2009 Vol. 6, No. 4
Objective Recently it has been suggested that, in patients with large patent foramen ovale (PFO) and atrial septal aneurysms (ASA), a certain amount of left atrial (LA) dysfunction may be active as an alternate mechanism promoting arterial embolism. Following this hypothesis, elderly patients, being more susceptible to atrial chambers stiffness, should present a more severe LA dysfunction profile. We sought to evaluate the grade of LA dysfunction in elderly patients submitted to transcatheter PFO closure. Methods We retrospectively enrolled 28 consecutive patients with previous stroke (mean age 67±12.5 years, 18 females) referred to our centre for catheter-based PFO closure after recurrent stroke. Baseline values of LA passive and active emptying, LA conduit function, LA ejection fraction, and spontaneous echocontrast (SEC) in the LA and LA appendage were compared with those of 50 atrial fibrillation patients, as well as a sex/age/cardiac risk matched population of 70 healthy controls. Results Pre-closure elderly subjects demonstrated significantly greater reservoir function as well as passive and active emptying, with reduced conduit function and LA ejection fraction, when compared to healthy and younger patients. After closure in elderly patients, LA parameters did not return completely to the levels of healthy patients, whereas LA dysfunction in younger subjects returned normal. Conclusions This study suggests that elderly patients have more severe LA dysfunction than younger patients, which affects the LA remodelling after closure.
Objective The sex hormone and the corresponding receptor may play some roles in the development of the metabolic syndrome (MS) in the elderly men. This study was designed to examine the relationship of level of the sex hormone and androgen receptor with MS in elderly men, thus to investigate the possible pathogenesis of MS . Methods This cross sectional study enrolled 587 elderly men, including 400 healthy controlls aged 62-92 years and 187 MS patients aged 60-87 years in Wan Shou Lu area of Beijing city. Dehydroepiandrosterone sulfate (DHAE-S), total testosterone (TT), sex hormone binding globulin (SHBG), free testosterone (FT), follicle-stimulating hormone (FSH),Estradiol (E2),luteinizing hormone(LH) and androgen receptor (AR) in blood were tested. Statistical analyses included the comparison analysis of variables and independent variables, correlation analysis using multi-factor linear regression, and multiple logistic regression analysis. Results DHAE-S, TT, SHBG, FT and AR fluorescence intensity in healthy control group were higher than those in MS group, however, FSH and E2 levels were lower in healthy group. Age was negatively correlated with diastolic blood pressure (DBP) and FT, but positively correlated with systolic blood pressure (SBP) and E2. AR fluorescence intensity was negatively correlated with SBP and LH. The logistic regression equation showed the negative correlation between DHEA-S, SHBG and the development of MS. Conclusions There are low levels of DHEA-S, TT, SHBG, FT and AR in the elderly patients with MS. On the contrary, FSH and E2 concentration are higher. It can be suggested that low levels of DHEA-S and SHBG may be the potential risk factors of MS in elderly men.
Objective To develop a tool capable of early and exactly predicting various outcomes in comatose survivors who restore spontaneous circulation after cardiopulmonary resuscitation (CPR) and validate its performance. Methods Variables that were both readily available and predictive of outcomes were identified by systematically reviewing published literature on resuscitation. A value was assigned to these variables. We used these variables in combination with APACHE II score to devise a multifactorial prediction score system, which we called PRCSs Prognostication Score (PRCSs-PS). Outcomes in 115 hospitalized comatose survivors after CPR were retrospectively reviewed using PRCSs-PS. Score of patients with different outcomes was compared. The area under the receiveroperating characteristic (ROC) curve was determined to evaluate performance of this tool to identify patients with a poor outcome (CPC4 and 5) and other outcomes (CPC1, 2, and 3) . Results There were differences of PRCSs-PS score among multiple groups with five different outcomes (CPC1-5) (F=65.91, P=0.000). Pairwise groups with different CPC were compared: no significant difference was noted between CPC1 and CPC2 (12.41±6.49 vs 17.38±6.91,P=0.092), but difference between other pairwise CPC groups was statistically significant (CPC2 vs CPC3:17.38±6.91 vs 24.50±5.80, P=0.041; CPC3 vs CPC4: 24.50±5.80 vs 32.29±5.24, P=0.006). The performance of PRCSs-PS to discriminate patients with a poor outcome from patients with other outcomes went as follows: it had 100% sensitivity, 78.6% specificity, and 178.6 diagnostic index at the score cut-off 22.5; it had 77.8% sensitivity, 100% specificity and 176.4 diagnostic index at the score cut-off 32.5. Score 23 and 33 were two key cut-off points. The area under the ROC curve was 0.968, showing excellent discrimination. Conclusions The final outcomes in post-resuscitation comatose survivors can be accurately predicted using PRCSs-PS Score.
