Untersuchungen über den In-vitro-Einfluß der kationischen Polypeptide Protaminsulfat und Trasylol auf Aggregation und Retraktion menschlicher Blutplättchen

Basische Polypeptide wie Polylysin, Protaminsulfat, Trasylol oder Lysozym können konzentrationsabhängig die Blutplättchenaggregation auslösen. Die Reaktion läuft im 2,7 mmol EDTA-Plasma ebenso wie in synthetischen Medien ab, ist also offenbar von der Anwesenheit zweiwertiger Kationen oder plasmatischer Kofaktoren weitgehend unabhängig. Eine Temperaturabhängigkeit ließ sich zwischen 4 und 37° C nicht feststellen, trotzdem konnten wir Stoffwechselsteigerungen in den aggregieren-den Plättchen nachweisen, die nach Art und Ausmaß etwa den durch Ca++- oder Mg++-auslösbaren Veränderungen entsprachen. Die Befunde könnten die bei der Heparinneutralisierung nach extrakorporaler Zirkulation in Form von Thrombo-embolien oder verstärkter Blutungsneigung auftretenden Komplikationen erklären.

[Pathobiology, pathology and genetics of pulmonary hypertension: Recommendations of the Cologne Consensus Conference 2016]

The 2015 European Guidelines on Diagnosis and Treatment of Pulmonary Hypertension (PH) are also valid for Germany. While the guidelines contain detailed recommendations regarding clinical aspects of pulmonary arterial hypertension (PAH) and other forms of PH, they contain only a relatively short paragraph on novel findings on the pathobiology, pathology, and genetics. However, these are of great importance for our understanding of this complex disease both from a clinical and scientific point of view, and they are essential for the development of novel treatment strategies. To this end, a number of current data are relevant, prompting a detailed commentary to the guidelines, and the consideration of new scientific data. In June 2016, a Consensus Conference organized by the PH working groups of the German Society of Cardiology (DGK), the German Society of Respiratory Medicine (DGP) and the German Society of Pediatric Cardiology (DGPK) was held in Cologne, Germany. This conference aimed to solve practical and controversial issues surrounding the implementation of the European Guidelines in Germany. To this end, a number of working groups was initiated, one of which was specifically dedicated to the pathobiology, pathology and genetics of PH. This article summarizes the results and recommendations of this working group.

[Pulmonary hypertension associated with left heart disease: recommendations of the Cologne Consensus Conference 2016]

The 2015 European Guidelines on Diagnosis and Treatment of Pulmonary Hypertension are also valid for Germany. While the guidelines contain detailed recommendations regarding pulmonary arterial hypertension (PAH), they contain only a relatively short paragraph on other, much more common forms of PH such as PH due to left heart disease. Despite the lack of data, targeted PAH treatments are increasingly being used for PH associated with left heart disease. This development is of concern because of limited ressources and the need to base treatments on scientific evidence. On the other hand, PH is a frequent problem that is highly relevant for morbidity and mortality in patients with left heart disease, representing an unmet need of targeted PH therapies. It that sense, the practical implementation of the European Guidelines in Germany requires the consideration of several specific issues and already existing novel data. This requires a detailed commentary to the guidelines, and in some aspects an update already appears necessary. In June 2016, a Consensus Conference organized by the PH working groups of the German Society of Cardiology (DGK), the German Society of Respiratory Medicine (DGP) and the German Society of Pediatric Cardiology (DGPK) was held in Cologne, Germany. This conference aimed to solve practical and controversial issues surrounding the implementation of the European Guidelines in Germany. To this end, several working groups were initiated, one of which was specifically dedicated to PH associated with left heart disease. This article summarizes the results and recommendations of this working group.

[Pulmonary hypertension due to left heart disease: recommendations of the Cologne Consensus Conference 2010]

The 2009 European Guidelines on Diagnosis and Treatment of Pulmonary Hypertension have been adopted for Germany. While the guidelines contain detailed recommendations regarding pulmonary arterial hypertension (PAH), they contain only a relatively short paragraph on other, much more frequent forms of PH such as PH due to left heart disease. Despite the lack of data, targeted PAH treatments are increasingly being used for PH associated with left heart disease. This development is of concern. On the other hand, PH is a frequent problem that is highly relevant for morbidity and mortality in patients with left heart disease, so that it may be speculated whether selected patients may benefit from targeted PH therapy. It that sense, the practical implementation of the European Guidelines in Germany requires the consideration of several specific issues and already existing novel data. This requires a detailed commentary to the guidelines, and in some aspects an update already appears necessary. In June 2010, a Consensus Conference organized by the PH working groups of the German Society of Cardiology (DGK), the German Society of Respiratory Medicine (DGP) and the German Society of Pediatric Cardiology (DGPK) was held in Cologne, Germany. This conference aimed to solve practical and controversial issues surrounding the implementation of the European Guidelines in Germany. To this end, a number of working groups was initiated, one of which was specifically dedicated to PH due to left heart disease. This commentary summarizes the results and recommendations of this working group.

