Seroprevalence of tick-borne diseases in the Northwest Federal District of the Russian Federation

Introduction. Knowledge about tick-borne disease (TBD) distribution is necessary to improve prevention, whereas detection of human serum IgG antibodies against relevant pathogens is a method for monitoring TBD prevalence in local population. The study objective was to estimate seroprevalence of IgG antibodies against tick-borne encephalitis virus (TBEV), Borrelia burgdorferi sensu lato, Coxiella burnetii, Anaplasma phagocytophilum, and Ehrlichia chaffeensis/E. muris in healthy residents from the five territories of the Northwestern Federal District of the Russian Federation (Arkhangelsk Oblast, Leningrad Oblast, Pskov Oblast, the Republic of Komi and the Republic of Karelia). Materials and methods. In 20172019, a total of 1244 serum samples from healthy residents, not vaccinated against TBDs or other flavivirus-caused infections was studied by ELISA. Results. 21.7% of the sera samples contained IgG antibodies against a single TBD pathogen, whereas 2.1% showed signs of coinfection with two or more pathogens. The most common were IgG antibodies against TBEV (5 territories, 12.2%), followed by Borrelia burgdorferi sensu lato (5 territories, 3.5%), C. burnetii (4 territories, 2.9%), Anaplasma phagoсytophilum (3 territories, 1.6%), E. chaffeensis/E. muris (5 territories, 1.5%). The IgG antibodies were more common in men (55.2%) than in women (44.8%), being found virtually evenly in age-independent manner (from juniors under 18 to seniors over 60). Conclusion. The results of this first comprehensive serosurveillance study in the Northwestern Federal District of the Russian Federation assessing serum IgG antibodies against tick-borne diseases indicate a wide distribution of such pathogens. Moreover, infections caused by C. burnetii, Anaplasma phagocytophilum, and Ehrlichia chaffeensis/E. muris might be highly underdiagnosed.

Evaluation of left ventricular filling pressure by echocardiography: incremental diagnostic information from left atrial strain

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): South-Eastern Norway Regional Health Authority

Background

Elevated left ventricular (LV) filling pressure is an important diagnostic feature of heart failure.

Objectives

To investigate determinants of left atrial (LA) reservoir and pump strain and if these parameters may serve as markers of LV filling pressure.

Methods

In a multicenter study of 322 patients with cardiovascular disease of different etiologies, LA strain by speckle tracking echocardiography was compared to conventional echocardiographic markers using invasive pressure as reference.

Results

Left ventricular filling pressure correlated well with LA reservoir and pump strain (r-values

‑0.52 and ‑0.57, respectively) (Figure). However, LV global longitudinal strain (GLS) was the strongest determinant of LA reservoir strain (r = 0.64), and correlated well with LA pump strain (r = 0.51).  For both LA strains, association with filling pressure was strongest in patients with reduced LV ejection fraction. In patients with normal GLS (≥18%), atrial strains provided no information regarding filling pressure (Figure). Reservoir strain <18% and pump strain <8% predicted elevated LV filling pressure better (p < 0.05) than the conventional indices LA volume, ratio of mitral early filling velocity/annular velocity and tricuspid regurgitation velocity. Accuracy to classify filling pressure as normal or elevated was 75% for both LA strains . When any one of the conventional indices were missing, and were replaced by LA strains, the combination of indices had accuracy 82% to correctly classify filling pressure.

Conclusions

Left atrial reservoir and pump strain may serve as clinical markers of LV filling pressure, but will be useful predominantly in patients with reduced systolic function.  Due to limited diagnostic accuracy, LA strain should be used in combination with other indices.

Abstract Figure

Everolimus Initiation With Early Calcineurin Inhibitor Withdrawal in De Novo Heart Transplant Recipients: Three-Year Results From the Randomized SCHEDULE Study

In a randomized, open-label trial, de novo heart transplant recipients were randomized to everolimus (3-6 ng/mL) with reduced-exposure calcineurin inhibitor (CNI; cyclosporine) to weeks 7-11 after transplant, followed by increased everolimus exposure (target 6-10 ng/mL) with cyclosporine withdrawal or standard-exposure cyclosporine. All patients received mycophenolate mofetil and corticosteroids. A total of 110 of 115 patients completed the 12-month study, and 102 attended a follow-up visit at month 36. Mean measured GFR (mGFR) at month 36 was 77.4 mL/min (standard deviation [SD] 20.2 mL/min) versus 59.2 mL/min (SD 17.4 mL/min) in the everolimus and CNI groups, respectively, a difference of 18.3 mL/min (95% CI 11.1-25.6 mL/min; p < 0.001) in the intention to treat population. Multivariate analysis showed treatment to be an independent determinant of mGFR at month 36. Coronary intravascular ultrasound at 36 months revealed significantly reduced progression of allograft vasculopathy in the everolimus group compared with the CNI group. Biopsy-proven acute rejection grade ≥2R occurred in 10.2% and 5.9% of everolimus- and CNI-treated patients, respectively, during months 12-36. Serious adverse events occurred in 37.3% and 19.6% of everolimus- and CNI-treated patients, respectively (p = 0.078). These results suggest that early CNI withdrawal after heart transplantation supported by everolimus, mycophenolic acid and steroids with lymphocyte-depleting induction is safe at intermediate follow-up. This regimen, used selectively, may offer adequate immunosuppressive potency with a sustained renal advantage.

The Effect of Everolimus Initiation and Calcineurin Inhibitor Elimination on Cardiac Allograft Vasculopathy in De Novo Recipients: One-Year Results of a Scandinavian Randomized Trial

Early initiation of everolimus with calcineurin inhibitor therapy has been shown to reduce the progression of cardiac allograft vasculopathy (CAV) in de novo heart transplant recipients. The effect of de novo everolimus therapy and early total elimination of calcineurin inhibitor therapy has, however, not been investigated and is relevant given the morbidity and lack of efficacy of current protocols in preventing CAV. This 12-month multicenter Scandinavian trial randomized 115 de novo heart transplant recipients to everolimus with complete calcineurin inhibitor elimination 7-11 weeks after HTx or standard cyclosporine immunosuppression. Ninety-five (83%) patients had matched intravascular ultrasound examinations at baseline and 12 months. Mean (± SD) recipient age was 49.9 ± 13.1 years. The everolimus group (n = 47) demonstrated significantly reduced CAV progression as compared to the calcineurin inhibitor group (n = 48) (ΔMaximal Intimal Thickness 0.03 ± 0.06 and 0.08 ± 0.12 mm, ΔPercent Atheroma Volume 1.3 ± 2.3 and 4.2 ± 5.0%, ΔTotal Atheroma Volume 1.1 ± 19.2 mm(3) and 13.8 ± 28.0 mm(3) [all p-values ≤ 0.01]). Everolimus patients also had a significantly greater decline in levels of soluble tumor necrosis factor receptor-1 as compared to the calcineurin inhibitor group (p = 0.02). These preliminary results suggest that an everolimus-based CNI-free can potentially be considered in suitable de novo HTx recipients.

