Hospital Chronicles (E-Journal)
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ANCA-positive Vasculitides and Coronary Artery Pathology
Get PDFVasculitides constitute a heterogeneous group of disorders affecting from large arteries to post-arteriolar capillaries. These disorders can affect all organs and are categorized on the basis of the affected artery diameter and the presence or absence of antibodies to neutrophil cytoplasmic antigens (ANCA). ANCA-positive vasculitides involve small to medium size arteries of many organs, primarily of the upper and lower respiratory system, the kidneys and the peripheral nervous system. Microscopic polyangiitis (MPA), Wegener granulomatosis (WG) and Churg-Strauss syndrome (CS) are forms of these vasculitides. Coronary arteries have been previously shown to be occasionally affected during the course of these diseases; however, this has never been formally assessed
Stable Coronary Artery Disease: When is Percutaneous Coronary Intervention Indicated?
Get PDFIn patients with chronic coronary artery disease (CAD) and good left ventricular function, percutaneous coronary intervention (PCI) does not confer any clear benefit in terms of hard long-term clinical outcomes, such as mortality, myocardial infarction or the need for subsequent revascularization, as compared with medical conservative treatment. Indeed, a meta-analysis of early data from 6 randomised controlled trials has showed convincingly that PCI improves anginal symptoms compared to conservative management, but there has been limited evidence on the effect of PCI on hard clinical outcomes. At the same time, the early fear of increased need for revascularization after PCI is probably not warranted. By comparing the benefits against cost considerations, it seems that many percutaneous interventions that are currently performed in patients with non-acute CAD are probably not justified
Challenges and Caveats for Stents of New Technology: Which Stent is Better? What are the Results in High-risk Patients?
Get PDFCoronary stenting has revolutionized percutaneous coronary revascularization. Two landmark studies published in 1994, Benestent and STRESS, demonstrated the significantly superior outcomes of intracoronary stenting versus balloon angioplasty. However, the success of bare-metal stents was limited by the occurrence of neointimal hyperplasia (NIH) leading to in-stent restenosis (ISR). The problem of neointimal hyperplasia, as measured by late loss, represented a significant hurdle, limiting the long-term patency of stents in many patient populations. The solution to the problem of ISR (the Achilles heel of the stent) was given by the evolution of new stent platforms coated with polymers eluting anti-proliferative drugs, drug eluting stents-DES... (excerpt
Assisted Circulation for the Failing Heart: Experience with the Novacor Left Ventricular Assist System
Get PDFSurgical therapy for the treatment of heart failure is a relatively young solution to a problem that has overwhelmed civilizations dating back to the First Dynasty. Despite centuries of enormous multi-disciplinary medical and technological advance, in 2006 nearly two thousand Americans died of cardiovascular disease each day, averaging 1 death every 35 seconds, and claiming more lives than the next 4 leading causes of death combined [1]. In 2007, one in 30 female deaths will be from breast cancer, while 1 in 2.6 will be from cardiovascular disease [2]. The prevalence of heart failure in our population is a staggering 5 million in the United States, and 6.5 million in Europe. Furthermore, based on the 44 year follow-up of the National Heart, Blood, and Lungs Institute Framingham Heart Study, 80% of men and 70% of women under age 65 who have heart failure will die within 8 years [3]. The focus of this article will be to review the history and future of the Novacor Left Ventricular Assist System (LVAS) as it relates to the failing heart; the story of how the innovator, the researcher, the engineer, and the surgeon have come together to offer a surgical solution to a medical problem of inconceivable scope
Utility of the Implantable Loop Recorder: Current Status
Get PDFOf similar size to a pacemaker, implantable loop recorders (ILRs) are implanted subcutaneously in the left precordial region. The ILRs are equipped with a memory loop and, once activated by the patient by means of a magnet, record a 1-lead electrocardiographic trace, both retrospectively and prospectively, for several minutes.ILRs have a monitoring capability of up to 36 months and are explanted once the diagnosis has been made or the battery has run down. The current indication of ILRs as diagnostic tools is rapresented by the evaluation of transitory symptoms of possible arrhythmic origin, such as syncope and palpitations. Moreover, the theoretical capability of the new generation ILRs to record any kind of arrhythmic events automatically (from atrial fibrillation, to atrial flutter/tachycardia, from ventricular tachycardia to bradyarrhytmic events) suggests the possibility to use these devices also in the longterm evaluation of the total (symptomatic and asymptomatic) arrhythmic burden of patients at risk of arrhythmic events
