Ethyl gallate isolated from phenol-enriched fraction of Caesalpinia mimosoides Lam. Promotes cutaneous wound healing: a scientific validation through bioassay-guided fractionation.

The tender shoots of Caesalpinia mimosoides Lam. are used ethnomedically by the traditional healers of Uttara Kannada district, Karnataka (India) for the treatment of wounds. The current study was aimed at exploring phenol-enriched fraction (PEF) of crude ethanol extract of tender shoots to isolate and characterize the most active bio-constituent through bioassay-guided fractionation procedure. The successive fractionation and sub-fractionation of PEF, followed by in vitro scratch wound, antimicrobial, and antioxidant activities, yielded a highly active natural antioxidant compound ethyl gallate (EG). In vitro wound healing potentiality of EG was evidenced by a significantly higher percentage of cell migration in L929 fibroblast cells (97.98 ± 0.46% at 3.81 µg/ml concentration) compared to a positive control group (98.44 ± 0.36%) at the 48th hour of incubation. A significantly higher rate of wound contraction (98.72 ± 0.41%), an elevated tensile strength of the incised wound (1,154.60 ± 1.42 g/mm2), and increased quantity of connective tissue elements were observed in the granulation tissues of the 1% EG ointment treated animal group on the 15th post-wounding day. The accelerated wound healing activity of 1% EG was also exhibited by histopathological examinations through Hematoxylin and Eosin, Masson's trichome, and Toluidine blue-stained sections. Significant up-regulation of enzymatic and non-enzymatic antioxidant contents (reduced glutathione, superoxide dismutase, and catalase) and down-regulation of oxidative stress marker (lipid peroxidation) clearly indicates the effective granular antioxidant activity of 1% EG in preventing oxidative damage to the skin tissues. Further, in vitro antimicrobial and antioxidant activities of EG supports the positive correlation with its enhanced wound-healing activity. Moreover, molecular docking and dynamics for 100 ns revealed the stable binding of EG with cyclooxygenase-2 (-6.2 kcal/mol) and matrix metalloproteinase-9 (-4.6 kcal/mol) and unstable binding with tumor necrosis factor-α (-7.2 kcal/mol), suggesting the potential applicability of EG in inflammation and wound treatment.

Attenuation of dermal wounds through topical application of ointment containing phenol enriched fraction of Caesalpinia mimosoides Lam.

Caesalpinia mimosoides Lam. is one of the important medicinal plants used by the traditional healers of Uttara Kannada district, Karnataka (India) for treating wounds. In our previous study ethanol extract of the plant was evaluated for its wound healing activity. In continuation, the present study was aimed to evaluate the phenol enriched fraction (PEF) of ethanol extract for wound healing activity along with its antioxidant, anti-inflammatory and antimicrobial properties. The potent wound healing activity of PEF was evidenced by observation of increased rate of cell migration in L929, 3T3L1 and L6 cells (92.59 ± 1.53%, 98.42 ± 0.82% and 96.63 ± 0.61% respectively) at 7.81 µg/ml doses in assays carried out in vitro. Significantly enhanced rate of wound contraction (97.92 ± 0.41%), tensile strength (973.67 ± 4.43 g/mm2), hydroxyproline (31.31 ± 0.64 mg/g) and hexosamine (8.30 ± 0.47 mg/g) contents were observed on 15th post wounding day in 5% PEF treated animals. The enzymatic and non-enzymatic cellular antioxidants (superoxide dismutase, catalase and reduced glutathione) were upregulated (15.89 ± 0.17 U/mg, 48.30 ± 4.60 U/mg and 4.04 ± 0.12 µg/g respectively) with the administration of 5% PEF. The significant antimicrobial, antioxidant and anti-inflammatory activities support the positive correlation of PEF with its enhanced wound healing activity. PEF contains expressive amounts of total phenolic and total flavonoid contents (578.28 ± 2.30 mg GAE/g and 270.76 ± 2.52 mg QE/g). Of the various chemicals displayed in RP-UFLC-DAD analysis of PEF, gallic acid (68.08 µg/mg) and ethyl gallate (255.91 µg/mg) were predominant. The results indicate that PEF has great potential for the topical management of open wounds.

