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Background Patients with Darier disease often present with staphylococcal skin infections and are at risk for complications when they undergo cardiothoracic surgery, such as acute aortic dissection repair. Case summary A 39-year-old woman with hypertension and Darier disease suffered an acute type A aortic dissection, requiring emergency operation with a Dacron graft. Twenty-five days post-operatively, she developed pneumonia and staph hominis was isolated in blood cultures and Bronchoalveolar Lavage. Following completion of antibiotics, multiple relapses occurred during a 6-month period, each time treated with appropriate antibiotic therapy. An 18F-fluorodeoxyglucose positron emission tomography computerized tomography showed persistent graft uptake and re-operation was performed. At 22 months of follow-up, the patient remains asymptomatic and the 18F-FDG PET/CT shows significant reduction in FDG uptake. Discussion Graft infection is a rare but serious complication. Antibiotic therapy is often inadequate and re-operation is needed. As staphylococcal skin infections often occur in patients with Darier disease, adequate preprocedural skin preparation and sterilization are very important in these patients.

Background Bacterial pericarditis is a rare, rapidly progressive, and highly fatal infection, even with drainage and antibiotics. Gram-positive cocci, specifically Streptococcus pneumoniae, have been the most common cause of bacterial pericarditis from either haematogenous dissemination, or spread from another adjacent site of infection. Following the introduction of antibiotics in the 1940s and more recently the pneumococcal conjugate vaccine, the incidence has drastically decreased. Case summary A previously healthy young male was diagnosed with acute pericarditis with no signs of haemodynamic compromise on initial presentation. Several hours later, he became unstable suffering from cardiac tamponade and septic shock. Despite urgent pericardiocentesis and drainage of purulent fluid, culture positive for streptococcus pneumoniae, multi-organ failure was eventually fatal. Discussion We describe a rare case of primary S. pneumoniae purulent pericarditis leading to tamponade, septic shock, and death. Due to the high mortality rate of purulent pericarditis, a high index of suspicion is needed in order to initiate appropriate therapy with antibiotics and drainage.

Funding Acknowledgements Type of funding sources: None. Background Intra-aortic balloon pump (IABP) can be used as circulatory support in order to stabilize haemodynamically compromised patients as either a bridge to therapy or to further mechanical support. Based on the current literature its use should be limited to up to two weeks and there are not enough data regarding its long term use’s efficacy and possible complications. Purpose To review the possible complications of the long-term use of IABP Methods We restrospectively analysed the data from 24 consecutive patients with end-stage heart failure (ESHF) who received long-term IABP support and recorded the complications during their hospitalization as well as their outcome. Results 24 patients (14 male and 10 female) were included. In 5 of them ESHF was attributed to ischemic cardiomyopathy and the in 19 to dilated cardiomyopathy. Their mean age was 45.6+/-14 years. The mean duration of IABP support was 70.2 days (minimum 30days maximum 192 days). The mean ejection fraction (EF) was 20%. Regarding the pharmacological therapy, 12/24 patients were on dobutamine, 4/24 on dobutamine and milrinone and 8/24 on dobutamine and noradrenaline. Regarding the clinical course of these patients, 7/24 underwent heart transplantation, 2/24 managed to wean from IABP, 5/24 received left lentrivular assist device (LVAD), 6/24 received biventricular assist veice (BiVAD) and 4/24 died. In terms of complications they were recorded as following : infection 7/24, bleeding 3/24, thrombosis 4/24, heparin-induced thrombocytopenia(HIT) 5/24, hematoma 4/24, ischemia 0/24 and rupture 1/24. Conclusions Although not indicated by the current guidelines, long term IABP can be used as a relatively safe circulatory support method.

The perception that women represent a low risk population for cardiovascular (CV) disease (CVD) needs to be reconsidered. Starting from risk factors, women are more likely to be susceptible to unhealthy behaviors and risk factors that have different impact on CV morbidity and mortality compared to men. Despite the large body of evidence as regards the effect of lifestyle factors on the CVD onset, the gender-specific effect of traditional and non-traditional risk factors on the prognosis of patients with already established CVD has not been well investigated and understood. Furthermore, CVD in women is often misdiagnosed, underestimated and undertreated. Women also experience hormonal changes from adolescence till elder life that affect CV physiology. Unfortunately, in most of the clinical trials women are under-represented, leading to limited knowledge of CV and systemic impact effects of several treatment modalities on women’s health. Thus, in this consensus a group of female Cardiologists from the Hellenic Society of Cardiology present the special features of CVD in women: the different needs in primary and secondary prevention, as well as therapeutic strategies, that may be implemented in daily clinical practice in order to eliminate underestimation and undertreatment of CVD in female population.

The perception that women represent a low-risk population for cardiovascular (CV) disease (CVD) needs to be reconsidered. Starting from risk factors, women are more likely to be susceptible to unhealthy behaviors and risk factors that have different impact on CV morbidity and mortality as compared to men. Despite the large body of evidence as regards the effect of lifestyle factors on the CVD onset, the gender-specific effect of traditional and non-traditional risk factors on the prognosis of patients with already established CVD has not been well investigated and understood. Furthermore, CVD in women is often misdiagnosed, underestimated, and undertreated. Women also experience hormonal changes from adolescence till elder life that affect CV physiology. Unfortunately, in most of the clinical trials women are underrepresented, leading to the limited knowledge of CV and systemic impact effects of several treatment modalities on women's health. Thus, in this consensus, a group of female cardiologists from the Hellenic Society of Cardiology presents the special features of CVD in women: the different needs in primary and secondary prevention, as well as therapeutic strategies that may be implemented in daily clinical practice to eliminate underestimation and undertreatment of CVD in the female population.

Myocardial bridges are often asymptomatic but may need therapy when causing ischaemia. They have rarely been reported in children or in association with CHD, where symptomatology may be mistakenly attributed to the CHD. We report a case of multiple myocardial bridges causing ischaemia in an adolescent with pulmonary stenosis and discuss management.

Introduction Acute aortic dissection (AAD) represents surgical emergency and current literature mainly consists of postoperative outcome reports. Long term outcome and quality of life have not extensively been investigated. Purpose This is a single center study to assess long term outcome and quality of life of patients who underwent emergency surgery for AAD. Methods From January 2007 until December 2009, 74 consecutive patients were operated for AAD type A in our hospital. Seventeen died during hospital stay and 12 died during follow-up. Mean follow up was 108±10 months. Seventeen patients refused to answer the SF-36 questionnaire; therefore our study group consists of 28 patients. The SF-36 Questionnaire was retrospectively obtained by phone calls, the first, fifth and tenth postoperative year and 2 summary scores are reported, physical (PCS) and mental (MCS). Results Our in-hospital mortality was 23%, late mortality 21.1% and the overall mortality was 39.2%. Significant differences in both physical and mental score over time were found among the 28 long-term survivors (Table). Both PCS and MCS at 1st, 5th and 10th year did not differ compared to age-matched general population but compared to subjects with one or more chronic diseases both PCS and MCS were both significantly better at 5yrs in our patients vs controls (p=0.0028 and p=0.0259, respectively). Likewise, at 5 years PCS but not MCS was better in comparison to subjects with a history of one hospitalization the preceding year (p=0.035 and p=0.1, respectively). Descriptive statistics of physical and mental component summary score over time Score 1 year (FU1) 5 years (FU2) 10 years (FU3) p-value Mean (SD) Mean (SD) Mean (SD) PCS 45.4 (7.7) 50.3 (7.0) 46.8 (9.2) 0.008* MCS 42.8 (15.1) 49.7 (12.7) 49.1 (12.3) 0.001** PCS, Physical component summary; *1 vs 5: p=0.003, 1 vs 10: p=0.469, 5 vs 10: p=0.027. MCS, Mental component summary; **1 vs 5: p=0.001, 1 vs 10: p=0.001, 5 vs 10: p=0.939. SD, standard deviation. Conclusion Quality of life improves after the 1st post-operative year and is comparable to healthy subjects. Although acute dissection is a catastrophic event with high mortality despite successful and timely repair, long term survival and quality of life on the long term are favorable.

