2013 Vol. 10, No. 2
Objective To examine the association of atherosclerosis burden in the survivors of an asymptomatic elderly cohort study and its relationship to other coronary risk factors (specifically, age) by evaluating aortic atherosclerotic wall burden by magnetic resonance imaging (MRI). Methods A total of 312 participants in an ongoing observational cohort study underwent cardiac and descending thoracic aorta imaging by MRI. Maximum wall thickness was measured and the mean wall thickness calculated. Wall/outer wall ratio was used as a normalized wall index (NWI) adjusted for artery size difference among participants. Percent wall volume (PWV) was calculated as NWI × 100. Results In this asymptomatic cohort (mean age: 76 years), the mean (SD) aortic wall area and wall thickness were 222 ± 45 mm2 and 2.7 ± 0.4 mm, respectively. Maximum wall thickness was 3.4 ± 0.6 mm, and PWV was 32% ± 4%. Women appeared to have smaller wall area, but after correcting for their smaller artery size, had significantly higher PWV than men (P = 0.03). Older age was associated with larger wall area (P = 0.04 for trend) with similar PWVs. However, there were no statistically significant associations between standard risk factors, Framingham global risk, or metabolic syndrome status, therapy for cholesterol or hypertension, coronary or aortic calcium score, and the aortic wall burden. Aortic calcification was associated with coronary calcification. Conclusions Asymptomatic elderly in this cohort had a greater descending thoracic aortic wall volume that correlated with age, and women had a significantly increased PWV compared to men. In these survivors, the atherosclerotic aortic wall burden was not significantly associated with traditional risk factors or with coronary or aortic calcium scores or coronary calcium progression. Results suggest that age, or as yet unidentified risk factor(s), may be responsible for the increase in atherosclerosis.
Background Ring annuloplasty is the standard treatment of ischemic mitral regurgitation (MR), however, it has been associated with some drawbacks. It abolishes normal annular dynamics and freezes the posterior leaflet. In the present study, we evaluated Paneth suture annuloplasty in chronic ischemic MR and both early and mid-term outcomes of the technique on a selected population. Methods The study period was from June 2010 to June 2012. We operated on 21 patients who had the diagnosis of coronary artery disease and MR of grade 3 or 4. The patients had both a coronary artery bypass operation and the mitral semicircular reduction annuloplasty described by Paneth-Burr. The data on the patients were retrospectively collected. Patients were contacted by outpatient clinic controls for mid-term results. Results The male/female ratio was 10/11. The mean age of the patients was 71.0 ± 6.4 years. Preoperative and postoperative left ventricular ejection fraction was statistically similar (P = 0.973). Early postoperative MR grade (mean, 0.57 ± 0.51) was statistically lower than the preoperative MR grades (mean, 3.38 ± 0.50) (P Conclusion Semicircular reduction annuloplasty is an effective, inexpensive and easy surgical annuloplasty technique with low mortality and morbidity in severe symptomatic ischemic MR.
Cardiovascular disease is a major cause of morbidity and mortality throughout the world. Most cardiovascular diseases, such as ischemic heart disease and cardiomyopathy, are associated with loss of functional cardiomyocytes. Unfortunately, the heart has a limited regenerative capacity and is not able to replace these cardiomyocytes once lost. In recent years, stem cells have been put forward as a poten-tial source for cardiac regeneration. Pre-clinical studies that use stem cell-derived cardiac cells show promising results. The mechanisms, though, are not well understood, results have been variable, sometimes transient in the long term, and often without a mechanistic explana-tion. There are still several major hurdles to be taken. Stem cell-derived cardiac cells should resemble original cardiac cell types and be able to integrate in the damaged heart. Integration requires administration of stem cell-derived cardiac cells at the right time using the right mode of delivery. Once delivered, transplanted cells need vascularization, electrophysiological coupling with the injured heart, and prevention of immunological rejection. Finally, stem cell therapy needs to be safe, reproducible, and affordable. In this review, we will give an introduction to the principles of stem cell based cardiac repair.
Both coronary artery perforation and intracoronary thrombus formation are life-threatening complications of percutaneous coronary interventions, which rarely occur simultaneously during angioplasty. We herein report a case of stent-related, left circumflex artery perforation, and subsequently acute left main artery thrombosis after the leakage was embolized with 7 microcoils. Intracoronary thromboectomy and systemic anticoagulant therapy were carefully used with good results. This case also represents some of our uncertainties regarding the best management of the patient.
