Glucose and arterial blood pressure variability in Obstructive Sleep Apnea Syndrome.

INTRODUCTION: Current evidence supports an association between Obstructive Sleep Apnea Syndrome (OSAS), insulin resistance, type 2 diabetes mellitus (DM) and cardiovascular disorders. The relationship is complex and still remains poorly understood. AIM: The aim of this study was to examine the potential correlation of sleep characteristics with glucose and arterial pressure values variability in non - diabetic, non-hypertensive patients with OSAS. SUBJECTS AND METHODS: We examined 22 subjects, 11 men and 11 women (mean age 54 ± 14,5 years), recently diagnosed with OSAS (Apnea - Hypopnea Index (AHI) ≥ 5 apneas/hypopneas per hour of sleep) by full night polysomnography (PSG). Fasting and postprandial after a 2 hour oral glucose tolerance test (OGTT) glucose and insulin levels were measured, and homeostatic model assessment of insulin resistance (HOMA(IR)) index profile as well as Matsuda insulin sensitivity index (ISI) were calculated. A 24 hour glucose monitoring with subcutaneous measurements every 5 minutes and a 24-hour arterial blood pressure (ABP) monitoring (Holter monitoring) were evaluated. RESULTS: AHI, a widely accepted marker of the severity of OSAS, was correlated with HOMA and Matsuda index (p = 0.016 and p = 0.022, respectively), Standard Deviation (SD) of glucose measurements (p = 0.05) and mean diastolic blood pressure (p = 0.007). Percentage of sleep time with saturation of hemoglobin with oxygen, as measured by pulse oximetry, (SpO2) < 90% was also correlated with HOMA and Matsuda index (p = 0.014 and p = 0.012, respectively), coefficient of variation (CV) of glucose measurements (p = 0.009) and SD of 24-hour systolic blood pressure. Moreover, minimum SpO2 was correlated with glucose levels (p = 0.018), Matsuda index (p = 0.30) and SD of 24-hour diastolic and systolic blood pressure (p = 0.005 and p = 0.022, respectively). CONCLUSIONS: Glucose and arterial pressure variability were associated with markers of OSAS severity (AHI, % sleep time with SpO2 < 90%, min SpO2), among nondiabetic patients. Thus, glucose and arterial pressure variability in OSAS may be an additional marker of cardiovascular risk as well as of future diabetes in these subjects. Nevertheless, the clinical significance of our observations remains to be confirmed by prospective studies.

Long term effects of nisoldipine on the progression of coronary atherosclerosis and the occurrence of clinical events: the NICOLE study.

BACKGROUND: Earlier angiographic studies have suggested that calcium antagonists may prevent the formation of new coronary lesions and the progression of minimal lesions. Conversely, a meta-analysis suggested that these drugs may increase cardiovascular mortality and morbidity in patients with coronary heart disease. OBJECTIVE: To investigate whether nisoldipine retards the progression of coronary atherosclerosis or reduces the occurrence of clinical events. DESIGN AND SETTING: The NICOLE study (NIsoldipine in COronary artery disease in LEuven) is a single centre, randomised, double blind, placebo controlled trial with coronary angiography at baseline, six months, and three years of follow up. PATIENTS: 826 patients who had undergone successful coronary angioplasty were randomised to nisoldipine 40 mg once daily or placebo. The intention to treat and per protocol population consisted of 819 and 578 patients, respectively. RESULTS: In the per protocol population, 625 of the nisoldipine treated and 655 of the placebo treated patients (NS) showed angiographic progression in at least one coronary arterial segment, defined as an increase in diameter stenosis of > or = 13%. The average minimum luminal diameter of the non-dilated lesions decreased by 0.163 mm and 0.167 mm in the nisoldipine and placebo groups, respectively (NS). The respective numbers of new lesions detected were 7 and 13 (NS). In the intention to treat population, the rates of death, stroke, and acute myocardial infarction were similar in both treatment groups. However, nisoldipine use was associated with fewer revascularisation procedures and thus the percentage of patients with any clinical event was lower (44.6% v 52.6%, p = 0.02). CONCLUSIONS: Nisoldipine has no demonstrable effect on the angiographic progression of coronary atherosclerosis or the risk of major cardiovascular events but its use is associated with fewer revascularisation procedures.