Dose-dependent haemodynamic response to prenalterol in patients with congestive heart failure

The effect of three doses of prenalterol, 12.5, 25 and 50 micrograms, on cardiac index (CI), pulmonary artery pressure (PAP), heart rate (HR), and stroke volume index (SVI) was investigated in 18 patients with congestive heart failure (CHF). Twelve patients received only prenalterol, while 6 patients received prenalterol 1 hour after an oral dose of hydralazine and isosorbid dinitrate. In 7 out of 12 patients a dose-dependent increase in HR was observed. The response of HR was inversely correlated to resting catecholamine levels; patients with high resting catecholamines--these are patients with severe CHF--did not show any increase in HR. CI increased in 8 out of 12 patients (average 1 . 1/min m) and SVI in 5 out of 12 patients. This inconsistent response was not dependent on left ventricular ejection fraction or plasma catecholamines at rest. Pretreatment with vasodilators did not improve the haemodynamic response to prenalterol. Four out of 17 patients demonstrated an increase in severity of arrhythmias suggestive of arrhythmogenic properties of prenalterol.

[Primary prevention of coronary heart disease with aspirin]

According to meta-analysis and the results of the two studies with the highest power, aspirin is effective in primary prevention of coronary heart disease. These beneficial effects, however, are at least partially out-weight by unwanted effects-such as intense gastrointestinal bleeding and hemorrhagic stroke. These side effects remain constant with increasing risk of coronary heart disease, whereas the protective effects increase. If an annual risk of coronary heart disease of < or =0.6% exists, aspirin is normally not indicated; for a risk of 0.7-1.4% the facts should be discussed with the patient. If a risk of > or =1.5% exists, aspirin should be given. Problems of aspirin therapy--such as "aspirin paradox" and "aspirin resistance"--have been documented for secondary prevention; they might, however, have likewise clinical implications in primary prevention.

[Primary prevention of coronary heart disease? What is cost effective in the clinical practice?]

In the primary prevention of coronary heart disease (CHD), the effect of aspirin and statins is well documented in several controlled randomized trials. For aspirin the results can be transferred into clinical practice due to its low price; for the more expensive statins, however, serious economic problems exist. In contrast to secondary prevention these drugs do not reach cost-efficiency in primary prevention; due to their high prices for the criteria of the randomized controlled studies values >60 000 or >100 000 [US dollars/YLS] are gained. Data from England and Scotland indicate that according to the inclusion criteria of the WOSCOPS- and AFCAPS/TexCAPS studies almost 20 and 60%, respectively, of the adult population had to be treated with a statin. Results of newer studies may even increase these numbers. These costs cannot be covered by any health care system. Primary prevention of CHD with statins reveals paradigmatically that for financial reasons evidence-based medicine can no longer be transferred into clinical practice. The limited resources of all health care systems make rationing with treatment allocation only to the high risk groups necessary. The American, European and German guidelines propose a > or =2% annual risk of CHD as the limit, for financial reasons the Britisch recommendations favor a limit of 3%; in order to save >50% of the costs. Despite the financial restraints of the German health care system, the limit of > or =2% annual risk of CHD as proposed by the German Cardiac Society may be realistic when the different preventive measures are applied following a step-by-step plan based on the costs. According to the Procam algorithms, persons without diabetes mellitus or familiar disposition, who in case of nicotine abuse have given up smoking and if hypertensive have blood pressure values within the therapeutic range, statins are only to be given under the following conditions: LDL-cholesterol > or =175 or > or =190 mg/dl, for a HDL-cholesterol < or =35 or < or =45 mg/dl, or triglyceride levels > or =200 or > or =175 mg/dl, respectively. Diabetics without CHD have the same risk as non-diabetics with CHD. Therefore, in diabetics the same measures should be taken for primary prevention as in non-diabetics for secondary prevention. Evaluation of cost-efficiency indicates that intensive blood sugar control as well as intensive antihypertensive treatment and application of statins are all cost-effective in primary prevention of diabetics.

Respiratory muscle dysfunction in idiopathic pulmonary arterial hypertension

Idiopathic pulmonary arterial hypertension (IPAH) is a pulmonary vasculopathy of unknown aetiology. Dyspnoea, peripheral airway obstruction and inefficient ventilation are common in IPAH. Data on respiratory muscle function are lacking. This prospective single-centre study included 26 female and 11 male patients with IPAH in World Health Organization functional classes II-IV. Mean+/-SD pulmonary artery pressure was 48.6+/-16.9 in females and 53.1+/-22.9 mmHg in males; cardiac output was 3.7+/-1.3 and 4.2+/-1.7 L x min(-1). Maximal inspiratory pressure (PI,max) was lower in the female patients than in 20 controls (5.3+/-2.0 versus 8.2+/-2.0 kPa). In the male patients, PI,max was lower than in 25 controls (6.8+/-2.2 versus 10.5+/-3.7 kPa). Maximal expiratory pressure (PE,max) was lower in the female patients than in controls (6.2+/-2.6 versus 9.5+/-2.1 kPa), and in male patients as compared to controls (7.1+/-1.6 versus 10.3+/-3.9 kPa). There was no correlation between PI,max or PE,max and parameters of pulmonary haemodynamics or exercise testing. The ratio of mouth occlusion pressure within the first 0.1 s of inspiration and PI,max was higher in IPAH than in controls (females 0.067+/-0.066 versus 0.021+/-0.008; males 0.047+/-0.061 versus 0.023+/-0.016). In conclusion, this study provides the first evidence of inspiratory and expiratory muscle weakness in idiopathic pulmonary arterial hypertension. The pathomechanisms and the prognostic significance should be further investigated.

