[Treatment of valvular heart diseases with catheterization techniques]

While valve surgery is an established form of treatment in significant valvular heart diseases, open heart surgery is not possible for all patients, owing to the risks involved. The incidence of valvular heart diseases increases sharply with age, and it is common that operative risks are overestimated due to age and associated diseases. This review deals with two catheter therapies that are in clinical use for valvular heart diseases: insertion of aortic valve prosthesis through a catheter and treatment of mitral valve insufficiency by clip implantation via the transvenous access.

Comparison of results of coronary artery bypass grafting versus percutaneous coronary intervention in octogenarians

The aim of the present study was to compare the outcomes after coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) in patients aged ≥80 years. The present analysis included 274 patients who underwent isolated CABG and 393 patients who underwent PCI. The patients undergoing PCI had a greater prevalence of a history of cardiac surgery and recent myocardial infarction and had more frequently undergone emergency revascularization. Patients undergoing CABG had a significantly greater prevalence of 3-vessel coronary artery disease. The unadjusted 30-day mortality rate was 8.8% after CABG and 7.4% after PCI (p = 0.514). However, on multivariate analysis, CABG was associated with a significantly increased risk of 30-day mortality (odds ratio 2.246, 95% confidence interval 1.141 to 4.422). The unadjusted overall intermediate survival was significantly poorer after PCI (at 5 years, CABG 72.2% vs PCI 59.5%, p = 0.004), but this was not confirmed on multivariate analysis. PCI and CABG had similar intermediate survival rates when adjusted for propensity score (p = 0.698), a finding confirmed by the analysis of 130 propensity score-matched pairs (at 5 years, CABG 66.4% vs PCI 58.9%, p = 0.730). In conclusion, the survival of patients aged ≥80 years undergoing CABG is excellent, and the suboptimal survival after PCI seems to be related to the disproportionately greater risk of these patients compared to those undergoing CABG. When adjusted for important clinical variables, PCI and CABG achieved similar intermediate results.

[Myocardial infarct during pregnancy]

Acute myocardial infarction during pregnancy is a rare but potentially fatal complication. We describe a 43-year-old patient with non-ST-segment elevation myocardial infarction during late pregnancy. She underwent coronary angiography but was treated conservatively after an occlusion of mid-size left oblique marginal branch was observed. During pregnancy many medications normally used in the setting of acute coronary syndrome are contraindicated and use of radiation should be minimized. Thus treatment of acute coronary syndrome must be carefully tailored in this patient group.

Clinical value of absolute quantification of myocardial perfusion with (15)O-water in coronary artery disease

BACKGROUND

The standard interpretation of perfusion imaging is based on the assessment of relative perfusion distribution. The limitations of that approach have been recognized in patients with multivessel disease and endothelial dysfunction. To date, however, no large clinical studies have investigated the value of measuring quantitative blood flow and compared that with relative uptake.

METHODS AND RESULTS

One hundred four patients with moderate (30%-70%) pretest likelihood of coronary artery disease (CAD) underwent PET imaging during adenosine stress using (15)O-water and dynamic imaging. Absolute myocardial blood flow was calculated from which both standard relative myocardial perfusion images and images scaled to a known absolute scale were produced. The patients and the regions then were classified as normal or abnormal and compared against the reference of conventional angiography with fractional flow reserve. In patient-based analysis, the positive predictive value, negative predictive value, and accuracy of absolute perfusion in the detection of any obstructive CAD were 86%, 97%, and 92%, respectively, with absolute quantification. The corresponding values with relative analysis were 61%, 83%, and 73%, respectively. In region-based analysis, the receiver operating characteristic curves confirmed that the absolute quantification was superior to relative assessment. In particular, the specificity and positive predictive value were low using just relative differences in flow. Only 9 of 24 patients with 3-vessel disease were correctly assessed using relative analysis.

CONCLUSIONS

The measurement of myocardial blood flow in absolute terms has a significant impact on the interpretation of myocardial perfusion. As expected, multivessel disease is more accurately detected.

Resting coronary flow velocity in the functional evaluation of coronary artery stenosis: study on sequential use of computed tomography angiography and transthoracic Doppler echocardiography

AIMS

Accelerated flow at the site of flow-limiting stenosis can be detected by transthoracic Doppler echocardiography (TTDE). We studied feasibility and accuracy of sequential coronary computed tomography angiography (CTA) and TTDE in detection of haemodynamically significant coronary artery disease (CAD).

METHODS AND RESULTS

We prospectively enrolled 107 patients with intermediate (30-70%) pre-test likelihood of CAD. All patients underwent CTA using a 64-slice scanner. Using TTDE, the ratio of maximal diastolic flow velocity to pre-stenotic flow velocity (M/P ratio) was measured in the coronary segments with stenosis in CTA. In all patients, the results were compared with invasive coronary angiography, including measurement of fractional flow reserve when appropriate. All analyses were done blinded. TTDE was feasible in 276 of 285 evaluated coronary segments. Significant coronary stenoses were associated with a higher M/P ratio than non-significant stenoses (3.59 ± 1.82 vs. 1.28 ± 0.60, P < 0.001). The optimal M/P ratio for detection of significant stenosis was 2.2 (area under receiver operating characteristic curve 0.92, P < 0.001). Compared with the strategy of CTA alone, sequential CTA and focused TTDE had a better positive predictive value (PPV; 61 vs. 78%) and diagnostic accuracy (93 vs. 96%, P = 0.006) without impairment of the negative predictive value (97 vs. 97%).