Usefulness of Nisoldipine for prevention of restenosis after percutaneous transluminal coronary angioplasty (results of the NICOLE study). NIsoldipine in COronary artery disease in LEuven.

The NIsoldipine in COronary artery disease in LEuven (NICOLE) study investigates (1) whether nisoldipine, a dihydropyridine calcium antagonist, reduces the progression of minor coronary arterial lesions in the long term, and (2) whether it reduces the restenosis rate after successful percutaneous transluminal coronary angioplasty (PTCA). The NICOLE study is a single-center, randomized, double-blind trial in 826 patients, who underwent a successful PTCA. Nisoldipine 40 mg coat-core or placebo was started the morning after the procedure and continued for 3 years. All coronary arterial segments were measured on preprocedural angiogram and on the second follow-up angiogram at 3 years. On the first follow-up angiogram at 6 months only the dilated segments were measured. Although the study is still ongoing until the primary end point is reached, we report in this study the angiographic restenosis data as well as the clinical events observed at 6-month follow-up. The per-protocol population consisted of 646 patients. Restenosis, defined as a > or =50% loss of the initial gain (National Heart, Lung, and Blood Institute criterion IV) occurred in 49% and 55% of the 308 nisoldipine-treated and the 338 placebo-treated patients, respectively (p = NS). At follow-up, the rates of death and myocardial infarction were low and similar in both groups, but in the nisoldipine group, less patients required early coronary angiography (18% vs 26%, p = 0.006) and subsequent revascularization procedures (32% vs 41%, p = 0.057). Thus, nisoldipine did not significantly reduce the angiographic restenosis rate after PTCA, but reduced the number of repeat revascularization procedures, which may be due to its antianginal action.

New method for placement of intracoronary stents in order to avoid their embolization in the intravascular space.

Stent dislodgment from the delivery catheter is a well-known complication of angioplasty with stent implantation. The aim of our study was to investigate the feasibility, effectiveness, and safety of a new technique of intracoronary stent implantation in order to avoid stent loss in the intravascular space. Fifty consecutive patients were candidates for angioplasty and stent placement. During angioplasty, a technique was followed according to which the guide wire "hindered" the dislodgment of the stent from the balloon catheter. Successful angioplasty and stent placement were performed in 46 out of 50 patients (92% success rate). In three cases of failure of stent implantation, the stent moved onto the balloon catheter; however, this was impeded by the guide wire. One non-Q-wave myocardial infarction occurred. No major complications (Q-wave myocardial infarction, CABG, or death) were observed. In conclusion, the technique applied was feasible enough, safe, and effective. However, the appropriate modification of its "hardware" will render it even more feasible and user-friendly.

Treatment of long dissections by use of a single long or multiple short stents: clinical and angiographic follow-up.

BACKGROUND: Recently, long (> or =20 mm) coronary stents were introduced for clinical use. They are intended as an alternative to multiple conventional stents to treat extensive dissections or suboptimal results of long lesions after balloon angioplasty. METHODS: In a total of 113 such consecutive vessels in 107 patients, the flexible Freedom stent was implanted. In 60 of these vessels, because of anatomic constraints, multiple overlapping short (16 mm) stents were implanted. The other 53 vessels were treated with a single long (> or =20 mm) stent. RESULTS: In the single stent group there were four implantation failures (8%) successfully managed by crossover to multiple overlapping short stents. During early follow-up, in-stent thrombosis was not observed, but three patients with a single long stent and two patients with multiple overlapping stents suffered myocardial infarction as a result of long lasting myocardial ischemia during a difficult angioplasty procedure. At 6-month follow-up, > or =50% restenosis was measured in 29% and 35% of the patients with a single long stent and in those with multiple overlapping stents, respectively (not significant). CONCLUSIONS: Compared with the alternative treatment modality (i.e., implantation of multiple short stents), no difference between in-hospital and 6-month outcome was observed. However, implantation of a single long stent, when technically feasible, reduces catheterization time, dye volume for the patient, and radiation exposure for both patient and operator during these embarrassing angioplasty procedures.