G6PD A- is the major cause of G6PD deficiency among the Siddis of Karnataka, India.

Background: Glucose-6-phosphate dehydrogenase (G6PD) deficiency is the most common human erythroenzymopathy affecting more than 400 million people worldwide. G6PD deficiency was reported in India more than 50 years ago and the prevalence rate varies from 5.7% to 27.9% in different caste and tribal groups.Aim: To study the prevalence of, and the mutations causing, G6PD deficiency among the Siddis of Karnataka.Subjects and methods: A total of 755 individuals were screened using the DPIP dye decolorisation method and the deficiency was further confirmed by quantitative assay. Molecular characterisation was performed by PCR-RFLP method and DNA sequencing. Biochemical characterisation was performed as per WHO criteria.Results: Of the 755 individuals, 71 individuals (9.4%) were found to be G6PD deficient with an enzyme activity ranging from 0.02 to 3.83 IU/gm Hb. Mutational analysis could be performed on 49 G6PD deficient individuals and 45 (91.8%) of them showed the presence of the G6PD A- variant while the remaining 4 (8.2%) had the G6PD Kerala-Kalyan mutation. Microsatellite analysis in G6PD A- individuals showed the presence of 166/195 bp, AC/CTT alleles.Conclusions: G6PD deficiencies among the Siddis are predominantly due to G6PD A- mutation. Furthermore, biochemical parameters and the microsatellite repeat markers in the Siddi A- chromosome confirmed they are African descendants with Indian admixture.

Evaluation of wound healing property of Caesalpinia mimosoides Lam.

ETHNOPHARMACOLOGICAL RELEVANCE: Caesalpinia mimosoides Lam. is one of the important traditional folk medicinal plants in the treatment of skin diseases and wounds used by healers of Uttara Kannada district of Karnataka state (India). However scientific validation of documented traditional knowledge related to medicinal plants is an important path in current scenario to fulfill the increasing demand of herbal medicine. AIM OF THE STUDY: The study was carried out to evaluate the claimed uses of Caesalpinia mimosoides using antimicrobial, wound healing and antioxidant activities followed by detection of possible active bio-constituents. MATERIALS AND METHODS: Extracts prepared by hot percolation method were subjected to preliminary phytochemical analysis followed by antimicrobial activity using MIC assay. In vivo wound healing activity was evaluated by circular excision and linear incision wound models. The extract with significant antimicrobial and wound healing activity was investigated for antioxidant capacity using DPPH, nitric oxide, antilipid peroxidation and total antioxidant activity methods. Total phenolic and flavonoid contents were also determined by Folin-Ciocalteu, Swain and Hillis methods. Possible bio-active constituents were identified by GC-MS technique. RP-UFLC-DAD analysis was carried out to quantify ethyl gallate and gallic acid in the plant extract. RESULTS: Preliminary phytochemical analysis showed positive results for ethanol and aqueous extracts for all the chemical constituents. The ethanol extract proved potent antimicrobial activity against both bacterial and fungal skin pathogens compared to other extracts. The efficacy of topical application of potent ethanol extract and traditionally used aqueous extracts was evidenced by the complete re-epithelization of the epidermal layer with increased percentage of wound contraction in a shorter period. However, aqueous extract failed to perform a consistent effect in the histopathological assessment. Ethanol extract showed effective scavenging activity against DPPH and nitric oxide free radicals with an expressive amount of phenolic and moderate concentration of flavonoid contents. Ethyl gallate and gallic acid were found to be the probable bio-active compounds evidenced by GCMS and RP-UFLC-DAD analysis. CONCLUSION: The study revealed the significant antimicrobial, wound healing and antioxidant activities of tender parts of C. mimosoides and proved the traditional folklore knowledge.

Clozapine-induced myocarditis: recognizing a potentially fatal adverse reaction.

A 46-year-old man with a history of paranoid schizophrenia was admitted with a recurrence of psychotic symptoms. Improvement was noted after the initiation of clozapine. After 2 weeks of clozapine therapy, chest pressure and abnormal cardiac biomarkers (in the presence of a normal coronary angiogram) raised suspicion of myocarditis. That diagnosis was confirmed by means of cardiac magnetic resonance imaging. Discontinuation of the clozapine led to resolution of the cardiac symptoms. Clozapine-induced myocarditis is rare and can be missed for lack of specific clinical findings. In order to prevent disease progression and a possibly fatal outcome, early recognition of the condition and prompt discontinuation of clozapine are necessary.

