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Aortic stenosis (AS) is a degenerative valvular disease that has, until recently, been considered to be a progressive and the most importantly unmodifiable process. However, recent histopathologic studies have clearly reported that the both development and progression of AS is based on an biochemically active process which is mediated by a chronic inflammation (featured by many similarities with atherosclerosis) and includes inflammatory-cell infiltrates, lipoproteins, lipids and factors responsible for calcification (extracellular-bone-matrix proteins and bone mineral). Targeted drug therapy to prevent the progression of calcific AS disease should ideally be based on the knowledge of risk factors and the molecular pathogenesis of the disease. Treatment trials using various drugs have been undertaken to test whether medical therapy (statins, renin-angiotensin inhibition and anti-osteoporosis drugs) can prevent or beneficially modify the disease course. Although retrospective and non-randomized studies suggested a positive effect of statins, benefit has not been seen in perspective randomized controlled trials. Inhibition of renin-angiotensin has shown discordant results in retrospective studies with no randomized controlled data published. In the future, we need to consider other medical therapies (antiosteoporosis drugs are attractive candidates) that might target different pathways in this disease process. Additionally, we need to detect the optimal moment to start statin therapy for this chronic slowly progressive disease; treatments aimed at the early disease process (pre-obstructive form of aortic sclerosis) may be ineffective with end-stage tissue changes.

Background and Aim of the Study: Following the SEAS and SALTIRE studies in moderate-to-severe aortic stenosis (AS), it was postulated that the statin treatment had been initiated far too late during the disease course. Thus, the study aim was to assess the effect of four-week atorvastatin treatment (20 mg/day) on levels of calcification biomarkers in patients with early-stage disease (i.e., aortic sclerosis or mild AS)., Methods: In total, 33 patients (18 males, 15 females; mean age 70 +/- 8 years) with aortic sclerosis or mild AS, who had never received statin treatment, were enrolled into the study. According to their baseline lipid levels, 17 patients were hypercholesterolemic and 16 normocholesterolemic. Hence, rather than apply randomization, all patients were administered atorvastatin at a moderate dose level. Plasma levels of three biomarkers of calcification were measured, namely osteoprotegerin (OPG), osteopontin (OPN), and soluble receptor activator of nuclear factor (NF)-kappaB ligand (sRANKL)., Results: Plasma levels of all three biomarkers were decreased after atorvastatin treatment. OPG levels fell from 13.23 +/- 5.33 to 10.92 +/- 5.34 pmol/l (p < 0.05), sRANKL from 105.36 +/- 69.47 to 86.74 +/- 71.36 ng/ml (p < 0.05), and OPN from 31.60 +/- 20.29 to 28.45 +/- 15.98 ng/ml (p = NS). When comparing patients with no/mild valvular calcification to those with moderate valvular calcification, only the OPG level before atorvastatin was statistically higher in patients from the latter group: 11.44 +/- 4.51 versus 16.09 +/- 5.67 pmol/l (p < 0.05)., Conclusion: Atorvastatin, at a dose level of 20 mg per day, reduced the plasma levels of calcification biomarkers in patients with aortic sclerosis and mild AS. The pre-atorvastatin OPG level was significantly higher when the aortic valve was moderately calcified, despite a persistent low transvalvular gradient.

Aims: in hypertrophic cardiomyopathy (HCM), the following five risk factors have a major role in the primary prevention of sudden death (SD): family history of SD (FHSD), syncope, massive wall thickness (MWTh) >30 mm, non-sustained ventricular tachycardia (nsVT) in Holter monitoring of electrocardiography, and abnormal blood pressure response to exercise (aBPRE). In HCM, as a genetic cardiac disease, the risk for SD may also exist from birth. The aim of the study was to compare the survival curves constructed for each of the five risk factors in a traditional follow-up model (started at the first presentation of a patient at the institution) and in a novel follow-up model (started at the date of birth). In an additional analysis, we compared the survival rate in three subgroups (without FHSD, with one SD, and with two or more SDs in a family)., Methods and Results: a total of 1306 consecutive HCM patients (705 males, 601 females, mean age of 47 years, and 193 patients were <18 years) evaluated at 15 referral centres in Poland were enrolled in the study. In a novel method of follow-up, all the five risk factors confirmed its prognostic power (FHSD: P = 0.0007; nsVT: P < 0.0001; aBPRE: P = 0.0081; syncope: P < 0.0001; MWTh P> 0.0001), whereas in a traditional method, only four factors predicted SD (except aBPRE). In a novel model of follow-up, FHSD in a single episode starts to influence the prognosis with a delay to the fifth decade of life (P = 0.0007). Multiple FHSD appears to be a very powerful risk factor (P < 0.0001), predicting frequent SDs in childhood and adolescence., Conclusion: the proposed concept of a lifelong calculated follow-up is a useful strategy in the risk stratification of SD. Multiple FHSD is a very ominous risk factor with strong impact, predicting frequent SD episodes in the early period of life.

The cardioprotective effects of food rich in omega-3 (omega-3) polyunsaturated fatty acids (PUFA) on cardiovascular risk has been of interest from the moment when a low rate of coronary heart disease was documented in the Eskimo population. The aim of the present review is to discuss recent studies documenting multidirectional action of omega-3 PUFA due to its pleiotropic properties. Experimental studies in cellular and animal models have extensively documented the favorable effects of omega-3 PUFA (eicosapentaenoic acid and docosahexaenoic acid) on: inflammatory processes, endothelial dysfunction, platelet aggregation and arrhythmogenesis. It was reported that antiarrhythmic effects of omega-3 PUFA resulted from stabilization of cardiomyocyte membrane and inhibition of ion channels. Moreover, PUFA possess several pleiotropic properties i.e. anti-inflammatory, anti-atherogenic and antithrombotic. Anti-atherogenic effects (plaque stabilization) of omega-3 PUFA have recently been demonstrated. It was documented (OCEAN study) that eicosapentaenoic acid from a source of highly purified ethyl esters is incorporated into plaques in a relatively short period of time and these higher concentrations of omega-3 PUFA may stabilize vulnerable atherosclerotic plaques. The anti-inflammatory effect of omega-3 PUFA is associated with reduction of levels of TNF-alpha and interleukin-6. Eicosapentaenoic acid and docosahexaenoic acid inhibit arachidonic acid metabolism to inflammatory eicosanoids.

Background: Improvements in ultrasound technology has enabled direct, transthoracic visualization of long portions of coronary arteries : the left anterior descending (LAD), circumflex (Cx) and right coronary artery (RCA). Transthoracic measurements of coronary flow velocity were proved to be highly reproducible and correlated with invasive measurements. While clinical applications of transthoracic echocardiography (TTE) of principal coronary arteries are still very limited they will likely grow. The echocardiographers may therefore be interested to know the ultrasonic views, technique of examination and be aware where to look for coronary arteries and how to optimize the images., Methods: A step-by-step approach to direct, transthoracic visualization of the LAD, Cx and RCA is presented. The technique of examination is discussed, correlations with basic coronary angiography views and heart anatomy are shown and extensively illustrated with photographs and movie-pictures. Hints concerning optimization of ultrasound images are presented and artifacts of imaging are discussed., Conclusions: Direct, transthoracic examination of the LAD, Cx and RCA in adults is possible and may become a useful adjunct to other methods of coronary artery examination but studies are needed to establish its role.