Hypertension in the elderly: Are we all on the same wavelength?

Hypertension is of frequent occurrence in the elderly population. Isolated systolic hypertension (ISH) accounts for the majority of cases of hypertension in the elderly. ISH is associated with a 2-4-fold increase in the risk of myocardial infarction, left ventricular hypertrophy, renal dysfunction, stroke, and cardiovascular mortality. There have been many studies to determine the optimal treatment for hypertension in the elderly. Why, when and how to treat hypertension in the elderly was the scope of the majority of these trials. Despite countless efforts many aspects remain obscure. While a number of novel drugs are being developed, the issue of whether all antihypertensive drugs bestow parallel benefits or whether some agents offer a therapeutic advantage beyond blood pressure control remains of crucial importance. Furthermore, the response of the elderly to different antihypertensive agents also differs from that of younger patients and may explain some of the disparities in outcomes of trials conducted in elderly patients with hypertension.

Coronary spasm-related acute myocardial infarction in a patient with essential thrombocythemia

We report a case of essential thrombocythemia (ET) in a 30-year-old female who exhibited inferior wall ST-elevation acute myocardial infarction (AMI) without significant obstructive coronary artery disease. Right coronary vasospasm was observed after intra-coronary methylergonovine administration and she received verapamil 120 mg/dthereafter and hydroxyurea 1500 mg/d for thrombocythemia. After discontinuation of the hydroxyurea for 9 mo based on the impression of coronary spasm-related instead of coronary thrombosis-related AMI, her platelet count rose but no chest pain was observed. It is suggested that coronary spasm potentially plays a role in patients with ET, AMI and no significant coronary artery stenosis.

Current characteristics of congenital coronary artery fistulas in adults: A decade of global experience

AIM

To describe the characteristics of coronary artery fistulas (CAFs) in adults, including donor vessels and whether termination was cameral or vascular.

METHODS

A PubMed search was performed for articles between 2000 and 2010 to describe the current characteristics of congenital CAFs in adults. A group of 304 adults was collected. Clinical data, presentations, diagnostic modalities, angiographic fistula findings and treatment strategies were gathered and analyzed. With regard to CAF origin, the subjects were tabulated into unilateral, bilateral or multilateral fistulas and compared. The group was stratified into two major subsets according to the mode of termination; coronary-cameral fistulas (CCFs) and coronary-vascular fistulas (CVFs). A comparison was made between the two subsets. Fistula-related major complications [aneurysm formation, infective endocarditis (IE), myocardial infarction (MI), rupture, pericardial effusion (PE) and tamponade] were described. Coronary artery-ventricular multiple micro-fistulas and acquired CAFs were excluded as well as anomalous origin of the coronary arteries from the pulmonary artery (PA).

RESULTS

A total of 304 adult subjects (47% male) with congenital CAFs were included. The mean age was 51.4 years (range, 18-86 years), with 20% older than 65 years of age. Dyspnea (31%), chest pain (23%) and angina pectoris (21%) were the prevalent clinical presentations. Continuous cardiac murmur was heard in 82% of the subjects. Of the applied diagnostic modalities, chest X-ray showed an abnormal shadow in 4% of the subjects. The cornerstone in establishing the diagnosis was echocardiography (68%), and conventional contrast coronary angiography (97%). However, multi-slice detector computed tomography was performed in 16%. The unilateral fistula originated from the left in 69% and from the right coronary artery in 31% of the subjects. Most patients (80%) had unilateral fistulas, 18% presented with bilateral fistulas and 2% with multilateral fistulas. Termination into the PA was reported in unilateral (44%), bilateral (73%) and multilateral (75%) fistulas. Fistulas with multiple origins (bilateral and multilateral) terminated more frequently into the PA (29%) than into other sites (10.6%) (P = 0.000). Aneurysmal formation was found in 14% of all subjects. Spontaneous rupture, PE and tamponade were reported in 2% of all subjects. In CCFs, the mean age was 46.2 years whereas in CVFs mean age was 55.6 years (P = 0.003). IE (4%) was exclusively associated with CCFs, while MI (2%) was only found in subjects with CVFs. Surgical ligation was frequently chosen for unilateral (57%), bilateral (51%) and multilateral fistulas (66%), but percutaneous therapeutic embolization (PTE) was increasingly reported (23%, 17% and 17%, respectively).

