[Practical considerations for the treatment of acute rhythm disturbances. Report of Belgium Interdisciplinary Working Group on Acute Cardiology]

Acute arrhythmia is a condition covering a wide variety of rhythm disturbances. The aim of the article is to give practical recommendations for the approach and the treatment of the patient presenting with an acute arrhythmia. We discuss bradycardia and tachycardia. Tachycardias are divided into the small QRS complex tachycardias and the wide QRS complex tachycardias. Another important distinction with immediate therapeutic consequences is that between the hemodynamic stable and unstable patient. Flowcharts with diagnostic means and therapeutic schemes are added and a table with practical considerations for electrical cardioversion.

Reverse cholesterol transport in mice expressing simian cholesteryl ester transfer protein

The role of cholesteryl ester transfer protein (CETP) in atherogenesis remains ambiguous, as both pro and antiatherogenic effects have been described. Expression of CETP increases HDL-cholesteryl ester turnover, but there is no direct evidence whether CETP mobilizes cholesterol in vivo. The rate of cholesterol removal injected into a leg muscle as cationized low density lipoprotein (cat-LDL) was compared in CETP transgenic and control mice. Four days after injection the exogenous cholesterol mass retained in muscle was 65% in CETP transgenic and 70% of injected dose in controls; it decreased to 52-54% by day 8 and negligible amounts remained on day 28. The cat-LDL was labeled with either 3H-cholesterol oleate (3H-CE) or 3H-cholesteryl oleoyl ether (3H-COE), a nonhydrolyzable analog of 3H-CE. After injection of 3H-CE cat-LDL, clearance of 3H-cholesterol had a t(1/2) of 4 days between day 4 and 8 but there was little loss of 3H-COE between day 4 and 51. Liver radioactivity on day 4 was 1.7% in controls and 3.4% in CETP transgenics; it was 2.8 and 4.6%, respectively, on day 8. 3H-COE in liver accounted for 60% of label in CETP transgenics. In conclusion, high levels of plasma CETP in mice do not enhance reverse cholesterol transport in vivo but may act on extracellularly located cholesteryl ester.

Effect of atherogenic diet on reverse cholesterol transport in vivo in atherosclerosis susceptible (C57BL/6) and resistant (C3H) mice

Mice susceptible (C57BL/6) or resistant (C3H) to atherosclerosis induced by a high cholesterol-cholate containing diet (A-diet) were used to study reverse cholesterol transport (RCT) in vivo as measured by loss of cholesterol from a depot created by injection of cationized LDL into the rectus femoris muscle. Plasma total and HDL-cholesterol (HDL-C), total and HDL phospholipid (HDL-PL) levels in chow fed C3H male and female mice were higher than in C57BL/6 mice. After one month on A-diet, plasma cholesterol more than doubled in both strains and genders. The decrease in HDL-C and HDL-PL was twice as great in C57BL/6 as in C3H female mice, while in male C3H mice there was no decrease. The loss of exogenous cholesterol mass (ECM) after injection of cationized LDL was more rapid in C3H than in C57BL/6 mice. In chow fed mice, ECM retained in muscle on day 12 was 37% in C57BL/6 and 20% in C3H females; in males it was 39% and 18% in C57BL/6 and C3H, respectively. On A-diet, 76% were retained in C57BL/6 and 28% in C3H females; these values were 59% and 28% in C57BL/6 and C3H males. Thus, the slow clearance of ECM (which represents RCT) in C57BL/6 mice on A-diet, that could be related to a marked decrease of HDL-PL, might contribute towards their susceptibility to atherosclerosis.

Coronary artery dissection during pregnancy and the postpartum period: two case reports and review of literature

Spontaneous coronary dissection is a rare event occurring particularly in women during the peripartum and postpartum period. Two cases related to the early postpartum period with a successful outcome are described, together with a comprehensive review of all the previously published cases. Diagnostic and therapeutic considerations of this unique clinical entity are discussed and reviewed.

Coronary artery dissection during pregnancy and the postpartum period: two case reports and review of literature

Spontaneous coronary dissection is a rare event occurring particularly in women during the peripartum and postpartum period. Two cases related to the early postpartum period with a successful outcome are described, together with a comprehensive review of all the previously published cases. Diagnostic and therapeutic considerations of this unique clinical entity are discussed and reviewed.

Macrophage cholesterol metabolism, apolipoprotein E, and scavenger receptor AI/II mRNA in atherosclerosis-susceptible and -resistant mice

Female mice known to be susceptible (C57BL) and resistant (C3H and BALB/c) to diet-induced atherosclerosis were studied. Feeding of a cholate-containing atherogenic diet for 1 month resulted in an increase in plasma total cholesterol, little or no change in total phospholipids and high density lipoprotein (HDL) cholesterol, and a fall in HDL phospholipid, which was most pronounced in the C57BL strain. In elicited macrophages, cholesterol esterification was lower with acetylated low density lipoprotein (acLDL) and higher with beta-very low density lipoprotein (beta-VLDL) in C57BL than in C3H or BALB/C strains. In resident macrophages, acLDL enhanced cholesterol esterification more than did rabbit beta-VLDL. With acLDL, more apolipoprotein E (apoE) was recovered in all macrophage cultures. In macrophages from chow-fed mice, most apoE was in the medium, whereas in mice fed an atherogenic diet, half of the apoE was in the cells. ApoE protein was highest in macrophages from BALB/c mice fed an atherogenic diet; an increase in apoE mRNA occurred in BALB/c and C3H macrophages. Scavenger receptor AI/II mRNA was significantly higher in macrophages from atherosclerosis-resistant mice. Thus, higher HDL phospholipid and plasma apoE levels (reported by others), together with high macrophage scavenger receptor AI/II mRNA, could inhibit accretion of cholesterol in the vessel wall in the 2 resistant strains.

Clearance of cationized LDL cholesterol from a muscle depot is not enhanced in human apolipoprotein A-IV transgenic mice

Human apolipoprotein A-IV (apoA-IV) transgenic mice fed an atherogenic diet were shown previously to develop less atherosclerosis than control mice. The question arose whether the antiatherogenic effect of human apoA-IV is due to enhancement of reverse cholesterol transport despite no increase in plasma high-density lipoprotein (HDL) cholesterol. We studied male and female mice overexpressing human apoA-IV and their wild-type (WT) controls, all of which were fed a chow diet. Plasma total and HDL cholesterol and total phospholipids were not increased in the transgenic mice, and regression analysis showed no correlation between plasma levels of cholesterol or phospholipids and plasma human apoA-IV. To study reverse cholesterol transport in vivo, the disappearance of cholesterol from a depot of [(3)H]cholesterol-labeled cationized low-density lipoprotein injected into the rectus femoris muscle was compared in high expressers of human apoA-IV and WT controls. The loss of radioactivity and the diminution of the exogenous cholesterol mass were determined on days 8 and 12 after injection. No enhanced loss of radioactivity or cholesterol mass was seen in the transgenic mice even at levels of 2500 mg/dL of human apoA-IV. In some instances, there was even slower loss of exogenous cholesterol (radioactivity and mass) in the transgenic mice. Although [(3)H]cholesterol efflux from cultured human skin fibroblasts and mouse peritoneal macrophages was only approximately 30% higher in the presence of sera from high expressers of human apoA-IV, addition of phosphatidylcholine liposomes enhanced the efflux in both groups to the same extent. Another paradoxical finding was that the cholesterol esterification rate in plasma was 34% to 36% lower in human apoA-IV mice than in WT controls. In conclusion, even though apoA-IV was found previously to be atheroprotective under hypercholesterolemic conditions, high plasma levels of human apoA-IV did not enhance cholesterol mobilization in vivo in normocholesterolemic mice.