Everolimus initiation and early calcineurin inhibitor withdrawal in heart transplant recipients: a randomized trial

In a randomized, open-label trial, everolimus was compared to cyclosporine in 115 de novo heart transplant recipients. Patients were assigned within 5 days posttransplant to low-exposure everolimus (3–6 ng/mL) with reduced-exposure cyclosporine (n = 56), or standard-exposure cyclosporine (n = 59), with both mycophenolate mofetil and corticosteroids. In the everolimus group, cyclosporine was withdrawn after 7–11 weeks and everolimus exposure increased (6–10 ng/mL). The primary efficacy end point, measured GFR at 12 months posttransplant, was significantly higher with everolimus versus cyclosporine (mean ± SD: 79.8 ± 17.7 mL/min/1.73 m2 vs. 61.5 ± 19.6 mL/min/1.73 m2; p < 0.001). Coronary intravascular ultrasound showed that the mean increase in maximal intimal thickness was smaller (0.03 mm [95% CI 0.01, 0.05 mm] vs. 0.08 mm [95% CI 0.05, 0.12 mm], p = 0.03), and the incidence of cardiac allograft vasculopathy (CAV) was lower (50.0% vs. 64.6%, p = 0.003), with everolimus versus cyclosporine at month 12. Biopsy-proven acute rejection after weeks 7–11 was more frequent with everolimus (p = 0.03). Left ventricular function was not inferior with everolimus versus cyclosporine. Cytomegalovirus infection was less common with everolimus (5.4% vs. 30.5%, p < 0.001); the incidence of bacterial infection was similar. In conclusion, everolimus-based immunosuppression with early elimination of cyclosporine markedly improved renal function after heart transplantation. Since postoperative safety was not jeopardized and development of CAV was attenuated, this strategy may benefit long-term outcome.

Systemic markers of inflammation are associated with cardiac allograft vasculopathy and an increased intimal inflammatory component

We evaluated an extensive profile of clinical variables and immune markers to assess the inflammatory milieu associated with cardiac allograft vasculopathy (CAV) assessed by intravascular ultrasound (IVUS) and virtual histology (VH). In total, 101 heart transplant (HTx) recipients were included and underwent IVUS/VH examination and measurement of plasma C-reactive protein (CRP), soluble tumor necrosis factor receptor-1, interleukin-6, osteoprotegerin, soluble gp130, von Willebrand factor, vascular cell adhesion molecule-1 (VCAM-1) and neopterin. Mean Maximal Intimal Thickness (MIT) was 0.61 +/- 0.19 mm and mean fibrotic, fibrofatty, dense calcified and necrotic core components were 55 +/- 15, 14 +/- 10, 15 +/- 13 and 17 +/- 9%, respectively. In multivariate analysis, CRP > 1.5 mg/L (OR 4.6, p < 0.01), VCAM-1 > 391 ng/mL (adjusted OR 3.2, p = 0.04) and neopterin > 7.7 nmol/L (OR 3.8, p = 0.02) were independently associated with MIT > 0.5 mm. Similarly, CRP > 1.5 mg/L (OR 3.7, p < 0.01) and VCAM-1 > 391 (OR 2.7, p = 0.04) were independently associated with an increased intimal inflammatory component (dense calcified/necrotic core component > 30%). Advanced CAV is associated with elevated CRP, VCAM-1 and neopterin and the two former biomarkers are also associated with an increased intimal inflammatory component. Forthcoming studies should clarify if routine measurements of these markers can accurately identify HTx recipients at risk of developing advanced CAV and vulnerable lesions.

Clopidogrel increases expression of chemokines in peripheral blood mononuclear cells in patients with coronary artery disease: results of a double-blind placebo-controlled study

BACKGROUND

Chemokines and platelet activation are both important in atherogenesis. Platelet inhibitors are widely used in coronary artery disease (CAD), and we hypothesized that the platelet inhibitor clopidogrel could modify chemokines in CAD patients.

OBJECTIVES

We sought to investigate the effect of clopidogrel on the expression of chemokines and chemokine receptors in peripheral blood mononuclear cells (PBMC) in CAD patients.

PATIENTS/METHODS

Thirty-seven patients with stable angina were randomized to clopidogrel (n = 18) or placebo (n = 19). PBMC, blood platelets and plasma were collected at baseline and after 7-10 days in the patients, and in 10 healthy controls. mRNA levels of chemokines and chemokine receptors in PBMC were analyzed by ribonuclease protection assays and real-time reverse transcriptase polymerase chain reaction. Platelet activation was studied by flow cytometry.

RESULTS

(i) At baseline, the gene expression of the regulated on activation normally T-cell expressed and secreted (RANTES) chemokines and macrophage inflammatory peptide (MIP)-1beta in PBMC, the expression of CD62P and CD63 on platelets and the levels of platelet-derived microparticles (PMP) were elevated in angina patients comparing healthy controls; (ii) markers of platelet activation were either reduced (CD63) or unchanged (CD62P, PMP, beta-thromboglobulin) during clopidogrel therapy; (iii) in contrast, clopidogrel significantly up-regulated the gene expression of RANTES and MIP-1beta in PBMC, while no changes were found in the placebo group; (iv) a stable adenosine 5'-diphosphate metabolite attenuated the release of MIP-1beta, but not of RANTES, from activated PBMC in vitro.

CONCLUSIONS

Even if we do not argue against a beneficial role for clopidogrel in CAD, our findings may suggest potential inflammatory effects of clopidogrel in CAD.

Serial measurements of peripheral vascular reactivity and exercise capacity in congestive heart failure and after heart transplantation

BACKGROUND

The regulation of nutritive blood flow to skeletal muscles during exercise seems to make an important contribution to exercise capacity. In congestive heart failure (CHF) this regulation seems to be impaired, with attenuated peripheral vasodilatory capacity. The results regarding improvement of peripheral vasoreactivity after heart transplantation (HTx) are conflicting, and the contribution of impaired peripheral vasoreactivity to the observed reduced exercise capacity among heart transplant recipients (HTR) has not been well elucidated. We therefore assessed the reversibility of impaired vasoreactivity in forearm and calf after HTx with relationship to exercise capacity.

