The prothrombin 20210A allele and the factor V Leiden are associated with venous thrombosis but not with early coronary artery disease

This study was performed in order to establish the role of the prothrombin 20210 G/A and factor V Leiden (R506Q) polymorphisms in the susceptibility to develop venous thromboembolism and early coronary artery disease (CAD). These polymorphisms were determined in 82 consecutive patients with venous thromboembolism, 175 male patients with early CAD, and 200 healthy controls from the same Caucasian population (Asturias, Northern Spain). DNA was amplified using polymerase chain reactions and digested with the appropriate restriction enzymes in order to define the prothrombin and factor V genotypes. The prevalence of the heterozygous for the prothrombin A allele was 3.5% in the general population and 15.8% in patients with venous thrombosis (P = 0.0007); the frequency was 4% in patients with early CAD. No sex-related differences in the prevalence of the A allele were observed, and the average age at the first venous thromboembolic event was similar between GG and AG patients. The frequency of carriers of the factor V Leiden polymorphism was 9.75% among patients with venous thromboembolism, compared with 3.5% among controls, and 3.4% in the patients with CAD. Our data showed an association between venous thromboembolism and the AG genotype at the prothrombin 20210 G/A polymorphism. This polymorphism was not related to an increased risk for early CAD in our population of male patients.

Apolipoprotein A1 gene polymorphisms and risk of early coronary disease

Genetic studies have identified polymorphisms at the apolipoprotein (Apo) A1 gene associated with HDL cholesterol and apolipoprotein levels, and a relationship between the severity of coronary artery disease and polymorphisms at the 5'-end of Apo A1 has been also reported. This study was designed to examine the relationship between polymorphism at the Apo A1 gene and the risk of early coronary artery disease. Furthermore, the association of the polymorphism with the classical risk factors was analyzed. A total of 176 male patients (mean age 43 +/- 5 years) diagnosed as having unstable angina (53 cases) or myocardial infarction (123 cases) were prospectively evaluated. Data referring to hypertension, diabetes and tobacco consumption were recorded. The levels of total cholesterol, HDL cholesterol, Apo A1 and B and triglycerides were determined. DNA was obtained from the 176 patients and from 200 controls. In order to determine the Apo A1 genotypes at two polymorphic sites (G/A at -75 bp, and C/T at +83 bp), DNA was PCR amplified and digested with MspI. The frequency of carriers of the rare allele at the -75 bp site (M1-) was 0.34 in cases and 0.24 in controls (p < 0.05). The frequencies of the M1- allele among patients with angina and myocardial infarction were 0.43 (p = 0.009, angina vs. controls) and 0.30, respectively. No significant association between this polymorphism and other cardiovascular risk factors was found. No difference in the frequencies for carriers of the rare allele at the +83-bp polymorphism (M2) was observed among patients with angina (0.08 vs. 0.07) or myocardial infarction (0.04 vs. 0.07), and no association between this polymorphism and tobacco, hypertension and diabetes was noted. Patients carrying the rare M2- allele had a lower concentration of total cholesterol compared to those without this allele (183 +/- 29 vs. 223 +/- 54, p < 0.04) and HDL cholesterol was also lower among patients carrying the M2- (26 +/- 4 vs. 33 +/- 9, p < 0.02). In our community male patients with a diagnosis of coronary artery disease and age less than 50 years showed a higher frequency of the M1- allele at the -75-bp site of the Apo A1 gene. There was a significant increase in the frequency of the M1- allele in patients with unstable angina and no association with risk factors. In the +83-bp polymorphism there was no difference in the allelelic frequencies or the risk factors, except for the HDL cholesterol and total cholesterol where the patients with the allele M2- had lower levels than those homozygous for the M2+.

Angiotensin-converting enzyme and angiotensin II receptor 1 polymorphisms: association with early coronary disease

OBJECTIVE

To examine the association between coronary artery disease and polymorphisms at the angiotensin-converting enzyme (ACE) and angiotensin II type 1 receptor (AT1R) genes.