Antigen-induced unresponsiveness results in altered T cell signaling

Pretransplant exposure to allogeneic lymphocytes can result in donor-specific unresponsiveness and prolonged allograft survival. Intracellular signaling events have been described in anergic T cell clones, but the biochemical events underlying in vivo induced unresponsiveness have not been studied in detail. We employed a TCR transgenic mouse, bearing the 2C TCR, providing adequate numbers of homogenous peripheral T cells to study biochemical aspects of T cell unresponsiveness in vivo. 2C mice exposed to semiallogeneic lymphocytes (H-2b x H-2d) experienced prolonged H-2d cardiac allograft survival, and cells from these mice did not proliferate or make IL-2 in response to alloantigen (H-2d). Importantly, there were marked differences in TCR-associated tyrosine phosphorylation activation patterns. The targets for the unresponsive state appear to be diminished Lck activation and absent ZAP-70 and LAT (linker for activation of T cells) phosphorylation. Our study demonstrates that Ag-induced tolerance in vivo is accompanied by altered early TCR-mediated signaling events.

High levels of human apolipoprotein A-I and high density lipoproteins in transgenic mice do not enhance efflux of cholesterol from a depot of injected lipoproteins. Relevance to regression of atherosclerosis?

The role of high density lipoprotein (HDL) and apolipoprotein A-I (apo A-I)in promoting cholesterol efflux from cultured cells and attenuation of development of atherosclerosis in transgenic (tg) animals has been well documented. The aim of the present study was to determine whether high levels of human (h) apo A-I will enhance cholesterol removal in vivo. h apo A-I in sera of tg mice was 429 +/- 18 and 308 +/- 10 mg/dl in male and female mice, the ratio of phospholipid (PL) to apo A-I was 0.94 in tg and 2.4 and 1.9 in male and female controls, taking mouse apo A-I as 100 mg/dl. The removal of lipoprotein cholesterol injected in the form of cationized low density lipoprotein (cat-LDL) into the rectus femoris muscle of h apo A-I tg is compared with control mice. After injection of cat-LDL labeled with [3H]cholesterol, the labeled cholesterol was cleared from the depot with a t 1/2 of about 4 days in both control and tg mice. The clearance of the exogenous cholesterol mass was initially much slower, it approached the t 1/2 of about 4 days between day 8 and 14 but there was no difference between tg and control mice. Cholesterol efflux from cultured macrophages exposed to media containing up to 10% serum was 56% higher with serum from tg mice than controls. In conclusion, the efflux of cholesterol from a localized depot of cat-LDL was not enhanced in h apo A-I tg mice. It appears, therefore, that while an increase above physiological levels of apo A-I or plasma HDL does play a pivotal role in the prevention of initiation and progression of early stages of atherosclerosis, the effectiveness of such an increase for the regression stage remains still to be demonstrated.

Thymic microenvironments, 3-D versus 2-D?

Lympho-stromal interactions in the thymus crucially de- termine the fate of developing T cells. Epithelial cells, inter- digitating reticular cells, macrophages and fibroblasts all play a role in the shaping of the T cell repertoire. Recently published evidence shows that lympho-stromal interaction acts bi-directional. Developing T cell themselves, at different stages of differentiation, control the microarchitecture of thymic microenvironments, a phenomenon designated as 'crosstalk'. This paper reviews experiments showing that developing T cells crosstalk to different thymic epithelial cells in a stepwise fashion. In this way, correctly organized thymic microenvironments guarantee normal thymopoiesis.

Dexamethasone impairs cholesterol egress from a localized lipoprotein depot in vivo

Plasma high density lipoproteins play a central role in the prevention and regression of atherosclerosis, as they are known to promote egress of cholesterol from cells. Glucocorticoids increase plasma HDL, but enhance esterification of cholesterol in macrophages in vitro. A novel model to measure cholesterol egress from a well defined depot in vivo was used currently to study the effect of dexamethasone on reverse cholesterol transport. Cationized LDL (cat LDL) (200 microg cholesterol) was injected into the rectus femoris muscle of mice and the egress of cholesterol was studied as a function of time. Daily subcutaneous injection of dexamethasone (1.25 microg) raised plasma HDL levels by 40-80%. In mice injected with cat LDL labeled with 3H-cholesterol, daily treatment with dexamethasone slowed the loss of labeled cholesterol from the depot. With dexamethasone, there was no removal of the mass of lipoprotein cholesterol up to 14 days after injection of cat LDL, while in the controls 75% of the exogenous cholesterol mass had been cleared from the depot. When the cat LDL had been labeled with 3H-cholesteryl ester (3H-CE), apparent hydrolysis of 3H-CE amounted to 46, 75 and 97% in controls, but only to 20, 48 and 65% in dexamethasone treated mice on days 4, 8 and 14, respectively. In addition, dexamethasone stimulated cholesterol re-esterification as evidenced by recovery of 80% of the retained cholesterol mass as CE. In experiments with cultured macrophages exposed to modified LDL, dexamethasone increased the amount of labeled cholesteryl ester by 50-75% as compared to controls. Histological examination of the rectus femoris muscle after injection of cat LDL showed that in dexamethasone treated mice cellular infiltration was sparser on day 4, but not on day 8, and persisted longer than in controls. In conclusion, dexamethasone treatment impeded cholesterol egress from a lipoprotein depot by: a) reduction of early inflow of mononuclear cells; b) partial inhibition of cholesteryl ester hydrolysis, and c) enhancement of cholesterol esterification. The latter effect did not permit cholesterol egress from the injected site even in the presence of high plasma HDL in dexamethasone treated mice.