Objective To report the clinical outcome and complications of endovascular stent-graft treatment for type B aortic dissection in elderly patients, as compared with younger patients in a single medical center. Methods From May 2002 to July 2008, endovascular stent-graft implantation was performed in 124 patients with type B aortic dissection at the Department of Cardiology, Shenyang Northern Hospital. Among them, 39 patients were 60 yrs or older (ranging from 68 to 81 years) while 85 patients were younger than 60 years old (ranging from 31 to 58 years). Patients were followed up for a mean period of 26 months (ranging from 1 to 78 months). Clinical data were analyzed between the two groups. Results Comparing with the younger group, the elderly group had higher prevalence of coronary artery disease (59.0% vs 24.7%, P=0.001). There was no significant difference of complication rates between the 2 groups (38.5% vs 31.8%, P=0.54). Kaplan-Meier analysis showed a similar 5-year survival rate(80.2% vs 89.6%; Log Rank, P=0.31) between the 2 groups. Conclusions Endovascular stent-graft implantation is safe and effective in the treatment of type B aortic dissection for both elderly and younger patients. The procedure-related complication rate seems independent of age.
Objective A novel index based on frequency-domain analysis of heart rate variability (HRV) was tested on patients with reduced left ventricular systolic function. This index, namely VHFI, was defined as the very high frequency (VHF) component of the power spectrum normalized to represent its relative value in proportion to the total power minus the very low frequency component. Methods Patients (n = 130) were divided into a study group, consisting 66 patients with decreased left ventricular systolic function, and a control group, consisting 64 patients with normal heart structure and function and without severe coronary artery stenosis (<50%). Results VHFI in the study group was significantly higher than that in the control group (19.17 ± 13.35 vs 11.37 ± 10.77, P <0.001). Cardiac events occurred in 18 patients during follow-up (33.34 ± 3.26 months). Defining the positive test as VHFI =15 and negative test as VHFI <15, achieved a sensitivity of 57.58% and a specificity of 78.13% for predicting decreased left ventricular systolic function, and achieved a sensitivity of 66.67% and a specificity of 64.29% for predicting cardiac events. Univariate Cox regression analysis showed that positive VHFI test was an independent variable in predictive cardiac events. Conclusions The results suggest that VHFI is a useful tool for quick evaluation of left ventricular systolic function and prediction of prognosis.
Objective To analyze the risk factors and clinical outcome of contrast induced nephropathy (CIN) in patients with coronary artery disease (CAD) after percutaneous coronary intervention (PCI) and discuss its prevention. Methods Fifty-four patients with CIN among 729 patients who received PCI were retrospectively studied and the related risk factors, cardiovascular events and preventive strategy were analyzed. Results CIN was strongly associated with pre-procedure chronic renal failure, diabetes mellitus and large-dose contrast. The incidence of cardiac mortality and major adverse cardiac events 1 year after PCI in CIN group was higher than that in group without CIN. Conclusion Chronic renal failure, diabetes mellitus and dosage of contrast agent were three independent risk factors of CIN. CIN could affect the patients’ prognosis. A well overall perioperative management of CAD patients following PCI, especially hydration therapy, is the most important strategy for prevention of CIN.
Background To report quality control methods and baseline reproducibility data of the ultrasound measurements of carotid artery intima-media thickness in the project of Establishment of an Integrated System for Coronary Heart Disease Prevention and Treatment. Methods Standard ultrasound scanning and measuring protocols were established by the study group. All sonographers and readers were trained by the carotid ultrasound core lab and all digital ultrasound images were centrally read. Ten subjects were scanned twice (with 1 week interval) by 2 sonographers independently and images were read by a single reader to evaluate the sonographer variability. Twenty subjects’ images were read twice (with 1 week interval) by a single reader to assess the reader variability and the reproducibility of IMT measured at different carotid segments. Results The intraclass correlation (ICC) of intra- and inter-sonographer and intrareader for mean IMT measurements was 0.99, 0.98 and 0.97 respectively; while for max IMT, it was 0.97, 0.99 and 0.95 respectively. Among different carotid segments and sites, ICC for mean IMT measurements of common carotid (CCA), carotid artery bulb (Bulb), internal carotid artery (ICA), overall near wall and overall far wall was 0.97, 0.99, 0.89, 0.93 and 0.98 respectively. Conclusion The reproducibility of IMT measurements according to our protocol is acceptable, although better reproducibility is found when measuring the mean IMT than max IMT, CCA and Bulb IMT than ICA IMT, and far wall IMT than near wall IMT.
Objective To study the change of diastolic cardiac function in diabetic patients and to determine the diagnostic value of plasma brain natriuretic peptide (BNP) and atria natriuretic peptide (ANP) for diastolic heart failure in patients with type 2 diabetes mellitus. Methods Twelve healthy subjects and seventy-one diabetic patients were included in the study. Plasma BNP and ANP were measured with immunoradiometic assay. Results Plasma levels of BNP and ANP increased significantly with increased severity of diastolic heart dysfunction. The ratio of E/A had significant negative correlation with the plasma levels of BNP (r=-0.669,P<0.001) and ANP (r=-0.579, P<0.01). AUC of ANP and BNP in ROC model was 91.9% and 65.3%, respectively. Conclusions The plasma level of BNP might be a valuable predictor for differential diagnosis of diastolic cardiac function in diabetic patients.
