2007 Vol. 4, No. 4
Background For patients with cardiovascular disease (CVD), co-existence of peripheral artery disease (PAD) predicts increased mortality, and such patients are also more likely to benefit from aggressive therapy. Surveillance of PAD is often neglected at health clinics. Our aim is to highlight the importance and ease of surveillance of PAD in patients with CVD. Objective To determine the prevalence of symptomatic and asymptomatic PAD in a Malaysian patient population with documented CVD. Methods and Results A total of 393 subjects with established CVD were recruited from three centres (85 women and 308 men), as part of a larger international (AGATHA) survey. PAD, determined by presence of claudicant symptoms on interview and/or abnormal ankle-brachial index (ABI) score of less than 0.9, was present in 21.4% of patients - of whom 64% were asymptomatic. Abnormal ABI is associated with higher systolic blood pressure and number of arterial beds affected. Conclusions Concomitant PAD is prevalent among CVD patients in Malaysia. ABI screening is simple and yields a high proportion of patients with extensive atherosclerosis who may require more aggressive atherosclerotic risk management.
Peripheral arterial disease remains an afterthought among many clinicians, including specialists in cardiovascular diseases. In this issue, Sim et al.1 illuminate the prevalence of peripheral arterial disease (PAD) among Malaysian patients with known coronary or cerebrovascular disease. There have been few reports on the prevalence of PAD in Asian countries, and no large-scale, multi-center reports among Malaysians. There are several important points to take home from this report. But most importantly, we should focus on how this report on PAD in a different population strengthens the same lessons about PAD that we have already learned.
Objective The aim of the study is to investigate the effects of psychosocial factors on the treatment of elderly patients with hypertension. Methods Atotalof 260 elderly Chinese patients with hypertension were treated with benazepril alone or benazepril combined with amlodipine for 8 weeks. The target blood pressure (BP) (both <140 mmHg systolic, SBP, and <90 mmHg diastolic, DBP) was achieved in 180 patients, who were then assigned to the well-controlled BP group; the rest were placed in the modestly controlled BP group. The psychosocial factors present in both groups were assessed by the Hamilton depression scale, Hamilton anxiety scale, life event scale and social support evaluation list before and after anti-hypertensive treatment. Results There were no significant differences in gender, mean age, hist ory of hypertension, education and smoking habit, or in SBP and DBP between the groups before treatment. Significant differences were also not found in all psychosocial factors before and after treatment in the patients. However, significant differences were found between the groups with respect to post-treatment SBP and marital status. The patients with modestly controlled BP had significantly higher scores, as well as incidents, on the depressive, anxiety, and stressful life event scales than those with well-controlled BP. The patients with well-controlled BP had significantly higher scores in tangible support, subjective support, and social support compared to the patients with modestly controlled BP. Logistic regression analysis showed the independent contribution of psychosocial factors in reaching the goal of lowering BP at treatment endpoint in these hypertensive patients. Conclusions The results suggest that psychosocial factors stand as a main barrier to achieving the BP-lowering target in the management of elderly Chinese patients with hypertension.
In this issue of the Journal of Geriatric Cardiology, the article of Yu, et al1 presents an intriguing issue in the field of hypertension treatment and pathophysiology. On one hand, it appears quite logical that social and psychological stresses may lead to a hypertensive status which increase all those physiological neuro-hormonal responses to stress, on the other hand, however, it seems similarly intuitive that poor social status and low familial support decrease the chance that patients are compliant with assigned therapy. It appears more difficult to understand where one begins and the other finishes or, in other words, which is the first phenomenon to start; the old Italian, probably worldwide-question “which came first: the egg or the chicken?” is very hard to answer. In his article, Yu and colleagues studied a small cohort of patients with hypertension and tried to discriminate the therapeutic response on the basis of psychosocial factors. The patients were whitecollar professionals with probably a quite good economic status, which in itself is a positive social factor. They did not have any disease other than hypertension, which is another positive “anti-stress” factor. Despite these limitations, patients with lower response to therapy are those with higher stressful, anxiety, and depressive scores.
