In-Hospital Tele-ECG Triage and Interventional Cardiologist Activation of the Infarct Team for STEMI Patients is Associated with Improved Late Clinical Outcomes.

BACKGROUND: Due to recent advances, door-to-balloon time (D2BT) has been reduced significantly for patients with ST-segment elevation myocardial infarction (STEMI). However, whether this reduction can be translated into a concrete mortality or morbidity benefit is still the subject of controversy. We conducted a before-and-after study to determine the impact of in-hospital tele-electrocardiography (ECG) triage and interventional cardiologist activation of the infarct team on D2BT and long-term clinical outcomes in STEMI patients undergoing primary percutaneous coronary intervention (PPCI). METHODS: A total of 272 consecutive patients with acute STEMI undergoing PPCI were enrolled in our study, comprising 102 tele-ECG patients and 170 conventional triage patients. Major adverse cardiovascular and cerebral vascular events (MACCE), including death, recurrent nonfatal MI, nonfatal stroke, and angina-driven target vessel revascularization were recorded during a 3-year follow-up. RESULTS: The median D2BT of the tele-ECG group was significantly shorter than control group (79 minutes vs. 109 minutes, p < 0.001). The tele-ECG triage group had a higher percentage of patients reaching the D2BT goal (< 90 minutes) (78% vs. 55%; p < 0.001). The MACCE rate was significantly lower in the Tele-ECG versus the control group (23.5% vs. 38.2%, p = 0.012). Tele-ECG group had a lower mortality rate which did not reached statistical significance (2% vs. 5.9%, p = 0.102). In multivariable Cox proportional hazards analyses, the implementation of tele-ECG triage (HR = 0.43, p = 0.003) and the presence of moderate or severe mitral regurgitation at presentation (HR = 1.87, p = 0.029) were discovered as independently associated with MACCE. CONCLUSIONS: In-hospital tele-ECG triage and interventional cardiologist activation can shorten D2BT and is associated with improved late clinical outcomes during a 3-year follow-up in STEMI patients undergoing PPCI.

Transradial versus transfemoral rotablation for heavily calcified coronary lesions in contemporary drug-eluting stent era.

BACKGROUND: Although radial access for drug-eluting stent (DES) combined with rotational atherectomy (RA) in patients with calcified coronary lesions may be associated with a lower risk of major bleeding complications and obtain favorable clinical results compared with femoral access, the long-term outcome data of this approach were limited in contemporary DES era. METHODS & RESULTS: This retrospective study sought to compare in-hospital and long-term outcomes for patients undergoing RA via the transradial (TR) and transfemoral (TF) route in 126 consecutive patients (59 radial, 67 femoral) from 2009 to 2014. TR RA procedures were performed in 44/62 (71%) by the three TR operators, compared with 15/64 (23%) by the four TF operators in the present study. Significantly smaller diameter guide catheters and burrs (1.39 ± 0.16 mm vs. 1.53 ± 0.24 mm, P = 0.001) were used in the TR group. Procedural success rates were similar in both TR and TF groups. There was a significantly less major access site bleeding complications in favor of radial artery access (2% vs. 16%, P = 0.012). The incidence of in-hospital death or myocardial infarction was low in both groups. Although a trend of lower adverse event rate was demonstrated in the TR group compared with the TF one, no statistical significance (21% vs. 27%, P = 0.135) was detected. CONCLUSIONS: Radial access, a useful alternative to femoral access for RA and DES, can be safely and successfully performed on up to 71% of the patients with heavily calcified coronary lesions needing RA by experienced TR operators.

The utilization of twelve-lead electrocardiography for predicting sudden cardiac death after heart transplantation.

BACKGROUND: Sudden cardiac death (SCD) occurs commonly after heart transplantation (HTX). The utilization of surface electrocardiography (ECG) to assess post-HTX SCD has not been investigated thoroughly. This study aimed to investigate the specific changes in surface ECG in HTX patients with SCD. METHODS: A total of 227 HTX patients (age 48 ± 14 y/o, mean donor age 34 ± 14 y/o, 173 males) were followed up regularly at the outpatient clinic. Twelve-lead ECG's were recorded during 1-2 monthly visits. Serial ECG parameters and relevant clinical data were collected and analyzed. RESULTS: During the follow-up period of 96 ± 51 months, SCD occurred in 28 (12.3%) patients. The baseline ECG parameters were comparable between patients with and without SCD. Important ECG trends of rising rest heart rates and prolongation of corrected QT (QTc) and JT (JTc) intervals were observed prior to development of SCD. After adjustment for other clinical variables, the independent predictors for SCD were older donor age (p = 0.014, OR 1.05, 95% CI 1.01-1.09), faster heart rate (p = 0.006, OR 1.06, 95% CI 1.02-1.1) and longer JTc interval (p = 0.015, OR 1.03, 95% CI 1.01-1.06). SCD occurred in 71.4% patients presenting with all three risk predictors. CONCLUSIONS: Besides older donor age, important ECG signs, including prolongation of the JTc interval and increased heart rate during post HTX follow up, could predict SCD.

