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Acute aortic syndrome (AAS) comprises acute aortic dissection, intramural hematoma, and penetrating ulcer of the aorta. The importance of accurate, rapid diagnosis and intervention for AAS is underscored by its clinical and epidemiologic overlap with acute coronary syndrome and by the risks of inappropriate treatment with antithrombotic agents. To explore these concerns, the recognition, management, and outcomes of AAS in the contemporary experience of a tertiary referral center were reviewed. Sixty-six consecutive patients with AAS admitted from January 2000 to December 2004 were identified, and their records reviewed. Misdiagnosis occurred in 39% (n = 26) and was associated with longer time to correct diagnosis (mean +/- SEM 51 +/- 12 vs 15 +/- 5 hours, p = 0.003). Acute coronary syndrome was the most common misdiagnosis, resulting in inappropriate treatment with acetylsalicylic acid in 26 (100%), clopidogrel in 1 (4%), heparin in 22 (85%), and fibrinolytic agents in 3 (12%). Exposure to antithrombotic agents was associated with higher rates of major bleeding (38% vs 13%) and a trend toward greater in-hospital mortality (27% vs 13%) (p = 0.02 for combined end point). Antithrombotic agent administration was also associated with increased hemorrhagic pericardial fluid (50% vs 25%), hemorrhagic pleural effusion (15% vs 3%), and hemodynamic instability (30% vs 13%) (p = 0.02 for combined end point). In conclusion, AAS is frequently confused with acute coronary syndrome, leading to delayed diagnosis and clinically significant bleeding as a consequence of inappropriate treatment with antithrombotic agents.

The effects of combined atorvastatin and amlodipine on blood pressure (BP) and low-density lipoprotein (LDL) cholesterol levels were investigated in 134 patients with documented coronary heart disease treated for 1 year. BP at baseline was 128 +/- 15/79 +/- 9 mm Hg and was controlled by the treating physician; no calcium channel blockers were allowed. Baseline means for plasma cholesterol were 6.4 +/- 1.1 mmol/L (147 +/- 39 mg/dl), triglycerides 2.0 +/- 0.9 mmol/L (177 +/- 88 mg/dl), LDL cholesterol 4.4 +/- 1.0 mmol/L (170 +/- 39 mg/dl), and high-density lipoprotein cholesterol 1.2 +/- 0.3 mmol/L (46 +/- 12 mg/dl). Patients were all given atorvastatin 10 mg, then increased to 80 mg if the LDL cholesterol was2.5 mmol/L (100 mg/dl). At 3 months, patients were randomized to amlodipine 10 mg or placebo. Plasma LDL cholesterol was decreased by 50%, and the LDL cholesterol target of2.5 mmol/L was achieved in 81% of the patients. BP targets were achieved in 69% of the atorvastatin + placebo group, versus 96% in the atorvastatin + amlodipine group (p = 0.0002). With use of combination atorvastatin + amlodipine at doses ranging from 10 to 80 mg and 5 to 10 mg, respectively, recommended therapeutic goals were reached in most select subjects with coronary artery disease who were concomitantly receiving aspirin and antihypertensive therapy.

The radial artery is commonly used as a conduit in coronary artery bypass grafting. No data exist on the effects of radial sheath insertion on radial artery function. Because many patients considered for coronary artery bypass grafting have had previous radial procedures, it is important to understand any effects radial sheath insertion may have on radial artery function. Twenty-two patients who underwent elective coronary angiography or angioplasty with a 6Fr sheath through the right radial artery were studied. Radial artery function was assessed using ultrasound to measure flow-mediated dilation (FMD). Reactive hyperemia was produced by 5-minute cuff inflation on the arm to suprasystolic pressures. Radial artery diameter was measured at rest and 1 minute after cuff deflation. FMD was expressed as percent change in radial diameter compared with at rest. In all cases, the left radial artery was studied as a control. Patients were studied before sheath insertion, immediately after sheath insertion, and 6 weeks after sheath insertion. The FMD of the cannulated arm was 13.2% before sheath insertion versus 3.6% immediately after sheath insertion (p

