Coexistent Coronary Artery Disease Research Articles

Concurrence of angiographic coronary artery disease in patients with apical ballooning syndrome (tako‐tsubo cardiomyopathy)

To determine the coexistence of coronary artery disease (CAD) in an unselected cohort of patients with apical ballooning syndrome (ABS). ABS is a clinical condition of unknown etiology with symptoms that mimic an acute coronary syndrome and is characterized by the presence of transient left ventricular dysfunction primarily affecting the apex of the heart. We conducted a retrospective case series in a single tertiary care hospital. Patients were identified by searching for several inclusive discharge diagnoses in all hospitalized patients. Suspected cases were analyzed using prespecified diagnostic criteria. Demographic, clinical, and imaging data were collected. Coronary lesions were assessed by quantitative angiography. Thirty-one cases of ABS were identified. The majority of the cases were female, and ischemia was documented in all patients by electrocardiographic or cardiac biomarker criteria. Nineteen patients (61.3%) had angiographic evidence of CAD, with multivessel involvement in seven (23%). Nine patients (29%) had luminal stenosis severity greater than 50% in at least one epicardial vessel. In an unselected cohort of patients with ABS, coronary atherosclerosis is commonly present. Whether CAD simply coexists or is related to the pathophysiology of ABS is unclear.

High prevalence of gastroesophageal reflux in patients with clinical unstable angina and known coronary artery disease

Esophageal disease may mimic acute anginal pain. However, the prevalence of gastroesophageal reflux in the acute setting of patients with clinically unstable angina (UA) pectoris is not known. The aim of this study was to determine the co-existence of coronary artery disease (CAD) and gastroesophageal reflux in UA, and to study the feasibility of esophageal investigation in the chest pain unit. 22 patients with clinical UA and confirmed CAD were monitored by continuous vector cardiography and pH-measurement during 24 h of observation. Symptoms of chest pain and episodes of ischemia and reflux were recorded. 11 patients (50%) showed abnormal gastroesophageal reflux and another three (14%) had an increased number of reflux episodes. pH-measurements and esophageal manometry were well tolerated. Few chest pain episodes were recorded during the study period, and no association between chest pain, reflux, and ischemia could be shown. Esophageal reflux is common in patients with UA and established CAD. As reflux-related chest pain may imitate angina pectoris, it is clinically important that gastroesophageal examination in patients with UA seems to be feasible and well tolerated in the 'acute setting'.

Carotid artery stenting in patients with coexistent carotid and coronary artery disease

Carotid artery stenting in patients with coexistent carotid and coronary artery disease

Mean platelet volume in patients with metabolic syndrome and its relationship with coronary artery disease

BackgroundMean platelet volume (MPV) is an indicator of platelet activation which is a central process in the pathophysiology of coronary heart disease. The metabolic syndrome (MS) is characterized as the clustering of closely associated and interdependent atherosclerotic risk factors. MS has also been shown to be strongly associated with poor outcome in patients with coronary artery disease (CAD). The present study was designed to investigate MPV values in patients MS and to interrogate the association with CAD. MethodsWe measured MPV in 205 consecutive patients with metabolic syndrome (mean age, 53±7 years) and 140 control subjects without metabolic syndrome (mean age, 52±6 years). All patients were selected from individuals who underwent coronary angiography in our hospital with a suspicion of coronary artery disease. To evaluate the severity of coronary artery disease, the patients with MS were subdivided depending upon the coexistence of coronary artery disease: normal coronary arteries, having coronary stenotic lesions of <50%, and having coronary stenotic lesions of >50%. ResultsThe MPV was significantly higher in patients with MS than in the control group (10.19±1.49 fl vs 8.21±1.02 fl, p<0.001). According to the CAD severity, there were no statistically significant differences in MPV among these subgroups. ConclusionWe have shown for the first time that patients with MS have higher MPV compared to control subjects with normal coronary angiograms and to be associated with CAD. Hence MPV can be used as a follow up marker in patients with MS in the point of CAD.