Prognostic value of circulating adipokine levels and expressions of adipokines in the myocardium of patients with chronic heart failure.

BACKGROUND: The aim of this study was to ascertain whether expressions of adipokines in the myocardium or their circulating levels can provide prognostic information concerning patients with chronic heart failure (HF). METHODS AND RESULTS: Circulating levels of 3 adipokines (leptin, adiponectin, and resistin), N-terminal pro-B-type natriuretic peptide (NT-proBNP), and high-sensitivity C-reactive protein were measured in 96 patients with chronic HF. Major adverse cardiac events (MACE) involving death, heart transplantation, and hospitalization with deteriorating HF during a median follow-up period of 288 days were recorded. From that group, immunohistochemistry and Western blotting studies of the myocardial tissues were conducted on 7 patients with end-stage HF undergoing heart transplantation. The levels of the 3 adipokines significantly correlated with that of NT-proBNP; however, only adiponectin concentration increased with the severity of HF, after correction for body mass index. Cox proportional hazards analyses revealed that high levels of corrected adiponectin were predictive of the development of MACE (hazard ratio, 2.947, P=0.037). Moreover, adiponectin was significantly expressed in the myocardium, and its tissue expression positively correlated with the severity of HF. CONCLUSIONS: This study showed that adiponectin is associated with clinical outcomes and severity of HF. Further research into the precise mechanisms of these adipokine derangements in HF is important to help clarify the exact role of adipokines in the pathophysiology of HF.

The effects and underlying mechanisms of S-allyl l-cysteine treatment of the retina after ischemia/reperfusion.

PURPOSE: Retinal ischemia-associated ocular disorders are vision-threatening. The aim of the present study was to examine whether S-allyl l-cysteine (SAC) is able to protect against retina ischemia/reperfusion injury. METHODS: In vivo, retinal ischemia in the rat was induced by raising intraocular pressure (IOP) to 120 mmHg for 60 min. In vitro, an ischemic-like insult, namely oxidative stress, was established by incubating retinal ganglion cell-5 (RGC-5) with 500 µM H(2)O(2) for 24 h. The mechanisms involved in these processes were evaluated by electrophysiology, immunohistochemistry, and molecular biological approaches. RESULTS: The retinal changes caused by the high IOP were characterized by a decrease in electroretinogram b-wave amplitudes, a loss of choline acetyltransferase immunolabeling amacrine cell bodies/neuronal processes, and an upregulation of the mRNA levels of hypoxia-inducible factor-1α (HIF-1α), vascular endothelium growth factor (VEGF), and matrix metalloproteinase-9 (MMP-9). The increased protein levels of HIF-1α, VEGF, and MMP-9 were also seen in RGC-5 cells subjected to defined oxidative stress. Of clinical importance, the ischemic/ischemic-like detrimental effects were concentration-dependently (least effect at 25 µM) and/or significantly (50 and/or 100 µM) blunted when SAC was applied 15 min before retinal ischemia or ischemic-like insult, respectively. CONCLUSION: SAC would seem to protect against retinal ischemia by acting as an antioxidant and inhibiting the upregulation of HIF-1α, VEGF, and MMP-9.

Associations between endothelin-1 and adiponectin in chronic heart failure.

OBJECTIVES: Endothelin-1 (ET-1) induces cardiac hypertrophy, whereas adiponectin may elicit protective effects in the vasculature and myocardium. We therefore evaluated the relationship between plasma ET-1 and adiponectin levels in heart failure (HF) patients, and the association between adiponectin expression and ET-1-induced hypertrophy of human cardiomyocytes (HCM) in vitro. METHODS: One hundred seventeen patients with chronic HF were enrolled into this study. A group of 7 patients with end-stage HF undergoing heart transplantation was included in the histopathological study. Baseline clinical evaluations and laboratory measurements were performed. HCM cultures were studied to investigate the effect of ET-1 on cell size and adiponectin expression. RESULTS: Plasma ET-1, adiponectin, and N-terminal pro-B-type natriuretic peptide (NT-proBNP) increased with the severity of HF. Higher New York Heart Association functional class, plasma ET-1, adiponectin, and NT-proBNP levels were significant predictors of adverse outcomes in these patients. The myocardial expression of adiponectin was significantly higher in the recipient hearts of patients undergoing emergency or urgent heart transplantation. In cell culture, ET-1 significantly increased cell size and adiponectin expression in HCM. CONCLUSIONS: Adiponectin was significantly elevated in HF and was significantly associated with ET-1. The study provides a basis for further investigation of ET-1 and adiponectin modulation as a therapeutic strategy for ventricular remodeling in HF.