[Perspectives in cardiological research]

German cardiological research is confronted with increasing difficulties. Clinical research is restricted by regulations, such as the working hours protecting law, the revised version of the legal articles against corruption and acceptance of advantage as well as by many parts of law for the general frame of the university structures. In addition more and more administrative duties are tranferred to doctors engaged in research. Furthermore cardiology is at a disadvantage as only part of the net profits for cardiological services are tranferred to the responsible clinic. Likewise the facilities for cooperation are increasingly restricted, as basic science institutions originally allocated to cardiological research, are now devoted to other subjects and as many pharmaceutical firms have left the country. Cardiology in our country is practically not supported by private research organizations. Research projects are, therefore, predominantly financed by grants from the Bundeministerium für Bildung und Forschung and by the Deutsche Forschungsgemeinschaft. The financial resources for research in our country are declining and much smaller compared, e. g., to the USA. As a consequence of the shortage of resources not only are the weak projects turned down; it is feared that also the very innovative projects are likewise excluded for entering unknown territory. In periods of financial restrictions the central office and the experts evaluating the projects have a special responsibility, which cannot be met by technical objections, such as e. g., an "unsufficient impact factor". In order to improve the conditions for cardiological research the net profits for cardiological services should be transferred unrestricted to the responsible clinic. The acceptance rate of cardiologcal projects may be increased by more intensive cooperation. At the end, the principle of help by self-help also applies to cardiological research; the British Heart Foundation has developed into an impressive research-supporting organization in similarly difficult times.

[Primary prevention of coronary heart disease with aspirin]

According to the meta-analysis and the results of the two studies with the highest power, aspirin is effective in primary prevention of coronary heart disease. These beneficial effects, however, are at least partially outweighed by unwanted effects-such as intense gastrointestinal bleeding and hemorrhagic stroke. These side effects remain constant with increasing risk of coronary heart disease, whereas the protective effects increase. If an annual risk of coronary heart disease of < or = 0.6% exists, aspirin is normally not indicated; for a risk of 0.7-1.4% the facts should be discussed with the patient. If a risk of > or = 1.5% exists, aspirin should be given.

Enhanced iodide transport after transfer of the human sodium iodide symporter gene is associated with lack of retention and low absorbed dose

Transfer of the sodium iodide symporter (hNIS) has been proposed as a new principle of cancer gene therapy. Using clinically relevant doses of (131)I for the treatment of NIS-expressing prostate carcinoma cells, we investigated the kinetics and the absorbed doses obtained in these tumors. hNIS-expressing cell lines accumulated up to 200 times more iodide when compared to wild-type cells. However, a rapid efflux of the radioactivity (80%) occurred during the first 20 min after replacement of the medium. In rats, the hNIS-expressing tumors accumulated up to 20 times more iodide when compared to contralateral transplanted wild-type tumors. After 24 h and doses of 550, 1200 or 2400 MBq/m(2) hNIS-expressing tumors lost 89, 89 and 91% of the initial activity, respectively. Dosimetric calculations showed that 1200 MBq/m(2) resulted in 3+/-0.5 Gy (wild-type tumor 0.15+/-0.1 Gy) and 2400 MBq/m(2) resulted in 3.1+/-0.9 Gy (wild-type tumor 0.26+/-0.02 Gy). Although transduction of the hNIS gene induces iodide transport in rat prostate adenocarcinoma a rapid efflux occurs, which leads to a low absorbed dose in genetically modified tumors. With regard to a therapeutic application additional conditions need to be defined leading to iodide trapping.

[Quo vadis cardiologia? Or: An nescis, mi fili, quantilla prudentia mundus regatur? (Pope Julius III)]

In order to recognize and to solve problems, a look in the future is essential despite many uncertainties. Besides sound bed side-teaching, the main aim in the education of the students should be to acquire self-responsiveness and an attitude of permanent learning. It is more than doubtful whether the high expectations of health politicians will be met to limit the cost of in-patient treatment by introducing diagnosis-related groups in combination with evidence-based medicine, as this method has several severe limitations in order to fulfill this duty. The new financial system based on diagnosis-related groups will be in favor of private investors compared to the government-dependent university hospitals. The changing population pyramid implies not only higher costs but in addition severe medical problems. Within the changing society, alterations in the patient's behavior are to be expected. Several factors will contribute to make the doctor's profession less attractive. In the developing countries a rapid increase in the non-communicative diseases, i.e., in coronary heart disease, has to be expected. Apart from the prolongation of life - especially during its terminal phase - it is mainly the allocation of resources between industrialized and developing countries which will determine the ethical discussion. Germany has lost its leading position of the 19th and beginning of the 20th century in medical sciences. This was based on the liberal university system introduced by Wilhelm von Humboldt. Several pioneering innovations of German cardiologists during the 20th century have not strengthened German industry - in contrast to the situation in the 19th century. The general conditions in Germany, which are not research oriented, have prompted the majority of the pharmaceutical firms to transfer their research activities into foreign countries. In addition Germany's cardiological research has lost basic sciences partners for clinically orientated basic research, as many institutes which formerly worked in the cardiovascular field, are now devoted to other specialties. Restrictive legal regulations--such as the law regulating working hours, anti-corruption laws and the new legal university framework--are not conducive to internationally competitive research. Creative and innovative research requires liberal general conditions and cannot be planed.