Objective To investigate the effects and mechanisms of rosuvastatin on angiotensin -converting enzyme 2 (ACE2) in the process of neointimal formation after vascular balloon injury in rats, and to explore the effects of ACE2 and rosuvastatin in restenosis. Methods Thirty-six Wistar rats were randomly allocated into three groups: control group (n = 12), surgery group (n = 12), and statin group (n = 12). Aortic endothelial denudation of rats was performed using 2F balloon catheters. At days 14 and 28 after injury, aortic arteries were harvested to examine the following. Intimal thickening was examined by hematoxylin and eosin staining. We measured angiotensin II (Ang II) and angiotensin 1-7 (Ang-[1–7]) levels by a radioimmunological method or enzyme-linked immunosorbent assay. Protein and mRNA expression of ACE2 and Ang II type 1 receptor (AT1) were investigated by immunohistochemistry, Western blots, and Reverse transcriptase-polymerase chain reaction (RT-PCR). We measured changes in proliferating cell nuclear antigen (PCNA) by immunohistochemistry. The level of phosphorylated extracellular signal regulated kinase 1/2 (P-ERK1/2) was evaluated by Western Blotting. Results Proliferation of vascular smooth muscle cells (VSMC) and intimal thickening were higher at day 14 after vascular balloon injury in the surgery group compared with the control group. Proliferation of VSMC was decreased by day 28 after injury, while intimal thickening continued. With rosuvastatin treatment, the extent of VSMC proliferation and intimal thickening was reduced at day 14 and 28 after injury. Ang II and P-ERK levels were significantly increased, Ang-(1–7) levels were significantly decreased, mRNA and protein expressions of ACE2 were significantly decreased, and AT1 expression was significantly increased at days 14 and 28 after vascular balloon injury in the surgery group compared with the control group. PCNA expression was higher in the surgery group than in the control group, and it was significantly decreased after being given rosuvastatin. Expression of ACE2 mRNA and protein, and Ang-(1–7) levels were significantly increased, while AT1 expression and levels of Ang II and P-ERK were significantly decreased in the statin group compared with the surgery group. Conclusions Expression of ACE2 mRNA and protein is decreased in the process of intimal thickening after balloon injury. The inhibitory effect of rosuvastatin on intimal thickening is related to upregulation of ACE2, an increase in Ang-(1–7), downregulation of AT1, and activation of the P-ERK pathway.
Atherosclerosis underlies the major causes of death in the Western World. Our main goal is to detect early changes of atherosclerosis and to identify subjects at highest cardiovascular risk that may aid in the development of prevention approaches and better management that will decrease cardiovascular morbidity and mortality. The new methods that are of interest include the advanced vascular ultrasound methods, the infra red and near infra red imaging techniques, the EndoPat device that reflects peripheral arterial tone, the electron beam computed tomography, the magnetic resonance imaging, and the molecular imaging techniques. In this review we will focus on the future of advanced imaging techniques that are being developed to detect early (pre-clinical) development of atherosclerosis.
Background Co-existence of obstructive sleep apnea (OSA) and chronic obstructive pulmonary disease (COPD) is referred to as overlap syndrome. Overlap patients have greater degree of hypoxia and pulmonary hypertension than patients with OSA or COPD alone. Studies showed that elderly patients with OSA alone do not have increased risk of atrial fibrillation (AF) but it is not known if overlap patients have higher risk of AF. Objective To determine whether elderly patients with overlap syndrome have an increased risk of AF. Methods In this single center, community-based retrospective cohort analysis, data were collected on 2,873 patients > 65 years of age without AF, presenting in the year 2006. Patients were divided into OSA group (n = 60), COPD group (n = 416), overlap syndrome group (n = 28) and group with no OSA or COPD (n = 2369). The primary endpoint was incidence of new-onset AF over the following two years. Logistic regression was performed to adjust for heart failure (HF), coronary artery disease, hypertension (HTN), cerebrovascular disease, cardiac valve disorders, diabetes mellitus, hyperlipidemia, chronic kidney disease (CKD) and obesity. Results The incidence of AF was 10% in COPD group, 6% in OSA group and 21% in overlap syndrome group (P P = 0.007). HF, CKD and HTN were also significantly associated with new-onset AF (P Conclusion Among elderly patients, the presence of overlap syndrome is associated with a marked increase in risk of new-onset AF as compared to the presence of OSA or COPD alone.
Chronic heart failure (CHF) represents a major and growing health problem, due to its high incidence and prevalence, its poor prognosis and its impact on health-care costs. Although CHF patients are mainly elderly, few studies were aimed at testing the efficacy of diagnostic and therapeutic approaches in this population. The difficulty in CHF diagnosis among the elderly is related to different factors, such as: the frequent presence of co-morbidity conditions mimicking or masking heart failure signs and symptoms; the different diagnostic cut-offs of natriuretic peptides; and the need to correctly evaluate diastolic function in order to assess CHF with preserved ejection fraction. Furthermore, the therapy of elderly CHF patients has not been well defined, considering the few studies involving very aged patients and the absence of a therapeutic strategy demonstrated to improve prognosis of CHF patients with preserved ejection fraction. The aim of this review is to focus on the most recent issues concerning the diagnosis and therapy of elderly patients affected by CHF.