Massive pericardial effusion with diastolic right ventricular compression secondary to hypothyroidism in a 73-year-old woman.

Pericardial effusion is commonly seen in patients with hypothyroidism, but a massive pericardial effusion with obvious diastolic right ventricular compression is uncommon. We herein report a case of 73-year-old woman seen in the ED with generalized weakness and hypotension. Echocardiography revealed a massive pericardial effusion with diastolic right ventricular compression, and thyroid function testing revealed marked hypothyroidism. The pericardial effusion resolved after the administration of thyroid replacement therapy. This case reveals the importance of including hypothyroidism in the differential diagnosis of pericardia effusion.

Transradial approach in myocardial infarction.

OBJECTIVE: This study investigates the feasibility, efficacy, and safety of routine primary percutaneous coronary intervention via transradial approach in patients with acute ST-elevation myocardial infarction. METHODS AND RESULTS: From 2005 to 2007,122 consecutive patients with acute ST-elevation myocardial infarction within 12 hours, including those experiencing cardiogenic shock, were eligible for primary transradial PCI if the radial artery pulse could be felt. Efficacy, safety, and major adverse cardiac events regarding mortality, recurrent non-fatal myocardial infarction, and revascularization were recorded. Eighty-five of 122 patients underwent transradial PCI, and 37 had transfemoral PCI. Older women, haemodynamic instability, and the presence of severe chronic kidney disease (stages 4 and 5) or end-stage renal disease were significantly related to choice of transfemoral approach (P < 0.05). Glycoprotein IIb/IIIa inhibitors were used more often in patients who underwent transradial PCI than in those who underwent transfemoral PCI (37% vs 16%; P = 0.043). The incidence of major bleeding complications requiring blood transfusion was significantly higher in the transfemoral group (P = 0.004). A similar procedural success rate was achieved in both groups (P = 0.737). During follow-up of 580 days, the total major adverse cardiac events were similar in both groups (P = 0.299). CONCLUSIONS: Routine transradial primary PCI can be safely and successfully performed on up to 70% of acute ST-elevation myocardial infarction patients and, compared with transfemoral approach, is associated with a significantly reduced rate of major bleeding complications.

Effect of emergency department in-hospital tele-electrocardiographic triage and interventional cardiologist activation of the infarct team on door-to-balloon times in ST-segment-elevation acute myocardial infarction.

Current guidelines recommend that >75% of patients with ST-elevation myocardial infarction (STEMI) receive primary percutaneous coronary intervention (PPCI) within 90 minutes. The goal has been hardly achievable, so we conducted a 2-year before-and-after study to determine the impact of emergency department (ED) tele-electrocardiographic (tele-ECG) triage and interventional cardiologist activation of the infarct team at door-to-balloon time (D2BT) and the proportion of patients undergoing PPCI within 90 minutes since arrival. In total 105 consecutive patients with acute STEMI (mean age 62 ± 13 years, 82% men) were studied, 54 before and 51 after the change in protocol. The 51patients in the tele-ECG group underwent tele-electrocardiography at the ED and electrocardiograms were transmitted to a third-generation mobile telephone of an on-call interventional cardiologist within 10 minutes of ED arrival. The infarct team was activated and PPCI was performed by the interventional cardiologist. Fifty-four patients with acute STEMI who underwent PPCI in the year before implementation of tele-electrocardiography served as control subjects. Median D2BT of the tele-ECG group was 86 minutes, significantly shorter than the median time of 125 minutes of the control group (p <0.0001). The proportion of patients who achieved a D2BT <90 minutes increased from 44% in the control group to 76% in the tele-ECG group (p = 0.0001). In conclusion, implementation of ED tele-ECG triage and interventional cardiologist activation of the infarct team can significantly shorten D2BT and result in a larger proportion of patients achieving guideline recommendations.

Baicalein significantly protects human retinal pigment epithelium cells against H2O2-induced oxidative stress by scavenging reactive oxygen species and downregulating the expression of matrix metalloproteinase-9 and vascular endothelial growth factor.