METHODS

A total of 181 patients younger than 50 years and 240 controls from the same homogeneous Caucasian population (Asturias, Northern Spain) were genotyped (using polymerase chain reaction) for the ACE insertion/deletion (ACE-I/D) and the AT1R A/C transversion (AT1R-A/C) (3-untranslated region) polymorphisms.

RESULTS

The DD-genotype was at a non-significant higher frequency among patients (50%) than in controls (41%). No difference between the two groups was found for the AT1R-genotypes. Distribution of ACE-genotypes according to AT1R-genotypes showed a significant association between ACE-DD and AT1R-CC and early coronary disease. Among the CC patients 58% were DD, compared to 21% among the controls (p = 0.02; OR = 5.32, 95% CI = 1.45, 19.51). We determined the distribution of these genotypes among the hypertensive and non-hypertensive patients. Frequencies of ACE- or AT1R-genotypes did not differ between the two groups. However, we found an interaction between the DD- and CC-genotypes in the group of normotensives. Among the CC patients, 13% of the hypertensives and 75% of the normotensives were DD (p = 0.014).

CONCLUSIONS

Our results indicate a synergistic contribution of ACE and AT1R polymorphisms to the risk of coronary artery disease. This gene-gene interaction could have clinical implications. Approximately 2% of individuals in our population are CC + DD, and the genotyping of both polymorphisms could identify those with a high relative risk for coronary artery disease.

Takayasu arteritis in Colombia

Takayasu arteritis has been recognized in Colombia just recently, and so far we do not have any report concerning its presentation here. In this first report, some issues related to the presentation of the disease are indicated and compared with those found in the medical literature. No differences were found in age and sex. Most of the cases were diagnosed during an inactive phase of the disease with advanced manifestations due to vascular lesion which suggests the existence of some genetic factor influencing such a presentation, or may be the consequence of a delay in diagnosing the disease during initial and active stages due to not suspecting it. Comparing the vessels which are affected among other races and countries, we can find both differences and similarities. With the purpose of discovering the demographic, clinical, angiographic and laboratorial characteristics of Takayasu arteritis in Colombia, the present study was carried out by studying 35 clinical cases in different medical centers of the country.

[Coronary spasm and heart arrest caused by ventricular fibrillation]

We report the cases of three young men, heavy smokers, without previous heart disease and who were resuscitated after cardiac arrest due to ventricular fibrillation attributed to coronary spasm. All of them complained of atypical chest pain and the exercise testing, echocardiogram and coronary angiography were normal. The first case was diagnosed by Holter monitoring and by provocative testing with intracoronary ergonovine; the second by provocative testing with intracoronary acetylcholine and the third by Holter monitoring. The patients were treated with a calcium antagonist and/or nitrates and in the follow up they remained asymptomatic.

Randomised study of effect of ibopamine on survival in patients with advanced severe heart failure. Second Prospective Randomised Study of Ibopamine on Mortality and Efficacy (PRIME II) Investigators

BACKGROUND

Drugs that improve symptoms in patients with heart failure must also be assessed for their effects on survival. Ibopamine stimulates DA-1 and DA-2 receptors and causes peripheral and renal vasodilatation; the drug improves symptoms of heart failure. We assessed the effect of ibopamine on survival in patients with advanced heart failure in a multicentre, randomised placebo-controlled study.

METHODS

Patients with advanced severe heart failure (New York Heart Association classes III and IV) and evidence of severe left-ventricular disease, who were already receiving optimum treatment for heart failure, were randomly allocated oral ibopamine 100 mg three times daily or placebo. The primary endpoint was all-cause mortality. The study was designed to recruit 2200 patients, and the minimum duration of treatment would be 6 months. We did intention-to-treat and on-treatment analyses; a post-hoc subgroup analysis was also done.

