Electrocardiographic Signs Of Myocardial Ischemia Research Articles

Metabolic Blood Hormones in Young People With Electrocardiographic Signs of Ischemic Myocardial Changes

Aim To study changes in blood concentrations of metabolic hormones and adipocytokines in people aged 25-44 years with electrocardiographic (ECG) signs of ischemic changes in the myocardium.Material and methods This study was a part of a cross-sectional survey of a random sample of Novosibirsk population aged 25-44 years. The study included 1363 people divided into two groups: group 1, subjects with ECG signs of ischemic changes in the myocardium and group 2, subjects without ECG changes. Blood serum concentrations of adipocytokines and metabolic hormones were measured by multiplex assay on a Luminex MAGPIX flow-through fluorometer.Results The group with ECG signs of myocardial ischemia had higher blood concentrations of adiponectin, resistin, glucagon, and interleukin 6 (IL-6) than in the comparison group. A multivariate logistic regression analysis showed that the glucagon concentration was associated with the presence of ECG signs of myocardial ischemia (OR, 1.019; CI, 1.018-1.034; p=0.017).Conclusion In young people aged 25-44 years, higher blood concentrations of glucagon are associated with the presence of ECG signs of myocardial ischemia.

Cystatin C and Chronic Complications of Diabetes Mellitus in a Subsaharian Population

Background: Type 2 diabetes (T2D) is a chronic and progressive condition whose early management is crucial in preventing the occurrence of its chronic degenerative complications. Cystatin C (CysC) is a biomarker that may have a beneficial interest in the early detection of microvascular and macrovascular complications of T2D. Methods: We carried out a cross-sectional analytic study at the National Obesity Center of the Yaounde Central Hospital. We recruited 135 patients with T2D and performed a neurologic physical exam using the Toronto clinical score, a fundoscopy, ECG, ABI, and the following paraclinicals: dosage of serum levels of Cystatin C, lipid profile (with determination of Atherogenic indexes), Creatinine (with calculation of glomerular filtration rate using CKD-EPI formula) and hs-CRP. Results: Prevalences of diabetic retinopathy, nephropathy, neuropathy and PAD were 3.0%, 8.9%, 38.5%, 28.1% respectively. Electrocardiographic signs of myocardial ischemia were present in 5.9 % of the participants. We found 0.3[0.5-0.3] mg/l as median levels of the HDL-cholesterol and 0.9[1.2-0.7] mg/l for LDL-cholesterol. The median value of GFR was 105.7[119,0-85.7] ml/min/1.73m². The median serum CysC level was 0.8[0.9-0.6]mg/l and varied with age (p=0.01), A1C (p=0.016) and high blood pressure (HBP) (p=0.006). There was a relationship between serum CysC and diabetic nephropathy (p=0.01) and neuropathy (p=0.025). There was no significant relationship with diabetic retinopathy (p=0.225), PAD (p=0.169) and ECG signs of myocardial ischemia (p=0.669). Conclusion: Chronic microvascular and macrovascular complications of type 2 diabetes are common and in our study are predominantly represented by diabetic neuropathy and PAD. Serum CysC can be useful in the diagnosis of chronic complications of T2D.

Cardiovascular risk and HIV infection in patients aged 50 years and older at the Ahala District Medical Center

Older people living with HIV (P50+) are living longer and longer and are therefore prone to age-related comorbidities. The objective of this study was to investigate the cardiovascular risk of P50+ followed in an HIV care unit in Cameroon. The proportion of P50+ was 13.9% and 80 were included in the study. The following prevalences of cardiovascular risk factors (CVRF) were found: sedentary lifestyle (77.5%), chronic smoking (5%). Fifteen percent reported having hypertension and 25% of the P50+ had high blood pressure during physical examination. Similarly, 2.5% of the patients reported diabetes and 7.5% of the P50+ had high blood sugar levels. The examinations performed revealed 2.5% of LDL dyslipidemia, 23.1% of glomerular filtration rate abnormalities, 5.7% of left ventricular hypertrophy (LVH), and 22.9% of electrocardiographic signs of myocardial ischemia. The study of the interdependence between CVRF and the characteristics of the population revealed a relationship of dependence between physical activity and age (p=0.002), diabetes and age (p=0.004), diabetes and duration of HIV (p=0.007), LVH and duration of HIV (p=0.001). Cardiovascular risk is high in P50+ which could make them vulnerable to cardiovascular events. It is therefore necessary or even essential that cardiovascular risk assessment be integrated into the continuum of care of PLWH in general and P50+ particularly in HIV care units.

