Nuclear-encoded proteins target to the plastid in Toxoplasma gondii and Plasmodium falciparum

A vestigial, nonphotosynthetic plastid has been identified recently in protozoan parasites of the phylum Apicomplexa. The apicomplexan plastid, or "apicoplast," is indispensable, but the complete sequence of both the Plasmodium falciparum and Toxoplasma gondii apicoplast genomes has offered no clue as to what essential metabolic function(s) this organelle might perform in parasites. To investigate possible functions of the apicoplast, we sought to identify nuclear-encoded genes whose products are targeted to the apicoplast in Plasmodium and Toxoplasma. We describe here nuclear genes encoding ribosomal proteins S9 and L28 and the fatty acid biosynthetic enzymes acyl carrier protein (ACP), beta-ketoacyl-ACP synthase III (FabH), and beta-hydroxyacyl-ACP dehydratase (FabZ). These genes show high similarity to plastid homologues, and immunolocalization of S9 and ACP verifies that the proteins accumulate in the plastid. All the putatively apicoplast-targeted proteins bear N-terminal presequences consistent with plastid targeting, and the ACP presequence is shown to be sufficient to target a recombinant green fluorescent protein reporter to the apicoplast in transgenic T. gondii. Localization of ACP, and very probably FabH and FabZ, in the apicoplast implicates fatty acid biosynthesis as a likely function of the apicoplast. Moreover, inhibition of P. falciparum growth by thiolactomycin, an inhibitor of FabH, indicates a vital role for apicoplast fatty acid biosynthesis. Because the fatty acid biosynthesis genes identified here are of a plastid/bacterial type, and distinct from those of the equivalent pathway in animals, fatty acid biosynthesis is potentially an excellent target for therapeutics directed against malaria, toxoplasmosis, and other apicomplexan-mediated diseases.

The phylogenetic position of alpha- and beta-tubulins from the Chlorarachnion host and Cercomonas (Cercozoa)

Alpha and beta-tubulin genes from Chlorarachnion and an alpha-tubulin gene from Cercomonas have been characterised. We found the Cercomonas and Chlorarachnion alpha tubulins to be closely related to one another, confirming the proposed relationship of these genera. In addition, the Chlorarachnion host and Cercomonas also appear to be more distantly related to Heterolobosea, Euglenozoa, chlorophytes, heterokonts, and alveolates. Chlorarachnion was also found to have two distinctly different types of both alpha- and beta-tubulin, one type being highly-divergent. Chlorarachnion contains a secondary endosymbiont of green algal origin, raising the possibility that one type of Chlorarachnion tubulins comes from the host and the other from the endosymbiont. Probing pulsed field-separated chromosomes showed that the highly-divergent genes are encoded by the host genome, and neither alpha- nor beta-tubulin cDNAs were found to include 5' extensions that might serve as targeting peptides. It appears that Chlorarachnion has distinct and divergent tubulin paralogues that are all derived from the host lineage. One Chlorarachnion beta-tubulin was also found to be a pseudogene, which is still expressed but aberrantly processed. Numerous unspliced introns and deletions resulting from mis-splicing are contained in the mRNAs from this gene.

Familial dilated cardiomyopathy: cardiac abnormalities are common in asymptomatic relatives and may represent early disease

OBJECTIVES

This study sought to determine whether early disease is identifiable in asymptomatic relatives of patients with dilated cardiomyopathy (DCM) by means of noninvasive cardiologic assessment.

BACKGROUND

DCM is diagnosed on the basis of advanced heart failure, where cardiac dilation and impaired contractility are recognized in the absence of a recognized etiology (World Health Organization criteria). However, initial clinical presentation may be with severe complications: thromboembolism, arrhythmia or sudden death. DCM has recently been recognized to be familial, with autosomal dominant inheritance in many cases. Familial disease is present in 9% to 20% of patients with DCM, and the ability to identify early disease in such people may improve patient management and aid in the understanding of pathogenesis.

METHOD

We prospectively assessed 408 asymptomatic relatives (mean [+/-SD] age 35 +/- 15 years, 193 men) of 110 consecutive patients with DCM by means of history and physical examination, two-dimensional echocardiography, 12-lead and signal-averaged electrocardiography and metabolic exercise testing. We hypothesized that signs of lesser cardiac dysfunction in such relatives might indicate early disease.

