Case report: Primary cardiac lymphoma manifesting as superior vena cava syndrome.

A 64-year-old man presented with symptoms indicative of superior vena cava syndrome. Imaging work-up revealed an obstructing right atrial mass, which was subsequently excised and diagnosed as primary cardiac lymphoma. Post-surgery, the patient showed significant clinical improvement and was started on a chemotherapy regimen with complete remission at 1 year.

Recommendations for Early and Comprehensive Management of Type 2 Diabetes and Its Related Cardio-Renal Complications.

Type 2 diabetes (T2D) is a global health problem accompanied by an elevated risk of complications, the most common being cardiac and renal diseases. In Lebanon, the prevalence of T2D is estimated at 8-13%. Local medical practice generally suffers from clinical inertia, with gaps in the yearly assessment of clinical manifestations and suboptimal screening for major complications. The joint statement presented here, endorsed by five Lebanese scientific medical societies, aims at providing physicians in Lebanon with a tool for early, effective, and comprehensive care of patients with T2D. Findings from major randomized clinical trials of antidiabetic medications with cardio-renal benefits are presented, together with recommendations from international medical societies. Optimal care should be multidisciplinary and should include a multifactorial risk assessment, lifestyle modifications, and a regular evaluation of risks, including the risks for cardiovascular (CV) and renal complications. With international guidelines supporting a shift in T2D management from glucose-lowering agents to disease-modifying drugs, the present statement recommends treatment initiation with metformin, followed by the addition of sodium-glucose cotransporter 2 inhibitors or glucagon-like peptide-1 receptor agonists due to their CV and renal protection properties, whenever possible. In addition to the selection of the most appropriate pharmacological therapy, efforts should be made to provide continuous education to patients about their disease, with the aim to achieve a patient-centered approach and to foster self-management and adherence to the medical plan. Increasing the level of patient engagement is expected to be associated with favorable health outcomes. Finally, this statement recommends setting an achievable individualized management plan and conducting regular follow-ups to monitor the patients' glycemic status and assess their risks every 3-6 months.

Prevalence, awareness, treatment, and control of hypertension in Lebanon.

The prevalence and factors related to hypertension (HTN) treatment and control are well investigated in the Western world but remain poorly understood in the Middle East and in middle-income countries such as Lebanon. In order to measure the prevalence, awareness, treatment, and control rates of HTN in Lebanon, the authors measured blood pressure (BP) in 1697 adults. The prevalence of optimal BP (<120/80 mm Hg) was 33% and that of pre-HTN (BP ≥120/80 mm Hg but <140/90 mm Hg) was 30%. The prevalence, awareness, treatment, and control (among treated hypertensive) rates of HTN were 36.9%, 53%, 48.9%, and 54.2%, respectively. Overall, only 27% of patients with HTN had their BP under control. Awareness was the most important predictor of treatment. No predictor of control could be identified. The authors concluded that HTN is prevalent in Lebanon and its overall control is low. Improving awareness is the most important target for intervention.

Long-acting nifedipine for hypertensive patients in the Middle East and Morocco: observations on efficacy and tolerability of monotherapy or combination therapy.

BACKGROUND: The Middle Eastern and North African region of developing countries is associated with poor rates of blood pressure (BP) control and antihypertensive prescribing patterns. This post hoc analysis of data from an international observational study aimed to investigate the efficacy and tolerability of long-acting nifedipine (30 mg or 60 mg; monotherapy or in combination) in the Middle Eastern and Moroccan populations defined as having high cardiovascular risk. METHODS: This was a prospective, noninterventional, multicenter observational study. Observations from patients (aged ≥ 18 years) with treated or untreated hypertension from the Middle East (Jordan, Saudi Arabia, Kuwait, Lebanon, Qatar, United Arab Emirates, and Yemen) and Morocco are presented. Hypertension grade and cardiovascular risk were defined at baseline, and systolic/diastolic BP change was defined at post-baseline visits (≤3). Adverse events and ratings of therapy efficacy and patient/physician satisfaction were recorded. RESULTS: The study included 1466 patients from the Middle East and 524 from Morocco. Characteristics of the populations differed, with a more severe hypertension profile in Moroccan patients. Despite these differences, nifedipine reduced BP to a similar extent in each group, with efficacy dependent on cardiovascular risk factors such as hypertension grade and age. Few adverse drug reactions occurred and nifedipine was well-tolerated in both populations. Efficacy and satisfaction with therapy were rated highly. CONCLUSION: Good rates of BP control were observed with nifedipine in patients with moderate-to-severe hypertension and high added risk. Published data in these countries suggest poor antihypertensive prescribing patterns and BP control; these data confirm this trend and suggest that suboptimal dosing may be prevalent.