CONCLUSION

Congenital CAFs are currently detected in elderly patients. Bilateral fistulas are more frequently reported and PTE is more frequently applied as a therapeutic strategy in adults.

Apical hypertrophic cardiomyopathy

We describe a patient with asymptomatic apical hypertrophic cardiomyopathy (AHCM) who later developed cardiac arrhythmias, and briefly discuss the diagnostic modalities, differential diagnosis and treatment option for this condition. AHCM is a rare form of hypertrophic cardiomyopathy which classically involves the apex of the left ventricle. AHCM can be an incidental finding, or patients may present with chest pain, palpitations, dyspnea, syncope, atrial fibrillation, myocardial infarction, embolic events, ventricular fibrillation and congestive heart failure. AHCM is frequently sporadic, but autosomal dominant inheritance has been reported in few families. The most frequent and classic electrocardiogram findings are giant negative T-waves in the precordial leads which are found in the majority of the patients followed by left ventricular (LV) hypertrophy. A transthoracic echocardiogram is the initial diagnostic tool in the evaluation of AHCM and shows hypertrophy of the LV apex. AHCM may mimic other conditions such as LV apical cardiac tumors, LV apical thrombus, isolated ventricular non-compaction, endomyocardial fibrosis and coronary artery disease. Other modalities, including left ventriculography, multislice spiral computed tomography, and cardiac magnetic resonance imagings are also valuable tools and are frequently used to differentiate AHCH from other conditions. Medications used to treat symptomatic patients with AHCM include verapamil, beta-blockers and antiarrhythmic agents such as amiodarone and procainamide. An implantable cardioverter defibrillator is recommended for high risk patients.

Non-invasive detection of vulnerable coronary plaque

Critical coronary stenoses have been shown to contribute to only a minority of acute coronary syndromes and sudden cardiac death. Autopsy studies have identified a subgroup of high-risk patients with disrupted vulnerable plaque and modest stenosis. Consequently, a clinical need exists to develop methods to identify these plaques prospectively before disruption and clinical expression of disease. Recent advances in invasive and non-invasive imaging techniques have shown the potential to identify these high-risk plaques. Non-invasive imaging with magnetic resonance imaging, computed tomography and positron emission tomography holds the potential to differentiate between low- and high-risk plaques. There have been significant technological advances in non-invasive imaging modalities, and the aim is to achieve a diagnostic sensitivity for these technologies similar to that of the invasive modalities. Molecular imaging with the use of novel targeted nanoparticles may help in detecting high-risk plaques that will ultimately cause acute myocardial infarction. Moreover, nanoparticle-based imaging may even provide non-invasive treatments for these plaques. However, at present none of these imaging modalities are able to detect vulnerable plaque nor have they been shown to definitively predict outcome. Further trials are needed to provide more information regarding the natural history of high-risk but non-flow-limiting plaque to establish patient specific targeted therapy and to refine plaque stabilizing strategies in the future.