RESULTS

Twenty-nine percent of relatives had abnormal results on the echocardiogram. Twenty percent (n = 45) had left ventricular enlargement (LVE), defined as LV end-diastolic diameter (LVEDD) > or = 112% predicted; 6% (n = 13) had depressed fractional shortening (dFS), defined as FS < or = 25%; and 3% (n = 7) had frank DCM, defined as LV dilation, impaired contractile performance and LVEDD > or = 112% plus FS < or = 25%. Other abnormalities of cardiac function were identified in relatives with LVE or dFS: A greater number with LVE had an abnormal metabolic exercise test result than normal relatives (9% vs. 1%, p < 0.05). Relatives with LVE and abnormal maximal oxygen consumption (VO2max) (defined as VO2max < 80% predicted) had a lower absolute VO2max than normal relatives (30 +/- 8 vs. 43 +/- 9 ml/min per kg, p = 0.01). The QRS duration (at the 25-Hz filter) on the signal-averaged electrocardiogram was prolonged in relatives with LVE (103 +/- 13 ms) and dFS (102 +/- 12 ms) compared with that of normal relatives (97 +/- 12 ms, p < 0.05). Over a mean 39-month follow-up period, 12 relatives with LVE (27%) and none with dFS developed symptomatic DCM (p < 0.0001). One relative with LVE died suddenly, and another underwent heart transplantation.

CONCLUSIONS

Nearly one-third of asymptomatic relatives (29%) have echocardiographic abnormalities, and 27% of such relatives progress to development of overt DCM. Early identification of such people would permit appropriate intervention that might influence the serious complications and mortality of this disease.

Origins of microsporidia

Microsporidia are obligate intracellular parasites that infect a wide range of eukaryotes, causing severe diseases in immunocompromised humans and losses to apiaries, fisheries and silk farms. They have often been considered to be primitive eukaryotes; however, more recent evidence suggests they are more closely related to fungi.

Widespread and ancient distribution of a noncanonical genetic code in diplomonads

Recently, a group of diplomonads has been found to use a genetic code in which TAA and TAG encode glutamine rather than termination. To survey the distribution of this characteristic in diplomonads, we sought to identify TAA and TAG codons at positions where glutamine is expected in genes for alpha-tubulin, elongation factor-1 alpha, and the gamma subunit of eukaryotic translation initiation factor-2. These sequences show that the variant genetic code is utilized by almost all diplomonads, with the genus Giardia alone using the universal genetic code. Comparative phylogenetic analysis reveals that the switch to this genetic code took place very early in the evolution of diplomonads and was likely a single event. Termination signals and downstream untranslated regions were also cloned from three Hexamita genes. In all three of these genes, the predicted TGA termination codon was found at the expected position. Interestingly, the untranslated regions of these genes are high in AT. This is incongruent with the coding regions, which are comparatively GC-rich.

Usefulness of signal-averaged electrocardiography in evaluation of idiopathic-dilated cardiomyopathy in families

Family studies have confirmed that familial dilated cardiomyopathy is common and that a large proportion of relatives have mild left ventricular enlargement and therefore potentially early disease. Previous studies have shown that patients with idiopathic dilated cardiomyopathy have abnormalities of the signal-averaged electrocardiogram (ECG). We assessed the usefulness of analysis of the signal-averaged ECG in the evaluation of familial dilated cardiomyopathy. Signal-averaged electrocardiographic recordings were obtained from 58 patients with idiopathic dilated cardiomyopathy, from 161 of their relatives (35 of whom had left ventricular enlargement), and from 59 healthy subjects. Signal-averaged ECGs were analyzed using both time domain and spectral turbulence analysis techniques. The time domain and spectral turbulence analysis variables were markedly abnormal in patients with idiopathic dilated cardiomyopathy compared with relatives considered normal and healthy controls (p <0.05). Late potentials were more common in patients with idiopathic dilated cardiomyopathy (17%) and in relatives with left ventricular enlargement (20%) than in normal relatives (5%) or healthy controls (5%) (p = 0.003). Spectral turbulence analysis was abnormal in 24% of patients with idiopathic dilated cardiomyopathy, 14% of relatives with left ventricular enlargement, 6% of normal relatives, and 5% of healthy controls (p = 0.0006). The sensitivity, specificity, and positive predictive accuracy for identification of relatives with left ventricular enlargement were 20%, 95%, and 54% for time domain analysis and 14%, 94%, and 42% for spectral turbulence analysis. Similar positive predictive accuracy was achievable with spectral turbulence analysis and with time domain analysis. In conclusion, the signal-averaged ECG is frequently abnormal in patients with idiopathic dilated cardiomyopathy and relatives with left ventricular enlargement.