First Choice of Antihypertensive Therapy
Get PDFThe first choice of antihypertensive therapy should include an agent with the best metabolic profile, usually an angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB), but additional agents should be used as needed to attain optimal blood pressure control, usually a diuretic or calcium-channel blocker (CCB) or both, whereas β-blockers should be used only if specially indicated for co-morbidities, such as in cases of coexisting coronary disease or chronic heart failure
ANCA-positive Vasculitides and Coronary Artery Pathology
Get PDFSystemic necrotizing vasculitides preferentially involve small- or medium-sized vessels and occasionally the coronary vessels and the myocardium. Cardiac involvement was noninvasively evaluated in a group of 32 patients with vasculitides but without cardiac symptoms with use of magnetic resonance imaging techniques and compared with a control group of 13 individuals. The study showed increased coronary vessel diameters in the majority of patients and in some patients to the degree of ectasia; myocardial scar was rare
Optimal Anti-ischemic Therapy: Newer Data from the HOPE, EUROPA and PEACE Trials
Get PDFSeveral trials have proposed ACE-inhibitors as the foundation of anti-ischemic secondary preventive therapy for both short and long-term benefit in systolic heart failure, and an important anti-ischemic therapy in ischemic heart disease, diabetic and renal disease patients. The results of the HOPE trial indicated that ramipril, with “tissue” ACE-inhibition features, would benefit a broad range of patients for both primary and secondary prevention of both ischemic and vascular disease, and was beneficial in all subgroups of atherosclerotic coronary disease, cerebrovascular disease, peripheral vascular disease, or diabetes with one cardiovascular risk factor. Subsequently, the EUROPA trial complemented the findings of the HOPE trial in indicating the unique ability of tissue ACE-inhibition, this time with use of perindopril, in preventing cardiovascular events. On the other hand, the findings of a third trial (PEACE) using trandolapril did not confirm these favorable effects, albeit in a lower risk group of patients with ischemic heart disease. Nevertheless, combined analysis of the results of all three trials indicated that there seems to be a significant reduction of cardiovascular events in all patients with ischemic heart disease treated with an ACE inhibitor even in the absence of systolic left ventricular dysfunction or evidence of heart failure. These unique findings of these landmark trials are herein discussed
Automatic External Defibrillators: the Potential for Widespread Prevention of Sudden Cardiac Death in the Community
Get PDFThe vast majority of witnessed sudden cardiac death is due to the unpredictable occurrence of ventricular fibrillation, which is almost uniformly reversed by the immediate application of defibrillation. Thus, there is dire need for development of the appropriate conditions for early defibrillation in places where the likelihood of an unexpected sudden death event is deemed probable. In this setting, the automatic external defibrillators (AED) in the hands of even trained lay persons has been considered to have the potential to be the single greatest advance in the treatment of cardiac arrest due to ventricular fibrillation since the development of cardiopulmonary resuscitation. Several studies suggest that the use of publicly accessible AEDs by lay persons is feasible and that organized AED training should also focus on community and on-site responders. The potential for widespread prevention of sudden cardiac death in the community with the use of AEDs is discussed in this brief overview
Echocardiography to Identify Responders to Cardiac Resynchronization Therapy
Get PDFCardiac resynchronization therapy (CRT), effected via biventricular pacing, is now considered an established therapy for patients with severe heart failure, with good clinical results. However, 20-30% of patients do not respond to CRT. At present, patient selection is mainly based on QRS duration. Evidence is accumulating that echocardiography may be an ideal technique to identify responders to CRT. Based on assessment of intra-ventricular dyssynchrony, accurate prediction of response to CRT will be feasible. In particular, tissue Doppler imaging, assessing septal-to-lateral wall delay (>60 ms), may allow precise assessment of intraventricular dyssynchrony