Delayed loss of cholesterol from a localized lipoprotein depot in apolipoprotein A-I-deficient mice

The anti-atherogenic role of high density lipoprotein is well known even though the mechanism has not been established. In this study, we have used a novel model system to test whether removal of lipoprotein cholesterol from a localized depot will be affected by apolipoprotein A-I (apo A-I) deficiency. We compared the egress of cholesterol injected in the form of cationized low density lipoprotein into the rectus femoris muscle of apo A-I K-O and control mice. When the injected lipoprotein had been labeled with [3H]cholesterol, the t1/2 of labeled cholesterol loss from the muscle was about 4 days in controls and more than 7 days in apo A-I K-O mice. The loss of cholesterol mass had an initial slow (about 4 days) and a later more rapid component; after day 4, the disappearance curves for apo A-I K-O and controls began to diverge, and by day 7, the loss of injected cholesterol was significantly slower in apo A-I K-O than in controls. The injected lipoprotein cholesterol is about 70% in esterified form and undergoes hydrolysis, which by day 4 was similar in control and apo A-I K-O mice. The efflux potential of serum from control and apo A-I K-O mice was studied using media containing 2% native or delipidated serum. A significantly lower efflux of [3H]cholesterol from macrophages was found with native and delipidated serum from apo A-I K-O mice. In conclusion, these findings show that lack of apo A-I results in a delay in cholesterol loss from a localized depot in vivo and from macrophages in culture. These results provide support for the thesis that anti-atherogenicity of high density lipoprotein is related in part to its role in cholesterol removal.

Cholesterol efflux in vivo from a depot of cationized LDL injected into a thigh muscle of small rodents

We have developed a model system to measure quantitatively removal of cholesterol from a well-defined depot in vivo. To that end, lipoproteins were injected into the rectus femoris muscle of small rodents, using a 25 microliters Hamilton syringe and a 27-gauge needle. In most experiments, the injected volume was 10 microliters containing 200 micrograms of cholesterol. The lipoproteins tested were native or modified LDL labeled with trace amounts of [3H]free cholesterol ([3H]FC). The amount of label or of cholesterol mass recovered at various time intervals after injection was normalized to that found after 10 min (designated time 0). In mice, the highest recovery of the [3H]cholesterol 24 h after injection was found with cationized LDL, and ranged between 78% and 84%, whereas retention of native LDL did not exceed 24%. Based on results of 9 experiments with cationized LDL, the loss of [3H]FC was mono-exponential between 1 and 14 days and the t1/2 was about 4 days. The disappearance curve of cholesterol mass showed an initial slow and a later more rapid component, the latter with a t1/2 of 4 days. The initial lag is most probably due to the presence of cholesteryl ester, which needs to be hydrolyzed prior to egress. This assumption was verified by injection of cat-LDL labeled with [3H]cholesteryl oleate and finding a similar lag as well as evidence of [3H]cholesteryl ester hydrolysis. Histological examination of the injected muscle 1-4 days after injection of cat LDL showed infiltration with mononuclear cells in an area limited to the site of injection. The presently described model system, which mimics to some extent events occurring during atherogenesis, permits quantitative evaluation of egress of deposited cholesterol and may allow to study the role of HDL in such a process.

Scavenger receptor activity and expression of apolipoprotein E mRNA in monocyte-derived macrophages of young and old healthy men

The aim of this study was to compare some aspects of lipid metabolism in monocyte-derived macrophages isolated from young males, aged 18-24 years, and old males, aged 74-90 years, who were found healthy in accordance with the Senieur protocol. The parameters tested were metabolism of 125I-acetylated low-density lipoproteins (LDL) and oxidized LDL, incorporation of [3H]cholesterol into cholesteryl ester and expression of apolipoprotein E (apo E) mRNA. Cell association and degradation of 125I-acetylated LDL by macrophages of old and young subjects, respectively, was 15,978 +/- 2492 and 9300 +/- 1416 ng/mg cell protein per 24 h. Incorporation of [3H]cholesterol into cellular [3H]cholesteryl ester in the presence of acetylated LDL in cells isolated from old subjects was twice that in cells from young subjects. The macrophages from both age groups metabolized less 125I-oxidized LDL than 125I-acetylated LDL. Cell association and degradation of 125I-oxidized LDL in cells from old and young subjects, respectively, was 6779 +/- 1398 and 3219 +/- 643 ng/mg cell protein per 24 h. Expression of apo E mRNA was determined by reverse transcriptase polymerase chain reaction. In the basal state, it was 5.8 +/- 0.4 and 2.4 +/- 0.2 photo-stimulated luminescence (PSL) units in cells from the old and young subjects, respectively, and increased after exposure to acetylated LDL. In conclusion, these findings suggest that a combination of higher scavenger receptor activity and increased expression of apo E mRNA in macrophages could contribute to (a) enhanced metabolism of modified LDL and (b) more efficient removal of cholesterol from arteries, thus leading to healthy old age.

Relative resistance of the hamster to aortic atherosclerosis in spite of prolonged vitamin E deficiency and dietary hypercholesterolemia. Putative effect of increased HDL?

Male golden hamsters were rendered hypercholesterolemic by feeding diets enriched with cholesterol and fat. In the first series of experiments, 5% butter and 1% cholesterol were added to a chow diet and plasma cholesterol levels were maintained at 350-390 mg/dl over the entire experimental period. Groups of hamsters and their age controls consuming the chow diet, were killed after 7, 15 and 20 months when the aorta was examined for atherosclerosis by determination of cholesterol mass. In the controls, aortic total cholesterol (TC) increased with age by 28% and esterified cholesterol increased to 11% of TC. In the hypercholesterolemic animals aortic TC was only 28% higher than in the controls and cholesteryl ester was also 11.5% of TC. In the second series, one group of hamsters were fed a semi-purified diet deficient in vitamin E, containing 1% cholesterol and 10% lard; a second group received the same diet, but supplemented with vitamin E. Controls consumed local chow. After 7 months on the vitamin E deficient diet plasma alpha-tocopherol was 0.05 mg/l, in those supplemented with vitamin E it was 20 mg/l, while in the controls it was 3.3 mg/l. Plasma thiobarbituric acid reactive substances (TBARS) were higher in the vitamin E deficient group and there was a greater propensity of lipoproteins (d < 1.063 g/ml) to peroxidation in vitro than in the vitamin E supplemented group. Plasma cholesterol was 366 mg/dl in the vitamin E deficient, 336 mg/dl in the vitamin E supplemented group, and 64 mg/dl in controls. Aortic cholesterol was 79.1 in vitamin E supplemented and 84.4 micrograms/10 mg dry weight in vitamin E deficient hamsters. In both series of experiments, HDL amounted to 36-41% of plasma TC in the hypercholesterolemic animals and 59-62% in the controls.

IN CONCLUSION

the hamster appears to be quite resistant to atherosclerosis in face of sustained hypercholesterolemia, even in the presence of increased peroxidative stress caused by vitamin E deficiency. This relative resistance could be related to commensurate increase in plasma HDL which was observed in both series of experiments. Since vitamin E deficiency did not enhance aortic cholesteryl ester deposition, the protective effect of HDL seems to be related to its role in reverse cholesterol transport, rather than in prevention of peroxidation.

