Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

Does radiofrequency with contact force supersede cryoballoon for atrial fibrillation ablation? A one-year follow-up retrospective study

Introduction

If catheter ablation of atrial fibrillation (AF) is now proved to be a safe and superior alternative to antiarrhythmic drugs for maintenance of sinus rhythm and improvement of symptoms, the best transcatheter technique is still a matter of debate. Radiofrequency (RF) and cryoballoon (CRYO) are the principal technologies sharing the spotlight, and several observational studies and RCT have compared both techniques with conflicting results.

Purpose

Current RF catheters now use contact-force technologies to precisely calibrate the energy delivered to tissue, according to the force applied to adjacent tissue in grams, time of contact in seconds and more recently power delivered in watts. The purpose of our study is to evaluate the contribution of this technology in “real life ” conditions and its hypothetical potential to supersede CRYO for the ablation of AF.

Methods

Design and population. We conducted a single center retrospective study, spreading over two years (1st January 2018–30th December 2019) and enrolling 376 patients that underwent a first ablation procedure in this period.

Endpoints. The primary endpoint was a comparison of the rate of AF recurrence for each technique, twelve months after initial procedure, respecting an initial 90 days blanking period.

Recurrence was defined as documented AF, atrial flutter, atrial tachycardia lasting at least 30 seconds (12-lead ECG, holter or telemetry) or 6 minutes (for atrial high rate episode on pacemaker interrogation), and/or the need of a second ablation procedure.

We evaluated secondary efficacy endpoints including death, procedure duration, fluoroscopy time and hospitalization for cardiovascular causes. Complications in direct relation with the initial procedure were the primary safety endpoint. Finally, we studied the impact of five factors on recurrence: temporal pattern of AF, left atrium dimension, arrhythmia duration, body mass index and CHADS2VA2Sc score.

Results

Patients who underwent RF ablation were similar to those who underwent cryoablation except for chronic kidney disease, type 2 diabetes and coronaropathy which were more prevalent in RF group.

We found a trend toward lower incidence of recurrences in the cryoballoon group, despite not statistically significant. Hospitalizations for cardiovascular causes and deaths from any cause were slightly higher in the radiofrequency group. As expected, time of procedure was lower and fluoroscopy time higher in cryoballoon group. Significant association was detected between recurrence and both left atrium diameter and CHADS2VA2Sc score.

Conclusion

In this retrospective study, albeit using latest generation ablation catheters in the two different technics, we found no significant difference in recurrence of AF between radiofrequency and cryoballoon ablation of AF. Left atrium diameter and higher CHADS2VA2Sc score are two predictors of recurrence, easy to use in daily clinical practice.

Funding Acknowledgement

Type of funding sources: None. Baseline characteristics – endpointsPrimary efficacy end point

Contemporary management of patients with atrial fibrillation in the Netherlands and Belgium: a report from the EORP-AF long-term general registry

BACKGROUND

Contemporary data regarding the characteristics, treatment and outcomes of patients with atrial fibrillation (AF) are needed. We aimed to assess these data and guideline adherence in the EURObservational Research Programme on Atrial Fibrillation (EORP-AF) long-term general registry.

METHODS

We analysed 967 patients from the EORP-AF long-term general registry included in the Netherlands and Belgium from 2013 to 2016. Baseline and 1‑year follow-up data were gathered.

RESULTS

At baseline, 887 patients (92%) received anticoagulant treatment. In 88 (10%) of these patients, no indication for chronic anticoagulant treatment was present. A rhythm intervention was performed or planned in 52 of these patients, meaning that the remaining 36 (41%) were anticoagulated without indication. Forty patients were not anticoagulated, even though they had an indication for chronic anticoagulation. Additionally, 63 of the 371 patients (17%) treated with a non-vitamin K antagonist oral anticoagulant (NOAC) were incorrectly dosed. In total, 50 patients (5%) were overtreated and 89 patients (9%) were undertreated. However, the occurrence of major adverse cardiac and cerebrovascular events (MACCE) was still low with 4.2% (37 patients).

CONCLUSIONS

Overtreatment and undertreatment with anticoagulants are still observable in 14% of this contemporary, West-European AF population. Still, MACCE occurred in only 4% of the patients after 1 year of follow-up.

