Acute Coronary Syndromes Among Patients with Prior Coronary Artery Bypass Surgery.

PURPOSE OF REVIEW: Acute coronary syndromes (ACS) often occur in individuals with prior coronary artery bypass graft surgery (CABG). Our goal was to describe the prevalence, clinical characteristics, prognosis, and treatment strategies in this group of patients. RECENT FINDINGS: Studies demonstrate that both acute and long-term major adverse cardiovascular outcomes are increased in patients with ACS and prior CABG compared to those without CABG. Much of this risk is attributed to the greater comorbid conditions present in patients with prior CABG. Data regarding optimal management of ACS in patients with prior CABG are limited, but most observational studies favor an early invasive approach for treatment. Native vessel percutaneous coronary intervention (PCI), if feasible, is generally preferred to bypass graft PCI. Patients with ACS and prior CABG represent a high-risk group of individuals, and implementing optimal preventive and treatment strategies are critically important to reduce the risk.

Common genetic variants associated with obesity in an African-American and Hispanic/Latino population.

INTRODUCTION: Over 35% of all adults in the world are currently obese and risk of obesity in racial or ethnic minority groups exist in the US, but the causes of these differences are not all known. As obesity is a leading cause of cardiovascular disease, an improved understanding of risk factors across racial and ethnic groups may improve outcomes. OBJECTIVE: The objective of this study was to determine if susceptibility to obesity is associated with genetic variation in candidate single nucleotide polymorphisms (SNPs) in African Americans and Hispanic/Latinos. MATERIALS AND METHODS: We examined data from 534 African Americans and 557 Hispanic/Latinos participants from the UIC Cohort of Patients, Family and Friends. Participants were genotyped for the top 26 obesity-associated SNPs within FTO, MC4R, TUB, APOA2, APOA5, ADIPOQ, ARL15, CDH13, KNG1, LEPR, leptin, and SCG3 genes. RESULTS: The mean (SD) age of participants was 49±13 years, 55% were female, and mean body mass index (BMI) was 31±7.5 kg/m2. After adjusting for age and sex, we found that rs8050136 in FTO (odds ratio [OR] 1.40, 95% confidence interval [CI] 1.1-1.8; P = 0.01) among African Americans and rs2272383 in TUB (OR 1.34, 95% CI 1.04-1.71; P = 0.02) among Hispanic/Latinos were associated with obesity. However, none of the SNPs in multivariable analysis of either AA or H/L cohorts were significant when adjusted for multiple correction. CONCLUSIONS: We show that candidate SNPs in the FTO and TUB genes are associated with obesity in African Americans and Hispanic/Latinos individuals respectively. While the underlying pathophysiological mechanisms by which common genetic variants cause obesity remain unclear, we have identified novel therapeutic targets across racial and ethnic groups.

Left Ventricular Velocity of Propagation: A Useful Non-Invasive Measurement When Assessing Hemodynamic Alterations in Pulmonary Arterial Hypertension.

BACKGROUND: Left ventricular (LV) velocity of propagation (Vp) has been shown to be inversely related to the LV relaxation time constant. We sought to examine Vp from a group of chronic pulmonary hypertension (cPH) patients and compare these values to Vp obtained in normal individuals and patients with known LV diastolic dysfunction (LVDD). METHODS: Echo-Doppler data and Vp measurements were retrospectively collected from all patients. The studied population was divided into four groups. Group I comprised of 15 patients with normal LV diastole, group II included 27 patients with stage 1 LVDD, group III was made up of 27 patients with stage 2 LVDD, and group IV included 66 patients with cPH. RESULTS: In the cPH population studied, patients had smaller end-diastolic LV cavities with the highest Vp values but their early mitral inflow to Vp ratios were not different from healthy controls. In addition, Vp values and pulmonary wedge capillary pressures were significantly associated in patients with LV dysfunction or pulmonary hypertension (P < 0.01). CONCLUSIONS: LVVp might be a useful non-invasive measurement to be routinely obtained in cPH patients as it probably not only reflects the compressive forces being exerted on the LV, known to increase Vp, but also might be quite useful for the non-invasive assessment of pulmonary capillary wedge pressures in these patients.