Effects of interactions of apolipoprotein A-II with apolipoproteins A-I or A-IV on [3H]cholesterol efflux and uptake in cell culture

Conflicting evidence has accumulated with years regarding the putative negative effect of apolipoprotein A-II on apo A-I mediated cholesterol efflux. In this study, this question was reexamined and in addition to the interaction of apo A-II with apo A-I, its possible effect on apo E and apo A-IV was investigated as well. Free cholesterol (FC) donors were the main components of atheroma, namely, mouse peritoneal macrophages (MP), bovine aortic smooth muscle (SMC) and fibroblasts labeled with [3H]FC. Acceptors of FC were dioleoylphosphatidylcholine (DOPC) liposomes containing apo A-I, rh-apo A-IV or rh-apo E alone or together with apo A-II. When [3H]FC labeled MP were incubated for 2 or 4 h with equimolar concentrations of apo A-I, A-II, A-IV or E, the lowest [3H]cholesterol efflux occurred with apo A-II. Exposure of [3H]FC MP to liposomes containing apo A-I/A-II at 1:2 M/M (keeping the total protein concentration at 50 micrograms/ml), resulted in a lower [3H]FC efflux as compared to apo A-I alone. However, when apo A-I or apo A-IV protein concentration was kept constant and supplemented with apo A-II, a lower [3H]FC efflux was found only at 1:3 M/M of apo A-I/A-II. Apo A-II added to apo E had no effect on FC efflux. With aortic SMC and fibroblasts, no inhibitory effect of addition of apo A-II to apo A-I or apo A-IV on cholesterol efflux was seen at apo A-I/A-II of 1:1 or 1:2 M/M. The uptake of macrophage derived [3H]FC by SMC or HepG2 cells was studied using the serum-free efflux media, containing PC liposomes + apolipoproteins, from 3H-labeled macrophages. The cellular uptake of [3H]FC was higher when apo A-II had been added to apo A-I or apo A-IV than when the apolipoproteins were added alone. In conclusion, apo A-II was found to be less effective in cholesterol efflux and to interfere with the action of A-I only when the cholesterol donors were macrophages and when the relative amount of apo A-I to apo A-II was low. This was not the case when SMC or fibroblasts served as cholesterol donors. In the presence of apo A-II, enhanced [3H]cholesterol delivery to cells was seen which could contribute to the proatherogenic activity of apo A-II.

Murine macrophages secrete factors that enhance uptake of non-lipoprotein [3H]cholesteryl ester by aortic smooth muscle cells

We have recently demonstrated that macrophage conditioned medium (MP medium) and beta VLDL enhance cholesterol esterification in cultured aortic smooth muscle cells by LDL receptor mediated and other pathways (Stein, O. et al. (1993) Arteroscl. Thromb. 13, 1350-1358). In view of the presence of extracellular non-lipoprotein cholesteryl ester (in the form of lipid droplets) in the atheroma, the effect of MP medium on the cellular uptake of liposomal cholesteryl linoleyl ether (CLE) or cholesteryl ester (CE) was studied. After 4 h incubation in MP medium, the uptake of liposomal [3H]CLE was up to 10-fold higher than in the presence of control medium of the same composition but not conditioned with macrophages (DV medium). Similar results were seen also with HSF derived from LDL receptor negative donors. The MP medium-stimulated uptake of liposomal [3H]CE resulted also in hydrolysis of 70-90% of the labeled compound, indicating that the [3H]CE was intracellular. While the MP medium effect on liposomal [3H]CLE uptake was evident after 4 h, its effect on [3H]cholesterol esterification by SMC in the presence of beta VLDL could be demonstrated only after 24 h. Addition of apoE to MP medium resulted in a small (30-40%) increase in the uptake of liposomal [3H]CLE; however, it was augmented more than 4-fold when apoE was added to DV medium. The MP medium effect on the uptake of liposomal [3H]CLE was interfered with by heparin, anti-LPL antibody or heparinase, while these treatments did not affect [3H]cholesterol esterification in the presence of beta VLDL. These results suggest that the interaction between SMC and two potential sources of lipids in atheroma, i.e., lipoproteins and non-lipoprotein lipid droplets, could be governed by different components of the MP medium. In the case of the lipid droplets, as modeled here in the form of liposomes, macrophage-derived lipoprotein lipase could play a major role in cholesteryl ester transfer into SMC.

Macrophage-conditioned medium and beta-VLDLs enhance cholesterol esterification in SMCs and HSFs by LDL receptor-mediated and other pathways

Thioglycolate-elicited mouse peritoneal macrophages were incubated for 24 hours in serum-free Dulbecco-Vogt medium containing 0.5% fatty acid-poor bovine serum albumin. This conditioned medium, designated MP medium, was used for experiments with bovine aortic smooth muscle cells (SMCs) or human skin fibroblasts (HSFs). Dulbecco-Vogt medium of the same albumin content but without macrophages served as a control medium. In SMCs labeled from plating the [3H]cholesterol and incubated with hypercholesterolemic rabbit beta-very-low-density lipoprotein (beta-VLDL) in Dulbecco-Vogt medium for 24 hours, there was an increase in cellular [3H]cholesteryl ester (CE) content compared with cells incubated without lipoprotein. When MP medium was used for the incubation of SMCs with beta-VLDL, cellular [3H]cholesteryl ester content increased threefold compared with cells incubated with Dulbecco-Vogt medium. A smaller increase in cholesterol esterification in the presence of MP medium was also encountered with low-density lipoprotein (LDL). The MP medium-induced increase in [3H]cholesterol esterification was not evident up to 6 hours of incubation. Similar results were also obtained with HSFs. The increase in [3H]cholesterol esterification with MP medium in the presence of beta-VLDL was also elicited in cells obtained from LDL receptor-negative donors with familial hypercholesterolemia (FH-HSF), even though in these cells significantly less [3H]cholesteryl ester was formed in the presence of beta-VLDL. MP medium contains numerous agents that could be responsible for the increase in cellular [3H]cholesteryl ester induced by lipoproteins. The first considered was lipoprotein lipase, but lack of inhibition of the MP medium effect by antiserum to lipoprotein lipase did not support this possibility.(ABSTRACT TRUNCATED AT 250 WORDS)

Coronary atherectomy versus angioplasty: the CAVA Study

Directional coronary atherectomy was developed with the hope that it would lower the risk of acute closure and restenosis by leaving a larger smoother lumen and fewer dissections than angioplasty. To evaluate this hypothesis, we compared the clinical and angiographic results of directional coronary atherectomy with those of percutaneous transluminal coronary angioplasty in well-matched groups. We studied 126 consecutive atherectomies and 127 angioplasties performed on similar lesions. Procedural results were evaluated with regard to dissections, complications, acute closure, and residual stenosis. Each patient's clinical course was followed, and each patient was contacted at 6 months for evaluation of recurrent angina, need for repeat catheterization, and angiographic rate of restenosis. Baseline clinical and angiographic characteristics of the two groups were well matched and met the criteria established as being appropriate for atherectomy. The angiographic success rate was 98% after angioplasty and 99% after atherectomy. There were fewer dissections after atherectomy (13%) compared with the number after angioplasty (22%; p = 0.03). Residual stenosis was 8.3 +/- 9% after atherectomy compared with 15 +/- 12% after angioplasty (p = 0.0001). However, there were more complications after atherectomy (p = 0.03). There was no significant difference between the two groups in the recurrence rate of angina or in the angiographic restenosis rate at 6 months. It was concluded that when lesion characteristics and vessel size are appropriate for atherectomy, the procedural success rate of either atherectomy or angioplasty is extremely high. Although atherectomy leads to a larger residual lumen and fewer dissections, the complication rate after atherectomy is higher than that after angioplasty. There is a trend toward more occlusions after atherectomy.(ABSTRACT TRUNCATED AT 250 WORDS)

Can lipoprotein lipase be the culprit in cholesteryl ester accretion in smooth muscle cells in atheroma?