Objective To study whether myeloperoxidase (MPO) can provide prognostic information in patients with acute coronary syndromes (ACS). Methods The study population consisted of 274 consecutive patients with ACS. All patients underwent coronary angiography which showed significant coronary artery disease and blood samples were collected at admission. Follow-ups were scheduled at 1, 3, and 6 months.The end point included cardiac death, acute myocardial infarction (MI), percutaneous or surgical revascularization. Results Patients with elevated MPO serum levels (MPO?Y72.2 AUU/L) were more likely to have diabetics and had a history of coronary events. Kaplan-Meier event rate curves with accumulative incidence of end point at 6-month follow-up in the MPO >72.2 AUU/L group was significantly higher than in MPO<72.2 AUU/L group. Conclusions MPO may be a powerful predictor of adverse outcome in patients with ACS.
The majority of acute myocardial infarctions occur because of the sudden development of a thrombus in a coronary artery. The thrombus is frequently associated with a ruptured plaque releasing tissue factor into the circulation which is highly thrombotic. Plaques that are prone to rupture tend to have large lipid pools, a large number of inflammatory cells, and a thin fibrous cap. The inflammatory cells are thought to contribute to the vulnerability of the plaque by inhibiting cells that synthesis collagen and by releasing proteinases that degrade collagen in the fibrous cap. The measurement of inflammatory makers such as C-reactive protein has been proposed as a potential way to identify patients that have inflamed and vulnerable plaques. Therapies, such as high doses of statins, can be initiated to reduce cardiovascular events in part by reducing inflammation and stabilizing vulnerable plaques.
Background and Objective To investigate the effects of simvastatin on lipid lowering therapy and platelet activation in elderly patients with hypercholesterolemia. Methods Fasting serum lipids, CD63, CD41a, serum glucose, hepatic and renal function, routine urine analysis (UA) were measured in 50 healthy subjects, and in 50 elderly patients with hypercholesterolemia before and after 4 weeks treatment with simvastatin (20mg daily for 4 weeks). Results 1. After simvastatin treatment for 4 weeks, the fasting serum level of lipids in elderly patients with hypercholesterolemia was significantly lower than before treatment (P0.05). Conclusions The results suggested that lipid lowering therapy with simvastatin inhibit platelet activity.
As a class of drugs, statins have gained renown for their ability to effectively reduce cardiovascular events in both patients with heart diseases (secondary prevention) and in those who, while not with manifest heart disease (primary prevention), are at increased risk based on a variety of risk factors including hypertension, diabetes, and age.
Objective Assessment of right ventricular function in patients with atrial septal defect (ASD) is difficult. The Doppler myocardial performance index (MPI) may provide a method of assessing function in these patients. The purposes of this study were to evaluate the right ventricular function and its changes in patients with ASD after transcatheter closure of ASD. Methods MPI, defined as the sum of isovolumic relaxation time and isovolumic contraction time derived by ejection time, was measured from tricuspid inflow and right ventricular outflow; Doppler velocity profiles recorded during routine echocardiography.Twenty nine patients ( 13 men, 16 women; mean age 25.28±12.69, range 6 to 57 years) were diagnosed to secundum ASD [the stretched diameters of ASD were from 9 To 36 (24.91±7.98) mm], and had a successfully placed Amplatzer septal occluder (ASO) (the sizes of ASO were from 11 to 40 mm ); there were 81 sex-matched, age-matched healthy people (control group 41men, 40 women; mean age 29.02±14.22, range 4 to 45 years ). MPI was measured again on 3 days and 1 month after closure of ASD. Change in the study group was assessed and compared to the control subjects with structurally normal hearts. A complete 2- dimensional and Doppler echocardiographic examination was performed in all study groups. Results 1) The isovolumic relaxation and isovolumic contraction times [respectively(77.59±14.39)ms vs (60.93 ±12.94)ms, P<0.0001; (28.28±10.88)ms vs (23.64±9.01)ms, P=0.027] were prolonged, and ejection time [(260.65±21.86 )ms vs (271.85 ±21.92)ms, P=0.033] was shortened in patients with ASD compared with that in control subjects, resulting in a marked increase in the MPI(0.40 ±0.07 vs 0.31 ±0.05, P<0.0001) from normal values; 2) by Pearson’s correlations, the MPI had no correlation with heart rate and blood pressure in control subjects and patients with ASD, but it correlated positively with age in patients with ASD; 3) by Pearson’s correlations, the MPI correlated positively with the diameter of ASD and pulmonary artery pressure; 4) after transcatheter closure of ASD, the MPI decreased markedly. Conclusions 1) MPI is a conceptually new, simple, and reproducible Doppler index in patients with ASD; 2) MPI is free from the effect of age, heart rate and blood pressure; (3) MPI appears to be relatively dependent on changes in the diameter of ASD and pulmonary artery pressure; 4) the right ventricular function was improved after transcatheter closure of ASD.
