Acute effects of diets rich in almonds and walnuts on endothelial function.

OBJECTIVE: Omega-3 fatty acids, especially alpha-linolenic acid (ALA), which are present in nuts may reduce cardiovascular disease (CVD) risk, by changing vascular inflammation and improving endothelial dysfunction. The objective of the study was to evaluate the acute effects of two different diets, one containing walnuts and the other almonds on endothelial function. METHODS: Twenty-seven overweight volunteers underwent a randomized 2-period, crossover, controlled intervention study. The subjects were given either walnut or almond diets which varied in monounsaturated fatty acid (MUFA) and polyunsaturated fatty acid (PUFA) content. The walnut diet provided 23.1% energy from PUFA and the almond diet provided 7.6% energy from PUFA. Endothelial function was assessed physiologically by flow-mediated dilation (FMD) and biochemically by sVCAM (soluble vascular cell adhesion molecules). RESULTS: The walnut diet significantly improved FMD (p=0.004) and decreased sVCAM (p=0.009) whereas the almond diet tended to improve FMD (p=0.06) and significantly decreased sVCAM (p=0.004). CONCLUSION: Both walnut and almond diets improved FMD and sVCAM and there was no significant difference in physiological and biochemical markers between the two diets.

Differential diagnosis of acute pericarditis from normal variant early repolarization and left ventricular hypertrophy with early repolarization: an electrocardiographic study.

BACKGROUND: Differentiation of ST-segment elevation on electrocardiogram (ECG) from acute pericarditis (AP), normal variant early repolarization (ER) and early repolarization of left ventricular hypertrophy (ERLVH) can be problematic. Hence, the authors evaluated the accuracy of the ST/T ratio in ECG to more optimally differentiate between AP, ST-segment elevation, ER and ERLVH. METHODS: Between September 2006 and July 2010, 80 patients were enrolled in this study consisting of 25 individuals with AP, 27 with ER and 28 with ERLVH. Each ECG was analyzed in a systematic manner including the measurement of PR interval, QRS duration, QT-segment duration, PR-segment deviation, ST-segment deviation and the height of T wave. The ratio of the height of ST segment to the height of T wave was measured in leads I, II, III, aVF and V2 through V6. RESULTS: The mean ages of the patients with AP, ER and ERLVH were 32 ± 16.5, 36 ± 15.4 and 53 ± 16 years, respectively. The ratio of the amplitude of ST segment to the amplitude of the T wave in leads I, V4, V5 and V6 proved to be a significant discriminator at a value of ≥0.25 (P < 0.05 for all). CONCLUSIONS: Leads I, V4, V5 and V6 can all be used to differentiate AP from ER and ERLVH. When ST elevation is present in lead I, the ST/T ratio has the best predictive value (0.82) to more accurately discriminate between AP, ER and ERLVH.

Left atrial volume by echocardiography in patients with false positive myocardial perfusion scans.

A stress-induced myocardial perfusion abnormality (MPS), in the absence of angiographically significant epicardial coronary artery disease, is considered a "false-positive" test result. We hypothesized that echocardiography would provide complementary prognostic and pathophysiologic data relevant to the management of patients with MPS and normal coronary angiograms. Accordingly, left atrial volume index (LAVi) was assessed by echocardiography in 38 patients with false positive MPS as defined by normal coronary angiograms and 26 patients with true negative MPS from a total of 1,356 patients stressed from July 2006-May 2008. Pathologically abnormal elevation of LAVi (≥ 32 mL/m(2)) was observed in 16 of 19 women (84%) and 11 of 19 men (58%) in the false positive MPS (FPMPS) group while none of the patients in the true negative MPS (TNMPS) group had elevated LAVi. In the FPMPS group mean LAVi was significantly higher in women than men (40.64 ± 11.4 mL/m(2) versus 32.6 ± 10.5 mL/m(2), P = 0.01). The mean LAVi in the FPMPS group was significantly different from the TNMPS group (36.6 ± 11.6 versus 21 ± 7 mL/m(2), P = 0.000). A stepwise logistic regression determined BSA, LAV and LAVi as useful in predicting false positive and true negative MPS. All three were significant predictors (P < 0.01) and the area under the ROC curve was 0.91. Our findings in this relatively small cohort suggest that patients with false positive MPS have a greater increased LAVi.