Bovine aortic smooth muscle cells and human skin fibroblasts were incubated with beta-very low density lipoprotein (beta VLDL) isolated from cholesterol-fed rabbits and labeled with [3H]cholesteryl oleate. Addition of lipoprotein lipase resulted in a 3.2-4.8-fold increase in cell associated radioactivity of which 45-61% was in free cholesterol, i.e., derived after intracellular hydrolysis. After exposure of smooth muscle cells to beta VLDL for up to 9 days and 60 min sodium heparin wash at 4 degrees C to remove extracellular surface bound lipoprotein, cellular cholesterol increase was 2 micrograms in controls and in the presence of lipoprotein lipase (LPL) it was tenfold higher. Addition of [3H]cholesteryl ester labeled beta VLDL during the last 48 h of incubation showed that 30-40% of total cellular label was in free cholesterol. This value represents the minimal cellular uptake of the added lipoprotein cholesteryl ester. Addition of recombinant apolipoprotein (apo) E to smooth muscle cells incubated with beta VLDL and [3H]oleate induced no further increase in [3H]cholesteryl oleate. We propose that following LPL-mediated binding of beta VLDL to heparan sulphate, this complex either undergoes endocytosis, or translocation of cholesteryl ester into the smooth muscle cells (SMC) occurs without endocytosis of the entire particle. The present results indicate that in the aortic wall macrophage-derived lipoprotein lipase could play a role in cholesteryl ester accretion in smooth muscle cells during atherogenesis.

Persistence of increased cholesteryl ester in human skin fibroblasts is caused by residual exogenous sphingomyelinase and is reversed by phospholipid liposomes

Human skin fibroblasts (HSF) were exposed to sphingomyelinase 50 or 5 mU/ml for 60 min, washed with 5 mM EDTA or 20% serum and with phosphate-buffered saline, and postincubated for 24 h in the presence of [14C]16:0 sphingomyelin (SP) liposomes. The recovery of up to 48% of label in the medium in ceramide provided evidence of persistence of sphingomyelinase activity. The rate of hydrolysis of [14C]16:0 SP remained the same irrespective of whether the liposomes were added immediately after the wash, or 3 or 6 h thereafter. In HSF labeled with [3H]cholesterol exposure to 50 mU/ml of sphingomyelinase for 60 min resulted in an increase in labeled cholesteryl ester (CE) at 6 and 24 h of postincubation. Addition of sphingomyelin liposomes reduced markedly the fraction of cellular labeled cholesteryl ester recovered after 24 h, while phosphatidylcholine liposomes were not effective. When the enzyme concentration had been reduced 5-20 fold the effect of sphingomyelin liposomes on cellular 3H-CE was evident already after 6 h of postincubation and some effect was seen also with phosphatidylcholine liposomes. Increase in the concentrations of SP liposomes to 150 micrograms/ml restored labeled cholesteryl ester to control values at 24 h. A significant reduction occurred also with 18:1 phosphatidylcholine liposomes but labeled cholesteryl ester remained 50-100% higher when compared with 18:1 or 18:2 SP. No correlation was seen between the rates of cholesteryl ester decrease and free cholesterol efflux into the medium. The inability to remove residual sphingomyelinase by regular washing procedures exaggerates and prolongs the recovery period of sphingomyelin during postincubation and delays the return of the cholesteryl ester pool to control levels. This can be counteracted by addition of phospholipid liposomes that can compete for the enzyme with the plasma membrane sphingomyelin and also substitute the hydrolyzed molecule in the plasma membrane to impede cholesterol flow to cell interior.

Modulation of sphingomyelinase-induced cholesterol esterification in fibroblasts, CaCo2 cells, macrophages and smooth muscle cells

The present study has focused on three questions concerning the effect of sphingomyelinase on release of free cholesterol from the plasma membrane and its intracellular translocation: (i) Can one change the direction of the flow of cholesterol? (ii) Can one modulate the flow? (iii) May such a mechanism be relevant in atherogenesis? (i) The results obtained show that even in the presence of potent nonlipoprotein cholesterol acceptors in the medium, the intracellular flow of cholesterol is not reduced as measured by cholesterol esterification. Moreover, in sphingomyelinase-treated cells, cholesterol efflux in presence of nonlipoprotein acceptors was not enhanced even when intracellular esterification was inhibited. (ii) Modulation of the sphingomyelinase induced cholesterol flow can be obtained by 100 microM verapamil which reduces it. In human skin fibroblast, interference with the delivery of free cholesterol to its site of esterification was found in the presence of brefeldin A. (iii) Aortic smooth muscle cells in culture are sensitive to low concentrations of sphingomyelinase and the increase in esterified cholesterol is evident also after exposure to the enzyme for 24 h. The present results suggest that in the plasma membrane, free cholesterol bound to sphingomyelin may be in a compartment which renders it more available for transport to the cell interior than for efflux. In view of the sensitivity of aortic smooth muscle cells to sphingomyelinase, this mechanism for enhanced esterification of cholesterol could be relevant to the transformation of arterial smooth muscle cells into foam cells in the process of atherogenesis.

Dissimilar effects of Brefeldin A on cholesteryl ester and triacylglycerol metabolism in CaCo2 and HepG2 cells as compared to peritoneal macrophages

The effect of Brefeldin A (BFA) on lipid metabolism was studied in two cell lines and in primary cultures of peritoneal macrophages. In both CaCo2 and HepG2 cells, which are models for human liver and intestine, addition of BFA resulted in a 2-10-fold increase in recovery of labeled cholesteryl ester when the cells had been prelabeled with free cholesterol or with [3H]oleic acid. This effect was linear for up to 6 h and could be elicited with doses of BFA as low as 0.03 micrograms/ml. The increase in cholesteryl ester induced by BFA was completely abolished by the ACAT inhibitor (Sandoz 58-035) and partly by forskolin. Intracellular hydrolysis of labeled cholesteryl ester was studied in the presence of the ACAT inhibitor and while in the controls 30-40% was hydrolyzed in 6 h, the values were 7-16% in the BFA treated cells. The slower rate of hydrolysis in the BFA treated cells could not account for the entire increase of cholesteryl ester and there was also no decrease in cholesteryl ester secretion. Even though activation of acyl-CoA:cholesterol acyltransferase by BFA was not demonstrated in cell homogenates, we hypothesize that in the intact cell the BFA induced increase in cholesteryl ester might have been related to the pronounced increase in modified endoplasmic reticulum which results from the dispersion of the Golgi apparatus. In the macrophages, BFA at doses of 0.25-1 micrograms/ml resulted in a 90% reduction in the incorporation of [3H]oleic acid into triacyglycerol. Incorporation of [3H]oleic acid into triacyglycerol in CaCo2 cells was not affected by BFA. In view of the ever-increasing use of BFA in cell biology, it seems important to emphasize that BFA may affect different pathways of lipid metabolism in various cells.