Objective To determine the occurrence of neurological changes during the first 48 hoursafter acute stroke as it relates to the initial stroke severity assessment. Methods The assessment with the National Institutes of Health Stroke Scale (NIHSS) was performed serially for the first 48 hours on 68 consecutive ischemic stroke patients admitted to the Department of Geriatric Cardiology at the Khanh Hoa Hospital, Nha Trang, Vietnam. Incidence of stroke progression (a?Y3-point increase on the NIHSS) was recorded and analysis performed to determine its association with initial stroke severity and other demographic and physiological variables. Deficit resolutionby 48 hours, defined as an NIHSS score of 0 or 1, measured thefrequency of functional recovery predicted by the initial deficit. Results Overall progression was noted in 28% of events (19/68). Applying Bayes’ solution to the observed frequency of worsening, the greatest likelihood of predicting future patientprogression occurred with NIHSS score of =7 and >7. Patients with an initial NIHSS score of =7 experienced a 13% (6/47) worsening rate versus those of an initial score of >7 with a 62% (13/21) worsening rate (P7 returned to a normal examination within this period (÷2, P<0.05). Conclusions This study suggests that the early clinical course of neurological deficit after acute stroke be dependent on the initial stroke severity and that a dichotomy in early outcome exist surrounding an initial NIHSS score of 7. These findings may have significant implications for the design and patient stratification in treatment protocols with respect to primary clinical outcome.
Objective The goal of this study was to examine the association between urotensin Ⅱ (U Ⅱ) concentration and the severity of coronary artery disease (CAD). Methods We studied U Ⅱ concentrations in 100 patients with known or suspected CAD referred for cardiac catheterization. Based on coronary angiograms, subjects were classified as having no or mild CAD (stenosis 0.05), but higher in the severe group (score =9) than in the normal or nearly normal group (score<3)( 2.50±1.62pmol/L vs 1.61±1.05pmol/L, P=0.03). UⅡ concentration had no relationship with other known risk factors, but it correlated with CAD severity (r=0.213, P=0.034). In multiple regression analysis, UⅡ is one of the determinants of the severity of CAD, other than age, abnormal glucose, hypertension and gender. Conclusios U Ⅱ is elevated in severe CAD and there is a significant relationship between U Ⅱ concentration and CAD severity.
Objective To compare the efficiency and safety of intracoronary transplantation of peripheral blood stem cells (PBSC) between elderly and younger patients with heart failure after myocardial infarction (MI). Methods Twenty-five patients with heart failure after MI were divided into aged group(≥60 year, s=13) and non-aged group(<60years,n=12)to receive intracoronary PBSC transplantation (PBSCT) following bone marrow cells mobilized by granulocyte colony-stimulating factor(G-CSF). Clinical data including coronary lesion characteristic, left ventricular shape,infarct region area and cardiac function, as well as adverse side effects between the two groups were compared. Left ventricular function was evaluated before and 6 months after the treatment by single photon emission computed tomography (SPECT). Results At 6 months, the left ventricular ejection fraction (LVEF) and 6 minute walk test (6MWT) distance increased, while the left ventricular diastolic diameter (LVDd) decreased significantly in both groups. There were no significant difference between the two groups in absolute change in the cardiac function parameters. Conclusions The present study demonstrated that autologous intracoronary PBSCT might be safe and feasible for both old and younger patients with heart failure after MI and left ventricular function is significantly improved.
