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Background Knowledge of cardiac filling pressures is critical in the diagnosis and management of patients with dyspnea or heart failure. Echocardiography and B-natriuretic peptide (BNP) testing are commonly used to estimate these pressures, but their incremental value beyond physical examination remains unknown. Methods Right and left heart filling pressures were prospectively estimated as "normal" or "abnormal" by staff cardiologists and cardiovascular trainees based upon physical examination findings alone, or examination coupled with echocardiographic and BNP data in patients referred for cardiac catheterization. Net reclassification improvement was calculated to determine whether echocardiographic/BNP data had incremental value in the determination of right and left heart pressures. Results Two hundred fifteen observations were made by 9 examiners in 116 consecutive patients. Right and left heart pressures were accurately predicted from examination alone in 71% and 60% of observations, respectively. Examination-based accuracy was greater for staff cardiologists compared with trainees for right heart (82 vs 67%, P =.03) and left heart pressures (71% vs 55%, P =.03). Exposure to echocardiographic and BNP data did not enhance accuracy beyond bedside examination alone, both for left heart pressures (net reclassification improvement=−0.004; 95% confidence interval, −0.12-0.12) and right heart pressures (net reclassification improvement=0.02, 95% confidence interval, −0.09-0.13). Conclusions Cardiac filling pressures can be estimated from physical examination with modest accuracy, which is enhanced with experience. While echocardiographic and BNP data predict cardiac filling pressures, they may not provide information of incremental value beyond examination alone. Rigorous teaching and practice of cardiac examination skills should continue to be emphasized during medical training.

Left ventricular noncompaction (LVNC) is a rare condition that is believed to represent an arrest in endomyocardial morphogenesis. This entity may be complicated by the development of mural thrombi and embolic events, however data on the associated thromboembolic risk is variable and poorly defined. We describe 2 cases of LVNC in African American patients presenting with thromboembolic manifestations and briefly review the available literature relevant to this complication.

Congestive heart failure (CHF) is a major public health problem that results in tremendous economic burden. Diastolic heart failure (DHF) forms an important subset with increasing incidence and prevalence. There are widely variable estimates of the prevalence, ranging from 13% to 74% of all CHF presentations, and this is predominantly a result of a lack of uniform criteria for establishing a diagnosis. New developments in management of DHF have lagged behind those for systolic heart failure (SHF), for which numerous new therapeutic and device strategies have been instituted. The renin-angiotensin-aldosterone system (RAAS) plays an important role in the pathophysiology of both SHF as well as DHF. The beneficial role of ACE inhibitors as well as aldosterone antagonists in SHF has been well established. Because of its unique role of the RAAS in establishing fibrosis at a molecular level, RAAS blockade provides an opportunity to expand the therapeutic options for DHF. Thus far, in patients with primary DHF only the angiotensin receptor type 1 antagonist candesartan has been reported to decrease morbidity and probably mortality. Large, ongoing randomized trials including TOPCAT (Trial of Aldosterone Antagonist Therapy in Adults with Preserved Ejection Fraction Congestive Heart) and the I-PRESERVE (Irbesartan in Heart Failure with Preserved Systolic Function) are currently underway to establish the role of aldosterone antagonists in patients with DHF.

This study analyzed 255,256 patients who had acute myocardial infarction and were enrolled in the National Registry of Myocardial Infarction 2, 3, and 4 (1994 to 2002). The objective was to determine in-hospital mortality rate among patients who had ST-segment depression on the initial electrocardiogram. Patients who had ST-segment depression had an in-hospital mortality rate (15.8%) similar to that of patients who had ST-segment elevation or left bundle branch block (15.5%). After adjusting for observed differences, ST-segment depression was associated with only a slightly lower odds ratio (0.91) of mortality compared with ST-segment elevation or left bundle branch block.

Background— Spontaneous coronary artery dissection (SCAD) is an acute coronary event of uncertain origin. Clinical features and prognosis remain insufficiently characterized. Methods and Results— A retrospective single-center cohort study identified 87 patients with angiographically confirmed SCAD. Incidence, clinical characteristics, treatment modalities, in-hospital outcomes, and long-term risk of SCAD recurrence or major adverse cardiac events were evaluated. Mean age was 42.6 years; 82% were female. Extreme exertion at SCAD onset was more frequent in men (7 of 16 versus 2 of 71; P Conclusions— SCAD affects a young, predominantly female population, frequently presenting as ST-elevation myocardial infarction. Although in-hospital mortality is low regardless of initial treatment, percutaneous coronary intervention is associated with high rates of complication. Risks of SCAD recurrence and major adverse cardiac events in the long term emphasize the need for close follow-up. Fibromuscular dysplasia is a novel association and potentially causative factor.

A 75-year-old woman with familial hypercholesterolemia was admitted with unstable angina. Thirteen years earlier, she had undergone coronary artery bypass grafting with a left internal mammary artery (LIMA) to the left anterior descending artery (LAD) and subsequently bilateral common carotid bypass surgery through a second sternotomy 3 years later. Physical examination revealed left brachial hypotension, a left subclavian bruit, and features of severe aortic stenosis. Transthoracic echocardiography demonstrated severe valvular and supravalvular aortic obstruction with an area of 0.50 cm2. Noncontrast computed tomography showed complete calcification of the ascending aorta (porcelain aorta) and confirmed supravalvular obstruction with calcific plaque (Figure 1). She was subsequently offered placement of a left ventricular apex-descending aorta conduit through a left thoracotomy. Preoperative diagnostic angiography revealed a critical ostial left subclavian artery stenosis, with flow reversal in the vertebral artery and preferential entering of contrast into the LIMA (steal phenomenon, Figure 2, Movie 1). The LIMA graft was widely …

[Figure][1] [![Graphic][3] ][3][![Graphic][4] ][4] A 71-year-old man with a history of coronary artery bypass grafting 10 years earlier presented with recurrent angina. A repeat coronary angiogram revealed a large pseudoaneurysm in the saphenous vein graft supplying the right

Cleft mitral valve is a rare congenital anomaly that may present in isolation or accompany other cardiac malformations. Our illustrative case series highlights the advantages of three-dimensional over conventional two-dimensional echocardiography in the diagnosis and morphologic assessment cleft mitral valve in adults.

Quadricuspid aortic valve is a rare congenital anomaly. It may present as an isolated anomaly but is occasionally associated with aortic regurgitation. Sinus of Valsalva aneurysm (SVA) is also an infrequent congenital anomaly, typically associated with tricuspid aortic valves. There are only a few reported cases of SVA (ruptured) associated with quadricuspid aortic valves in the literature. We report the first case of the association of quadricuspid aortic valve with an unruptured SVA in an adult patient.

Brain natriuretic peptide (BNP) level is elevated in heart failure and reflects its severity. It is unknown why some patients have extremely high BNP levels. The authors retrospectively reviewed data on 179 consecutive patients whose BNP levels fell within one of several predetermined ranges: mild elevation, 500 to 1000 pg/mL (n=82); moderate elevation, 2000 to 3000 pg/mL (n=48); and high elevation, 4000 to 20,000 pg/mL (n=49). The statistical analysis was conducted with the unpaired t test and Pearson's correlation coefficient. Adjustments were made for age, sex, and serum creatinine level. Patients with moderate BNP elevation were more symptomatic and had more advanced structural and hemodynamic changes than did patients with lower BNP elevation. Characteristics of the high BNP level group did not differ from those of the moderate BNP level group. Serum creatinine level correlated with BNP level, but neither age nor sex did. High BNP level (4000-20,000 pg/mL) is determined more by renal dysfunction than by the severity of heart failure.