Background Critical care management of patients undergoing transcatheter aortic valve implantation (TAVI) is a major determinant of their outcome. Aims The aim of this study was to compare the prognostic performance of four general scoring systems [Acute Physiology and Chronic Health Evaluation (APACHE), Simplified Acute Physiology Score (SAPS), Sequential Organ Failure Assessment (SOFA), and MultiOrgan Dysfunction (MOD) scores] in TAVI patients. Methods Between 1 June 2008 and 30 June 2014, 75 patients (81.2 ± 6.4 years old, 36 men and 39 women) who underwent TAVI were scored during the first 24 h of their stay at the intensive care unit (ICU). The outcome measures were in-hospital and 30-day mortality and in-hospital and 30-day morbidity defined as myocardial infarction, implantation of permanent pacemaker, stroke, tamponade, major bleeding, vascular access site complications and prolonged ventilation. Results Four patients (5.3%) died in ICU and one more during follow-up, indicating a 30-day mortality rate of 6.6%. Regarding in-hospital mortality, the area under the ROC curve (AUC) was 0.92 for SAPS II, 0.88 for APACHE II, 0.73 for MODS and 0.74 for SOFA. Regarding 30 day-mortality, SAPS II and APACHE II performed equally higher (AUC = 0.88) than the other two scores (0.79 for MODS and 0.80 for SOFA). SAPS II had the best calibration among all four scores for in-hospital and 30-day mortality ( χ2 = 3.06 and χ2 = 3.29, respectively). AUCs for in-hospital and 30-day morbidity were above 0.7 for SAPS II and APACHE II. Conclusions SAPS II and APACHE II are reliable mortality and morbidity risk stratification models for TAVI patients with high calibration and discrimination.

We present the case of a 68-year-old woman, currently asymptomatic but with a history of paroxysmal atrial fibrillation and tachycardia-bradycardia syndrome, for which she underwent a DDD pacemaker implantation and was started on oral anticoagulants. A recent chest X-ray (figure 1), for respiratory infection, was performed and the patient was referred to our institution for evaluation. Following diagnostic procedures, the patient was successfully operated on. heartjnl;105/8/656/F1F1F1Figure 1Preoperative chest X-ray (A) and chest CT with contrast (B). QUESTION: What is the most likely diagnosis?Mitral stenosis.Pericardial cyst.Left atrial appendage aneurysm.Left atrial myxoma.Atrial septal defect.

BACKGROUND: Inflammation plays an important role in the initiation and progression of acute aortic dissection (AAD). New inflammatory indices derived from full cell blood count and its differential may be associated with increased risk. We evaluated platelet‐lymphocyte (PLR), red cell distribution width (RDW) and RDW/PLT's (platelets) (RPR) in AAD. METHODS: We studied 120 consecutive patients with AAD type I admitted for emergency surgery (group I), 121 consecutive patients with aortic aneurysms of the ascending aorta prior to elective repair (group II) and 121 controls (group III), age and sex matched. RESULTS: PLR was significantly higher in group I vs both groups II and III (P

Clinical introduction A 53-year-old woman with no previous medical history complained of easy fatigue over the last 6 months. She had a positive family history for coronary artery disease but no other risk factors. On physical examination, a 3/6 pansystolic murmur was heard over the apex, and the lung auscultation was unremarkable. Her ECG showed a left anterior fascicular block, with poor R wave progression in the anterior leads (see online supplementary image A). A subsequent echocardiogram revealed a slightly dilated for the patient’s body surface area (BSA) (1.73 m2) left ventricle (55/35 mm), with preserved systolic function and a moderate functional mitral regurgitation. The estimated pulmonary artery pressure was 45 mm Hg. During treadmill radionuclide scintigraphy, her exercise tolerance was normal, with good inotropic response, and 96% oxygen saturation at rest and at peak exercise. A 2 mm ST segment depression was noted at peak effort, which persisted well into recovery (see online supplementary image B). The scintigraphy scan showed extensive reversible anteroapical wall ischaemia (see online supplementary image C). At this point she was referred to us for right and left heart catheterisation. Intracardiac pressures and saturations were: right atrium (RA)RA=3 mm Hg, right ventricle (RV)=26/3 mm Hg, Pulmonary artery (PA)=26/10/mean 16 mm Hg, pulmonary capillary wedge pressure (PCWP)=11 mm Hg, left ventricle (LV)=110/10 mm Hg, Aorta (Ao)=110/60/mean 80 mm Hg, Superior vena cava saturation (SVCsat)=62%, RAsat=62%, PAsat=78%, Aosat=96% and estimated pulmonary to systematic flow ratio (Qp/Qs)=1.8. Her coronary angiography and CT angiography are shown in figure 1A,B. Supplementary material 1 Supplementary material 2 Supplementary material 3 Question What is the most likely diagnosis? Right coronary fistula to right ventricle Kawasaki disease with fistula Anomalous origin of the left coronary artery from the pulmonary artery Persistent truncus arteriosus

Cardiovascular events may occur even after complete revascularization in patients with coronary artery disease. We measured preoperative osteopontin (OPN) levels in 131 consecutive patients (66.5±10years old, 117 men and 14 women) with left ventricular ejection fraction of50.7±9.2%and low logistic EuroScore (3.5±3.2%) undergoing elective Coronary Artery Bypass Grafting (CABG) surgery. Patients were prospectively followed up for a median of 12 months (range 11–24). The primary study endpoint was the composite of cardiovascular death, nonfatal myocardial infarction, need for repeat revascularization, and hospitalization for cardiovascular events. Pre-op OPN plasma levels were 77.9 (49.5, 150.9). Patients with prior acute myocardial infarction (AMI) had significantly higher OPN levels compared to those without [131.5 (52.2, 219) versus 73.3 (45.1, 125),p=0.007]. OPN levels were positively related to EuroScore (r=0.2,p=0.031). Pre-op OPN levels did not differ between patients who had a major adverse event during follow-up compared to those with no event (p=0.209) and had no effect on the hazard of future adverse cardiac events [HR (95% CI): 1.48 (0.43–4.99),p=0.527]. The history of AMI was associated with increased risk of subsequent cardiovascular events at follow-up (p=0.02). OPN is associated with preoperative risk assessment prior to low-risk CABG but did not independently predict outcome.

A right coronary artery origin from the left coronary sinus and a left coronary origin from the right sinus although rarely encountered during routine cardiac catheterization, they represent two relatively common autopsy findings in young patients suffering sudden cardiac death. The interarterial course of the aberrant artery, between the aortic root and the pulmonary artery has been considered as a malignant variant, because of the higher risk of myocardial ischemia and sudden death. We present two rare cases of ectopic coronary origin from the opposite sinus of Valsalva.