Benefit and tolerability of the coadministration of ezetimibe and atorvastatin in acute coronary syndrome patients.

BACKGROUND AND AIM: The effect of ezetimibe-statin combination on inflammatory markers in acute coronary syndrome is unknown. The aim of our study is to evaluate the effect of this combination on the lipid profile, the CRP hs and the sCD40 ligand levels in acute coronary syndrome (ACS) patients. METHODS: This is a randomized, double-blind study including 93 patients admitted for ACS randomized in 2 groups, ezetimibe 10 mg + atorvastatin 10 mg vs atorvastatin 20 mg + placebo, for 12 weeks follow-up; blood samples were collected for lipid profile, ALT, AST, CRP and sCD40L at baseline, 12 hours, 4 weeks, and 12 weeks. RESULTS: There was no significant difference in total cholesterol levels, HDL, LDL, CRP, but there was a significant decrease in sCD40L levels in the ezetimibe combination group, with less side effects in the combination group, mainly myalgia (p = 0.012). CONCLUSION: Ezetimibe combination with low dose statin in patients in acute coronary syndrome could be a safe, potent therapy to reduce LDL level with antiinflammatory effect.

Comparison of the effects of combination atorvastatin (40 mg) + ezetimibe (10 mg) versus atorvastatin (40 mg) alone on secretory phospholipase A2 activity in patients with stable coronary artery disease or coronary artery disease equivalent.

Secretory phospholipase A2 (sPLA2) is an enzyme that plays an important role in the pathogenesis of atherosclerosis and of adverse cardiovascular events. It is currently the target of emerging therapeutic agents. Our study was designed to investigate the effect of aggressive lowering of low-density lipoprotein (LDL) cholesterol with ezetimibe and atorvastatin on sPLA2 activity. We randomized 100 patients with stable coronary artery disease (CAD) or CAD equivalent (diabetes, stroke, or peripheral vascular disease) to receive ezetimibe 10 mg/day in association with atorvastatin 40 mg/day (combination therapy group) versus atorvastatin 40 mg/day and placebo (monotherapy group). Patients on statin therapy before inclusion were allowed to enter the study as long as the potency of the statin was lower than atorvastatin 40 mg/day. Lipid profile, high-sensitivity C-reactive protein (hs-CRP), and sPLA activity were measured at baseline and after 8 weeks of therapy. The decrease in LDL cholesterol was more significant in the combination therapy group, but the decrease in hs-CRP was similar. sPLA2 activity significantly decreased in the ezetimibe/atorvastatin group from 29 U/ml (interquartile range 23 to 35) to 26 U/ml (23 to 29, p = 0.001) but remained similar in the placebo/atorvastatin group (23 U/ml, 19 to 32, vs 22 U/ml, 19 to 28, p = NS). In a multivariate stepwise linear regression model, change in sPLA2 correlated with change in hs-CRP (p <0.001), baseline LDL cholesterol level (p = 0.001), body mass index (p = 0.003), diabetes mellitus (p = 0.04) and combination therapy with ezetimibe/atorvastatin (p = 0.05). In conclusion, this study demonstrates that coadministration of ezetimibe and atorvastatin decreases sPLA2 activity.

Effect of ezetimibe/atorvastatin combination on oxidized low density lipoprotein cholesterol in patients with coronary artery disease or coronary artery disease equivalent.

Ezetimibe is effective in providing additional low-density lipoprotein (LDL) cholesterol lowering when coadministered with statins, but its effect beyond LDL cholesterol lowering is unknown. Oxidized LDL (ox-LDL) is a better predictor of adverse cardiovascular events than standard lipid parameters. The objective of this study was to investigate the effect of ezetimibe on ox-LDL. A total of 100 patients with coronary artery disease or coronary artery disease equivalent were randomized to atorvastatin 40 mg/day and ezetimibe 10 mg/day or to atorvastatin 40 mg/day and placebo. LDL cholesterol, LDL cholesterol subfractions, and ox-LDL were measured at baseline and after 8 weeks of therapy. The ezetimibe group had a larger reduction in total LDL cholesterol compared to placebo. This was due mainly to a larger reduction in large buoyant LDL (24% vs 10%, p = 0.008). Ox-LDL level did not change in the placebo group (50 +/- 13 vs 51 +/- 13 U/L), while it decreased in the ezetimibe group, from 51 +/- 13 to 46 +/- 10 U/L (p = 0.01 vs baseline and p = 0.02 vs final level in placebo). The change in ox-LDL correlated significantly with those in total LDL and in large buoyant LDL (r = 0.6 and r = 0.5, respectively, p <0.01 for both), but not with that of small dense LDL, high-density lipoprotein, or very low density lipoprotein. In conclusion, this study demonstrates that ezetimibe decreases ox-LDL cholesterol through reductions in total LDL cholesterol and in large buoyant LDL cholesterol.