Differing myocardial response to a single session of hemodialysis in end-stage renal disease with and without type 2 diabetes mellitus and coronary artery disease

BackgroundThough hemodialysis (HD) acutely improves cardiac function, the impact of background diseases like coronary artery disease (CAD) and Type 2 diabetes (DM) in the setting of end-stage renal disease (ESRD) is not known. Tissue velocity echocardiography (TVE) offers a fast choice to follow changes in myocardial function after HD in ESRD with concomitant DM and /or CAD.Methods46 subjects (17 with ESRD, Group 1; 15 with DM, Group 2; 14 with DM+CAD, Group 3) underwent standard and TVE prior to and shortly after HD. Besides standard Doppler variables, regional myocardial systolic and diastolic velocities, as well as systolic strain rate were post processed.ResultsCompared with pre-HD, post-HD body weight (kg) significantly decreased in all the three groups (51 ± 9 vs. 48 ± 8, 62 ± 10 vs.59 ± 10, and 61 ± 9 vs. 58 ± 9 respectively; all p < 0.01). Left ventricular end diastolic dimensions (mm) also decreased post- HD (46 ± 5 vs. 42 ± 7, 53 ± 7 vs. 50 ± 7, 51 ± 7 vs. 47 ± 8 respectively; all p < 0.01). Regional longitudinal peak systolic velocity in septum (cm/s) significantly increased post-HD in Group 1(5.7 ± 1.6 vs. 7.2 ± 2.3; p < 0.001) while remained unchanged in the other two groups. Similar trends were noted in other left ventricular walls. When the myocardial velocities (cm/s) were computed globally, the improvement was seen only in Group 1 (6.3 ± 1.5 vs. 7.9 ± 2.0; p < 0.001). Global early regional diastolic velocity (cm/s) improved in Group 1, remained unchanged in Group 2, while significantly decreased in Group 3(-5.9 ± 1.3 vs. -4.1 ± 1.8; p < 0.01). Global systolic strain rate (1/sec) increased in the first 2 Groups but remained unchanged (-0.87 ± 0.4 vs. -0.94 ± 0.3; p = ns) in Group 3.ConclusionA single HD session improves LV function only in ESRD without coexistent DM and/or CAD. The present data suggest that not only dialysis-dependent changes in loading conditions but also co-existent background diseases determine the myocardial response to HD.

Increased Urinary Albumin Excretion Rates Can Be a Marker of Coexisting Coronary Artery Disease in Patients with Peripheral Arterial Disease

Coexisting coronary artery disease (CAD) is an important cause of morbidity and mortality in patients with peripheral arterial disease (PAD). Clinical evaluation and noninvasive tests have some important limitations for the detection of CAD in patients with PAD. The purpose of this study was to investigate whether urinary albumin excretion (UAE) was a sign of atherosclerotic involvement of coronary arteries in patients with PAD. Our study consisted of 65 consecutive patients (56 men, 9 women, mean age; 59.7+/-7.9 years) with PAD who underwent coronary angiography. Urinary albumin excretion was measured in 24-hour urine samples by immunoprecipitation technique. PAD was defined as the presence of > or =50% stenotic lesions in at least 1 of the iliac, femoral, popliteal, tibialis anterior, tibialis posterior, or peroneal arteries. CAD was defined as > or =25% diameter stenosis in at least 1 coronary artery. Patients without any coronary lesions were accepted as having normal coronaries. Age, sex, distributions of coronary risk factors, and UAE rates were compared between patients with and without CAD. Mean UAE was 17.9+/-15.6 mg/day in the total population. Thirty-seven percent of patients had CAD, and 63% had no coronary lesion. UAE rates were 22.33+/-18.74 and 15.32+/-13.01 mg/day in patients with CAD and those with normal coronary arteries, respectively (p = 0.021). Microalbuminuria was detected in 25% in patients with CAD and 12% in those without coronary artery lesions (p = 0.184). The difference was not statistically significant. The distributions of other risk factors and sex were not different between the 2 groups. These data suggest that in patients with PAD, urinary albumin excretion rates may be used to determine those with a high probability of CAD. Further studies are required to decide whether this noninvasive testing is appropriate in detecting high-risk patients.

