Quantitative coronary arterial stenosis assessment by multidetector CT and invasive coronary angiography for identifying patients with myocardial perfusion abnormalities.

BACKGROUND: Semi-quantitative stenosis assessment by coronary CT angiography only modestly predicts stress-induced myocardial perfusion abnormalities. The performance of quantitative CT angiography (QCTA) for identifying patients with myocardial perfusion defects remains unclear. METHODS: CorE-64 is a multicenter, international study to assess the accuracy of 64-slice QCTA for detecting ≥50% coronary arterial stenoses by quantitative coronary angiography (QCA). Patients referred for cardiac catheterization with suspected or known coronary artery disease were enrolled. Area under the receiver-operating-characteristic curve (AUC) was used to evaluate the diagnostic accuracy of the most severe coronary artery stenosis in a subset of 63 patients assessed by QCTA and QCA for detecting myocardial perfusion abnormalities on exercise or pharmacologic stress SPECT. RESULTS: Diagnostic accuracy of QCTA for identifying patients with myocardial perfusion abnormalities by SPECT revealed an AUC of 0.71, compared to 0.72 by QCA (P = .75). AUC did not improve after excluding studies with fixed myocardial perfusion abnormalities and total coronary arterial occlusions. Optimal stenosis threshold for QCTA was 43% yielding a sensitivity of 0.81 and specificity of 0.50, respectively, compared to 0.75 and 0.69 by QCA at a threshold of 59%. Sensitivity and specificity of QCTA to identify patients with both obstructive lesions and myocardial perfusion defects were 0.94 and 0.77, respectively. CONCLUSIONS: Coronary artery stenosis assessment by QCTA or QCA only modestly predicts the presence and the absence of myocardial perfusion abnormalities by SPECT. Confounding variables affecting the relationship between coronary anatomy and myocardial perfusion likely account for some of the observed discrepancies between coronary angiography and SPECT results.

Perioperative serum procalcitonin concentrations in patients with acute aortic dissection.

We investigated the perioperative serum procalcitonin (PCT) concentrations in 5 consecutive patients who underwent surgery for acute aortic dissection (2 men, 3 women; mean age 72 +/- 9 years, age range 52-81 years). Surgery used cardiopulmonary bypass with deep hypothermic circulatory arrest. Blood samples were taken prior to surgery, upon arrival in the intensive care unit, and 6, 12, 18, 24, and 48 h after intensive care unit arrival. Prior to surgery, the PCT level was 4.2 +/- 3.4 (range 0.8-8.3) ng/ml. The PCT increase was greatest at 24 h (5.8 +/- 4.5 ng/ml). Preoperatively, the C-reactive protein concentration was 8.0 +/- 8.3 (range 0.9-23.8) mg/dl, and the white blood cell count was 8.5 +/- 3.1 x 10(3). C-reactive protein continued to increase at 48 h, while the white blood cell count peaked at 24 h. In spite of no symptoms of infectious diseases or septicemia, all patients had a significant preoperative PCT elevation. This finding may have something to do with the specific preoperative condition of acute aortic dissection. However, more clinical investigation is needed to clarify the PCT changes during and after surgery for acute aortic dissection.

Dilation and reduced distensibility of carotid artery in patients with abdominal aortic aneurysms.

BACKGROUND: Although patients with abdominal aortic aneurysms (AAA) frequently have coexisting systemic atherosclerosis, the dilatative manifestation of AAA is the opposite of the occlusion characteristic of atherosclerotic disease. It has been suggested that this dilatative disease is caused by an alteration in connective tissue metabolism in systemic arterial wall. Such a condition might alter systemic arterial diameter and wall behavior. We investigated arterial characteristics in AAA patients, including morphologic changes and wall mechanics in the carotid artery. METHODS AND RESULTS: Atherosclerotic intimal changes such as intima-media thickness (IMT), plaque formation, diameter, and wall elasticity of the carotid artery were determined ultrasonographically in patients with AAA (n = 102) and compared with age-matched patients with the atherosclerotic diseases arteriosclerosis obliterans (ASO, n = 115) and coronary artery disease (CAD, n = 123) and with age-matched healthy control patients (CTL, n = 45). Intimal disease in AAA was significantly milder than in ASO, at the same level as CAD, and more severe than in CTL. Although end-diastolic luminal diameters (mm) in AAA (7.05 +/- 1.08), ASO (6.74 +/- 0.18), and CAD (6.66 +/- 0.83) were significantly higher than in CTL (5.97 +/- 0.93), they were also excessively increased compared with the equivalent diameters seen in ASO (P <.01) and CAD (P <.01). Luminal distensibility (x 10(-6) cm(2). dyne(-1)) in AAA (0.83 +/- 0.48) was excessively decreased compared not only with CTL (1.70 +/- 1.11, P <.01) but also with ASO (1.12 +/- 0.47, P <.01) and CAD (1.18 +/- 0.59, P <. 01). These relations remained true when adjusted for blood pressure and luminal diameter. Intra-AAA group analysis showed that distensibility in ruptured cases (n = 14) was significantly lower than in nonruptured cases (n = 88) (0.58 +/- 0.24 vs 0.88 +/- 0.50, P <.05). CONCLUSIONS: Excessive arterial dilation and reduced distensibility without severe intimal disease were found in the carotid arteries of patients with AAA. This suggests that these patients may be subject to systemic arterial alterations, including structural and functional abnormalities.