Incidental detection of myocardial clefts in a patient with acute inferior ST-segment elevation myocardial infarction: a very unusual and potentially ominous association—a case-report

Background

The crescent availability of high-resolution cardiac imaging allows detection of myocardial structural variations. Differentiate these entities from others with different clinical significance can be challenging. Clinicians should be familiar with myocardial clefts to avoid erroneous diagnosis.

Case summary

A 63-year-old smoker man alerted the emergency medical system for sudden chest pain. The electrocardiogram showed Pardee wave in inferior leads. Coronary angiography evidenced a 100% occlusion of right coronary artery that was treated by angioplasty and drug-eluting stent implantation with optimal angiographic result. At ventriculography, two fissure-like protrusion were observed in the inferior wall. Urgent transthoracic echocardiogram (TTE) demonstrated two deep fissures on the mid-inferior wall, contained by a thin sub-epicardial layer, with sub-total obliteration during systole. A diagnosis of myocardial clefts was suspected and after Heart Team discussion, a conservative strategy was proposed. Early cardiac magnetic resonance (CMR) confirmed two myocardial crypts on the mid-inferior wall. Stability of myocardial fissures and absence of left ventricular remodelling was confirmed by TTE, in a 2 years of follow-up period.

Discussion

Myocardial cleft should always be considered in the differential diagnosis of myocardial wall defects. In a patient presenting with an acute myocardial infarction, the main differential diagnosis is pseudoaneurysm. In this setting modified TTE views and meticulous analysis of CMR sequences are recommended to confirm the diagnosis and estimate the risk of myocardial rupture.

Sudden cardiogenic shock mimicking fulminant myocarditis in a surviving teenager affected by severe acute respiratory syndrome coronavirus 2 infection

In the context of the coronavirus disease 2019 pandemic, myocardial injury is a relatively frequent finding. Progression to cardiogenic shock has been rarely described, especially in healthy young patients. The underlying mechanisms are to date controversial. A previously healthy 18-year-old female teenager affected by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) developed fulminant cardiogenic shock requiring a prompt extracorporeal membrane oxygenation support. Cardiac involvement was predominant compared with the pulmonary one. Myocardial biopsies were performed; and in order to clarify the pathophysiology of the acute heart failure, optical and transmission electron microscopy study was realized. Two additional immunohistology techniques were developed in order to (i) detect a SARS-CoV-2 recombinant fusion nucleoprotein by using a specific antibody and (ii) study fractalkine expression induced by activated endothelium because this molecule is well known to be elevated in patients with severe cytokine release syndrome. SARS-CoV-2 genome was not detected in the myocardium. Even if the clinical presentation, laboratory markers, and cardiac imaging techniques strongly suggested fulminant myocarditis, histology and immunohistology were not fully consistent with this diagnosis according to the Dallas criteria. Although rare suspected coronavirus particles were found by transmission electron microscopy in the cardiac endothelium, neither significant immunoreactivity for the viral nucleocapsid protein nor image suggestive of endotheliitis was detected. Intense endothelial immunoreactivity pattern for fractalkine expression was observed. From a clinical point of view, the left ventricular systolic function gradually improved, and the patient survived after a long stay in the intensive care unit. Our observations suggest that a massive cytokine storm induced by SARS-CoV-2 infection was the main cause of the cardiogenic shock, making a direct viral injury pathway very unlikely.

[Case of refractory cardiogenic shock due to venlafaxine overdose : illustration of the support with veno-arterial extracorporeal membrane oxygenation]

Venlafaxine is a widely prescribed antidepressant drug acting as a reuptake inhibitor of serotonin and noradrenaline. An overdose of venlafaxine can cause cardiovascular toxicity and cardiogenic shock can occur. A 32-year-old man ingested 12g of sustained-release venlafaxine in a suicidal attempt and developed within 24h acute heart failure with refractory cardiogenic shock requiring support by ECMO. The blood toxicology showed persistence of high levels of venlafaxine at day 10. The patient fully recovered and showed normal cardiac function at 3-months follow-up.

