Hospital Chronicles (E-Journal)
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Genetic Polymorphisms: An Insertion/Deletion Polymorphism of the a2B-Adrenoceptor Gene as a Risk Factor for Acute Coronary Events
Get PDFBACKGROUND: We have recently identified a variant form of the human a2B-adrenoreceptor (AR) gene. Based on the coronary vasoconstrictive property of a2-adrenoreceptors in humans, we hypothesized that the naturally occurring D (deletion) variant confers reduced receptor desensitization and therefore increased vasoconstriction in humans. This property could be associated with cardiovascular pathologies such as acute myocardial infarction (AMI) and sudden cardiac death (SCD). To test this hypothesis, we carried out two separate clinical genetic studies in middle-aged Finnish men, reported in two separate original publications. ? METHODS: We examined a subset (912 men, aged 46 to 64 years) of the Kuopio Ischemic Heart Disease Risk Factor Study, an ongoing prospective population???based study investigating risk factors for cardiovascular diseases and related outcomes in men from eastern Finland (Prospective Follow-up study). Seven hundred out-of-hospital deaths of Finnish men in the Helsinki region were subjected to autopsy and formed the basis of the second, cross-sectional study investigating the associations between the a2B-AR I/D polymorphism and coronary heart disease (Autopsy study). DNA for genotyping was extracted using standard methods. The a2B-adrenoreceptor insertion/deletion (I/D) genotypes were determined using PCR-amplification and DNA electrophoresis. ? RESULTS: Of the 912 subjects, 192 (21%) had the D/D genotype, 256 (28%) had the I/I genotype, and 464 (51%) were heterozygous. Thirty-seven acute coronary events occurred during the follow-up time: 15 in the D/D genotype group (7.8%), 12 in the I/D group (2.6%), and 10 in the I/I group (3.9%). Using a univariate analysis, the risk for an acute coronary event differed significantly between the three genotype groups (p = 0.017). The D/D genotype group had a 3-fold increased risk for an acute coronary event in comparison with the I/D group (95% CI = 1.4 ??? 6.5, p = 0.004), and a non-significantly increased risk of 1.9 relative to the I/I genotype group (95% CI = 0.8 - 4.1, p = 0.128). In a Cox proportional hazards??? model adjusting for several variables, the relative risk associated with the D/D genotype was 2.2 (95% CI = 1.1 ??? 4.4, p = 0.02). In the autopsy cohort, a2B-AR I/D genotyping was accomplished for 683 men (98%). Of these, 152 (22%) had the D/D genotype, 186 (27%) had the I/I genotype, and 345 (51%) were heterozygous. The D/D genotype was associated with an increased risk for SCD and prehospital fatal AMI, with adjusted odds ratios (OR) of 1.8 - 2.4 compared to the other two genotypes (p < 0.05). ? CONCLUSION: the D variant of the a2B-AR gene is a causal risk factor for AMI and SCD in Finnish men. Further genetic epidemiological studies are still needed to confirm the causality and to test its generalization to other populations, and its physiological in vivo effects need to be identified. ? Key Words: a2B-adrenoreceptor polymorphism; coronary heart disease; acute myocardial infarction; sudden cardiac death; genotyping; genetic studie
Non-classical Indications for Cardiac Resynchronization Therapy
Get PDFBased on randomized controlled studies, cardiac resynchronization therapy (CRT) is currently indicated in patients with systolic heart failure of New York Heart Association (NYHA) functional class III and IV, left ventricular ejection fraction < 35% and wide QRS (>120 ms). Most of the enrolled patients were in sinus rhythm, were not previously paced and had mainly LBBB. Thus, there are uncertainties regarding several other populations, not included or underrepresented in the main studies. These populations include patients with atrial fibrillation (AF), previous pacemakers considered for upgrade to CRT, RBBB, narrow QRS < 120 ms, NYHA functional class <III, or right heart failure. These non-classical indications are herein reviewed. Although CRT seems to benefit patients with AF and patients with preexisting pacemakers, in patients with NYHA functional class II-III, or with narrow QRS, or with RBBB, or in those with predominant right heart failure, the role of CRT is not established yet and further relevant clinical trials are needed
Stem Cells and Cardiac Repair
Get PDFContrary to the initial belief that the heart is a terminally differentiated organ that cannot replace its own cell damage, there is now proof that the circulating blood provides the injured tissue with adult stem and progenitor cells, which have the potential to differentiate into cardiomyocytes and ultimately improve cardiac function. Thus, transplantation of stem cells into the myocardium in patients with severe myocardial dysfunction post-myocardial infarction is being currently investigated for experimental as well as for clinical purposes. Many issues regarding the mode of action remain to be elucidated. The BOOST trial was the first completed, randomized study that showed safety, feasibility and efficacy of the method. However, a more recent doubleblind, placebo-controlled study failed to reveal an increase in global left ventricular nejection fraction and cast doubt on the efficacy of the method. Thus, further randomized studies are needed to evaluate this novel approach in the treatment of ischemic heart failure and determine its role, safety and efficacy
Concomitant Intraoperative Radiofrequency and Microwave Ablation of Atrial Fibrillation and Repair of Atrial Septal Defect
Get PDFAtrial fibrillation (AF) is the most frequent form of atrial arrhythmias in adults with congenital heart disease. Some serious complications are related with the presence of AF after surgery. Because of the complexity and the risk of bleeding, the Maze III procedure has been largely replaced by alternative energy sources. A patient with multiple atrial septal defects (ASD) and AF underwent surgical closure with autologous pericardial patch and radiofrequency and microwave ablation of AF
