a patient with Behçet's disease.

We report the case of a patient who was admitted to the immunology unit of our medical facility. The patient had a history of recurrent oral ulcers, low-grade fever, weight loss, and fatigue. Echocardiographic examination revealed a right ventricular mass that was initially thought to be a myxoma in an unusual location, and the patient was sent to surgery. Surgery revealed the mass to be a thrombus. After 5 months of anticoagulation therapy, the patient was readmitted to our institution with the same complaints, and a right atrial thrombus was found on echocardiographic examination. After a careful reevaluation of the patient's history and episodes of recurrent oral and genital ulcers, as well as the papulopustular lesions found on his first admission to hospital, Behçet's disease was diagnosed. The patient received thrombolytic therapy with a regression of thrombus, and continued with immunosuppressive and anticoagulation therapy. Five months later, echocardiographic examination showed complete disappearance of thrombus.

Treatment of myofascial pain.

OBJECTIVE: To investigate the effectiveness of ultrasound treatment and trigger point injections in combination with neck-stretching exercises on myofascial trigger points of the upper trapezius muscle. DESIGN: Depression and anxiety associated with chronic pain were assessed using the Beck Depression Inventory (BDI) and the Taylor Manifest Anxiety Scale (TMAS). The study population comprised 102 patients who had myofascial trigger points in one side of the upper trapezius. The patients were randomly assigned to one of three groups: group 1 received ultrasound therapy to trigger points in conjunction with neck-stretching exercises; group 2 received trigger point injections and performed neck-stretching exercises; and group 3, the control group, performed neck-stretching exercises only. Treatment effectiveness was assessed using subjective pain intensity (PI) with a visual analog scale, pressure pain threshold (PT) with algometry, and range of motion (with a goniometer) of the upper trapezius muscle. RESULTS: Compared with the control group, patients in groups 1 and 2 had a statistically significant reduction in PI, an increase in PT, and an increase in range of motion. There were no statistically significant differences between treatment groups 1 and 2. Although not statistically significant, patients in the control group had better results at the 3-mo follow-up. The BDI scores indicated depression in 22.9% of the patient, with 4.8% of the patients having severe depression. High anxiety scores on the TMAS were present in 89.3% of the patients. When BDI and TMAS scores were compared with PI or PT levels, no significant correlations were found, but when compared with pain duration before treatment, correlations were significant. CONCLUSIONS: Patients with myofascial pain syndrome had higher scores for anxiety than for depression. When combined with neck stretching exercises, ultrasound treatment and trigger point injections were found to be equally effective.

Exercise performance in patients with dilated cardiomyopathy: relationship to resting left ventricular function.

Relationship between maximal exercise tolerance and resting indexes of left ventricular systolic and diastolic function were evaluated in 35 men, aged 55.1 +/- 10.4 years, with dilated cardiomyopathy. Clinical diagnosis of dilated cardiomyopathy was confirmed with M-mode echocardiography (M-mode echocardiographic end-diastolic dimension >55 mm, fractional shortening <25%, increased E point septal separation). Coronary angiography was considered mandatory for exclusion of patients with coronary artery disease. Patients with mitral regurgitation (> or =grade 2) and rhythm other than sinus were excluded. According to the functional classification of New York Heart Association 6 patients were in class I, 11 in class II, 12 in class III and 6 in class IV. Left ventricular ejection fraction (LVEF), stroke volume (SV) and left ventricular end-diastolic pressure (LVEDP) were measured with contrast angiography. Peak early (VE) and late (VA) transmitral filling velocities and their ratio (E/A), isovolumetric relaxation time (IRT) and deceleration time (DT) were computed from pulsed wave Doppler echocardiograms. On completion of all resting measurements, patients underwent symptom limited upright treadmill exercise testing using a modified Naughton protocol and maximal exercise performance metabolic equivalent work load (NETS) was calculated from the speed, incline and length of time at the stage using standard tables to make interpatient comparisons. Significant correlation has been found between NYHA class and METS (r= -0.77, P<0.001). However NYHA class II and NYHA class III patients were found to have similar METS (P=0.317). Patients were further divided into two groups on the basis of exercise data. Group I consisted of 22 patients with relatively preserved exercise tolerance (> or =4 METS) and Group II included 13 patients with impaired exercise tolerance (> or =4 METS). This arbitrary classification was based upon previously described survival differences in these two groups. There were no differences between two groups in terms of age, gender distribution (all were male), heart rate and arterial blood pressure. LVEF, LVEDP, stroke volume, VE, VA, E/A, IRT and DT were also similar between two groups. Strong positive correlation was observed between LVEDP and VE (r=0.74) while IRT and VA negatively correlated with LVEDP (r= -0.77 and r= -0.81 respectively) but neither of resting indexes of left ventricular systolic and diastolic function showed significant correlation with METS and exercise duration.