Calcium channels and iron uptake into the heart

Iron overload can lead to iron deposits in many tissues, particularly in the heart. It has also been shown to be associated with elevated oxidative stress in tissues. Elevated cardiac iron deposits can lead to iron overload cardiomyopathy, a condition which provokes mortality due to heart failure in iron-overloaded patients. Currently, the mechanism of iron uptake into cardiomyocytes is still not clearly understood. Growing evidence suggests L-type Ca(2+) channels (LTCCs) as a possible pathway for ferrous iron (Fe(2+)) uptake into cardiomyocytes under iron overload conditions. Nevertheless, controversy still exists since some findings on pharmacological interventions and those using different cell types do not support LTCC's role as a portal for iron uptake in cardiac cells. Recently, T-type Ca(2+) channels (TTCC) have been shown to play an important role in the diseased heart. Although TTCC and iron uptake in cardiomyocytes has not been investigated greatly, a recent finding indicated that TTCC could be an important portal in thalassemic hearts. In this review, comprehensive findings collected from previous studies as well as a discussion of the controversy regarding iron uptake mechanisms into cardiomyocytes via calcium channels are presented with the hope that understanding the cellular iron uptake mechanism in cardiomyocytes will lead to improved treatment and prevention strategies, particularly in iron-overloaded patients.

Coexistence of acute myocardial infarction with normal coronary arteries and migraine with aura in a female patient

Acute myocardial infarction with normal coronary arteries is a well known condition, which is typically diagnosed in young patients. Coronary vasospasm, inherited, acquired or malignancy-induced hypercoagulable state, collagen vascular disease and coronary arterial embolism have been considered as underlying etiologic factors. An association between migraine with aura and increased risk of ischemic stroke, angina and myocardial infarction has been demonstrated in studies. Patients with migraine and especially with aura should be followed closely against cardiovascular events even if they are young and do not have traditional risk factors.

Implications of discoveries from genome-wide association studies in current cardiovascular practice

Genome-wide association studies (GWAS) have identified several genetic variants associated with coronary heart disease (CHD), and variations in plasma lipoproteins and blood pressure (BP). Loci corresponding to CDKN2A/CDKN2B/ANRIL, MTHFD1L, CELSR2, PSRC1 and SORT1 genes have been associated with CHD, and TMEM57, DOCK7, CELSR2, APOB, ABCG5, HMGCR, TRIB1, FADS2/S3, LDLR, NCAN and TOMM40-APOE with total cholesterol. Similarly, CELSR2-PSRC1-SORT1, PCSK9, APOB, HMGCR, NCAN-CILP2-PBX4, LDLR, TOMM40-APOE, and APOC1-APOE are associated with variations in low-density lipoprotein cholesterol levels. Altogether, forty, forty three and twenty loci have been associated with high-density lipoprotein cholesterol, triglycerides and BP phenotypes, respectively. Some of these identified loci are common for all the traits, some do not map to functional genes, and some are located in genes that encode for proteins not previously known to be involved in the biological pathway of the trait. GWAS have been successful at identifying new and unexpected genetic loci common to diseases and traits, thus rapidly providing key novel insights into disease biology. Since genotype information is fixed, with minimum biological variability, it is useful in early life risk prediction. However, these variants explain only a small proportion of the observed variance of these traits. Therefore, the utility of genetic determinants in assessing risk at later stages of life has limited immediate clinical impact. The future application of genetic screening will be in identifying risk groups early in life to direct targeted preventive measures.

Phase I of cardiac rehabilitation: A new challenge for evidence based physiotherapy

Cardiac rehabilitation protocols applied during the in-hospital phase (phase I) are subjective and their results are contested when evaluated considering what should be the three basic principles of exercise prescription: specificity, overload and reversibility. In this review, we focus on the problems associated with the models of exercise prescription applied at this early stage in-hospital and adopted today, especially the lack of clinical studies demonstrating its effectiveness. Moreover, we present the concept of "periodization" as a useful tool in the search for better results.

