Effect of weight loss on ventricular repolarization in normotensive severely obese patients with and without heart failure.

BACKGROUND: Obesity has been reported to be associated with delayed ventricular repolarization. The purpose of this study was to assess ventricular repolarization in normotensive severely obese subjects with and without heart failure (HF) and to assess the effect of weight loss on ventricular repolarization in such patients. METHODS: Twenty-eight patients with and 39 patients without HF (body mass index ≥ 40 kg/m(2)) were studied before and after weight loss from bariatric surgery. Corrected QT interval (QTc) was measured on 12-lead electrocardiograms using Bazett's formula. QTc dispersion was calculated by subtracting the minimum from the maximum QTc on each 12-lead electrocardiogram. Electrocardiograms and transthoracic echocardiograms were performed preoperatively and at the nadir of postoperative weight loss. RESULTS: Mean QTc and QTc dispersion were significantly longer/greater in subjects with HF than in those without HF (P < 0.0001). Weight loss produced significant reductions in mean QTc and QTc dispersion in both subgroups (P < 0.0001). Pre-weight loss left ventricular (LV) mass/height and presence or absence of HF independently predicted pre-weight loss QTc and QTc dispersion (P < 0.0001). Weight loss-induced decrease in LV mass/height independently predicted weight loss-induced decreases in QTc and QTc dispersion (P < 0.0001). CONCLUSIONS: HF independently predicts QTc and QTc dispersion in normotensive severely obese patients. Decrease in the LV mass resulting from weight loss independently predicts reduction in QTc and QTc dispersion in such patients.

Heart failure with a normal left ventricular ejection fraction: epidemiology, pathophysiology, diagnosis and management.

Heart failure (HF) with a normal left ventricular (LV) ejection fraction (HFNEF) occurs in 40-71% of patients with HF and carries a prognosis similar to that of HF with a reduced LV ejection fraction (LVEF). The pathophysiology of HFNEF is distinct from that of HF with a reduced LVEF and is characterized by impaired relaxation of myocardium, LV stiffness and, in many cases, increased arterial stiffness. Systemic hypertension accounts for most cases of HFNEF in the United States. Those with HFNEF tend to be older and obese. Diabetes mellitus and atrial fibrillation occur with disproportionately high frequency in HFNEF. The diagnosis of HFNEF requires the presence of symptoms or signs of HF, a normal or near-normal LVEF and evidence of LV diastolic dysfunction based on cardiac catheterization or Doppler echocardiographic techniques and/or elevation of plasma natriuretic peptide levels. Current guidelines for management of HFNEF include control of systolic and diastolic hypertension, control of the ventricular rate in patients with atrial fibrillation and judicious use of diuretics. In selected cases, coronary revascularization or restoration of sinus rhythm in those with atrial fibrillation may be indicated. To date, no drug or drug group has consistently improved survival in HFNEF. For this reason and because of the poor long-term prognosis, preventative measures and effective treatment of underlying causes and precipitating factors are particularly important in avoiding HF exacerbations in patients with HFNEF.

Risk factors for atherosclerosis in patients with chronic kidney disease: recognition and management.

Heart disease is the most common cause of death in patients with chronic kidney disease (CKD), particularly in those receiving dialysis. Atherosclerosic cardiovascular (CV) disease (CVD) accounts for a large number of these deaths. Atherosclerosis is accelerated in patients with CKD due predominantly to the high prevalence of traditional CVD risk factors in the CKD population. CKD aggravates pre-existent traditional risk factors such as hypertension and dyslipidemia due to secondary renal parenchymal hypertension and secondary dyslipidemia. In addition, a variety of non-traditional risk factors that occur commonly in CKD patients contribute to CV risk. Recent studies suggest that CKD itself may be an independent risk factor for CVD, particularly coronary heart disease (CHD). Many therapies aimed at CV risk factor modification that have been successful in reducing CV risk in the general population are less effective or ineffective in favorably modifying CV risk in CKD.

Chronic Inflammation and Coronary Atherosclerosis in Patients with End-Stage Renal Disease.