Immune Cells and Immunosenescence

Aging is associated with progressive loss of physiological integrity, leading to impaired physical and mental functions as well as increased morbidity and mortality. With advancing age, the immune system is no longer able to adequately control autoimmunity, infections, or cancer. The abilities of the elderly to slow down undesirable effects of aging may depend on the genetic background, lifestyle, geographic region, and other presently unknown factors. Although most aspects of the immunity are constantly declining in relation to age, some features are retained, while e.g. the ability to produce high levels of cytokines, response to pathogens by increased inflammation, and imbalanced proteolytic activity are found in the elderly, and might eventually cause harm. In this context, it is important to differentiate between the effect of immunosenescence that is contributing to this decline and adaptations of the immune system that can be quickly reversed if necessary.

[LEFT ATRIAL APPENDAGE CLOSURE IN A PATIENT WITH SYSTEMIC SCLEROSIS]

We report the clinical history of a 69 year-old female who suffered from systemic sclerosis and in whom we performed a percutaneous left atrial appendage closure due to recurrent gastrointestinal bleedings under anticoagulant therapy for chronic atrial fibrillation. We review the impact of scleroderma on the cardiac and digestive systems and discuss the issue of anticoagulation and its alternatives in uncommon clinical situations. We also describe the indications, technical aspects and potential complications of percutaneous left atrial appendage closure.

[CARDIOVASCULAR INVOLVEMENTS IN BEHÇET'S DISEASE: "ANGIO-BEHÇET"]

Behçet's disease is a relapsing, immune-mediated systemic vasculitis that may affect blood vessels of all types and sizes. Nowadays, the etiology remains unclear. In the absence of a biological marker or pathognomonic radiology, the diagnosis is mainly based on clinical manifestations. The cardiovascular involvement, known as "angio-Behçet", is relatively common and affects up to 40% of patients. It typi- cally occurs in a young male, usually during the onset of the disease. In general, immunosuppressive and anticoagulant therapies initiated early are likely to induce a remarkable cli- nical improvement. Nevertheless, prompt recognition of the polymorphous cardiovascular manifestations of the disease is challenging and may be responsible for some considerable delay prior to initiation of adequate therapy. The aim of this article is to describe the spectrum of cardiovascular involve- ments of Behçet's disease in order to optimize detection and therapeutic management.

[A CASE OF FLECAINIDE INTOXICATION]

Flecainide acetate is an antiarrhythmic agent commonly used in clinical practice, in particular, for the treatment of supraventricular tachycardias. We report a rare case of voluntary poisoning by flecainide. The patient was successfully resuscitated.A review of the literature related to this type of intoxication is presented.

[A left intraventricular mass]

We report the case of a 29-years-old male presenting with a large mass inserted at the hypokinetic apex of the left ventricle. Without any early regression under anticoagulant therapy and taking into account recent neurological manifestations, surgical extraction was decided. The mass corresponded to a chronic thrombus lying on a non-transmural myocardial necrosis. This case gives us the opportunity to review all causes of intracardiac masses.

[Clinical case of the month. Spontaneous hematoma and acquired hemophilia]

Acquired haemophilia is a rare disease, 50% of the cases are idiopathic. We report a case admitted in cardiology for spontaneous hematoma. Observation of isolated prolonged activated partial thromboplastin time (aPPT) without anticoagulation treatment and the absence of correction with normal plasma suggested diagnosis. Confirmation of inhibitors to FVIII allowed perfusions of activated prothrombin complex concentrates.

Low occurrence of Clostridium difficile in fecal samples of healthy calves and pigs at slaughter and in minced meat in Switzerland

Clostridium difficile is a cause of diarrhea and colitis in humans. The increase of incidence and severity of C. difficile infections in humans in past years is due, at least in part, to the emergence of more virulent strains (PCR ribotypes 027 and 078). Recent studies describe the occurrence of hypervirulent strains in ground meat products. Therefore, food animals and food need to be assessed for their possible role as vectors of C. difficile to humans. In this pilot study, fecal samples of 204 calves and 165 pigs, as well as 46 minced meat products were investigated to determine the occurrence of C. difficile in farm animals at slaughter and in ground meat products at the retail level in Switzerland. C. difficile was isolated from only one fecal sample of a calf. All samples from pigs and ground meat were negative. Further characterization revealed that the isolated strain harbored genes for toxins A and B as well as binary toxin, and belonged to the ribotype 078. Based on these results, low occurrence of C. difficile in farm animals at slaughter and retail ground meat in Switzerland is postulated. However, further studies are necessary to confirm these preliminary data and to assess future trends.

