2005 Vol. 2, No. 4
To this day, the target hemoglobin level that minimi/es cardiovascular risk in chronic kidney disease (CKD) patients remains unclear. When one examines the many randomized trials of epoetin therapy in aggregate, enhanced quality of life provides the most cogent argument for hemoglobin levels above 110 g/L. It remains unclear whether treatment of anemia im-proves longevity, or even a surrogate marker (such as left ven-tricular [LV] mass index), especially when applied at earlier phases of CKD.
Atherosclerotic renal artery stenosis (ARAS), a common clinical finding, is increasing in prevalence as the population ages. ARAS is seen in ~ 7% of persons over 65 years of age and in ~ 20% of patients at the time of coronary angiography. It is an important cause of chronic kidney disease and may result in 11-14% of cases of end stage renal disease.
Background For many years in ischemic heart disease, ventricles rather than atria received attention so not much is known about left atrial function in left ventricular ischemia. Objective Our study aimed to evaluate left atrial appendage (LAA) function by means of biplane transesophageal echocardiography in patients ten days after acute coronary syndromes (ACS). Methods The study was performed on 16 adult patients (65.9±9.9 years old) in whom transesophageal echocardiography was done 10 days after ACS. The following left atrial appendage (LAA) planimetric parameters were analyzed: LAA transversal dimension, LAA longitudinal dimension,LAA maximal area, and LAA minimal area. LAA ejection fraction was calculated and analyzed. The following LAA Doppler parameters were analyzed: the peak LAA emptying and the peak LAA filling velocities. The control group consisted of 14 patients (43±14.6 years old) without cardiovascular diseases. Results Both LAA longitudinal dimension and LAA transversal dimension were significantly higher in patients with ACS than in control patients. The same was observed for LAA maximal area. Also LAA ejection fraction was higher in patients with ACS . LAA minimal area did not differ in the patients in either group. LAA peak emptying flow (LAAE) and LAA peak filling flow (LAAF) were significantly higher in patients of the study group than of the control group. Conclusion Our study shows that two weeks after acute coronary syndrome LAA as a reservoir as well as a pump works at a higher level than it does in the control group.
In this issue of Journal of Geriatric Cardiology, Dr. Piotrowski and colleagues explored the function of the left atrial appendage (LA A)—a small, blind-ended structure of the heart which has been often ignored by cardiologists.1 Although the function and relationship between LAA and left ventricle (LV) in healthy and abnormal conditions, for instance, in atrial fibrillation or myocardial infarction, have been studied for years by physiologists and clinicians.2 Nevertheless, just like what had the authors pointed out that in ischemic heart disease, ventricles rather than atria have received far more attention for many years; therefore much less is known about the func-tion of LAA, especially in acute coronary syndromes.
Background and objective The safety of intravenous glycoprotein Ilh/llla inhibitors (GPI) in elderly patients admitted with acute coronary syndrome (ACS) has not yet been established. The purpose of this study was to evaluate the safety of GPI in elderly patients with ACS. Methods Ninety consecutive patients >7I) years of age admitted to a county hospital between 1999-2004 were included. All patients had typical ACS symptoms along with high-risk markers. Results There was no difference in the TIMI risk score between patients who received GPI (n=47) and those who did not (n=43). Patients who received GPI had a lower creatinine clearance (40 cc/min vs. 47cc/min, p= 0.04). Patients who received GPI had a lower incidence of death, rcinfarction or major bleeding (199f vs. 4%, p=0.()3). There was no significant difference in major bleeding between the 2 groups. None of the patients in cither group developed thrombocytopcnia. Conclusion This retrospective small study suggests that the use of GPI in a selected group of elderly patients with acute coronary syndrome may be safe.
The treatment of elderly patients with acute coronary syndromes (ACS) remains challenging. About two thirds of patients with ACS and four fifth of patients who died from ACS are older than 65 years.1 In spite of the tremendous ad-vances in our understanding of its pathophysiolgy during the past decades and multiple treatment options we now have, ACS is still a leading cause of death., both in developed countries and in many developing countries, including China. ACS re-sult from the disruption of the atherosclerotic plaque, leading to intracoronary thrombus formation with aggregated plate-lets within a fibrin mesh. In light of this, fibrinolitics, antiplatelet and anticoagulant agents, together with revascularizations and beta blockers, are currently major com-ponents of therapy for ACS .Because of the shift of risk ben-efit ratio among different age groups, it is extremely complex to evaluate the potential risk and benefit for each of these intervention. For example, there has been considerable con-troversy around whether the results of thrombolysis trials, con-ducted mainly in younger patients, can be applied to elderly patients. Frequently the evaluation should be performed on an individualized basis at the treating physician's discretion.