METHODS AND RESULTS

The vasoreactivity of both forearm and calf was studied with venous occlusion plethysmography and related to exercise capacity in 64 patients with CHF and in 22 controls. Of these patients, 29 patients underwent HTx, and the same measurements were performed 10 days, 6 months and 1 year after HTx, and in a group of 15 HTR who had undergone HTx several years ago. Our main findings were (1) impaired resting blood flow in patients with CHF improved after HTx and even surpassed levels of controls; (2) peak forearm blood flow remained attenuated early after HTx, but normalized during the first year postoperatively; (3) both forearm and calf minimal resistance remained elevated after HTx; (4) vascular reactivity displays regional variations in forearm and calf both during CHF and after HTx; and (5) peripheral vascular reactivity relate to exercise performance in both patients with CHF and HTR, but the relationship seemed more pronounced in CHF.

CONCLUSION

With impaired vasoreactivity related to limited exercise capacity in CHF, improvement is evident after HTx, but both forearm and calf minimal resistance remains elevated. These findings suggest increased vasoconstrictor drive to both exercising and non-exercising muscles, possibly contributing to persistent physical limitation after HTx.

[Angioplasty in acute myocardial infarction in patients transferred from other hospitals]

BACKGROUND

Primary or rescue angioplasty are reperfusion modalities in selected patients with acute myocardial infarction, after initial diagnosis in local hospitals. We sought to evaluate the feasibility and safety of transporting patients to a tertiary care hospital for interventional treatment.

MATERIALS AND METHODS

Between January 1999 and April 2000, 50 consecutive patients were included in this prospective observational study. Comparisons were performed between patients admitted to primary angioplasty, either directly (n = 20; group A) or from other hospitals (n = 14; group B), and those transferred for rescue angioplasty (n = 16; group C).

RESULTS

No severe complications occurred during interhospital transport. Median time interval from onset of symptoms to hospitalization was comparable between groups. Median time interval from onset of symptoms to balloon inflation in group C (340 minutes) was significantly longer than in groups A and B (181 and 130 minutes). All patients were alive at follow-up after median 230 days. Median echocardiographically determined left ventricular ejection fraction in group A was non-significantly higher (50%) than in groups B and C (43% and 46%).

INTERPRETATION

Acute transfer for primary or rescue angioplasty is feasible and safe for selected patients with acute myocardial infarction.

Omega-3 fatty acids enhance tumor necrosis factor-alpha levels in heart transplant recipients

BACKGROUND

Proinflammatory cytokines may contribute to clinical complications in heart transplant (HTx) recipients. Previous studies have shown immunomodulating effects of omega-3 fatty acids, but the results are somewhat conflicting. In this study, we examined plasma levels of tumor necrosis factor alpha (TNF-alpha), interleukin (IL) 10, and their relations to antioxidant vitamins in 45 HTx recipients before and after treatment with omega-3 fatty acids or placebo.

METHODS

The patients were long-time survivors of heart transplantation, randomized in a double-blind fashion to receive omega-3 fatty acids (3.4 g/day) or placebo for 1 year. Plasma levels of cytokines were measured by enzyme immunoassays and vitamin A, vitamin E, and beta-carotene by high-performance liquid chromatography.

RESULTS

In the omega-3, but not in the placebo group, there was a rise in the proinflammatory cytokine TNF-alpha (P<0.05), a decrease in the anti-inflammatory cytokine IL-10 (P=0.07), and a rise in TNF/IL-10 ratio (P<0.05) after 12 months, suggesting a proinflammatory net effect. In the omega-3 group, the increase in TNF-alpha was associated with an increase in eicosapentaenoic acid in plasma (r=0.58, P<0.02). During omega-3 fatty-acid treatment, but not during placebo, there was a decrease in vitamin E (P<0.05) and beta-carotene (P<0.05) levels, and the decrease in vitamin E was inversely correlated with the increase in TNF-alpha (r= -0.56, P<0.01). The rise in TNF-alpha levels during omega-3 fatty acids treatment was most pronounced in those patients with transplant coronary artery disease (P<0.04).

CONCLUSION

Our data suggest that omega-3 fatty acids in HTx recipients may change the balance between proinflammatory and anti-inflammatory cytokines in an inflammatory direction, possibly related to prooxidative effects of these fatty acids.

[Immunomodulating treatment in advanced heart failure--effect of intravenous immunoglobulin]

BACKGROUND

Congestive heart failure is characterised by enhanced immune activation. Immune-mediated mechanisms may play a pathogenic role, hence the growing interest in therapeutic regimens that could modulate the immune response in heart failure.

MATERIAL AND METHODS

In the present report we discuss the pathogenic role of immunological and inflammatory mediators in the pathophysiology of heart failure and discuss different treatment modalities with focus on our recent study with intravenous immunoglobulin. In that study 40 patients with symptomatic chronic heart failure and left ventricular ejection fraction (LVEF) < 40% were randomised in a double-blind fashion to receive therapy with immunoglobulin or placebo for a total period of 26 weeks.

RESULTS

We found that intravenous immunoglobulin, but not placebo, shifted the cytokine balance in an anti-inflammatory direction, and that such a shift was associated with improvement in LVEF by 5 EF units. Functional capacity and haemodynamic variables also improved.

INTERPRETATION

Our study supports the hypothesis that immunological variables might be of significant importance in the pathogenesis of heart failure and it suggests a potential for immunomodulating therapy in addition to optimal conventional cardiovascular treatment regimens in such patients. These issues are further discussed in the present article.

Effect of folic acid treatment on endothelium-dependent vasodilation and nitric oxide-derived end products in hyperhomocysteinemic subjects

PURPOSE

An elevated plasma homocysteine concentration is an independent risk factor for cardiovascular diseases. In this study, we tested the hypothesis that hyperhomocysteinemia induces endothelial dysfunction mediated, at least in part, through nitric oxide-dependent mechanisms and that folic acid supplementation improves endothelial function in hyperhomocysteinemic subjects.

SUBJECTS AND METHODS

Endothelial function was evaluated in healthy controls and hyperhomocysteinemic subjects by measuring plasma levels of the nitric oxide-derived end products nitrite and nitrate and by assessing vasodilatory responses in the skin microcirculation and forearm vasculature. In the subjects with hyperhomocysteinemia, these measurements were repeated after 6 weeks and 12 months of folic acid supplementation.

RESULTS

Compared with healthy controls, hyperhomocysteinemic subjects had significantly lower median plasma levels of nitric oxide-derived end products (12.1 microM [range 4.4 to 41.8] versus 24.6 microM [13.6 to 53.2]; P <0.001), a significantly lower endothelium-dependent vasodilatory response to acetylcholine (P <0.01), hyperemic response in the microcirculation (P <0.01), and total forearm blood flow during reactive hyperemia (P = 0.01). There was no significant difference in the endothelium-independent response. Folic acid treatment for 12 months increased the plasma level of nitric oxide-derived end products by 121% (95% confidence interval [CI], 72% to 170%), the vasodilatory response to acetylcholine by 124% (95% CI, 36% to 212%), and the ischemia-mediated hyperemic responses in the microcirculation by 60% (95% CI, 25% to 96%) and in the forearm vasculature by 47% (95% CI, 21% to 73%).