CONCLUSION

Sequential use of CTA and TTDE is feasible for combined anatomic and functional evaluation of coronary stenoses. Compared with coronary CTA alone, addition of TTDE improved PPV for detection of significant CAD.

Cardiac Positron Emission Tomography/Computed Tomography Imaging Accurately Detects Anatomically and Functionally Significant Coronary Artery Disease

Background— Computed tomography (CT) is increasingly used to detect coronary artery disease, but the evaluation of stenoses is often uncertain. Perfusion imaging has an established role in detecting ischemia and guiding therapy. Hybrid positron emission tomography (PET)/CT allows combination angiography and perfusion imaging in short, quantitative, low-radiation-dose protocols.

Methods and Results— We enrolled 107 patients with an intermediate (30% to 70%) pretest likelihood of coronary artery disease. All patients underwent PET/CT (quantitative PET with 15 O-water and CT angiography), and the results were compared with the gold standard, invasive angiography, including measurement of fractional flow reserve when appropriate. Although PET and CT angiography alone both demonstrated 97% negative predictive value, CT angiography alone was suboptimal in assessing the severity of stenosis (positive predictive value, 81%). Perfusion imaging alone could not always separate microvascular disease from epicardial stenoses, but hybrid PET/CT significantly improved this accuracy to 98%. The radiation dose of the combined PET and CT protocols was 9.3 mSv (86 patients) with prospective triggering and 21.8 mSv (21 patients) with spiral CT.

Conclusion— Cardiac hybrid PET/CT imaging allows accurate noninvasive detection of coronary artery disease in a symptomatic population. The method is feasible and can be performed routinely with <10 mSv in most patients.

Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT00627172.

Valvular calcification and its relationship to atherosclerosis in chronic kidney disease

BACKGROUND AND AIM OF THE STUDY

Cardiovascular calcification is a common complication in patients with chronic kidney disease (CKD). The study aim was to identify the characteristics and risk factors of valvular calcification, and its relationship to atherosclerosis, in CKD.

METHODS

In this cross-sectional study, a total of 135 patients with CKD (mean age 52 +/- 11 years) included 58 pre-dialysis patients, 36 dialysis patients, and 41 renal transplant recipients. A control group of 58 subjects was also examined. The characteristics of valvular calcification were assessed using transthoracic echocardiography.

RESULTS

The combined prevalences of mitral or aortic valve calcification were 31% in pre-dialysis patients, 50% in dialysis patients, 29% in renal transplant recipients, and 12% in controls (p = 0.001). The prevalences of mitral annular calcification were 17%, 31%, 27% and 2%, respectively (p = 0.001). In multivariate analysis, the risk factors for valvular calcification in CKD were age, duration of dialysis treatment and interleukin-6 level. Mitral annular calcification proved to be five-fold more common in diabetic patients than among non-diabetics. A close association between valvular calcification and patients with or without increased carotid intima-media thickness (44% versus 15%, p < 0.001), carotid plaque (77% versus 49%, p = 0.002), calcified carotid plaque (65% versus 26%, p = 0.001), coronary artery disease (40% versus 15%, p = 0.003) and peripheral arterial disease (46% versus 9%, p < 0.001) was found.

CONCLUSION

Valvular calcification is common in CKD, and is closely associated with findings of intimal arterial disease. The presence of inflammation and the duration of dialysis treatment contribute to this complication. Diabetes is also a prominent risk factor for mitral annular calcification in CKD.

Impaired left ventricular filling in young female diabetics. An echocardiographic study

To assess left ventricular (LV) function in diabetes mellitus, M-mode echocardiograms were recorded in 36 insulin-treated diabetic women, mean age 25 +/- 6 (SD) years, and 13 healthy women of the same age. Echocardiographic tracings of the septum and LV posterior wall were digitized and continuous plots were made of LV dimension and its rate of change. The pattern of LV filling was abnormal in 19 diabetics, when the mean value +/- 2 SD in the healthy women was taken as the normal range of the indices. The most common abnormality was a prolonged rapid filling period. The LV systolic function was normal in all diabetics. Diabetics with severe microvascular complications had thicker LV walls (p less than 0.05) and smaller LV end-diastolic diameters and stroke volumes (p less than 0.01) than the healthy women. The electrocardiographic voltage was lower in the diabetic group (p less than 0.05). These studies suggest that minor abnormalities in LV function reflecting stiffness of the myocardium are common in young female diabetics, a patient group with a relatively low prevalence of coronary artery disease.

Efficacy and safety levels of preserved and preservative-free tafluprost are equivalent in patients with glaucoma or ocular hypertension: results from a pharmacodynamics analysis

PURPOSE

Tafluprost is a new prostaglandin F(2alpha) (PGF(2alpha)) derivative in development for the treatment of glaucoma. Tafluprost is the first PGF(2alpha) analogue with a preservative-free formulation.

METHODS

This randomized, investigator-masked, multicentre, crossover phase III study evaluated the pharmacodynamics and safety of preserved and preservative-free tafluprost 0.0015% eyedrops administered for 4 weeks in 43 patients with open-angle glaucoma or ocular hypertension. The primary variable was change from baseline in overall diurnal intraocular pressure (IOP) at 4 weeks. Adverse events and other safety parameters were also analysed.