Heart rate variability enhances the prognostic value of established parameters in patients with congestive heart failure

This prospective study evaluated whether heart rate variability (HRV) assessed from Holter ECG has prognostic value in addition to established parameters in patients with congestive heart failure (CHF). The study included 222 patients with CHF due to dilated or ischemic cardiomyopathy (left ventricular ejection fraction LVEF 21+/-1%; mean+/-SEM). During a mean follow-up of 15+/-1 months, 38 (17%) patients died and 45 (20%) were hospitalized due to worsening of CHF. The HRV parameter SDNN (standard deviation of all intervals between normal beats) was significantly lower in non-surviving or hospitalized than in event-free patients (118+/-6 vs 142+/-5 ms), as were LVEF (18+/-1 vs 23+/-1%), and peak oxygen uptake during exercise (peak VO(2)) (12.8+/-0.5 vs 15.6+/-0.5 ml/min/kg). While each of these parameters was a risk predictor in univariate analysis, multivariate analysis revealed that HRV provides both independent and additional prognostic information with respect to the risk 'cardiac mortality or deterioration of CHF'. It is concluded that the determination of HRV enhances the prognostic power given by the most widely used parameters LVEF and peak VO(2) in the prediction of mortality or deterioration of CHF and thus enables to improve risk stratification.

Troponin T concentrations 72 hours after myocardial infarction as a serological estimate of infarct size

BACKGROUND

After acute myocardial infarction, the structural protein T is released considerably longer than cytosolic creatine kinase (CK), CK MB isoenzyme (CK-MB), or lactate dehydrogenase (LDH) and late troponin T release (> 48 hours after onset of chest pain) appears to be less affected by early coronary reperfusion.

OBJECTIVE

To investigate the precision of a single measurement of circulating troponin T concentrations 72 hours after onset of chest pain compared with standard scintigraphic and enzymatic estimates of myocardial infarct size.

METHODS

Quantitative single photon emission computed tomography thallium-201 scintigraphy at rest was performed in 37 patients 2-3 weeks after myocardial infarction (group 1: 14 patients without early coronary reperfusion; group 2: 23 patients with early reperfusion achieved by thrombolytic therapy, by percutaneous transluminal coronary angioplasty, or by both).

RESULTS

In both groups, the number of myocardial segments with abnormal thallium-201 uptake indicating the individual extent of irreversible myocardial damage correlated significantly with the troponin T concentrations 72 hours after infarction as well as with peak concentrations of CK, CK-MB, and LDH.

CONCLUSION

The data show that a single measurement of circulating troponin T 72 hours after onset of chest pain--independent of reperfusion--is superior for the estimation of myocardial infarct size to measurement of peak CK, CK-MB, or LDH, which require serial determinations and depend on coronary reperfusion.

Peripheral airway obstruction in primary pulmonary hypertension

BACKGROUND

As there is controversy about changes in lung function in primary pulmonary hypertension (PPH), lung mechanics were assessed with a focus on expiratory airflow in relation to pulmonary haemodynamics.

METHODS

A cross sectional study was performed in 64 controls and 171 patients with PPH (117 women) of mean (SD) age 45 (13) years, pulmonary artery pressure (PAPmean) 57 (15) mm Hg, and pulmonary vascular resistance 1371 (644) dyne.s/cm(5).

RESULTS

Mean (SD) total lung capacity was similar in patients with PPH and controls (98 (12)% predicted v 102 (17)% predicted, mean difference -4 (95% confidence interval (CI) -7.89 to -0.11); residual volume (RV) was increased (118 (24)% predicted v 109 (27)% predicted, mean difference 9 (95% CI 1.86 to 16.14); and vital capacity (VC) was decreased (91 (16)% predicted v 102 (10)% predicted, mean difference -11 (95% CI 15.19 to -6.80). RV/TLC was increased (117 (27)% predicted v 97 (29)% predicted, mean difference 20 (95% CI 12.3 to 27.8)) and correlated with PAPmean (r=0.31, p<0.001). In patients with PAPmean above the median of 56 mm Hg, RV/TLC was further increased (125 (32)% predicted v 111 (22)% predicted, mean difference -14 (95% CI -22.2 to -5.8)). Expiratory flow-volume curves were reduced and curvilinear in patients with PPH.

CONCLUSIONS

Peripheral airway obstruction is common in PPH and is more pronounced in severe disease. This may contribute to symptoms. Reversibility of bronchodilation and relation to exercise capacity need further evaluation.

[Cardiomyopathy associated with uncontrolled self medication of anabolic steroids]

Though doping has become increasingly ostracized in the context of professional sports, an enormous number of unrecorded cases must be assumed in semi-professional competitive sports as well as in popular sports. This holds especially true for those forms of sports which are done in order to obtain a well-proportioned, athletic, healthy looking body. This case report describes a formerly healthy young man who had to be urgently admitted to an intensive care unit due to severe myocardial pump failure. As anamnestic information was insufficient and inadequate, the taking of anabolic steroids in high doses was proven, as their metabolites could be detected by urine analysis. Until now, myocardial contractile dysfunction has persisted for more than twelve months after the initial admission. Though other diagnoses which might have led to this impaired myocardial contractile performance have been excluded, cardiomyopathy associated with the taking of anabolic steroids must be assumed. Even in non-professional and public sports, a widespread abuse of doping substances exists. Hence, cardiomyopathy associated with the misuse of anabolic steroids has to be considered especially in young, formerly healthy patients.