Effect of high bolus dose tirofiban on the inflammatory response following percutaneous coronary intervention.

BACKGROUND: Tirofiban at the bolus dose of 10 microg/kg does not suppress the inflammatory response following percutaneous coronary intervention (PCI). This may be due to less than optimal inhibition of platelet aggregation. High bolus dose tirofiban (25 microg/kg) allows better inhibition of platelet aggregation but its anti-inflammatory effect remains unknown. HYPOTHESIS: High bolus dose tirofiban exhibits anti-inflammatory activity. METHODS: A total of 100 patients referred for PCI were randomized to receive high bolus dose tirofiban followed by a 24-h infusion or a bolus and an infusion of saline. Patients with elevated troponin or with thrombus in the culprit lesion were excluded. Inflammatory markers were measured at baseline and at 24 h. RESULTS: Levels of soluble CD40 ligand (sCD40L) were not affected by PCI while those of interleukin-6 (IL-6) and of high sensitivity C-reactive protein (hs-CRP) significantly increased. Despite inhibiting platelet's aggregation by > 90%, tirofiban did not suppress the rise of IL-6 and hs-CRP. Median (interquartile range) elevation of IL-6 was 0.6 pg/mL (-1.5-3.6) versus 0.4 pg/mL (-0.7-1.8) and that of hs-CRP was 2.1 mg/L (0.7-5.2) versus 2.4 mg/L (1-4.7) in the tirofiban and the control groups, respectively (p = ns). However, in patients with diabetes mellitus, tirofiban significantly suppressed the rise of hs-CRP by 65% (p = 0.01), but did not significantly affect the rise of IL-6. CONCLUSION: In low-risk patients undergoing PCI, tirofiban did not attenuate the rise of inflammatory markers. However, the significant effect in diabetics suggests that tirofiban may have anti-inflammatory activity in higher risk patients.

[Epidemiology of cardiac tumors in adults in Lebanon]. / Epidémiologie des tumeurs cardiaques des adultes au Liban.

Primary cardiac tumors are rare but potentially fatal. No studies have discussed this issue yet on the national level. We describe the epidemiology of cardiac tumors in adults in Lebanon. The data were taken from the hospitals, the patients and/or their doctors by means of a questionnaire. Fifty-seven cases of cardiac tumors were found, mainly myxomas in the left atrium. Dyspnea was the most frequent symptom. Transthoracic echocardiography was the main diagnostic tool. Transesophageal echocardiography was inconstantly made, scanner and MRI rarely while contrast echocardiography has never been used. Almost half of the patients had a follow-up and none had a familial screening. The collected data urged us to propose a unique and homogenous strategy for diagnosis, treatment and follow-up of cardiac tumors in Lebanon.

[Control of blood pressure morning surge in a Lebanese hypertensive population]. / Contrôle du pic matinal de la pression artérielle par telmisartan chez une population libanaise hypertendue.

OBJECTIVE: The primary endpoint of this prospective clinical study is to ascertain the degree of blood pressure control in the early-morning hours after 8 weeks of treatment with Telmisartan in hypertensive patients using home blood pressure measurements. METHODS: Two hundred forty Lebanese patients with uncontrolled hypertension are enrolled in the study. The blood pressure is measured at the initial visit, then at week 4 of follow-up (optional visit) and after the 8 weeks period, by the physician at his office (with pulse rate) and by the patient at home in the morning. RESULTS: The blood pressure measured by the patient at home in the morning has a mean value of 129.7/79.1 mmHg, significantly less than 135/85 mmHg (P < 10(-1)), and it is reduced by 31.9/13.5 mmHg (P < 10(-5)). At the physician's office, the reduction is 34.8/16 mmHg (P < 10(-4)). Heart rate is decreased by 4.7+/-0.5 bpm (P < 10(-5)). The drug was well tolerated. CONCLUSION: This study has demonstrated that Telmisartan, by his long half-life, protects the patients against the early-morning hours blood pressure surge, period during which coronary and cerebral events are the most frequent.

Percutaneous coronary intervention increases leptin and decreases adiponectin levels.