Comparing stress testing and fractional flow reserve to evaluate presence, location and extent of ischemia in coronary artery disease.

BACKGROUND: FFR provides an accurate and reproducible assessment of the functional severity of coronary stenosis. Whereas stress testing remains the preferred initial modality for assessment of ischemia, there is limited data comparing it with FFR. We sought to determine the correlation between cardiac stress testing and coronary fractional flow reserve (FFR) measurement for assessing the presence, location, and burden of myocardial ischemia in patients referred for evaluation of coronary artery disease (CAD). METHODS: Over 5-year study period, of the 5420 consecutive coronary angiograms that were screened, 326 patients had FFR measurements. Of these, 96 patients with FFR measurements who had a preceding stress test (stress echocardiography [SE] or myocardial perfusion imaging [MPI]) within a year were included. RESULTS: Of the 96 patients, there were 46 (48%) men and 50 (52%) women with a mean age of 61 ± 10 years. SE was performed in 57 (59.3%) and MPI in 32 (40.7%) of patients. FFR was ≤0.79 in 54 (56%) patients. Stress testing had low sensitivity (55%) and specificity (47%) compared to FFR. The concordance between FFR and stress testing was low for both presence (k=0.03) and location (k=0.05) of the ischemic territory. The number of ischemic vascular territories was correctly estimated in only 39% of the stress tests. SE was more likely to overestimate and MPI more likely to underestimate extent of ischemia. CONCLUSIONS: In patients referred for evaluation of CAD, there was poor correlation between stress testing and FFR. A prospective study comparing these two modalities with FFR is needed.

Myocardial ischemia in a patient with peripheral vascular disease, an arteriovenous fistula, and patent coronary artery bypass grafts.

Patients with coronary artery disease often have concurrent peripheral vascular disease. The presence of concurrent vascular pathologies can pose unique challenges among patients who have undergone coronary artery bypass grafting utilizing the left internal mammary artery. We describe a patient with peripheral vascular disease and prior history of coronary artery bypass grafting, who presented with recurrent anginal symptoms and an abnormal stress test despite the absence of significant residual unrevascularized coronary artery disease. Additional evaluation led to the identification of an ipsilateral severe subclavian stenosis with a concomitant ipsilateral upper extremity arteriovenous fistula. Patient's symptoms resolved with the treatment of the underlying vascular lesions.

Reverse Takotsubo cardiomyopathy: a story of a critically ill man with transient cardiac dysfunction.

Reverse Takotsubo cardiomyopathy (TCM) is a recently described variant of classic TCM. In contrast to classic TCM, the regional wall motion abnormalities are localized in the basal segments. The condition can be triggered by acute stressful events, including acute medical illnesses. The wall motion abnormalities and left ventricular dysfunction are usually completely reversible. We present a case of an 84-year-old man with a complicated postoperative course after laparoscopic cholecystectomy with multiple laparotomies and recurrent sepsis. Echocardiographic evaluation demonstrated left ventricular dysfunction and wall motion abnormalities in a pattern resembling reverse TCM. He had no significant coronary disease on angiography and follow-up echocardiography showed complete resolution of left ventricular systolic dysfunction and regional wall motion abnormalities.

Clinical and economic studies of eptifibatide in coronary stenting.

