A prospective study of patients with refractory angina: outcomes and the role of high-sensitivity troponin T.

BACKGROUND: The predictors of cardiovascular events in patients with chronic refractory angina are limited. High-sensitivity cardiac troponin T (hs-cTnT) assays are biomarkers that may be used to determine the prognosis of patients with stable coronary artery disease. HYPOTHESIS: Hs-cTnT is a predictor of death and nonfatal myocardial infarction (MI) in patients with refractory angina. METHODS: We prospectively enrolled 117 consecutive patients in this study. A heart team ruled out myocardial revascularization feasibility after assessing recent coronary angiograms; evidence of myocardial ischemia served as an inclusion criterion. Optimal medical therapy was encouraged via outpatient visits every 6 months; plasma hs-cTnT levels were determined at baseline. The primary endpoint was the composite incidence of death and nonfatal MI. RESULTS: During a median follow-up period of 28.0 months (interquartile range, 18.0-47.5 months), an estimated 28.0-month cumulative event rate of 13.4% was determined via the Kaplan-Meier method. Univariate predictors of the composite endpoint were hs-cTnT levels and LV dysfunction. Following a multivariate analysis, only hs-cTnT was independently associated with the events in question, either as a continuous variable (hazard ratio per unit increase in the natural logarithm: 2.83, 95% confidence interval: 1.62-4.92, P < 0.001) or as a categorical variable (hazard ratio for concentrations above the 99th percentile: 5.14, 95% confidence interval: 2.05-12.91, P < 0.001). CONCLUSIONS: In patients with chronic refractory angina, plasma concentration of hs-cTnT is the strongest predictor of death and nonfatal MI. Notably, none of the outcomes in question occurred in patients with baseline plasma levels <5.0 ng/L.

Frequency of Deep Vein Thrombosis and/or Pulmonary Embolism After Coronary Artery Bypass Grafting Investigation Regardless of Clinical Suspicion.

Venous thromboembolism (VTE) includes deep vein thrombosis (DVT) and/or pulmonary embolism (PE). Many surgeons and clinicians believe that VTE after coronary artery bypass grafting (CABG) has little clinical significance because it is seldom diagnosed. This study aimed to identify VTE after CABG, independent of clinical suspicion. In this prospective, observational, single-center study, 100 patients underwent computed tomographic pulmonary angiography (multidetector-64) and lower extremity venous compressive ultrasound after elective CABG. Patients with high risk for VTE were excluded. Aspirin was maintained throughout the preoperative and postoperative periods, and early ambulation was encouraged. Postoperatively, no mechanical or heparin prophylaxis was used in any patients. At the discretion of the surgeons, 83 surgeries were on-pump, and 17 were off-pump. On average, tomography and ultrasound were performed 7 ± 3 days after CABG. Isolated PE was observed in 13 of 100 patients (13%), simultaneous PE and DVT in 8 of 100 (8%), and isolated DVT in 4 of 100 (4%), thus totaling 25/100 VTEs (25%). Of the 21 PEs, 3 of 21 (14%) involved subsegmental, 15 of 21 (71%) segmental, 1 of 21 (5%) lobar, and 2 of 21 (10%) central pulmonary arteries. Of the 12 DVTs, all were distal (below the popliteal vein), and 2 of 12 (17%) were also proximal; 5 of 12 (42%) were unilateral, of which 3 of 5 (60%) on the contralateral saphenous vein-harvested leg. No VTE caused hemodynamic instability, and none was clinically suspected. In conclusion, VTEs were frequent, some extensive proximal VTEs occurred, but most were distally localized. Many patients in this series would have been discharged without diagnosis of and treatment for PE and/or DVT.

Critical evaluation of screening questionnaires for obstructive sleep apnea in patients undergoing coronary artery bypass grafting and abdominal surgery.