[Interest of BNP value after cardiac resynchronisation therapy]

Cardiac resynchronisation therapy (CRT) induces, among responders, an early but sustained decrease of BNP levels. The changes of this parameter at 6 months, as well as its relative variations over the same time period, allow identification of the patients susceptible to benefit from CRT. Measurements of BNP levels might offer a useful tool for treatment optimisation in this particularly frail group of patients.

[Cardiac amyloidosis]

We present a case of a 54-year-old female presenting with renal failure and, two years later, heart failure, both due to primary systemic amyloidosis. The case gives us the opportunity to review the litterature on the topic.

Successful percutaneous closure of multiple coronary artery fistulas with coils embolization in two adults

Fistulas between coronary arteries and cardiac cavities or other vascular structures are uncommon findings usually detected early in life. We describe two cases of late transcatheter occlusion of a double coronary artery fistula in adults complaining of incremental dyspnoea.

[Clinical case of the month. Constrictive pericarditis with a macroscopically normal pericardium: apropos of a case]

The diagnosis of constrictive pericarditis is not easy to make. This rare condition can be suggested by clinical, echocardiograohic, hemodynamic, and radiological signs. It must be distinguished from restrictive cardiomyopathy as therapeutic options are radically different. We present an ambiguous case of constrictive pericarditis with macroscopically normal pericardium recognized 10 years after open-chest cardiac surgery: a large pericardiectomy rapidly induced clinical improvement.

Incomplete myocardial rupture following inferior myocardial infarction: a case report

In an era of early and invasive therapeutic approaches, myocardial rupture has become an uncommon complication of myocardial infarction. While septal wall rupture most often leads to devastating haemodynamic consequences, free wall rupture is usually fatal. We report a case of a 48-year-old man in whom an incomplete myocardial rupture located in the inferior part of the interventricular septum was promptly detected during the acute phase of an inferior myocardial infarction treated by early percutaneous coronary angioplasty. A conservative rather than a surgical approach was decided with a favourable short-term outcome.

Endovascular treatment of a coronary artery bypass graft to right ventricle fistula with balloon embolization

Fistula formation between a coronary artery bypass graft and a cardiac cavity is an uncommon finding. We describe a case of transcatheter occlusion of a coronary artery bypass graft to right ventricle fistula in a patient presenting with a subacute inferior myocardial infarction.

Unilateral pulmonary edema caused by paravalvular leakage recognized by bedside transesophageal echocardiography

We describe a case of acute unilateral left pulmonary edema occuring in an old man one year after mitral valve replacement. Transesophageal echocardiography identified a paravalvular leakage with severe mitral regurgitant jet directed to both left pulmonary veins. A prompt surgical closure of the leakage by pericardial patch was decided with rapid clinical and radiological improvement.

Modification of neutrophil function by plasma of rheumatoid arthritis patients treated with infliximab

OBJECTIVE

To examine whether the release of superoxide anions from neutrophils of healthy donors was affected when incubated with plasma from infliximab-treated rheumatoid arthritis (RA) patients.

METHODS

Fifteen consecutive seropositive RA patients were treated with 3mg/kg infliximab on weeks 0, 2, 6, and 14. Disease activity was assessed by DAS28 score and by IL-6 level. Neutrophils from healthy donors were incubated with plasma drawn before each infliximab treatment. PMA-stimulated superoxide release was measured by the ferricytochrome C reduction method.

RESULTS

53% of the patients had a favorable clinical response. IL-6 levels showed a significant decline at week two, with a gradual increase thereafter. Treatment with infliximab did not change the superoxide production. However, when the group was divided retrospectively to responders (DeltaDAS28 > -1.2) and non-responders (DeltaDAS28 < -1.2), two different patterns were seen, although the pre-treatment levels were similar: Among the responders IL-6 remained low at its 2 weeks level till week 14, while in the non responders IL-6 increased 3 times (P < 0.03) from week 2 to 14. The responders showed mild, but continuous, reduction of superoxide release, while in the non-responders it increased significantly from week 2 on.