OBJECTIVE: The study was designed to examine the effect of percutaneous coronary intervention (PCI) on adiponectin and leptin levels. We have previously demonstrated that PCI triggers a systemic inflammatory response. We hypothesized that inflammation participates in the pathogenesis of diabetes mellitus and the metabolic syndrome by modulating levels of adiponectin and leptin. DESIGN: Prospective study in which inflammation was induced by PCI. PATIENTS: Forty-eight patients with stable coronary artery disease and without diabetes mellitus. MEASUREMENTS: High-sensitivity C-reactive protein (hs-CRP), interleukin-6 (IL-6), leptin and adiponectin were measured at baseline and 48 h after the procedure. RESULTS: Following PCI, hs-CRP increased by 211%, IL-6 by 87% and leptin by 19%, while adiponectin decreased by 14% (P < 0.001 for all). The change in IL-6 correlated with that in hs-CRP (rho = 0.32; P = 0.027), as did the changes in IL-6 and leptin (rho = 0.31; P = 0.03). The change in adiponectin, however, did not correlate with the change in any of the other markers. CONCLUSION: This study demonstrates that PCI affects the levels of adiponectin and leptin within 48 h. These effects may be secondary to the inflammatory response triggered by PCI.

Effects of clopidogrel on soluble CD40 ligand and on high-sensitivity C-reactive protein in patients with stable coronary artery disease.

BACKGROUND: Antiplatelet therapy with clopidogrel decreases ischemic complication especially in patients with acute coronary syndromes or after percutaneous coronary interventions. Our study was designed to test the effects of clopidogrel on soluble CD40 ligand (sCD40l) and on high-sensitivity C-reactive protein (hs-CRP) in patients with stable coronary artery disease (CAD). METHODS: This is a randomized, double-blind, placebo-controlled study. A total of 73 patients with stable CAD for > 6 months were randomized to receive either clopidogrel (loading dose 300 mg followed by 75 mg/d) for 8 weeks or placebo. Soluble CD40 ligand and hs-CRP were measured at baseline and at completion of the study. RESULTS: All patients were on aspirin therapy, and 74% were on statins. Median and interquartile ranges (IQR) of sCD40l decreased from 64 pg/mL (43-99) at baseline to 53 pg/mL (35-77) at 8 weeks (P = .03) in the clopidogrel group and remained unchanged in the placebo group (59 pg/mL, IQR 35-77 vs 55 pg/mL, IQR 35-78) (P = non significant). Levels of hs-CRP were not affected by therapy and remained unchanged in both groups. CONCLUSIONS: In patients with stable CAD, clopidogrel inhibits the release of sCD40l by platelets, which may contribute to the clinical benefit provided by this drug. This, however, does not translate in a reduction of subclinical inflammation, as measured by hs-CRP.

Effects of tirofiban and statins on high-sensitivity C-reactive protein, interleukin-6, and soluble CD40 ligand following percutaneous coronary interventions in patients with stable coronary artery disease.

This study assessed the effects of tirofiban and statins on high-sensitivity C-reactive protein, interleukin-6, and soluble CD40 ligand after percutaneous coronary intervention in patients who had stable coronary artery disease. Tirofiban insignificantly limited the increase of soluble CD40 ligand after revascularization, especially in patients who had high levels of this marker at baseline (p = 0.06), whereas statins significantly inhibited increases in interleukin-6 and, to a lesser extent, high-sensitivity C-reactive protein without affecting the soluble CD40 ligand.

[Coronary angioplasty for primary cardiogenic shock following acute myocardial infarction]. / L'angioplastie à la phase aiguë de l'infarctus du myocarde compliqué d'un choc cardiogénique primaire.

