Hospital Chronicles (E-Journal)
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Pharmacologic and Nonpharmacologic Therapeutic Approaches of Atrial Fibrillation in Patients With Congestive Heart Failure
Get PDFAtrial fibrillation (AF) and congestive heart failure (CHF) constitute the two ???epidemics?? of cardiovascular disease that often coexist and result in significant morbidity and mortality. Due to the complex interaction between AF and CHF, neither can be? treated optimally without treating both. Despite an extensive amount of research and literature about each of these disorders separately, there is a paucity of controlled clinical trial data for the management of AF among patients with CHF. Consequently, the optimal therapy of these patients remains controversial. New treatment approaches, both pharmacologic and nonpharmacologic, including catheter ablation techniques, as well as the results of ongoing clinical trials are likely to alter future AF management in CHF patients
SPECT/CT Fusion Imaging Integrating Anatomy and Perfusion of the Heart
Get PDFIn the rapidly changing world of medicine, boundaries between specialties are constantly being challenged. Fused and hybrid imaging with integration of single photon emission computed tomography (SPECT) and computed tomography (CT)(SPECT/ CT) and positron emission tomography (PET) and CT (PET/CT), represent an area of very rapid growth with significant implications for the medical profession. SPECT and PET scanners have now been linked to computer topographic (CT) scanners, which are digital radiological systems which acquire data in the axial plane, producing images of the heart, as well as other internal organs, of high spatial and contrast resolution. The combination of SPECT or PET and CT for image fusion, either as a single unit or as a software???based integration of SPECT or PET myocardial perfusion imaging (MPI) and CT angiography (CTA) data sets from standalone scanners, can provide us with a simultaneous noninvasive assessment of coronary anatomy and myocardial perfusion
Similar Incidence of Stroke in Paroxysmal Versus Sustained Atrial Fibrillation?/ Performance Measures for Atrial Fibrillation
Get PDFNo clear evidence exists regarding the effect of atrial fibrillation (AF) duration and frequency on the occurrence of stroke. Some studies have suggested a lower stroke risk in paroxysmal than in persistent AF. In contrast, other studies have reported a comparable stroke risk of paroxysmal to permanent AF. Upcoming trials such as the TRENDS and the ASSERT studies will provide further insight into the direct relation of AF duration and systemic embolism in a large group of patients with an implantable device. Recently, an ACC/AHA physician consortium provided clinical performance measures for adults with nonvalvular atrial fibrillation or atrial flutter
The Role of Double Renin-Angiotensin System Blockade
Get PDFBlockade of the renin-angiotensin system (RAS) is now recognized as an effective means of lowering blood pressure (BP) and protecting hypertensive patients from end-organ damage. There are nowadays three pharmacologic approaches to blockade of the RAS: with angiotensin-converting enzyme (ACE) inhibitors, introduced in the 1970s, with angiotensin II (Ang II) AT1 receptor blockers (ARBs), introduced in the 199 0s, and with direct renin inhibitors, a new class whose first agent, aliskiren, was introduced in 2006. Clinical studies with the first two classes have shown that neither one achieves complete blockade of the RAS. With chronic use of ACE inhibitors, there is a gradual return of Ang II towards pretreatment levels because enzymes other than ACE (e.g., chymase and others) can cleave off two aminoacids from the decapeptide Ang I, even though there is no evidence of ???escape?? in terms of BP control. With ARBs there is a partial blockade of AT1 receptors of variable degree and duration, depending on the affinity of each agent for the receptor and of the duration of the blockade (surmountable or insurmountable)
Sudden Death in the Athlete
Get PDFArrhythmias in the athlete can range from benign and asymptomatic to highly symptomatic and life-threatening. There is risk of not diagnosing an important cardiovascular condition which may predispose to a serious or life threatening arrhythmia. At the same time there is the risk of unnecessarily restricting the athlete with a more benign condition. Sudden cardiac death in the athlete, although relatively uncommon, remains a challenge as the screening techniques for identification of individuals at risk are insensitive. Many of the underlying cardiovascular diseases responsible for sudden death with exercise can be identified. These include hypertrophic cardiomyopathy, arrhythmogenic right ventricular dysplasia, Wolff-Parkinson-White syndrome, anomalous origin of the coronary artery, and the inherited long QT syndromes. To prevent fatalities and unnecessary restriction on athletic participation, the best available information has recently been updated with consensus recommendations and guidelines regarding eligibility. In this manuscript the cardiovascular conditions and cardiac arrhythmias that predispose to sudden cardiac death in the athlete are discussed
Transesophageal Echocardiography
Get PDFDespite the progress made in the field of ultrasound, the echocardiographic examination is still of a relatively poor quality in a number of patients. This is basically due to obstacles from the thorax and the lung which very often impede the ultrasound beam transmission. Many of these technical limitations can now be overcome with the advent of transesophageal approach. Transesophageal echocardiography (TEE) is particularly useful when the transthoracic study is not diagnostic, when there is clinico-echocardiographic discordance, in patients with suspected endocarditis and valve dysfunction, in patients with prosthetic valves, particularly mitral valve prosthesis, in patients presenting with systemic thromboemboli, in patients with disease of the aorta, in patients with mitral regurgitation needing to define the cause particularly when surgery is contemplated, and during cardiac or non-cardiac surgery. In this brief overview the clinical applications of TEE are discussed
A Paradigm Shift and New Therapeutic Options for the Metabolic Syndrome