Transcatheter aortic valve implantation (TAVI) is a novel therapeutic option for severe aortic stenosis in old patients with high surgical risk. The aim of this study was to assess changes in quality of life (QoL) along with functional status and late survival after this procedure.Thirty-six consecutive patients (80.5 ± 5.9 years, 21 men and 15 women) with a logistic Euroscore of 29.7 ± 13.7 underwent TAVI using the 18-Fr CoreValve prosthesis. Aortic valve prosthesis was inserted retrograde using a femoral or a subclavian arterial approach. QoL was evaluated by administering the Short Form 36 (SF-36) tool and the shorter SF-12 version 2 (SF-12v2) questionnaires before and 1-year after TAVI.TAVI was successfully performed in all patients. The estimated 1-year overall survival rate using Kaplan-Meier method was 68%. One-year follow-up also showed a marked improvement in echocardiographic parameters (peak gradient 76.2 ± 26.1 vs 15.4 ± 7.8 mm Hg, P.001; aortic valve area 0.7 ± 0.1 vs 2.6 ± 2.7 cm(2), P.001) with a significant change in New York Heart Association class (3 ± 0.7 vs 1.2 ± 0.4, P.001). Both preprocedural summary SF-36 and SF-12v12 physical and mental scores showed a significant improvement 1 year after TAVI (21.6 vs 46.7, P.001; 42.9 vs 55.2, P.001; 22 vs 48.9, P.001; 43.3 vs 52.2, P.001, respectively).Our results show a marked 1-year clinical benefit in functional status and physical and mental health in patients who underwent TAVI.

Ischemia modified albumin (IMA), as measured using the albumin cobalt binding test, is currently the most promising biomarker for early detection of ischemia before the onset of irreversible cardiac injury. This paper reviews the information available on IMA, including its pathophysiology, analysis, clinical applications and future perspectives. The data provided was identified by a search of MEDLINE using the terms IMA, biomarkers and ischemia. IMA may be useful to cover the complete diagnostic window of patients presenting with acute coronary syndromes (ACS) in the Emergency Department, along with the electrocardiogram and cardiac troponins. Preliminary data regarding the significance of IMA in the prognosis of either ACS or following revascularization need further study.

Heart-type fatty acid-binding protein (H-FABP) is considered a marker of myocardial necrosis but whether or not it is modified by myocardial ischemia is not clear. We sought to investigate if H-FABP serum levels increase following non-urgent coronary angioplasty.We studied 31 patients undergoing coronary angioplasty. Peripheral venous samples were drawn immediately before angioplasty, 1 h after the first balloon inflation and 24 h after the procedure and assayed for H-FABP.Serum levels of H-FABP increased significantly at 1 h vs baseline from 2554 +/- 1268 to 3322 +/- 245 pg ml(-1) (p = 0.024). However, no differences were observed between 1 h and 24 h after angioplasty (3268 +/- 1861 vs 3322 +/- 2459 pg ml(-1), p = 0.87). Moreover, no significant difference was observed when we compared 24 h after angioplasty with the baseline (3268 +/- 1861 vs 2554 +/- 1268 pg ml(-1), p = 0.112).We conclude that H-FABP significantly increases after elective coronary angioplasty at 1 h compared with baseline values; whether or not this has any prognostic significance for future events, as it occurs with troponins, needs to be studied further.

Any increase of cardiac biomarkers after coronary artery bypass grafting (CABG) indicates myocyte necrosis and is likely to be related to an impaired outcome. We investigated whether ischaemia-modified albumin (IMA), a biomarker of ischaemia, is also raised following CABG.We studied 50 stable consecutive patients undergoing elective isolated CABG on cardiopulmonary bypass, of whom 46 were men and four women, aged 64 +/- 9 years. Blood samples were obtained the day before the operation (pre-op) as well as immediately after the operation, 24 h postoperatively (post-op) and the fourth day post-op and assayed for creatine kinase, the MB isoenzyme of creatine kinase, cardiac troponin-I, albumin and IMA.The typical rising and falling pattern of myocardial necrosis of all three cardiac enzymes was observed post-op (p0.0001). IMA increased significantly following CABG at all three time points (113 +/- 43, 106.7 +/- 22.6 and 110.2 +/- 12.5 U ml(-1), respectively) compared with pre-op values (91.7 +/- 10.5 U ml(-1)), (p0.0001); the sample immediately post-op was significantly higher compared with the following samples (immediately post-op vs 24 h, p = 0.008 and immediately post-op vs 4 days, p = 0.03, with no significant difference between the last two). IMA level changes during the study course were independent of the albumin changes. Haemoglobin decreased significantly post-op (p0.0001 vs baseline) whereas serum creatinine did not differ during the study period.IMA increases significantly following CABG but whether or not this carries a prognostic significance remains to be elucidated.

Ischemia modified albumin (IMA) is considered a biomarker of myocardial ischemia. We sought to investigate whether IMA plasma levels change during pharmacological stress test, in patients with stable coronary artery disease.We studied 37 patients undergoing non-invasive evaluation with a pharmacological stress test, either with radionuclide myocardial perfusion imaging with adenosine or stress echocardiography with dobutamine. Peripheral venous samples were collected before the stress test (baseline), at the end of adenosine infusion or at the peak dose of dobutamine and 60 min after the completion of the stress test for IMA measurement.IMA plasma levels significantly increased at peak vs. baseline (91.28+/-9.59 U/ml vs. 97.97+/-9.69 U/ml, p0.0001) and subsequently, decreased significantly at 60 min compared to peak (97.97+/-9.69 U/ml vs. 94+/-15.22 U/ml, p=0.016), returning to values similar to those at baseline (p=0.134). Similarly, in patients with a negative stress test, IMA significantly increased at peak compared to baseline (91.08+/-10.03 U/ml vs. 99.58+/-8.43 U/ml, p=0.006) and returned to baseline at 60 min (99.58+/-8.43 U/ml vs. 91.83+/-7.93 U/ml, p=0.019), the 60 minute levels being similar to baseline values (p=0.212). Conversely, in patients with a positive stress test, IMA significantly increased at peak compared to baseline (91.38+/-10.13 U/ml vs. 97.17+/-10.34 U/ml, p=0.006) and although decreased at 1 h, this did not reach statistical significance compared either to the baseline or to the peak values (95.04+/-17.76 U/ml vs. 91.38+/-10.13 U/ml, p=0.315 and 95.04+/-17.76 U/ml vs. 97.17+/-10.34 U/ml, p=0.235, respectively).IMA plasma levels change significantly during pharmacologic stress testing, in patients with coronary artery disease, but with no difference between the positive and the negative tests.

Background: Ischemia-modified albumin (IMA) is considered a marker of myocardial ischemia whereas cardiac enzymes are released when cardiac necrosis occurs. It has previously been shown that permanent pacemaker-defibrillator insertion is associated with myocardial injury expressed as cardiac enzyme rise. Objective: We assessed whether pacemaker-defibrillator implantation also induces changes in IMA plasma levels and whether, therefore, myocardial ischemia precedes necrosis. Methods: We studied 64 consecutive patients undergoing pacemaker or defibrillator implantation; 43 were men and 21 women and their age was 70 ± 11 years (range 23–84 years). Blood samples were collected at baseline, six hours and 48 hours following the procedure. IMA measured by the albumin cobalt binding test (ACB, Integra 800 analyzer), as well as creatine kinase (CK), the MB isoenzyme of creatine kinase (CK-MB) and cardiac troponin I (Tn-I) were evaluated. Results: Data analysis showed that compared to baseline measurements, IMA increased at six hours (P = 0.015) and at 48 hours (P = 0.003)[97.6 ± 10.2 vs 101.4 ± 10.7 vs 102.1 ± 9.2 U/mL at baseline, six hours and 48 hours, respectively]; similarly, CK increased at six hours (P = 0.0001) and remained high at 48 hours (P = 0.0001) [74.9 ± 49.9 vs 136.1±186.7 vs 115.2 ± 63.9 mIU/mL], while CK-MB increased at six hours (P = 0.0001), but returned to baseline values at 48 hours (P = 0.05) [0.90 ± 0.89 vs 1.27 ± 134 vs 0.71 ± 0.63 ng/mL] and Tn-I increased at six hours (P = 0.0001) and returned to baseline levels at 48 hours (P = 0.32) [0.057 ± 0.23 vs 0.16 ± 0.36 vs 0.03 ± 0.045 ng/mL]. Conclusion: Permanent pacemaker-defibrillator insertion is associated with myocardial ischemia and necrosis.