JUPITER and satellites: Clinical implications of the JUPITER study and its secondary analyses

THE JUSTIFICATION FOR THE USE OF STATINS IN PREVENTION: an intervention trial evaluating rosuvastatin (JUPITER) study was a real breakthrough in primary cardiovascular disease prevention with statins, since it was conducted in apparently healthy individuals with normal levels of low-density lipoprotein cholesterol (LDL-C < 130 mg/dL) and increased inflammatory state, reflected by a high concentration of high-sensitivity C-reactive protein (hs-CRP ≥ 2 mg/L). These individuals would not have qualified for statin treatment according to current treatment guidelines. In JUPITER, rosuvastatin was associated with significant reductions in cardiovascular outcomes as well as in overall mortality compared with placebo. In this paper the most important secondary analyses of the JUPITER trial are discussed, by focusing on their novel findings regarding the role of statins in primary prevention. Also, the characteristics of otherwise healthy normocholesterolemic subjects who are anticipated to benefit more from statin treatment in the clinical setting are discussed. Subjects at "intermediate" or "high" 10-year risk according to the Framingham score, those who exhibit low post-treatment levels of both LDL-C (< 70 mg/dL) and hs-CRP (< 1 mg/L), who are 70 years of age or older, as well as those with moderate chronic kidney disease (estimated glomerular filtration rate < 60 mL/min every 1.73 m(2)) are anticipated to benefit more from statin treatment. Unlikely other statin primary prevention trials, JUPITER added to our knowledge that statins may be effective drugs in the primary prevention of cardiovascular disease in normocholesterolemic individuals at moderate-to-high risk. Also, statin treatment may reduce the risk of venous thromboembolism and preserve renal function. An increase in physician-reported diabetes represents a major safety concern associated with the use of the most potent statins.

Conventional risk factors among newly diagnosed coronary heart disease patients in Delhi

AIM

To analyze the conventional risk factors among newly diagnosed cases of coronary heart disease (CHD) admitted to a hospital in Delhi, India.

METHODS

This hospital-based prospective study included 276 consecutive newly diagnosed cases of CHD in the Coronary Care Unit of a tertiary care hospital in Delhi.

RESULTS

The mean age of the cases was 49.7 ± 9.5 years, with the youngest case aged 27 years. The two risk factors present most frequently among the cases were inadequate physical activity and abnormal lipid profile. Just about 3.6% of cases in our study had a physical activity level (PAL) that could be termed as "active", with a large proportion (96.4%) having a PAL suggestive of a sedentary lifestyle. A majority of patients were found to be current tobacco smokers (53.3%) and 188 (68.1%) subjects were lifetime ever smokers. There was not a single case who did not have one or more of the risk factors. More than one-quarter (n = 76) had six or more of the studied risk factors.

CONCLUSION

Indians have among the CHD highest mortality rates amongst all ethnic groups studied so far. It is important to study the regional epidemiology of the cardiovascular events to allow for location-specific prevention and control programs.

Transcatheter aortic valve implantation: Current status and future perspectives

Although surgical aortic valve replacement is the standard therapy for severe aortic stenosis (AS), about one third of patients are considered inoperable due to unacceptable surgical risk. Under medical treatment alone these patients have a very poor prognosis with a mortality rate of 50% at 2 years. Transcatheter aortic valve implantation (TAVI) has been used in these patients, and has shown robust results in the only randomized clinical trial of severe AS treatment performed so far. In this review, we will focus on the two commercially available systems: Edwards SAPIEN valve and CoreValve Revalving system. Both systems have demonstrated success rates of over 90% with 30-d mortality rates below 10% in the most recent transfemoral TAVI studies. Moreover, long-term studies have shown that the valves have good haemodynamic performance. Some studies are currently exploring the non-inferiority of TAVI procedures vs conventional surgery in high-risk patients, and long-term clinical results of the percutaneous valves. In this article we review the current status of TAVI including selection of patients, a comparison of available prostheses, results and complications of the procedure, clinical outcomes, and future perspectives.

