Cardiac metastasis and tumor embolism in a patient with adenocarcinoma of the colon presenting with paraneoplastic polymyositis

Colorectal cancer usually presents with alterations in the bowel habit. Less commonly, the presenting symptoms may be part of a paraneoplastic syndrome. Metastasis can occur by lymphatic or hematogenous spread, most frequently to the lungs and liver. We present the case of a 56-year-old man admitted with paraneoplastic polymyositis due to a poorly differentiated colon adenocarcinoma. The evolution was unfavorable with death on the 19th day following admission due to pulmonary thromboembolism and subsequent pulmonary edema. Autopsy showed micrometastases with lymphatic and venous emboli to the heart, liver, kidney, adrenal gland and lung. The case highlights the diversity of manifestation that can occur in a colon adenocarcinoma.

Liver biopsy versus noninvasive methods--fibroscan and fibrotest in the diagnosis of non-alcoholic fatty liver disease: a review of the literature

The prevalence of non-alcoholic fatty liver disease (NAFLD) is increasing in general population so it is impossible to perform liver biopsy in such a large number of patients to identify those with advanced fibrosis or non-alcoholic steatohepatitis. Liver biopsy has a potential sampling error, it is invasive and prone to complications, so it is no longer considered as mandatory as first line screening tools for chronic liver disease. The development of non-invasive biomarkers, FibroTest-ActiTest in 2001 and more recently FibroMax, as well as transient elastography (TE) has changed the management of chronic liver disease. The aim of this review is to summarize the advantages and limits of the available non-invasive biomarkers of liver fibrosis, in comparison with liver biopsy in NAFLD patients.

The impact of the metabolic syndrome on the patients with acute coronary syndrome

BACKGROUND

The subjects with metabolic syndrome are an increased risk for the development of diabetes mellitus and cardiovascular disease as well as an increased mortality for cardiovascular disease in all causes. The prevalence of the metabolic syndrome after acute coronary syndrome has not been studied yet. We aimed to evaluate the prevalence of the metabolic syndrome and to evaluate its cardiovascular risk potential using the National Cholesterol Education Program's Adult Treatment Panel III (NCEP-ATP III) criteria.

METHODS

We performed a cross sectional study in 256 patients with acute coronary syndrome. The definition of the metabolic syndrome was based on NCEP-ATP III criteria. The cardiovascular risk factors that define the metabolic syndrome and their correlation with the cardiovascular risk were evaluated by descriptive and interferential statistical methods.

RESULTS

The prevalence of metabolic syndrome was 47.26%, as assessed by criteria of the NCEP-ATP III. The presence of the metabolic syndrome has been positively correlated with the cardiovascular risk (OR 1.29; 95% CI, 1.05-1.54, p=0.047). The cardiovascular risk has significantly correlated with the increasing of the components number that defines the metabolic syndrome. Among the components of the metabolic syndrome, HDL-Cholesterol was the most significantly correlated with the cardiovascular risk in the patients with acute coronary syndrome (OR 3.60; 95% CI 2.14-5.06; p=0.002).

CONCLUSION

The prevalence of the metabolic syndrome according to the NCEP-ATP III criteria was high, and positively correlated with the cardiovascular risk in the patients with acute coronary syndrome. The cardiovascular risk rises proportionally with the number of metabolic components.

Recurrent thrombembolic risk in patients with multiple thrombophilic disorders

Genetic mutations of the coagulation factors II and V (G20210A and G1691A - factor V Leiden)--as well as the one for methylene tetrahydrofolat reductase's (MTHFT) gene C677T are diseases with dominant autosomal transmission characterized by thromboembolic events leading to deep vein thrombosis and/or pulmonary embolism. The authors show the clinical observation of 2 cases of recurrent deep venous thrombosis evolving with pulmonary embolism in patients with genetic defects of the coagulating factors. The positive diagnostic was put on the paraclinical findings and the etiology was established from the homocysteine genetic modification of the G20210A prothrombin and factor V Leiden and MTHFT mutation. Publishing these cases will allow us to emphasize the importance of the genetic factors for thromboembolic episodes and especially for the consequences of the long-term anticoagulant therapy.