FINDINGS

After we had recruited 1906 patients the trial was stopped early, because of an excess of deaths among patients in the ibopamine group. 232 (25%) of 953 patients in the ibopamine group died, compared with 193 (20%) of 953 patients in the placebo group (relative risk 1.26 [95% CI 1.04-1.53], p = 0.017). The average length of follow-up was 347 days in the ibopamine group and 363 days in the placebo group. In multivariate analysis, only the use of antiarrhythmic drugs at baseline was a significant independent predictor of increased fatality in ibopamine-treated patients.

INTERPRETATION

Ibopamine seems to increase the risk of death among patients with advanced heart failure who are already receiving optimum therapy, but the reasons for this increase are not clear. Our finding that antiarrhythmic treatment was a significant predictor of increased mortality in ibopamine-treated patients may be important, but exploratory analyses must be interpreted with caution.

Adaptation mechanisms during myocardial ischemia in chronic unstable angina pectoris

Unstable angina with a clinical duration of < 2 months is characterized angiographically by a high incidence of complex lesions. Some patients have ischemic rest pain syndromes of longer duration. Thus, we retrospectively analyzed, in blinded fashion, the clinical and angiographic findings in 52 patients with unstable angina of < 2 months' duration (group A), and compared the results with those of 32 patients with unstable angina of > 6 months' duration (group B). Group B had a greater number of diseased vessels and better collateral circulation, but had fewer eccentric lesions. There were no differences in age, left ventricular function, or history of prior myocardial infarction. Thus, chronic unstable angina is associated with more extensive coronary disease than unstable angina of shorter duration. The role of different anatomic substrata and collateral circulation is discussed.

Aldosterone levels and cardiac hypertrophy in professional cyclists

Aldosterone has been associated with the development of cardiac hypertrophy and a correlation has been found between levels of aldosterone and the degree of cardiac hypertrophy in hypertensive patients. Our study aimed to test the relation between physiologic cardiac hypertrophy and serum aldosterone in a group of highly trained cyclists. Determination of the left ventricular mass index (LVMI) was performed in a group of 40 professional cyclists by using Devereux's formula with correction for body surface area. After an overnight fast, blood samples were collected and serum aldosterone levels were measured using RIA. LVMI and serum aldosterone were intercorrelated using linear regression analysis. Twenty-three of the 40 cyclists (58%) presented an LVMI > 130 g.m-1 and the other 17 subjects (42%) presented an LVMI < 130 g.m-1. Serum aldosterone levels did not correlate with LVMI in either of the groups (LVMI > 130 g.m-1, r = -0.089; LVMI < 130 g.m-1, r = 0.146). The lack of correlation of this hypertrophy with serum aldosterone levels suggests that physiologic hypertrophy of the athlete's heart could be caused by a different stimulus to that seen in pathologic hypertrophy of hypertensives.

Prevalence and upper limit of cardiac hypertrophy in professional cyclists

The term athlete's heart refers to an increased left ventricular mass. Few studies have assessed the prevalence and normal upper limit of cardiac hypertrophy in highly trained cyclists and this was the aim of this study. A group of 40 professional road cyclists [mean age 26 (SD 3) years] who had participated in European competitions for 3-10 years, were evaluated at the beginning of the 1992-93 season. Evaluation included a clinical history and physical examination, one and two-dimensional echocardiography, 12-lead resting electrocardiogram and a graded exercise test. Determination of the left ventricular mass index (LVMI) was performed using Devereux's formula with correction for the body surface area. Systolic and diastolic blood pressure were measured at rest and at peak exercise. Of the group 23 cyclists (58%) presented a LVMI greater than 130 g.m-2, 21 cyclists presented a diastolic ventricular thickness equal to or greater than 13 mm, with a superior limit of 19 mm; 3 cyclists presented asymmetrical septum hypertrophy; and the relationship between posterior wall and left ventricular diastolic radius was equal to or greater than 0.45 in 14 cases (35%). Electrocardiographic abnormalities of ST-T segment were seen in only 1 subject. No correlation was found between the degree of ventricular hypertrophy and arterial blood pressure. We concluded that these professional cyclists showed a high prevalence of cardiac hypertrophy (58%). The distribution of this hypertrophy was concentric in 20/33 and asymmetric in 3/23 of the subjects with left ventricular hypertrophy. The electrocardiograms were normal in 98% of the subjects.