BACKGROUND transcatheter aortic valve implantation (TAVI) has emerged as an alternative to surgical aortic valve replacement for patients with severe aortic stenosis considered inoperable or at high operative risk, but the long-term outcome remains unknown. HYPOTHESIS we assessed the 4-year clinical and echocardiographic outcomes of patients undergoing TAVI with the self-expanding Medtronic CoreValve prosthesis. METHODS sixty-three patients (mean age 80 ± 6 years) with severe aortic stenosis (AS) at high risk for surgical aortic valve replacement (Logistic EuroSCORE 28.8 ± 10.9%) were included in this study. RESULTS all-cause cumulative mortality at 1, 2, 3 and 4 years was 14.3, 25.4, 28.6 and 36.5%, respectively. The cumulative incidence of documented major stroke at 4 years was 6.3%. In survivors, there was a significant improvement in functional status at 4 years. Paravalvular leak (trivial/mild to moderate) was observed in the majority of patients post-TAVI with no case of progression to severe regurgitation at 4-year follow-up. In multivariate analysis, independent predictor for increased all-cause mortality was left ventricular ejection fraction

The authors investigated whether neutrophil to lymphocyte ratio (N/L) can contribute to the diagnosis and risk assessment in patients with type A acute aortic dissection (AAD).The authors studied 120 consecutive patients with type A AAD (group I) and compared them with 121 consecutive patients with chronic aneurysms (group II) and 121 age- and sex-matched healthy subjects (group III).It was found that white blood cell count, N/L, D-dimer and C-reactive protein were significantly higher in group I versus both groups II and III (p0.001 for all comparisons). White blood cell count and D-dimer were much higher in patients who died compared to survivors in group I (p = 0.023 and p = 0.033, respectively). A cutoff value of N/L4.6 was associated with 0.89 sensitivity and 0.91 specificity for AAD.High N/L may contribute to the diagnostic evaluation and prompt immediate therapy in patients with type A AAD.

Heart rate (HR) is a strong prognostic indicator in patients with coronary artery disease (CAD). However, there is only limited evidence on HR and the use of b-blockers in patients with CAD in contemporary clinical practice.CLARIFY is an international, prospective, observational, longitudinal registry of outpatients with stable CAD, defined as prior myocardial infarction or revascularization procedure, evidence of coronary stenosis50%, or chest pain associated with proven myocardial ischemia. A total of 33,283 patients from 45 countries were enrolled between November 2009 and July 2010; of these, 559 patients were enrolled in Greece (age 62.3 ± 10.6 years, 84.44% men).HR measured by pulse was 68.3 ± 10.2 bpm and by electrocardiogram 67.6 ± 10.9, with an excellent correlation (r=0.91, p0.001). Overall, 42.8% had HR70 bpm. B-blockers were prescribed in 74.2% of patients. Resting HR by pulse on b-blocker was 67.8 bpm and without b-blocker 69.6 bpm (p=0.069). HR70 bpm was independently associated with a lack of physical activity, higher systolic blood pressure, and a higher prevalence of asthma or chronic obstructive pulmonary disease and carotid artery disease.Despite the use of HR lowering agents, the percentage of patients with HR70 bpm was high. It is likely that we can further improve HR control in Greek patients with stable CAD by both increasing the prescription of b-blockers and up-titrating their dose, as well as by using and up-titrating other available HR lowering agents.

We describe the case of a recipient of an implantable cardioverter defibrillator with multiple syncopal episodes due both to superior vena cava obstruction and electrical instability. These complications occurred in the presence of two transvenous implantable cardioverter defibrillator leads. The patient has been managed conservatively with anticoagulants and new antiarrhythmic drugs with improvement in both his clinical problems.

Purpose: Raloxifene is a selective estrogen receptor modulator and an attractive alternative to estrogen replacement as it obviates the need for a progestin and does not increase C-reactive protein levels. We compared the effects of simvastatin and raloxifene treatments on the lipid profile, the levels of adhesion molecules and the endothelium dependent and independent vasoreactivity. Subjects & Methods: We treated 12 postmenopausal women with hypercholesterolemia and coronary artery disease with raloxifene 60 mg/day and simvastatin 20 mg/day in a randomized, double-blind, crossover study. Each treatment period was 8 weeks long with a 4-week washout interval. Plasma lipids and cellular adhesion molecules were evaluated and peripheral blood flow studies with venous occlusion plethysmography were performed. Results: Both simvastatin and raloxifene significantly reduced total [33% (27–40), 12% (0–24)] and LDL [44% (36–52), 16% (0–33)] cholesterol compared to baseline values (p < 0.05) but simvastatin was more effective than raloxifene (p < 0.005). None of the treatments had any significant effect on HDL cholesterol and triglyceride levels. Only raloxifene significantly reduced Lp(a) [18% (1–36)] and ICAM-1 [17% (8–25)] and VCAM-1 [24% (15–33)] plasma levels compared to baseline (p = 0.019, p < 0.0001 and p = 0.003, respectively). Hyperemic blood flow response on raloxifene was significantly higher compared to baseline [52% (0–105)], (p < 0.05), whereas no significant change was noted on simvastatin. Endothelium independent blood flow induced by nitroglycerine was not influenced by either active treatment. Conclusions: Raloxifene administration is associated with lower ICAM-1, VCAM-1 and Lp(a) plasma levels and enhanced endothelium dependent dilation compared to simvastatin although simvastatin is more powerful in total and LDL cholesterol reduction.

Objectives We sought to investigate whether heart-type fatty acid binding protein (H-FABP), a new marker of myocardial necrosis, increases in relation to elective cardioversion of atrial fibrillation (AF). Methods We studied 25 consecutive patients (61 ± 16 years old, 21 men) admitted to our hospital for elective cardioversion of AF. Peripheral venous samples were drawn immediately before cardioversion, one hour and 24 h after the procedure and assayed for H-FABP. Results A mean of 309 ± 183 J was used for cardioversion. Successful cardioversion in sinus rhythm was achieved in 18 patients (72%). Serum levels of H-FABP did not change significantly either in relation to the procedure [1385 (256–17,127) pg/mL at baseline, 1125 (290–15,238) pg/mL 1 h post and 1045.5 (66–2981) pg/mL 24 h post cardioversion, p = 0.37] or to the success of the procedure. Conclusion H-FABP does not significantly change following elective cardioversion for AF and we, therefore, speculate that myocardial necrosis does not occur during cardioversion.