Lipoprotein (a) and lipid and non-lipid risk factors in coronaries risk assessment

PURPOSE

Several studies showed that elevated plasma levels of lipoprotein(a) [Lp(a)] represent a predictor for cardiovascular risk. Based on already existing literature data, we aim to study the relationship between Lp(a), lipids and other cardiovascular risk factors in individuals with or without coronary heart disease.

METHODS

We performed a cross-sectional transversal study on 208 patients (100 men and 108 women) aged between 37-75, with or without old myocardial infarction. In all the patients were evaluated the cardiovascular risk factors, the plasma level of the lipid fractions and Lp(a). The relationship between Lp(a) and the lipid and non-lipid risk factors were evaluated by the logistic regression method.

RESULTS

The myocardial infarction group had higher values of plasma levels of Lp(a) (0.37 +/- 0.28 vs. 0.29 +/- 0.23 g/L, p < 0.05), and LDL-C (125.66 +/- 41.21 vs. 113.44 +/- 46.64 mg/dL, p < 0.05), than the group without coronary heart disease, as well as higher values of plasmatic TC/HDL-C ratio (4.31 +/- 1.55 vs. 4.08 +/- 1.29, p < 0.05), with significantly decreased plasmatic levels of HDL-C (45.88 +/- 12.04 vs. 53.22 +/- 23.12 mg/dL, p < 0.05). The association between the high Lp(a) plasma levels and the severity of coronary vessels number involved was significant. Multivariate analysis performed with adjustments for cardiovascular risk factors showed that the Lp(a), LDL-C and CT/HDL-C ratio levels are significant and independent predictive markers of coronary heart disease.

CONCLUSION

The results show that the high Lp(a) plasma levels represent an independent cardiovascular risk factor, with superior risk prediction than the conventional lipid fractions. Our results confirm the Lp(a) as a marker for cardiovascular risk assessment in clinical practice.

The correlation between alcohol consumption, lipids, apolipoproteins and coronary heart disease

Moderate alcohol consumption is associated with a lower risk of coronary heart disease. Whether alcohol is truly protective or whether the amount, type, or pattern of intake is the most important is still under debate. The aim of this study was to evaluate the relationship between effect of presence, rhythm, frequency of alcohol consumption on lipid and apo-lipoproteic profile, and indirectly of cardiovascular risk.

METHODS

We performed a cross-sectional transversal study on 105 patients free of coronary heart disease (men and women) aged 58.08 (10.43) years. Alcohol and dietary intakes were assessed by using validated questionnaires. The dosages of lipids were measured by the enzymatic method and the dosages of apolipoproteins were measured by immuno-turbidometric methods.

RESULTS

Presence of chronic alcohol consumption independently correlated with HDL-Cholesterol (p < 0.5) and apoA-I levels (p < 0.05). Ethylic dose positively associated with HDL-C (r = 0.71, p = 0.003) and apoA-I levels (r = 0.65, p = 0.002). Mean HDL-C levels significantly increase from the <1 drink/day group (46.58 +/- 35.12) to >7 drinks/day group (55.54 +/- 49.12) (p < 0.05). apoA-I also had a higher mean level for the >7 drinks/day group (1.78 +/- 1.21) than the 1-6 drinks/day group (1.58 +/- 0.05) and than the <1 drink/day group (1.53 +/- 0.09). Differences were found to be significant (p < 0.05).

CONCLUSION

Alcohol consumption interferes with lipids and lipoproteins balance and is one of the parameters that indirectly decrease the cardiovascular risk. A higher ethylic quantity and rhythm of consumption correlates with a higher protection offered by HDL-Cholesterol and apo A-I.

Apolipoproteins A-I and B-markers in coronary risk evaluation

OBJECTIVES

To investigate if apoB, apoA-I and apoB/apoA-I ratios are independent risk factors for coronary heart disease and to determine their value in relationship with serum lipid fractions in evaluating the risk of coronary events.

