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Introduction Anomalous origin of coronary arteries has been observed in about 0.35-2.10% of the population. Patients with anomalous right coronary artery (ARCA) may present with significant symptoms, arrhythmias or ACS, and at times sudden death. Traditionally, surgical correction has been the recommended treatment. However, these may be technically challenging, and bypass grafting for such anomalies has the potential for graft failure because of competitive flow. We sought to determine the intermediate and long-term outcomes of drug-eluting stent placement for patients with symptomatic ARCA. We also looked at angiographic findings suggestive of interarterial course as confirmed by subsequent computed tomography (CT) findings. Methods Between January 2005 and December 2012, we enrolled 11 patients for elective percutaneous coronary intervention (PCI) of ARCA in a single center, prospective, nonrandomized fashion. Patients were followed up in clinic at 1 week, 3 months, 6 months, and 1 year, and then annually or more frequently if needed. All patients underwent a cardiac CT, as well as functional stress testing when needed to assess for recurrence of disease. Results All 11 of our patients, who presented with significant symptomatic stenosis with an ARCA, were successfully treated with PCI. Mean follow-up duration was 8.5 years. The only two deaths during follow-up were related to noncardiac causes (sepsis), with a mortality rate of 18.2%. Two patients had a positive functional study and on subsequent coronary angiography, one of them had significant in-stent restenosis (target lesion revascularization of 9.1%) and one distal to the stent (target vessel revascularization 9.1%). We found the observation of a "slit-like lesion" on angiography to have a sensitivity of 100% and specificity of 86% for the diagnosis of interarterial course of the anomalous vessel seen on subsequent CT. Conclusions Our study results suggest that PCI of ARCA is an effective and low-risk alternative to surgical correction, with good procedural success and long-term outcomes. It can provide symptomatic relief in such patients and may reduce the risk of sudden death in younger patients, without the inherent risks associated with surgical repair.

Introduction: Medication non-adherence is a major healthcare barrier, especially among diseases which are largely asymptomatic such as hypertension. The impact of poor medication adherence ranges from patient specific adverse health outcomes to broader strains on health care system resources. Accordingly, there is rich literature examining the causes and consequences of suboptimal medication adherence. Objective: To document the relationship between blood pressure medication adherence, socioeconomic status, health care costs, and outcomes among Medicare beneficiaries with heart disease in the United States. Methods: The CDC Wonder database was used to retrieve Centers for Medicare and Medicaid Services’ data pertaining to blood pressure medication adherence, socio-economic variables, per-capita healthcare costs, and cardiovascular outcomes among beneficiaries by county across the United States. Spearman correlation was used to analyze the relationship between various factors. Results: Among Medicare beneficiaries, blood pressure medication non-adherence rates ranged from 15.9% to 56.2% with a mean of 26.5% ± 5.3% among the 3,196 counties reporting data. Factors that strongly correlated with non-adherence include poor educational attainment (0.678, p&lt0.01) and poverty status (0.613, p&lt0.01). Although non-adherence had a weakly positive relationship with inpatient costs (0.183, p&lt0.01) and total overall costs (0.324, p&lt0.01), it demonstrated a solid correlation with cardiovascular deaths (0.42, p&lt0.01), stroke death (0.420, p&lt0.01), stroke hospitalization (0.415, p&lt0.01), and hypertension related hospitalization (0.561, p&lt0.01). Conclusions: Our analysis of Medicare beneficiary data across the United States demonstrates a strong correlation between socioeconomic determinants of health and poor medication adherence. Our data further demonstrates that poor medication adherence translates into both worse cardiovascular outcomes and higher health care costs. In an era where health care spending has become overwhelmingly problematic, these findings provide compelling evidence for increased efforts focusing on educational and incentive based programs to improve medication adherence.

Medication non-adherence is a major healthcare barrier, especially among diseases that are largely asymptomatic such as hypertension. The impact of poor medication adherence ranges from patient specific adverse health outcomes to broader strains on health care system resources. The CDC Wonder

Magnetic resonance angiography (MRA) of central and peripheral vessels is a well-established method. ACC/AHA 2005 Practice Guidelines for the Management of Patients with Peripheral Arterial Disease recommends that MRA of the extremities should be performed with gadolinium enhancement (class I recommendation). However, due to concerns about the cost and safety of gadolinium-based contrast agents in certain patients, there is significant ongoing development in the field of non-contrast MRA with promising results. Appropriate indications for peripheral MRA include diagnosis of peripheral arterial disease (PAD), selecting patients for endovascular intervention or surgical bypass of lower extremity PAD, and post-revascularization surveillance of lower extremity PAD. Other indications include assessment of peripheral arterial aneurysms, dissection, and peripheral thromboembolism. The role of MRA in acute critical limb ischemia is limited due to the need for urgent diagnosis and intervention that can be achieved with invasive angiography.