CONCLUSIONS

Homocysteine appears to induce its atherogenic effect, at least in part, by depressing endothelial function, possibly through nitric oxide-dependent mechanisms. This effect can be reversed by folic acid supplementation.

[Inhalation of a prostacyclin analog (iloprost) in primary and secondary pulmonary hypertension]

BACKGROUND

Vasodilative therapy in the form of calcium channel blockers and, recently, continuous intravenous prostacyclin has improved exercise capacity and reduced mortality in primary pulmonary hypertension. Their clinical value is limited by either low rate of response or serious side effects. These shortcomings could be overcome by the use of iloprost, a stable prostacyclin analogue. Administering it by inhalation, we assessed its short-term efficacy in patients with primary and secondary pulmonary hypertension.

MATERIAL AND METHODS

We studied six patients with primary and six with secondary pulmonary hypertension, all with New York Heart Association functional class III or IV symptoms of congestive heart failure. Iloprost was nebulised with 8 l/min of oxygen and administered in increasing doses from 10 to 40 micrograms via a facemask. The haemodynamic effects of iloprost was assessed by right-heart catheterisation.

RESULTS

Inhalation of iloprost was well tolerated, and produced a median reduction in mean pulmonary artery pressure from 52 (42-63) to 41 (35-56) mm Hg (p < 0.05). Cardiac output increased from 3.5 (2.8-4.3) to 4.1 (3.1-5.1) l/min (p < 0.05) and pulmonary vascular resistance decreased from 1036 (722-1526) to 753 (446-1107) dyn.sek.cm-5 (p < 0.01). No changes occurred in heart rate, systemic blood pressure or pulmonary wedge pressure.

INTERPRETATION

Drug testing with inhalation of iloprost is safe and causes beneficial haemodynamic changes with selective pulmonary vasodilatation. Since the long-term effect of medical intervention is based on the degree of acute pulmonary vascular reactivity, inhalation of iloprost may be a new therapeutic option for severe pulmonary hypertension.

Effect of pravastatin on plasma markers of inflammation and peripheral endothelial function in male heart transplant recipients

Statins appear to have several biologic effects beyond those of lipid metabolism, and we hypothesized that immunomodulating effects of statins are important for the beneficial effects of these medications after heart transplantation. Our findings suggest that pravastatin treatment reduces plasma markers of inflammation and improves peripheral endothelial function in heart transplant recipients, possibly contributing to the observed clinical benefits of statin treatment in these patients.

Omega-3 fatty acids improve blood pressure control and preserve renal function in hypertensive heart transplant recipients

BACKGROUND

Hypertension and cyclosporine-induced nephrotoxicity are common complications in heart transplant recipients. Omega-3 fatty acids may prevent blood pressure rise early, but have not been studied long-term after heart transplantation.

METHODS AND RESULTS

Forty-five clinically stable hypertensive heart transplant recipients were studied 1-12 years after transplantation and randomized in a double-blind fashion to receive either 3.4 g of omega-3 fatty acids daily or placebo for 1 year. Ambulatory 24 h blood pressure monitoring and haemodynamic studies were performed before randomization and at the end of the study. Systolic blood pressure increased by 8+/-3 mmHg (P<0.01) in the placebo group, with a non-significant increase in diastolic blood pressure of 3+/-2 mmHg (P=0.10), accompanied by a 14% increase in systemic vascular resistance (P<0.05). In contrast, no change in blood pressure or systemic vascular resistance was recorded in the omega-3 group. Plasma creatinine increased (P<0.01) and glomerular filtration rate decreased (P<0.05) in the placebo group, while no changes were observed in the omega-3 group. The antihypertensive effect was related to an increase in serum eicosapentaenoic and docosahexaenoic acid.

CONCLUSION

Treatment with omega-3 fatty acids may reduce the long-term continuous rise in blood pressure after heart transplantation and may offer a direct or indirect renoprotective effect, making these fatty acids a potentially attractive treatment for post-transplant hypertension.

Immunomodulating therapy with intravenous immunoglobulin in patients with chronic heart failure

BACKGROUND

Congestive heart failure (CHF) is characterized by enhanced immune activation, and immune-mediated mechanisms may play a pathogenic role in this disorder. Based on the immunomodulatory effects of intravenous immunoglobulin (IVIG), we hypothesized that IVIG could downregulate inflammatory responses in CHF patients and have potential beneficial effects on the left ventricular ejection fraction (LVEF).

METHODS AND RESULTS

Forty patients with chronic symptomatic CHF and LVEF of <40%, stratified according to cause (ie, ischemic and idiopathic dilated cardiomyopathy), were randomized in a double-blind fashion to receive therapy with IVIG or placebo for a total period of 26 weeks. Our main findings were that (1) IVIG, but not placebo, induced a marked rise in plasma levels of the anti-inflammatory mediators interleukin (IL)-10, IL-1 receptor antagonist, and soluble tumor necrosis factor receptors; (2) significantly correlated with these anti-inflammatory effects, IVIG, but not placebo, induced a significant increase in LVEF from 26+/-2% to 31+/-3% (P:<0.01), and this was found independent of the cause of heart failure; and (3) N-terminal pro-atrial natriuretic peptide decreased significantly after induction therapy and continued to decrease toward the end of study during IVIG therapy (P:<0.001) but remained unchanged during placebo.

CONCLUSIONS

We demonstrated an IVIG-induced change in the balance between inflammatory and anti-inflammatory cytokines that favored an anti-inflammatory net effect in CHF. This effect was significantly correlated with an improvement in LVEF, suggesting a potential for immunomodulating therapy in addition to optimal conventional cardiovascular treatment regimens in CHF patients.