To assess the effect of regular and high-dose dipyridamole on coronary flow velocity in the left anterior descending artery (LAD), and to determine whether assessment of coronary flow velocity reserve (CVFR) is more sensitive for detection of ischemia than standard echocardiographic criteria, 47 patients were studied prospectively: 16 patients with stenosis of the LAD, 18 patients with angiographically normal LADs, and 13 patients with minimal disease. Patients underwent transesophageal echocardiographic study of wall motion and LAD flow velocity at baseline and at hyperemia, and for angina and electrocardiographic changes. The mean CFVR values after 0.56 mg/kg and after 0.84 mg/kg of dipyridamole were similar: 2.52 ± 0.87 versus 2.62 ± 0.90. A CFVR

Fetal transesophageal and intracardiac echocardiography by utilizing ultrasound technology permits accurate definition of cardiac anatomy in fetal sheep. Because fetal transesophageal echocardiography is less invasive than intracardiac echocardiography, it has the potential to serve as a monitoring tool for currently developed open and fetoscopic fetal cardiac interventions.

Among these 42 patients, TEE was superior to TTE in detecting pericardial thickening (11 of 13 vs 5 of 13), intrapericardial metastases (13 of 13 vs 3 of 13), intrapericardial clot (5 of 5 vs 0 of 5), and pericardial cysts (1 of 1 vs 0 of 1), respectively. TEE added little to TTE in detecting pericardial effusions. The unavoidable bias in the interpretation due to the awareness of the clinical history before the echocardiograms is a limitation of the study.

The clinical profiles, presentation, and outcomes of patients with acute aortic dissections and associated periaortic hematomas on aortic imaging have not been described in a large cohort. This study sought to assess the prognostic implications of periaortic hematomas in patients with aortic dissections and to identify factors associated with in-hospital mortality in patients with periaortic hematomas. The study population was 971 patients with acute aortic dissections enrolled in the International Registry of Acute Aortic Dissection with available imaging data on presentation with the presence or absence of periaortic hematomas. Patients with periaortic hematomas (n = 227, 23.4%) were more likely to be women, to have a history of hypertension and atherosclerosis, and to present early to the hospital. At presentation, they had greater frequencies of shock, cardiac tamponade, coma, and/or altered consciousness. Clinical outcomes were significantly worse in patients with periaortic hematomas, including significantly greater mortality (33% vs 20.3%, p

To evaluate the clinical characteristics, risk factors, and outcomes of hypotension in unselected patients who had acute aortic dissection (AAD), we studied 1,073 such patients who were enrolled in the International Registry of Acute Aortic Dissection between 1996 and 2001. Hypotension was noted in 313 patients (29.2%) who had AAD (46.0% on admission). Multivariate logistic regression identified ageor=70 years (odds ratio [OR] 2.0, 95% confidence interval [CI] 1.4 to 2.9), type A dissection (referent type B AAD; OR 2.1, 95% CI 1.4 to 3.2), neurologic deficit (OR 3.8, 95% CI 2.2 to 6.6), syncope (OR 2.9, 95% CI 1.8 to 4.7), aortic regurgitation requiring valve surgery (OR 1.9, 95% CI 1.1 to 3.3), cardiac tamponade (OR 5.1, 95% CI 3.0 to 8.8), and new Q-wave or ST-segment deviation on an electrocardiogram (OR 1.6, 95% CI 1.1 to 2.4) as independent associations of hypotension (c statistic 0.78). Hospital complications (neurologic deficits 22.7% vs 12.0%, altered mental status 26.1% vs 4.4%, myocardial ischemia 14.6% vs 6.9%, mesenteric ischemia 6.9% vs 2.6%, or limb ischemia 14.6% vs 6.9%, and death 55.0% vs 10.3%) occurred more frequently in patients who had hypotension than in those who did not (p0.001 for all comparisons). We concluded that hypotension that occurred in25% of patients who had AAD was associated with a much higher rate of in-hospital adverse events. Our study also identified factors associated with hypotension in patients who had AAD.