Nifekalant in the treatment of life-threatening ventricular tachyarrhythmias

The aim of the present study is to review the literature and discuss nifekalant's potential use as a first aid drug in an emergency care setting. The PubMed database was used to identify papers, using keywords nifekalant, MS-551, amiodarone and lidocaine. Nifekalant hydrochloride, formally known as MS-551, is a class III antiarrhythmic agent which acts only by increasing the time course of myocardial repolarization. It was developed and is currently being used only in Japan for the treatment of ventricular tachyarrhythmias. It is a non-selective K(+) channel blocker without any β-blocking actions. Administration of nifekalant suppressed sustained ventricular tachyarrhythmias in acute coronary syndrome patients, and in cardiac arrest victims as well as during or after cardiac surgery. The major adverse effect of nifekalant is QT interval prolongation and occurrence of torsades de pointes which requires frequent monitoring of the QT interval during nifekalant infusion with adequate dose adjustment. Nifekalant is a possible effective antiarrhythmic agent for refractory ventricular tachyarrhythmias. Further clinical studies are required before nifekalant is routinely used in the emergency care setting.

Ischemia/reperfusion injury and cardioprotective mechanisms: Role of mitochondria and reactive oxygen species

Reperfusion therapy must be applied as soon as possible to attenuate the ischemic insult of acute myocardial infarction (AMI). However reperfusion is responsible for additional myocardial damage, which likely involves opening of the mitochondrial permeability transition pore (mPTP). In reperfusion injury, mitochondrial damage is a determining factor in causing loss of cardiomyocyte function and viability. Major mechanisms of mitochondrial dysfunction include the long lasting opening of mPTPs and the oxidative stress resulting from formation of reactive oxygen species (ROS). Several signaling cardioprotective pathways are activated by stimuli such as preconditioning and postconditioning, obtained with brief intermittent ischemia or with pharmacological agents. These pathways converge on a common target, the mitochondria, to preserve their function after ischemia/reperfusion. The present review discusses the role of mitochondria in cardioprotection, especially the involvement of adenosine triphosphate-dependent potassium channels, ROS signaling, and the mPTP. Ischemic postconditioning has emerged as a new way to target the mitochondria, and to drastically reduce lethal reperfusion injury. Several clinical studies using ischemic postconditioning during angioplasty now support its protective effects, and an interesting alternative is pharmacological postconditioning. In fact ischemic postconditioning and the mPTP desensitizer, cyclosporine A, have been shown to induce comparable protection in AMI patients.

Diagnosis and management of pericardial effusion

Pericardial effusion is a common finding in everyday clinical practice. The first challenge to the clinician is to try to establish an etiologic diagnosis. Sometimes, the pericardial effusion can be easily related to a known underlying disease, such as acute myocardial infarction, cardiac surgery, end-stage renal disease or widespread metastatic neoplasm. When no obvious cause is apparent, some clinical findings can be useful to establish a diagnosis of probability. The presence of acute inflammatory signs (chest pain, fever, pericardial friction rub) is predictive for acute idiopathic pericarditis irrespective of the size of the effusion or the presence or absence of tamponade. Severe effusion with absence of inflammatory signs and absence of tamponade is predictive for chronic idiopathic pericardial effusion, and tamponade without inflammatory signs for neoplastic pericardial effusion. Epidemiologic considerations are very important, as in developed countries acute idiopathic pericarditis and idiopathic pericardial effusion are the most common etiologies, but in some underdeveloped geographic areas tuberculous pericarditis is the leading cause of pericardial effusion. The second point is the evaluation of the hemodynamic compromise caused by pericardial fluid. Cardiac tamponade is not an "all or none" phenomenon, but a syndrome with a continuum of severity ranging from an asymptomatic elevation of intrapericardial pressure detectable only through hemodynamic methods to a clinical tamponade recognized by the presence of dyspnea, tachycardia, jugular venous distension, pulsus paradoxus and in the more severe cases arterial hypotension and shock. In the middle, echocardiographic tamponade is recognized by the presence of cardiac chamber collapses and characteristic alterations in respiratory variations of mitral and tricuspid flow. Medical treatment of pericardial effusion is mainly dictated by the presence of inflammatory signs and by the underlying disease if present. Pericardial drainage is mandatory when clinical tamponade is present. In the absence of clinical tamponade, examination of the pericardial fluid is indicated when there is a clinical suspicion of purulent pericarditis and in patients with underlying neoplasia. Patients with chronic massive idiopathic pericardial effusion should also be submitted to pericardial drainage because of the risk of developing unexpected tamponade. The selection of the pericardial drainage procedure depends on the etiology of the effusion. Simple pericardiocentesis is usually sufficient in patients with acute idiopathic or viral pericarditis. Purulent pericarditis should be drained surgically, usually through subxiphoid pericardiotomy. Neoplastic pericardial effusion constitutes a more difficult challenge because reaccumulation of pericardial fluid is a concern. The therapeutic possibilities include extended indwelling pericardial catheter, percutaneous pericardiostomy and intrapericardial instillation of antineoplastic and sclerosing agents. Massive chronic idiopathic pericardial effusions do not respond to medical treatment and tend to recur after pericardiocentesis, so wide anterior pericardiectomy is finally necessary in many cases.