RESULTS

Decreased IOP was clearly observed with both formulations at week 1 and was sustained until week 4. The overall treatment difference (preservative-free versus preserved formulations) at week 4 was 0.01 mmHg (95% confidence interval - 0.46 to 0.49; p = 0.96). There were no unexpected safety-related findings. Both formulations were well tolerated and most adverse events were ocular and mild in severity.

CONCLUSIONS

THE reduction in IOP achieved by preservative-free tafluprost is equivalent to that obtained with the preserved formulation. The preservative-free formulation was generally well tolerated.

Long-term prognosis after coronary artery bypass surgery

OBJECTIVE

To analyse the risk of coronary heart disease (CHD) events and total mortality among patients who had coronary artery bypass graft (CABG) surgery during 1988-1992.

METHODS

A population-based myocardial infarction (MI) register included data on invasive cardiac procedures among residents of the study area. The subjects aged 35-64 years were followed-up for 12 years for non-fatal and fatal CHD events and all-cause mortality, excluding events within 30 days of the CABG operation. CABG was performed on 1158 men and 215 women.

RESULTS

The overall survival of men who underwent CABG was similar to the survival of the corresponding background population for about ten years but started to worsen after that. At twelve years of follow-up, 23% (n=266, 95% CI 234-298) of the men who had undergone the operation had died, while the expected proportion, based on mortality in the background population, was 20% (n=231, 95% CI 226-237). The CHD mortality of men who had undergone the operation was clearly higher than in the background population. Among women, the mortality after CABG was about twice the expected mortality in the corresponding background population. In Cox proportional hazards models age, smoking, history of MI, body mass index and diabetes were significant predictors of mortality.

CONCLUSIONS

The prognosis of male CABG patients did not differ from the prognosis of the corresponding background population for about ten years, but started to deteriorate after that. History of MI prior to CABG and major cardiovascular risk factors was a predictor of an adverse outcome.

Thoracoscopic microwave ablation of atrial fibrillation

The aim of the study was to assess the safety and efficacy of thoracoscopic microwave ablation in treating atrial fibrillation (AF). AF predisposes to embolic complications and may cause heart failure. The treatment of AF is still challenging in spite of the promising results of endocardial radiofrequency approach. The present study is a follow-up study of 22 patients (mean age 45 years, range 21-59) with disabling paroxysmal (n=10) or persistent (n=12) AF who underwent a thoracoscopic microwave isolation of pulmonary veins. The patients had a lone AF. All the patients had suffered from severely disabling AF for >1 year (range 1-16 years) without any response to antiarrhythmic medication. The patients have been followed-up on an average of 11 months (range 3-22 months). During the follow-up, 13 (60%) patients have become asymptomatic without any documentation of AF since at least two months, six (27%) patients with anti-arrhythmic medication have clinically improved. Because of major intrathoracic bleeding and because of liver damage the thoracoscopy wound had to be expanded to open thoracotomy in two patients. Thoracoscopic AF microwave ablation seems to be a promising alternative to endocardial ablation in the treatment of highly symptomatic paroxysmal and persistent AF.

Are coronary event rates declining slower in women than in men - evidence from two population-based myocardial infarction registers in Finland?

Background

Studies have suggested that the prevention and treatment of coronary heart disease may not have been as effective in women as in men. Therefore, we aimed to examine whether the incidence, attack rate and mortality of myocardial infarction (MI) events have declined less in women than in men.

Methods

Two large population-based MI registers, the FINAMI register and the Finnish Cardiovascular Disease Register (CVDR) were used for comparing the event rates among men and women aged ≥35 years in two time periods, 1994–1996 and 2000–2002.

Results

In the FINAMI register a total of 5,252 events were recorded in men and 4,898 in women. Corresponding numbers in the CVDR were 78,709 and 70,464. Both FINAMI and CVDR data suggested smaller declines in incidence and attack rate of MI events in women than in men. In CVDR data the decline in mortality was also smaller in women than in men, while in FINAMI data this difference did not reach statistical significance. In the large CVDR data set, negative binomial regression models revealed smaller declines in incidence (p = 0.006), attack rate (p = 0.008) and mortality (p = 0.04) in women than in men aged <55 years. In persons ≥55 years no difference was observed between women and men.

Conclusion

The incidence and attack rate of MI events have declined less in women aged <55 than in men of similar age. In older persons no significant differences were observed. Further studies are warranted to find out the reasons why the development has been less favourable for young women than for men.

Coronary artery flow velocity profile measured by transthoracic Doppler echocardiography predicts myocardial viability after acute myocardial infarction

OBJECTIVE

To study whether flow velocity profile in the left anterior descending coronary artery (LAD) measured by transthoracic Doppler echocardiography (TTDE) predicts myocardial viability after reperfused anterior acute myocardial infarction (AMI).

PATIENTS AND METHODS

15 patients who had their first anterior ST elevation AMI and were successfully reperfused by coronary angioplasty and five controls without coronary artery disease were selected. Blood flow velocity spectrum was measured from the mid-LAD by TTDE 3 days after coronary angioplasty. Myocardial viability in the LAD region was quantified 3 months after AMI by relative uptake of 18F-fluorodeoxyglucose (FDG) imaged with positron emission tomography. Myocardium was graded as viable, partially viable or non-viable (relative FDG uptake >85%, 67-85% and <67%, respectively). Main outcome measures were diastolic deceleration time (DDT) of LAD flow velocity 3 days after AMI and myocardial viability 3 months after AMI.