Objective In order to provide ihe maximum benefit of cardiac resynchronization therapy (CRT), we tried to use an echocardiography method to optimize the airioventricular and interventricular delay. Methods The study included 6 patients who underwent implanta-tion of biventricular pacemakers for drug-resistant heart failure. Two-dimensional echocardiography and tissue Doppler imaging were carried out before and after the pacemaker implantation. The optimal AV delay was defined as the AV delay resulting in maximum time-velocity integral (TV1) of transmitral filling flow, the longest left ventricular filling time (LVFT) and the minimum mitral regurgitation (MR). The optimal VV delay was defined as the VV delay producing the maximum LV synchrony and the largest aortic TV1. Results CRT was successfully performed in all patients. After pacemaker implantation, an acute improvement in left ventricular ejection fraction (LVEF) was observed from 26.5% to 35%. Meanwhile, the QRS duration decreased from 170ms to 15()ms. The optimal AV delay was programmed at 130. 120, 120, 120, 150 and 110ms respectively with heart rate corrected, LVFT significantly lengthened and TV I of MR decreased (non-optimal vs optimal AV delay: LVFT: 469ms vs 523ms; TV1 of MR: 16.43cm vs 13.06cm, P0.()5) and froml.31cm/s to 2.5()cm/s (P<().()5) respectively. The septal-to-lateral delay in peak velocity improved from 56.4ms to 13.3ms after CRT (P<0.01). Conclusions Optimization of AV and VV delays may further enhance the efficacy of CRT. However, there was interindividual variability of optimal values, warranting individual patient examination.
Objective To investigate plasma N-terminal pro-brain natriuretic peptide (NT-BNP) levels and to assess their clinical signifi-cance in elderly patients with isolated diastolic dysfunction. Methods Plasma NT-BNP level were measured by electrochemiluminescence immunoassay in 34 symptomatic patients (Group 1), 34 asymptomatic patients (Group 2) with isolated diastolic dysfunction, and in 16 elderly healthy subjects (control group, Group 3), serving controls. Colored Doppler echocardiography was performed to evaluate the patients' cardiac structures and functions. Results The plasma NT-BNP level in Group 1 was significantly higher than those in Group 2 and Group 3 and increased with the severity of heart failure. There was no significant difference of plasma NT-BNP levels between Group 2 and Group 3 (p>().()5). A NT-BNP value of 102.75 pg/mL showed a sensitivity of 88.2%, a specificity of 87.5%, and an accuracy of 88.1 % for diagnosing diastolic dysfunction. Patients with restrictive filling pattern on echocardiography had higher NT-BNP levels than those of impaired relaxation pattern (1961.2±304.9 versus 460.1 ±92.7pg/mL, p<0.001). Conclusion The elevation of plasma NT-BNP level in elderly patients with isolated diastolic dysfunction correlates with the severity of their diastolic abnormalities. The level of plasma NT-BNP has an important clinical value in the diagnosis of elderly patients with isolated diastolic dysfunction.
The current issue of the Journal of Geriatric Cardiology contains an interesting paper by Dr. Yixin Song and colleagues raising important issues in the diagnosis and management of heart failure in elderly patients. Readers of this journal are in all likelihood aware that the epidemic of heart failure is of great impact medically and economically worldwide. The primary risk factors for heart failure are age, coronary artery disease (CAD), and hypertension, with diabetes, valvular heart disease, and non-ischemic cardiomyopathies also contributing to heart failure rates.1 Recent estimates for the US put heart failure prevalence at 5.2 million cases with an annual incidence of 600,000 new cases per year.2 Extrapolations from limited data provide an estimate of 23 million cases of heart failure in China with an annual incidence of 2.6 million cases.2 Percentage of total deaths due to heart failure is likely higher in China than the US: heart failure mortality is estimated of 8. 5% of all deaths in Shanghai and 6% in Beijing versus only 2% in US, though the statistics from Hong Kong and Taiwan show a similar 2% as in the US.' Reasons for the higher rates of mortality from heart failure in Shanghai and Beijing compared to US despite much lower rates of CAD likely include higher rates of non-coronary heart disease and uncontrolled hypertension, along with delayed diagnosis and reduced access to medical treatment. Heart failure mortality rates have declined by 2/3 in Japan in the past 10 years, presumably in large part due to improved medical management, but have been unchanged in Shanghai.' This discrepancy suggests that China has the opportunity to dramatically reduce heart failure morbidity and mortality as it moves toward implementation of more aggressive efforts to diagnose and manage heart failure. The paper by Song and colleagues, while reporting on only a small number of patients from a solely diagnostic perspective, is an important marker of increased interest in heart failure evaluation and management in China.