Circulating biochemical marker levels of collagen metabolism are abnormal in patients with abdominal aortic aneurysm.

Changes in extracellular matrix composition induced by abnormal collagen metabolism in the aortic wall may be an important factor in the progression of aortic structural changes. The authors have measured several types of biochemical marker for collagen metabolism in plasma: carboxyterminal propeptide of type Icollagen (PICP) for a pure collagen synthesis marker, matrix metalloproteinase-1 (MMP-1) for a degradation marker of collagen matrix, and tissue inhibitors of metalloproteinase-1 (TIMP-1) as a native inhibitor of MMP-1. Subjects of this study were 17 patients with abdominal aortic aneurysm (AAA), 14 patients with atherosclerosis obliterans (ASO), and 22 age/sex-matched healthy controls (HC). Blood samples were drawn from a forearm vein and measured by radioimmunoassay or enzyme-linked immunosorbent assay. Plasma concentrations of PICP in patients with AAA were significantly decreased compared to those in HC patients (82.0 +/- 16.4 vs 111.3 +/- 40.3 ng/mL; p < 0.01), but those in patients with ASO (105.4 +/- 55.4 ng/mL) were comparable to control concentrations. Although no differences in plasma concentrations of MMP-1 were observed among the three subject groups (HC, 20.0 +/- 5.6 ng/mL; ASO, 21.4 +/- 13.8 ng/mL; AAA, 24.5 +/- 11.7 ng/mL; NS), MMP-1/PICP ratio as an index of collagen degradation to collagen neosynthesis in AAA was significantly elevated compared to HC (0.32 +/- 0.18 vs 0.20 +/- 0.08; p < 0.01). Plasma concentrations of TIMP-1 in patients with AAA (293.8 +/- 61.2 ng/mL) or ASO (327.6 +/- 54.9 ng/mL) were significantly higher than in HC (227.3 +/- 60.2 ng/mL; both p < 0.01). In conclusion, these data suggest that although a compensatory mechanism such as increased TIMP-1 may be activated, collagen neosynthesis may decrease with relatively increased collagen degradation in patients with AAA.

Postoperative renal function after an abdominal aortic aneurysm repair requiring a suprarenal aortic cross-clamp.

We describe herein the postoperative renal functions of patients who required a suprarenal aortic cross-clamp during abdominal aortic surgery. Seven patients required a unilateral suprarenal aortic cross-clamp (group A) and six patients required a bilateral suprarenal clamp (group B). Eighty-three patients who required an infrarenal aortic clamp were assigned to group C. Renal hypothermia with renal perfusion or topical cooling during suprarenal clamp was not performed. No hospital deaths were encountered. In group B, the postoperative creatinine and blood urea nitrogen (BUN) levels remained statistically significantly higher than that of group C until the seventh postoperative day. The postoperative renal dysfunction (serum creatinine level >2.0 mg/dl) was 28.6% in group A and 50% in group B, while it was only 8.4% in group C, although no patient required either temporary or permanent hemodialysis. The postoperative peak BUN over 30 min suprarenal clamp was significantly higher than that within 30 min. In summary, the postoperative renal function was impaired after an extended bilateral suprarenal clamp. These findings suggest that if prolonged renal ischemia is thus expected, then renal preservation should be considered.

Plasma B-type natriuretic peptide measurement in a multiphasic health screening program.