RESULTS

DDT of LAD flow velocity correlated with myocardial FDG uptake in the LAD region (r = 0.91, p<0.01). DDT was markedly longer in patients with viable myocardium (876+/-76 ms, n = 3) than partially viable (356+/-89 ms, n = 6, p<0.01), or non-viable myocardium (128+/-13 ms, n = 6, p<0.01). In controls, DDT was comparable (909+/-76 ms, n = 5) to patients with viable myocardium. DDT <190 ms was always associated with non-viable myocardium.

CONCLUSIONS

DDT of LAD flow velocity is strongly associated with myocardial viability after reperfused anterior AMI. Non-invasive TTDE of the LAD may be used in the acute phase to predict long-term viability of the jeopardised myocardium.

Randomized study on simple versus complex stenting of coronary artery bifurcation lesions: the Nordic bifurcation study

BACKGROUND

The optimal stenting strategy in coronary artery bifurcation lesions is unknown. In the present study, a strategy of stenting both the main vessel and the side branch (MV+SB) was compared with a strategy of stenting the main vessel only, with optional stenting of the side branch (MV), with sirolimus-eluting stents.

METHODS AND RESULTS

A total of 413 patients with a bifurcation lesion were randomized. The primary end point was a major adverse cardiac event: cardiac death, myocardial infarction, target-vessel revascularization, or stent thrombosis after 6 months. At 6 months, there were no significant differences in rates of major adverse cardiac events between the groups (MV+SB 3.4%, MV 2.9%; P=NS). In the MV+SB group, there were significantly longer procedure and fluoroscopy times, higher contrast volumes, and higher rates of procedure-related increases in biomarkers of myocardial injury. A total of 307 patients had a quantitative coronary assessment at the index procedure and after 8 months. The combined angiographic end point of diameter stenosis >50% of main vessel and occlusion of the side branch after 8 months was found in 5.3% in the MV group and 5.1% in the MV+SB group (P=NS).

CONCLUSIONS

Independent of stenting strategy, excellent clinical and angiographic results were obtained with percutaneous treatment of de novo coronary artery bifurcation lesions with sirolimus-eluting stents. The simple stenting strategy used in the MV group was associated with reduced procedure and fluoroscopy times and lower rates of procedure-related biomarker elevation. Therefore, this strategy can be recommended as the routine bifurcation stenting technique.

Decreased Myocardial Free Fatty Acid Uptake in Patients With Idiopathic Dilated Cardiomyopathy: Evidence of Relationship With Insulin Resistance and Left Ventricular Dysfunction

BACKGROUND

Results on myocardial substrate metabolism in the failing heart have been contradictory. Insulin resistance, a common comorbidity in heart failure patients, and medical therapy may modify myocardial metabolism in complex fashions. Therefore, we characterized myocardial oxidative and free fatty acid (FFA) metabolism in patients with idiopathic dilated cardiomyopathy (IDCM) and investigated the contributions of insulin resistance and beta-blocker therapy.

METHODS AND RESULTS

Nineteen patients with IDCM (age 58 +/- 8 years, ejection fraction 33 +/- 8.8%) and 15 healthy controls underwent examination of myocardial blood perfusion, oxidative and FFA metabolism using positron emission tomography and [(15)O]H(2)O, [(11)C]acetate and [(11)C]palmitate, respectively. Echocardiography was used to assess myocardial function, work, and efficiency of forward work. Insulin resistance was calculated using the homeostasis model assessment index (HOMA index) and the degree of beta-blockade was estimated with a beta-adrenoceptor occupancy test. IDCM patients were characterized by decreased cardiac efficiency (35 +/- 2 versus 57 +/- 12 mm Hg.L.g(-1), P < .0001) and reduced myocardial FFA uptake (5.5 +/- 2.0 versus 6.4 +/- 1.2 mumol.100 g(-1).min(-1), P < .05), but the FFA beta-oxidation rate constant was not changed. In the patients, myocardial FFA uptake was inversely associated with left ventricular (LV) ejection fraction (r = -0.63, P < .01), indicating that further depression of LV function induces an opposite switch to greater FFA uptake. The FFA beta-oxidation rate constant correlated positively with the HOMA index (r = 0.53, P < .05). In patients on beta-1 selective beta-blockers, beta-1 adrenoceptor occupancy correlated inversely with LV work, oxidative metabolism, and FFA uptake; similar relationships were not found in patients on nonselective beta-blocker.

CONCLUSIONS

Myocardial FFA metabolism is reduced in patients with IDCM. However, when LV function is further depressed and insulin resistance manifested, myocardial FFA uptake and oxidation are, in turn, upregulated. These findings may partly explain the discrepancies between previous studies about cardiac metabolism in heart failure.