Objective To evaluate the feasibility, safety and efficacy of percutaneous stent implantation for treating left main coronary artery (LMCA) stenosis. Methods Consecutive patients with unprotected left main coronary artery disease treated by stent-based percutaneous intervention (PCI) at 6 medical centers in China were enrolled. Procedural data and clinical outcomes were obtained from all patients. Results From January 2001 to December 2004, 138 patients (79 males and 59 females; mean age: 69.7 + 5.8 years) underwent PCI for LMCA stenosis. Bare metal stents (BMS) were implanted in 51 patients with non-bifurcational lesions and in 5 patients with bifurcational lesions from January of 2001 to June of 2003 (BMS group);, drug eluting stents (DBS) were used unselectively to cover both bifurcational and non-bifurcational lesions in 86 patients from July of 2003 to December of 2004 (DBS group). Proce-dural success rate of the 138 cases was 98% (135/138). One patient (0.7%) with bifurcation lesion who was treated with DES died from severe heart failure 2 weeks after the procedure. During a mean follow up period of 21.3 + 5.6 months, one patient died from renal failure, one from sudden cardiac death, 4 underwent target lesion revascularization (TLR) in the BMS group, which all occurred in patients with bifurcational lesions; whereas in the DES group no deaths occurred and only one patient with bifurcational lesion had TLR. Conclusions (1) PCI is feasible and relatively safe to treat unprotected left main coronary artery disease in elderly patients at medical centers with experienced professionals. (2) BMS and DES have similar immediate and long-term efficacy in the treatment of ostium and shaft lesions of the LMCA. (3) DES are strongly suggested in the therapy of distal bifurcation lesion of unprotected LMCA.
Objective To investigate the relationship between transcription factor and the change of protein expression levels in heart failure. Methods Bioinformatic method was used to analyze the data of binding-sites on the 5' flaking regions of four genes whose mRNA level changed in failing heart from three databases about nucleic acid-EMBL, transcriptional regulation factor-TRANSFAC and protein-SWISS-PORT. The expression level of selected transcription factor was determined by immunohischemical method. Results Nine transcription factors were inferred to influence the proteins' levels in occurrence and development of heart failure. Serum response factor (SRF) was selected from the nine factors and assayed. The results showed that there was a higher level of SRF in healthy group than in chronic heart failure (CHF). and the level was associated with the degree of CHF. It was also found that there was a relative higher level of SRF in the acute myocardial infarction (AMI) than that in CHF, but which was lower than the healthy. Conclusion It showed that SRF had a quantitative change in the development of heart failure, and suggested SRF might play an important regulative role in heart failure. The expression changes of proteins related to myocardial function might be regulated by the quantitative change of transcription factor(s).
Background Previous studies reported a close relationship between obesity and insulin resistance in the essential hypertensive patients. Objective In this study, we examined the relationship between the skin fold thickness and insulin resistance then developed a formula to estimate the insulin resistance index according to the skin fold thickness in the essential hypertensive patients. Subjects and Methods Medical records of 80 patients (37 males, 43 females) were reviewed and the data were tabulated. Anthropometric indexes (including height, weight, waist circumference, hip circumference, and skins fold thickness at 5 fatty difference points on the Erdheim diagram), fasting plasma glucose and insulin concentration were recorded. The mean age was 57.0 ± 9.2 years. The insulin resistance index was calculated following the Homeostasis Model Assessment (HOMA) formula. Results Compared with the group with BMI 23 kg/m2 had higher fasting insulin concentration (8.85 ± 4.97 pmol/L vs 15.60 ± 8.70 pmol/L, P 0.05). There < .as a positive correlation between skin fold thickness and the fasting insulin concentration and insulin resistance index. The skin fold thickness at point A8 had the best coefficient correlated with fasting plasma insulin(r=0.79, P < 0.001) and insulin resistance index (r= 0.79. P < 0.001). A formula to estimate the insulin resistance index by skin fold thickness at point A8 as: Insulin resistance index = 0.12 x [skin fold thickness at A8 point (mm)l - 1. Conclusion: In the essential hypertensive patients, the formula to estimate insulin resistance index as 0.12 x [skin fold thickness at A8 point (mm)|-1 may predict accurately the level of insulin resistance.
Background and Objectives Tetramethylpyrazine (TMP) is a herb used widely in Traditional Chinese Medicine (TCM) as an antianginal drug. The exact mechanism whereby TMP treat ischcmic heart disease is still not fully understood. The purpose of this study is to examine the anti-inflammatory effect of TMP in patients with acute coronary syndromes (ACS). Methods Thirty-two patients with acute myocardial infarction or unstable angina were randomly assigned to TMP group or control group. All patients received the same standard treatment. Patients in TMP group received TMP 3mg/kg every 12 hours for 5 days. Plasma concentrations of high-sensitivity C-reactive protein (CRP), serum amyloid A (SAA) and plasminogen activator inhibitor-1 (PAI-1) were measured at baseline and after 5 days of therapy. Results Both CRP and SAA concentrations increased significantly in control group (P<0.05). Conclusion TMP has an anti-inflammatory and profibrinolytic effect in patients with ACS. These effects may contribute to the clinical benefits of TMP in ischemic heart disease.