Effect of coronary collateral circulation on exercise stress test.

In this study, patients who have recovery-only ST segment depression in exercise stress test were chosen. It is proposed that coronary collateral circulation could improve with stress-increased coronary perfusion, and accordingly, patients with recovery-only ST segment depression were evaluated by coronary angiography for grading the coronary collateral circulation. Twenty-one men and five women were assigned to the study group. Sixteen men and two women who had exercise-induced ST segment depression were assigned to the control group. Age and gender of both groups were not statistically different (p>0.05). The reason for terminating the exercise stress test was chest pain in two of 26 patients in the study group versus 15 of 18 in the control group (p<0.001). In both groups coronary collateral frequency and grade were directly correlated with the severity of the coronary artery disease (p<0.001 in the study group, and p<0.05 in the control group). When both groups were compared for the frequency of significant coronary collateral circulation, 14 of 26 patients in the study group versus 4 of 18 patients in the control group had significant coronary collateral circulation (p=0.035). The authors conclude that recovery-only ST segment depression correlates well with the frequency of significant coronary collateral circulation, and coronary collaterals may prevent myocardial ischemia during exercise.

Effects of percutaneous transluminal coronary angioplasty on late potentials and high frequency mid-QRS potentials.

The high frequency mid-QRS potentials and late potentials are important in coronary artery disease because they are related to the extent of ischemia and prognosis. In this study, the effects of successful percutaneous transluminal coronary angioplasty (PTCA) on these potentials were evaluated. Twenty-four patients with coronary artery disease (aged 34-67 years, 5 women, 19 men) were examined. Eight of these patients had a history of myocardial infarction (4 anterior, 3 inferior, 1 anterior and inferior). Signal averaged ECG was recorded at 40- to 250-Hz frequency ranges for late potentials and 150- to 250-Hz frequency ranges for mid-QRS potentials before PTCA, and they were repeated 1 month later. The QRS duration (107.7 +/- 9.8 to 105.3 +/- 9.3 ms, p < 0.0001) root-mean-square voltage (39.4 +/- 20.1 to 47.7 +/- 22.2 microV, p < 0.00001) and low amplitude signal duration (30.7 +/- 9.9 to 27.7 +/- 9.3 ms, p < 0.001) showed significant changes in 40- to 250-Hz ranges before and after PTCA. The same results were also obtained in the 150- to 250-Hz frequency ranges: the QRS duration decreased (90.9 +/- 9.8 to 86.5 +/- 9.1 ms, p < 0.005) and the root-mean-square voltage increased (5.5 +/- 1.6 to 6.1 +/- 1.8 microV, p < 0.00001). Thus, successful PTCA causes improvement in late potential parameters, so the risk of malign arrhythmia that affects the prognosis can be reduced. Additionally, the increase in high frequency mid-QRS potentials shows the decrease in the ischemia after PTCA.

Analysis of high frequency QRS potentials observed during acute myocardial infarction.