[Secondary and primary prevention of coronary heart disease: platelet aggregation inhibitors and anticoagulants]

This review presents the results of primary and secondary prevention of coronary heart disease (CHD) with antiplatelet drugs and anticoagulants; therapeutic recommendations are derived. According to the results of the trials and due to its low price aspirin (ASS) can be still considered as the drug of choice. Its protective action has been documented for secondary prevention in patients with previous myocardial infarction, coronary angioplasty (PCI), unstable and stable angina, but not in patients with coronary artery bypass surgery, heart failure as well as in primary prevention. The doses recommended are 75-325 mg/d. If ASS is not tolerated clopidogrel is an alternative, but an expensive one. Anticoagulation for primary prevention of CHD may be considered in high risk patients, who do not tolerate ASS (alternative: clopidogrel). In secondary prevention anticoagulation is only recommended for special conditions, such as ASS intolerance (alternative: clopidogrel), ventricular aneurysm, ventricular thrombus, severe heart failure and/or atrial fibrillation.

Do cytokines enable risk stratification to be improved in NYHA functional class III patients? Comparison with other potential predictors of prognosis

AIMS

Elevated plasma levels of proinflammatory cytokines have been reported in patients with congestive heart failure. The purpose of this study was to assess whether cytokines improve risk stratification in a homogeneous group of NYHA class III patients with a left ventricular ejection fraction <40%.

METHODS AND RESULTS

Plasma concentrations of big endothelin, tumour necrosis factor alpha, interleukins -1, -6, -10 and -12, sCD14 and GM-CSF were measured by ELISA in 91 NYHA III patients [mean (SD) age: 55 (10) years, 69% male, 34% coronary artery disease, 66% dilated cardiomyopathy] with a left ventricular ejection fraction and a peak oxygen uptake (peak VO2) of 19 (9)% and 12.1 (3.6) ml x min(-1) x kg(-1), respectively. During follow-up [22 (13) months], 31 patients (34%) died due to cardiovascular causes. In non-survivors, interleukin-6 was twice as high as in survivors [12.8 (16.9) pg x ml(-1)vs 5.6(5.3) pg x ml(-1), P<0.003], whereas plasma concentrations of the other cytokines showed no significant differences. Concerning long-term survival (> or =1 year), multivariate Cox regression analysis revealed an independent prognostic power for interleukin-6, which was further improved by combining with left ventricular ejection fraction and peak VO2, while for short-term survival (up to 6 months) interleukin-6 did not allow risk stratification.

CONCLUSION

In NYHA class III patients, plasma concentrations of interleukin-6 are predictive of long-term survival. However, its value may be limited for clinical decision-making for cardiac transplantation (short-term survival).

Differential effects of radiocontrast agents on human umbilical vein endothelial cells: cytotoxicity and modulators of thrombogenicity

The endothelium plays a central role in the regulation of blood flow and coagulation. The impact of radiocontrast agents on endothelial cells is therefore potentially clinically important, particularly in percutaneous interventions for acute coronary thrombosis. The effects of radiocontrast agents on endothelial cell viability and determinants of thrombogenicity were studied in human umbilical vein endothelial cells (HUVECs) in vitro. Intercellular tight junctions were assessed using immunofluorescence microscopy and measurement of the transmonolayer electrical resistance (TMR). The concentrations of endothelin-1 (E), von Willebrand factor (vWF), plasminogen activator inhibitor-1 (PAI-1) and thrombomodulin (T) were measured in the cell culture media. The ionic, high osmolal radiocontrast agent diatrizoate induced concentration-dependent cell death and an opening of tight junctions with the attendant abolition of the TMR. The concentration of E decreased, vWF increased in the cell culture media, the concentration of PAI-1 and T was not significantly changed by diatrizoate. Radiocontrast agents with reduced osmolality (ioxaglate: ionic; iopamidol: non-ionic) induced an increase in PAI-1 and vWF, but E and T were not significantly changed.

CONCLUSIONS

Radiocontrast agents have differential effects on endothelial cells in vitro including the secretion of modulators of thrombogenesis. The effects are most pronounced in the markedly hyperosmolal compound diatrizoate suggesting a contributory role of hypertonicity. Ioxaglate and iopamidol both increased the prothrombotic factors vWF and PAI-1 to the same degree indicating a similar risk of thrombogenicity between low-osmolal ionic and non-ionic radiocontrast agents in this in vitro model.

Attenuation by fibrates of plasminogen activator inhibitor type-1 expression in human arterial smooth muscle cells

Human atherosclerotic lesions exhibit increased expression of plasminogen activator inhibitor type-1 (PAI-1) that has been implicated in atherogenesis. Although vascular smooth muscle cells are a predominant source of PAI-1 expression potentially favorable modulation of PAI-1 expression by fibrates has not yet been characterized in these cells. Human aortic smooth muscle cells were exposed to selected growth factors. PAI-1 expression was stimulated most powerfully by TGF-beta (EC50 = 0.2 ng/ml, up to 12-fold increase). Gemfibrozil inhibited basal PAI-1 expression by 23% (p = ns) and TGF-beta-induced PAI-1 expression by 52% (p = 0.017) whereas t-PA and total protein synthesis was not affected. Changes in PAI-1 protein accumulation reflected PAI-1 gene expression attributable to modulation of half-life of PAI-1 mRNA by gemfibrozil. Inhibition by other fibrates was less. Gemfibrozil specifically attenuates TGF-beta-induced PAI-1 expression in human arterial smooth muscle cells. Thus, fibrates are promising agents for normalizing increased PAI-1 expression in arterial walls in patients in whom PAI-1 expression is increased.