Gender and geographic differences in CAD risk factors and CHADS2 scores in atrial fibrillation patients.

Atrial fibrillation (AF) is a cardiac arrhythmia associated with a wide range of other co-morbid medical conditions. The state of West Virginia has a higher prevalence of coronary artery disease (CAD) and CAD risk factors compared to the national average. We hypothesized that West Virginians with atrial fibrillation would also have a higher prevalence of CAD risk factors and higher CHADS2 stroke risk scores. This is particularly important since Louisiana is the only high CAD risk southern state included in the original verification of the CHADS2 risk scoring system (i.e. California, Connecticut, Louisiana, Maine, Missouri, New Hampshire, and Vermont). Accordingly, we performed a retrospective analysis of the association between AF and CAD, CAD risk factors and CHADS2 scores in a cohort of men and women in the West Virginia University Hospital population. We report a greater positive association between AF and hypertension, diabetes mellitus and obesity than the national average. AF was seen more commonly among men. But, CHADS2 scores were higher among women as a result of a higher prevalence of diabetes mellitus. This study indicates that AF is associated with a greater prevalence of CAD risk factors and higher CHADS2 scores among West Virginians in comparison with the rest of the nation.

Effect of intensive lifestyle changes on endothelial function and on inflammatory markers of atherosclerosis.

Intensive lifestyle changes have been shown to regress atherosclerosis, improve cardiovascular risk profiles, and decrease angina pectoris and cardiac events. We evaluated the influence of the Multisite Cardiac Lifestyle Intervention Program, an ongoing health insurance-covered lifestyle intervention conducted at our site, on endothelial function and inflammatory markers of atherosclerosis in this pilot study. Twenty-seven participants with coronary artery disease (CAD) and/or risk factors for CAD (nonsmokers, 14 men; mean age 56 years) were enrolled in the experimental group and asked to make changes in diet (10% calories from fat, plant based), engage in moderate exercise (3 hours/week), and practice stress management (1 hour/day). Twenty historically (age, gender, CAD, and CAD risk factors) matched participants were enrolled in the control group with usual standard of care. At baseline endothelium-dependent brachial artery flow-mediated dilatation (FMD) was performed in the 2 groups. Serum markers of inflammation, endothelial dysfunction, and angiogenesis were performed only in the experimental group. After 12 weeks, FMD had improved in the experimental group from a baseline of 4.23 + or - 0.13 to 4.65 + or - 0.15 mm, whereas in the control group it decreased from 4.62 + or - 0.16 to 4.48 + or - 0.17 mm. Changes were significantly different in favor of the experimental group (p <0.0001). Also, significant decreases occurred in C-reactive protein (from 2.07 + or - 0.57 to 1.6 + or - 0.43 mg/L, p = 0.03) and interleukin-6 (from 2.52 + or - 0.62 to 1.23 + or - 0.3 pg/ml, p = 0.02) after 12 weeks. Significant improvement in FMD, C-reactive protein, and interleukin-6 with intensive lifestyle changes in the experimental group suggests > or = 1 potential mechanism underlying the clinical benefits seen in previous trials.

Left ventricular noncompaction: a rare disorder in adults and its association with 1p36 chromosomal anomaly.

We report on a case of a 25-year-old male with 1p36 deletion syndrome, who was diagnosed with left ventricular noncompaction (LVNC). The association of this rare chromosomal abnormality with LVNC is reported in the pediatric literature, but it has not previously been specifically reported in adults. It is important to diagnose this unclassified cardiomyopathy in the adult population with this chromosomal abnormality for appropriate management and treatment as highlighted in our case.