Giant T-wave inversion in patients with acute coronary insufficiency

We have observed an electrocardiographic (ECG) pattern of deep T-wave or "giant T wave" inversion in patients with acute coronary insufficiency. We reviewed the ECGs of 936 patients admitted to our coronary care unit during a one-year period. We found the pattern of giant T-wave inversion was present in nine patients (1 percent). We examined the echocardiograms of all of these patients and we analyzed the coronary angiograms on the seven patients in whom it was performed. We found that giant T-wave inversion was usually found in patients with stenosis in the left coronary system. In addition, the majority of these patients also had echocardiographic evidence of left ventricular hypertrophy. We conclude that the high frequency of a partially patent vessel in the left coronary system suggests that this ECG pattern may be useful in identifying patients who might benefit from coronary revascularization.

Fish oil ingestion in smokers and nonsmokers enhances peroxidation of plasma lipoproteins

The effect of fish oil ingestion (10 g MaxEPA/day) on the susceptibility of plasma lipoproteins to peroxidation was examined in 20 smokers (study A and B) and 22 nonsmokers (study C). The subjects were examined at the onset of each study (baseline values), divided into control and experimental groups and reexamined 4 weeks later. Smokers were examined 40 h after abstention from smoking (0 time) and 90 min after acute smoking (4-6 cigarettes). The parameters studied were TBARS, which provide an indication of peroxidative injury, and metabolism of conditioned LDL by macrophages as a biological indicator. These parameters were significantly higher (P less than 0.05-0.001) when the 90 min values of smokers were compared to time 0. After 4 weeks of fish oil ingestion, a significant rise above baseline values (33-50%) in plasma and LDL TBARS was found in smokers examined at time 0 and after acute smoking. Peroxidative modification of LDL isolated from smokers fed fish oil resulted in significantly higher TBARS (34-41%) and its metabolism by macrophages was higher (65-139%) compared to baseline values. In nonsmokers, the baseline values of the above parameters were lower than in smokers. Ingestion of fish oil resulted in a significant rise in TBARS in plasma (33%), LDL (137%), conditioned LDL (36-40%) and metabolism of conditioned LDL (70%) by macrophages. In 6 nonsmokers and 4 smokers, 400 mg of vitamin E/day were given with the fish oil. In the nonsmokers, vitamin E counteracted the effect of fish oil more effectively than in the smokers. In the light of the present results, indiscriminate recommendation of fish oil supplementation to the population at large should be cautioned.

Metabolism of 3-[3H]sphingosine sphingomyelin labeled with [14C]palmitic or [14C]linoleic acid by Hep G2 cells and rat liver in vivo

The metabolism of sphingomyelin labeled with 3-[3H]sphingosine and [14C]16:0 or [14C]18:2 fatty acid was studied in cultured Hep G2 cells or macrophages and after injection into rats. In pulse-chase experiments, the loss of 3H and 14C-label was more rapid when the cells had been pulsed with 18:2 than with 16:0 sphingomyelin. At the end of 24 h chase, the labeled ceramide contained more [14C]18:2 fatty acid than [14C]16:0. In addition, the 3H-label derived from 3-[3H]sphingomyelin was recovered also as free sphingosine. After injection in vivo, more [3H]sphingosine-labeled sphingomyelin was present in the liver 3 and 24 h after injection of 16:0 than after injection of 18:2 sphingomyelin. The ratio of [3H]ceramide derived from 16:0 sphingomyelin to that derived from 18:2 sphingomyelin as percent of injected dose was 1.84 3 h after injection and 1.31 after 24 h. The ratio of 3H/14C in liver ceramide was 6.4 3 h after injection of 18:2 sphingomyelin and 3.4 after 16:0 sphingomyelin. The present results show that 3-[3H]sphingomyelin is metabolized quite extensively and that the fate of the sphingosine moiety is related to the type of fatty acid present in the phospholipid. These findings indicate that there is little or no reutilization of 18:2 ceramide for sphingomyelin formation and suggest that sphingosine derived from 18:2 sphingomyelin is channeled primarily for catabolism.

Exercise-induced ventricular tachycardia in association with a myocardial bridge

Sustained ventricular tachycardia induced by exercise is uncommon. This is a report of a patient who has a positive exercise test at a high level of exercise. The electrocardiogram has classic ischemic ST depressions. Following the appearance of these ST depressions, the patient developed ventricular tachycardia at a rapid rate. Workup that included an echocardiogram and cardiac catheterization revealed myocardial bridging of the left anterior descending artery as the only structural abnormality. Electrophysiologic studies revealed the patient to have ventricular tachycardia only with isoproterenol (Isuprel) infusion.

Removal of cholesteryl ester from hepatic reticuloendothelial cells in vivo is not enhanced by plasma cholesteryl ester transfer protein

The putative role of cholesteryl ester transfer protein (CETP) in the removal of cholesteryl ester from hepatic reticuloendothelial cells in vivo was studied in hamsters. The parameter tested was retention of [3H]cholesteryl linoleyl ether ([3H]CLE), a nonhydrolysable analog of cholesteryl ester, in the liver after injection of [3H]CLE labeled acetylated LDL, which is targetted to nonparenchymatous littoral cells. In hamsters fed laboratory chow, plasma cholesteryl ester transfer activity (CETA) was 10.6 +/- 0.9 units and the retention of [3H]CLE in the liver 28 days after injection was 86% of the 4 h value. It was about 55% in rats fed the same diet, in which CETA was not detectable. When the diet was supplemented with 2% cholesterol and 15% margarine, CETA activity in hamsters increased 2-fold, yet no change in retention of [3H]CLE in liver was seen after 28 days. In rats, the retention of [3H]CLE in the liver was also not changed by the dietary fat supplementation. These results do not support the role of CETP in vivo in removal of cholesteryl ester from intact reticuloendothelial cells.