BACKGROUND: Obstructive sleep apnea (OSA) is an independent risk factor for complications after surgery. However, OSA remains largely under recognized, and questionnaires designed to detect OSA have shown inconsistent results. Patients with cardiovascular diseases may not present with the typical symptoms of OSA. We therefore sought to compare the performance of screening questionnaires of patients referred for coronary artery bypass grafting (CABG) versus abdominal surgery (Abd surgery). METHODS: We studied 40 consecutive patients referred for CABG [29 men; age 56 ± 7 years; body mass index (BMI) 30 ± 4 kg/m(2)], and 41 referred to Abd Surgery matched for age, gender, and BMI (28 men; age 56 ± 8 years; BMI 29 ± 5 kg/m(2)). All patients were evaluated with validated questionnaires to predict OSA (STOP-Bang and Berlin), Epworth sleepiness scale (ESS) and full overnight polysomnography. RESULTS: The prevalence of OSA (apnea-hypopnea index ≥15 events/hour) in the CABG and Abd surgery groups was similar (52 and 41 %, respectively, p = 0.32). The Berlin questionnaire showed similar sensitivity (67 vs. 82 %, p = 0.17) but lower specificity in the CABG group (26 vs. 62 %, p = 0.02). The STOP-BANG questionnaire had a high sensitivity (90 vs. 94 %, p = 0.42) but low specificity (5 vs. 13 %, p = 0.25) in the CABG and Abd surgery groups, respectively. Patients referred for CABG slept less (323 [285-376] vs. 378 [308-415] minutes, p = 0.04) but had lower levels of daytime sleepiness than Abd surgery patients had (ESS, 6 ± 4 vs. 9 ± 5; p = 0.01, respectively). CONCLUSIONS: Presenting clinical characteristics of OSA are modulated by the population evaluated and may affect the performance of screening questionnaires.

Favorable effects of ezetimibe alone or in association with simvastatin on the removal from plasma of chylomicrons in coronary heart disease subjects.

OBJECTIVE: Reductions on the clearance from plasma of chylomicrons are associated with atherosclerosis. Statins improve the removal from plasma of chylomicrons in a dose dependent manner. There is controversy whether ezetimibe modifies the plasma clearance of chylomicrons. Effects of ezetimibe alone or in combination with simvastatin were compared with low and high dose of the latter, upon the kinetics of a chylomicron-like emulsion in coronary heart disease (CHD) patients. METHODS: 25 CHD patients were randomized for treatment with ezetimibe 10 mg (group 1) or simvastatin 20 mg (group 2) with progression to ezetimibe + simvastatin 10/20 mg or simvastatin 80 mg, respectively. Kinetic studies were performed at baseline and after each treatment period of 6 weeks. The fractional catabolic rates (FCR) of the emulsion labeled with (14)C-CE and (3)H-TG, that represent respectively chylomicron remnant and triglyceride removal, were calculated. Comparisons were made by ANOVA. RESULTS: The (14)CE-FCR in group 1 were 0.005 ± 0.004, 0.011 ± 0.008 and 0.018 ± 0.005 min(-1) and in group 2 were 0.004 ± 0.003, 0.011 ± 0.008 and 0.019 ± 0.007 min(-1) respectively at baseline, after 6 and 12 weeks (p < 0.05 vs. baseline, and 6 vs. 12 weeks). The (3)H-TG-FCR in group 1 were 0.017 ± 0.011, 0.024 ± 0.011 and 0.042 ± 0.013 min(-1) and in group 2 were 0.016 ± 0.009, 0.022 ± 0.009 and 0.037 ± 0.012 min(-1) at baseline, after 6 and 12 weeks (p < 0.05 vs. baseline, and 6 vs. 12 weeks). There were no differences between groups in time. CONCLUSION: Both treatments increased similarly the removal from plasma of chylomicron and remnants in CHD patients.

Paper-filtered coffee increases cholesterol and inflammation biomarkers independent of roasting degree: a clinical trial.

OBJECTIVE: The aim of this study was to compare the effects of medium light roast (MLR) and medium roast (MR) paper-filtered coffee on cardiovascular risk factors in healthy volunteers. METHODS: This randomized crossover trial compared the effects of consuming three or four cups (150 mL) of MLR or MR coffee per day for 4 wk in 20 healthy volunteers. Plasma lipids, lipoprotein(a) (Lp[a]), total homocysteine, and endothelial dysfunction-related inflammation biomarkers, serum glycemic biomarkers, and blood pressure were measured at baseline and after each intervention. RESULTS: Both roasts increased plasma total cholesterol, low-density lipoprotein-cholesterol, and soluble vascular cell adhesion molecule-1 (sVCAM-1) concentrations (10%, 12%, and 18% for MLR; 12%, 14%, and 14% for MR, respectively) (P < 0.05). MR also increased high-density lipoportein-cholesterol concentration by 7% (P = 0.003). Plasma fibrinogen concentration increased 8% after MR intake (P = 0.01), and soluble E-selectin increased 12% after MLR intake (P = 0.02). No changes were observed for Lp(a), total homocysteine, glycemic biomarkers, and blood pressure. CONCLUSION: Moderate paper-filtered coffee consumption may have an undesirable effect on plasma cholesterol and inflammation biomarkers in healthy individuals regardless of its antioxidant content.