PURPOSE: Age-related macular degeneration is a leading cause of blindness in the elderly. At a later stage, neovascular or exudative age-related macular degeneration can lead to severe central vision loss that is related to aging-associated cumulative oxidative stress of the human retinal pigment epithelium (hRPE) cells. Early prevention with antioxidants is mandatory. The aim of this study was to determine whether and how baicalein can act as an antioxidant. METHODS: The methods used included lactate dehydrogenase, 2',7'-dichloro-fluorescein diacetate, or enzyme-linked immunosorbent assay to measure cell viability, oxygen free radical levels, or the levels of vascular endothelial growth factor (VEGF)/matrix metalloproteinase-9 (MMP-9), respectively. RESULTS: H2O2 dose-dependently reduced the cell viability of hRPE cells. This negative effect was dose-dependently (with a lower effect at 20µM) and significantly counteracted by pretreatment with baicalein (50µM). Treatment with H2O2 significantly stimulated the formation of oxygen free radicals. This increase was dose-dependently and significantly blunted by baicalein. Further, treatment with a sublethal dose of H2O2 was associated with an upregulation in the levels of VEGF and MMP-9. The increases in these proteins were also dose-dependently (with a lower effect at 20µM) and significantly (50µM) blunted by pretreatment with baicalein. CONCLUSION: This study supports an antioxidative role for baicalein whereby it protects hRPE cells against H2O2-induced oxidative stress by downregulating the levels of VEGF and MMP-9, which are increased by H2O2.

Therapeutic effects and mechanisms of action of mannitol during H2O2-induced oxidative stress in human retinal pigment epithelium cells.

BACKGROUND: Age-related macular degeneration (AMD) is a leading cause of blindness in the elderly. At a later stage, neovascular or exudative AMD can lead to severe central vision loss that is related to aging-associated cumulative oxidative stress of the human retinal pigment epithelium (hRPE) and choroid capillary. Early prevention with antioxidants is mandatory. The aim of this study was to determine whether and how mannitol can act as an antioxidant. METHODS: The methods used included measurements of cell viability, oxygen free radical (OFR) levels, lipid peroxide (LP) levels, and OFR-related enzyme protein levels. RESULTS: H(2)O(2) dose-dependently reduced the cell viability of hRPE cells. This negative effect was significantly counteracted by pretreatment with mannitol (1 mM). H(2)O(2) significantly stimulated the formation of OFR and LP. These increases were dose-dependently and significantly blunted by mannitol. Furthermore, treatment with H(2)O(2) was associated with a reduction in the level of catalase, but not of manganese superoxide dismutase (MnSOD). In contrast, it was shown that mannitol protected hRPE cells against the H(2)O(2)-induced oxidative stress by increasing the level of catalase, but not the level of MnSOD. CONCLUSION: This study supports an antioxidative role for mannitol that acts through up-regulating the level of catalase, which is decreased by H(2)O(2).

Live/real time three-dimensional transthoracic echocardiographic assessment of pulmonary regurgitation.

There is no gold standard for the measurement of pulmonary regurgitation (PR) severity. Two-dimensional (2D) transthoracic echocardiography is most commonly used to quantify PR severity using color Doppler criteria for aortic regurgitation. However, this method is limited by visualization of only one or two dimensions of the proximal PR jet or vena contracta (VC) precluding accurate assessment of its shape or size. This limitation would be expected to be obviated by three-dimensional (3D) transthoracic echocardiography, which could provide a more accurate quantitative assessment of PR severity. This study evaluated 82 adult patients with PR using 2D and 3D. PR VC area by 3D was obtained by planimetry by positioning the cropping plane exactly parallel to the VC, which was viewed en face by cropping of the 3D data set. Regurgitant volumes were calculated by 2D (assuming a circular VC) and by 3D as a product of the VC and velocity time integral obtained by color Doppler-guided conventional Doppler interrogation of the PR jet.The 3D VC area correlated with 2D jet width (JW)/right ventricular outflow tract (RVOT) width (r = 0.71) and 2D VC area (r = 0.79). 3D JW/RVOT width correlated with 2D JW/RVOT (r = 0.87). 3D regurgitant volumes also correlated with 2D regurgitant volumes (r = 0.76). The 3D VC values of <0.20, 0.20-0.45, 0.46-1.15, and >1.15 cm(2) and regurgitant volumes of <15 ml, 15-50 ml, 51-115 ml, and >115 ml were effective as cutoffs for grades 1, 2, 3, and 4 PR, respectively. In conclusion, quantification of 3D VC area and regurgitant volumes correlate reasonably well with the current 2D methods for measurement of PR. Since 3D visualizes PR VC in three dimensions, it would be expected to provide a more accurate and more quantitative assessment of PR severity as compared to 2D.