Coronary artery disease (CAD) is highly prevalent worldwide, yet there is a paucity of data regarding the clinical characteristics and management of outpatients with stable CAD. In this paper, we report the baseline data of the Greek cohort and we compare our national data with the global results of the entire registry, as well as the results from the western European countries.CLARIFY is an international, prospective, observational, longitudinal registry of outpatients with stable CAD, defined as prior myocardial infarction or revascularization procedure, evidence of coronary stenosis50%, or chest pain associated with proven myocardial ischemia. A total of 33,283 patients from 45 countries in 4 continents were enrolled between November 2009 and July 2010; of these, 14,726 were from western European countries (Austria, Belgium, Denmark, France, Germany, Greece, Ireland, Italy, Netherlands, Portugal, Spain, Switzerland and the United Kingdom) and 559 patients were enrolled in Greece.Compared to their counterparts in western Europe and the entire cohort, Greeks were younger (p0.0001, p0.0001, respectively), more predominantly male (p0.0039, p0.0001), with a higher body mass index (p0.0002, p0.0001) and a larger waist circumference (p0.0001, p0.0001), as well as a higher prevalence of family history of CAD (p0.0008, 0.0005), hyperlipidemia (p0.0001, p0.0001) and smoking (p0.0001, p0.0001). Noninvasive testing (p0.0001, p0.0001, respectively) and coronary angiography (p0.0001, 0.0013) along with surgical revascularization (CABG) (p0.0001, 0.0088) were performed more often in Greece. Antiplatelets, b-blockers and lipid lowering medications were used to an equal extent in Greece as in the other two cohorts.There are substantial differences in demographics, clinical profiles and treatment in patients with stable CAD within the data set, which are also observed for Greek data. Interestingly, these differences are consistent in relation to the global as well as the western European data.

ZD4522 - a new HMG-CoA reductase inhibitor - causes rapid and profound reductions in plasma LDL-C levels in patients with primary hypercholesterolaemia

Aims: To test the hypothesis that ketanserin augments coronary collateral blood flow and decreases myocardial ischemia during balloon angioplasty. Methods and Results: Forty-four patients with single vessel disease and stable angina were studied. Collateral flow was determined during balloon inflations, based on the distal velocity time integral (13 patients) or on coronary wedge/mean arterial pressure measurements (10 patients). The 2nd and 3rd inflations lasted the same time and between them 1.5 mg intracoronary ketanserin in 10 ml normal saline was administered over 3 min. In 21 control subjects normal saline alone was given. In the flow velocity group the velocity time integral was 78.5 ± 53.1 mm during the 2nd inflation and 106.0 ± 43.2 mm during the 3rd (p < .05), while the ST deviation was 1.1 ± .7 and .7 ± .7 mm, respectively (p. < .05). In the intracoronary pressure group the CWP/MBP was .40 ± .10 during the 2nd inflation and .45 ± .11 during the 3rd (p. < .05), while the ST deviation was 1.2 ± .8 and .8 ± .8 mm respectively (p. < .05). In the controls no variables changed during the tested inflations. Conclusion: Intracoronary administration of ketanserin augments coronary collateral flow and decreases myocardial ischemia during balloon angioplasty. This could be of clinical significance in the management of acute ischemic syndromes.

Early diagnosis and treatment are pivotal for patients with acute aortic dissection (AAD). D-dimer is a rule-out diagnostic test for pulmonary embolism but there is evidence that it may also be applicable to AAD. We evaluated plasma D-dimer, white cell blood count (WBC), C-reactive protein (CRP) and N-terminal pro-B-type natriuretic peptide (BNP) in 18 consecutive patients with established AAD, 21 consecutive patients with dilated ascending aortas scheduled for elective surgery and 8 normal subjects. Patients with AAD had significantly higher elevated D-dimer, compared to chronic aneurysms and normal controls (p

Aim Ischaemia modified albumin (IMA) is considered a marker of myocardial ischaemia, in contrast to the biomarkers of myocardial injury [creatine kinase (CK), the MB isoenzyme of CK, and cardiac troponin I (Tn-I)] that are released when cardiac necrosis occurs. Ischaemia modified albumin has been reported to increase following percutaneous coronary intervention and in acute coronary syndromes. We sought to determine whether IMA increases following radiofrequency (RF) ablation. Methods and results We studied 40 consecutive patients who underwent RF catheter ablation; 20 were men and 20 women and their age was 47 ± 16 (16–77) years. All patients underwent electrophysiological study and subsequent RF ablation. Peripheral venous samples were collected before the procedure (baseline), immediately after the procedure, 2 h post-procedure and the following day (20 h post-procedure) and assayed for CK, the MB isoenzyme of CK, cardiac Tn-I and IMA. Ischaemia-modified albumin plasma levels did not differ significantly at all four time points, baseline, and following ablation ( P = 0.5974), whereas CK, CK-MB, and Tn-I increased significantly at all time points compared with baseline ( P < 0.0001). Post-ablation, all but three 3 CK measurements were in the normal range; 14 patients had CK-MB plasma levels above the upper limit of normal; all but one patient had Tn-I elevated. Conclusion The IMA plasma levels do not change significantly following RF ablation, unlike biomarkers of myocardial injury, implying that myocardial necrosis occurs without preceding ischaemia.

Objectives. This study sought to compare hormone replacement therapy (HRT), simvastatin and their combination in the management of hypercholesterolemia in postmenopausal women with coronary artery disease (CAD).Background. Lipid-lowering therapy reduces mortality in hypercholesterolemic women with CAD. In postmenopausal women HRT seems to increase survival, particularly those with ischemic heart disease, and this is partly due to changes in lipid levels.Methods. We studied 16 postmenopausal women with CAD and fasting total cholesterol

Background and hypothesis: In vitro studies have shown that atrial natriuretic peptide (ANP) causes relaxation of pre-constricted blood vessel strips and inhibits the contraction of isolated vessels in response to norepinephrine and angiotensin II. The present study examined the effects of exogenous ANP on the coronary collateral blood flow during angioplasty. Methods: We studied 15 patients undergoing elective balloon angioplasty during the second and third balloon inflations. A Doppler flow guidewire was advanced distal to the lesion and used for the estimation of coronary blood flow velocity. After the second balloon inflation, 25 ng/kg/min of ANP were administered intracoronarily for 8 min. Electrocardiogram, pressure, and flow velocity were recorded immediately before each balloon deflation. Fourteen other patients served as controls and received normal saline infusion. Results: Velocity time integral increased from 65 ± 40 to 79 ± 46 mm (p < 0.05) during the third balloon inflation, whereas ST deviation decreased from 1.3 ± 0.9 to 0.7 ± 1.0 mV (p< 0.05). These variables did not change in the control group during the two tested balloon inflations. Conclusion: Exogenous ANP augments coronary collateral blood flow and ameliorates myocardial ischemia during angioplasty.

Altered sequence of ventricular activation sequence results in marked derangements in mechanical events. In the present study, we investigated the comparative effects of atrial and AV sequential pacing on collateral blood flow during angioplasty. Twenty-eight patients with stable angina and left anterior descending artery disease undergoing balloon angioplasty were studied. Collateral flow was determined during balloon inflation from the distal flow velocity of the ipsilateral artery (17 patients) or from the increase of the maximal diastolic blood flow velocity (Vc) of the contralateral artery (11 patients). Flow measurements were made using the Doppler flow guidewire. The relative resistance in the collateral vascular bed (RR) also was estimated in the latter group of patients. After the first balloon inflation, two similar consecutive balloon inflations were done under atrial and AV sequential pacing, at a rate of 15 beats/min higher than the sinus rate, in the absence of vasoactive medication. One minute after the initiation of pacing, the second and third balloon inflations were begun and the pacing continued until the balloon inflations were completed. In the ipsilateral group, average peak velocity was 84.6 +/- 24.2 mm/2 during atrial pacing and 82.7 +/- 29.7 mm/s during AV sequential pacing (P = NS). In the contralateral group, Vc was 18% +/- 12% during atrial pacing and 17% +/- 14% during AV sequential pacing, and the RR was 4.5 +/- 4.7 and 4.9 +/- 6.4, respectively (both P = NS). The coronary wedge/mean blood pressure was similar during the two tested balloon inflations. Short-term AV sequential pacing at rest does not adversely affect collateral blood flow and resistance in patients with left anterior descending artery disease.