Five-year follow-up of a randomized comparison between off-pump and on-pump stable multivessel coronary artery bypass grafting. The MASS III Trial.

BACKGROUND: Coronary artery bypass graft surgery with cardiopulmonary bypass is a safe, routine procedure. Nevertheless, significant morbidity remains, mostly because of the body's response to the nonphysiological nature of cardiopulmonary bypass. Few data are available on the effects of off-pump coronary artery bypass graft surgery (OPCAB) on cardiac events and long-term clinical outcomes. METHODS AND RESULTS: In a single-center randomized trial, 308 patients undergoing coronary artery bypass graft surgery were randomly assigned: 155 to OPCAB and 153 to on-pump CAB (ONCAB). Primary composite end points were death, myocardial infarction, further revascularization (surgery or angioplasty), or stroke. After 5-year follow-up, the primary composite end point was not different between groups (hazard ratio 0.71, 95% CI 0.41 to 1.22; P=0.21). A statistical difference was found between OPCAB and ONCAB groups in the duration of surgery (240±65 versus 300±87.5 minutes; P<0.001), in the length of ICU stay (19.5±17.8 versus 43±17.0 hours; P<0.001), time to extubation (4.6±6.8 versus 9.3±5.7 hours; P<0.001), hospital stay (6±2 versus 9±2 days; P<0.001), higher incidence of atrial fibrillation (35 versus 4% of patients; P<0.001), and blood requirements (31 versus 61% of patients; P<0.001), respectively. The number of grafts per patient was higher in the ONCAB than the OPCAB group (2.97 versus 2.49 grafts/patient; P<0.001). CONCLUSIONS: No difference was found between groups in the primary composite end point at 5-years follow-up. Although OPCAB surgery was related to a lower number of grafts and higher episodes of atrial fibrillation, it had no significant implications related to long-term outcomes. Clinical Trial Registration-URL: http://www.controlled-trials.com. Unique identifier: ISRCTN66068876.

Clinical profile of patients enroled in a cell therapy trial for severe coronary artery disease.

AIMS AND OBJECTIVES: To compare the clinical profile of patients included in a clinical trial of autologous bone marrow cells as an adjunctive therapy to coronary artery bypass grafting with that of patients undergoing routine coronary artery bypass grafting. BACKGROUND: The therapeutic potential of autologous bone marrow cells has been explored in the treatment of severe coronary artery disease. There are few data regarding the clinical and socio-economic profile of patients included in clinical trials using bone marrow cell. DESIGN: Case-control study. METHOD: Sixty-seven patients (61 SD 9) years, 82% men) with multivessel coronary artery disease were divided into two groups: patients in the bone marrow cell group (n = 34) underwent incomplete coronary artery bypass grafting + intramyocardial injection of autologous bone marrow cells (lymphomonocytic fraction -2.0 (SD 0.2 x 10(8)) cells/patient) in the ischaemic, non-revascularised myocardium, whereas patients in the coronary artery bypass grafting group (n = 33) underwent routine bypass surgery. Demographics, socio-economic status, clinical and echocardiographic data were collected. Statistical analysis included the Fisher's exact test (categorical variables) and the Student's t-test (continuous variables). RESULTS: There were no significant differences between groups regarding age, gender, BMI, heart rate, blood pressure and echo data. There was a greater prevalence of obesity (65 vs. 33%; OR = 3.7 [1.3-10.1]), of previous myocardial infarction (68 vs. 39%; OR = 3.2 [1.2-8.8]) and prior revascularisation procedures (59 vs. 24%; OR = 4.5 [1.6-12.7]) in the autologous bone marrow cells group and of smokers in the coronary artery bypass grafting group (51 vs. 23%; OR = 3.5 [1.2-10.4]). CONCLUSIONS: Patients included in this clinical trial of autologous bone marrow cells for severe coronary artery disease presented a greater prevalence of myocardial revascularisation procedures, indicating a more severe clinical presentation of the disease. Fewer smokers in this group could be attributable to life style changes after previous cardiovascular events and/or interventions. RELEVANCE TO CLINICAL PRACTICE: The knowledge of the clinical profile of patients included in cell therapy trials may help researchers in the identification of patients that may be enroled in future clinical trials of this new therapeutic strategy.