Aneurysm of the mitral-aortic intervalvular fibrosa as a rare cause of angina pectoris: angiographic demonstration.

Aneurysms of the mitral-aortic interventricular fibrosa (MAIF) are exceptionally rare complications, commonly following aortic valve endocarditis. This report describes the angiographic findings of such an aneurysm, in a patient who developed an uncommon symptomatology of unstable angina pectoris, caused by the aneurysm's expansion against the coronary arteries. Surgical treatment is also discussed.

Posterior right diagonal artery. An angiographic study.

The purpose of this prospectively performed study was the angiographic visualization of the posterior right diagonal artery (PRDA) and its differentiation from the epicardial branches of the right coronary artery (RCA), that is, the right marginal artery and the posterior descending artery (PDA). The authors prospectively studied the angiographic findings of 607 patients who underwent coronary angiography. The incidence of the angiographically demonstrated PRDA and its distinction from other epicardial branches arising from the distal third of the RCA was the main point of interest. Two types of PDA in those cases where PRDA was present were also demonstrated. Of the patients examined, 535 had dominant right coronary circulation, 59 had left dominant coronary circulation, and 13 had balanced coronary circulation. PRDA was present in 81 patients with right dominant coronary circulation (15.1%), in 2 patients with balanced coronary circulation (15.4%), and in none with left dominant coronary circulation. PRDA was revealed in 48 (40%) of 120 patients with a short PDA and in only 33 (8%) of 415 patients having long PDA. It is imperative to search always for the PRDA, when one is studying coronary arteriographies, bearing in mind that this artery may perfuse the inferior part of the posterior interventricular septum and the adjoining are, depending on the type of PDA.

Angioplasty without the use of "Y connector": a new, easier, bloodless method.

The "Y connector" that is used in angioplasty has the following disadvantages: 1) it is not blood-tight; 2) we need to "screw and unscrew" every time we want to inject contrast material or measure the pressure; and 3) it does not allow the advancement of the guidewire or the balloon catheter during the injection of contrast material. We created a new type of connection composed of a cut sheath for the femoral artery, connected with a cut (at the "hub") guiding catheter. The aim of this study was to examine the feasibility, efficacy, and safety of the new method. Using the new technique we performed plain-balloon angioplasty, implantation of stent, and atherectomy in 350 patients. The technical success of the method was 100%, and no complications related to the method were seen. In conclusion, the novel connection that we created eliminated all the disadvantages of the "Y connector" and was found to have 100% technical success and safety.

Stress echocardiography using adenosine combined with nitroglycerin-dobutamine in the detection of viable myocardium in patients with previous myocardial infarction.