Platelet adhesion and aggregation at the site of coronary stenting can have catastrophic clinical and economic consequences. Therefore, effective platelet inhibition is vital during and after percutaneous coronary intervention. Eptifibatide is an intravenous antiplatelet agent that blocks the final common pathway of platelet aggregation and thrombus formation by binding to glycoprotein IIb/IIIa receptors on the surface of platelets. In clinical studies, eptifibatide was associated with a significant reduction of mortality, myocardial infarction, or target vessel revascularization in patients with acute coronary syndrome undergoing percutaneous coronary intervention. However, recent trials conducted in the era of dual antiplatelet therapy and newer anticoagulants failed to demonstrate similar results. The previously seen favorable benefit of eptifibatide was mainly offset by the increased risk of bleeding. Current American College of Cardiology/American Heart Association guidelines recommend its use as an adjunct in high-risk patients who are undergoing percutaneous coronary intervention with traditional anticoagulants (heparin or enoxaparin), who are not otherwise at high risk of bleeding. In patients receiving bivalirudin (a newer safer anticoagulant), routine use of eptifibatide is discouraged except in select situations (eg, angiographic complications). Although older pharmacoeconomic studies favor eptifibatide, in the current era of P2Y12 inhibitors and newer safer anticoagulants, the increased costs associated with bleeding make the routine use of eptifibatide an economically nonviable option. The cost-effectiveness of eptifibatide with the use of strategies that decrease the bleeding risk (eg, transradial access) is unknown. This review provides an overview of key clinical and economic studies of eptifibatide well into the current era of potent antiplatelet agents, novel safer anticoagulants, and contemporary percutaneous coronary intervention.

Right ventricular myocardial performance index derived from tissue Doppler echocardiography is useful in differentiating apical ballooning syndrome from cardiomyopathy due to left anterior descending coronary artery disease.

BACKGROUND: Apical ballooning syndrome (ABS) and obstructive coronary artery disease of the left anterior descending coronary artery (LAD) can both result in similar left ventricular apical wall motion abnormalities. The right ventricle may more likely be involved in ABS, and its careful evaluation may help differentiate the two conditions. Therefore, the aim of this study was to determine the roles of echocardiographic measures of right ventricular (RV) function, namely, Doppler tissue imaging-derived RV index of myocardial performance (RIMP), RV basal free wall systolic excursion velocity (RV S'), and tricuspid annular plane systolic excursion, in differentiating ABS from obstructive LAD disease. METHODS: A total of 80 patients with new extensive apical left ventricular wall motion abnormalities on echocardiography who underwent coronary angiography were identified retrospectively. Patients with insufficient echocardiographic data were excluded (n = 17). Admission clinical and echocardiographic data were compared between patients with obstructive disease of the LAD (LAD group; n = 46) and those with normal coronary arteries (ABS group; n = 17). RESULTS: The ABS group had significantly greater RIMP (1.03 ± 0.22 vs 0.44 ± 0.18, P < .001). In predicting ABS, RIMP > 0.74 had sensitivity of 94%, specificity of 94%, positive predictive value of 84%, and negative predictive value of 98%, with excellent discriminatory ability (area under the receiver operating characteristic curve, 0.96 ± 0.03). Other measures of RV function (i.e., tricuspid annular plane systolic excursion and RV S') were similar between the two groups. CONCLUSIONS: Doppler tissue imaging-derived RIMP may help differentiate ABS from obstructive LAD disease with high accuracy. This easily obtainable measurement may offer a noninvasive tool to differentiate these two conditions.

Recognizing cardiac syncope in patients presenting to the emergency department with trauma.

BACKGROUND: Cardiac syncope is associated with poor outcomes and may result in traumatic injuries. In patients presenting to the emergency department (ED) with trauma, recognizing the cause of syncope is particularly challenging. Also, clinical markers to identify cardiac syncope are not well established. STUDY OBJECTIVES: We sought to evaluate clinical markers that could identify cardiac syncope in patients with traumatic falls derived from a large urban trauma database. METHODS: All patients presenting to the ED during a 10-year study period with a traumatic fall were identified retrospectively. The subset of patients with syncope was ascertained by chart review and defined as cardiac syncope (e.g., presence of dysrhythmia, valvular abnormality), non-cardiac syncope (e.g., vasovagal, neurological), or syncope of unknown cause. RESULTS: Of the 5420 patients with traumatic falls, 180 (3.3%) patients with syncope were identified. Among the 180 patients with syncope, the cause was identified as cardiac in 24 (13%), noncardiac in 58 (32%), and unknown in 98 (54%). Three independent predictors (i.e., risk factors) of cardiac syncope were identified: age >65 years, presence of coronary artery disease, and pathological Q waves. Presence of at least one risk factor accurately predicted cardiac syncope in this population, with a sensitivity of 100%, a specificity of 43%, and a negative predictive value of 100% (area under the receiver operating characteristic curve: 0.80 ± 0.04). CONCLUSION: In patients with traumatic falls and syncope, simple clinical and electrocardiographical variables may identify patients with cardiac causes of syncope. Proper identification of cardiac syncope in this population can potentially prevent recurrence of life-threatening traumatic injury.