Prediction of coronary artery disease in patients undergoing carotid endarterectomy

The authors determined the factors that predict the coexistence of coronary artery disease (CAD) in patients who undergo carotid endarterectomy (CEA). Data from 200 consecutive Japanese patients who underwent CEA for extracranial carotid artery stenosis were studied. Among 73 patients with CAD, 35 (48%) had three-vessel or left main CAD (that is, severe CAD). Peripheral artery disease was an independent predictor of CAD (odds ratio [OR] 2.61, 95% confidence interval [CI] 1.08-6.3). In addition, diabetes mellitus ([DM]; OR 2.8, 95% CI 1.24-6.32) and peripheral artery disease (PAD) (OR 2.83, 95% CI 1.05-7.57) were independent predictors of severe CAD in the 200 patients. The percentage of patients with CAD as well as those with the severe form of the disease increased stepwise as the number of major coronary risk factors in patients increased. Asymptomatic CAD was newly detected during the pre-CEA assessment in 18 (25%) of the 73 patients in whom CAD was eventually diagnosed. Diabetes mellitus was an independent predictor of occult CAD among the 200 patients (OR 4.83, 95% CI 1.53-15.2). In patients with DM, PAD, or multiple major coronary risk factors who have been scheduled for CEA, one should carefully search for concomitant CAD, especially severe CAD, even when the patient has had no previous episode of angina.

Physiologic Compensation Is Supranormal in Compensated Aortic Stenosis: Does it Return to Normal After Aortic Valve Replacement or Is it Blunted by Coexistent Coronary Artery Disease?

In compensated aortic stenosis (AS), cardiac performance measured at the ventricular chamber is typically supranormal, whereas measurements at the myocardium are often impaired. We investigated intramyocardial mechanics after aortic valve replacement (AVR) and the effects relative to the presence or absence of coronary artery disease (CAD+ or CAD-), respectively. Twenty-nine patients (46 to 91 years, 10 female) with late but not decompensated AS underwent cardiovascular MRI before AVR (PRE), with follow-up at 6+/-1 (EARLY) and 13+/-2 months (LATE) to determine radiofrequency tissue-tagged left ventricle (LV) transmural circumferential strain, torsion, structure, and function. At the myocardial level, concentric LV hypertrophy regressed 18% LATE (93+/-22 versus 77+/-17 g/m2; P<0.0001), whereas at the LV chamber level, ejection fraction was supranormal PRE, 67+/-6% (ranging as high as 83%) decreasing to 59+/-6% LATE (P<0.05), representing not dysfunction but a return to more normal LV physiology. Between the CAD+ and CAD- groups, intramyocardial strain was similar PRE (19+/-10 versus 20+/-10) but different LATE, with dichotomization specifically related to the CAD state. In the CAD- patients, strain increased to 23+/-10% (+20%), whereas in CAD+ patients it fell to 16+/-11% (-26%), representing a nearly 50% decline after AVR (P<0.05). This was particularly evident at the apex, where CAD- strain LATE improved 17%, whereas for CAD+ it decreased 2.5-fold. Transmural strain and myocardial torsion followed a similar pattern, critically dependent on CAD. AVR impacted LV geometry and mitral apparatus, resulting in decreased mitral regurgitation, negating the double valve consideration. In AS patients after AVR, reverse remodeling of the supranormal systolic function parallels improvement in cardiovascular MRI-derived regression of LV hypertrophy and LV intramyocardial strain. However, discordant effects are evident after AVR, driven by CAD status, suggesting that the typical AVR benefits are experienced disproportionately by those without CAD and not by those obliged to undergo concomitant coronary artery bypass grafting/AVR.

Transcardiac gradients of N‐terminal B‐type natriuretic peptide in aortic valve stenosis

Plasma B-type natriuretic peptide (BNP), as well as the N-terminal part of the prohormone (Nt-BNP), are frequently elevated in aortic valve stenosis (AS). Yet, their release from the heart into the circulation has never been directly studied in AS. To assess the release of Nt-BNP in AS with focus on the identification of its main determinants. We studied 49 adult patients undergoing preoperative cardiac catheterization for isolated AS. Blood was sampled from the aortic root and the coronary sinus for Nt-BNP determination by immunoassay. The mean (+/-S.E.) transcardiac Nt-BNP step-up averaged 79+/-53 pmol/l in 11 control patients free of structural heart disease, 75+/-32 pmol/l in 31 AS patients free of heart failure (HF), 236+/-62 pmol/l in 8 AS patients with diastolic HF (ejection fraction > or = 50%, pulmonary wedge pressure > 14 mm Hg) and 469+/-66 pmol/l in 7 AS patients with systolic HF (ejection fraction < 50%, wedge pressure > 14 mm Hg) (p<0.001). The transcardiac Nt-BNP gradient was independently associated with left ventricular (LV) end-diastolic pressure (beta=0.47, p<0.001) and ejection fraction (beta=-0.29, p<0.019) and with co-existent coronary artery disease (beta=0.23, p=0.050). LV diastolic and systolic dysfunction along with coronary artery disease are likely to be the key determinants of cardiac Nt-BNP release in AS. The transcardiac Nt-BNP gradient increases on average three-fold with the development of diastolic HF and six-fold in systolic HF.