Embolization of atrial septal occluder device into the pulmonary artery: a rare complication and usefulness of live/real time three-dimensional transthoracic echocardiography.

Percutaneous closure of atrial septal defects (ASD) in adults has emerged as an alternative to surgery. We report a rare complication of an atrial septal occluder device embolization into the pulmonary artery which was detected by fluoroscopy and echocardiography. The potential usefulness of live/real time three-dimensional transthoracic echocardiography in the management of patients undergoing percutaneous ASD occlusion is described.

Severe coronary tortuosity and the relationship to significant coronary artery disease.

Severe coronary artery tortuosity on coronary angiogram has not been previously evaluated to determine whether it is associated with coronary artery disease or risk factors for coronary artery disease. A retrospective analysis of all patients who underwent coronary angiography at West Virginia University Hospital during an eight month period was performed. All patients with severe coronary tortuosity (SCT), defined as two consecutive 180 degrees turns by visual estimation in a major epicardial artery, were identified and their medical records reviewed for the presence of coronary artery disease risk factors and presence of significant coronary artery disease. A randomly chosen group of patients who underwent coronary angiography during the same time who did not have SCT was used for a control group. Multivariable analysis using logistic regression was performed to determine predictors of SCT. Severe coronary tortuosity was found in 12.45% of our 1221 patients. Female gender was found to be significantly higher in the tortuosity group of patients compared to the control group (p = 0.039). The presence of severe tortuosity was associated with a statistically significant lower incidence of significant coronary artery disease (p = 0.003). Hypertension, hyperlipidemia, smoking, family history of coronary artery disease, diabetes mellitus, and age > or =65 years were not predictors of SCT. Our study did not find that coronary artery disease risk factors were predictors of coronary tortuosity. Future investigations may provide further insight into the significance or cause of coronary artery tortuosity.

Incremental value of live/real time three-dimensional transthoracic echocardiography in the assessment of right ventricular masses.

This case series demonstrates the incremental value of three-dimensional transthoracic echocardiography (3D TTE) over two-dimensional transthoracic echocardiography (2D TTE) in the assessment of 11 patients with right ventricular (RV) masses or mass-like lesions (three cases of RV thrombus, one myxoma, one fibroma, one lipoma, one chordoma, and one sarcoma and three cases of RV noncompaction, which are considered to be mass-like in nature). 3D TTE was of incremental value in the assessment of these masses in that 3D TTE has the capacity to section the mass and view it from multiple angles, giving the examiner a more comprehensive assessment of the mass. This was particularly helpful in the cases of thrombi, as the presence of echolucencies indicated clot lysis. In addition, certainty in the number of thrombi present was an advantage of 3D TTE. Also, sectioning of cardiac tumors allowed more confidence in narrowing the differential diagnosis of the etiology of the mass. In addition, 3D TTE allowed us to identify precise location of the attachments of the masses as well as to determine whether there were mobile components to the mass. Another noteworthy advantage of 3D TTE was that the volumes of the masses could be calculated. Additionally, the findings by 3D TTE correlated well with pathologic examination of RV tumors, and some of the masses measured larger by 3D TTE than by 2D TTE, which was also validated in one case by surgery. As in the case of RV fibroma, another advantage was that 3D TTE actually identified more masses than 2D TTE. RV noncompaction was also well studied, and the assessment with 3D TTE helped to give a more definitive diagnosis in these patients.

Two- and three-dimensional transthoracic and transesophageal echocardiographic findings in epithelioid hemangioma involving the mitral valve.

We are describing two-dimensional and live/real time three-dimensional transthoracic as well as two-dimensional transesophageal echocardiographic findings in an elderly patient with epithelioid hemangioma involving the anterior leaflet of the mitral valve.

Inducible nitric oxide synthase attenuates adrenergic signaling in alcohol fed rats.