Peripheral endothelial dysfunction in heart transplant recipients: possible role of proinflammatory cytokines

Endothelium-dependent vasodilation in the peripheral circulation may be impaired in heart transplant recipients (HTx rec). Conflicting results have been obtained and the mechanisms involved have not been examined. In the present study, we examined whether long-time survivors of heart transplantation (Tx) show signs of endothelial dysfunction in the peripheral microcirculation, and further investigated the possible role of endothelium-related markers and proinflammatory cytokines in this process. The vasodilatory responses to acetylcholine (Ach) (endothelium-dependent) and sodium nitroprusside (SNP) (endothelium-independent) were evaluated by skin laser-Doppler perfusion measurements in 63 clinically stable HTx rec 6 yr (range 1-13 yr) after Tx, and compared with 20 healthy controls. Ten HTx rec were also followed prospectively with three repeated measurements during the first year after Tx. Plasma von Willebrand factor, big-endothelin (b-ET), and proinflammatory cytokines were measured by enzyme immunoassays. Vascular responses to both Ach and SNP were significantly attenuated in the HTx rec compared with controls. In longitudinal testing, there was a significant reduction in endothelium-dependent vasodilation, but not independent vasodilation from 1 to 12 months after Tx. Plasma levels of vWF and b-ET, as well as levels of proinflammatory cytokines, tumor necrosis factor (TNF)-alpha, interleukin (IL)-6 and IL-1beta, were all markedly increased in HTx rec. HTx rec responses to Ach were negatively correlated to TNF-alpha levels in plasma (r = -0.39, p < 0.01). Moreover, there was also a significant positive correlation between plasma b-ET and TNF-alpha (r = 0.34, p < 0.01). In the long-term follow-up of HTx rec, endothelial dysfunction is demonstrated by both regulation of blood flow in the skin microcirculation and by raised markers of endothelial activation in plasma. This endothelial dysfunction may be related to enhanced levels of proinflammatory cytokines in these patients.

[Nitric oxide--basal biochemistry and physiological aspects]

Nitric oxide (NO) is a naturally occurring molecule found in a variety of cell types and organ systems, including the cardiovascular, immune and nervous system. NO is normally produced in the endothelium from L-arginine by the constitutive isoform of the NO synthase (cNOS). Thereby, NO is an important regulator of vascular tone, prevents platelet adhesion, aggregation and activation, limits leukocyte adhesion to the endothelium and regulates myocardial contractility. This physiological production of NO is important for blood pressure regulation, blood flow distribution and tissue perfusion. Following injury or certain inflammatory stimuli, the expression of an inducible NO synthase (iNOS) can occur in a great variety of cells. In the last decade research on NO has suggested new treatment strategies for several diseases. In this review we discuss the biochemistry of NO and its basal physiological implications, with special emphasis on NO produced in the endothelium.

[Endothelial function in coronary atherosclerosis and heart failure--the role of nitric oxide in regulation of vasomotor tone]

The endothelium plays a pivotal role in synthesizing biologically active substances that modulate the vascular tone of underlying smooth muscle cells. Assessment of endothelial function requires measurement of the effects of endothelium-dependent and -independent vasodilators on the systemic microcirculation or resistance vessels. Endothelial dysfunction has been demonstrated early in the course of coronary artery disease, both by studying vasomotor responses in coronary and peripheral vessels, and in the peripheral circulation of patients with chronic heart failure. The impairment of endothelium-dependent vasodilation is related to an abnormality in the endothelium-derived nitric oxide system. The evolving understanding of the complex and probably multifactorial underlying molecular mechanisms of endothelial dysfunction has lead to the identification of potential beneficial therapeutic interventions. Restoration of endothelial function has been associated with fewer episodes of ischaemia in coronary artery disease and improved exercise capacity in heart failure. In light of recent studies we discuss the role of the endothelium, with special emphasis on nitric oxide, in the regulation of vascular tone in coronary artery disease and heart failure.

Possible role of proinflammatory cytokines in heart allograft coronary artery disease

Transplant coronary artery disease (Tx-CAD) is the main determinant of long-term prognosis after heart transplantation. Immunologic processes may play a central role in the development of Tx-CAD, but the pathogenesis has not been fully clarified. We examined plasma levels of the proinflammatory cytokines tumor necrosis factor-alpha (TNF-alpha), interleukins (IL)-1beta and IL-6, and the CC-chemokine macrophage chemoattractant protein-1 (MCP-1) in 62 cardiac allograft recipients undergoing yearly heart catherization with coronary angiography for evaluation of graft disease. In this cross-sectional study, we found significantly increased levels of IL-1beta, IL-6, TNF-alpha, and MCP-1 compared with healthy controls even several years (median 7 years) after transplantation in periods with no intercurrent illness. Although no significant differences were found in plasma levels of IL-1beta and TNF-alpha between patients with (n = 25) and without (n = 37) Tx-CAD, the Tx-CAD group had significantly increased levels of IL-6 and MCP-1 compared with both controls and transplant recipients without Tx-CAD. Increased IL-6 levels compared with controls were found only in patients with Tx-CAD. Finally, while there was no significant relation between Tx-CAD and altered lipid status, the combination of high plasma concentrations of IL-6 or MCP-1 and high low-density lipoprotein cholesterol was strongly associated with increased occurrence of Tx-CAD. These findings indicate that cardiac allograft recipients have a persistent immune activation long term after transplantation. This activation, as particularly reflected in increased MCP-1 and IL-6 levels, may be related to the development of Tx-CAD.

[Heart transplantation in Norway]

The first heart transplantation in the Nordic countries was performed at Rikshospitalet, Oslo in 1983. In this paper, we present our experience with this treatment up to 1999. 317 heart transplantations have been performed, an average of 23 transplantations per year. 82% of the recipients were males; 50% had heart failure due to coronary heart disease. Mean age of the recipients was 47 years (range 1-64). Our indications and contraindications are similar to most other transplantation centres. Triple immunosuppression with ciclosporin, prednisolone and azathioprine have been used as standard treatment. The survival rate after one and ten years are 85% and 53% respectively, with a significantly higher survival rate among recipients younger than 50 at transplantation, especially if the graft was from a donor younger than 35 years. The most common early postoperative complications were acute cellular rejections and infections. Transplant accelerated coronary heart disease and cancer were the main causes of late death. We believe that close co-operation between Riskshospitalet and local centres will provide the best treatment for patients needing a heart transplant.

Nonspecific microvascular vasodilation during iontophoresis is attenuated by application of hyperosmolar saline

Iontophoretic administration of acetylcholine chloride (ACh) and sodium nitroprusside (SNP) combined with laser Doppler skin blood perfusion measurements are used for determination of endothelial-dependent and -independent vasodilation. However, the method is biased by nonspecific vasodilation. The primary aim of this study was to investigate if iontophoresis-induced nonspecific vasodilation may be attenuated by addition of high molar concentrations of NaCl to the iontophoresis solutions. Secondary we investigated the applicability of 5 mol/liter NaCl solution as vehicle for ACh and SNP in this method. Skin perfusion changes were determined for iontophoresis of pure vehicles, deionized water and 5 mol/liter NaCl solution, in 12 healthy volunteers. Responses in skin perfusion to iontophoresis of ACh and SNP dissolved in both vehicles were also investigated. Addition of 5 mol/liter NaCl to deionized water significantly attenuated the nonspecific vasodilation and lowered the potential applied over the skin. The inter- and intraindividual coefficients of variation to ACh and SNP responses became, however, higher using hyperosmolar vehicle. During iontophoresis of SNP (in deionized water) we were unable to distinguish between SNP and vehicle effects. This study shows that the nonspecific vasodilation induced by iontophoresis can be attenuated by addition of 5 mol/liter NaCl, possibly due to lower electrical potential over the skin. However, the variability of the method was not improved. When deionized water was used as vehicle the effect of SNP could not be differentiated from that of the vehicle. This was not the case for ACh.