Drug Insight: an overview of current anticoagulation therapy after heart valve replacement

Vitamin K antagonists, such as warfarin, are the gold standard approach for the long-term anticoagulant therapy of patients with mechanical heart valves. Management decisions are, however, based predominantly on expert consensus and on data from nonrandomized, follow-up studies, which have inherent limitations in their methods. Low-intensity anticoagulation therapy provides protection against thromboembolic complications in patients with most types of modern prosthetic heart valve. The addition of low-dose aspirin is safe if international normalized ratio values below 3.5 are maintained. A combined regimen should be considered in high-risk patients and those with coexistent coronary artery or cerebrovascular disease, and in patients who have suffered a thromboembolic event despite a therapeutic international normalized ratio. Thromboprophylaxis with unfractionated or low-molecular-weight heparins is restricted to specific situations, such as when a patient is intolerant to vitamin K antagonists, when surgical procedures require discontinuation of oral anticoagulation, or when the patient is pregnant. A lack of uniformity across practice guidelines make it difficult to reach treatment decisions. Each patient's preference, expressed after counseling about the risks and benefits of each treatment strategy, and an individual assessment of the patient's risk factors, should guide treatment decisions. At present, new anticoagulant agents such as factor Xa inhibitors do not represent a treatment option for heart valve recipients.

High Prevalence of Important Cardiac Findings in Patients with Peripheral Arterial Disease Referred for Echocardiography

Patients with peripheral arterial disease (PAD) diagnosed by ankle-brachial index evaluation are known to have high cardiovascular mortality. Although this has primarily been attributed to coexistent coronary artery disease, the prevalence of abnormal echocardiographic findings for patients with PAD has not been studied. Our goal was to study the association between PAD and clinically important echocardiographic findings in symptomatic patients with PAD referred for echocardiography. Eligible patients were identified from a database of 615 consecutive patients referred for clinically indicated ankle-brachial index evaluation in our vascular laboratory. Patients were included (n = 309) if they also had a complete transthoracic echocardiogram in the digital echocardiogram database at our institution. Final transthoracic echocardiographic reports were retrospectively reviewed for study indication and clinically important echocardiographic findings. Patients with PAD (ankle-brachial index < 0.9) (n = 190) were compared with patients without PAD (n = 119). Patients with PAD were found to have a high prevalence of clinically important echocardiographic findings, and significantly more clinically important echocardiographic findings (61.6% vs 35.3%, P < .001), including more left ventricular (LV) dysfunction and aortic stenosis, than patients without PAD. On multivariate logistic regression analysis, the presence of PAD was found to be an independent predictor of LV ejection fraction < 50% (odds ratio 2.86, 95% confidence interval 1.54-5.32, P = .001), LV ejection fraction < 35% (odds ratio 2.48, 95% confidence interval 1.22-5.07, P = .02), and any clinically important echocardiographic finding (odds ratio 2.65, 95% confidence interval 1.61-4.36, P < .001). In symptomatic patients with PAD referred for echocardiography, there is a high prevalence of clinically important echocardiographic findings, including LV dysfunction, and PAD appears to be an independent predictor of an abnormal echocardiogram. These findings suggest that a prospective echocardiographic screening study in symptomatic patients with PAD is warranted.