[Informed consent as viewed by patients participating in cardiology drug trial]. / Entendimento do termo de consentimento por pacientes partícipes em pesquisas com fármaco na cardiologia.

BACKGROUND: In clinical tests, the Informed Consent is critical to preserve the ethics, but due to its high complexity level, it cannot be fully understood. This study assesses the Informed Consent as viewed by patients. OBJECTIVE: We addressed the issue of what do patients understand about the studies based on the IC. METHODS: We invited participants of outpatient clinical drug trials phase II, III and IV to answer a questionnaire with 29 questions, such as: why have you accepted to participate? Did you read the Informed Consent before signing it? By signing it, were you sure you have fully understood it? Eighty individuals (20 women and 60 men) showed up, from 106 patients. The variables of each question were considered as often as they appeared. The comparison of the averages among the groups was made by t tests of Student or Wilcoxon; and for associations, Chi-square or Likelihood Ratio, or Fisher's exact test. RESULTS: Ages averaged 58.7 +/- 9.3 years. Concerning their reasons to taking part in the survey, 66.2% pointed out their own benefit; 42.5%, for science's sake; 25.0% claimed they were doing so at their doctor's request; 50% did not understand the Informed Consent properly; and 32.9% did not read it, but signed it. Among those who were administered placebo after randomization (n = 47), 66.7% did not understand the meaning of the informed consent. A strong correlation between failure to understand the meaning of placebo with literacy level (p = 0,02) was verified, which is an evidence that the smaller is the literacy level, the smaller is the understanding level. CONCLUSION: The Informed Consent is poorly understood by patients and for some of them, trusting a doctor affected their decision in taking part in the clinical trial with drugs. Their literacy level also influenced their understanding of the term 'placebo'.

Entendimento do termo de consentimento por pacientes partícipes em pesquisas com fármaco na cardiologia / Informed consent as viewed by patients participating in cardiology drug trial / La comprensión del formulario de consentimiento por los pacientes que forman parte de investigaciones con fármaco en la cardiología

Fundamento: Em ensaios clínicos, o Termo de Consentimento Livre e Esclarecido (TCLE) é fundamental para preservar a ética, mas pela sua complexidade ele pode não ser entendido completamente. Neste estudo, avaliamos o entendimento do TCLE pelo paciente. Objetivo: Abordamos a questão sobre o nível de compreensão dos pacientes em relação aos estudos baseados no Consentimento Informado. Métodos: Convidamos participantes de pesquisa ambulatorial fases II, III e IV, com fármacos, para responder um questionário estruturado com 29 questões, tais como: por que aceitou participar? Leu o TCLE antes de assinar? Ao assiná-lo, estava certo de tê-lo entendido? Oitenta indivíduos (20 mulheres e 60 homens) compareceram, num universo de 106 pacientes. As variáveis de cada questão foram consideradas por frequência de ocorrência. A comparação entre as médias entre os grupos foi realizada pelos testes t de Student ou Wilcoxon; e para associações, o Qui-quadrado ou Razão de Verossimilhança, ou teste exato de Fisher. Resultados: A média das idades foi de 58,7 ± 9,3 anos. Das motivações para participar da pesquisa, 66,2 por cento apontaram seu próprio benefício; 42,5 por cento, o bem da ciência; 25,0 por cento alegaram atender a um pedido de seu médico; 50 por cento não entenderam corretamente o TCLE; e 32,9 por cento sequer o leram, mas o assinaram. Dentre os que receberam placebo após a randomização (n = 47), 66,7 por cento não entenderam o significado deste termo. Houve forte correlação entre o não entender o significado de placebo com a escolaridade (p = 0,02), evidenciando que quanto menor o nível de instrução, menor este entendimento. Conclusão: O TCLE é pouco compreendido pelos pacientes e para alguns deles a confiança no médico teve impacto na decisão de participar do ensaio clínico com fármaco, havendo também influência do nível de instrução dos sujeitos no entendimento do termo "placebo".