CONCLUSION

The reduction in IL-6 in RA sera following anti-TNFalpha therapy has little influence on the capacity of these sera to stimulate healthy neutrophils to produce superoxide, suggesting the existence of non-TNFalpha non-IL-6 dependent neutrophil-stimulating mediators in RA sera. The increasing level of IL-6 among the non-responders after initial dramatic decline might represent an escape phenomenon, possibly caused by alternative mediator(s). Clinically, this IL-6 "escape" might be used as a tool for early identification of responders from non-responders.

Prevalence of mechanical dyssynchrony in patients with heart failure and preserved left ventricular function (a report from the Belgian Multicenter Registry on dyssynchrony)

The present study evaluated the prevalence of mechanical inter- and intraventricular dyssynchrony in patients with heart failure and preserved left ventricular (LV) ejection fraction (LVEF). We studied 138 patients with heart failure (age 67+/-11 years; 76% men); 60 patients had preserved LVEF (>40%). Using conventional Doppler echocardiography, an interventricular mechanical delay>or=40 ms was defined as interventricular dyssynchrony. Using pulse-wave tissue Doppler imaging, the time from the beginning of the QRS complex to onset of systolic motion was measured in 4 basal LV segments. A dispersion of >or=60 ms was defined as intraventricular dyssynchrony. The prevalence of inter- and intraventricular dyssynchrony was lower in patients with preserved LVEF than in those with reduced LVEF (17% vs 41%, p<0.01 for interventricular dyssynchrony, 18% vs 36%, p<0.01 for intraventricular dyssynchrony). However, patients with preserved LVEF and a QRS width>or=120 ms had higher values for the parameters for inter- and intraventricular dyssynchrony than patients with a QRS width<120 ms (interventricular mechanical delay 33+/-20 vs 20+/-16 ms, p<0.05; tissue Doppler imaging dispersion 42+/-26 vs 33+/-22 ms, p<0.05). In patients with a QRS width>or=120 ms, the prevalence of inter- and intraventricular dyssynchrony was comparable for patients with preserved and reduced LVEF (42% vs 55%, p=NS for interventricular dyssynchrony and 45% vs 46%, p=NS for intraventricular dyssynchrony). In conclusion, the prevalence of inter- and intraventricular dyssynchrony was low (17% and 18%, respectively) in patients with heart failure and preserved LVEF. However, in the presence of a QRS width of >or=120 ms, this prevalence increased to almost 50%, comparable to that for patients with heart failure and reduced LVEF and a QRS width of >or=120 ms.

[Clinical value of cardiac resynchronization therapy in patients with congestive heart failure]

Besides major progress in the pharmacologic treatment of severe chronic heart failure, cardiac resynchronization therapy (CRT) has developped over the last ten years. We report the follow-up of the 36 first patients with a CRT device implanted from July 2000 to November 2002 at the CHR de la Citadelle Hospital in Liege. After a mean follow up of 6 months, no death was observed. The functional benefit of resynchronization is validated by a significant improvement in the NYHA class, an increase in the walking distance measured by the six minute walk test from 268 +/- 103 to 342 +/- 106 meters (p < 0.004) and by a not significant rise in the VO2 max (from 11.1 +/- 2.8 to 14 +/- 10 ml/kg/min; P=0.1). The quality of life, assessed by the Minnesota-Living-In-CHF score, improves from 49 +/- 20 to 35 +/- 22 after the six month follow-up (P=0.02) The echocardiogram also shows a better left ventricular ejection fraction at six months, from 24 +/- 7% to 31 +/- 7% (P<0.05). Based on a better NYHA functional class, responders (n=24; 71%) and non responders (n=10; 29%) were compared; a correlation between the functional class change and the improvement of the ejection fraction was documented, but not with the reduction in QRS width. Our registry, with the potential pitfalls of a monocentric prospective study, confirms the feasability, safety and efficacy of CRT in severe chrbnic heart failure uncompletely corrected pharmocalogically. It remains however approximately 30% of non responding patients, in whom the current clinical studies should help identify the right criteria to predict and discriminate responders.