Evidence that eukaryotic triosephosphate isomerase is of alpha-proteobacterial origin

We have cloned and sequenced genes for triosephosphate isomerase (TPI) from the gamma-proteobacterium Francisella tularensis, the green non-sulfur bacterium Chloroflexus aurantiacus, and the alpha-proteobacterium Rhizobium etli and used these in phylogenetic analysis with TPI sequences from other members of the Bacteria, Archaea, and Eukarya. These analyses show that eukaryotic TPI genes are most closely related to the homologue from the alpha-proteobacterium and most distantly related to archaebacterial homologues. This relationship suggests that the TPI genes present in modern eukaryotic genomes were derived from an alpha-proteobacterial genome (possibly that of the protomitochondrial endosymbiont) after the divergence of Archaea and Eukarya. Among these eukaryotic genes are some from deeply branching, amitochondrial eukaryotes (namely Giardia), which further suggests that this event took place quite early in eukaryotic evolution.

Heart rate variability in idiopathic dilated cardiomyopathy: relation to disease severity and prognosis

OBJECTIVE

To assess the clinical importance of heart rate variability (HRV) in patients with idiopathic dilated cardiomyopathy (DCM).

PATIENTS AND METHODS

Time domain analysis of 24 hour HRV was performed in 64 patients with DCM, 19 of their relatives with left ventricular enlargement (possible early DCM), and 33 healthy control subjects.

RESULTS

Measures of HRV were reduced in patients with DCM compared with controls (P < 0.05). HRV parameters were similar in relatives and controls. Measures of HRV were lower in DCM patients in whom progressive heart failure developed (n = 28) than in those who remained clinically stable (n = 36) during a follow up of 24 (20) months (P = 0.0001). Reduced HRV was associated with NYHA functional class, left ventricular end diastolic dimension, reduced left ventricular ejection fraction, and peak exercise oxygen consumption (P < 0.05) in all patients. DCM patients with standard deviation of normal to normal RR intervals calculated over the 24 hour period (SDNN) < 50 ms had a significantly lower survival rate free of progressive heart failure than those with SDNN > 50 ms (P = 0.0002, at 12 months; P = 0.0001, during overall follow up). Stepwise multiple regression analysis showed that SDNN < 50 ms identified, independently of other clinical variables, patients who were at increased risk of developing progressive heart failure (P = 0.0004).

CONCLUSIONS

HRV is reduced in patients with DCM and related to disease severity. HRV is clinically useful as an early non-invasive marker of DCM deterioration.

Cardiac autoantibodies in dilated cardiomyopathy become undetectable with disease progression

OBJECTIVE

To determine the relation of cardiac autoantibody and disease status in a consecutive series of patients with dilated cardiomyopathy by prospective antibody testing at diagnosis and at follow up.

METHODS

Antibody status was assessed by indirect immunofluorescence in 110 patients with dilated cardiomyopathy (85 male, mean (SD) age 44 (13) years) at diagnosis and at follow up (mean (SD) 14 (12) months); in 57 of them cardiac specific anti-alpha myosin antibody titres were also measured by an enzyme-linked immunosorbent assay (ELISA). Patients underwent complete evaluation at diagnosis and clinical and non-invasive assessment at follow up, including exercise testing with maximal oxygen consumption measurements.