Background: In clinical tests, the Informed Consent is critical to preserve the ethics, but due to its high complexity level, it cannot be fully understood. This study assesses the Informed Consent as viewed by patients. Objective: We addressed the issue of what do patients understand about the studies based on the IC. Methods: We invited participants of outpatient clinical drug trials phase II, III and IV to answer a questionnaire with 29 questions, such as: why have you accepted to participate? Did you read the Informed Consent before signing it? By signing it, were you sure you have fully understood it? Eighty individuals (20 women and 60 men) showed up, from 106 patients. The variables of each question were considered as often as they appeared. The comparison of the averages among the groups was made by t tests of Student or Wilcoxon; and for associations, Chi-square or Likelihood Ratio, or Fisher's exact test. Results: Ages averaged 58.7 ± 9.3 years. Concerning their reasons to taking part in the survey, 66.2 percent pointed out their own benefit; 42.5 percent, for science's sake; 25.0 percent claimed they were doing so at their doctor's request; 50 percent did not understand the Informed Consent properly; and 32.9 percent did not read it, but signed it. Among those who were administered placebo after randomization (n = 47), 66.7 percent did not understand the meaning of the informed consent. A strong correlation between failure to understand the meaning of placebo with literacy level (p = 0,02) was verified, which is an evidence that the smaller is the literacy level, the smaller is the understanding level. Conclusion: The Informed Consent is poorly understood by patients and for some of them, trusting a doctor affected their decision in taking part in the clinical trial with drugs. Their literacy level also influenced their understanding of the term "placebo".

Fundamento: En ensayos clínicos, el Formulario de Consentimiento Informado (FCI) es fundamental para que se preserve la ética, sin embargo por su complexidad él puede no comprenderse completamente. En este estudio, evaluamos la comprensión del FCI por parte del paciente. Objetivo: Abordamos la cuestión sobre el nivel de comprensión de los pacientes respecto a los estudios basados en el Consentimiento Informado. Métodos: Invitamos a los participantes de investigación clínica fase II, III y IV con fármacos para responder un cuestionario estructurado con 29 cuestiones, tales como: ¿Por qué aceptó participar?¿Leyó el FCI antes de firmarlo?¿Al firmarlo estaba seguro de haberlo entendido? Ochenta individuos (20 mujeres y 60 varones) comparecieron, en un total de 106 pacientes. Las variables de cada cuestión se llevaron a cabo por frecuencia de ocurrencia. La comparación entre los promedios entre los grupos se realizó mediante las pruebas t de Student o Wilcoxon; y para asociaciones, el Chi-cuadrado o Razón de Verosimilitud, o prueba exacta de Fisher. Resultados: El promedio de las edades fue de 58,7 ± 9,3 años. De las motivaciones para participar en la investigación, el 66,2 por ciento señaló su propio beneficio; un 42,5 por ciento, el bien de la ciencia; un 25,0 por ciento alegó atender a una petición de su médico; el 50 por ciento no comprendió correctamente el FCI; y un 32,9 por ciento tampoco leyó el formulario, pero lo firmó. Entre los que recibieron placebo tras la randomización (n = 47), un 66,7 por ciento no entendió el significado de este término. Hubo una fuerte correlación entre las personas que no entendían el significado de placebo con la escolaridad (p = 0,02), evidenciando que cuanto menor era el nivel de instrucción, menor era la comprensión. Conclusión: EL FCI es poco comprendido por los pacientes y para algunos de ellos la confianza en el médico tuvo impacto en la decisión de participar en el ensayo clínico con fármaco, habiendo...

Association of lipoprotein lipase D9N polymorphism with myocardial infarction in type 2 diabetes: the genetics, outcomes, and lipids in type 2 diabetes (GOLD) study.