The key role of chronic inflammation in the pathogenesis of atherosclerosis has become increasingly apparent in recent years based on the results of experimental, epidemiologic and clinical studies. Coronary artery disease and its complications occur with disproportionately high frequency in patients with end-stage renal disease (ESRD) and contribute substantially to cardiovascular morbidity and mortality in this population. Traditional cardiovascular risk factors occur commonly in patients with ESRD. In addition, a variety of patient-related and dialysis-related factors unique to ESRD predispose to chronic inflammation and by doing so are thought to contribute to coronary atherosclerosis and its complications. These risk factors may serve as therapeutic targets and as such may offer the potential for altering the natural history of coronary atherosclerosis in ESRD.

The tale of mind & heart: psychiatric disorders & coronary heart disease.

The mind-body interaction has always intrigued humans. Most people, on the basis of either intuition or personal experience, believe that emotional stress can cause or alter the course of even major physical diseases. Sir William Osler described his typical patient with angina pectoris as 'a man whose engine is always set full speed ahead' and described his patients with cardiac disease as 'worriers'. In recent years there has been tangible evidence for the existence of this interaction however modern medicine is still trying to unravel its intricacies. In this article we review the current knowledge regarding the effect of depression, anxiety disorders and the detrimental effect it has on coronary heart disease. In addition we discuss some of the proven acute psychological triggers for acute coronary syndrome.

Cardiovascular mortality in dialysis patients.

In their broad spectrum, cardiovascular diseases are, collectively, the major cause of death in patients on dialysis. The population of patients treated with peritoneal dialysis and hemodialysis are not only subject to the traditional risk factors for heart disease, but also to certain uremia-associated risk factors that are unique in this population. In the dialysis population, data regarding the effectiveness of routine pharmacologic and procedural interventions on cardiovascular outcomes are limited. Most dialysis patients are excluded from clinical trials, and so data from randomized controlled trials investigating outcomes in patients undergoing peritoneal dialysis or hemodialysis are almost absent. In this review, we discuss some of the major cardiovascular problems in the dialysis population, the impact of those problems on survival, and when data are available, the impact of therapeutic strategies.

Electric cardioversion of atrial fibrillation.

Electrical cardioversion (EC) has been performed for atrial fibrillation (AF) for over 40 years. EC is safe, effective and reliable method for aborting AF especially in unstable situations. Numerous technical and patient characteristics contribute to the success of EC. Recently various developments in this field and newer antiarrhythmic agents have lead to substantial evolution of this procedure. We review the current clinical applications, and techniques.

Chilaiditi syndrome complicated by cecal perforation.

Chilaiditi sign is a radiological finding which describes the interposition of a part of the bowel between the diaphragm and the liver, a finding that can be misinterpreted as pneumoperitonium. Chilaiditi syndrome refers to a clinically symptomatic patient in the presence of the classical radiographic findings. It is a very rare syndrome which usually follows a benign course. Here we report the first documented case of Chiliaditi syndrome complicated by cecal perforation.

A case of aortic dissection in a cocaine abuser: a case report and review of literature.

BACKGROUND: Prompt diagnosis and management of aortic dissection are key to reduce patient morbidity and mortality; hence the need to a have a high index of suspicion for this condition. We believe it's important to report this case because it underscores the relationship between cocaine abuse and aortic dissection. In addition it strongly emphasizes basic principles in medicine: patients should not be profiled, and chronic complaints may need reassessment. CASE PRESENTATION: We are presenting a case of Stanford type A aortic dissection in a 46 year old patient with history of cocaine abuse. The aortic dissection presented as worsening of chronic upper abdominal pains he has had for years. He presented to us hours after using crack cocaine. CONCLUSION: Aortic dissection associated with cocaine abuse develops at a younger age. Therefore it's crucial to have high index of suspicion for aortic dissection in this subset of patients. Furthermore as this case illustrates, serious diseases can masquerade in old complaints. Patients should never be profiled, and chronic complaints should always be revisited.