Short-term effect of atorvastatin on ischaemic threshold in hypercholesterolaemic patients with stable ischaemic heart disease

OBJECTIVE

Hypercholesterolaemia is associated with a loss of endothelium-dependent vasodilation, which may facilitate the occurrence of myocardial ischaemia in patients with coronary artery disease (CAD). The improvement of endothelial dilator function after 4 to 6 weeks of oral lipid-lowering therapy has been documented. Whether this early restoration of endothelial function by statins translates into anti-ischaemic effects is unknown. This study was designed to determine the effect of 4 weeks' treatment with 80 mg atorvastatin daily on exercise-induced ischaemia in patients with stable ischaemic heart disease (IHD) receiving standard anti-anginal drug therapy.

METHODS AND RESULTS

A total of 41 patients with documented CAD, exercise-induced ischaemia and LDL-cholesterol > 130 mg/dl underwent exercise ECG, angina score and lipid level assessment at baseline, after 4 weeks of placebo treatment, and after 4 weeks of therapy with atorvastatin 80 mg. Primary endpoint was the change in time to 1 mm ST-segment depression (= ischaemic threshold) between placebo and treatment period. Atorvastatin treatment resulted in a 55% reduction of low-density lipoprotein (LDL) cholesterol (from mean of 162 (SD 32) to 72 (20) mg/dl). For a comparable rate-pressure product, the average time to 1 mm ST-segment depression was 295 (112) s at baseline, 314 (149) s after placebo and 301 (131) s after atorvastatin, indicating that the ischaemic threshold was not significantly modulated after 4 weeks of atorvastatin treatment. There was also no significant change in global angina score or in time to maximal ST-segment depression.

CONCLUSIONS

High-dose atorvastatin treatment for 4 weeks drastically reduced LDL-cholesterol. However, the present study did not demonstrate a significant effect on the ischaemic threshold in patients with stable IHD already under treatment with anti-ischaemic agents.

Modulation of polymorphonuclear leukocytes function by incubation with human serum from oxidant-challenged individuals

Polymorphonuclear leukocytes (PMN) from healthy donors were tested for stimulated release of superoxide anions after being incubated with serum of welders and of a group of unexposed individuals. These two groups were further subdivided either according to age or to smoking habits. The experiments showed that stimulated superoxide production from PMN was inhibited (P < 0.05) by serum from young smokers as compared to that of young nonsmokers, both from the unexposed group. Incubation of PMN with serum from elderly nonsmoking individuals decreased superoxide production as compared to incubation with serum from young nonsmoking individuals, both from the unexposed group. A decrease in superoxide production by incubation with serum of welders as compared to that of unexposed individuals was significant only when the comparison was carried out between the young, non-smoking subgroups. These findings suggest that age, smoking, and exposure to oxidants induce appearance in serum of factors that affect the PMN function

[Clinical case of the month. Treatment of obstructive hypertrophic cardiomyopathy by percutaneous septal ablation]

Hypertrophic obstructive cardiomyopathy is a rare pathology characterized by the presence of an interventricular septal hypertrophy leading to an ejectional obstruction of the left ventricular outflow tract. Several therapeutic approaches have been proposed. Besides pharmacological and surgical (septal myomectomy or cardiac pacing) therapies, a more recent therapy is represented by a septal reduction obtained by percutaneous occlusion of the septal coronary branch supplying this myocardial segment. A clinical case leads to a review of the literature.