From vulnerable plaque to vulnerable patient--Part III: Executive summary of the Screening for Heart Attack Prevention and Education (SHAPE) Task Force report

Screening for early-stage asymptomatic cancers (eg, cancers of breast and colon) to prevent late-stage malignancies has been widely accepted. However, although atherosclerotic cardiovascular disease (eg, heart attack and stroke) accounts for more death and disability than all cancers combined, there are no national screening guidelines for asymptomatic (subclinical) atherosclerosis, and there is no government- or healthcare-sponsored reimbursement for atherosclerosis screening. Part I and Part II of this consensus statement elaborated on new discoveries in the field of atherosclerosis that led to the concept of the "vulnerable patient." These landmark discoveries, along with new diagnostic and therapeutic options, have set the stage for the next step: translation of this knowledge into a new practice of preventive cardiology. The identification and treatment of the vulnerable patient are the focuses of this consensus statement. In this report, the Screening for Heart Attack Prevention and Education (SHAPE) Task Force presents a new practice guideline for cardiovascular screening in the asymptomatic at-risk population. In summary, the SHAPE Guideline calls for noninvasive screening of all asymptomatic men 45-75 years of age and asymptomatic women 55-75 years of age (except those defined as very low risk) to detect and treat those with subclinical atherosclerosis. A variety of screening tests are available, and the cost-effectiveness of their use in a comprehensive strategy must be validated. Some of these screening tests, such as measurement of coronary artery calcification by computed tomography scanning and carotid artery intima-media thickness and plaque by ultrasonography, have been available longer than others and are capable of providing direct evidence for the presence and extent of atherosclerosis. Both of these imaging methods provide prognostic information of proven value regarding the future risk of heart attack and stroke. Careful and responsible implementation of these tests as part of a comprehensive risk assessment and reduction approach is warranted and outlined by this report. Other tests for the detection of atherosclerosis and abnormal arterial structure and function, such as magnetic resonance imaging of the great arteries, studies of small and large artery stiffness, and assessment of systemic endothelial dysfunction, are emerging and must be further validated. The screening results (severity of subclinical arterial disease) combined with risk factor assessment are used for risk stratification to identify the vulnerable patient and initiate appropriate therapy. The higher the risk, the more vulnerable an individual is to a near-term adverse event. Because <10% of the population who test positive for atherosclerosis will experience a near-term event, additional risk stratification based on reliable markers of disease activity is needed and is expected to further focus the search for the vulnerable patient in the future. All individuals with asymptomatic atherosclerosis should be counseled and treated to prevent progression to overt clinical disease. The aggressiveness of the treatment should be proportional to the level of risk. Individuals with no evidence of subclinical disease may be reassured of the low risk of a future near-term event, yet encouraged to adhere to a healthy lifestyle and maintain appropriate risk factor levels. Early heart attack care education is urged for all individuals with a positive test for atherosclerosis. The SHAPE Task Force reinforces existing guidelines for the screening and treatment of risk factors in younger populations. Cardiovascular healthcare professionals and policymakers are urged to adopt the SHAPE proposal and its attendant cost-effectiveness as a new strategy to contain the epidemic of atherosclerotic cardiovascular disease and the rising cost of therapies associated with this epidemic.

Levels and Activation of Matrix Metalloproteinases in Aqueous Humor Are Elevated in Uveitis-Related Secondary Glaucoma

PURPOSE

To measure the levels of matrix metalloproteinase (MMP)-2 and tissue inhibitors of metalloproteinases (TIMP)-2 and to study the expression pattern and molecular forms of MMP-2, 8, 9, 13, and 14 and TIMP-1 and 2 in aqueous humor samples in cases of uveitis-related secondary glaucoma (USG) with a history of up to 20 years by comparison with primary open-angle glaucoma (POAG) and cataracts.

METHODS

33 aqueous humor samples were collected during intraocular surgery. MMP-2 and TIMP-2 levels were analyzed by enzyme-linked immunosorbent assay. Molecular forms and activation degrees of MMPs and TIMPs were analyzed by Western immunoblotting and zymography. The results were related to the clinical data.

RESULTS

Enzyme-linked immunosorbent assay measurements of both MMP-2 and TIMP-2 were statistically significantly increased in the USG samples relative to POAG and cataracts (P=0.002). In Western blotting all the MMPs showed increased expression and conversion to their active forms in USG, whereas in the POAG and cataract samples MMPs were found mainly in their latent forms. MMP-8, 9, 13, and 14 showed statistically significantly elevated expression in USG relative to POAG and cataracts on densitometric scanning of Western blots. On zymography, MMP-2 and 9 activation was significantly enhanced in USG compared with POAG and cataracts.

CONCLUSIONS

Increased expression of MMPs and their conversion to active forms is characteristics of the aqueous humor in USG, even with a very long history. This emphasizes the fact that increased MMP expression reflects inflammatory disease activity and is probably associated with the development of USG and its complications. Although intraocular pressure is elevated in both glaucoma types, MMP expression in POAG more closely resembles that in cataracts, and therefore the role of MMPs in USG differs very markedly from that in POAG.

Aortic valve insufficiency in patients with chronic rheumatic diseases

Aortic valve lesions are often found in patients with rheumatic diseases, but their clinical significance has not been properly evaluated. In the present study, the echocardiographic files of the cardiology unit of the Oulu University Hospital were screened for a diagnosis of aortic insufficiency (AI). The aetiology of the valve disease and specific details of the rheumatic disease were evaluated in 160 patients. Twenty-eight patients (18%) had a history of rheumatic fever. Rheumatic disease was found in 14 patients (8.8%) with AI, which is significantly more than the prevalence of rheumatic diseases (1.8%) in the corresponding age group (35-100 years) in Finland. Rheumatoid arthritis or juvenile rheumatoid arthritis was found in seven patients (4.4%), whereas ankylosing spondylitis or seronegative spondylarthropathy were found in four patients (2.5%). Other rheumatic diseases included Takayasu's arteritis (two patients) and scleroderma (one patient). When 38 patients with pure AI without other possible aetiology were analysed, rheumatic disease was found in five patients (13%). Patients with rheumatic disease as a potential aetiology of AI often had symptomatic valve disease, which required surgical treatment, although great differences between different aetiologies were not found.