The effect of β-adrenergic blockade on coronary collateral blood flow has not been clarified. We examined the acute effects of β-adrenergic blockade on coronary collateral blood flow. Fifteen patients (Part A) with stable angina were studied while undergoing coronary angioplasty. According to the protocol, all patients underwent a minimum of three balloon inflations. Collateral flow velocity was determined during balloon inflations using the Doppler flow guidewire positioned distally to the lesion. The two tested balloon inflations, the second and third, were maintained for the same length of time. Between the second and third balloon inflations, 1 mg of propranolol was administered IC into the treated artery. Ten controls were studied following saline infusion. In 10 other patients (Part B), the effect of 1 mg IC propranolol on the coronary artery area distal to the lesion was studied, and five patients served as controls. In the treated group, in Part A blood pressure remained stable during the balloon inflations tested. Heart rate decreased from 79 ± 11 to 73 ± 12 beats/min (P < .05), velocity time integral from 9.6 ± 8.2 to 6.6 ± 4.1 cm (P < .05), and ST elevation from 1.3 ± .9 to .9 ± 1.0 mV (P < .05) between the second and third balloon inflations. In the controls the variables examined did not change during the balloon inflations tested. In Part B, neither propranolol nor normal saline had any significant effect on coronary artery lumen area. Thus, IC administration of β-adrenergic blockade decreases coronary collateral blood flow, and this potentially worsens the ischemic zone. However, β-adrenergic blockade ameliorates myocardial ischemia during coronary angioplasty.

17β-estradiol, administered acutely, protects ischemic myocardium in male rabbits. In the present study we investigated the effect of short-term estrogen on myocardial infarct size in oophorectomized female rabbits. We oophorectomized 24 sexually mature New Zealand white female rabbits. Twelve animals were left untreated and 12 received oral conjugated estrogens, 0.15 mg/day, for 4 weeks. At a second stage, a third group of 12 oopherectomized female rabbits was treated with intramuscular conjugated estrogens, 1 mg/day, also for 4 weeks. All rabbits underwent 30 minutes of coronary artery occlusion and 2 hours of reperfusion while on anesthesia with IV pentobarbital. Infarct and risk area were delineated by Zn-Cd fluorescent particles and tetrazolium chloride staining. The infarct size was expressed as a percentage of the risk zone (I/R %). Data are reported on 26 animals that survived the treatment period and the experiment. Heart rate, systolic, and mean blood pressure and double product did not differ between the three groups at baseline, ischemia, and reperfusion. The infarct size of the risk zone was significantly smaller in the intramuscular group compared with both the oral and the placebo group (18.5 ± 3.5% vs. 41.3 ± 9.2% and 43 ± 8.4%, respectively, P = 0.03). Conjugated estrogens, administered intramuscularly at a high dose, protect ischemic myocardium in oophorectomized female rabbits.

We investigated the effects of coronary rotational atherectomy (PTCRA) on plasma levels of endothelin-1 (ET-1), atrial natriuretic peptide (ANP), and cyclic adenosine monophosphate (cAMP). We studied 14 patients undergoing PTCRA and compared them with 14 patients undergoing plain balloon angioplasty. Blood samples were taken from the femoral vein at baseline, after the end of the atherectomy, after the first balloon inflation, after the end of the procedure, and 4 hours later. ET-1 increased in the angioplasty group from 6.3 ± 3.2 pmol/L at baseline to 8.5 ± 3.9 pmol/L at the end of the procedure (F = 3.83, P = .02), whereas it did not change in the PTCRA group. ANP increased in the PTCRA group from 78.1 ± 15.7 pmol/L at baseline to 89.7 ± 24.0 pmol/L at the end of the procedure (F = 6.75, P = .0001), whereas it did not change in the angioplasty group. cAMP decreased in the PTCRA group, whereas it did not change in the angioplasty group. In conclusion, ET-1 increases less, ANP increases more, and cAMP decreases more during atherectomy than during plain balloon angioplasty.

OBJECTIVES We examined whether ischemia-modified albumin (IMA) plasma levels change during exercise stress testing (EST) in patients with known coronary artery disease and whether the induced changes differ between positive and negative exercise tests. BACKGROUND Ischemia modified albumin is considered a marker of myocardial ischemia and increases after coronary angioplasty and in acute coronary syndromes. METHODS We studied 40 consecutive patients with established coronary artery disease who underwent EST. Venous samples, for IMA measurement, were collected before the stress test (baseline), at peak exercise, and 60 min after the completion of the exercise test. RESULTS There was significant difference in the IMA values at the 3 prespecified time points (p = 0.012), whereas there was no interaction between the IMA changes and the result of the stress test, whether positive or negative (p for the interaction term = 0.94). Baseline, peak EST, and post-EST IMA levels were similar in patients with positive and negative exercise tests (p = 0.61). The IMA significantly decreased at peak exercise compared with baseline values in positive (p < 0.0001) and in negative EST (p = 0.012). Moreover, IMA concentration increased 60 min after EST compared with peak-EST values in positive (p < 0.0001) and in negative tests (p = 0.003), returning to pre-EST levels in both groups. CONCLUSIONS The IMA plasma levels change significantly during exercise testing in patients with coronary artery disease, but there is no difference between positive and negative stress tests; this possibly implies that the observed changes do not reflect myocardial ischemia.