Effects of moderate alcohol consumption on inflammatory biomarkers.

OBJECTIVES: Although light to moderate alcohol consumption has been associated with lower all-cause and cardiovascular (CV) mortality, the underlying mechanisms are only partly understood. Evidence has emerged in recent years that atherosclerosis is an inflammatory disease. We hypothesize that beneficial effects of moderate alcohol consumption on CV mortality may be linked to antiinflammatory effects. METHODS AND RESULTS: The association between alcohol consumption and concentrations of high sensitivity C-reactive protein (hs-CRP) and fibrinogen were investigated. Six hundred and thirtysix eligible individuals apparently healthy were included. 393 (61.8%) were men and 243 (38.2%) were women. The mean ages for men and women were 51.5 +/- 12.4 y and 50.8 +/- 12.1 y, respectively. Daily alcohol intake showed an apparent U-shaped association with hs-CRP and fibrinogen values in men, with lowest levels at an alcohol intake of 20-70 g daily (0.139 +/- 0.116 mg/dl for hs-CRP and 274 +/- 51.7 mg/dl for fibrinogen). Proportional odds model analysis showed moderate alcohol consumption (20 to 70 g vs. no drinking per day, OR = 0.32, 95% CI: 0.14-0.74), and regular exercise (> or = 3 times/week vs. no, OR = 0.52, 95% CI: 0.35-0.77) were negatively correlated with elevated hs-CRP values. CONCLUSIONS: Our results parallel the demonstration of a U-shaped relationship between alcohol consumption and cardiovascular mortality, and suggest that anti-inflammatory effects of moderate alcohol intake may partly be linked to a low cardiovascular and overall mortality.

Live/real time three-dimensional transthoracic echocardiographic assessment of left ventricular volumes, ejection fraction, and mass compared with magnetic resonance imaging.

Due to reliance upon geometric assumptions and foreshortening issues, the traditionally utilized transthoracic two-dimensional echocardiography (2DTTE) has shown limitations in assessing left ventricular (LV) volume, mass, and function. Cardiac magnetic resonance imaging (MRI) has shown potential in accurately defining these LV characteristics. Recently, the emergence of live/real time three-dimensional (3D) TTE has demonstrated incremental value over 2DTTE and comparable value with MRI in assessing LV parameters. Here we report 58 consecutive patients with diverse cardiac disorders and clinical characteristics, referred for clinical MRI studies, who were evaluated by cardiac MRI and 3DTTE. Our results show good correlation between the two modalities.

Increased endothelial monocyte adhesiveness is related to clinical outcomes in chronic heart failure.

BACKGROUND: Vascular inflammation and endothelial dysfunction are evident in patients with chronic heart failure (CHF). We hypothesized that circulating peripheral blood mononuclear cells (PBMCs) may be activated and the resultant increased endothelial monocyte adhesion may be functionally and pathophysiologically relevant in CHF. In the present study, we investigated the clinical significance of the activity of PBMCs in patients with CHF. METHODS: PBMCs were isolated from 34 CHF patients, from 10 healthy volunteers (normal control group) and from 17 patients admitted for investigation of suspected coronary artery disease (disease control group). In each patient, the adhesiveness of PBMCs to cultured human aortic endothelial cells (HAECs) with or without tumor necrosis factor-alpha (TNF-alpha) stimulation was determined. Major adverse cardiac events (death, heart transplantation or hospitalization with worsening heart failure) were determined in the 34 CHF patients during a median follow-up period of 182 days. RESULTS: Compared with those from both control groups and from mild CHF patients, PBMCs isolated from severe CHF patients adhered more to the HAECs. The endothelial adhesiveness of PBMCs correlated positively with the circulating levels of CAMs and can supply prognostic information in CHF patients. The difference between event-free curves based on the median levels of endothelial-PBMC adhesion was significant (log rank test, p=0.0139). CONCLUSIONS: Endothelial adhesiveness of PBMCs is increased and correlated to clinical outcomes, and may be pathophysiologically relevant to the progression of CHF.

Usefulness of live/real time three-dimensional transthoracic echocardiography in the identification of individual segment/scallop prolapse of the mitral valve.

In this report, we present 34 patients in whom surgical intervention was undertaken for severe mitral insufficiency due to mitral valve prolapse (MVP). Location and severity of MVP and regurgitation were assessed preoperatively by live/real time three-dimensional transthoracic echocardiography and closely agreed with the surgical findings.