Chronic, excessive alcohol consumption is associated with myocardial dysfunction in humans. The molecular mechanisms and cellular signaling pathways contributing to this cardiac dysfunction remain largely unknown. This study examined the effects of chronic alcohol consumption on myocardial function and cardiac myocyte signaling pathways. Adult male rats were fed a commercially prepared diet containing either ethanol (13 g/kg/d) or isocaloric control diet for 1 month. In vivo hemodynamics were measured in awake rats after inserting a catheter tip in the left ventricle under general anesthesia. Ventricular dysfunction was evidenced in awake, alcohol-fed rats by increased left ventricular end diastolic pressure, decreased systolic developed left ventricular pressure, and decreases in both positive and negative dp/dt compared with controls. Cardiac myocytes isolated from alcohol-fed rats also demonstrated an attenuated response to the beta-adrenergic agonist, isoproterenol, compared to controls. This response was significantly reversed by the nitric oxide synthase (NOS) inhibitor, N-monomethyl-L-arginine (L-NMMA). Western analyses confirmed inducible nitric oxide synthase (iNOS) protein synthesis in cardiac myocytes isolated from alcohol fed rats. It is therefore concluded that chronic alcohol ingestion results in iNOS-mediated attenuation of adrenergic signaling and depression in both systolic and diastolic function in rats.

An analysis of the efficacy and safety of enhanced external counterpulsation at West Virginia University Hospitals.

A retrospective analysis was conducted of 79 consecutive patients who underwent enhanced external counterpulsation (EECP) at West Virginia University Hospitals during the period of November 1998 to September 2005 to determine its efficacy and safety in treating angina. A chart review and/or phone survey was performed to analyze pertinent clinical data (sublingual nitroglycerin use and angina class) pre and post EECP. A total of 60 (76%) patients who were referred for EECP successfully finished the 35 treatments. Seventy-five percent of the patient population improved at least one angina class after a full course of treatment. Therapy was discontinued due to adverse effects in 12 (15%) patients. Statistically significant improvements in angina class and reduction in anti-angina medications were observed in every co-morbid subgroup analyzed, including patients with peripheral vascular disease, diabetes, hyperlipidemia, hypertension, smoking, Post-MI, and LVEF < 40% (P < .05, Wilcoxon Signed-Rank test). Overall, EECP was effective in improving angina as reflected in a substantial reduction in antiangina medications in 59 (75%) patients.

Emotional stress and reversible myocardial dysfunction.

A growing body of clinical and experimental literature supports a strong association between emotional stress and adverse outcomes from CVD. Effects of emotional stress on coronary blood flow and cardiac arrhythmias provide only a partial explanation. A direct impact of emotional stress on myocardial function has recently received attention as a result of reports of patients presenting with new onset of unexplained reversible heart failure following episodes of emotional stress. Potential mechanisms responsible for myocardial dysfunction following emotional stress remain to be elucidated. This review will explore potential pathophysiologic mechanisms linking emotional stress to adverse cardiovascular outcomes beginning with primary and secondary risk factors and leading to direct effects of emotional stress on reversible myocardial dysfunction.

p38 MAP kinase inhibitor reverses stress-induced cardiac myocyte dysfunction.