Familial ochronosis

We report the case of a 72-year-old female with alkaptonuric ochronosis and symptomatic aortic stenosis requiring aortic valve replacement. She was the seventh of nine children, and four of the nine siblings were diagnosed as having ochronosis. Only one, however presented with aortic stenosis.

Interrelationships between lipoprotein(a) and other cardiovascular risk factors

Lipoprotein(a) [Lp(a)] had been shown to be a strong independent risk factor for ischaemic heart disease. Our aim was to investigate the relationships between Lp(a) and other cardiovascular risk factors. 423 male miners (age 40 +/- 8 years) were analysed according to the following variables: age, arterial blood pressure, alcohol and cigarette consumption, total cholesterol and Lp(a). Analysis of the data was performed using the Kruskal-Wallis and Spearman tests. Analysis of variance showed statistical differences in Lp(a) levels with cigarette consumption (p < 0.02) and age (p < 0.001). No differences with corrected total cholesterol, blood pressure and alcohol consumption were found. Lp(a) and total cholesterol were correlated (p < 0.0001), but after correction for the estimated contribution of Lp(a) cholesterol this significant correlation disappeared. We conclude that male smokers have significantly lower Lp(a) values than non-smokers and those who quit. Our findings suggest that cigarette consumption is a probable environmental factor that might influence Lp(a) levels.

[Spontaneous calcific embolization in calcified aortic valve stenosis. A case report]

Calcific embolism from an aortic stenosis is an uncommon event that can be seen after cardiac surgery or left heart catheterization but extremely rare in a spontaneous way. We report a case of a patient with calcified aortic stenosis presenting a spontaneous calcareous embolism in the retinal artery. We review the literature about this problem as well.

[The long-term evolution of patients with senile aortic stenosis undergoing percutaneous valve dilatation]

The long-term follow-up of 35 patients with mean age of 74.3 +/- 8 years (64-86) who underwent percutaneous aortic valvuloplasty (PAV) is presented. The mean duration of the follow-up study was 33 months (range 1-48). Global mortality was 42% (14 patients) and was related to post-PAV aortic valvular area (47% mortality in less than 0.7 cm2 area group vs 28% in greater than or equal to 0.7 cm2 group) and left ventricular ejection fraction (67% in EF less than 35% group vs 35% in EF greater than or equal to 35% group). The actuarial probability of remaining alive and free of symptoms and of cardiac surgery or new PAV was 57, 41, 33, and 20% at 1, 2, 3 and 4 years. After PAV clinical improvement was obtained in most of the patients (68%), but only 42% of those with successful dilatation remain asymptomatic after a 24 months period (85 +/- 28 mmHg, p = NS). Transvalvular gradient studied by Doppler decreased immediately after PAV (92.8 +/- 26 mmHg vs 51 +/- 16 mmHg, p less than 0.001), but returned to baseline values after 12 months. These results show that PAV yields a clinical improvement in most of the patients, but this improvement is transitory, does not modify the natural history of the disease and has a high degree of restenosis. Thus, its use must be limited to a reduced group of patients who are not candidates for cardiac surgery.

[Heart hydatidosis diagnoses with bidimensional echocardiography]

A case of calcificated intramyocardiac hydatid cyst is presented. The initial diagnosis was coronary artery disease and the onset was chest pain and typical abnormalities of the electrocardiogram. The diagnosis of hydatid disease was suspected from chest roentgenogram and confirmed by two-dimensional echocardiography and left ventriculography. Coronary arteriography was normal and surgical treatment successfully carried out.