Left ventricular noncompaction is frequently seen in non-ischemic cardiomyopathy (NICM). The number of non-compacted segments determines the diagnosis of left ventricular noncompaction cardiomyopathy (LVNC). This study evaluates the impact of increasing number of noncompacted segments on structural

With the increasing prevalence of cardiovascular disease amongst the aging population as well as the expanding indications for the use of oral anticoagulants, physicians are more likely to encounter patients on these medications in the inpatient and outpatient settings. To provide appropriate care for these patients, physicians must understand the pharmacology of the available oral anticoagulants, the clinical indication for anticoagulation, and the appropriate preoperative, perioperative, and postoperative management of these patients. While short-term anticoagulation is often times achieved with the use of intravenous or subcutaneous heparin, chronic anticoagulation is achieved with warfarin or other newer novel anticoagulants (NOAC). Due to the different pharmacologic properties, each of the anticoagulants provides varying challenges and limitations in the clinical setting. Patient with cardiovascular disease have numerous indications for requiring chronic anticoagulant therapy including atrial fibrillation/flutter, prosthetic heart valves, significant heart failure including those requiring mechanical assist devices, and thromboembolic disease. Understanding the clinical indication necessitating the use of oral anticoagulation as well as the specific pharmacology of these agents is essential to providing adequate care to these patients. This chapter provides an in-depth review of the numerous anticoagulant strategies available, the indications for prescribing these therapies, as well as the preoperative, perioperative, and postoperative management of patients on these medications.

Background Cardiac magnetic resonance imaging (CMR) can accurately delineate myocardial scar for substrate guided ventricular tachycardia (VT) ablation. Susceptibility artifact from cardiac rhythm management device (CRMD) generator and leads can significantly affect image quality limiting the evaluation of myocardial scar and foci of VT. We conducted a retrospective study to correlate scars from CMR to the voltage mapping obtained at electrophysiology study (EPS).

Background The presence of microvascular obstruction (MO) on delayed enhanced cardiac magnetic resonance (DECMR) imaging is associated with adverse remodeling and poor prognosis after STEMI. Identifying which patients that may develop MO prior to undergoing acute mechanical reperfusion maybe important in managing patients for more direct interventions. We sought to evaluate clinical predictors of MO as depicted by DECMR. Methods We included 255 patients with their first STEMI reperfused with primary percutaneous intervention. A standard DE-CMR was performed acutely at a mean of 3.9±2.0 days after admission. Clinical risk factors, time to reperfusion as well as angiographic variables were prospectively collected. The angiographic area at risk and the infarct size as a % of the left ventricle (LV) were computed. The number of segments with MO, defined as an area of hypoenhancement surrounded by delayed enhancement on DE-CMR, were summed to calculate MO extent.

Methods We analyzed 181 patients from the DEfibrillators To REduce Risk by MagnetIc ResoNance Imaging Evaluation Trial. All patients underwent cine and contrastenhanced (CE) CMR. Cine and CE studies were scored on a 17-segment model by the consensus of two readers. Cine images were scored for wall motion (WM): 0 = normal, 1 = mild hypokinesis, 2 = moderate to severe hypokinesis, 3 = akinesis, 4 = dyskinesis. CE images were scored for hyperenhanced (HE) infarct transmurality: 0 = none, 1 = 1-25% HE, 2 = 26-50% HE, 3 = 51-75% HE, 4 = 76-100% HE. Manually planimetered, quantitative analysis was also performed to obtain LV ejection fraction (EF) and infarct size using QMass MR 7.2 (Medis, Leiden, the Netherlands). DV-Myo segments were defined as having WM score ≥ 2 and HE score ≤ 1. DVMyo involving 2-4 of 17 segments (12-24% of LV) was considered prognostically significant only. DV-Myo involving ≥ 5 of 17 segments (≥ 29% of LV) was considered functionally significant. Results Baseline characteristics included male sex (84%) and mean age 61.5 ± 11.2 (31-88). Patients were on standard medical therapy, including beta-blockers (93%), ACE inhibitor/ARB (82%), anti-platelet (100%) and lipid lowering agents (94%). The population had a mean EF of 38.9 ± 11.6% (range 11.4 69.1%) and infarct size 17.3 ± 10.3% of LV (range 0 59.5%). A total of 3077 segments were evaluated, of which 442 (14%) segments met criteria for DV-Myo. Prognostically significant DV-Myo was present in 49/181 patients (27.1%). These patients had a mean of 2.7 ± 0.7 affected segments and a mean EF of 34.4 ± 7.7%. Functionally significant DV-Myo was present in an additional 33/181 patients (18.2%). These patients had a mean of 8.1 ± 3.0 affected segments and a mean EF of 26.2 ± 8.5%.