The value of high frequency QRS potentials (HFQRS) during acute myocardial infarction (AMI) was assessed to define infarct size and prognosis. HFQRS were recorded by signal-averaged ECG with 150-250 Hz frequency ranges, using X, Y, Z orthogonal leads. Recordings were obtained in surviving AMI patients (n = 33, 12 inferior, 11 anterior, 10 anterior-inferior) on the first and tenth days, but in non-survived patients (n = 5, 2 inferior, 1 anterior, 2 anterior-inferior) only on the first day. Additionally, the frequency of ventricular tachycardia (VT) was evaluated by 24-h Holter monitoring in all patients at the same days. The control group consisted of 11 healthy people. In surviving AMI patients, RMS voltage of vector magnitude reduced in anterior and anterior-inferior MI but filtered QRS duration was longer in inferior MI than normals (P < 0.05, < 0.05, < 0.01, respectively). In nonsurvived patients, RMS voltages of leads X, Y, Z and vector magnitude were lower than normals (P < 0.01, < 0.05, < 0.01, < 0.01, respectively) and surviving AMI patients (P < 0.01, < 0.05, < 0.05, < 0.05, respectively), the filtered QRS duration was found to be longer than normals and survived patients (P < 0.01, < 0.01). In patients who had VT on Holter monitoring, filtered QRS duration was significantly longer than in patients without VT (P < 0.05). As a result, HFQRS was important for defining infarct size but not malignant ventricular arrhythmias. VT was related to filtered QRS duration. HFQRS may offer significant prognostic information and contribute to early risk stratification of AMI patients.

Right ventricular cardiomyopathy similar to Uhl's anomaly with atrial flutter and complete AV block.

We report an adult patient with right ventricular cardiomyopathy similar to Uhl's anomaly. In this patient an interesting manifestation is a transient atrial flutter with complete A-V block. Right ventricular cardiomyopathy (arrhythmogenic right ventricular dysplasia) is considered a cause of life-threatening arrhythmia. The right ventricular musculature is partially or totally absent and is replaced by fatty and fibrous tissue. Patients may present with ventricular arrhythmias, right heart failure or asymptomatic cardiomegaly. Only a few cases with atrioventricular conduction disturbance have been reported in the literature by now. We report such a case.

Evaluation of coronary arterial disease by oral dipyridamole stress testing using 12-lead electrocardiography.

We studied the values of oral dipyridamole needed to detect coronary arterial disease using 12-lead electrocardiography. The relationship between dipyridamole-induced ST segment depression and coronary arterial lesions, coronary collaterals and myocardial infarction was investigated. 375 mg oral dipyridamole was given to 31 patients (22 with coronary arterial disease, 9 controls). 12-lead electrocardiogram was recorded before and 45 minutes after the test. The control group and the patients, who had no ST segment depression after dipyridamole, performed isometric contraction (handgrip) for 5 minutes and then the 12-lead electrocardiogram was recorded. All patients had coronary angiography. We also performed treadmill stress testing in 28 patients. Dipyridamole testing was positive (greater than or equal to 1 mm ST depression on electrocardiogram) in 7 of 22 patients with coronary arterial disease, of whom 6 had positive treadmill stress testing. Only 2 patients had previous myocardial infarction in the group with positive dipyridamole tests. Of the 15 in whom dipyridamole testing was negative, 5 had positive treadmill stress testing, while 13 of them had had previous myocardial infarction. All patients in the control group had negative dipyridamole stress testing and normal coronary angiograms. No additional ST segment changes were observed in the group who had performed isometric contraction test (both dipyridamole test negative and control groups). Sensitivity and specificity of the test were 32 and 100%, respectively. Comparison of collateral vessels between the groups positive and negative for dipyridamole revealed no difference. But the number of patients with old myocardial infarction was higher in those testing negative than in those who proved positive.(ABSTRACT TRUNCATED AT 250 WORDS)

Evaluation of right ventricular function in patients with idiopathic dilated and ischemic cardiomyopathy by equilibrium radionuclide ventriculography.