MATERIALS AND METHODS

We carried out a comparative observational study on 289 subjects divided into two groups: 144 subjects with old myocardial infarction, and 145 subjects without coronary heart disease, but with cardiovascular risk factors. None of the subjects received lipid-lowering drugs in the previous 3 months.

RESULTS

The mean values of lipid fractions were lower in subjects with myocardial infarction than in subjects without coronary heart disease: total cholesterol (186.06 +/- 48.11 vs. 206.93 +/- 42.28 mg/dl, p = 0.0001), LDL-cholesterol (118.57 +/- 42.95 vs. 129.53 +/- 39.75 mg/dl, p = 0.023), HDL-cholesterol (43.64 +/- 12.32 vs. 50.48 +/- 21.09 mg/dl, p = 0.0008) and triglycerides (145.38 +/- 62.74 vs. 167.56 +/- 82.11 mg/dl, p = 0.01). The plasmatic levels of apoB were higher in subjects with myocardial infarction (1.12 +/- 0.57 vs. 0.86 +/- 0.27 g/l, p = 0.0001), but the apoA-I was lower (1.31 +/- 0.47 vs. 1.40 +/- 0.39 g/l, p = 0.101). The multivariate analysis indicated that plasmatic concentrations of apoB over 1.7 g/l are closely correlated with myocardial infarction (OR 3.96; 95% CI 2.87-5.02, p = 0.001) independent of other covariables such as age, smoking, diabetes, hypertension, lipid CT/HDL-C and the LDL-C/HDL-C ratio. The protective effect of apolipoprotein A1 against cardiovascular events after the adjustment for other cardiovascular risk factors (OR 0.72; 95% CI 0.57-0.83, p = 0.004) was also independent in multivariate analysis.

CONCLUSION

These results highlight the significance of apoA-I and apoB in the evaluation of the cardiovascular risk. From this point of view, their predictive value is superior to that of serum lipid fractions. The data suggest that the determination of apoA-I and apoB is useful enough to be introduced in current clinical practice.

Hyperhomocysteinemia: clinical and therapeutical involvement in venous thrombosis

Hyperhomocysteinemia, considered "the cholesterol of nineties", is an established risk factor for cardiovascular diseases and premature atherosclerosis. Hyperhomocysteinemia is due to genetic and acquired factors (unhealthy lifestyle with poor diet in folate and vitamin B, elderly, renal impairment, thyroid diseases, malignancies). More recently, hyperhomocysteinemia was associated with venous thrombosis. Several studies found a correlation with a usual site of thrombosis (central retinal vein, mesenterical level, cerebral veins, Budd-Chiari syndrome). Other studies showed the association between hyperhomocysteinemia and recurrent venous thrombosis. This condition is of high interest because homocysteine may represent a potentially reversible cause of thrombophilia. Although methylenetetrahydrofolate reductase (MTHFR) C677T genotype and deficits of folic acid, vitamin B12 lead to hyperhomocysteinemia, in cases with a thrombotic event the correlations between homocysteine level and folic acid as well as between homocysteinemia and vitamin B12 were found to be weak and no significant correlation between homocysteinemia and MTHFR was identified. Recently, some authors reported an independent association between low levels of folic acid or vitamin B12 and venous thrombosis. Regarding the MTHFR genotype, the risk for venous thrombosis is increased only in patients with factor V Leiden. A recent meta-analysis of 24 retrospective and 3 prospective studies published in electronic literature showed that a 5 micromol/L higher homocysteine level was associated with a 27% (95% CI: 1-59) higher risk of venous thrombosis in prospective studies and a 60% (95% CI: 10-134) higher risk in retrospective studies. A meta-analysis of the short-term trials of therapy with folic acid showed a reduction of 25% of homocysteinemia and a further reduction of 7% when vitamin B12 was associated. This situation may be associated with a 10% to 20% decreased risk of venous thrombosis. Further trials are required to estimate if this is worthwhile from the clinical point of view. In medical practice the measurement of homocysteinemia may be indicated in unexplained idiopathic venous thrombosis, or recurrent episodes or venous thrombosis occurred at an early age or at an uncommon site.