Ο σακχαρώδης διαβήτης, νόσος συστηματική, συνοδεύεται από επιπλοκές, μία από τις οποίες είναι και το διαβητικό πόδι. Το διαβητικό πόδι ήταν και παραμένει μια παρεξηγημένη κλινική οντότητα, γιατί στην ανάπτυξη του συμμετέχουν τόσο η μακροαγγειοπάθεια όσο και η νευροπάθεια, συχνά δε επιπλέκεται από φλεγμονή. Τα φτωχά θεραπευτικά αποτελέσματα και η κακοδαιμονία του προβλήματος σχετίζονται με την εσφαλμένη εκτίμηση της προεξάρχουσας υποκείμενης διαταραχής. Αυτό ήταν αρκετό για την λεπτομερέστερη μελέτη του όλου θέματος. Η διερεύνηση διαβητικού ασθενούς με συμπτωματολογία από τα κάτω άκρα, επιτυγχάνεται με την κλινική αξιολόγηση και την παρακλινική μελέτη. Πρωταρχική σημασία στην κλινική εκτίμηση του ασθενή έχει το καλό ιστορικό και η συστηματοποιημένη αντικειμενική εξέταση. Από το πλήθος των παρακλινικών εξετάσεων περιοριστήκαμε στους υπερήχους, την φωτοπληθυσμογραφία και την διαδερματική οξυμετρία (TcPO₂).Οι κυριότεροι λόγοι είναι ότι, και οι τρεις είναι μέθοδοι απλές, εύχρηστες, αναίμακτες, ακίνδυνες, αναπαραγώγιμες, επαναλαμβάνονται εύκολα και έχουν μικρό κόστος. Ιδιαίτερη έμφαση δόθηκε στην οξυμετρία διότι: είναι δείκτης μεταβολικός, εκτιμά επαρκώς την μικροκυκλοφορία, δεν επηρεάζεται από την επασβέστωση του μέσου χιτώνα των αρτηριών και ανιχνεύει βλάβες και περιφερικότερα των σφυρών. Στην εργασία περιλαμβάνονται 113 ασθενείς,61 άνδρες και 52 γυναίκες, ηλικίας 40-70 ετών. Οι ασθενείς χωρίστηκαν σε 4 ομάδες: στην ομάδα Α περιλαμβάνονται 27 υγιείς μάρτυρες, μέσης ηλικίας 59,5 ετών, στην ομάδα Β 29 ασθενείς με αθηροσκληρυντική περιφερική αγγειοπάθεια χωρίς διαβήτη, μέσης ηλικίας 60,4 ετών και στην ομάδα Γ 57 διαβητικοί ασθενείς. Οι ασθενείς αυτοί χωρίστηκαν σε δύο υπο-ομάδες, την ομάδα Γ₁ όπου περιλαμβάνονται 30 ασθενείς με συμπτωματολογία από τα κάτω άκρα, μέσης ηλικίας 57,0 ετών και την ομάδα Γ₂ με 27 ασθενείς χωρίς συμπτώματα από τα κάτω άκρα, μέσης ηλικίας 46,9 ετών. Η επιλογή των ασθενών ήταν τυχαία και η ταξινόμηση τους στις ομάδες έγινε με κλινικά κριτήρια. Από σύμπτωση οι ομάδες ήταν συγκρίσιμες, γιατί οι διαβητικοί είχαν την ίδια βαρύτητα διαβήτη και οι αγγειοπαθείς ήταν του ίδιου σταδίου. Επειδή οι μετρήσεις έγιναν και στα δύο πόδια, εξετάστηκαν μεν 113 ασθενείς αλλά συγκρίνονται και μελετώνται 226 αντίστοιχα τιμές. Κατά την εξέταση των ασθενών εφαρμόστηκε συγκεκριμένο πρωτόκολλο. Χρησιμοποιήθηκαν οι υπέρηχοι για τον προσδιορισμό του σφυροβραχιόνιου δείκτη και της ροής, η φωτοπληθυσμογραφία για τον προσδιορισμό του δακτυλοβραχιόνιου δείκτη και η διαδερματική οξυμετρία για τον υπολογισμό της μερικής πιέσεως Ο₂ (TcPΟ₂) και του δείκτη ΤοΡΟ₂. Ως προς την οξυμετρία προτιμήθηκε η αλλαγή της θέσεως του μέλους στον χώρο (ύπτια, ανάρροπη, κατάρροπη, όρθια). Η στατιστική επεξεργασία των τιμών TcPΟ₂ έγινε με την δοκιμασία αναλύσεως μιας κατευθύνσεως τόσο στην οριζόντια όσο και στην κάθετη σύγκριση, και όπου το αποτέλεσμα της δοκιμασίας αυτής ήταν στατιστικώς σημαντικό ακολουθούσε η δοκιμασία t-test μεταξύ των διαφόρων ομάδων. Ακολούθησε τέλος η συσχέτιση των τιμών TcPΟ₂ προς τις άλλες παραμέτρους. Από την ανάλυση των αποτελεσμάτων συνάγονται τα εξής: Κατά την σύγκριση των τιμών TcPΟ₂ στις 4 ύπτιες θέσεις δεν διαπιστώθηκε στατιστικώς σημαντική διαφορά σε καμία ομάδα και θεωρήθηκαν ως "ενιαία" θέση στην επεξεργασία των τιμών. Κατά την σύγκριση των τιμών TcPΟ₂ στις ύπτιες θέσεις δεν διαπιστώθηκε στατιστικώς σημαντική διαφορά σε καμία ομάδα και θεωρήθηκαν ως “ενιαία” θέση στην επεξεργασία των τιμών. Κατά την σύγκριση των τιμών TcPΟ₂ στις ύπτια, ανάρροπη, κατάρροπη και όρθια θέση, διαπιστώθηκαν στατιστικώς σημαντικές διαφορές για όλες τις θέσεις, σε όλες τις ομάδες, πλην της σχέσεως κατάρροπης - όρθιας θέσεως στους αθηροσκληρυντικούς και στους ασυμπτωματικούς διαβητικούς ασθενεί ς. Ανευρέθησαν στατιστικώς σημαντικές διαφορές στις τιμές TcPΟ₂ στις ύπτιες και στην ανάρροπη θέση, κατά την σύγκριση φυσιολογικών ατόμων και ασθενών με περιφερική αγγειοπάθεια, διαβητικών και μη. Οι σημαντικότερες στατιστικώς διαφορές αφορούν την ανάρροπη θέση, με υπεροχή των διαβητικών έναντι των αθηροσκληρυντικών ασθενών. Από την σύγκριση των τιμών TcPΟ₂ μεταξύ φυσιολογικών ατόμων και ασυμπτωματικών διαβητικών ασθενών και αθηροσκληρυντικών και συμπτωματικών διαβητικών ασθενών, δεν διαπιστώθηκαν στατιστικά σημαντικές διαφορές για καμία θέση. Οι στατιστικώς σημαντικές διαφορές που προκύπτουν από την σύγκριση των τιμών του δείκτη TcPΟ₂ μεταξύ φυσιολογικών ατόμων και ασθενών με περιφερική αγγειοπάθεια διαβητικών ή μη, δεν πλεονεκτούν έναντι των αντίστοιχων των απόλυτων τιμών TcPΟ₂. Η συσχέτιση των απόλυτων τιμών TcPΟ₂ και του δείκτη TcPΟ₂ τον σφυροβραχιόνιο και δακτυλοβραχιόνιο δείκτη και την ροή, δεν είναι πολύ ικανοποιητική. Τα αποτελέσματα μας οδηγούν στο συμπέρασμα ότι, η διαδερματική οξυμετρία είναι, πολύ αξιόπιστη μέθοδος για την εκτίμηση της περιφερικής αγγειοπάθειας σε διαβητικούς και μη ασθενείς, ιδιαίτερα δε ενδείκνυται για την διερεύνηση του διαβητικού ποδιού. Η επιλογή της αλλαγής θέσεως του μέλους στο χώρο πλεονεκτεί σαφώς έναντι άλλων τρόπων που έχουν από άλλους εφαρμοστεί. Η διαδερματική οξυμετρία μπορεί να τύχει ευρείας εφαρμογής στην καθημέρα πράξη και μπορεί να συμβάλλει όχι μόνο στην ορθή αντιμετώπιση του διαβητικού ποδιού, αλλά και στην πρωϊμώτερη ανάδειξη προκλινικών βλαβών στους διαβητικούς ασθενείς.