Spectrum of Calcific Aortic Valve Disease

Received October 26, 2004; revision received January 13, 2005; accepted February 4, 2005. Calcific aortic valve disease is a slowly progressive disorder with a disease continuum that ranges from mild valve thickening without obstruction of blood flow, termed aortic sclerosis, to severe calcification with impaired leaflet motion, or aortic stenosis (Figure 1). In the past, this process was thought to be “degenerative” because of time-dependent wear-and-tear of the leaflets with passive calcium deposition. Now, there is compelling histopathologic and clinical data suggesting that calcific valve disease is an active disease process akin to atherosclerosis with lipoprotein deposition, chronic inflammation, and active leaflet calcification. The overlap in the clinical factors associated with calcific valve disease and atherosclerosis and the correlation between the severity of coronary artery and aortic valve calcification provide further support for a shared disease process. Figure 1. Gross specimen of minimally diseased aortic valve (left) and severely stenotic aortic valve (right). In the severely stenotic valve, there are prominent lipocalcific changes on aortic side of valve cusps (arrow), with sparing of commissures. ### Anatomy of Normal Aortic Valve The normal aortic valve comprises 3 layers. The ventricularis, on the ventricular side of the leaflet, is composed of elastin-rich fibers that are aligned in a radial direction, perpendicular to the leaflet margin. The fibrosa, on the aortic side of the leaflet, comprises primarily fibroblasts and collagen fibers arranged circumferentially, parallel to the leaflet margin. The spongiosa is a layer of loose connective tissue at the base of the leaflet, between the fibrosa and ventricularis, composed of fibroblasts, mesenchymal cells, and a mucopolysaccharide-rich matrix. These layers work in concert to provide tensile strength and pliability for decades of repetitive motion. ### Early Lesion of Aortic Sclerosis Histopathologic studies of aortic sclerosis show focal subendothelial plaquelike lesions on the aortic side of the leaflet that extend to the adjacent fibrosa layer. Similarities to …

Isolated Type 2 Diabetes mellitus Causes Myocardial Dysfunction That Becomes Worse in the Presence of Cardiovascular Diseases: Results of the Myocardial Doppler in Diabetes (MYDID) Study 1

Aims: Patients with type 2 diabetes mellitus (DM) often suffer disproportionately and have a worse outcome when burdened with cardiovascular complications compared with those without DM. A specific heart muscle disease reportedly caused by DM per se may explain this. We sought to investigate whether an echo Doppler diagnosis of such a myocardial disease is clinically relevant in DM with or without coexistent coronary artery disease (CAD) and/or hypertension (HTN). Subjects andMethods: Two hundred subjects (127 males, 73 females, 56 ± 10 years) including controls (n = 23), patients with HTN (n = 20), CAD (n = 35), uncomplicated DM (n = 59), DM+HTN (n = 27), DM+CAD (n = 16) and DM+CAD+HTN (n = 20) underwent tissue Doppler-enhanced dobutamine stress echocardiography. Myocardial function was assessed by measuring left ventricular myocardial peak systolic velocity (PSV) and early diastolic velocity at rest and during peak stress, besides measurements of standard Doppler variables. Results: Average left ventricular PSV at rest was significantly lower in CAD (4.7 ± 1.5) compared with controls (5.7 ± 1.2) and in DM+CAD+HTN (4.6 ± 1.4) compared with DM (5.6 ± 1.3; all p < 0.05). During peak stress, lower PSV persisted in CAD (9.5 ± 3.1) and DM+CAD+HTN (8.1 ± 2.7), while appearing de novo in DM (11.3 ± 2.6) and HTN (11.0 ± 2.3) unlike in the controls (12.5 ± 2.5; all p < 0.001). When pooled together, DM subjects with CAD and/or HTN or both had significantly lower PSV (9.1 ± 2.7) than those without (10.0 ± 2.8; p < 0.001). Early diastolic velocity response was equally lower in both groups compared with the controls. Conclusion: The results suggest that dobutamine stress unmasks myocardial functional disturbances caused by uncomplicated DM. The discrete disturbances become quantitatively more pronounced in the presence of coexistent cardiovascular diseases.