CARDIOVASCULAR RISK AND HIV INFECTION IN PATIENTS AGED 50 YEARS AND OLDER AT THE AHALA DISTRICT MEDICAL CENTER, CAMEROON

Aim and objectives: Older people living with HIV (P50+) are living longer and longer and are therefore prone to age-related comorbidities. The objective of this study was to investigate the cardiovascular risk of P50+ followed in an HIV care unit in Cameroon.
 Methods: Cardiovascular risk factors (CVRF) were assessed through clinical examination and the following paraclinical exams fasting blood glucose, lipid profile, creatinine level with calculation of glomerular filtration rate according to the Cockcroft and Gault formula and resting electrocardiogram.
 Results: The proportion of P50+ was 13.9% and 80 patients were included in the study. The following prevalence of CVRF were found sedentary lifestyle (77.5%), chronic smoking (5%). Fifteen percent reported having hypertension and 25% of the P50+ had high blood pressure during physical examination. Similarly, 2.5% of the patients reported diabetes and 7.5% of the P50+ had high blood sugar levels. The examinations performed revealed 2.5% of LDL-cholesterol dyslipidemia, 23.1% of glomerular filtration rate abnormalities, 5.7% of left ventricular hypertrophy (LVH), and 22.9% of electrocardiographic signs of myocardial ischemia. The study of the interdependence between CVRF and the characteristics of the population revealed a relationship of dependence between physical activity and age (p=0.002), diabetes and age (p=0.004), diabetes and duration of HIV (p=0.007), LVH and duration of HIV (p=0.001).
 Conclusion: Cardiovascular risk is high in P50+ which could make them vulnerable to cardiovascular events. It is therefore necessary or even essential that cardiovascular risk assessment be integrated into the continuum of care of PLWH in general and P50+ particularly in HIV care units.
 
 Peer Review History: 
 Received: 29 April 2022; Revised: 8 June; Accepted: 28 June, Available online: 15 July 2022
 Academic Editor: Dr. A.A. Mgbahurike, University of Port Harcourt, Nigeria, amaka_mgbahurike@yahoo.com
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 Received file: Reviewer's Comments:
 Average Peer review marks at initial stage: 6.0/10
 Average Peer review marks at publication stage: 7.0/10
 Reviewers:
 Dr. Peter Juma Ochieng, Biotech Research Center (BRC), Obuda University, Hungary, peter26juma@gmail.com
 Dr. Esther Marguerite Chase DJANGA, Faculty of Medicine and Biomedical Sciences. Department of Public Health. University of Yaoundé I, Cameroon. e.djanga@yahoo.com
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Effect and Significance of Electrocardiographic Changes on Standing and Hyperventilation Prior to Exercise Electrocardiographic Testing

Electrocardiographic changes on standing from supine position and subsequent hyperventilation were studied in 100 persons. Changes were correlated with any evidence of myocardial ischemia during stress and/or recovery phase of treadmill stress testing. 15 individuals showed electrocardiographic changes on standing from supine position. Increase in heart rate of more than 30 beats per minute without a fall of more than 20 mm Hg in systolic blood pressure was seen in three cases. Two of them developed ischemic changes during exercise. Decrease in R wave amplitude in leads V2 to V6 was seen in one individual who developed ischemic changes during exercise. New inversion of T waves in leads V2 to V4 in a case with pre-existing RBBB and inverted T wave becoming positive in lead V2 were also associated with electrocardiographic evidence of myocardial ischemia during exercise testing. Mild change in QRS axis, decrease in R wave amplitude in leads II, III, aVF and/or V3 to V5 , ST segment depression of less than 1 mm and decrease in amplitude or inversion of T waves in leads II, III, aVF and V1 to V6 did not have any correlation with evidence of myocardial ischemia during exercise. Fourteen persons showed new electrocardiographic changes during hyperventilation after standing. Three cases had decrease in heart rate. All the three had evidence of myocardial ischemia during treadmill testing. Increase in amplitude of R wave in lead V4, normalization of pre-excitation with unmasking of old myocardial infarction and ST segment depression of more than 2 mm in inferior and lateral precordial leads with ST segment elevation in lead aVR were also associated with development of ECG evidence of myocardial ischemia during treadmill testing. Decrease in R wave amplitude in leads II, III, aVF and/or V4 - V6 , ST segment depression of less than 1mm in inferior or lateral precordial leads and inversion of T waves did not have any significant correlation with development of electrocardiographic signs of myocardial ischemia during treadmill stress test.