Induction of endothelin-1 expression by oxidative stress in vascular smooth muscle cells

Atherosclerosis is based on endothelial dysfunction leading to impaired vasomotor function. This is partially due to nitric oxide (NO) depletion caused by oxidative stress. Since the vasoconstrictor endothelin-1 (ET-1) might also be involved in endothelial dysfunction, we investigated whether oxidative stress regulates ET-1 expression in vascular smooth muscle cells (VSMC). Human aortic VSMC were treated with H(2)O(2) (200 microM) for up to 8 h. mRNA expression of preproendothelin (prepro-ET) was analyzed by RT-PCR. ET-1 protein and the marker for oxidative stress, 8-isoprostane, were determined by ELISA. Activity of cytosolic phospholipase A2 (cPLA(2)) as an indicator of ET-1 autocrine activity was measured photometrically. Stimulation of VSMC with H(2)O(2) resulted in increased expression of prepro-ET mRNA after 1 h with a maximum after 6 h (fourfold), similar to treatment with angiotensin II. ET-1 protein was significantly increased by H(2)O(2) treatment with a maximum after 8 h (P<.05). This effect was inhibited by the antioxidants resveratrol (100 microM) and quercetin (50 microM). In quiesced VSMC, incubation with H(2)O(2)-conditioned medium resulted in increased cPLA(2) activity compared to the controls (P<.05). This activity was partially inhibited by the ET(A)-receptor antagonist, PD 142893 (10 microM), indicating functional ET-1 in the conditioned medium. The presence of oxidative stress in H(2)O(2)-treated VSMC was associated by significantly increased formation of 8-isoprostane (P<.05). The data indicate for the first time that oxidative stress increases ET-1 generation and autocrine ET-1 activity in VSMC, a mechanism that might contribute to endothelial dysfunction in atherosclerosis.

Risk stratification in middle-aged patients with congestive heart failure: prospective comparison of the Heart Failure Survival Score (HFSS) and a simplified two-variable model

AIMS

The performance of a US-American scoring system (Heart Failure Survival Score, HFSS) was prospectively evaluated in a sample of ambulatory patients with congestive heart failure (CHF). Additionally, it was investigated whether the HFSS might be simplified by assessment of the distance ambulated during a 6-min walk test (6'WT) instead of determination of peak oxygen uptake (peak VO(2)).

METHODS AND RESULTS

In 208 middle-aged CHF patients (age 54+/-10 years, 82% male, NYHA class 2.3+/-0.7; follow-up 28+/-14 months) the seven variables of the HFSS: CHF aetiology; heart rate; mean arterial pressure; serum sodium concentration; intraventricular conduction time; left ventricular ejection fraction (LVEF); and peak VO(2), were determined. Additionally, a 6'WT was performed. The HFSS allowed discrimination between patients at low, medium and high risk, with mortality rates of 16, 39 and 50%, respectively. However, the prognostic power of the HFSS was not superior to a two-variable model consisting only of LVEF and peak VO(2). The areas under the receiver operating curves (AUC) for prediction of 1-year survival were even higher for the two-variable model (0.84 vs. 0.74, P<0.05). Replacing peak VO(2) with 6'WT resulted in a similar AUC (0.83).

CONCLUSION

The HFSS continued to predict survival when applied to this patient sample. However, the HFSS was inferior to a two-variable model containing only LVEF and either peak VO(2) or 6'WT. As the 6'WT requires no sophisticated equipment, a simplified two-variable model containing only LVEF and 6'WT may be more widely applicable, and is therefore recommended.

Ecarin clotting time but not aPTT correlates with PEG-hirudin plasma activity

BACKGROUND

Novel antithrombotic agents such as hirudin have shown promise in the therapy of acute coronary syndromes. PEG-hirudin (polyethyleneglycol conjugated hirudin) has been developed to provide a longer plasma half-life and more stable antithrombotic plasma levels. Privious trials indicated a narrow therapeutic window for hirudin and a number of aPTT (activated partial thromboplastin time)-monitored trials investigating hirudin in acute coronary syndromes had to be stopped because of intracranial bleeding complications.

OBJECTIVES

The present study evaluates the ecarin clotting time (ECT), a parameter based on the conversion of prothrombin by the snake venom enzyme ecarin, for the monitoring of PEG-hirudin therapy.

METHODS

Plasma from either healthy volunteers (n=20) or from patients (n=10) suffering from unstable angina pectoris (UAP) was spiked with increasing PEG-hirudin concentrations. In a prospective randomized clinical trial patients with UAP were treated with intravenous PEG-hirudin or heparin over 72 hours. Patients were randomized to the following treatment groups: (1) heparin control group, n=15; (2) PEG-hirudin low dose (0.1 mg/kg bolus, 0.01 mg/kg/h infusion), n=19; (3) intermediate dose (0.15 mg/kg and 0.015 mg/kg/h), n=17; 4) high-dose (0.2 mg/kg and 0.02 mg/kg/h), n=16. Spiked plasma samples and plasma from UAP patients treated with i.v. PEG-hirudin were analyzed for aPTT, ECT, and PEG-hirudin levels.

RESULTS

A linear correlation up to the highest therapeutic concentrations could be observed between PEG-hirudin plasma concentrations and the ECT. This was true for both plasma samples spiked with PEG-hirudin in vitro as well as for samples taken from patients treated with i.v. PEG-hirudin (correlation coefficient 0.9, respect.) In contrast the aPTT did not show a reliable linear correlation to PEG-hirudin concentrations.