The Relation between Homocysteine and Calcific Aortic Valve Stenosis

Background: In patients diagnosed with calcific aortic valve stenosis, cardiac risk factors are similar to those of coronary artery disease; homocysteine concentration is an independent risk factor for coronary artery disease. The aim of this study was to investigate the correlation between plasma homocysteine levels and aortic valve stenosis and the influence of homocysteine levels on the coexistence of coronary artery disease in patients with moderate to severe aortic valve stenosis. Methods: Fifty-eight patients who had been diagnosed with moderate to severe aortic stenosis formed the test group of this study, and 47 healthy subjects without coronary artery disease or aortic valve stenosis formed the control group. The patients with aortic stenosis were divided into two groups according to the presence or absence of coronary artery disease in their coronary angiograms. After 12 h fasting venous blood samples were collected and total cholesterol, low-density lipoprotein, high-density lipoprotein, triglycerides and homocysteine levels were measured and compared between the two groups. Measurements and Results: The mean blood homocysteine level was 10.8 ± 3.3 µmol/l in patients with aortic valve stenosis and 8.1 ± 4.7 µmol/l in the control group; the difference between these levels was statistically insignificant. The patients with aortic valve stenosis had significantly higher levels of total cholesterol and hypertension and were more likely to have a positive family history for coronary artery disease. When the two subgroups of patients with aortic valve stenosis were compared, mean blood homocysteine levels were 13.2 ± 3.1 and 8.3 ± 2.2 µmol/l, respectively, showing significantly higher levels in the group with coronary artery disease. In this comparison patients with coronary artery disease were also found to have significantly higher levels of total cholesterol and LDL and they were more likely to be smokers. Conclusions: Although there was no relation between blood homocysteine levels and the existence of aortic valve stenosis, in cases with both coronary heart disease and aortic stenosis homocysteine levels were significantly higher than in the patients with pure aortic valve stenosis.

Clinical Characteristics, Risk Factors, and Medical Treatment of 561 Patients With Peripheral Arterial Disease Followed in an Academic Vascular Surgery Clinic

The charts of all 561 patients (69% men and 31% women, mean age 71 +/- 10 years) with peripheral arterial disease (PAD) followed in an academic vascular surgery clinic were reviewed. Coexistent coronary artery disease (CAD) was present in 364 of 561 patients (65%). Of the 561 patients with PAD, 442 (79%) were current or exsmokers, 385 (69%) had hypertension, 225 (40%) had diabetes, 358 (64%) had a serum low-density lipoprotein (LDL) cholesterol > or =100 mg/dL, and 228 (41%) had a serum high-density lipoprotein cholesterol <40 mg/dL. Cilostazol or pentoxifylline was given to 301 of 301 patients (100%) with intermittent claudication. Aspirin or clopidogrel was given to 501 of 561 patients (89%) with PAD. Statins were given to 282 of 358 patients (79%) with PAD and an increased serum LDL cholesterol. If CAD was present, beta blockers were given to 301 of 364 patients (83%) and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers to 303 of 364 patients (83%).

Non-invasive visualization of the coronary arteries with retrospective ECG-gated MSCT in patients with acute typ-A aortic dissection - reduction of motion artifacts

Objectives: Non-invasive methods have replaced angiography in the diagnosis of aortic dissection. Angiography maybe used to evaluate coexisting coronary artery disease (CAD), which can delay surgery and increase the risk of rupture. In this regard, noninvasive coronary angiography using MSCT-techniques may be a safe and effective alternative to visualize the coronary anatomy in patients prior to surgical repair.

Effect of Comorbid Chronic Diseases on Prevalence and Odds of Depression in Adults With Diabetes

The objective of this study was to determine the effect of coexisting chronic conditions on prevalence and odds of depression in individuals with diabetes. Data on 1794 adults with diabetes from the 1999 National Health Interview Survey were analyzed. Six chronic conditions were identified: hypertension, coronary artery disease, chronic arthritis, stroke, chronic obstructive pulmonary disease, and end-stage renal disease. Chronic conditions were counted and categorized into 4 groups: diabetes alone, diabetes + 1 condition, diabetes + 2 conditions, and diabetes + 3 or more conditions. Prevalence of depression was calculated by number of chronic conditions and for each condition. Adjusted odds of depression were calculated by number of chronic conditions and for each chronic condition while simultaneously controlling for covariates and for each chronic condition using multiple logistic regression. STATA was used for statistical analyses. Using diabetes alone as reference, adjusted odds of major depression by number of conditions were: diabetes + 1 (1.31; 95% confidence interval [CI], 0.67-2.55), diabetes + 2 (2.09; 95% CI, 1.06-4.12), and diabetes + 3 or more (4.09; 95% CI, 2.04-8.17). Adjusted odds of major depression for each coexisting chronic conditions were: hypertension (1.22; 95% CI, 0.78-1.90), coronary artery disease (2.00; 95% CI, 1.27-3.14), chronic arthritis (2.02; 95% CI, 1.35-3.02), stroke (2.15; 95% CI, 1.10-4.31), chronic obstructive pulmonary disease (0.96; 95% CI, 0.52-1.81), and end-stage renal disease (1.19; 95% CI, 0.57-2.49). Odds of major depression are significantly increased among adults with diabetes in the presence of two or more coexisting chronic conditions, and coexistence of coronary artery disease, chronic arthritis, and stroke in particular, are associated with increased odds of major depression.