Therapeutic monitoring of busulfan in pediatric bone marrow transplantation

The aim of this study was to describe busulfan disposition in a pediatric population who underwent bone marrow transplantation (BMT). Busulfan administered dose was 1 mg/kg every 6 h for 4 days. Plasma determinations were performed after the first dosing at 0, 15, 30, 60, 90, 120, 180, 240, 300, and 360 min. A noncompartment analysis model for extravascular absorption was used for the pharmacokinetic analysis. To obtain the area under the concentration-time curve (AUC) within the "therapeutic window" of 1,000-1,200 microM x minutes a busulfan dose adjustment Was performed at the fourth dose. Forty-five busulfan pharmacokinetic analyses were performed in 34 children. Eleven children had their dose adjusted [1.19 +/- 0.14) mg/kg] at the fourth dose and the AUC was monitored at the fifth one. The mean AUC +/- SD after the fifth dose (998.1 +/- 189.2 microM x min) was different (p = .006)from that after the first dose (1 mg/kg) (687.63 +/- 166.43 microM x min). Six children had their first AUC into the "therapeutic window," 17 children had their dose adjusted [1.2 (+/- 0.22) mg/kg], but the "adjusted" AUC was not available. These data suggest that it may be reasonable to recommend a busulfan dose of 1.2 mg/kg to achieve the accepted therapeutic target in children undergoing BMT.

Monitoring of busulfan area under the curve: estimation by a single measurement

Because the busulfan area under the concentration-time curve (AUC) has been correlated with the outcome of bone marrow transplantation (BMT) and the occurrence of veno-occlusive disease after BMT, a rapid determination of AUC is needed to ensure its suitable dosage. The present work describes a method based on combining aliquots from the 10 blood samples collected for an AUC busulfan determination and performing a single determination of the resulting mixture. In 42 patients undergoing a preparative regimen for bone marrow transplantation this combined sample AUC was compared with the regular determined AUC obtained from 10 consecutive samples drawn at various time intervals after dosing. It is apparent that the AUCs calculated by pharmacokinetic analysis using a noncompartmental model package and those obtained by analyzing the sample mixture are very similar ( r = 0.961). The proposed method allows rapid adjustment of the busulfan dose, reducing the number of uncorrected dosages during therapy.

Evaluation of silicone as an endovascular stent membrane: in vivo canine studies

PURPOSE

Comparative evaluation of the biological effects of a silicone-covered stent versus a bare-metal stent, in an animal model.

METHODS

Twelve stent implants were placed in the iliac arteries of six adult dogs. Each animal received one 8-mm x 20-mm silicone-covered stent (Permalume; Boston Scientific Vascular, Watertown, MA, USA), in the right iliac artery and one Wallstent (Boston Scientific Vascular) of the same diameter and length in the left iliac artery, during systemic anticoagulation. Angiography was performed before and after implantations. Animals were then allowed to recover and no platelet suppression was given during a 6-week interval, after which the animals were euthanized. The stented arteries were isolated and pressure-fixed in situ with 10% buffered formalin at a pressure of approximately 100 mmHg for a period of 1 hr. Two of 12 stented specimens were opened lengthwise and the luminal surfaces were photographed. Ten of 12 stented arterial segments were encased in methacrylate, then stained with hematoxylin and eosin. Neointimal thickness was quantified on histologic cross-section, for both bare and covered stents. The mean neointimal thicknesses were compared for significant difference using a student t-test.

RESULTS

All implants were widely patent at 6-week follow-up angiography. Histologic analysis showed bare metal stents covered by a thin uniform lining of neointima composed of smooth muscle cells in a hyaline matrix (mean thickness of 189 +/- 47 microm). Silicone covered stents were devoid of neointima. There was no chronic thrombus or mature endothelium noted anywhere upon the internal silicone surfaces of any of the specimens. There was no foreign body reaction to the silicone cover.

CONCLUSION

Short-term implantation of a silicone-lined Wallstent in canine iliac arteries is well tolerated. Silicone appears to be inert at 6 weeks in this experimental application.

Superoxide anion release by peripheral polymorphonuclear leukocytes in welders

OBJECTIVES

To investigate peripheral blood neutrophil [polymorphonuclear leukocyte (PMN)] function in a group of 23 welders compared with that in an age- and smoking habit-matched non-exposed control group.

METHODS

Stimulated release of superoxide anions from PMN isolated from peripheral blood of welders and of a matched group was carried out.

RESULTS

The stimulated release of superoxide anions in PMNs from welders was significantly lower (P = 0.021) than that of a control group. Smokers and older workers had a lower function of PMNs than non-smokers and younger workers.

CONCLUSIONS

PMN function of welders is lower than that of controls. This effect might indicate reduced immunological defences in oxidant-exposed individuals. It is possible that PMN function might serve as a biological marker of exposure in the periodic health surveillance of welders.