CONCLUSION

Monitoring of PEG-hirudin therapy by ECT may help to avoid inadequate anticoagulation or overdosing. Thus, the safety and efficacy profile of PEG-hirudin therapy is likely to be enhanced by ECT monitoring.

d,l-sotalol enhances baroreflex sensitivity in conscious rats surviving acute myocardial infarction

The aim of the present study was to characterize the influence of D,L-sotalol on arterial baroreflex sensitivity (BRS) which is generally considered as an estimate of vagal activity and has prognostic value in patients after myocardial infarction (MI). Conscious rats were studied 3 days after left anterior descending coronary artery ligation (n= 5) or sham-operation (SH, n= 6). BRS was determined by linear regression analysis of the RR-interval (interval between heart beats) and mean arterial pressure changes evoked by i.v. bolus injections of methoxamine (inducing reflex bradycardia, RB) and nitroprusside (inducing reflex tachycardia, RT). In MI-rats heart rate and mean arterial pressure were not significantly different from values in SH-rats, left ventricular end-diastolic pressure was increased and contractility was depressed. The BRS (RB: MI: 0.48 +/- 0.04(*), SH: 0.79 +/- 0.08; RT: MI: 0.41 +/- 0.05(*), SH: 0.86 +/- 0.08 ms mmHg(-1)) ((*)P< 0.05 vs SH) was markedly reduced. d, l -Sotalol (1.5 mg kg(-1)i.v.) reduced heart rate (MI: -11 +/- 3 %(*), SH: -11 +/- 3 %(*)) and mean arterial pressure only moderately [MI: -6 +/- 4 %(n.s.), SH: -7 +/- 2 %(*)], while BRS depression in MI-rats was completely neutralized [RB: MI: 1.08 +/- 0.14(*), SH: 1.19 +/- 0.11(*); RT: MI: 0.84 +/- 0.08(*), SH: 0.88 +/- 0.12 (n.s.) ms mmHg(-1)] ((*)P< 0.05 vs pretreatment). The BRS is reduced in rats early after MI, indicating a depressed reflex vagal activity. Treatment with D,L-sotalol at a dose with little effect on heart rate and mean arterial pressure markedly enhances and, thus, restores BRS in MI-rats. These data suggest that D,L-sotalol has both peripheral and central effects leading to an increase of reflex vagal control of heart rate in rats.

Troponin T elevation after successful directional atherectomy

BACKGROUND

The incidence and correlates of postinterventional cardiac troponin T (cTnT) elevation have not been evaluated in patients with successful directional atherectomy (DCA).

METHODS

Total creatine kinase (CK) activity, CK-MB mass concentrations and cTnT levels were measured in 36 patients before, and serially 4, 24, 48 and 72 hours after successful DCA. Patients were followed for death, Q-wave infarction, need for emergency bypass surgery, periprocedural vascular complications (transient in-lab vessel closure, side branch compromise, large dissection), and non-Q-wave infarction on ECG. Patients were followed for clinical outcomes and angiographic restenosis for 6 months. Vascular correlates were studied by coronary angiography and intravascular ultrasound before, immediately after and 4 hours after elective and successful DCA.

RESULTS

25 patients (69.4%) had elevated levels of cTnT, whereas CK-MB mass > or = 6 ng/ml and mild elevations of total CK activity were present in only 36.1 and 5.6%, respectively. Elevated cTnT was related to vascular complications in 44% of cases. Inapparent microembolization of platelets or plaque debris was considered responsible for most of the remaining micronecroses. During 6 month follow-up rates of clinical restenosis (44 vs 9%, p = 0.059) tended to be higher in patients with as compared to patients without cTnT release after DCA.

CONCLUSION

Successful DCA is associated with postprocedural elevations of cTnT which relate to minor vascular complications and presumably microembolization of platelets or plaque debris. The superior diagnostic performance of cTnT compared to CK-MB mass may relate to more sensitive identification of microinfarction. Further studies are mandatory to confirm the association between elevation of cTnT and risk of restenosis and TVR.

Respiratory muscle dysfunction in congestive heart failure: clinical correlation and prognostic significance

BACKGROUND

In congestive heart failure (CHF), the prognostic significance of impaired respiratory muscle strength has not been established.

METHODS AND RESULTS

Maximal inspiratory pressure (Pi(max)) was prospectively determined in 244 consecutive patients (207 men) with CHF (ischemic, n=75; idiopathic dilated cardiomyopathy, n=169; age, 54+/-11 years; left ventricular ejection fraction [LVEF], 22+/-10%). Pi(max) was lower in the 244 patients with CHF than in 25 control subjects (7.6+/-3.3 versus 10.5+/-3.7 kPa; P=0.001). The 57 patients (23%) who died during follow-up (23+/-16 months; range, 1 to 48 months) had an even more reduced Pi(max) (6.3+/-3.2 versus 8.1+/-3.2 kPa in survivors; P=0.001). Kaplan-Meier survival curves differentiated between patients subdivided according to quartiles for Pi(max) (P=0.014). Pi(max) was a strong risk predictor in both univariate (P=0.001) and multivariate Cox proportional hazard analyses (P=0.03); multivariate analyses also included NYHA functional class, LVEF, peak oxygen consumption (peak VO(2)), and norepinephrine plasma concentration. The areas under the receiver-operating characteristic curves for prediction of 1-year survival were comparable for Pi(max) and peak VO(2) (area under the curve [AUC], 0.68 versus 0.73; P=0.28), and they improved with the triple combination of Pi(max), peak VO(2), and LVEF (AUC, 0.82; P=0.004 compared with AUC of Pi(max)).

CONCLUSIONS

In patients with CHF, inspiratory muscle strength is reduced and emerges as a novel, independent predictor of prognosis. Because testing for Pi(max) is simple in clinical practice, it might serve as an additional factor to improve risk stratification and patient selection for cardiac transplantation.