Lactate concentration gradient from right atrium to pulmonary artery: a commentary

Inadequate myocardial performance is a common complication of severe sepsis. Studies in humans strongly argue against a decrease in coronary blood flow in the pathogenesis of this sepsis-induced cardiac injury. Moreover, regional myocardial ischemia may well be present in sepsis patients with coexistent coronary artery disease. Nevertheless, the diagnosis of myocardial ischemia remains difficult in patients with sepsis, since elevation of troponin in these patients can be the result of a variety of conditions other than acute myocardial ischemia. The use of the right atrium to pulmonary artery lactate gradient could perhaps help the clinician in detecting myocardial ischemia in patients with sepsis.

Coronary Artery Ectasia: A Ten-year Experience in a Tertiary Hospital in Singapore

Introduction: Coronary artery ectasia (CAE) is a well-recognised, albeit rare, angiographic finding of abnormal coronary dilatation. To our best knowledge, its incidence has never been described in Singapore. We aimed to determine the incidence of CAE at our teaching hospital and to describe patient and angiographic characteristics. Materials and Methods: Cases were identified through a search of our hospital’s computer database and all records were reviewed. Results: Over the 10-year study period (1992-2001), 8641 patients underwent coronary angiography. CAE was diagnosed in 104 patients, giving an incidence of 1.2%. The majority (74%) were male. The median age was 54 years (range, 25 to 79 years). Sixty-six per cent of patients were Chinese, 19% Malays, 12% Indians and 3% other races. Concomitant diabetes mellitus was present in 31%, hypertension in 58% and dyslipidaemia in 63% of patients. Co-existent obstructive coronary artery disease was present in 82% of cases. The frequency of arterial involvement was: right coronary artery (RCA), 65%; left anterior descending artery (LAD), 48%; circumflex artery (CX), 43%; and left main artery (LM), 2%. CAE affected only 1 major vessel in 62% of cases and all 3 vessels in 20%. Eighteen patients were advised to undergo bypass surgery, while percutaneous coronary intervention was recommended in 26 patients. Conclusions: The incidence of ectasia was 1.2%. The majority of patients were males in their sixth decade with underlying dyslipidaemia or hypertension. CAE was associated with obstructive coronary artery disease in more than 80% of cases. The RCA was most commonly affected and most patients had single vessel involvement.

The role of coronary angiography in acute type A aortic dissection.

In recent years, non-invasive methods have replaced angiography in the diagnosis of aortic dissection. Angiography maybe used to evaluate coexisting coronary artery disease (CAD), which can delay surgery and increase the risk of rupture. We set out to examine the role of angiography in acute aortic dissection. A retrospective analysis of patients who underwent repair of acute aortic dissection between January 1992 and June 2002 was conducted. The effect of angiography on the need for concomitant coronary artery surgery (CABG), delay to surgery and outcome were analysed. Seventy-four patients were identified. Initial diagnosis was established by non-invasive techniques. Twenty-three patients (31%) underwent angiography (Group I) in three this was unsuccessful. Three in Group I and four in the non-angiography group (Group II, n=51) had history of angina. One patient in Group I underwent concomitant CABG compared to seven in Group II. The patient who underwent CABG in Group I; and four out of seven in Group II died (NS). Patients who underwent concomitant CABG had a significantly higher mortality rate (P=0.04). Mortality in Group I was 35% (n=8) and in Group II was 29% (n=15) (NS). Mortality rate was also significantly higher in patients who presented with syncope (P=0.01) or hypotension (P=0.04). Median transfer time from arrival at our centre to the operating room was 5 h in Group I and 1.5 h in Group II (P<0.001). Mortality rate was higher in patients who took longer to transfer to the operating room, but this did not reach statistical significance. We have shown that coronary angiography did not affect the occurrence of CABG and was not associated with improved hospital survival. Furthermore, there is a considerable delay to surgery caused by angiography. Therefore in this setting coronary angiography is not recommended.