RESULTS

The frequency of cardiac specific antibodies by immunofluorescence was lower at follow up than at diagnosis (28 (25%) v 11 (10%), P = 0.002). Mean (SEM) anti-alpha myosin antibody titres at follow up were also lower than at diagnosis (0.24 (0.02) v 0.30 (0.02), P = 0.038); 24% of patients at diagnosis and 14% at follow up had an abnormal ELISA result. None of the patients who were negative by immunofluorescence or ELISA at diagnosis became positive at follow up. Presence of antibody at diagnosis was associated with milder symptoms and greater exercise capacity at follow up and persistence of antibody at follow up was associated with stable disease and milder symptoms at diagnosis.

CONCLUSIONS

Cardiac specific autoantibodies in dilated cardiomyopathy become undetectable with disease progression; this is a recognised feature of other autoimmune conditions, such as type 1 diabetes. Detection of these antibodies at diagnosis and at follow up may provide a non-invasive marker of early dilated cardiomyopathy.

Alpha-tubulin from early-diverging eukaryotic lineages and the evolution of the tubulin family

The tubulin gene family, which includes alpha-,beta-, and gamma-tubulin subfamilies, is composed of highly conserved proteins which are the principle structural and functional components of eukaryotic microtubules. We are interested in (1) establishing when in eukaryotic evolution the duplications leading to paralogous alpha, beta, and gamma subfamilies occurred and (2) the possible utility of tubulin sequences in reconstructing organismal phylogeny. To broaden the taxonomic representation of alpha-tubulins so that it roughly equals that of beta-tubulins, alpha-tubulin genes from three Microsporidia (Encephalitozoon hellem, Nosema locustae, and Spraguea lophii), two Parabasalia (Monocercomonas sp. and Trichomitus batrachorum), and one Heterolobosean (Acrasis rosea) were sequenced. With these new genes, phylogenetic trees of alpha- and beta-tubulins were constructed and compared. Trees were congruent with each other, but incongruent with other molecular phylogenies. The agreement between alpha- and beta-tubulin trees could arise by the co-adaptation of one molecule to variants of the other as a result of their intimate steric association in microtubules. Thus, these trees may not be providing independent support for the phylogenetic results. However, one of these unexpected results, that microsporidia cluster with fungi, is supported by other circumstantial evidence, and may therefore reflect a real relationship despite the basal position usually assigned to microsporidia. Relationships between the three tubulins were also examined by constructing trees of all three types. These trees were found to be of limited value for determining the position of the root within each subfamily because of the great interfamily distances, but they do confirm the classification of all known genes into three monophyletic subfamilies. Divergent genes from Caenorhabditis elegans and Saccharomyces cerevisiae that have been proposed to represent the novel classes delta- and epsilon-tubulin were found to be specifically related to gamma-tubulins from animals and fungi respectively, and therefore are best seen as rapidly evolving orthologues of gamma-tubulin.

Linked genes for calmodulin and E2 ubiquitin-conjugating enzyme in Trichomonas vaginalis

In searching the genomes of early-diverging protists to study whether the possession of calmodulin is ancestral to all eukaryotes, the gene for calmodulin was identified in Trichomonas vaginalis. This flagellate is a member of the Parabasalia, one of the earliest lineages of recognized eukaryotes to have diverged. This sequence was used to isolate a homologous 1.250-kb fragment from the T. vaginalis genome by inverse polymerase chain reaction. This fragment was also completely sequenced and shown to contain the 3' end of the single-copy calmodulin gene and the 3' end of a gene encoding a protein with high similarity to E2 ubiquitin-conjugating enzymes, a family which has previously only been identified in animals, plants, and fungi. Phylogenetic analysis of 50 members of the E2 family distinguishes at least nine separate subfamilies one of which includes the T. vaginalis E2-homologue and an uncharacterized gene from yeast chromosome XII.

Comparison of time domain and spectral turbulence analysis of the signal-averaged electrocardiogram for the prediction of prognosis in idiopathic dilated cardiomyopathy

BACKGROUND

Despite significant advances in the treatment of heart failure, the prognosis of patients with idiopathic dilated cardiomyopathy remains poor. Although several of prognostic variables have been shown to be useful in risk stratification of patients with idiopathic dilated cardiomyopathy, their predictive accuracy is low and clinical usefulness uncertain.