Percutaneous endovascular management of atherosclerotic axillary artery stenosis: Report of 2 cases and review of literature

With recent advancement in percutaneous endovascular management, most atherosclerotic peripheral arterial diseases are amenable for intervention. However, there is limited published literature about atherosclerotic axillary artery involvement and its endovascular management. We report two cases of atherosclerotic axillary artery stenosis, which were successfully managed with stent angioplasty using self expanding nitinol stents. The associated coronary artery disease was treated by percutaneous angioplasty and stenting. The long term follow-up revealed patent axillary stents in both cases.

Differential diagnosis of tachycardia with a typical left bundle branch block morphology

The evaluation of wide QRS complex tachycardias (WCT) remains a common dilemma for clinicians. Numerous algorithms exist to aid in arriving at the correct diagnosis. Unfortunately, these algorithms are difficult to remember, and overreliance on them may prevent cardiologists from understanding the mechanisms underlying these arrhythmias. One distinct subcategory of WCTs are those that present with a "typical" or "classic" left bundle branch block pattern. These tachycardias may be supraventricular or ventricular in origin and arise from functional or fixed aberrancy, bystander or participating atriofascicular pre-excitation, and bundle branch reentry. This review will describe these arrhythmias, illustrate their mechanisms, and discuss their clinical features and treatment strategies.

PPARγ activator, rosiglitazone: Is it beneficial or harmful to the cardiovascular system?

Rosiglitazone is a synthetic agonist of peroxisome proliferator-activated receptor γ which is used to improve insulin resistance in patients with type II diabetes. Rosiglitazone exerts its glucose-lowering effects by improving insulin sensitivity. Data from various studies in the past decade suggest that the therapeutic effects of rosiglitazone reach far beyond its use as an insulin sensitizer since it also has other benefits on the cardiovascular system such as improvement of contractile dysfunction, inhibition of the inflammatory response by reducing neutrophil and macrophage accumulation, and the protection of myocardial injury during ischemic/reperfusion in different animal models. Previous clinical studies in type II diabetes patients demonstrated that rosiglitazone played an important role in protecting against arteriosclerosis by normalizing the metabolic disorders and reducing chronic inflammation of the vascular system. Despite these benefits, inconsistent findings have been reported, and growing evidence has demonstrated adverse effects of rosiglitazone on the cardiovascular system, including increased risk of acute myocardial infarction, heart failure and chronic heart failure. As a result, rosiglitazone has been recently withdrawn from EU countries. Nevertheless, the effect of rosiglitazone on ischemic heart disease has not yet been firmly established. Future prospective clinical trials designed for the specific purpose of establishing the cardiovascular benefit or risk of rosiglitazone would be the best way to resolve the uncertainties regarding the safety of rosiglitazone in patients with heart disease.