The aim of this study was to assess the value of adenosine (A) and the combination of nitroglycerin (N) with dobutamine (D) stress echocardiography (SE) in the identification of viable myocardium. The clinical and electrocardiographic (ECG) effects of both tests were also evaluated. Fifty-two coronary artery disease patients, aged 56.4 +/- 8 years, with left ventricular dysfunction due to a previous myocardial infarction (mean ejection fraction: 49 +/- 8%) were included in the study. Cardiac catheterization was performed in all patients before A (140 micrograms/kg/minute for five minutes) and the combination of N with D (5-10 micrograms/kg/minute) stress echocardiography. On the echocardiogram, the left ventricle was divided into 16 segments and wall motion was graded semiquantitatively from 1 (normal) to 4 (dyskinesia). The echocardiographic index was also estimated. A segment was considered viable during A infusion when resting asynergy showed deterioration of one grade or more. In contrast, segmental viability was considered to be present during the combination of N with D infusion when resting asynergy showed improvement of one grade or more. A thallium 201 single photon emission computed tomography (SPECT) with reinjection was performed as reference standard for the identification of viable myocardium. Stress echocardiography during infusion of A was associated with short-duration angina attacks in 3 (5.8%) patients and transient complete atrioventricular (AV) block in 1 (1.9%), whereas during the combination of N with D infusion, 6 (11.5%) patients experienced ventricular bigeminy lasting for a short period. ST segment elevation greater than 1 mm was recorded in those leads having a Q wave, in 19 (36.5%) patients. In 10 of these 19 (52.6%), viable myocardium was present in SPECT, as it was in 33 patients (63.5%) having no ST segment elevation (P = NS). Of a total of 832 segments that were graded during A-SE, 276 exhibited resting asynergy and the remaining 556 had normal motion and thickening at rest. The echocardiographic index during A infusion increased from 1.52 +/- 0.22 to 1.71 +/- 0.24 (P < 0.001), whereas during D and N infusion it decreased from 1.53 +/- 0.31 to 1.30 +/- 0.42 (P < 0.001). With SPECT considered as the gold standard for the identification of viable myocardium, sensitivity, specificity, and positive and negative predictive values of A-SE in detecting viable myocardium were 54%, 86%, 65% and 80%, respectively. The respective values for the combination of nitroglycerin with D-SE were 91%, 89%, 78%, and 96%, respectively. Stress echocardiography during A, and the combination of N with D, constitute safe methods in the identification of viable myocardium. The detection of ST segment elevation in the ECG leads with a Q wave during the combined infusion of nitroglycerin and dobutamine is not related to the presence of viable myocardial tissue. The A-SE provide moderate diagnostic accuracy, while the combination of N with D during SE is much superior in detecting viable myocardium.

Detection of myocardial viability in the prediction of improvement in left ventricular function after successful coronary revascularization by using the dobutamine stress echocardiography and quantitative SPECT rest-redistribution-reinjection 201TI imaging after dipyridamole infusion.

The aim of this study was to assess the feasibility, safety, and respective diagnostic accuracy of low-dose dobutamine infusion and rest-redistribution-reinjection thallium 201 single photon emission computed tomography (SPECT) after dipyridamole infusion (Th-DIP), in the prediction of functional improvement of asynergic infarcted zones, after successful revascularization in patients with chronic ischemic heart disease. Thirty-one patients with a previous myocardial infarction and left ventricular dysfunction (mean ejection fraction: 41 +/- 5.8%) were studied. The regional wall motion of the left ventricle was evaluated by basic echocardiography before and 14 +/- 1.7 weeks after successful revascularization (19 by percutaneous transluminal coronary angioplasty and 12 by coronary artery bypass grafting). Dobutamine stress echocardiography (DSE) was performed in all patients with dobutamine infusion of 5 and 10 micrograms/kg/minute over five minutes. Within three days after DSE and prior to revascularization, all patients underwent Th-DIP for myocardial viability assessment. A 16-ventricular-segment model was used for basic, DSE, and Th-DIP images. Viability was assessed by applying the standard criteria for each technique. In the 31 patients, 496 segments were analyzed. By basic echocardiography, 164 (33%) of them were classified as asynergic. The DSE detected viable tissue in 69/496 (14%) segments, whereas Th-DIP identified viability in 95/496 (19%) segments. When the postrevascularization basic echocardiographic study was used as the gold standard in identifying myocardial viability, the sensitivity and specificity for the DSE and Th-DIP were 86.5%, 94.4% and 90.5%, 69%, respectively. No major side effects were observed with both techniques. In conclusion, DSE seems to be an accurate method for identifying viable but asynergic myocardium in patients with chronic ischemic heart disease, whereas Th-DIP overestimates the postrevascularization recovery. Detection of hibernating myocardium can be obtained by these two noninvasive methods. However, DSE seems to be more useful in determining the prospective selection of patients who are going to benefit from revascularization.

Angioplasty of a left anterior descending artery originating from the right sinus of Valsalva (discussion in decision making).