HYPOTHESIS

This study was undertaken to assess the signal-averaged electrocardiogram (SAECG) in patients with idiopathic dilated cardiomyopathy and to compare the ability of time domain and spectral turbulence analytic techniques to predict clinical outcome.

METHODS

SAECG analysis was performed in 80 patients with idiopathic dilated cardiomyopathy. Nineteen patients had left bundle-branch block and eight were taking low-dose amiodarone for life-threatening arrhythmias. Conventional time domain and spectral turbulence analyses of the SAECG were performed using Del Mar 183 software.

RESULTS

During a follow-up of 27 +/- 19 months, 24 patients developed progressive heart failure, while the others remained clinically stable. Late potentials were detected in 28% of patients and were equally frequent in patients with and without progressive heart failure (38 vs. 23%, p = 0.20). Spectral turbulence analysis was abnormal in 34% of patients, and patients with abnormal results developed progressive heart failure more frequently than those with normal results (50 vs. 17%, p = 0.01). All spectral turbulence analysis parameters were significantly different in patients with progressive heart failure compared with those who remained clinically stable (p < or = 0.01). Furthermore, progressive heart failure-free survival at 2 years was significantly lower in patients with abnormal compared with normal results (63 vs. 87%; p < 0.05), but was similar in patients with and without late potentials (72 vs. 83%; p = 0.30). The relative risk for developing progressive heart failure using spectral turbulence analysis was 3.4 (95% confidence interval 1.2-9.7) and 2.8 (95% confidence interval 1.1-8.7) using time domain analysis. The sensitivity, specificity, and the positive and negative predictive accuracy for identifying patients who developed progressive heart failure were 50, 83, 50, and 83%, respectively, (p = 0.01) for spectral turbulence analysis, and 36, 85, 45 and 80%, respectively, (p = 0.09) for time domain analysis.

CONCLUSION

Abnormalities in the SAECG of patients with idiopathic dilated cardiomyopathy are common and appear to provide a noninvasive marker for development of progressive heart failure.

A non-canonical genetic code in an early diverging eukaryotic lineage

The nearly invariant nature of the 'Universal Genetic Code' attests to its early establishment in evolution and to the difficulty of altering it now, since so many molecules are required for, and depend upon, faithful translation. Nevertheless, variations on the universal code are known in a handful of genomes. We have found one such variant in diplomonads, an early-diverging eukaryotic lineage. Genes for alpha-tubulin, beta-tubulin and elongation factor 1 alpha (EF-1alpha) from two unclassified strains of Hexamitidae were found to contain TAA and TAG (TAR) triplets at positions suggesting a variant code in which TAR codes for glutamine. We found confirmation of this hypothesis by identifying genes encoding glutamine-tRNAs with CUA and UUA anticodons. The alpha-tubulin and EF-1alpha genes from two other diplomonads, Spironucleus muris and Hexamita inflata, were also sequenced and shown to contain no such non-canonical codons. However, tRNA genes with the anticodons UUA and CUA were found in H.inflata, suggesting that this diplomonad also uses these codons, albeit infrequently. The high GC content of these genomes and the presence of two isoaccepting tRNAs compound the difficulty of understanding how this variant code arose by strictly neutral means.

Decreased heart rate variability in patients with congestive heart failure and chronotropic incompetence

Heart rate variability was studied in 41 patients (aged 48 +/- 12 years) with congestive heart failure secondary to idiopathic dilated cardiomyopathy. All patients underwent a treadmill exercise test and 24-hour Holter ECG monitoring. Chronotropic incompetence was defined as the failure to achieve > or = 80% of the predicted maximal heart rate response given by 220--age (years) at peak exercise. Spectral heart rate variability was analyzed from 24-hour Holter ECGs and was expressed as total (0.01-1.00 Hz), low (0.04-0.15 Hz), and high (0.15-0.40 Hz) frequency components. The standard deviation of all normal RR intervals (SDNN) was also computed. Chronotropic incompetence was observed in ten patients. Peak oxygen consumption was significantly lower in patients with chronotropic incompetence compared with those without chronotropic incompetence. The total (5.11 +/- 1.26 ln [ms2] vs 6.41 +/- 0.92 ln [ms2]; P = 0.009) and low (3.38 +/- 1.65 ln [ms2] vs 5.45 +/- 1.34 ln [ms2]; P = 0.003), but not the high (3.42 +/- 1.04 ln [ms2] vs 4.00 +/- 1.12 ln [ms2]; P = 0.249) frequency components of heart rate variability were significantly lower in patients with chronotropic incompetence, although there was no significant difference in mean heart rate (88 +/- 20 beats/min vs 86 +/- 15 beats/min; P = 0.831) or left ventricular ejection fraction (22% +/- 10% vs 24% +/- 10%; P = 0.619). SDNN was also significantly lower in patients with chronotropic incompetence compared with those without chronotropic incompetence (64 +/- 34 ms vs 102 +/- 37 ms; P = 0.030).