Cytokine network in congestive heart failure secondary to ischemic or idiopathic dilated cardiomyopathy

Inflammatory cytokines may play a pathogenic role in the development of congestive heart failure (CHF). Elevated circulating levels of inflammatory cytokines have been reported in CHF, but most studies have focused on only a few cytokine parameters. However, the activity of these cytokines are modulated by soluble cytokine receptors and cytokines with anti-inflammatory activities, and in the present study several of these interacting factors were examined simultaneously in 38 CHF patients with various degrees of heart failure and in 21 healthy controls. Patients with CHF had increased plasma concentrations of tumor necrosis factor (TNF)alpha, interleukin-6, soluble TNF receptors and the soluble interleukin-6 receptor, glycoprotein (gp)130. They also had elevated ratios of TNFalpha/soluble TNF receptors and interleukin-6/soluble gp130 as well as enhanced interleukin-6 bioactivity in serum, suggesting inflammatory net effects. In addition to raised circulating levels of inflammatory cytokines, CHF patients with severe heart failure also had abnormalities in the levels of anti-inflammatory cytokines, with decreased levels of transforming growth factor beta1 and inadequately raised interleukin-10 in relation to the elevated TNFalpha concentrations. This dysbalance between inflammatory and anti-inflammatory cytokines was also found in monocyte supernatants from CHF patients. The abnormalities in the cytokine network were most pronounced in patients with the most severe heart failure, and several of the immunologic parameters, in particular soluble gp130, were correlated with variables reflecting deranged hemodynamic status. The present study analyzing the complexity of the cytokine network in CHF, demonstrates profound disturbances in the levels of both inflammatory and anti-inflammatory mediators with a marked dysbalance favoring inflammatory effects.

Exercise capacity in heart transplant recipients: relation to impaired endothelium-dependent vasodilation of the peripheral microcirculation

OBJECTIVES

The aim of this study was to examine the responses to endothelium-dependent and -independent vasodilators on the peripheral microcirculation in heart transplant recipients in relation to exercise capacity compared with that in healthy controls.

BACKGROUND

Impaired endothelium-dependent vasodilation of the microcirculation may play an important role in the limitation of exercise capacity after heart transplantation.

METHODS

Microvascular perfusion responses to four graded levels of iontophoretically applied 1% acetylcholine (endothelium-dependent vasodilator) and 1% sodium nitroprusside (SNP) (endothelium-independent) in the forearm skin of 42 transplant recipients and 16 age-matched controls were determined by laser Doppler perfusion measurements. Maximal exercise capacity was assessed by peak oxygen uptake (peak VO2) during progressive, symptom-limited, upright bicycle exercise.

RESULTS

With similar baseline perfusion levels in transplant recipients and controls (4.2 +/- 0.4 vs 4.6 +/- 0.6 arbitrary units [AU]), the increases in perfusion to acetylcholine, but not to SNP, were significantly attenuated in the transplant recipients: 7.0 +/- 1.0 vs 11.0 +/- 2.0, 12.7 +/- 1.5 vs 21.0 +/- 2.8, 21.0 +/- 1.9 vs 32.7 +/- 2.4, and 28.0 +/- 1.6 vs 39.2 +/- 2.4 AU, respectively (all p < 0.01). Peak VO2 was significantly lower in the transplant recipients (22.4 +/- 1.0 vs 38.0 +/- 2.9 ml/kg/min; p < 0.01). Furthermore, acetylcholine responses of the transplant recipients correlated closely to their peak VO2, irrespective of level of application (r = 0.63; p < 0.001, all four acetylcholine responses taken together), whereas no such correlation was found for SNP responses. In the control group, no relation was observed in acetylcholine/SNP responses to peak VO2.

CONCLUSIONS

Exercise limitation in transplant recipients appears strongly associated with attenuated endothelium-dependent vasodilation of the peripheral microcirculation.

Endothelium-dependent vasodilation of the skin microcirculation in heart transplant recipients

Patients with heart failure demonstrate attenuated endothelium-dependent vasodilation of the peripheral circulation, while this is suggested to be reversed after heart transplantation. However, data from human subjects are limited and conflict with studies on the peripheral vasomotor tone in cyclosporine-treated animals, suggesting endothelial dysfunction. We recorded forearm skin perfusion responses following graded iontophoresis of 1% acetylcholine (endothelium-dependent) and 1% sodium nitroprusside (endothelium-independent) by laser Doppler perfusion measurements in 32 heart transplant recipients and 15 age-matched controls. In addition, the hyperemic response to 3 min of blood flow occlusion to the forearm was measured on the third finger pulp. With comparable baseline values, the increases in perfusion to the 4 applications of acetylcholine were significantly attenuated in heart transplant recipients compared with controls: 59 +/- 9 vs. 146 +/- 32, 242 +/- 39 vs. 492 +/- 77, 480 +/- 66 vs. 845 +/- 120 and 699 +/- 77 vs. 993 +/- 139% (mean +/- SEM; all p < 0.01). Peak hyperemia (134 +/- 4 vs. 153 +/- 12 arbitrary units (AU); p < 0.05)), time for the hyperemic perfusion to return to preocclusive baseline (52.4 vs. 102.9 s; p < 0.01) and hence the area under the perfusion curve (1469 +/- 244 vs. 4581 +/- 921 AU s; p < 0.01) were reduced among heart transplant recipients. The area under the perfusion curve correlated significantly with mean arterial blood pressure (r = -0.60; p < 0.01) and with the responses to iontophoresis of acetylcholine (r = 0.41; p < 0.01). Two non-invasive tests of vascular function demonstrate attenuated endothelial-dependent microvascular responses in heart transplant recipients. The relative impact of prior congestive heart failure and postoperative factors, such as treatment with cyclosporine, remains to be determined.