Stress is gaining increasing acceptance as an independent risk factor contributing to adverse cardiovascular outcomes. Potential mechanisms responsible for the deleterious effects of stress on the development and progression of cardiovascular disease remain to be elucidated. An established animal model of stress in humans is the prenatally stressed (PS) rat. We stressed rats in their third trimester of pregnancy by daily injections of saline and moving from cage to cage. Male offspring of these stressed dams (PS) and age-matched male control offspring (control) were further subjected to restraint stress (R) at 6 and 7 wk of age. Echocardiography revealed a significant decrease in fractional shortening in PS + R vs. controls + R (45.8 +/- 3.9 vs. 61.9 +/- 2.4%, PS + R vs. controls + R; P < 0.01; n = 12). Isolated adult rat ventricular myocytes from PS + R also revealed diminished fractional shortening (6.7 +/- 0.8 vs. 12.7 +/- 1.1%, PS + R vs. controls + R; P < 0.01; n = 24) and blunted inotropic responses to isoproterenol (P < 0.01; n = 24) determined by automated border detection. The p38 mitogen-activated protein (MAP) kinase inhibitor SB-203580 blocked p38 MAP kinase phosphorylation, reversed the depression in fractional shortening, and partially ameliorated the blunted adrenergic signaling seen in adult rat ventricular myocytes from PS + R. Phosphorylation of p38 MAP kinase in cardiac myocytes by stress may be sufficient to lead to myocardial dysfunction in animal models and possibly humans.

Effects of cocaine and caffeine alone and in combination on cardiovascular performance: an experimental hemodynamic and coronary flow reserve study in a canine model.

BACKGROUND: With the proliferation of cocaine abuse, increased incidence of catastrophic cardiovascular events like angina pectoris, myocardial infarction, ventricular arrhythmias or sudden death are reported. Cocaine-dependent subjects commonly abuse multiple substances. Many of them drink coffee before and after cocaine use. The high frequency of simultaneous exposure to both the drugs may influence outcome of the cocaine's treatment. Cocaine and caffeine's independent effects on cardiodynamics are documented but to our knowledge combined effects of both on complete cardiovascular hemodynamics remains to be examined. METHODS: Eighteen dogs were instrumented to pass cardiac catheters into right and left heart. The experiments were performed after they recovered from the effects of anesthesia. In phase I (30 experiments on 8 dogs), the doses were established by dose-response curve. In phases II and III, another 10 dogs were subjected to 28 experiments. They were given i.v. cocaine followed by caffeine and vice versa to study their effects on hemodynamics and coronary flow reserve. RESULTS: Phase 1: The doses of cocaine (2 mg/kg) and caffeine (5 mg/kg) were established. Phase II: Cocaine increased heart rate, blood pressure and dP/dt but CFR decreased significantly. Caffeine administered after cocaine attenuated these effects (dP/dt decreased to 4910+/-104 from 5066+/-110 mm Hg s; p

Primary percutaneous balloon pericardiotomy.

Percutaneous balloon pericardiotomy was reported by Palacious et al in 1991. From 1996-2000, we utilized this procedure as the initial treatment for 17 patients at West Virginia University Hospital in Morgantown with cardiac tamponade who had a high likelihood of recurrence of pericardial effusion. Primary pericardiotomy was successful after the initial procedure in 82% (n = 14) of these patients, so it appears to be an effective non-surgical procedure for patients at high risk for re-accumulation of pericardial effusions. In addition, our comparison at this institution revealed that primary percutaneous pericardial window creation is significantly less costly than pericardiocentesis followed by surgical pericardial window creation.

Carbon monoxide poisoning: a case report of reversible cardiormyopathy.

Acute carbon monoxide poisoning is the most common cause of poison-related deaths in the U.S. A 21-year-old white woman was referred to Ruby Memorial Hospital after exposure to carbon monoxide (CO) from a faulty furnace. She developed acute weakness, dyspnea, nausea and vomiting. An electrocardiogram revealed sinus tachycardia, non-specific ST-T wave abnormalities, and a prolonged QTc interval. The chest X-ray revealed pulmonary edema and the 2-D echocardiography revealed decreased left ventricular systolic function with an ejection fraction of 25%. She was treated with high-flow oxygen and supportive medical therapy with complete resolution of the left ventricular dysfunction six weeks later. She has been followed for over one year without medical therapy and without recurrence of her symptoms. This case illustrates that the depressant effect of CO poisoning on the myocardium can be reversed in the short term with supportive medical therapy and recovery sustained in the long term without medical therapy.