In this case report, we describe a successful percutaneous transluminal coronary angioplasty of an abnormally originating left anterior descending artery from the right sinus of Valsalva. We discuss about the decision making in this rare and challenging case, since there is more than one opinion as to which is the appropriate treatment in this group of patients.

Cortical blindness following coronary arteriography: a rare but self-cured complication. Two case reports.

The rare and self-cured complication of cortical blindness following coronary arteriography is presented in 2 patients who underwent cardiac catheterization. Both patients were submitted to an aortocoronary bypass grafting procedure a few years before and were under clinical investigation for a new onset of unstable angina pectoris.

Single coronary artery from the right sinus of Valsalva, associated with absence of left anterior descending and an ostium-secundum-type atrial septal defect: a rare combination. A case report.

A case of single coronary artery from the sinus of Valsalva, with an anomalous origin of the left circumflex coronary artery from the just proximal portion of the right coronary artery, absence of the left anterior descending, and an ostium-secundum-type atrial septal defect is presented. This combination seems to be very rare.

Significance of echocardiographic atrioventricular plane displacement for the evaluation of left ventricular filling and end-diastolic pressure in patients with coronary artery disease.

The aim of this study is to assess the left ventricular filling and estimate the end-diastolic pressure of the left ventricle in patients with coronary artery disease (CAD) by echocardiographic measurement of the atrioventricular plane displacement (AVPD). In 101 patients (mean age 59 +/- 12 years) with CAD, a complete transthoracic echocardiographic study was performed, just prior to cardiac catheterization. The AVPD was recorded by M-mode echocardiography, from apical four and two chamber views. The recordings were obtained at four sites, corresponding to the septal, lateral, anterior and inferior walls of the left ventricle. The mean AVPD resulting from atrial systole (At), the mean total (T) diastolic AVPD, the ratio At/T(%) and the ratio of mitral annulus excursion during early and late diastole [(T-At)/At] were calculated. Firty-two age-matched healthy subjects served as control group. Both At and At/T were significantly greater in patients with CAD than in the controls (6.06 +/- 0.94 vs 5.53 +/- 0.55 mm, p < 0.01 and 43.4 +/- 5.9% vs 33.49 +/- 4.45%, p < 0.001 respectively). The ratio [(T-At)/At] correlated with the E/A ratio of transmitral flow, both in healthy subjects (r = 0.850, p < 0.001) and in patients with CAD (r = 0.722, p < 0.001). Correlation also existed both in patients with segmental wall motion abnormality (SWMA) (r = 0.691, p < 0.001) and in patients with SWMA (r = 0.818, p < 0.001). In patients with CAD, At/T further correlated with the left ventricular end-diastolic pressure (r = 0.517, p < 0.001). In patients with SWMA and in patients without, a correlation was also found (r = 0.516, p < 0.001 and r = 0.566, p < 0.001 respectively).(ABSTRACT TRUNCATED AT 250 WORDS)

Analysis of left atrioventricular plane movement during diastole in ischemic heart disease.