Objective Atrioventricular block (AVB) is a common and serious arrhythmia. At present, there is no perfect method of treatment for this kind of arrhythmia. The purpose of this study was to regenerate cardiac atrioventricular conduction by autologous transplantation of bone marrow mesenchymal stem cells (MSCs), and explore new methods for therapy of atrioventricular block. Methods Eleven Mongrel canines were randomized to MSCs transplantation (n=6) or control (n=5) group. The models of permanent and complete AVB in 11 canines were established by ablating His bundle with radiofrequency technique. At 4 weeks after AVB, bone marrow was aspirated from the iliac crest. MSCs were isolated and culture-expanded by means of gradient centrifugal and adherence to growth technique, and differentiated by 5-azacytidine in vitro. Differentiated MSCs (1ml, 1.5×107cells) labeled with BrdU were autotransplanted into His bundle area of canines by direct injection in the experimental group, and 1ml DMEM in the control group. At 1-12 weeks after operation, the effects of autologous MSCs transplantation on AVB models were evaluated by electrocardiogram, pathologic and immunohistochemical staining technique. Results Compared with the control group, there was a distinct improvement in atrioventricular conduction function in the experimental group. MSCs transplanted in His bundle were differentiated into analogous conduction system cells and endothelial cells in vivo, and established gap junction with host cardiomyocytes. Conclusions The committed-induced MSCs transplanted into His bundle area could differentiate into analogous conduction system cells and improve His conduction function in canine AVB models.
Coronary bypass graft surgery (CABG) is a revascularization procedure which reduces myocardial ischemia and cardiovascular morbidity and mortality in selected patients; however, up to 40% of saphanous vein grafts may degenerate over 10 years. Although coronary angiography is the gold standard to detect graft patency and native vessel disease, sometimes it is difficult to locate the grafts resulting in increased exposure to radiation and contrast administration. This case highlights the utility of cardiac computerized tomography and magnetic resonance imaging to provide comprehensive noninvasive assessment in a patient post CABG.
The progression of atherosclerosis of the coronary artery does not stop after coronary arterial bypass grafting (CABG) surgery. In contrary, new stenotic lesions or even occlusions could develop more quickly in the native artery segment proximal to the insertion site of the graft. Other lesions could develop at the native arterial segment beyond the insertion site of the graft or on the graft itself, especially if this is a saphenous vein graft. New lesions on an arterial graft were less common. A few months, one year, or a few years after CABG, when the symptoms of coronary heart disease (CAD) re-occur, a thorough assessment of the patency of the grafts or native coronary arteries is indicated. Then, complete revascularization is needed in order to decrease short and long term morbidity and mortality.
The elderly population consists of those over age 75 years and appears to represent the fastest-growing segment of the population. Intravenous thrombolytic therapy (TT) is the most common strategy for the treatment of acute myocardial infarction (AMI) in many parts of the world. However, TT carries a higher risk of intra-cranial hemorrhage (ICH) in the elderly patients. Primary percutaneous transluminal coronary angioplasty and stenting (PCI) represents an important alternative in these elderly individuals with contraindications to TT. In developing countries, or in areas without availability of primary PCI, TT remains the only therapeutic modality. Dedicated randomized trials are needed to provide a comprehensive understanding of AMI management in the elderly group.
The increase in life expectance makes the diagnosis of PFO a possible and not easily manageable event in patients > 60-years-old due to the presence of different comorbidities and in particular of diastolic dysfunction which is considered as a contraindication to PFO closure. The literature review suggests that aged patients with PFO cannot be excluded “a priori” from PFO closure that should evaluated as therapeutic options in presence of anatomical and functional indications. Moreover in the elderly many other syndromes than paradoxical stroke mediated by PFO required full assessment and, if needed, transcather PFO closure: deoxygenating in obstructive sleeping apnoea, unexplained increased dyspnoea associated with hypoxemia after lung surgery, paralysis of the hemidiaphragm, and platypnea orthodeoxia. Differently from in the young and middle age, the management of PFO in aged patients should obligatory include the careful evaluation of potential comorbidities and eventual contraindications, such as severe diastolic dysfunction due to for example to hypertensive cardiomyopathy and coronary heart disease, the main causes of diastolic dysfunction.