We performed equilibrium radionuclide ventriculography in 12 patients with idiopathic dilated cardiomyopathy, 11 patients with ischemic cardiomyopathy and 11 normal subjects to determine whether measurements of right ventricular function could be used to distinguish dilated cardiomyopathy from ischemic cardiomyopathy. The left ventricular ejection fraction in patients with dilated cardiomyopathy (26 +/- 8%, mean +/- SD) or ischemic cardiomyopathy (32 +/- 5%) was significantly lower than in normals (69 +/- 6%, p less than 0.001). The right ventricular ejection fraction (RVEF) in normals was 57 +/- 7%. RVEF was decreased in 11 of 12 patients with dilated cardiomyopathy and the mean value (32 +/- 10%) was significantly lower than that in patients with ischemic cardiomyopathy (56 +/- 7%, p less than 0.001), none of whom had decreased RVEF. Our data show that right ventricular dysfunction commonly exists in patients with dilated cardiomyopathy but not in patients with ischemic cardiomyopathy. This finding may be useful in the differentiation between dilated and ischemic cardiomyopathy.

Right ventricular systolic and diastolic function at rest in patients with coronary artery disease. Assessment with equilibrium radionuclide ventriculography.

Right ventricular systolic and diastolic function was studied in patients with ischemic heart disease using equilibrium radionuclide ventriculography. In patients with inferior myocardial infarction and proximal right coronary lesions, the right ventricular ejection fraction (0.43 +/- 0.06, n = 10, mean +/- SD) and peak filling rate (1.7 +/- 0.4 EDV/sec) were lower than normals (0.57 +/- 0.07 and 2.7 +/- 0.4 EDV/sec, n = 10, p less than 0.001, respectively). In these patients, the right ventricular time to peak filling rate was longer than in normals (225 +/- 36 msec vs 136 +/- 45 msec, p less than 0.001), while the left ventricular ejection fraction remained normal. In patients with inferior myocardial infarction and distal right coronary lesions, the right ventricular ejection fraction, peak filling rate and time to peak filling rate were not different from those in normals. Even in patients with proximal right coronary lesions, the right ventricular ejection fraction was normal unless they had an inferior myocardial infarction. A decreased left ventricular ejection fraction and abnormal motion of the ventricular septum did not affect the right ventricular ejection fraction. The present results suggest that patients with an inferior myocardial infarction and proximal right coronary lesion often develop right ventricular systolic and diastolic dysfunction.

Right and left ventricular dysfunction in patients with dilated cardiomyopathy: a study with equilibrium radionuclide ventriculography.

Right and left ventricular function was evaluated in 28 patients with dilated cardiomyopathy to determine whether both ventricular functions were equally impaired in each patient. The ejection fractions of both ventricles were measured using equilibrium radionuclide ventriculography. In 13 patients the left ventricular ejection fraction (LVEF) was lower than the right ventricular ejection fraction (RVEF) by 6% or more, their mean values being 24 +/- 8% (mean +/- SD) and 37 +/- 7%, respectively (group 1). The difference between the LVEF and RVEF was less than 6% in nine patients; LVEF 29 +/- 8% and RVEF 30 +/- 7% (group 2). In six patients the RVEF was lower than the LVEF by 6% or more, and their mean values were 21 +/- 6% and 37 +/- 10%, respectively (group 3). The frequency of ventricular tachycardia, which was determined by the Holter ECG, was significantly higher in group 3 (100%, 6/6) than in the others (group 1 + 2; 41%, 9/22), p less than 0.05. The NYHA functional class correlated well with the LVEF, but not with the RVEF. It was concluded that the left and right ventricular functions are not necessarily equally impaired in patients with dilated cardiomyopathy, and that the difference may correlate with their clinical features.