Objective To observe the influence of neuregulin-1 on the cardiac function of post-myocardial infarction rats. Methods Left ventricular MI was created in Sprague-Dawley rats by ligalion of the left anterior descending coronary. Six months after the operation, rats were evaluated with echocardiology methods. 36 rats that had an infarct area and a EF around 60% were randomized into 3 groups: MI group(n=12) were injected a blank vehicle fluid intravenously for 5 days, after which they continued to be raised on standard food and water for 30 days. MI+NRG group(n=12). received NRG-1 10(J.g ? kg ' intravenously for 5 days, after which they continued to be raised on standard food and water for 30 days. Ml+Capl group (n=12) received captopril orally (dissolved in their drinking water 2g/L) for 30 days , after which tap water substituted the solution for 5 days. Final echocardiographic and hcmodynamic measurements were made at the end of 1 month of therapy. Total RNA was extracted from fro/en left ventricular tissues, and was reverse transcribed into first-strand PCR was performed with primers for BNPx ANP. Results Rats treated with neuregulin had a smaller LVDs (F=0.()14), a better LVEF (P=0.004 ),and a tendency towards less lung perfusion than untreated rats. Neuregulin decreased the expression of ANP mRNA in the ventricle (P=0.025 ).Conclusion Neuregulin markedly improved the cardiac function of rats that survived myocardial infarction, and decreased the expression of ANP mRNA in the ventricle.
Objective To investigate whether the calcium channel blocker umlodipine could inhibit macrophage matrix metalloproteinase-2 (MMP-2) and matrix melalloproteinasc-9 (MMP-9) expression and secretion. Methods Peritoneal macrophages were isolated from BALB/C mice and incubated with low (5|ig/L ), middle ( 1'p.g/L) and high (30?u,g/L) concentrations of amlodipine. or in the medium alone (controls) for 24 hours, and the expression and secretion of MMP-2 and MM-9 of the cells were analyzed by RT-PCR and gelatin zymography. Results Compared with controls, amlodipine at low concentration had no significant effects on the expression and secretion of either MMP-2 and MMP-9 (P>0.05) at middle concentrationit it could inhibited MMP-2 and MMP-9 expressions completely and significantly reduced the secretion of MMP-9 (P<().()5); but it had no effect on the secretion of MMP-2. At high concentration it also inhibited MMP-2 and MMP-9 expression completely. Conclusion Amlodipine at 15 ig/L inhibited the expression of MMP-2 and MMP-9 and reduced the secretion of MMP-9, suggesting that amlodipine may stabilize atherosclerotic plaque.
Coronary heart disease (CHD) remains the number one killer of men and women in the United States of America despite major advances in interventional technologies for the treatment of coronary artery disease. CHD is rapidly becoming a major cause of morbidity and mortality in developing nations as well and is now recognized as the leading cause of death worldwide. The recognition and treatment of coronary risk factors such as high cholesterol levels, hypertension, smoking, obesity and diabetes has made a positive impact on CHD morbidity and mortality. The most successful treatment has targeted lowering LDL cholesterol with HMG CoA Reductase Inhibitors or the statin class of medications. Recent studies have extended the boundaries of treatment to different risk groups and are reporting significant reductions in coronary events.
Many studies have demonstrated a correlation between increasing age and adverse drug reactions. This increased risk is related to aged-related changes in pharmacokinetics and pharmacodynamics. In addition, chronic illnesses such as congestive heart failure, coronary artery disease and hypertension are more prevalent in the elderly who also have an increased risk of diabetes, arthritis and cancer. Consequently elderly patients are often treated with multiple medications, which may cause drug interactions and adverse drug reactions. Adequate undergraduate training in clinical pharmacology and continued professional development in evidence-based therapeutics will undoubtedly reduce inappropriate prescribing and improve the quality of medications. Good communications between physicians and patients are also critically important in avoidance or prevention of adverse drug reactions in the elderly.
During aging, cardiac contractile response to P-AR stimulation is decreased in humans and animal models. Recent studies demonstrate that the positive inotropic effects of both f^-AR and P2-AR stimulation are significantly decreased with aging. This is accompanied by decreases in both P-AR subtype densities and a reduction in membrane adenylyl cyclase activity. However, neither G protein-coupled receptor kinases (GRKs) nor inhibitory G proteins (G.) appears to contribute to the age-associated reduction in the P-AR modulation of contraction. Thus, while both aging and chronic heart failure exhibit a diminution in cardiac P-AR responsiveness, only heart failure exhibits increased GRK-mediated dcsensitization of p-ARs and an upregulation of G proteins.