Spontaneous coronary hematoma during systemic thrombolysis for acute myocardial infarction: intracoronary ultrasound findings, percutaneous coronary intervention and complications.

A case of coronary dissection with large parietal hematoma, involving the proximal left anterior descending and the left main coronary arteries after systemic thrombolysis for acute anterior myocardial infarction is described. The peculiar intravascular ultrasound features, therapy options, complications after stenting and follow-up are described.

Microalbuminuria predicts cardiovascular events and renal insufficiency in patients with essential hypertension.

BACKGROUND: Some patients with essential hypertension manifest greater than normal urinary excretion of albumin (UAE). Authors of a few retrospective studies have suggested that there is an association between microalbuminuria and cardiovascular risk. OBJECTIVE: To evaluate whether microalbuminuria is associated with a greater than normal risk of cardiovascular and renal events. METHODS: We performed a retrospective cohort analysis of 141 hypertensive individuals followed up for approximately 7 years. Hypertensive patients were defined as having microalbuminuria if the baseline average UAE of three urine collections was in the range 30-300 mg/24 h. RESULTS: Fifty-four patients had microalbuminuria and 87 had normal UAE. At baseline, the two groups were similar for age, weight, blood pressure, and rate of clearance of creatinine. Serum levels of cholesterol, triglycerides, and uric acid in patients with microalbuminuria were higher than levels in those with normal UAE, whereas levels of high-density lipoprotein cholesterol in patients with microalbuminuria were lower than levels in patient with normal UAE. During follow-up, 12 cardiovascular events occurred among the 54 (21.3%) patients with microalbuminuria and only two such events among the 87 patients with normal UAE (P < 0.0002). Stepwise logistic regression analysis showed that UAE (P = 0.003), cholesterol level (P = 0.047) and diastolic blood pressure (P = 0.03) were independent predictors of the cardiovascular outcome. Rate of clearance of creatinine from patients with microalbuminuria decreased more than did that from those with normal UAE (decrease of 12.1 +/- 2.77 versus 7.1 +/- 0.88 ml/min, P < 0.03). CONCLUSIONS: This study suggests that hypertensive individuals with microalbuminuria manifest a greater incidence of cardiovascular events and a greater decline in renal function than do patients with normal UAE.

Increased thickness of the carotid artery in patients with essential hypertension and microalbuminuria.

In patients with essential hypertension, the presence of microalbuminuria carries an increased risk for cardiovascular morbidity and mortality. The mechanisms responsible for this association are not clear. Microalbuminuria could signal the presence of generalised atherosclerosis. To determine the extent of atherosclerosis, we measured by B-mode ultrasound imaging the thickness of the intima and media layers of the carotid artery in 30 hypertensive patients with microalbuminuria, 30 patients without microalbuminuria and 30 normotensive healthy subjects. In hypertensive patients with microalbuminuria, urinary albumin excretion (55 +/- 4.7 mg/24 h) was greater (P < 0.01) than in patients without microalbuminuria (12 +/- 0.9 mg/24 h) and in healthy subjects (7.1 +/- 0.52 mg/24 h). In hypertensive patients with microalbuminuria, the thickness of the carotid artery (0.78 +/- 0.02 mm) was greater (P < 0.01) than in patients without microalbuminuria (0.69 +/- 0.01 mm) and in healthy subjects (0.64 +/- 0.02 mm). In hypertensive patients with microalbuminuria, the mean insulin area-under-the curve (59,703 +/- 4,874 pmol/L x 2 h) and glucose area-under-the curve (928 +/- 40.0 mmol/L x 2 h) were significantly greater (P < 0.005) than in patients without microalbuminuria (38,774 +/- 4,104 pmol/L x 2 h and 803 +/- 34.7 mmol/L x 2 h, respectively), and in normotensive healthy subjects (27,557 +/- 2563 pmol/L x 2 h and 837 +/- 31.2 mmol/L x 2 h, respectively). Serum levels of total cholesterol, triglycerides and lipoprotein(a) were higher in hypertensives with than in those without microalbuminuria. The thickness of the carotid artery was significantly correlated with microalbuminuria, blood pressure, cholesterol, serum triglycerides and insulin area-under-the curve. In conclusion, this study shows that hypertensive patients with microalbuminuria have an increased thickness of the carotid intima and media layers suggesting a greater degree of atherosclerosis. Measurements of urinary albumin excretion may be important in the evaluation of patients with essential hypertension.

Microalbuminuria in salt-sensitive patients. A marker for renal and cardiovascular risk factors.

We previously showed that a high salt diet increases glomerular capillary pressure in salt-sensitive hypertensive patients and suggested that this may underlie the greater propensity of these patients to develop renal failure. Because microalbuminuria is considered an initial sign of renal damage, we have tested whether salt-sensitive patients display greater urinary albumin excretion than salt-resistant hypertensive patients. Twenty-two patients were placed on a low sodium intake (20 mEq/d) for 7 days followed by a high sodium diet (250 mEq/d) for 7 more days. Twelve patients were classified as salt sensitive and 10 as salt resistant. Urinary albumin excretion was greater in salt-sensitive than salt-resistant patients (54 +/- 11 versus 22 +/- 5 mg/24 h, P < .01). During the low sodium diet, glomerular filtration rate, renal plasma flow, and filtration fraction were similar between the two groups. During the high sodium intake, glomerular filtration, renal plasma flow, filtration fraction, and calculated intraglomerular pressure did not change in salt-resistant patients; in salt-sensitive patients, however, renal plasma flow decreased, and filtration fraction and intraglomerular pressure increased, whereas glomerular filtration rate did not change. Urinary albumin excretion was significantly correlated with glomerular capillary pressure. Salt-sensitive patients displayed higher serum levels of low-density lipoprotein cholesterol and lipoprotein(a) and lower levels of high-density lipoprotein cholesterol than salt-resistant patients. These studies have shown greater urinary albumin excretion and serum concentrations of atherogenic lipoproteins in salt-sensitive than in salt-resistant hypertensive patients, suggesting that salt sensitivity may be a marker for greater risk of renal and cardiovascular complications.

Long-term effects of a converting enzyme inhibitor and a calcium channel blocker on urinary albumin excretion in patients with essential hypertension.

Microalbuminuria in patients with essential hypertension is associated with increased incidence of cardiovascular morbidity and mortality. Reduction of urinary albumin excretion (UAE) with therapy could reduce cardiovascular events. The long-term effect of commonly used antihypertensive agents on UAE has not been properly investigated. In the present study, we have prospectively studied the effects of therapy for 24 months with a converting enzyme inhibitor, enalapril, or a calcium channel blocker, nicardipine, on UAE in 40 patients with essential hypertension and microalbuminuria. Enalapril and nicardipine were equally effective in reducing arterial pressure. However, enalapril decreased UAE from 77.1 +/- 10.4 to 30.4 +/- 7.9 mg/24 h after 1 year, and to 24.7 +/- 4.8 (P < .01) after 2 years of therapy. UAE however, did not change in patients treated with nicardipine (from 65.2 +/- 12 to 73 +/- 14 after 1 year, and to 52.7 +/- 21 mg/24 h after 2 years of therapy). The impact of reducing UAE on overall cardiovascular morbidity and mortality and on future progression of renal failure in patients with essential hypertension remains to be established.