BACKGROUND Cardiac hypertrophy is associated with numerous alterations in the coronary circulation. OBJECTIVE To test the hypothesis that, during angioplasty, the coronary collateral blood flow during repetitive coronary occlusions increases more in hypertensives than it does in normotensives. METHODS We studied 34 patients (22 normotensives and 12 hypertensives) with stable angina and single-vessel disease undergoing coronary angioplasty during two similar balloon inflations. Each balloon inflation was maintained for 120 s. The coronary blood flow velocity was estimated using the Doppler-flow guide wire, which was positioned distally to the lesion. Flow velocities were recorded before balloon deflation. RESULTS The average peak velocity increased by 29.0 +/- 14.7 mm/s in the hypertensives and decreased by 9.4 +/- 4.9 mm/s in the normotensives (P < 0.01) during the second balloon inflation, whereas the velocity-time integral increased by 33.1 +/- 19.2 mm and decreased by 14.3 +/- 11.3 mm (P < 0.05), respectively. The ST-segment elevation decreased by 1.13 +/- 1.27 and by 0.17 +/- 0.16 mV, respectively (P = 0.01). The increase in the average peak velocity which occurred during the second balloon inflation was related to the left ventricular mass (r = 0.47, P = 0.004). CONCLUSION These results indicate that the coronary collateral blood flow velocity improves with repetitive coronary occlusions during angioplasty in patients with systemic hypertension and that this increase is correlated to the left ventricular mass.

Mean platelet volume (MPV) and platelet size distribution width (PDW) are markers of platelet (PLT) size and variability in PLT size as well as PLT activation [1–3]. Reduced PLT count and increased MPV values have been reported in unruptured abdominal aortic aneurysms [4,5]. Others, however, have noted lower PLT indices (MPV and PDW) in patients with aortic aneurysm compared to age-matched controls [6]. High-grade inflammation is associated with low MPV whereas low-grade inflammation is associated with high MPV; inflammation may play a role in pathogenesis of aneurysm formation and rupture [3]. We studied PLT indices in patients with acute aortic dissection (AAD), chronic aortic aneurysms and age and sex matched normal subjects. We studied, prospectively, 100 consecutive patients with AAD admitted to our hospital for emergency surgery (group I), 100 patients with chronic aneurysms of the ascending aorta scheduled for coronary angiography prior to elective surgical repair (group II) and 100 age and sex matched normal subjects who served as controls (group III). The diagnosis was confirmed for all patients with computed tomography. Dissection was classified according to the Stanford criteria. In patients with AAD, blood samples were obtained as soon as the patient came to hospital and for patients in group II the morning of the admission, prior to catheterization. All patients gave informed consent and the study protocol was approved by the Ethics Committee of our institution. The authors of this manuscript have certified that they comply with the PrinciplesofEthicalPublishingintheInternationalJournalofCardiology. PLT indices were evaluated with anautomatic counter, including PLT count, MPV, PDW and MPV/PLT ratio (Coulter LH780, Hematology Analyzer, Beckman, Miami, USA).Bloodsamples were collected in tubes with potassium ethylenediaminetetraacetate and were analyzed 1 h after venipuncture. We also measured D-dimers with Elisa (Vidas Ddimer, Biomerieux, France) and CRP with an immunoturbidimetric method (Cobas Integra, Roche, Mannheim, Germany). The groups were compared by means of chi-square or Fishers' exact test, Kruskal Wallis test or non-parametric one-way analysis of variance, Mann–Whitney test and Spearman rank correlation coefficient, as appropriate. Baseline characteristics for all three groups are presented in Table 1. In type A dissection, 8 patients died before surgery and the remaining were all but one operated; this patient declined surgery. There were 3 deaths in the operating room and 7 post-operative deaths. In type B dissection, 2 patients died on arrival to our unit; 2 patients were transferred elsewhere for vascular surgery and 1 was operated on site; the remaining 10 were managed conservativelyand did well. Ingroup II, there were 2 deaths. As expected, aortic cross clamping time and cardiopulmonary bypass time were significantly longer in group I than in group II (p b 0.001) whereas the duration of hospitalization was similar in the 2 groups (p = 0.192). Table 2 illustratestheresultsofstudiedbiochemicalvariablesamong groups. Within group I, PLT count was lower [186 (146,212) vs 222 (195,264)] and the MPV/PLT ratio was higher [0.047(0.036, 0.059) vs 0.037(0.033, 0.04)] in type A dissection compared to type B (p = 0.009 and p = 0.008, respectively). In addition, MPV as well as the MPV/PLT ratiowere significantlylowerinpatientswithmore extensivedissection with involvementof the abdominal aorta and the iliacarteries; in detail, when comparing thoracic vs thoracic–abdominal vs thoracic–abdominal–iliacdissection,MPVwas8.7(8.1,9.5),7.9(7.4,8.4)and8.1(7.1,8.7), respectively (p = 0.013) and MPV/PLT ratio was 0.05 (0.037, 0.062), 0.041 (0.036, 0.047) and 0.038 (0.034, 0.048), respectively (p = 0.042).

Transcatheter aortic valve implantation (TAVI) is a tremendous therapeutic advance for patients with severe aortic stenosis and high-surgical risk. Since TAVI-treated patients are elderly with multiple co-existing conditions, limited life expectancy and disproportionate health-care expenditures, the aspect of the health-related quality of life (HRQoL) benefits becomes of fundamental importance. Based on recent evidence, TAVI appears to improve significantly HRQoL measures compared with optimal standard care, which are restored to age-adjusted population norms over time.

Background Biomarkers for monitoring progression and prognosis of thoracic aneurysm are of great interest. Homocysteine (Hcy) induces elastolysis in arterial media and may directly affect fibrillin-1 or collagen whereas lipoprotein (Lp) (a) inhibits elastolysis by reducing activation of matrix metallopeptidase-9. Methods We studied 31 consecutive patients with acute aortic dissection (AAD) admitted for emergency surgery (group I, 60±13years old, 25 men), 30 consecutive patients with chronic aneurysms of the ascending aorta (group II, 67±12years old, 24 men) and 20 healthy controls (group III, 58±15years old, 14 men). We evaluated Hcy, folate, B12, Lp(a) and methylenetetrahydrofolate reductase (MTHFR) C677T polymorphism at baseline. Results Hcy, folate and B12 differed significantly among the 3 studied groups ( P =0.016, P =0.004 and P =0.001, respectively). The levels of Hcy and B12 were significantly higher in group I compared to both groups II and III ( P =0.05 and P =0.002, P P =0.017, respectively) and without significant differences between groups II and III ( P =0.083 and P =0.124). Folate was significantly lower in group I compared to both groups II and III ( P =0.001 and P =0.006, respectively) and without marked difference between groups II and III ( P =0.409). No significant difference was found in serum levels of Lp (a) ( P =0.074) or among the frequency of MTHFR C677T genotypes. Conclusions Patients with AAD present with higher Hcy and lower folate compared to both chronic aneurysms and controls.

Osteopontin (OPN) is a multifunctional protein associated with vascular injury and has been linked to atherosclerosis and inflammation. We sought to investigate whether OPN changes in relation to coronary artery by-pass grafting (CABG) surgery.We studied 50 consecutive patients (63 ± 10 years old, 6 women and 44 men) undergoing elective CABG. Plasma OPN levels were determined by an enzyme-linked immunosorbent assay at baseline and in 24 and 72 h, post-operatively. Cardiac enzymes - creatine kinase, the MB isoenzyme of creatine kinase, troponin-I- and C-reactive protein (CRP) were also determined at all three time points.OPN levels 72 h post-op decreased significantly compared to pre-op and 24h post-op levels (p0.001) whereas there was no difference between the pre-op and first post-op values (p=0.57). The relative change in OPN levels between pre-op and 72 h post-op correlated negatively with absolute troponin-I levels at 72 h post-op (-0.51, p=0.005). OPN levels 72 h post-op correlated significantly with CRP at baseline (r=0.73, p=0.002).OPN plasma concentrations decreased after CABG surgery in the early post-operative period. The significance of this observation needs further investigation.