The aim of this study was to determine whether measurement of plasma levels of atrial natriuretic peptide (ANP) and B-type natriuretic peptide (BNP) is an efficacious method to predict patients with heart disease irrespective of left ventricular function in a multiphasic health screening program. We have examined whether patients with various heart disease selected by physical examination, ECG, and chest X-rays can be identified by plasma levels of ANP and BNP. We examined 481 consecutive subjects who visited our checkup clinic for a multiphasic health screening test. By routine methods, among the 481 subjects, 13 were found to have some form of heart disease (old myocardial infarction, 2; cardiomyopathy, 2; valvular heart disease, 2; hypertensive heart disease, 5, and lone atrial fibrillation, 2). Sensitivity, specificity, and quintile analysis for identification of the patients with heart disease were determined by various cutoff levels of plasma ANP and BNP. Receiver operating characteristic (ROC) curves were constructed for the identification of these patients. A plasma BNP level of 40 pg/ml had a sensitivity of 85% and a specificity of 92% for heart disease detection. The area under the ROC curve for BNP was significantly greater than that for ANP (0.94 vs. 0.81; p < 0.001). A plasma BNP level of 13 pg/ml or less gave a 100% negative prediction value for heart disease. Plasma BNP concentration is a useful biochemical marker for the screening of asymptomatic patients with heart disease due to various etiologies from large population samples.

Vasodilatory effects of B-type natriuretic peptide are impaired in patients with chronic heart failure.

BACKGROUND: B-type natriuretic peptide (BNP) and atrial natriuretic peptide (ANP) are secreted from the heart and are thought to be equally important factors in the regulation of vascular tone in health and in congestive heart failure (CHF). However, no studies directly compare vasodilator effects of these peptides in healthy subjects and in patients with CHF. METHODS: Plethysmography was used to determine the vasodilatory effects of BNP and to compare these to the effects of ANP in patients with CHF (n = 15) and age-matched healthy subjects (n = 16). Graded doses of ANP and BNP (8, 16, 32, and 48 pmol/min per 100 ml of tissue volume for both) were administered randomly into the brachial artery. Forearm blood flow (FBF) was measured, and cyclic GMP (cGMP) spillover was calculated. RESULTS: Responses in FBF to both peptides in CHF were significantly lower than those of healthy subjects (BNP p < 0.05; ANP p < 0.01). Similarly, forearm spillover of cGMP was significantly lower in CHF than in healthy subjects (BNP p < 0.05; ANP p < 0.01). When vascular responses in healthy subjects were compared between BNP and ANP, BNP-induced changes in FBF (p < 0.05) and forearm cGMP spillover (p < 0.01) were significantly less than changes induced by ANP. In CHF, though, FBF change and cGMP spillover induced by the two peptides were not significantly different. CONCLUSIONS: These results suggest that the metabolism and action of these natriuretic peptides in CHF may differ from the healthy state.

Effect of the maze procedure for atrial fibrillation on atrial and brain natriuretic peptide.

We studied plasma levels of atrial and brain natriuretic peptides at rest and after exercise before and after intracardiac surgery with and without the maze procedure in patients with chronic heart failure secondary to valvular heart disease. The present study found that an increased response of both cardiac natriuretic peptides is attenuated with resulting water retention after the maze procedure.

Potent and long-lasting vasodilatory effects of adrenomedullin in humans. Comparisons between normal subjects and patients with chronic heart failure.

BACKGROUND: Adrenomedullin (ADM) is a recently discovered hypotensive peptide that has been isolated from human pheochromocytoma cells. Observations that ADM is produced from cardiovascular tissue and is found in plasma suggest that it may be important in the regulation of regional vascular resistance. METHODS AND RESULTS: Limb vascular responses to ADM were examined in 10 healthy subjects and compared with those in 18 patients with chronic heart failure (CHF). The peptide increased forearm blood flow (FBF) from 2.7 +/- 0.3 to 11.8 +/- 0.9 mL.min-1.100 mL-1 in the control group and from 2.4 +/- 0.3 to 6.5 +/- 0.7 mL.min-1.100 mL-1 in the CHF group. The ADM-induced FBF increase was significantly impaired in the CHF group (P < .01). After cessation of the infusion, an increased FBF level was sustained for > 60 minutes in the control group, whereas in the CHF group the response returned to the baseline in < 30 minutes. The ADM infusion increased forearm skin blood flow in both groups (P < .05), whereas the skin blood flow response was impaired in the CHF group (P < .01). The role of nitric oxide in ADM-induced vasorelaxation was also studied in 11 healthy subjects and 6 patients with CHF. FBF and skin blood flow responses during ADM administration were significantly attenuated by NG-monomethyl-L-arginine administration in healthy control subjects (P < .05), whereas both flow responses remained the same in the CHF group. CONCLUSIONS: These observations demonstrate that ADM exerts a potent and long-lasting vasodilatory effect on skeletal muscle arteries with involvement of nitric oxide-dependent mechanisms in normal human peripheral vasculature and that these vascular effects are significantly attenuated in patients with CHF, in part because of impaired production of nitric oxide in the forearm resistance vessels.