The association of polymorphisms affecting lipid metabolism with the risk of myocardial infarction (MI) in type 2 diabetes mellitus was investigated. The Genetics, Outcomes and Lipids in type 2 Diabetes (GOLD) Study is a prospective, multicenter study, conducted on 990 patients presenting diabetes and MI (n=386), or diabetes without previous manifestation of stroke, peripheral or coronary arterial disease (n=604), recruited from 27 institutions in Brazil. APO A1 (A/G -75 and C/T +83) and APO C3 (C/G 3'UTR) non-coding sequences, CETP (Taq 1B), LPL (D9N), APO E (epsilon2, epsilon3, epsilon4,), PON-1 (Q192R), and two LCAT variants Arg(147)-->Trp and Tyr(171)-->Stop were tested by PCR-RFLP. There was a higher prevalence of LPL DN genotype (19% vs.12%, p=0.03) and a higher frequency of the N allele (11% vs. 7%) among subjects with MI when compared to controls, with an odds ratio of MI for carriers of 9N allele of 2.46 (95% CI=1.79-3.39, p<0.0001). This association was present in men and women, in non-smokers and in hypertensive patients. A logistic regression model including gender, duration of diabetes, systolic blood pressure, HDL-C, left ventricle hypertrophy and D9N polymorphism showed that the latter still remained significantly associated with MI (OR=1.50, 95% CI=1.02-2.25, p=0.049). These findings suggest that D9N polymorphism can be a useful risk marker for myocardial infarction and that further potential candidate genes should be screened for exploratory analysis and for future therapeutic intervention in diabetes.

Dynamic regulation of MTHFR mRNA expression and C677T genotype modulate mortality in coronary artery disease patients after revascularization.

INTRODUCTION: A large body of evidence links plasma homocysteine (Hcy) concentrations and cardiovascular disease. A common MTHFR polymorphism (C677T) leads to a variant with reduced activity and associated with increased Hcy levels. Coronary surgery precipitates a significant and sustained increase in the blood concentrations of Hcy and elevated levels of plasma Hcy have been associated to saphenous vein (SV) graft disease after CABG. However, the effects of MTHFR genotypes in the incidence of cardiovascular events after CABG have not been investigated prospectively. Here, we investigate whether MTHFR gene variants are associated with an increased cardiovascular risk in individuals submitted to CABG. We also propose a molecular mechanism to explain our findings. METHODS: We performed MTHFR C677T genotypes in 558 patients with two or three vessel-disease and normal left ventricular function prospectively followed in the MASS II Trial, a randomized study to compare treatments for multivessel CAD and preserved left ventricle function. Follow-up time was 5 years. Survival curves were calculated with the Kaplan-Meier method, and evaluated with the log-rank statistic. We assessed the relationship between baseline variables and the composite end-point of death, myocardial infarction and refractory angina using a Cox proportional hazards survival model. Finally, using an ex-vivo organ culture we have reproduced the arterialization of SV implants by culturing human SV either under venous hemodynamic condition (flow: 5 mL/min; no pressure) or arterial hemodynamic condition (flow: 50 mL/min; pressure: 80 mm Hg) for 1 day. MTHFR gene expression was quantified by real time RT-PCR in 15 SV from different individuals in both experimental conditions. RESULTS: There were no significant differences among individuals within each genotype group for baseline clinical characteristics. A statistically significant association between the TT genotype, associated with increased serum levels of Hcy, and cardiovascular mortality after 5 years was verified (p=0.007) in individuals submitted to CABG surgery. In addition, MTHFR TT genotype was still significantly associated with a 4.4 fold increased risk in cardiovascular outcomes (p=0.01) even after adjustment of a Cox multivariate model for age, sex, hypertension, diabetes, LDL, HDL, triglycerides, and number of diseased vessels in this population. Finally, a significant reduction in MTHFR gene expression was demonstrated in human SV when submitted to an arterial hemodynamic condition (p=0.02). CONCLUSIONS: There is a dynamic regulation of MTHFR gene expression during the arterialization process of human saphenous vein grafts resulting in lower levels of gene expression when in an arterial hemodynamic condition. In addition, the C677T MTHFR functional variant is associated with a worse outcome in individuals submitted to CABG. Taken together, these data suggest an important role of Hcy metabolism in individuals after CABG.

Head-to-head comparison of dobutamine and adenosine stress real-time myocardial perfusion echocardiography for the detection of coronary artery disease.