Matrix metalloproteinases and their tissue inhibitors in aqueous humor of patients with primary open-angle glaucoma, exfoliation syndrome, and exfoliation glaucoma

PURPOSE

To study extracellular matrix (ECM) metabolism by matrix metalloproteinases (MMPs) and their tissue inhibitors (TIMPs) in aqueous humor (AH) samples collected from primary open-angle glaucoma (POAG), exfoliation syndrome (EXS), and exfoliation glaucoma (EXG) in relation to samples derived from cataract control patients.

MATERIALS AND METHODS

Seventy-one AH samples were collected during cataract extraction and trabeculectomy. The expression and molecular forms of MMP-2, -8, -9, -13, and -14 and tissue inhibitor of metalloproteinases-1 and -2 (TIMPs) were analyzed by Western immunoblotting. Gelatinase and collagenase activities were studied by zymography and type I collagen degradation assays, respectively. MMP-2 and TIMP-2 concentrations were measured by ELISA assays.

RESULTS

By Western immunoblotting all the studied MMPs were mainly in their latent form in all diagnostic groups. Zymography demonstrated that MMP-2 represents the major gelatinase in AH. Similarly, type I collagenolytic activity was low and similar in cataract and glaucoma samples. In ELISA measurements the TIMP-2 levels were significantly elevated in glaucoma and EXS samples in comparison to cataract controls (P < 0.05).

CONCLUSION

TIMP-2 is elevated in glaucomatous process over MMP-2, which support and further extend the conjuncture that the ECM accumulation rather than degradation predominates in the pathogenesis of POAG and EXG.

Beat-to-beat oscillations in pulse pressure

We compared 5-min standard deviations (SD) and frequency domain measures of beat-to-beat pulse pressure (PP) variability with those of RR-interval, systolic (SBP) and diastolic (DBP) blood pressure variabilities, and with cross-spectral baroreflex sensitivity (BRS) in a population-based sample of 150 healthy individuals, aged 35-64 years. Beat-to-beat variability of PP was composed of similar frequency components as the other spectral variabilities, and was closely related to SBP variability. The proportion of high frequency (HF) component from overall variability was higher in PP variability than in SBP and DBP variabilities. The low frequency (LF) component and the SD of beat-to-beat PP correlated inversely with BRS (-0.48 and -0.32, respectively; P<0.001 for both). To test a hypothesis that arterial stiffening is associated with increased beat-to-beat oscillation in PP, we examined associations of beat-to-beat PP variability with risk factors of atherosclerosis, i.e. with age, gender, smoking, blood pressure, body mass index, serum lipids, glucose, insulin and homeostasis model assessment of insulin resistance. The SD of beat-to-beat PP variability correlated with age (0.21, P = 0.010), PP (0.31, P<0.001) and body mass index (0.22, P = 0.008). The LF component of PP variability correlated not only with age (0.17, P = 0.041), PP (0.27, P = 0.001) and body mass index (0.22, P = 0.007), but also with serum insulin (0.17, P = 0.042), homeostasis model assessment of insulin resistance (0.18, P = 0.031) and serum triglycerides (0.16, P = 0.048). Our findings suggest that increased beat-to-beat oscillation of PP reflects arterial stiffening and impaired baroreflex function.

Increased pulse pressure is associated with reduced baroreflex sensitivity

Although pulse pressure (PP), heart rate variability (HRV) and baroreflex sensitivity (BRS) have been shown to predict cardiovascular events and mortality in various populations, their relationships have not been clarified. We examined these associations in two separate population-based samples of healthy middle-aged subjects. In population 1, data were obtained from 149 subjects (71 men and 78 women) aged 35-64 (mean 47.7) years, and in population 2, from 214 subjects (88 men and 126 women) aged 40-62 (mean 50.5) years. Increased 24-h ambulatory PP was related to decreased cross-spectral BRS independent of age and gender (beta=-0.28, P<0.001 for population 1; beta=-0.22, P=0.003 for population 2). This association remained significant when 24-h ambulatory diastolic blood pressure, body mass index, smoking and alcohol intake were added as covariates in the multivariate analysis. Increased ambulatory PP was also associated with increased beat-to-beat systolic arterial pressure variability. Associations between ambulatory PP and HRV were not significant after controlling for age and gender. Our results suggest that elevated PP does not affect overall HRV, but it interferes with baroreflex-mediated control of the heart rate. This association may be due to a common denominator, such as arterial stiffness, for PP and BRS.

Exercise training improves insulin stimulated skeletal muscle glucose uptake independent of changes in perfusion in patients with dilated cardiomyopathy

OBJECTIVE

The purpose of the present study was to investigate the effects of a 5-month exercise training program on skeletal muscle perfusion and insulin sensitivity at rest and during exercise in patients with idiopathic dilative cardiomyopathy (DCM).