Objectives To evaluate the association of coronary artery endothelial function and plasma levels of low density lipoprotein cholesterol (LDL-C) and high density lipoprotein cholesterol (HDL-C) in patients with Type 2 Diabetes Mellitus (DM). Methods We investigated 90 participants from our institution between October 2007 to March 2010: non-DM (n = 60) and DM (n = 30). As an indicator of coronary endothelial dysfunction, we used non-invasive Doppler echocardiography to quantify coronary flow velocity reserve (CFVR) in the distal part of the left descending artery after rest and after intravenous adenosine administration. Results Plasma level of LDL-C was significantly higher in patients with DM than in non-DM (3.21±0.64 vs. 2.86±0.72 mmo/L, P vs. 1.05 ± 0.19 mmo/L). Furthermore, the CFVR value was lower in DM patients than non-diabetics (2.45 ± 0.62 vs. 2.98 ± 0.68, P r = -0.35, P r = -0.29, P r = -0.42, P P = 0.008), LDL-C (β = -0.217, s = 0.105,sβ= -0.282, 95% CI: -0.428 - -0.005, P = 0.045) remained independently correlated with CFVR in the DM group. However, we found no correlation between HDL-C level and CFVR in any group. Conclusions Diabetes may contribute to coronary artery disease (CAD) by inducing dysfunction of the coronary artery endothelium. Increased LDL-C level may adversely impair coronary endothelial function in DM. HDL-C may lose its endothelial-protective effects, in part as a result of pathological conditions, especially under abnormal glucose metabolism.
Objective Risk factor modification is key to preventing subsequent cardiac events after a heart attack. This study was designed to investigate the disparity between preventive guidelines and clinical practice among smoking patients. Methods The study was carried out in smokers admitted with myocardial infarction (MI). A total of 275 patients who had been regularly followed for over one year after MI were randomly selected and enrolled in this study. We investigated changes in smoking behavior and the adherence rate to ACC/AHA Guidelines for secondary prevention in patients with coronary artery disease at the time of, and one year after, the index event. Results The study population consisted of 275 patients (97.1% males) with a mean age of 57.0 ± 11.2 years. Achievement of target goals at one year was as follows: smoking cessation, 52.3%; blood pressure, 83.9%; HbA1c, 32.7%; lipid profile, 65.5%; and body mass index (BMI), 50.6%. Over one year, 80% of the patients attempted to quit smoking; 27% of them re-started smoking within one month after discharge while 65% succeeded in cessation of smoking. At one year, only 52% of the patients overall had stopped smoking. From the multivariate logistic analysis including smoking patterns and clinical characteristics, the severity of coronary artery disease was the only independent predictor for smoking cessation (Relative risk (RR): 1.230; P = 0.022). Conclusions Only a small percentage of MI patients adhere to guidelines for secondary prevention and a sizable proportion fail to stop smoking. These findings underscore the need for an effective patient education system.
Iatrogenic aortocoronary dissection is a rare but potentially disastrous complication of percutaneous coronary intervention. The left main dissection extending into distal bifurcation involving both the left anterior descending and left circumflex is a complex and vital complication, which is classified as Eshtehardi Type II dissection. We presented a case of iatrogenic left main coronary artery dissection with upcoming closure of both major branches, which was successfully managed by immediate bail-out TAP-stenting. The 77-year-old patient was dis-charged without any complication, and 1-year follow-up indicated stent patency and favorable clinical result. Immediate bail-out stenting is a feasible and reasonable initial management for this lethal complication.
Percutaneous coronary intervention (PCI) in an anomalous right coronary artery (RCA) can be technically difficult because selective cannulation of the vessel may not be easy. We thereby present two cases with unstable angina pectoris of anomalous originated RCA. The PCI were successfully performed in two patients with a special guiding wire manipulating skill which we called “gone with the flow” com-bined with balloon anchoring technology, providing excellent angiographic visualization and sound guide support for stent delivery throughout the procedure without severe cardiovascular adverse effects. Our primary data suggested that PCI for geriatric patients with an anomalous origin of RCA accompanied by severe atherosclerotic lesions might also be a safe, available, and feasible strategy.
Biological aging predisposes older adults to increased cardiovascular disease (CHD) and greater disease complexity. Given the high age-related prevalence of CHD and age-related compounding factors, the recently updated American Heart Association/American College of Cardiology Foundation CHD-related guidelines increased their focus on older patients. These guidelines are predominately evidence-based (using data from quality randomized clinical trials) and are organized to delineate medications and procedures that best treat particular car-diovascular diseases. While such rationale and thought work well in young and middle aged adults, they become problematic in patients who are very old. Data pertaining to adults aged ≥ 80 are virtually absent from most randomized clinical trials, and even in the instances when very old patients were included, eligibility criteria typically excluded candidates with co-morbidities and complexities of customary CHD patients. While medications and interventions yielding benefit in clinical trials should theoretically produce the greatest benefits for patients with high intrinsic risk, age-related cardiovascular complexities also increase iatrogenic risks. Navigating between the potential for high benefit and high risk in “evidence-based” cardiovascular management remains a key Geriatric Cardiology challenge. In this review we con-sider the expanded Geriatric Cardiology content of current guidelines, acknowledging both the progress that has been made, as well as the work that still needs to be accomplished to truly address the patient-centered priorities of older CHD patients.