Clinical evidence of interaction between clopidogrel and proton pump inhibitors

Clopidogrel is approved for reduction of atherothrombotic events in patients with cardiovascular (CV) and cerebrovascular disease. Dual antiplatelet therapy with aspirin and clopidogrel decreases the risk of major adverse cardiac events after acute coronary syndrome or percutaneous coronary intervention, compared with aspirin alone. Due to concern about gastrointestinal bleeding in patients who are receiving clopidogrel and aspirin therapy, current guidelines recommend combined use of a proton pump inhibitor (PPI) to decrease the risk of bleeding. Data from previous pharmacological studies have shown that PPIs, which are extensively metabolized by the cytochrome system, may decrease the ADP-induced platelet aggregation of clopidogrel. Results from retrospective cohort studies have shown a higher incidence of major CV events in patients receiving both clopidogrel and PPIs than in those without PPIs. However, other retrospective analyses of randomized clinical trials have not shown that the concomitant PPI administration is associated with increased CV events among clopidogrel users. These controversial results suggest that large specific studies are needed. This article reviews the metabolism of clopidogrel and PPIs, existing clinical data regarding the interaction between clopidogrel and PPIs, and tries to provide recommendations for health care professionals.

Vagal nerve stimulation in prevention and management of coronary heart disease

Coronary heart disease (CHD) that is due to atherosclerosis is associated with low-grade systemic inflammation. Congestive cardiac failure and arrhythmias that are responsible for mortality in CHD can be suppressed by appropriate vagal stimulation that is anti-inflammatory in nature. Acetylcholine, the principal vagal neurotransmitter, is a potent anti-inflammatory molecule. Polyunsaturated fatty acids (PUFAs) augment acetylcholine release, while acetylcholine can enhance the formation of prostacyclin, lipoxins, resolvins, protectins and maresins from PUFAs, which are anti-inflammatory and anti-arrhythmic molecules. Furthermore, plasma and tissue levels of PUFAs are low in those with CHD and atherosclerosis. Hence, vagal nerve stimulation is beneficial in the prevention of CHD and cardiac arrhythmias. Thus, measurement of catecholamines, acetylcholine, various PUFAs, and their products lipoxins, resolvins, protectins and maresins in the plasma and peripheral leukocytes, and vagal tone by heart rate variation could be useful in the prediction, prevention and management of CHD and cardiac arrhythmias.

Chronic cola drinking induces metabolic and cardiac alterations in rats

AIM

To investigate the effects of chronic drinking of cola beverages on metabolic and echocardiographic parameters in rats.

METHODS

Forty-eight male Wistar rats were divided in 3 groups and allowed to drink regular cola (C), diet cola (L), or tap water (W) ad libitum during 6 mo. After this period, 50% of the animals in each group were euthanized. The remaining rats drank tap water ad libitum for an additional 6 mo and were then sacrificed. Rat weight, food, and beverage consumption were measured regularly. Biochemical, echocardiographic and systolic blood pressure data were obtained at baseline, and at 6 mo (treatment) and 12 mo (washout). A complete histopathology study was performed after sacrifice.

RESULTS

After 6 mo, C rats had increased body weight (+7%, P < 0.01), increased liquid consumption (+69%, P < 0.001), and decreased food intake (-31%, P < 0.001). C rats showed mild hyperglycemia and hypertriglyceridemia. Normoglycemia (+69%, P < 0.01) and sustained hypertriglyceridemia (+69%, P < 0.01) were observed in C after washout. Both cola beverages induced an increase in left ventricular diastolic diameter (C: +9%, L: +7%, P < 0.05 vs W) and volumes (diastolic C: +26%, L: +22%, P < 0.01 vs W; systolic C: +24%, L: +24%, P < 0.05 vs W) and reduction of relative posterior wall thickness (C: -8%, L: -10%, P < 0.05 vs W). Cardiac output tended to increase (C: +25%, P < 0.05 vs W; L: +17%, not significant vs W). Heart rate was not affected. Pathology findings were scarce, related to aging rather than treatment.