CONCLUSIONS

The observation that heart rate variability is significantly decreased in patients with congestive heart failure who have chronotropic incompetence suggests that chronotropic incompetence may relate to an abnormal autonomic influence on the heart in these patients.

Expression of inducible nitric oxide synthase in human heart failure

BACKGROUND

There is increasing evidence that alterations in nitric oxide synthesis are of pathophysiological importance in heart failure. A number of studies have shown altered nitric oxide production by the endothelial constitutive isoform of nitric oxide synthase (NOS), but there is very little information on the role of the inducible isoform.

METHODS AND RESULTS

We analyzed inducible NOS (iNOS) expression in ventricular myocardium taken from 11 control subjects (who had died suddenly from noncardiac causes), from 10 donor hearts before implantation, and from 51 patients with heart failure (24 with dilated cardiomyopathy [DCM], 17 with ischemic heart disease [IHD], and 10 with valvular heart disease [VHD]). Reverse transcription-polymerase chain reaction was used to confirm the presence of intact mRNA and to detect expression of iNOS and atrial natriuretic peptide (ANP). ANP was used as a molecular phenotypic marker of ventricular failure. iNOS was expressed in 36 of 51 biopsies (71%) from patients with heart failure and in none of the control patients (P<.0001). iNOS expression could also be detected in 50% of the donor hearts. All samples that expressed iNOS also expressed ANP. iNOS gene expression occurred in 67% of patients with DCM, 59% of patients with IHD, and 100% of patients with VHD. To determine whether iNOS protein was expressed in failing ventricles, immunohistochemistry was performed on three donor hearts and nine failing hearts with iNOS mRNA expression. Staining for iNOS was almost undetectable in the donor myocardium and in control sections, but all failing hearts showed diffuse cytoplasmic staining in cardiac myocytes. Expression of iNOS could be observed in all four chambers. Western blot analysis with the same primary antibody showed a specific positive band for iNOS protein in the heart failure specimens; minimal iNOS protein expression was seen in donor heart samples.

CONCLUSIONS

iNOS expression occurs in failing human cardiac myocytes and may be involved in the pathophysiology of DCM, IHD, and VHD.

Complete nucleotide sequence of the Sulfolobus islandicus multicopy plasmid pRN1

The complete sequence of the 5350-bp plasmid pRN1 from the crenarchaeote Sulfolobus islandicus has been determined. This plasmid is the first to be sequenced from this group of thermoacidophilic archaebacteria (Archaea) and its high copy number and wide host range make it a good candidate for a cloning vector. pRN1 contains several open reading frames, including one that spans over half the plasmid and has significant similarity to the helicase domain of viral primase proteins. Directly upstream of this putative primase is a homologue of Cop, a family of small proteins from promiscuous eubacterial plasmids which control copy number by repressing the expression of the replication initiation protein. In eubacterial plasmids cop is found upstream of the replication initiator protein. The location of a cop homologue upstream of a primase-like gene in pRN1 suggests that it controls DNA replication in a manner similar to these eubacterial plasmids, but does so using a mixture of components from plasmids and viruses.

Abnormal cytokine profiles in patients with idiopathic dilated cardiomyopathy and their asymptomatic relatives

OBJECTIVES

Immunological abnormalities in idiopathic dilated cardiomyopathy (DCM) include an increase in soluble interleukin (IL)-2 receptor, disease specific cardiac autoantibodies, an HLA-DR4 association, and familial aggregation of disease; however, cytokine profiles have not been defined. Serum concentrations of IL-2, IL-4, IL-10, and IL-12 were measured in patients with DCM (WHO criteria), relatives with asymptomatic left ventricular enlargement (LVE), patients with ischaemic heart failure (IHD), and healthy controls.