Alzheimer's disease (AD) is a fatal, progressive dementia for which there is no cure and for which a molecular basis has yet to be established. However, considerable evidence suggests that AD is linked to neurotoxic assemblies of the 42-amino-acid peptide amyloid beta (Abeta). There is now a clear body of evidence that shows this neurotoxicity resides not only in insoluble fibrils of Abeta but also in soluble Abeta ADDLs (Abeta-derived diffusible ligands) and larger protofibrils. Further, anti-Abeta antibodies have been reported to reverse memory failure in human amyloid precursor protein (hAPP)-expressed transgenic mice in a manner that suggests symptom reversal is attributable to targeting of ADDLs. Clearly, a search for drugs targeting the assembly of these soluble Abeta species represents a new and potentially important approach to the treatment of AD. In this work we describe the development of a dot-blot immunoassay to measure ADDL at the femtomole level, its use in defining the time course of ADDL formation, and its use in determining the presence of ADDLs in the hAPP transgenic mouse brain. Discussion of a protocol to screen agents for inhibition of neurotoxic ADDLformation both in vivo and in vitro is also presented. The methods are suitable for screening combinatorial libraries and, importantly, provide the potential for simultaneous information on candidate transport across the blood-brain barrier.

Alzheimer's disease is the most common cause of dementia in older individuals with compelling evidence favoring neuron dysfunction and death triggered by assembled forms of A beta(1-42). While large neurotoxic amyloid fibrils have been known for years, recent studies show that soluble protofibril and A beta(1-42)-derived diffusible ligands (ADDLs) may also be involved in neurotoxicity. In the present work, dot-blot immunoassays discriminating ADDLs from monomers were used to screen libraries of per-substituted beta-cyclodextrin (beta-CD) derivatives for inhibition of ADDLs formation. Libraries were prepared from per-6-iodo-beta-CD by treatment with various amine nucleophiles. The most active library tested (containing2000 derivatives) was derived from imidazole, N, N-dimethylethylenediamine and furfurylamine, which at 10 microM total library, inhibited ADDLs formation (10 nM A beta(1-42)) over a period of 4 hours. The latter was confirmed by a western blot assay showing decreased amounts of the initially formed A beta(1-42) tetramer. These preliminary experiments suggest that derivatized forms of beta-CD can interfere with the oligomerization process of A beta(1-42).

Background A growing body of data has demonstrated a direct relationship between epicardial fat volume(EFV) and cardiovascular diseases. In fact, EFV has been shown to be an independent predictor of coronary atherosclerosis and atrial fibrillation. Currently, there is no standard protocol for assessing EFV using cardiac magnetic resonance imaging (CMR). Quantification of peri-ventricular EFV utilizing end diastolic short-axis cine sequences has been described; however, this technique is often challenging due to inadequate visualization of the pericardium. Oftentimes, the pericardium is better visualized during the systolic phase. Thus, we sought to determine the correlation and reproducibility of conventional EFV quantification using end diastolic with end systolic short-axis slices.

Background Manual planimetry for quantitative analysis of ejection fraction (EF) and infarct size (IS) on cardiac magnetic resonance (CMR) imaging are too time-consuming, and therefore, impractical in daily clinical practice. We sought to derive and examine the predictive accuracy of a semi-quantitative scoring technique to screen patients with an EF ≤35% or an IS ≥18.5%, known independent predictors of increased cardiac events and mortality.