Get PDFThe metabolic syndrome, characterized by obesity, dyslipidemia, insulin resistance and hypertension, increases the risk of cardiovascular morbidity and mortality. In recent years, the convergence of evidence from several studies has resulted in a major shift both in the understanding of the pathophysiology and the treatment options for this disease. Shunning away from the glucocentric hypothesis, this is now based on a unified ‘lipotoxicity’ hypothesis, according to which metabolic syndrome and type 2 diabetes mellitus can be caused by the ectopic accumulation of triglycerides and long-chain fatty acids in liver, muscle and pancreatic islets. This lipocentric approach is integrated with the analysis of inflammatory reactions associated with end-organ damage, including the vascular wall. Transcription factors and coactivators, including peroxisome proliferator-activated receptor coactivator-1 are crucial in mediating insulin resistance and accelerating vascular wall inflammation, and represent promising therapeutic targets. This new integrated view of the metabolic syndrome also takes into account the genetic differences among individuals and consequent variant response to therapy
ECG Changes and Voltage Attenuation in Congestive Heart Failure
Get PDFThe electrocardiogram (ECG) is invaluable in providing diagnosis, prognosis, and information for decision making in the management of patients with congestive heart failure (CHF). In addition to the traditional applications of the ECG, which are of importance in the management of patients with CHF, and include indeed the bulk of ECG derived information, a recently described association of peripheral edema with attenuated ECG voltage, provides an expanded dimension in diagnostics. These attenuations result in decreased amplitude of QRS complexes, P-waves, and shortened duration of QRS complexes and QT intervals, with significant diagnostic implications. Alleviation of peripheral edema in response to diuresis in patients with CHF reverses all above alterations
The Emerging Role of Inflammation and Fibrosis in Atrial Fibrillation and the Potential of Counter Interventions
Get PDFThere are now emerging data to support the association between in?¬?ammation and atrial fibrillation (AF). Initial observations were made after coronary artery bypass surgery, noting a peak incidence of AF on the second and third post-operative days, which coincided with the peak elevation of CRP levels. This association was subsequently shown in several other situations of AF. Data also emerge which link the renin-angiotensin aldosterone system (RAAS) to this inflammatory process. A putative link between in?¬?ammation and thromboembolic complications of AF has also been suspected. Given the important role of the RAAS in in?¬?ammation and AF, it could be postulated that interruption of the RAAS may exert positive effects upon this process. Statins with their anti-inflammatory action as part of their pleiotropic effects, as well as other anti-inflammatory agents, such as steroids and fish oils, might be of help in AF therapy according to some clinical studies. Finally, there appears to be a connection with atrial fibrosis in AF, as increased atrial ?¬brosis has been shown to correspond to an increase in conduction heterogeneity and AF vulnerability. Thus, inflammation and fibrosis may constitute new therapeutic targets in the management of AF. More studies are needed to clarify these important issues
Primary Percutaneous Coronary Intervention in Acute ST-Elevation Myocardial Infarction: The Experience of "Evagelismos" General Hospital of Athens
Get PDFBACKROUND: Primary percutaneous coronary intervention (PCI) has been shown to be a better reperfusion strategy in patients with ST-elevation myocardial infarction (STEMI) compared with thrombolysis, particularly when applied early. The objective of the present study was to report our experience from treating patients presenting to the emergency room of our hospital with STEMI with primary PCI. PATIENTS AND METHODS: The population of the study included 100 patients who presented to our hospital with STEMI and underwent primary PCI over a 12-month period. Patients’ clinical and angiographic data were retrospectively collected and patients were followed up for 9 months. Technical details of the primary PCI, including stent implantation, and use of drug eluting stents, thrombus aspiration catheter, or platelet glycoprotein IIb/ΙΙΙa inhibitors were recorded and correlated to clinical and angiographic patient data. RESULTS: Of 196 patients who presented o the emergency room with STEMI during the study period, 100 (51%) patients (85 men and 15 women) underwent primary PCI. PCI was successful with TIMI 3 flow of the infarct-related coronary artery in 79 (79%) patients. Six (6%) patients died during hospitalization and another 4 (4.3%) patients died during the 9-month follow up period. Twenty one (22%) patients required rehospitalization for acute coronary syndrome, of whom 17 needed a repeat PCI and 4 patients were submitted to coronary artery bypass grafting. Left ventricular ejection fraction (LVEF) was <50% in 54 (54%) patients. In 52 patients primary PCI was performed in less than 4 hours from onset of symptoms. In his cohort, 19 patients were thrombolyzed before arriving to the catheterization laboratory. Antithrombotic therapy with platelet glycoprotein IIb/IIIa inhibitors was used in 48 (48%) patients. Univariate analysis showed that the odds of achieving TIMI 3 flow were higher after using IIb/ΙΙΙa inhibitors (odds ratio-OR 6.4) or if the LVEF ≥50% (vs LVEF < 50%) at the beginning of the PCI (OR 6.4). If the time from the onset of symptoms to PCI was >4 hours, the odds of achieving TIMI 3 flow were reduced by 23.4% compared to time from symptoms to PCI <4 hours. The presence of TIMI 3 flow of the infarct-related artery reduced the odds of death by 10.2% compared to the absence of TIMI 3 flow of the infarct-related coronary artery. CONCLUSION: Our results are in keeping with those published by other groups performing primary PCI. We demonstrated the importance of time interval from onset of symptoms until PCI is started. We found that the use of GP IIb/IIIa inhibitors was beneficial and emphasized the predictive value of LVEF >50% and the importance of achieving TIMI 3 flow in the IRA at the end of the procedure