BACKGROUND

Patients with chronic heart failure are characterized by impaired insulin sensitivity and endothelial function. It is hypothesized that exercise training improves metabolism by enhancing perfusion in patients with heart failure.

METHODS

Fifteen DCM patients (New York Heart Association I-III) on stable medical therapy participated in the study. Patients were divided to receive either supervised strength and aerobic training (n=9, left ventricular ejection fraction [LVEF]=34 +/- 8%) for 5 months (3 times per week at an intensity of 70% of peak oxygen uptake [VO2]) or standard care (n=7, LVEF=36 +/- 6%) based on their living proximity to the exercise training site. Muscle blood flow, oxygen consumption, and glucose uptake were quantified using [15O]-water, [15O]-oxygen, [18F]FDG, and positron emission tomography (PET) during euglycemic hyperinsulinemia and 1-legged isometric exercise. PET studies were performed twice for each patient at the same individual workloads.

RESULTS

Exercise training improved exercise capacity by 27% (P<.001). Whole body insulin-stimulated glucose uptake enhanced by 23% (P<.05) and muscle glucose uptake by 53% (P<.05) in the trained group but tended to decrease in the untrained group. When studied using identical workloads, muscle glucose uptake in exercising muscles was enhanced by 55% (P<.05), whereas no changes were observed in muscle blood flow and oxygen uptake.

CONCLUSIONS

Exercise training counteracts the impaired insulin sensitivity caused by DCM. Training improves exercise capacity with a concomitant enhancement in whole body, resting, and exercising skeletal muscle glucose uptake. The improved insulin sensitivity is not explained by changes in muscle perfusion suggesting enhanced cellular glucose extraction.

Anxiety and hostility are associated with reduced baroreflex sensitivity and increased beat-to-beat blood pressure variability

OBJECTIVE

The purpose of this study was to determine whether psychological factors are associated with heart rate variability (HRV), blood pressure variability (BPV), and baroreflex sensitivity (BRS) among healthy middle-aged men and women.

METHODS

A population-based sample of 71 men and 79 women (35-64 years of age) was studied. Five-minute supine recordings of ECG and beat-to-beat photoplethysmographic finger systolic arterial pressure and diastolic arterial pressure were obtained during paced breathing. Power spectra were computed using a fast Fourier transform for low-frequency (0.04-0.15 Hz) and high-frequency (0.15-0.40 Hz) powers. BRS was calculated by cross-spectral analysis of R-R interval and systolic arterial pressure variabilities. Psychological factors were evaluated by three self-report questionnaires: the Brief Symptom Inventory, the shortened version of the Spielberger State-Trait Anger Expression Inventory, and the Toronto Alexithymia Scale.

RESULTS

Psychological factors were not related to HRV. Anxiety was associated with decreased BRS (p = 0.001) and higher low-frequency (p = 0.002) power of systolic arterial pressure variability. These associations were independent of age, gender, other psychological factors, heart rate, and systolic and diastolic blood pressures. Hostility was an independent correlate of increased low-frequency power of diastolic arterial pressure (p = 0.001) and increased high-frequency power of systolic arterial pressure (p = 0.033) variability.

CONCLUSIONS

Anxiety and hostility are related to reduced BRS and increased low-frequency power of BPV. Reduced BRS reflects decreased parasympathetic outflow to the heart and may increase BPV through an increased sympathetic predominance.

Candidate locus analysis of familial ascending aortic aneurysms and dissections confirms the linkage to the chromosome 5q13-14 in Finnish families

OBJECTIVE

The purpose of the study was to carry out a candidate gene analysis in families with familial thoracic aortic aneurysms and dissections.

METHODS

The study material consisted of 11 Finnish families (with 115 members genotyped) who underwent echocardiographic examination for measurement of the aortic root diameter. Selected candidate genes included the loci for Marfan and Ehlers-Danlos syndromes, the genes of matrix metalloproteinases 3 and 9 and tissue inhibitor of metalloproteinase 2 as well two loci on the chromosomes 5q13-14 and 11q23.2-q24, previously found to be linked to the disease.

RESULTS

The chromosomal locus 5q13-14 was linked to the disease risk (nonparametric linkage score 3.0, P =.005) confirming the previous linkage. Other candidate genes and loci were excluded as major loci in these families.

CONCLUSIONS

The identification of the gene at chromosomal location 5q13-14 causing the development of such diseases would give us important knowledge on the pathogenesis of the disease and enable the identification of subjects at risk. This in turn would lead to appropriate treatment before the occurrence of fatal complications and, likely, to the development of new treatment methods.