We sought to determine the value of dobutamine versus adenosine real-time myocardial perfusion (MP) echocardiography for detecting coronary artery disease and the value of quantitative analysis of MP over electrocardiography, wall motion, and qualitative MP. We studied 54 patients by real-time MP echocardiography and coronary angiography. Replenishment velocity (beta) and an index of myocardial blood flow (A(n)xbeta) were derived from quantitative MP. During dobutamine stress, beta (1.7 +/- 0.7 vs 2.7 +/- 1.2; P < .001) and A(n)xbeta (2.2 +/- 1.0 vs 3.5 +/- 1.6; P < .001) reserves were lower in patients with coronary artery disease. The same was observed with adenosine for beta (1.7 +/- 0.8 vs 2.5 +/- 1.1; P < .001) and A(n)xbeta (1.9 +/- 0.7 vs 3.2 +/- 1.4; P < .001) reserves. Accuracy of electrocardiography, wall motion, qualitative MP, and quantitative MP were 61%, 76%, 76%, and 80% for dobutamine and 70%, 70%, 76%, and 80% for adenosine, respectively. Quantitative MP had incremental diagnostic value over other variables during dobutamine (chi(2) 23.7-38.4; P < .001) and adenosine (chi(2) 26.7-59.4; P < .001). In conclusion, dobutamine and adenosine real-time MP echocardiography hold similar accuracy for detecting coronary artery disease. Quantitative MP provides incremental diagnostic information over other variables.

Trimetazidine to reverse ischemia in patients with class I or II angina: a randomized, double-blind, placebo-controlled dobutamine-atropine stress echocardiography study.

AIMS: We sought to evaluate the effects of trimetazidine on ischemia induced by dobutamine-atropine stress echocardiography in patients with class I or class II angina. METHODS: In a randomized, double-blind, placebo-controlled study, 66 patients with proved coronary disease were subjected to dobutamine-atropine stress echocardiography. Ischemia was proved in 56 patients who were included in the study and who had been on standard maintenance medications (propranolol, aspirin and statin). They were randomized to placebo or trimetazidine, 20 mg three times daily for a 12-week period, when dobutamine-atropine stress echocardiography was repeated. RESULTS: Fifty-two patients (56.53+/-8.9 years old) completed the study. No differences were seen between groups at entry. Thirty patients had class I and 26 class II angina. At the end of the study, 42 had class I and 14 class II angina (P=0.01), owing to patients being in the trimetazidine arm. We did not observe any differences between groups either for onset time of ventricular ischemic dysfunction, or for wall-motion score index. Comparing variation at peak using the delta wall-motion score index, we observed no differences, but only a trend toward reduction favoring trimetazidine (P=0.09). CONCLUSION: We did not detect a significant anti-ischemic effect of trimetazidine in patients with mild angina, but there was a clear improvement in angina class.

Monophasic versus biphasic waveform shocks for atrial fibrillation cardioversion in patients with concomitant amiodarone therapy.

AIMS: With transthoracic cardioversion of atrial fibrillation (AF), biphasic are more effective than monophasic waveforms. We sought to determine the ideal energy levels for biphasic waveforms. Methods We compared biphasic truncated exponential waveforms with monophasic damped sine waveform defibrillators, in a prospective, single-centre, randomized (1:1 ratio) study. The study included 154 patients receiving concomitant amiodarone; 77 received serial biphasic (50, 100, 150, up to 175 J) and 77 monophasic shocks (100, 200, 300, up to 360 J), as necessary. Results First-shock efficacy was similar in the two groups (57 vs. 55%, P = 0.871, respectively), as were serial-shocks (90 vs. 92%, P = 0.780). Both groups received equal numbers of shocks (1.8 +/- 1.1 vs. 1.7 +/- 1.0, P = 0.921). In both groups, serum creatine kinase levels showed a small but significant increase. The increase was, however, higher in the monophasic group. CONCLUSION: In patients with concomitant amiodarone therapy, biphasic truncated exponential shocks, using half the energy, were as effective as monophasic damped sine shocks. The biphasic scheme was not more efficacious for cardioverting AF. In our population, a first shock of at least 100 J seemed advisable with either waveform. If necessary, escalating shocks must be performed, but ideal levels of increase per shock are still uncertain for biphasic waveforms.

Spontaneous aortic dissection limited to sinus of Valsalva and involving the left main coronary artery.