[Thrombolytic treatment in acute myocardial infarction. Choice of preparations in Norwegian hospitals]

In 1994 Statens legemiddelkontroll recommended Norwegian hospitals to increase the use of recombinant tissue plasminogen activator (r-tPA) in thrombolytic treatment of acute myocardial infarction. Using a questionnaire, which was distributed to all medical departments in Norwegian hospitals, we examined and assessed the preference of thrombolytic agents. None of the coronary care units administered r-tPA routinely as their first choice. Of 59 hospitals involved, 35 (59%) considered r-tPA on a wider indication (i.e. young age, short history of symptoms, and anterior wall infarction) than the 24 (41%) that only used r-tPA when streptokinase had recently been given. Of a total of 11,191 cases of myocardial infarction in 1996, 628 (6%) were treated with r-tPA. Closer examination of 2,818 cases of myocardial infarction in 13 hospitals revealed that thrombolytic treatment was given in 1,016 (36%) instances. In 206 cases (20%), the chosen agent was r-tPA, whereas 810 (80%) were given streptokinase. The reasons for the preference of streptokinase to r-tPA are discussed.

Effect of heart transplantation on impaired peripheral microvascular perfusion and reactivity in congestive heart failure

Whether reduced peripheral blood flow in congestive heart failure is reversed after heart transplantation, has not been closely examined. We therefore studied skin microvascular resting perfusion and reactivity in patients pre- and postoperatively. Resting digital skin perfusion, together with the responses to cold pressor test, postocclusive reactive hyperemia and direct skin heating were examined with laser Doppler perfusion measurements. We examined 28 patients with congestive heart failure and 14 of these patients after heart transplantation and compared them to 13 healthy controls. Measurements were performed within 3 months preoperatively and 12 days, 1, 2, 3 and 6 months postoperatively. Patients with congestive heart failure had significantly lower resting perfusion levels than controls and demonstrated attenuated responses to both stimuli of vasodilation (all P<0.01). While peak hyperemic responses improved significantly after transplantation, postocclusive area under the hyperemic curve decreased further, and none of these variables were normalized after 6 months. In contrast, minimal perfusion during cold pressor test increased from a significantly lower level in the patients with congestive heart failure (P<0.05), to a level similar to that of the controls within 12 days postoperatively. Thus, skin microvascular perfusion and reactivity improve, but are not normalized within 6 months of transplantation. Both pre- and postoperative factors may be involved in maintaining a dysfunction of the peripheral microcirculation, which may contribute to exercise intolerance and hypertension in heart transplant recipients.

Elevated circulating levels of C-C chemokines in patients with congestive heart failure

BACKGROUND

Immunologic and inflammatory responses appear to play a pathogenic role in the development of congestive heart failure (CHF). Activation and migration of leukocytes to areas of inflammation are important factors in these immunologic responses. Because the C-C chemokines are potent chemoattractants of monocytes and lymphocytes and can modulate other functions of these cells (eg, generation of reactive oxygen species), we measured circulating levels of three C-C chemokines in CHF.

METHODS AND RESULTS

Levels of macrophage chemoattractant protein-1 (MCP-1), macrophage inflammatory protein- 1alpha (MIP-1alpha), and RANTES (regulated on activation normally T-cell expressed and secreted) were measured by enzyme immunoassays in 44 patients with CHF and 21 healthy control subjects. CHF patients had significantly elevated levels of all chemokines with the highest levels in New York Heart Association class IV, and MCP-1 and MIP-1alpha levels were significantly inversely correlated with left ventricular ejection fraction. Elevated C-C chemokine levels were found independent of the cause of the heart failure, but MCP-1 levels were particularly raised in patients with coronary artery disease. Studies on cells isolated from peripheral blood suggested that platelets, CD3+ lymphocytes, and in particular, monocytes, might contribute to the elevated C-C chemokine levels in CHF. The increased MCP-1 levels in CHF were correlated with increased monocyte activity reflected in an enhancing effect of serum from CHF patients on O2-generation in monocytes, which was inhibited by neutralizing antibodies against MCP-1.

CONCLUSIONS

This first demonstration of increased circulating levels of C-C chemokines in CHF with particularly high levels in patients with severe disease may represent previously unrecognized pathogenic factors in CHF.

Levels of circulating adhesion molecules in congestive heart failure and after heart transplantation

Recent reports suggest a role for immunologic and inflammatory processes in the pathogenesis of congestive heart failure (CHF) and accelerated coronary artery disease (CAD) after heart transplantation (HT). The interaction between endothelial cells, leukocytes, and platelets involving various adhesion molecules may be of particular importance. We therefore measured serum levels of soluble(s) vascular cell adhesion molecule-1 (VCAM-1), sP-selectin, and sE-selectin in 34 patients with severe CHF (23 with CAD and 11 with idiopathic dilated cardiomyopathy) and in 20 healthy controls. Twenty of the patients were followed with serial measurements of these circulating adhesion molecules (CAMs) for up to 2 years after HT. Levels of all 3 CAMs were significantly elevated in patients with CHF compared with controls irrespective of the etiology of heart failure, with particularly high concentrations of sVCAM-1. After HT, different patterns in CAMs were found over time. Whereas there was a normalization of sE-selectin levels after HT, concentrations of sVCAM-1 also declined, but without normalization. In contrast, sP-selectin levels were persistently elevated, with the highest concentrations at the end of the study period. The persistent elevation of sP-selectin and the lack of normalization of sVCAM-1 levels were associated with persistently raised serum levels of tumor necrosis factor-alpha, and these findings were not related to either acute episodes of allograft rejection or intercurrent infections. These results support the notion that immunologic and inflammatory processes are important features of CHF. Furthermore, the persistently elevated levels of CAMs and tumor necrosis factor-alpha found up to 2 years after HT may reflect a state of persistent immune activation in these patients, possibly involved in the development of CAD after HT.

Hypertension prophylaxis with omega-3 fatty acids in heart transplant recipients

OBJECTIVES

This study sought to determine whether omega-3 fatty acids act as hypertension prophylaxis in heart transplant recipients and have an impact on vascular reactivity.

BACKGROUND

Cyclosporine-induced hypertension is probably related to endothelial dysfunction. Suggested vasodilatory mechanisms of omega-3 fatty acids may therefore be particularly beneficial in heart transplant recipients.

METHODS

Heart transplant recipients were randomized to receive either 4 g of omega-3 fatty acids (treatment group, n = 14) daily or corn oil (placebo group, n = 14) from the fourth postoperative day. Twenty-four hour blood pressure monitoring was performed at day 12 and 1,2,3 and 6 months postoperatively. Microvascular endothelium-dependent vasodilation, evaluated by skin laser Doppler perfusion measurements of postocclusive reactive hyperemia, was determined preoperatively and at the end of the study.