4-hydroxynonenal induces apoptosis, NF-kappaB-activation and formation of 8-isoprostane in vascular smooth muscle cells

Oxidation of lipids is considered a key feature of atherogenesis. Lipid peroxidation products such as oxidized LDL or the bioactive aldehyde 4-hydroxynonenal (HNE) exert mitogenic effects on vascular smooth muscle cells (VSMC). These effects appear to be concentration-dependent since in addition to our previous reports on growth promotion at lower concentrations we here indicate induction of apoptosis in VSMC by 4-hydroxynonenal (HNE) at higher concentrations (100 micromol/L). In a line with HNE's previously documented effects on key mitogenic signaling elements, we also report on activation by this aldehyde of the redox-sensitive transcription factor NF-kappaB, a key regulator of apoptosis: HNE (1.0 micromol/L) induced DNA-binding of NF-kappaB in VSMC. The effect was inhibited by antioxidants, N-acetylcysteine and pyrrolidine dithio-carbamate. HNE caused phosphorylation but not degradation of the inhibitory subunit IkappaB-alpha. HNE itself acts as an oxidant as was investigated with measurements of 8-isoprostane which ranks among the most valuable available biomarkers of lipid peroxidation: HNE (1.0 micromol/L) increased 8-isoprostane levels in VSMC by 4.5-fold (p < 0.05). Compared to the controls, plasma samples from apoEnull mice exhibited elevated levels of 8-isoprostane (40 pg/mL, 3.2-fold increase) and the combined aldehydes HNE and malonaldehyde (1.5 micromol/L, 2.5-fold increase), (p < 0.05, resp). In addition, immunohistochemistry indicated the presence of HNE-protein adducts in atheroscerlotic lesions of apoEnull mice. Thus HNE is present in atherosclerotic tissue at concentrations that are bioactive in vitro. The data further indicate the involvement of the lipid peroxidation product HNE in atherogenesis.

Effects of propafenone on anisotropic conduction properties within the three-dimensional structure of the canine ventricular wall

BACKGROUND

Structural complexities of the intact ventricular wall cause a very complex spread of activation. The effects of regional tissue damage and of antiarrhythmic drugs on directional differences in activation should help to further elucidate intramural conduction patterns.

METHODS AND RESULTS

In 10 healthy dogs and in 5 dogs with subacute anterior wall infarction, 6 parallel rows of 6 needle electrodes with 4 bipolar electrode pairs per needle were inserted into the left anterior ventricular wall. Using a computerized multiplexer-mapping system, the spread of activation in epi-, endo- and midmyocardial muscle layers and in the surviving epicardium, respectively, was reconstructed. Marked differences in conduction velocities relative to fiber orientation were evident in the surviving epicardium of infarcted hearts. Directional differences in conduction velocities, although less pronounced, were still preserved throughout the intact ventricular wall. Epicardial transverse conduction in intact hearts was significantly faster than transverse conduction in infarcted hearts (0.87 +/- 0.11 m/s vs 0.68 +/- 0.1 m/s). In normal hearts, propafenone (2 mg/kg) decreased conduction velocities primarily in longitudinal directions (-27 +/- 10%), but also moderately in transverse directions (-13 +/- 7 %) of all muscle layers, with no significant effect on straight (-4 +/- 8 %), but on oblique transmural conduction (-33 +/- 18 %). In infarcted hearts propafenone decreased conduction particularly in longitudinal direction (-23 +/- 14 %) without affecting conduction transverse to the fiber orientation (+3 +/- 6%).

CONCLUSIONS

Longitudinal intramural shortcircuits reduce directional differences in activation. Transmural infarction results in a loss of alternative intramural pathways, unmasking marked anisotropy in the surviving epicardium. Conduction delay in intramural pathways explains the effects of propafenone on transverse and oblique transmural conduction. Primarily longitudinal conduction delay results in reduced tissue anisotropy.

The neuronal norepinephrine transporter in experimental heart failure: evidence for a posttranscriptional downregulation

An impairment of norepinephrine (NE) re-uptake by the neuronal NE transporter (NET) has been shown to contribute to the increased cardiac net-release of NE in congestive heart failure (CHF). The present study investigated which mechanisms are involved in the impairment of NET. Rats with supracoronary aortic banding characterized by myocardial hypertrophy, elevated left ventricular end diastolic pressures and severe pulmonary congestion were used as an experimental model for CHF. Compared to sham-operated controls, aortic-banded rats had enhanced plasma NE concentrations and decreased cardiac NE stores. In isolated perfused hearts of aortic-banded rats, functional impairment of NET was indicated by a 37% reduction in [(3)H]-NE-uptake. In addition, pharmacological blockade of NET with desipramine led to a markedly attenuated increase in the overflow of endogenous NE from hearts of aortic-banded rats. Determination of cardiac NET protein and of NET mRNA in the left stellate ganglion by [(3)H]-desipramine binding and competitive RT-PCR, respectively, revealed a 41% reduction of binding sites but no difference in gene expression. The density of sympathetic nerve fibers within the heart was unchanged, as shown by glyoxylic acid-induced histofluorescence. In conclusion, as impairment of intracardiac NE re-uptake by a reduction of NET binding sites is neither mediated by a decreased NET gene expression nor by a loss of noradrenergic nerve terminals, a posttranscriptional downregulation of NET per neuron is suggested in CHF.