BACKGROUND: In the setting of acute myocardial infarction (AMI), several investigators have demonstrated that emergency coronary angioplasty (PTCA) reduces in-hospital mortality of primary cardiogenic shock (CS) from 90% to less than 50% ; however, few studies have focused on the current outcome of non selected patients in whom the onset of AMI is immediately complicated by CS. PURPOSE OF THE STUDY: To evaluate in-hospital mortality of the patients admitted to our institution for Q wave AMI presented in CS. MATERIAL AND METHOD: Between 05/93 and 05/03, 30 consecutive pts, 26 men and 4 women, in CS following AMI were treated with direct PTCA, 26 without thrombolysis and 4 as rescue after failed streptokinase. AMI was defined by prolonged chest pain and > or =1 mm ST segment elevation in > or =2 contiguous peripheral leads or > or =2 mm for precordial leads on the admission ECG. The diagnosis of CS was based on the combination of systolic blood pressure of <90 mm Hg, unresponsive to volume expansion, signs of acute circulatory failure (cyanosis, cold extremities, restlessness, mental confusion or coma) and congestive heart failure secondary to myocardial dysfunction. In 40% of cases the diagnosis of CS was only clinical and in 60% of cases was confirmed by a Swan Ganz catheter. Mean age was 62.3 +/- 12.3 years, 7 had triple vessel disease, 14 a double vessel disease, 8 a single vessel disease and in one case a left main disease. The AMI was anterior in 22 pts (73%), inferior in 8 (27%). Intraaortic balloon was used in 3 pts, CPR in 16 (47%), transitory pacemaker in 1 pt, inotropes in 25 pts, emergency coronary artery bypass grafting (CABG) in 1 pt. RESULTS: Success for PTCA with a residual stenosis < 50% and a TIMI flow III was obtained in 26 pts (87%). Mean time between CS and revascularization was 219 +/- 302 minutes. 19 pts (63%) survived and 11 pts (37%) died while at the hospital, 6 from intractable shock, 4 from multiple organ failure and in 1 case from pulmonary hemorrhage. Mean time of revascularization for the surviving was 190 +/- 329 min, and for the dead 295 +/- 212 min. Hospital mortality for inferior infarction is 12.5% after successful angioplasty. Comparison of surviving and non surviving number of patients according to revascularization time showed a significant difference of these groups whether the revascularization was accomplished before or after 120 minutes. [table: see text] CONCLUSION: Direct PTCA for AMI immediately complicated by CS, can be achieved with a high success rate, and can significantly reduce in-hospital mortality; this improvement of survival is most evident if revascularizarion is performed early.

[Management of acute transmural myocardial infarction: a study on 200 patients admitted to a tertiary care medical center]. / Prise en charge de l'infarctus du myocarde transmural à la phase aiguë: Etude de 200 patients admis dans un hôpital de soins tertiaires.

OBJECTIVE: To verify if the management of acute transmural myocardial infarction in a university hospital, follows the international guidelines of the ACC/AHA. DESIGN: This is a retrospective study on 200 consecutive patients admitted with an acute transmural myocardial infarction. Data were obtained by review of medical records. RESULTS: 20.5% of patients were treated with primary angioplasty, 44% received thrombolytic therapy and 35.5% a conventional medical treatment. Mean age was 62 +/- 11.64 years and 72% of the patients were males. Risk factors were: smoking 62%, hyperlipidemia 46%, hypertension 43.5%, diabetes 33.5%, obesity 13.5%, and a family history of coronary artery disease 25%. 17.5% of patients had a prior history of myocardial infarction and 4.5% had prior coronary artery bypass graft surgery. The mean delay between onset of symptoms and arrival to the hospital was 12 hours. Chest pain was the main symptom and was present in 88% of patients. Cardiac arrest was observed in 7% of patients upon arrival to the emergency department. Administration of thrombolytic therapy followed the established criteria in all cases. Angioplasty was mainly performed in cases of cardiogenic shock, and as a rescue for failed thrombolytic therapy and for pain recurrence. The two reperfusion modalities were given equally to elderly patients, patients with prior coronary artery bypass surgery and to those with anterior wall myocardial infarction. Coronary angiography was done in 94% of patients, coronary angioplasty was subsequently performed on 30.1%, and bypass surgery on 27%. Mortality rate was 11.2%, and it was significantly higher in patients treated conventionally by comparison with thrombolysis and/or PTCA. Major arrhythmias were observed in 13.5% of cases and infections in 3.5%. Mean length of stay was 2.85 +/- 3.1 days in the intensive care unit and 8.9 +/- 6.7 days in the hospital. Treatment on discharge followed the international recommendations; aspirin was given to 87.5% of patients, beta-blockers to 63.3%, ACE inhibitors to 59% and statines to 32%. CONCLUSION: The management of acute transmural myocardial infarction at our institution follows the international guidelines. However, the delay between the onset of symptoms and arrival to the hospital needs to be shortened. Public awareness campaigns should be useful for that purpose. In addition, the treatment on discharge should be improved.

T wave pacing inducing electrical storm and multiple shocks in an ICD-recipient: a novel complication of the automatic gain control function.

Implantable cardioverter-defibrillator (ICD) is highly effective in treating life-threatening ventricular arrhythmias, but it can also have proarrhythmic effect in some cases. We report the case of a 72 years old patient with an ischemic cardiomyopathy in whom an ICD was implanted for a poorly tolerated ventricular tachycardia (Profiles MD-Ventritex). Forty-eight hours after implantation, the patient suddenly received 15 successive shocks. ECG tracings and intracardiac EGM showed the presence of several VT episodes, all induced by the antibradycardia pacing of the ICD: the automatic gain control function of the device failed to detect ventricular premature beats in this patient, leading to a bradycardia pacing falling on the T wave and inducing multiple VTs and shocks.