RESULTS

With comparable characteristics at the time of randomization, blood levels of cyclosporine did not at any point differ between the groups. After 6 months, systolic blood pressure decreased 2 +/- 4 mm Hg (mean +/- SEM) in the treatment group and increased 17 +/- 4 mm Hg in the placebo group (p < 0.01), whereas diastolic blood pressure increased 10 +/- 3 and 21 +/- 2 mm Hg (p < 0.01), respectively. The decrease in systolic blood pressure was inversely proportional to increases in concentrations of serum eicosapentaenoic and docosahexaenoic acid (p = 0.01). After 6 months, five patients in the treatment group and nine in the placebo group needed additional antihypertensive treatment. Although the endothelial-dependent phase of the reactive hyperemic response remained unchanged in the treatment group, it decreased significantly in the placebo group.

CONCLUSIONS

Postoperative daily administration of 4 g of omega-3 fatty acids in heart transplant recipients is effective as hypertension prophylaxis, depending on increases in serum eicosapentaenoic and docosahexaenoic acids. Preservation of microvascular endothelial function, demonstrated by a more pronounced response to forearm skin ischemia in the treatment group, may contribute to the hypotensive role of omega-3 fatty acids.

[Cardiology education in Norway--does it keep up with the needs?]

Despite an increase in the number of education positions for cardiologists in Norway in the late 1980s, there is felt to be a marked lack of sub-specialists in cardiology in most types of hospitals. A working group under the Norwegian Society of Cardiology has used a questionnaire in 1993, membership data from the Norwegian Society of Cardiology in 1994, a telephone query to all hospitals in the country, and data from the Norwegian Medical Association in 1995 to examine this apparent lack of specialists and the potentials for educating them. We were able to confirm a current lack of approximately 60 cardiologists. In addition, the capacity for education has been reduced and will not compensate for the predicted retirement of specialists from approximately year 2000. The capacity for educating cardiologists must be increased.

Attenuated microvascular perfusion and reactivity in cardiac transplant recipients treated with cyclosporine

Orthotopic heart transplant recipients (TX pts) treated with cyclosporine develop postoperative hypertension and their functional capacity remains less than normal. Altered responsiveness to adrenegic stimuli and impaired release of endothelial-derived relaxing factor are proposed mechanisms of cyclosporine-induced raised peripheral vascular resistance. We compared responses to vasoconstrictor tests that stimulate sympathetic neural outflow (Valasalva maneuver and cold pressor test) and a vasodilator test that is dependent on the presence of a functionally intact endothelium (postocclusive hyperemia) in 16 TX pts with age-matched healthy controls, applying laser Doppler perfusion measurements (LDPM). Mean time since transplantation was 4.5 years (1-10 years). All TX pts received the triple regimen of prednisone, azathioprine and cyclosporine. Fourteen were considered hypertensive. Basal LDPM at rest expressed in arbitrary flux units (AU), was significantly lower in the TX pts (15.9 AU) than the controls (21.5 AU; p < 0.01). The maximal flux changes in the vasoconstrictor and vasodilator responses were comparable. However, the TX pts recovered faster from these responses and flux values at mid-to-late phase were lower following peak hyperemia and higher at any point following a cold pressor test than in the controls. Furthermore, a correlation was found between flux levels 30 s after either stimulus (r = 0.56; p < 0.0009) and time to reach prestimulus baseline after either test (r = 0.55; p < 0.002). With indirect evidence of comparable microvascular architecture, our findings suggest endothelial dysfunction in TX pts with intact functional capacity of the sympathetic nervous system.

[Intermittent claudication and beta-blockaders. An unfortunate combination?]

beta-adrenergic blockers have been considered relatively contraindicated in patients with peripheral arterial disease because of reports claiming that these drugs may worsen intermittent claudication. The authors review the published randomized controlled trials and discuss the results of comparisons of this treatment with treatment with alternative drugs. None of the studies of beta-blockade in patients with intermittent claudication showed a reduction of walking distance or impairment of peripheral flow compared with patients given placebo, except one study using a beta-blocker with intrinsic sympathomimetic activity. Alternative drugs are included in only few trials and do not seem to be beneficial. There is a lack of evidence to suggest that beta-blockers adversely effect walking capacity or worsen symptoms in mild to moderate intermittent claudication. beta-blockers should not be avoided if considered in other respects to be the optimal therapy for associated atherosclerotic disease.

A new color M-mode index of diastolic filling compared with radionuclide ventriculography

We correlated the new diastolic index 'delay of apical peak velocity', as measured by colour M-mode Doppler, with radionuclide ventriculographic indices of ventricular function. Thirty-seven patients with coronary artery disease participated in the prospective and blinded study, which included repeated acquisitions to determine the effect of realigning the Doppler sample beam. In multiple regression, neither peak filling rate, left ventricular phase histogram width nor ejection fraction were statistically significantly related to delay of apical peak velocity. The standard deviation of the differences between duplicate colour M-mode acquisitions corresponded to half the reference range of the index. We conclude that in this blinded investigation, the new Doppler index did not provide information about ventricular function equivalent to radionuclide ventriculography. The index may be significantly influenced by sample beam position.

Changes in Lp(a) lipoprotein and other plasma proteins during acute myocardial infarction

The sequential changes of Lp(a) lipoprotein concentrations in patients (n = 59) suffering acute myocardial infarction (AMI) were examined and compared with other plasma proteins. The temporal and quantitative characteristics of the responses in concentration of acute phase reactants (CRP, haptoglobin, alpha 1-antitrypsin, alpha-acid glycoprotein), lipids (total cholesterol, triglycerides, HDL cholesterol, LDL cholesterol) and apolipoproteins AI and B were similar to previous reports. Lp(a) lipoprotein showed transient changes with an initial decrease of 10-25% compared to the 3-month control value, followed by rebound on day 7-11 above admission level, before again declining. We were able to demonstrate a quantitative relationship between infarct size and alterations in plasma levels of acute phase reactants. However, in addition to rather unusual significant fluctuations during AMI, Lp(a) lipoprotein changes seemed unrelated to infarct size. These findings do not support the view that Lp(a) lipoprotein acts as an acute phase reactant.

[Lung damage in amiodarone therapy]

Amiodarone pulmonary toxicity is the most serious side effect of amiodarone therapy. We describe a patient who died of this adverse effect. The clinical presentation is most often that of an indolent illness, with cough and/or fever. The diagnosis is made by careful exclusion of other causes of the observed illness and the finding of clinical, radiographic, physiologic, and pathologic abnormalities compatible with amiodarone toxicity. Examination prior to drug therapy, including lung function tests, is recommended for later controls. Of the therapeutic options, discontinuation of amiodarone is most frequent. However, for some patients with life-threatening ventricular arrhythmias this is the only effective therapy.