DESIGN

Serum from 20 individuals from each of the four groups was assayed for cytokine concentrations by a commercial enzyme linked immunosorbent assay.

RESULTS

IL-2 concentrations were abnormally increased in DCM patients and relatives with LVE. Concentrations of IL-10 were increased in DCM patients. Concentrations of IL-4 and IL-12 were not increased in any of the groups.

CONCLUSION

These abnormalities may reflect defective/inappropriate T cell function in patients with DCM and in their relatives with LVE.

QT dispersion and RR variations on 12-lead ECGs in patients with congestive heart failure secondary to idiopathic dilated cardiomyopathy

Increased QT dispersion, which has been proposed as a marker of ventricular repolarization inhomogeneity, may predispose to ventricular arrhythmias. Data on QT dispersion in patients with congestive heart failure are scarce. In this study, conventional 12-lead ECGs were recorded in 135 consecutive patients with congestive heart failure secondary to idiopathic dilated cardiomyopathy. Seventy-five patients were excluded from QT interval assessments due to one or more of the following reasons: (1) low amplitude of the T wave (n = 3), (2) atrial fibrillation (n = 26) and (3) bundle branch block (n = 46). QT dispersion was calculated as (1) QT-range: the difference between the maximum and minimum QT intervals on any of the 12 leads and (2) QT-SD: the standard deviation of the QT interval in all the 12 leads. RR intervals were measured in leads II, aVL, V2 and V5. QT-SD (20.85 +/- 5.00 ms) was significantly (r = 0.8997, P < 0.001) related to QT-range (65.65 +/- 15.77 ms), but not to the QT interval. Neither QT-range nor QT-SD was significantly related to age, left ventricular dimensions, left ventricular end diastolic pressure, left ventricular ejection fraction or left ventricular wall thickness. There was no significant difference in QT dispersion between survivors and those who died (n = 8) or were transplanted (n = 9) during 34 +/- 23 month follow-up. No significant difference in QT dispersion was observed between patients with and without ventricular tachycardia (> or = three consecutive beats) detected on 24-h Holter ECGs. RR interval variation was significantly lower in patients who died compared with survivors (standard deviation: 10.37 +/- 3.61 vs 36.02 +/- 35.03 ms, P < 0.001; coefficient of variance: 1.87 +/- 0.7% vs 4.50 +/- 4.9%, P = 0.001). This was also true in patients with bundle branch block. These observations suggest that QT dispersion in idiopathic dilated cardiomyopathy is not significantly related to either QT interval or cardiac size and function and does not predict death. The application of QT dispersion assessment is limited by the commonly encountered atrial fibrillation and bundle branch block in this patient population. However, reduced RR variation on standard 12-lead ECGs has important prognostic implications in these patients.

Organ-specific cardiac autoantibodies in dilated cardiomyopathy--an update

Autoimmune disease is characterized by the presence of organ- and disease-specific autoantibodies in patients and first degree relatives; antibody detection may precede disease onset by several years. We investigated potential involvement of organ-specific autoimmunity in dilated cardiomyopathy (DCM). Using indirect immunofluorescence and absorption studies, organ- and disease-specific IgG cardiac antibodies were found in one-third of DCM patients. Antibody status at diagnosis was associated with better exercise capacity; at 1-year follow-up two-thirds of antibody-positive patients became negative. These findings suggest that antibodies are early markers; their absence in the majority of patients at diagnosis may relate to long-standing pre-clinical DCM. Antibody screening was performed in asymptomatic DCM relatives, 177 from 33 families with > 1 affected individual (familial DCM) and 165 from 31 pedigrees with non-familial DCM. Antibodies were detected in 37 (58%) pedigrees and were more common among relatives than in normals (20% vs 3.5%, P = 0.0001). Antibody-positive relatives were younger, had larger left ventricular end-systolic dimension and reduced % fractional shortening compared to antibody-negative relatives. These findings provide evidence for autoimmunity in a subset (58%) including both familial and non-familial DCM; cardiac-specific antibodies may identify relatives at risk of developing DCM.