Prevalence and particularities of dyslipidaemia in subjects with coronary heart disease

The purpose of the study was to evaluate the lipid profile and the prevalence of dyslipidaemia and other risk factors in subjects with and without coronary heart disease.

METHODS

We conducted a retrospective study in 1519 subjects, admitted in Internal Medicine and Cardiology Department, Cluj-Napoca between January 2003 and December 2004. The first group consisted of 760 patients with coronary heart disease and the second group including 759 subjects in which coronary heart disease was excluded based on standard criteria. The cardiovascular risk factors and the serum lipid fractions were analyzed in order to test their relationship with the demographic characteristics and clinical forms of coronary heart disease.

RESULTS

The mean values of lipid fractions were lower in subjects with coronary heart disease than in subjects without coronary heart disease: total cholesterol (204.44 +/- 43.07 vs. 224.51 +/- 51.73 mg/dl, p = 0.0001), LDL-cholesterol (132.69 +/- 34.77 vs. 148.76 +/- 48.72 mg/dl, p = 0.0001), HDL-cholesterol (39.72 +/- 10.02 vs. 44.33 +/- 11.95 mg/dl, p = 0.0001), triglycerides (156.81 +/- 70.84 vs. 159.99 +/- 115.3 mg/dl, p = 0.517), non-HDL-cholesterol (164.72 +/- 39.9 vs. 180.19 +/- 51.58 mg/dl, p = 0.0001). The prevalence of dyslipidaemia was higher in group 1 than in group 2 (91.2% vs. 85.3%; p = 0.01). The most common lipid abnormalities in patients with coronary heat disease were increased LDL-C (84.22% vs. 81.21%, p = 0.09), followed by low HDL-C (55.26% vs. 35.57%, p = 0.001). The multivariate analysis showed that LDL-C (OR 1.27; 95% CI 1.01-1.88, p = 0.004), TC/HDL-C > 4.5 (OR 3.62; 95% CI 2.85-8.86, p = 0.001) and LDL-C/HDL-C > 3.5 (OR 4.21; 95% CI 1.89-4.66, p = 0.001) ratio, as being strongly associated with coronary events.

CONCLUSION

The study found a high prevalence of dyslipidaemia in Romanian patients with coronary heart disease. The most frequent lipid disorders were increased LDL-C, and low HDL-C. According to our results more than 90% of the patients with coronary heart disease are dyslipidaemic, and require non-pharmacological or pharmacological therapy.

[Left diastolic ventricular function, systolic blood pressure and erythrocyte magnesium in young type I diabetics]

Early cardiac involvement has been reported in type I diabetes mellitus. This study was undertaken to evaluate the relationship of systolic blood pressure (SBP), erythrocyte magnesium (MgE) and left ventricular diastolic function (LVDF). Forty-four patients with insulin-dependand diabetes (IDD) aged 26 to 31 years, without apparent cardiac complications 8.5 +/- 6 years after the onset of disease were studied. They were compared with 20 healthy subjects of the same age who comprised the control group. Left ventricular diastolic function was evaluated by isotopic technetium 9m ventriculography with a Gamma-Picker scintilation chamber, by determining maximum left ventricular filling velocities (I, VFmax). The MgF was measured by EDTA titrimetry. Patients were divided into two subgroups depending on the SBP: Group A (20 patients) with a mean SBP of 136 +/- 4.2 mmHf and Group B (24 patients) with a mean SBP of 118 +/- 4.4 mmHg; the control group had a mean SBP of 110 +/- 4.4 mmHg. The following results were obtained. [table: see text] The authors conclude that even small increases of SBP may, with a decrease in Mg, be a risk factor for early cardiac complications in IDD in young adults.