Effect of vitamin C and E supplementation on susceptibility of plasma lipoproteins to peroxidation induced by acute smoking

The effect of acute smoking on plasma lipoproteins was studied in seventeen smokers. In study 1, 7 subjects were examined prior to and 2 weeks after supplementation with vitamin C. In study 2, the effect of acute smoking was first determined in 10 additional subjects and subsequently they were divided into 3 groups, 3 and 4 subjects were supplemented with vitamin C or E, respectively, for 4 weeks, and 3 remained untreated. Plasma and LDL TBARS were examined at time zero (i.e., 40-48 h after total abstention from smoking) and at 90 min after acute smoking (5-7 cigarettes). In all 17 subjects examined prior to vitamin supplementation, significantly higher TBARS values were found in plasma, native LDL and LDL conditioned with smooth muscle cells (SMC) when the 90 min values were compared to 0 time. The LDL isolated after 90 min and conditioned with SMC was metabolized more extensively by mouse peritoneal macrophages than its zero time counterpart. The differences between the 0 time and 90 min values were not seen after the subjects had been supplemented with vitamin C for 2 or 4 weeks or with vitamin E for 4 weeks. The present results indicate that acute smoking exerts an oxidative stress on plasma lipoproteins and that higher plasma levels of natural antioxidants, such as vitamins C and E have a protective role.

Cholesteryl ester transfer activity in hamster plasma: increase by fat and cholesterol rich diets

We investigated the presence of cholesteryl ester transfer activity (CETA) in plasma of hamsters kept on various dietary regimens. In hamsters kept on a regular diet, CETA activity was about 5 units/4 mg protein of d greater than 1.21 g/ml fraction of plasma, as compared to about 35 units present in human d greater than 1.21 g/ml fraction. Addition of 15% margarine or butter alone or together with 2% cholesterol resulted in a 2-3-fold increase in plasma CETA. The increase in plasma CETA was correlated with plasma cholesterol levels (r = 0.78; P less than 0.001) and plasma triacylglycerol levels (r = 0.56, P less than 0.001). Hamsters consuming the cholesterol + butter-supplemented diets had the highest plasma CETA, cholesterol and triacylglycerol levels, while CETA in plasma of rats and mice remained nondetectable even after 4 weeks on the diet. The causal relation between hypercholesterolemia, hypertriglyceridemia and evaluation in CETA in hamsters remains to be elucidated.

Cholesterol removal by peritoneal lavage with phospholipid-HDL apoprotein mixtures in hypercholesterolemic hamsters

Syrian hamsters were rendered hypercholesterolemic by supplementation of their diet with 1% cholesterol and 15% butter. The hamsters were injected intraperitoneally (i.p.) with about 20 mg of phospholipid liposomes containing trace amounts of [3H]cholesteryl linoleyl ether ([ 3H]CLE) alone or combined with 10 mg delipidated high-density lipoprotein (apoHDL). After 2 h the peritoneal cavity was washed repeatedly with up to 15 ml phosphate-buffered saline. 60%-70% of [3H]CLE were retained after i.p. injection without apoHDL, 30-50% in the presence of apoHDL. The amount of free cholesterol recovered in the peritoneal lavage was significantly higher when apoHDL was combined with 18:2 sphingomyelin or dilinoleyl phosphatidylcholine liposomes, when compared to either liposomes or apoHDL alone. It is suggested that supplementation of dialysate with HDL apolipoproteins and phospholipids in patients undergoing continuous peritoneal dialysis could be of use in a cholesterol depletion regimen.

Cigarette smoking renders LDL susceptible to peroxidative modification and enhanced metabolism by macrophages

The effect of cigarette smoking on peroxidation of plasma low density lipoprotein (LDL) was studied in 16 smokers aged 23-56 years; 12 nonsmokers of similar age served as controls. The smokers were asked to refrain from smoking 24-40 h prior to testing. Peroxidation was assessed by determination of thiobarbituric acid reactive substances (TBARS) in fresh plasma and LDL and by an increase in 125I-LDL metabolism by peritoneal macrophages. There was no difference in TBARS in freshly prepared plasma or LDL of smokers and nonsmokers. However, LDL of smokers, conditioned by incubation with bovine aortic smooth muscle cells (SMC), had 2-fold or higher TBARS values when compared to SMC conditioned LDL of nonsmokers. 2-4-fold higher TBARS values were seen also in SMC conditioned LDL when the comparison was made between LDL isolated from plasma before smoking of 6-7 cigarettes (time 0), and LDL of the same individual isolated from plasma 90 min thereafter. The metabolism of SMC conditioned 125I-LDL by peritoneal macrophages was examined; LDL isolated from plasma of smokers at time 0 was metabolized twice as avidly as LDL of nonsmokers and a further increase was seen with LDL isolated 90 min after acute smoking. The present results indicate that cigarette smoking renders plasma LDL more susceptible to subsequent peroxidative modification by cellular elements.

Effects of occlusion of the left anterior descending coronary artery during angioplasty on right-sided cardiac pressures and electrocardiographic changes

Controversy persists regarding the presence and extent of right ventricular involvement with acute anterior injury. Also unclear are the incidence and significance of ST elevations in the right-sided leads in acute left anterior descending artery occlusion. Baseline and coronary occlusion hemodynamics and 15-lead electrocardiograms (addition of RV3 through RV5) were recorded in 42 patients during 32 left anterior descending and 13 right coronary artery angioplasties. The right coronary and left anterior descending artery angioplasties had similar baseline right and left ventricular hemodynamics, as well as identical right atrial to pulmonary wedge pressure ratios (0.51 right coronary vs 0.51 left anterior descending). Whereas the right coronary and left anterior descending occlusions produced similar elevations in right ventricular filling pressures, the left anterior descending occlusions produced greater elevations in left ventricular filling pressures. The right atrial to pulmonary wedge ratio increased with right coronary occlusions, but was unchanged with left anterior descending occlusions (0.79 right vs 0.46 left, p less than or equal to 0.0001). Presence of right-lead ST elevations in 10 left anterior descending occlusions did not con-note increased right ventricular filling pressures, but did suggest increased left ventricular ischemia and dysfunction. In conclusion, right ventricular dysfunction, as manifested by increased filling pressures, is seen with both right coronary and left anterior descending occlusions. Although it is the predominant abnormality in right coronary occlusions, in left anterior descending occlusions it is proportional to left ventricular dysfunction. ST elevations in a right lead with left anterior descending occlusions do not constitute a marker for increased right ventricular dysfunction.

Full dose subcutaneous heparin therapy

Anticoagulation is used extensively for the treatment and prevention of thromboembolic disease. Full dose anticoagulation with heparin is usually administered intravenously via continuous 24-hour infusion to avoid complications with intermittent intravenous administration. Continuous intravenous therapy is costly and cumbersome for nurses and patients. Subcutaneous administration of heparin in full dosage offers an attractive therapeutic alternative. This study examines the safety, efficacy, and cost considerations of this form of therapy. Fifteen patients admitted to the hospital for myocardial infarction were evaluated. After the patients were transferred from the cardiac intensive care unit, intravenous heparin was discontinued, while therapeutic anticoagulation was maintained via the subcutaneous route. Complications were limited to local hematoma formation. A cost comparison revealed substantial savings with subcutaneous administration.