CONCLUSION

This experimental model may prove useful to investigate the consequences of high consumption of soft drinks.

Percutaneous approach to treatment of coronary disease in a patient with uremic cardiomyopathy

Uremic cardiomyopathy is chronic ischemic left ventricular dysfunction characterized by heart failure, myocardial ischemia, hypotension in dialysis and arrhythmia. This nosologic entity represents a leading cause of morbidity and mortality among patients with end-stage renal disease receiving long-term hemodialysis. It is intuitive that revascularization in the presence of coronary artery disease in these patients represents an effective option for improving their prognosis. Although the surgical option seems to be followed by the best clinical outcome, some patients refuse this option and others are not good candidates for surgery. The present report describes the case of a patient affected by uremic cardiomyopathy and severe coronary artery disease in whom revascularization with percutaneous coronary angioplasty was followed by a significant improvement in quality of life.

Molecular biology of heart disease

Dr. Robert Roberts is currently Professor of Medicine and Director of the Ruddy Canadian Cardiovascular Genetics Centre along with being President and CEO of the University of Ottawa Heart Institute. Prior to this appointment, he was Chief of Cardiology for 23 years at Baylor College of Medicine, Houston, Texas. His original research was in cardiac enzymology which led to the development of the MBCK test which was the standard diagnostic assay for myocardial infarction for more than 3 decades. In the late 1970s, his research interests switched to molecular biology and the genetics of cardiomyopathies. He is regarded as one of the founders of molecular cardiology and has identified and sequenced more than 20 genes responsible for cardiovascular disorders. In the past 6 years, he has pursued genome-wide association studies to identify genes predisposing to coronary artery disease (CAD) and myocardial infarction. The first genetic variant for CAD, 9p21, was identified by Dr. Robert's laboratory and, in collaboration with the international consortium, CARDIoGRAM, has identified 13 novel genes for CAD.

Increased heart rate and atherosclerosis: potential implications of ivabradine therapy

Despite all the therapeutic advances in the field of cardiology, cardiovascular diseases, and in particular coronary artery disease, remain the leading cause of death and disability worldwide, thereby underlining the importance of acquiring new therapeutic options in this field. A reduction in elevated resting heart rate (HR) has long been postulated as a therapeutic approach in the management of cardiovascular disease. An increased HR has been shown to be associated with increased progression of coronary atherosclerosis in animal models and patients. A high HR has also been associated with a greatly increased risk of plaque rupture in patients with coronary atherosclerosis. Endothelial function may be an important link between HR and atherosclerosis. An increased HR has been shown experimentally to cause endothelial dysfunction. Inflammation plays a significant role in the pathogenesis and progression of atherosclerosis. In the literature, there is data that shows an association between HR and circulating markers of vascular inflammation. In addition, HR reduction by pharmacological intervention with ivabradine (a selective HR-lowering agent that acts by inhibiting the pacemaker ionic current I(f) in sinoatrial node cells) reduces the formation of atherosclerotic plaques in animal models of lipid-induced atherosclerosis. The aim of this editorial is to review the possible role of ivabradine on atherosclerosis.

Cardiac mass in a patient with colorectal cancer: "Not all that glitters is gold!"

When performing echocardiography in a 74-year-old woman admitted with non ST elevation myocardial infarction and concomitant colorectal cancer (CC), a dense calcification of the mitral annulus was detected. Differential diagnosis between secondary metastasis and other etiologies of cardiac masses was essential for staging and therapeutic decision-making. Multimodality imaging with echocardiography alongside a computed tomography scan and cardiac magnetic resonance was crucial for the final diagnosis of caseous calcification of the mitral annulus (CCMA). CCMA is briefly reviewed and some possible explanations for the previously undescribed association of CC with CCMA are suggested.