The aim of the present study was to investigate the properties of diastolic left atrioventricular plane displacement (AVPD) in coronary artery disease (CAD) patients. In 125 patients (mean age 58.7 +/- 13.7) with CAD and in 51 age-matched healthy subjects, a complete transthoracic echocardiographic study was performed. The AVPD was recorded by M-mode echocardiography, from apical four and two chamber views at four sites corresponding to the septal, lateral, anterior and inferior walls of the left ventricle. Mean AVPD in early diastole (E-AVPD), mean AVPD from atrial systole (A-AVPD) and the ratio A-AVPD/E-AVPD were determined. In normal subjects, such as in 35 patients without left ventricular segmental wall motion abnormalities (SWMA), stepwise multiple regression analysis showed none of these factors to be significantly related to E-AVPD or A-AVPD. Aging was correlated negatively to the E-AVPD/A-AVPD ratio (p < 0.05). In 90 patients with left ventricular SWMA, stepwise multiple regression analysis showed that indices of left ventricular systolic function correlated positively to E-AVPD (p < 0.001) and A-AVPD (p < 0.001). The E-AVPD/A-AVPD ratio was correlated to left ventricular ejection fraction and heart rate (p < 0.005). Mean E-AVPD was significantly lower in CAD patients than in normal subjects (p 0.001), while A-AVPD was higher in patients without left ventricular SWMA in comparison to normal subjects (p = 0.02). Also, mean A-AVPD/E-AVPD was higher in CAD patients than in the control group (p < 0.001). Mean E-AVPD/A-AVPD was correlated to the E/A ratio of transmitral flow in CAD patients with (r = 0.669) and without (r = 0.771) SWMA. The E-AVPD and A-AVPD in CAD patients with SWMA is reduced according to the deterioration of left ventricular systolic function. The atrial contribution to the longitudinal distension of the left ventricle is increased in CAD patients. In CAD patients, especially those without left ventricular SWMA, the E-AVPD/A-AVPD ratio has a good correlation to left ventricular filling behavior.

Correlation of clinical and electrocardiography variables with coronary lesions in unstable angina pectoris.

The relation of clinical and electrocardiographic variables to the severity of coronary lesions in unstable angina was studied in 84 men and 8 women, aged thirty-nine to seventy-five, who were subjected to coronary arteriography within two weeks. Eighty-seven patients (94.6%) had significant stenosis (50% of the diameter) of at least one vessel, whereas 5 (5.4%) had normal coronary arteries. Eleven (12%) had one-vessel disease, 13 (14%) had two-vessel, and 63 (68.5%) had three-vessel disease. Twelve (13%) had also significant left main stem stenosis. Except for 1 patient with artificial pacemaker, three-vessel and/or left main stem disease was present in 20 (100%) patients with ST segment deviation > or = 0.2mV as compared with 20 of 36 patients (55.5%) with ST segment deviation of 0.1-0.19 mV and 24 of the 35 (68.6%) with no additional ECG changes or with T wave inversion only (P < 0.005). The direction of ST segment deviation (elevation or depression) made no difference. Preexisting angina or infarction was associated with three-vessel disease and/or left main stem disease in 74.1% and 81.4%, respectively, as compared with 45.5% (P = 0.05) of the patients with angina of recent onset. Pain at rest persisting for more than forty-eight hours was associated with three-vessel and/or main stem disease in 93.1% of the patients as compared with 60.3% of patients in whom rest angina subsided within forty-eight hours (P < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Atrial pressure and experimental atrial fibrillation.

A possible profibrillatory effect on the atria of an elevated atrial pressure and the site of atrial stimulation was examined. In 15 anesthetized dogs, right or left atrial or biatrial pacing was applied at a high rate (300-600/min) for 5 seconds at double threshold intensity under a wide range of atrial pressures achieved by venous or arterial transfusion or bleeding. Induction of atrial fibrillation in 236 of 1,971 pacing runs was associated with a significantly higher (P < 0.001) atrial pressure (21.6 +/- 12.2 mmHg, mean +/- SD) than maintenance of sinus rhythm (16.8 +/- 11.1 mmHg in 1,735 of 1,971 pacing runs). Stimulation of the right atrium resulted in atrial fibrillation more frequently than left atrial or biatrial stimulation, with biatrial stimulation less frequent than right or left atrial stimulation. The induction of atrial fibrillation was related to the atrial pressure and to the site of stimulation but not to the pacing rate or the prepacing heart rate. The prepacing heart rate, associated with failure to induce sustained atrial fibrillation, was higher than that associated with atrial fibrillation in 12 of 15 experiments (significantly in 6) and not significantly lower in 3 of 15. Atrial fibrillation lasting 1 minute or more was more frequently associated with simultaneous stimulation of both atria than of either atrium alone. Thus, an elevated atrial pressure may facilitate the induction of atrial fibrillation. The site of stimulation also plays an important role for both the induction and maintenance of atrial fibrillation in this model.