Autoimmunity to alpha myosin in a subset of patients with idiopathic dilated cardiomyopathy

OBJECTIVE

To use an enzyme linked immunoassay (ELISA) technique to assess frequency and disease specificity of anti-alpha-myosin antibodies in patients with dilated cardiomyopathy and their relatives.

METHODS

Evaluation was performed on sera (dilution 1/320) from 123 consecutive patients with dilated cardiomyopathy (WHO criteria) (age 42 (SD 14) years), 252 of their relatives (35 (17) years), 203 healthy controls (45 (16) years), and 92 patients with ischaemic heart disease (63 (11) years).

RESULTS

Abnormal antibody levels were commoner in patients with dilated cardiomyopathy (25, 20%) than in ischaemic heart disease (4, 4%), or normal controls (4, 2%, P = 0.001). Forty one (16%) of the relatives had abnormal results compared to the controls (4, 2%, P < 0.001) and antibodies were detected in 20 (38%) of pedigrees. Relatives from non-familial kindreds had higher antibody levels than those with familial disease (P << 0.001), and higher antibody levels were identified in 53 relatives of probands who had abnormal results compared to 116 relatives for whom the proband had a normal result (0.37 (SEM 0.02) v 0.22 (0.01); P < 0.001).

CONCLUSIONS

The finding of anti-alpha-myosin antibodies in 20% of patients with dilated cardiomyopathy, in 16% of their asymptomatic relatives, and in 38% of families (particularly those with non-familial disease and where proband also had an abnormal result) provides additional evidence for autoimmunity against alpha myosin in a subset of patients.

Prognosis of idiopathic dilated cardiomyopathy

Previous reports in referral populations have emphasized the poor prognosis of dilated cardiomyopathy. This study evaluated mortality and morbidity in patients presenting at a referral center between 1989 and 1993. One hundred seventy-two consecutive patients were studied. At presentation, 82 were in New York Heart Association functional class III/IV. Mean (+/- SD) left ventricular end-diastolic dimension was 69 +/- 11 mm, ejection fraction was 25 +/- 10%, VO2 max was 21 +/- 9 mL/min/kg, and sodium was 136 +/- 9 mM. Treatments included vasodilators (n = 157, 92%), anticoagulation (n = 50, 29%), amiodarone (n = 52, 30%), and cardiac defibrillator (n = 5, 3%). During the follow-up period (mean, 26 +/- 29 months), 16 patients died and 60 developed progressive heart failure; 46 (27%) required cardiac transplantation. The majority of the patients (102, 59%) were stable or improved. Established prognostic determinants (left ventricular end-diastolic dimension, ejection fraction, sodium, and arrhythmia) were of low predictive value for the development of progressive heart failure or sudden death. The 1- and 2-year probabilities of death or transplantation was 16 and 21%, respectively (death only 6 and 7%, respectively). These observations are subject to referral bias, but suggest that the majority of patients can remain stable. Any improvement in survival compared to earlier experience can be due to earlier diagnosis, availability of transplantation, and new heart failure management strategies.

Concerted evolution in protists: recent homogenization of a polyubiquitin gene in Trichomonas vaginalis

Ubiquitin is a 76-amino-acid protein with a remarkably high degree of conservation between all known sequences. Ubiquitin genes are almost always multicopy in eukaryotes, and often are found as polyubiquitin genes--fused tandem repeats which are coexpressed. Seventeen ubiquitin sequences from the amitochondrial protist Trichomonas vaginalis have been examined here, including an 11-repeat fragment of a polyubiquitin gene. These sequences reveal a number of interesting features that are not seen in other eukaryotes. The predicted amino acid sequences lack several universally conserved residues, and individual units do not always encode identical peptides as is usually the case. On the nucleotide level, these repeats are in general highly variable, but one region in the polyubiquitin is extremely homogeneous, with seven repeats absolutely identical. Such extended stretches of homogeneity have never been observed in ubiquitin genes and since substitutions are common in other coding units, it is likely that these repeats are the product of a very recent homogenization or amplification.