Ethnomedicinal plants to cure skin diseases-an account of the traditional knowledge in the coastal parts of Central Western Ghats, Karnataka, India.

ETHNOPHARMACOLOGICAL RELEVANCE: Documentation of ethnomedicinal knowledge pertaining to the treatment of different types of skin diseases from the Central Western Ghats of India, a rich habitat of different ethnic communities. MATERIALS AND METHODS: Frequent field surveys were carried out to invent the 'key informants' in the treatment of skin diseases in the study area. The information was collected through semi-structured open ended interviews with questionnaire in their local Kannada language. All medicinal plants recorded for the treatment of skin diseases were photographed in the field; voucher specimens were made subsequently and are deposited in the Herbarium, P.G. Department of Botany, Karnatak University, Dharwad. The information such as botanical name, status, family, vernacular name, habit and habitat, analysis like percentage of parts used, percentage of drug preparations, use value (UV), informants consensus factor (ICF), fidelity level (FL) and correlation between UV and use mention (Np) of the plants are provided. RESULTS: In all, 48 informants were interviewed. Amongst which 38 were the 'key informants' who gave the information exclusively about the treatment of skin diseases. Among 102 plant species collected, seven species are endemic to India and eleven species have their nativity outside India. Twelve species could be considered as new claims for skin diseases as their use has not been mentioned in Ayurveda or any other research articles surveyed. Of all the drug formulations, paste is the most preferred method (50%) followed by oil extraction (18.89%), juice (14.44%), ash (4.44%) etc. The highest UV is for Pongamia pinnata, Naregamia alata, Randia dumetorum and Girardinia diversifolia (1.50 each). The treatment for different types of skin diseases by the herbal healers are classified into 13 categories, out of which ringworm scored the highest ICF value. Similarly, the 100% FL value scored was in the order of 10 plants for boils, 4 plants for different types of sore, 2 plants for ringworm, intertrigo, eczema and pruritus respectively. As Caesalpinia mimosoides and Basella alba in the treatment of boils, Hygrophila schulli for inter trigo, Cissus discolor for ringworm, Mammea suriga for eczema scored high FL and high Np value, they can be considered as important species. CONCLUSIONS: The documentation and data analysis of the ethnomedicinal knowledge in the coastal regions of Uttara Kannada district of Central Western Ghats have provided the information about important plants in the treatment of different types of skin diseases. Further scientific analysis of such plants may provide novel compounds for the treatment of skin diseases.

Isolated cardiac involvement in primary amyloidosis: presenting as sick sinus syndrome and heart failure.

Cardiac amyloidosis is an infiltrative cardiomyopathy with a grave prognosis. Its clinical manifestations include restrictive cardiomyopathy, diastolic heart failure, conduction defects, and arrhythmias. Isolated cardiac involvement and significant conduction disturbances are reported very infrequently. We report a rare case of isolated cardiac involvement in primary amyloidosis, in a 76-year-old man who initially presented with sick sinus syndrome that necessitated permanent pacemaker insertion. Subsequent symptoms of heart failure led to additional evaluation, including an endomyocardial biopsy that revealed primary cardiac amyloidosis. Medical therapy improved the patient's symptoms, and he was discharged from the hospital in stable condition. In addition to discussing the patient's case, we review the relevant medical literature.

Elevated troponin predicts long-term adverse cardiovascular outcomes in hypertensive crisis: a retrospective study.