Divergent fate of unsaturated and saturated ceramides and sphingomyelins in rat liver and cells in culture

The metabolism of sphingomyelins and ceramides with defined labeled fatty acids was compared after injection in vivo or incubation with cultured cells. The liver was the major site of uptake of sphingomyelins and ceramides with 18:2 or 16:0 fatty acids, but with both sphingolipids a higher recovery of radioactivity was found with 16:0 species. The distribution of radioactivity among liver lipids showed that 1.5 h after injection of 18:2 sphingomyelin, only 21% of the label was found as sphingomyelin, and this value was 37% in the case of 16:0 sphingomyelin. There was a very marked difference in the metabolism of 18:2 and 16:0 ceramides. After injection of 18:2 ceramide only 14% of the radioactivity was recovered as sphingomyelin, and this value was more than 50% with 16:0 ceramide. [14C]18:2 ceramide was converted also to glucoceramide and hydrolyzed more extensively than 16:0 ceramide. These observations were extended to sphingomyelins and ceramides with other fatty acids, using Hep-G2 cells in culture. Significantly more radioactivity was recovered as labeled sphingomyelin after incubation with 16:0, 18:0, 20:0 and 24:0 sphingomyelins than with 18:1 and 18:2 sphingomyelins, while more labeled phosphatidylcholine and phosphatidylethanolamine were found with the unsaturated sphingomyelins. In analogy to the findings in vivo, in the Hep-G2 cells more 16:0, 18:0 and 24:0 ceramides were converted to sphingomyelin than 18:1 or 18:2 ceramides. These differences were also seen with cultured macrophages, in which a more marked reutilization for sphingomyelin formation was found with the saturated ceramide series. The sphingomyelin liposomes were tested also for their capacity to mobilize cholesterol, and a rise in plasma unesterified cholesterol occurred after injection of 18:2 sphingomyelin. Marked enhancement of cholesterol efflux from cholesterol ester-loaded macrophages was also seen with 18:1 and 18:2, 20:0 sphingomyelin in the presence of delipidated high-density lipoprotein. The present results demonstrate that the metabolic fate of sphingolipids is related to their fatty acid composition. While ceramides with saturated fatty acids are predominantly reutilized for sphingomyelin formation, those with unsaturated fatty acids undergo probably more rapid hydrolysis with liberation of fatty acids and channeling into glycerolipids.

Pericardial effusion early in acute myocardial infarction

The incidence and significance of pericardial effusions early in acute myocardial infarction remain unclear. Using two-dimensional echocardiography, 172 patients with an acute myocardial infarction were evaluated within 72 h of presentation. Thirty patients (17%) had a pericardial effusion (29 small, 1 moderate) while 142 (83%) did not. No patient developed cardiac tamponade or required pericardiocentesis. Patients with pericardial effusions had higher peak creatine kinase as compared to patients without effusions (2036 +/- 1466 vs. 1483 +/- 1241, p less than 0.05) and a greater number of aneurysms (20% vs. 6%, p less than 0.05). In-hospital mortality was higher in the patients with pericardial effusions (10% vs. 2%, p less than 0.05). In conclusion, pericardial effusions are common in the early AMI period but are generally small and hemodynamically insignificant. They are associated with larger infarcts and greater mortality.

Anticipation of bypass surgery: can it induce silent myocardial ischemia?

Psychological stress has been demonstrated to induce myocardial ischemia. To determine whether stressful events before a coronary artery bypass grafting procedure precipitate myocardial ischemia, silent or symptomatic, and whether this can have an effect on the prognosis, 26 patients were evaluated before a bypass operation with continuous Holter monitor recording. Specific events monitored were signing surgical consent, receiving preoperative medications, shaving and preparing, and transfer to the operating room. A positive Holter result was defined as an ST segment depression of 1 mm or more lasting one minute or longer. Six patients (23%) were found to have one or more episodes of substantial ST segment depression, with a total of ten episodes lasting 208 minutes recorded. All episodes were silent and not associated with an increase in mean heart rate. The majority of episodes occurred randomly, although three episodes did occur between 5 and 6 AM at the time of transport to the operating room. This appeared to be related more to the circadian rhythm than to the stress of transport. No perioperative or postoperative myocardial infarctions occurred, and all patients were alive at 30 days. In conclusion, silent myocardial ischemia present in the immediate preoperative period does not appear to be related to specific preoperative events. Frequency of early morning ischemia may warrant changes in the medication schedule to provide additional protection during these hours.

Use of 3H-cholesteryl linoleyl ether as a quantitative marker for loss of cholesteryl ester during regression of cholesterol-induced aortic atheromas in rabbits

In this study, use was made of 3H-cholesteryl linoleyl ether (3H-CLE) to follow regression of aortic atheromatosis induced by feeding cholesterol to rabbits. After a 3-month induction period, the rabbits were divided into two groups with an attempt to match them by plasma cholesterol levels. They were injected with rabbit plasma labeled with 3H-CLE, and the baseline group rabbits were killed 10 to 12 days after injection. The experimental (regression) group rabbits were given rabbit chow containing 3% cholestyramine and were killed up to 330 days thereafter. Aortic 3H-CLE of both the baseline and the regression groups correlated highly with the plasma cholesterol levels at the time of injection of label. The radioactivity recovered in the aortas of the baseline and regression groups was not significantly different, indicating retention of label between day 12 and 330 days after injection. During that time, the mean aortic cholesteryl ester content decreased from 7.6 +/- 1.3 mg to 3.1 +/- 0.7 mg (p less than 0.01). The specific activity of 3H-CLE/cholesteryl ester determined in the aortic arch and the thoracic and abdominal aorta was significantly increased in all three regions examined in the regression group as compared to the baseline group. The present data show that 3H-CLE is retained in the atheromatous aorta for at least 330 days and that its use may add another dimension to the quantitative evaluation of regression of atherosclerotic lesions.

Septal rupture: effect of oxygen administration

A patient with interventricular septal rupture as a complication of myocardial infarction was studied to determine whether varying the concentration of inspired oxygen would alter the magnitude of intracardiac shunt. A significant correlation was found showing that high concentration of inspired oxygen results in increased left to right shunting probably due to systemic vasoconstriction and pulmonary vasodilatation.

Relationship between location of chest pain and site of coronary artery occlusion

Chest pain characteristics and site of coronary artery occlusion were evaluated in 148 patients having single-vessel coronary angioplasty and in 95 patients having double-vessel angioplasty. The locations of chest pain included substernal and left precordium, right precordium and epigastric. The possible sites of pain radiation were limited to neck/jaw, left arm, right arm, and interscapular. The patient described whether or not the pain was typical of previous angina, and the presence of ST segment deviation was noted to be certain that ischemia was present. The analysis showed that the occluded artery could not be reliably identified. However, it was possible to say which artery was most likely not diseased. Patients presenting with substernal or left chest pain with radiation to the left arm had a less than 10% chance of having right coronary artery disease. A patient presenting with epigastric pain radiating to the neck or jaw had a less than 13% chance of having left anterior descending disease. It is concluded that in patients with single- and double-vessel coronary disease, there is some relationship between chest pain pattern and disease location.