Objective Chronic atrial fibrillation (AF) results in dedifferentiation of atrial cardiomyocytes that plays an important role in the perpetuation of AF. In this study, we aimed to investigate the changes of titin and α-smooth muscle actin (α-SMA) after long time of AF reversal. Methods Twenty-four goats were randomized into four groups: (1) sinus rhythm (SR), (2) 3 months AF (3-mo AF), (3) 3 months SR after 3 months AF (3-mo post AF), (4) 6 months SR after 3-mo AF (6-mo post AF), with 6 in each group. By pacing on the anterior bottom of left atria appendage (LAA), we established a goat model of chronic AF. Atria effective refractory period (AERP) was measured with electrophysiological methods. Ultra-structure was studied with echocardiography, light and electron microscopy. Titin and α-SMA protein expressions were determined by Western blot. Results The animals underwent high rate pacing on LAA for a mean of 42.23 ± 21.70 days before presenting AF. Electrophysiological analysis revealed that AERP completely resumed in 3-mo post AF goats. Echocardiography displayed that the size of left atrium resumed almost in 6-mo post AF goats (P< 0.01). Pathological and electron microscopic examination revealed the disorder of myofibrils, augmentation of intercellular space, myolysis, accumulation of glycogen, and numerous bigger mitochondria among atrial cardiomyocytes in 3-mo AF goats. They recovered mostly in 6-mo post AF goats. Western blot showed that the band density of titin significantly reduced in 3-mo AF goats compared to SR ones [1826 ± 319 vs 5012 ± 854, P < 0.01]. In 3- and 6-mo post AF goats, titin increased gradually and it reversed completely in 6-mo post AF goats (3841 ± 601 and 4523 ± 833 respectively, P < 0.01). Conversely, the band density of α-SMA was significantly higher in 3-mo AF goats (5324 ± 948) than in SR ones (1619 ± 271, P < 0.01). In 3- and 6-mo post-AF goats, α-SMA decreased gradually, and it recovered mostly in 6-mo post AF goats (4437 ± 792 and 2205 ± 540 respectively, P< 0.01,). Conclusions These data indicate that the reversal of dedifferentiation of atrial cardiomyocyts is a very slow process, and it is definitely essential for normal cardiac function.
Objective To investigate the effects of insulin-like growth factor-1 (IGF-1) and oxidized low density lipoprotein (oxLDL) on expression of phosphatase PHLPP1 in vascular smooth muscle cells (VSMCs). Methods Rabbit aortic VSMCs were cultured. VSMCs proliferation ability was determined by measuring cell number and mitochondrial dehydrogenase (MD) activity with MTT assay. Western blot was used to detect the protein expression of phosphatase PHLPP1. Results IGF-1 (100μg/L) increased cell number and MD activity to 3.02 and 3.59 times of that in control group. oxLDL(50μg/ ml) elevated the above two parameters to 2.03 and 2.91 times respectively. Western blot showed that IGF-1 and oxLDL inhibited the expression of PHLPP1 to 39.27% and 40.26% of the control group (P<0.01). Conclusion IGF-1 and oxLDL may enhance the proliferation of VSMCs by decreasing the expression of phosphatase PHLPP1.
The use of the internal mammary artery (IMA) in coronary artery bypass graft(CABG) for myocardial revascularization is gaining popularity in routine practice, especially when the target vessel is the left anterior descending artery (LAD). Occasionally, IMA hypoperfusion occurs when there is inadequate flow through the IMA graft to the LAD artery due to the exist of lateral branches.4,5 The graft hypoperfusion can occur both acutely and chronically resulting in malperfusion syndrome and dysfunctional graft with persistent ischemia in the region of supply. Here we report a recent case who had recurrent LAD ischemia six days after two-vessel coronary artery bypass grafting(CABG) due to internal mammary artery steal syndrome. Patient was successfully treated with transcutaneous steel coil embolization to occlude the anomalous vessel. This resulted in improved perfusion in LAD and symptomatic improvement.
Heart failure (HF) is a major clinical manifestation of many cardiac disease processes when the cardiovascular compensatory mechanisms fail. Five million patients suffer from HF with an additional 555,000 new patients diagnosed HF annually. Moreover, there are an estimated 400,000 to 460,000 deaths attributable to sudden cardiac death (SCD) in the United States each year.1 Mortality in the heart failure population is about six to seven times higher than that of the agematched general population. Approximate 40%-50% of the total mortality in HF patients is associated with SCD, of which ventricular tachyarrhythmias are the underlying cause for the majority of cases.2-4 However, the mechanisms of SCD in HF is not yet fully understood. In the following review, we will focus on arrhythmogenic substra
Sepsis and related syndromes are the major cause of multiple organ failure and death in patients with critical illnesses. Neuroendocrine dysfunction has long been thought to be an important event in sepsis. In clinic, optimal management of the hormones could alleviate severe complications in sepsis. In this article, we review the dysfunction of neuroendocrine system as well as autonomic nervous system in sepsis, and summarize the respective therapy strategies.