Elevated circulating levels of inflammatory cytokines in patients with abdominal aortic aneurysm

The basic feature in the pathogenesis of abdominal aortic aneurysm (AAA) is the degradation of extracellular matrix components. This process is induced partly by cytokines secreted from inflammatory and mesenchymal cells. Circulating levels of inflammatory cytokines were studied in AAA patients and compared with subjects suffering from atherosclerotic disease only. Furthermore, the predictive value of cytokine concentrations was evaluated for aneurysm expansion rate. Circulating levels of interleukin 1 beta (IL-1 beta), interleukin 6 (IL-6), tumor necrosis factor-alpha (TNF-alpha), and interferon-gamma (IFN-gamma) were measured in 50 AAA patients (40 men, 10 women), 42 patients with coronary heart disease (CHD) (23 men, 19 women), and 38 controls whose angiogram was normal (17 men, 21 women). No differences in cytokine concentrations were found between the CHD patients and the controls. AAA disease was found to be associated with significantly higher IL-1 beta and IL-6 concentrations in both male patients (median concentrations of 19.40 pmol/L and 6.45 pmol/L, respectively) and female patients (19.26 pmol/L and 7.99 pmol/L) than in either the CHD patients or the controls (P < .005). TNF-alpha levels were slightly higher in the AAA patients (1.64 pmol/L in the males and 1.59 pmol/L in the females) than in the other groups (P < .05). IFN-gamma levels were elevated significantly in the female AAA patients (3.75 pmol/L) compared with levels found in the other female (P < .05) or male (P < .01) patient groups. The measured cytokine concentrations were not related to the size of the aneurysm or the maximal thickness of the thrombus within the aneurysm. IFN-gamma concentration showed a significant positive correlation to the aneurysm expansion (R = .37, P < .02) and negative correlation to the concentration of aminoterminal propeptide of type III procollagen during 6-month follow up (R = -.42, P < .005). The results show that circulating levels of inflammatory cytokines are elevated in patients with AAA disease, suggesting that the production of these cytokines is increased in these patients compared with CHD patients and controls. Elevated INF-gamma concentrations seem to predict an increased rate of expansion in AAA.

Lymphocyte responses to Chlamydia antigens in patients with coronary heart disease

AIMS

To clarify the relationship of Chlamydia pneumoniae infection and coronary atherosclerosis we studied cell-mediated and humoral immune responses to Chlamydia in 93 patients with angiographically confirmed coronary heart disease and in 115 controls without angiographically demonstrable lesions.

METHODS AND RESULTS

Cell-mediated responses were analysed by measuring lymphocyte proliferative reactivity to whole elementary body antigens of C. pneumoniae. Control antigens included C. trachomatis and purified protein derivative of tuberculin. Chlamydia-specific antibodies were measured using microimmunofluorescence assay. Marked C. pneumoniae-specific immune reactivity, demonstrated by the high incidence of elevated IgG and IgA antibodies and strong lymphocyte proliferative response, was associated with coronary heart disease in male but not in female patients or controls. In male patients, the cell-mediated responses were strong to C. pneumoniae (median stimulation index 9,6) and to C. trachomatis (stimulation index 6,9). The females with coronary heart disease showed significantly stronger cell-mediated responses to C. pneumoniae (stimulation index 6,5) than to C. trachomatis (3,8; P < 0.001) and were comparable to the controls.

CONCLUSION

Marked cell-mediated and humoral immunity to C. pneumoniae in males with coronary heart disease suggest that the immune mechanisms triggered by Chlamydia are a possible contributing factor in the disease pathogenesis of coronary atherosclerosis in males. The Chlamydia-specific cell-mediated responses seem to be predominantly induced by antigenic structures that are similar among different Chlamydia-species.

No evidence for ischemic preconditioning during repeated vessel occlusion in coronary angioplasty

Coronary angioplasty has been the favoured model in studying ischemic preconditioning in humans, but results have remained controversial, possibly due to some artefacts related to coronary balloon angioplasty as an ischemia model. We examined this issue by monitoring the sequential metabolic, functional and neurohumoral changes during repeated vessel occlusion in coronary angioplasty performed in patients with chronic angina pectoris. Two groups of patients undergoing two successive balloon inflations of approximately 2 min duration were studied. These balloon inflations were preceded by a short inflation performed immediately after introduction of the balloon into the stenosis. The aim of this primary inflation was to establish adequate coronary blood flow with the deflated balloon in the stenosis and to guarantee that the subsequent two balloon inflations were truly comparable in time. Group I consisted of 23 patients, in whom the changes in the degree of angina, pulmonary capillary wedge pressure (PCWP), atrial natriuretic peptide (ANP) and circulating catecholamines during the procedure were studied. The sequential changes in myocardial metabolism were monitored in group II of nine patients by determining the lactate extraction ratios and femoroarterial coronary sinus (Fa-CS) differences in pH and pCO2 before and after each balloon inflation. In group I, PCWP and total catecholamines increased similarly during both balloon inflations, but ANP remained unchanged. In group II patients the lactate extraction ratios turned negative, the Fa-CS pH-differences increased and the pCO2-differences decreased during vessel occlusions, the changes being somewhat more prominent during the second balloon inflation. To study adaptation to ischemia, the group I patients were divided into two subgroups with and without signs of ischemic dysfunction during balloon inflations (PCWP increase > 5 mmHg and < 5 mmHg, respectively), and the group II patients were divided into two subgroups with and without metabolic ischemia (lactate-producers and non-producers). The ANP levels were constantly higher in the patients demonstrating ischemic dysfunction during balloon inflations, but catecholamine levels increased only after the second balloon inflation. The anginal pain experienced by the patients and the signs of metabolic ischemia were identical during both balloon inflations. We conclude that acute ischemic preconditioning does not occur in patients with repeated vessel occlusions of approximately 2 min duration. The patients without ischemia during the procedure had more critical stenoses and pre-existing collaterals. However, other protective mechanisms, such as chronic adaptation at the cellular level or recruitment of new collaterals, cannot be excluded.