BACKGROUND: Hypertensive crisis is associated with poor clinical outcomes. Elevated troponin, frequently observed in hypertensive crisis, may be attributed to myocardial supply-demand mismatch or obstructive coronary artery disease (CAD). However, in patients presenting with hypertensive crisis and an elevated troponin, the prevalence of CAD and the long-term adverse cardiovascular outcomes are unknown. OBJECTIVE: We sought to assess the impact of elevated troponin on cardiovascular outcomes and evaluate the role of troponin as a predictor of obstructive CAD in patients with hypertensive crisis. METHODS: Patients who presented with hypertensive crisis (n = 236) were screened retrospectively. Baseline and follow-up data including the event rates were obtained using electronic patient records. Those without an assay for cardiac Troponin I (cTnI) (n = 65) were excluded. Of the remaining 171 patients, those with elevated cTnI (cTnI ≥ 0.12 ng/ml) (n = 56) were compared with those with normal cTnI (cTnI < 0.12 ng/ml) (n = 115) at 2 years for the occurrence of major adverse cardiac or cerebrovascular events (MACCE) (composite of myocardial infarction, unstable angina, hypertensive crisis, pulmonary edema, stroke or transient ischemic attack). RESULTS: At 2 years, MACCE occurred in 40 (71.4%) patients with elevated cTnI compared with 44 (38.3%) patients with normal cTnI [hazard ratio: 2.77; 95% confidence interval (CI): 1.79-4.27; P < 0.001]. Also, patients with elevated cTnI were significantly more likely to have underlying obstructive CAD (odds ratio: 8.97; 95% CI: 1.4-55.9; P < 0.01). CONCLUSION: In patients with hypertensive crisis, elevated cTnI confers a significantly greater risk of long-term MACCE, and is a strong predictor of obstructive CAD.

Ethnomedicinal practices in different communities of Uttara Kannada district of Karnataka for treatment of wounds.

ETHNOPHARMACOLOGICAL RELEVANCE: Uttara Kannada district is located in the heart of the Western Ghats, one of the biodiversity hotspots, in Karnataka state of India. The thick evergreen forests are home to several ethnic communities. The study was under taken for documentation and analysis of ethnomedicinal plants in the treatment of wounds. MATERIALS AND METHODS: Field trips were made in Uttara Kannada district to identify the key informants. The collection of information was through semi-structured open ended interviews with a questionnaire. The questionnaire was designed to obtain the information about their experience in the field of treatment, number of patients treated per week, knowledge about the medicinal plants, vernacular names, parts of the plants used and other ingredients added during the drug formulations. Plants mentioned for treatment were photographed in the field, cuttings of the samples were taken and voucher specimens are deposited in the herbarium of P.G. Department of Botany, Karnatak University, Dharwad. The information such as botanical name, status, family, vernacular name habit and habitat, statistical analysis like percentage of parts used, Use value (UV) and Informants Consensus Factor (ICF) are provided. RESULTS: Present study resulted in recording 106 medicinal plant species of 55 families and 86 formulations to treat different types of wounds by 44 key informants. Among the 106 plants recorded four species are endemic to India and 22 species have the nativity outside India. Rest of the species have nativity both in India and elsewhere. The highest number of species belonged to Apocynaceae and Rubiaceae (6 species each). Trees are used more often (35.84%), followed by herbs (28.30%), shrubs (23.58%), climbers (11.32) and parasites (0.80%). Leaves are the major part of the plants used in the formulations (28.57%). The highest Use value is for Calycopteris floribunda (1.80), followed by Rauvolfia serpentina and Achyranthes aspera (1.67). The different types of wounds treated by traditional healers are classified into 15 categories and the highest ICF scored is for the burns (0.66). CONCLUSIONS: Ethnomedicinal survey in Uttara Kannada district of Karnataka revealed uses of 106 plants in traditional practices for curing various types of wounds. The statistical analysis confirmed high degree of sharing the knowledge amongst 44 key informants. Information about the largest number of remedies was obtained from the Havyaka Brahmin ethnic community which has strong Sanskrit background.

Usefulness of left ventricular end-systolic dimension by echocardiography to predict reverse remodeling in patients with newly diagnosed severe left ventricular systolic dysfunction.