Aortic dissection limited to one sinus of Valsalva has been described exclusively as an iatrogenic complication during catheterization interventions. This life-threatening subtype had a very small area of dissection, when coronary ostia are frequently involved. We report a 43-year-old man with dissection limited to left sinus of Valsalva, involving the left main coronary artery and causing non-ST-myocardial infarction, including severe reversible ST-depression, maximum of 9 mm in V5 lead. Dissection was suggested by cineangiography, transesophageal echocardiogram, and contrast-enhanced multidetector computed tomography. Surgical treatment was successful. There were not any associated diseases in the sinuses of Valsalsa, aortic valve or coronary arteries. Unlike previous reported cases of aortic dissection with such limited localization, the present case was spontaneous, and not iatrogenic.

Myocardial bridging causing transmural ischemia. Successful coronary artery bypass surgery.

Myocardial bridging is a common and usually benign inborn coronary anomaly. We report on a 51-year-old man who presented with recent angina on minimum physical effort. Cineangiography showed myocardial bridging of the mid-left anterior descending artery (LAD), and intracoronary ultrasonography excluded atherosclerotic disease. Gated single-photon emission computed tomography (SPECT), with exercise stress, showed an extensive anterior perfusion defect, and remarkable ST-segment elevation (up to 10 mm) in recovery. Vasospasm of the LAD was the main hypothesis. Additional oral drugs did not bring about improvement, as indicated on a new SPECT; disabling angina persisted. Surgical revascularization of the LAD by left internal mammary artery graft was performed. Two years later, SPECT and exercise tests returned to normal. The patient remains asymptomatic.

Trimetazidine to reverse ischemia in patients with class I or II angina: a randomized, double-blind, placebo-controlled dobutamine–atropine stress echocardiography study / Trimetazidine to reverse ischemia in patients with class I or II angina: a randomized, double-blind, placebo-controlled dobutamine–atropine stress echocardiography study

Aims We sought to evaluate the effects of trimetazidine on ischemia induced by dobutamine–atropine stress echocardiography in patients with class I or class II angina. Methods In a randomized, double-blind, placebocontrolled study, 66 patients with proved coronary disease were subjected to dobutamine–atropine stress echocardiography. Ischemia was proved in 56 patients who were included in the study and who had been on standard maintenance medications (propranolol, aspirin and statin). They were randomized to placebo or trimetazidine, 20mg three times daily for a 12-week period, when dobutamine–atropine stress echocardiography was repeated. Results Fifty-two patients (56.53 ±8.9 years old) completed the study. No differences were seen between groups at entry. Thirty patients had class I and 26 class II angina. At the end of the study, 42 had class I and 14 class II angina (P =0.01), owing to patients being in the trimetazidine arm. We did not observe any differences between groups either for onset time of ventricular ischemic dysfunction, or for wall-motion score index.

Stratifying the risk in unstable angina with dobutamine stress echocardiography.

OBJECTIVE: To evaluate the role of dobutamine stress echocardiography (DSE) in the risk stratification of low to moderate risk unstable angina (UA) patients, to predict the combined clinical outcome of cardiovascular death, myocardial infarction (MI), recurrent UA and the need of revascularization procedures in a 6 month period. METHODS: Multicenter prospective study. Patients should be admitted to the hospital and asymptomatic in the last 24 hours. The exam was performed up to 72 hours from the hospital admission and no medication was stopped prior to the test. RESULTS: Ninety-five consecutive patients were evaluated by DSE. Forty patients (42,1%) had a positive ischemic test and fifty five (57,9%) had a negative one. Clinical events occurred in twenty eight patients, twenty six of whom had a positive test. The rest of the patients (67) did not have clinical events and fifty three of them, had a negative test. The sensibility, specificity, accuracy, positive predictive value and negative predictive value of the test related to the clinical events were: 92,9%, 79,1%, 83,2%, 65% and 96,4%, respectively. Event-free survival after 6 months for pacients with a negative DSE was 96% compared to 35% for those with a positive DSE (p<0,001). The UA classification, left ventricular ejection fraction, rest and peak wall motion score index, DSE result and history of previous MI were associated with the combined end point by univariate analysis. The test result was the only independent predictor of cardiac events by multivariate analysis (p<0.001). CONCLUSION: O DSE has shown an excellent negative predictive value allowing for early hospital discharge without further exams. The positive test result was the only independent predictor for adverse cardiac events.