[Clinical case of the month. Biventricular stimulation, a new adjuvant therapy in the treatment of congestive heart failure]

The pharmacological treatment of congestive heart failure has improved its morbidity and mortality. Nevertheless, many patients remain disabled in spite of optimal treatment. The availability of alternative therapies such as heart transplantation or cardiomyoplasty is limited. Newer devices are awaited. Biventricular pacing is a potential option to improve the homogeneity of contraction and the overall mechanical performance without myocardial oxygen consumption increase. This approach has proved acute hemodynamic and functional benefits but has to demonstrate a favourable influence on long term morbidity and mortality.

Determination of urinary hippuric acid in toluene abuse

BACKGROUND

Volatile substance abuse is practiced mainly by adolescents and young adults. Its effects are central nervous system excitation followed by central nervous system depression, at times accompanied by seizures. It may cause sudden death as a result of ventricular arrhythmias, reflex vagal inhibition, respiratory depression, and anoxia. Chronic toxicity may involve the nervous system, heart, kidney, and liver. Toluene-based adhesives are among the most commonly inhaled substances.

CASE REPORT

A 14-year-old female presented with confusion, hallucinations, and intermittent laughing and crying after having inhaled contact glue several times daily in the course of 5 days. Her condition improved within 3 h. Urinary hippuric acid was 93.9 g/g creatinine indicating heavy toluene exposure (biological exposure index, BEI, is 1.6 g/g creatinine).

CONCLUSION

In this patient, urinary hippuric acid was a biomarker for her toluene abuse.

Exercise versus dobutamine-induced ST elevation in the infarct-related electrocardiographic leads: clinical significance and correlation with functional recovery

BACKGROUND

The clinical significance of stress-induced ST elevation early after acute myocardial infarction and its relation to functional recovery remain controversial. The aims of this study were (1) to determine the incidence of ST elevation during dobutamine and exercise tests and (2) to assess the relative accuracy of exercise and dobutamine ST elevation for predicting functional recovery after acute myocardial infarction.

METHODS AND RESULTS

We investigated 52 patients who underwent supine exercise (from 25 W to maximal charge) and dobutamine (from 5 to 40 microg/kg per minute and up to 1 mg atropine) stress electrocardiography in the same position. ST elevation was defined as new or worsening at >1 mm, 80 ms after J point. Echocardiography and quantitative angiography were available in all patients before hospital discharge. The follow-up resting echocardiogram was recorded 30 +/- 6 days after the acute event. ST elevation developed during 30 (58%) dobutamine and 24 (46%) exercise tests. The sum of ST elevation was higher during dobutamine testing (7.7 +/- 3.8 mm) than during exercise (5.5 +/- 2.5 mm) (P =.03). A low peak creatine kinase level was the single independent predictor of dobutamine-induced ST elevation. Functional improvement occurred in 35 patients. Two independent predictors of functional recovery were selected from multivariate analysis: dobutamine ST elevation (chi(2) = 9.1; P =.0026) and low peak creatine kinase level (chi(2) = 5.1; P =.025). When dobutamine ST elevation was not included in multivariate analysis, exercise-induced ST elevation emerged as an independent predictor of functional recovery (chi(2) = 5.0; P =.023). Significant linear correlation was found between the sum of ST elevation at peak dobutamine stress and the extent of functional recovery (r = 0.87; P <.0001). In contrast, no correlation was observed with exercise ST elevation (r = 0.06; P = not significant).

CONCLUSIONS

Stress-induced ST elevation is an ancillary sign of viable myocardium that can recover. The sum of ST elevation at peak dobutamine stress correlates with the extent of functional recovery.

Ehlers-Danlos syndrome mimicking mesenteric vasculitis: therapy, then diagnosis

The etiology of acute intraabdominal bleeding is often unclear at the time emergent arteriography is performed. During localization and embolization, the arteriogram may suggest the diagnosis of vasculitis. However, controlling the bleeding remains the priority. Connective tissue diseases such as Ehlers-Danlos syndrome (EDS) may also cause bleeding and mimic vasculitis and must be included in the differential diagnosis. We present such a case in which the initial findings were misleading.