In many patients with left ventricular (LV) systolic dysfunction, the LV ejection fraction (LVEF)-a surrogate for reverse remodeling-fails to improve despite optimal medical therapy. The early identification of such patients would allow instituting aggressive treatment, including early therapy with implantable cardioverter defibrillators. We sought to establish the predictors of reverse remodeling in patients with LV systolic dysfunction receiving optimal medical therapy. Patients (n = 568) with newly documented LVEF of ≤0.35, who had ≥1 follow-up echocardiogram after ≥3 months, were evaluated. Reverse remodeling was defined as improvement in LVEF to >0.35. The clinical, laboratory, and echocardiographic data were compared between patients with (n = 263) and without (n = 305) reverse remodeling. The mean follow-up was 27 ± 16 months. Patients who demonstrated reverse remodeling had a significantly greater mean follow-up LVEF (0.51 ± 0.09 vs 0.25 ± 0.08; p <0.001). On multivariate analysis, the baseline LV end-systolic diameter index was the strongest predictor of reverse remodeling (odds ratio 5.79; 95% confidence interval 1.82 to 18.46; p <0.001). Other independent predictors of reverse remodeling were female gender (odds ratio 1.88; 95% confidence interval 1.19 to 2.98; p = 0.007), and nonischemic cardiomyopathy (odds ratio 1.65; 95% confidence interval 1.05 to 2.58; p = 0.03). Baseline LVEF was not an independent predictor of reverse remodeling. In conclusion, among patients with newly diagnosed LV systolic dysfunction, the LV end-systolic diameter index, but not the LVEF, at diagnosis, was a strong predictor of reverse remodeling. Patients with a low likelihood of reverse remodeling might benefit from more aggressive heart failure therapy, including the possible early use of implantable cardioverter defibrillators.

Incidence of left ventricular function improvement after primary prevention ICD implantation for non-ischaemic dilated cardiomyopathy: a multicentre experience.

BACKGROUND: The SCD-HeFT study demonstrated a benefit of primary prevention implantable cardioverter-defibrillator (ICD) implantation in patients with non-ischaemic dilated cardiomyopathy (NIDCM). However, NIDCM may improve spontaneously, even after waiting 6-9 months on optimal medical treatment. OBJECTIVE: To assess the incidence of left ventricular (LV) function improvement in patients receiving primary prevention ICDs for NIDCM. METHODS: All patients with NIDCM receiving primary prevention ICDs (non-cardiac resynchronisation therapy) from 2005 to the present at our institutions were retrospectively studied. All patients had NIDCM confirmed by a lack of significant stenoses on coronary angiography, a lack of significant valvular abnormalities on echo, and LV dysfunction with ejection fraction (EF) <35%. All patients had to have had a diagnosis of NIDCM for at least 9 months and be receiving optimal medical treatment for at least 3 months before implant according to the guidelines. All patients had at least New York Heart Association (NYHA) II symptoms. Baseline and follow-up EF was documented by quantitative echo and/or multi-gated acquisition scan. RESULTS: 332 patients were identified by a database search. Patients were aged 67+/-11 years, 75% of them were male, NYHA 2.3+/-0.7, with EF 25+/-13%, and LV diastolic diameter 61+/-10 mm. Time from initial NIDCM diagnosis to implant was 11+/-6 months and duration of medical treatment before implant was 8+/-5 months. Treatment at the time of implant included ACE inhibitors or ARBs (85%), beta blockers (77%), spironolactone (53%), loop diuretic (63%) and digoxin (50%). Repeat EF assessment was available in 309/332 (93%) 8+/-6 months after implant. EF improved to >35% in 37/309 (12%) patients. Patients who improved had a shorter time from diagnosis to implant (9+/-3 vs 13+/-5 months respectively, p=0.03). No other significant predictors were identified for patients with improved EF. CONCLUSIONS: In spite of following guidelines for implantation of primary prevention ICDs in patients with NIDCM, a substantial number of patients (12%) experience improvement in LV function to levels above those recommended for ICD implant. A shorter time from diagnosis to implant may predict post-implant improvement.

Implantable cardioverter defibrillator (ICD) for polymorphic ventricular tachycardia (VT) due to coronary vasospasm.

We report a case of a young woman who presented with atypical angina. During an episode of chest pain she had a documented run of sustained polymorphic ventricular tachycardia (VT). In addition to medical therapy, she received an ICD to prevent future episodes of sudden cardiac death.