A Unique Right Coronary Artery Intra-coronary Collateral Pathway
Get PDFIn the coronary angiogram of a 73-year-old man with angina pectoris, we noted the right coronary artery (RCA) proximally occluded with an atrial intra-coronary collateral pathway emerging from a proximal sinus node artery (SNA) and ending to a distal “right posterior” SNA (RPSNA), which was retrogradely supplying the peripheral RCA; such right posterior sinus node artery was first described, coined and reported back in 2000
Subclavian and Vertebral Artery Angioplasty - Vertebro-Basilar Insufficiency: Clinical Aspects and Diagnosis
Get PDFBACKGROUND: Percutaneous transluminal angioplasty (PTA) for significant stenosis involving the origin of the vertebral artery is now a well established treatment for selected patients when posterior cerebral arterial circulation is compromised. We demonstrate from our short and long-term results, after transluminal treatment of subclavian and vertebral artery stenosis, the feasibility and safety of treatment with balloon angioplasty and stenting. PATIENTS AND METHODS: A total of 181 patients underwent endovascular treatment and were divided into two groups. In group A, we treated patients with chronic vertebrobasilar insufficient. In this group, 21 patients with severe vertebral artery stenosis had also concomitant severe stenosis in other supra aortic arteries. In group B we treated patients with subclavian steal syndrome. In this group 21 patients presented with coexistence of severe stenosis in other supra aortic arteries. Stent patency of subclavian and vertebral artery during follow up was assessed by duplex scan and physical examination, with comparison of brachial blood pressure of both arms especially in patients with subclavian stenosis. Digital angiography was performed in available patients. Cerebral oximetry and intracranial Doppler were used to determine the group of patients that we had to treat with balloon angioplasty and stenting. RESULTS: Successful stenting was achieved in all cases. There were no complications. The primary stenting patency during follow-up (mean 8.6 months) was 98.6%. With use of intracranial Doppler we found 31 patients with higher blood flow in the basilar artery after stenting and 24 patients were found with increased brain regional oxygen saturation in the anterior cerebral artery. CONCLUSION: Endovascular treatment of subclavian and vertebral arteries with balloon angioplasty and stenting was found to be necessary in certain cases and a less invasive alternative to surgical repair. Long-term results must still be confirmed in further studies
Current Guidelines for Hypertension: Important Highlights for Clinical Practice
Get PDFIn 2007 the European Society of Hypertension, the American Heart Association and the International Society of Hypertension-World Health Organization published new guidelines for the management of hypertension. According to these new guidelines, drug treatment is recommended in all subjects with consistent elevation of blood pressure above 140 mmHg systolic and/or 90 mmHg diastolic. In high-risk subjects, treatment initiation is indicated in lower blood pressure levels (systolic above 130 mmHg and/or diastolic above 85 mmHg). The higher the blood pressure level the sooner the treatment is commenced, with emphasis being placed on the critical role of combination pharmacotherapy in order to achieve optimal blood pressure control.. The implementation of the new guidelines is expected to achieve more effective cardiovascular protection in hypertensive patients
A prospective study of febrile neutropenia in lung cancer patients
Get PDFBACKGROUND: There are few data on microbiology of febrile neutropenia (FN) in lung cancer patients. The primary objective of this study was to evaluate the epidemiology of FN in this population. PATIENTS AND METHODS All patients with lung cancer treated with chemotherapy in the Institut Jules Bordet (a cancer hospital) and who developed FN (PMN < 500/mm?³) were included in the present prospective study. Febrile neutropenia was defined as any febrile episode (38.5?°C once or 38.0?°C twice) occurring during neutropenia (neutrophil count < 500/mm?³). RESULTS Ninety five patients, 62 with non-small cell and 33 with small cell lung carcinoma developed FN. A total of 102 FN episodes were observed. Of these, 46 were microbiologically and 14 clinically documented. The most frequent site of infection was the lung (31%). Gram-negative bacteria, mainly Escherichia coli and Haemophilus influenzae, were most commonly observed. In bacteremic patients, Gram-positive bacteria, essentially Streptococcus sp, Enterococcus sp and Staphylococcus aureus, accounted for 39% of the micro-organisms. CONCLUSION Lung constitutes the predominant site of infection in febrile neutropenic lung cancer patients. In these patients, E. coli and H. influenzae are the most commonly documented pathogens, except in case of bacteremia where Streptococcus sp and S. aureus as well as E. coli are the principal pathogens
European Lung Cancer Working Party. Clinical Practice Guidelines. Small Cell Lung Cancer: V. Extensive disease
Get PDFThe present guidelines on the management of extensive disease small cell lung cancer (SCLC) were formulated by the ELCWP in October 2007. They are designed to answer the following nine questions: 1) What is the definition of extensive disease? 2)What are the active drugs? 3) What is the best induction regimen? 4) Is there a role for maintenance chemotherapy? 5) Is there a role for dose-intensive chemotherapy? 6) Is there a role for the use of haemopoietic growth factors and stem cells support? 7) Is there a role for alternating or sequential chemotherapy? 8) Is there a role for biological treatments? 9) Is there a place for second-line chemotherapy