Left Ventricular Diastolic Function Assessment of a Heterogeneous Cohort of Pulmonary Arterial Hypertension Patients.

BACKGROUND: Pulmonary arterial hypertension (PAH) is known to trigger right ventricular (RV) remodeling that might compromise left ventricular (LV) filling due to inter-ventricular interdependence. In this study, we aimed to examine standard echocardiographic measurements of LV diastolic function in PAH patients. METHODS: In this retrospective study, we identified clinical as well as complete echocardiographic data from 128 chronic PAH patients to fully assess LV diastolic dysfunction (LVDD) using standard recommended Doppler guidelines. Accordingly, patients were divided into three groups: LVDD 0, LVDD 1 and LVDD 2. RESULTS: The mean age of the studied population was 57 ± 14 years with a mean pulmonary artery systolic pressure (PASP) of 55 ± 21 mm Hg. A total of 36% of the study patients had normal LV diastolic function. However, 64% had LVDD with LVDD stage 1 being the most common (48%). In terms of echocardiographic data, significant differences were found among the three LVDD groups in regards to PASP, LV end systolic and diastolic volumes, tricuspid annular plane systolic excursion, right ventricular fractional area change as well as many other tissue Doppler imaging parameters. Finally, just age and PASP were predictors of abnormal LV diastolic function (P < 0.05). CONCLUSIONS: Impaired relaxation is a common abnormality in PAH patients. Additional studies are warranted to determine whether LVDD alters prognosis or is related to changes in the symptomatic profile of this group of patients.

Ularitide: a natriuretic peptide candidate for the treatment of acutely decompensated heart failure.

Treatment for acutely decompensated heart failure (ADHF) has not changed much in the last two decades. Currently available therapies have variable efficacy and can be associated with adverse outcomes. Natriuretic peptides properties include diuresis, natriuresis, vasorelaxation, inhibition of renin-angiotensin-aldosterone system, and are thus chosen in the treatment of ADHF. Two forms of natriuretic peptides are currently available for the treatment of ADHF. Urodilatin (INN: ularitide) represents another member of the natriuretic peptide family with a unique molecular structure that may provide distinct benefits in the treatment of ADHF. Early clinical exploratory and Phase II studies have demonstrated that ularitide has potential cardiovascular and renal benefits. Ularitide is currently being tested in the Phase III TRUE-AHF clinical study. TRUE-AHF has features that may be different when compared with other recent outcome studies in ADHF. These distinct differences aim to maximize clinical effects and minimize potential adverse events of ularitide. However, whether this rationale translates into a better outcome needs to be awaited.

Importance of End-Diastolic Rather than End-Systolic Right Atrial Size in Chronic Pulmonary Hypertension.

BACKGROUND: Right atrial (RA) enlargement has been associated with worse clinical outcomes in chronic pulmonary hypertension (cPH) patients. Even though current guidelines only recommend measurement of RA dimensions at the end of ventricular systole in these patients, there is paucity of information regarding the potential utility of RA dimensions obtained at the end of ventricular diastole. METHODS: In this retrospective study, standard echocardiographic data were collected from 80 studies. The population studied was divided into Group I that consisted of 35 patients (52 ± 10 years) without PH while Group II included 45 patients (56 ± 14 years; P = 0.2) with cPH. RA measurements were obtained not only at the end of ventricular systole, but also at the end of ventricular diastole to determine which RA measurement was more indicative of abnormal right ventricular afterload. RESULTS: Even though all RA measurements were abnormal, RA area (>8.4 cm(2) ) measured at the end of ventricular diastole was the most useful RA variable to identify cPH patients with elevated pulmonary pressures (P < 0.0001) and with an abnormal pulmonary vascular resistance (P = 0.001). CONCLUSIONS: Based on these results, it appears that isolated RA measurements made at the end of ventricular systole are insufficient to fully explain the hemodynamic load of cPH. Additional studies are now required to determine whether sequential monitoring of the composite change in RA dimensions that occur throughout the cardiac cycle over time correlates better with response to vasodilator therapy and overall clinical outcomes.