Prognostic signs of an unfavorable course of coronary heart disease in patients with type 2 diabetes mellitus

Background. Despite the successful development of medical technologies in the diagnosis of coronary heart disease, mortality due to cardiovascular diseases in the population of patients with diabetes mellitus (DM) is not reduced. The development of an algorithm for the early diagnosis of coronary heart di­sease and ways to correct it is a topical problem of cardiology and endocrinology. The purpose is to determine prognostic signs for an unfavorable course of coronary heart disease and develop a table of test probabilities in order to enhance the effectiveness of risk stratification in patients with type 2 DM. Materials and methods. During 2017–2019, there were observed 40 patients (16 men and 24 women) with type 2 DM in combination with coronary heart disease. We took into account the presence of acute myocardial infarction, acute cerebrovascular accidents (stroke), repeated surgical interventions (percutaneous coronary intervention, coronary artery bypass grafting) for the last 3 years. The average age of patients was 65.5 years. Results. In total, 119 signs recorded in the first three days from the moment of patient’s admission were analyzed as possible predictors of an unfavorable prognosis. As markers of coronary heart disease, parameters were adopted that showed the highest occurrence in the group of patients with adverse course of DM and coronary heart disease. The most patho­gnomonic predictors of coronary heart disease progression in patients with type 2 DM were left ventricular systolic dysfunction (ejection fraction < 40 %), systolic blood pressure > 160 mmHg or diastolic blood pressure above 100 mmHg, electrocardiographic signs of myocardial ischemia, persisting upon discharge from the hospital. Conclusions. Criteria that negatively affect the long-term outcome of coronary heart disease in patients with type 2 diabetes are decompensation of DM, in particular, a high level of fasting glycemia (> 13 mmol/l), as well as an increase in total cholesterol and low-density lipoprotein cholesterol.

Effect of permanent right internal mammary artery occlusion on right coronary artery supply: A randomized placebo-controlled clinical trial

This was a prospective superiority trial in 100 patients with chronic coronary artery disease randomly allocated (1:1) to RIMA vascular device occlusion (verum group) or to RIMA sham procedure (placebo group). The primary study end point was RCA collateral flow index (CFI) as obtained during a 1-minute ostial RCA balloon occlusion at baseline before and at follow-up examination 6 weeks after the trial intervention. CFI is the ratio between simultaneous mean coronary occlusive divided by mean aortic pressure both subtracted by central venous pressure. Simultaneously obtained secondary study end points were the registration of angina pectoris and quantitative intracoronary ECG ST-segment shift. CFI change during the follow-up period was +0.036 ± 0.068 in the verum group and -0.021 ± 0.097 in the placebo group (P = .0011). Angina pectoris during the same RCA balloon occlusions had disappeared at follow-up in 14/49 patients of the verum group and in 4/49 patients of the placebo group (P = .0091). Simultaneous intracoronary ECG ST-segment shift change revealed diminished myocardial ischemia at follow-up in the verum group and more severe ischemia in the placebo group. Permanent RIMA device occlusion augments RCA supply to the effect of diminishing clinical and electrocardiographic signs of myocardial ischemia during a brief controlled coronary occlusion.

Risk stratification vs routine intensive care stay in non ST segment elevation myocardial infarction (NSTEMI)

Non-ST-segment-elevation acute coronary syndromes (NSTE ACS) encompass a wide spectrum of clinical conditions characterised by acute ischemic symptoms, electrocardiographic signs of myocardial ischemia (which may or may not be evident), and elevation of the biochemical markers of myocardial injury: when troponin values are within normal range, the case will be defined as unstable angina, if this clinical entity has not been declared deceased after the introduction of high-sensitivity troponin measurements [1].

Cardiac protection of germinated brown rice extract in rabbit model of chronic myocardial infarction.

Ischemic heart disease is a leading cause of mortality in the world. This study aimed to investigate the cardioprotective effects of germinated brown rice (GBR) on a rabbit model of chronic myocardial infarction. Eighteen New Zealand white rabbits were randomly divided into three groups receiving: 1) regular rabbit food; 2) regular rabbit food plus vehicle; and 3) regular rabbit food plus GBR for 120 d. The left circumflex coronary artery was ligated to induce myocardial ischemia 60 d after starting the experiment (baseline). Heart functions were monitored by electrocardiography and echocardiography at 0, 30, and 60 d after coronary artery ligation. The incidences of heart rate (HR) and ventricular arrhythmias have been compared between groups. GBR showed the effects to prevent life-threatening ventricular tachycardia and electrocardiographic signs of myocardial ischemia in a model of arrhythmias. GBR consumption group exhibited significantly improved cardiac function and reduced the HR, along with reduced mean arterial pressure and plasma glucose level. The results demonstrated that GBR exerts cardioprotective effects against chronic myocardial injury in rabbits. These biological actions of GBR may explain the benefits gained from the use of GBR products as a possible prophylactic lifestyle intervention.

Takotsubo syndrome after induction of general anesthesia: three clinical cases

Takotsubo syndrome (stress-induced cardiomyopathy, or apical ballooning syndrome) is a rare critical condition with approximate incidence of 0.00006% and relatively favorable prognosis. It is characterized by electrocardiographic signs of myocardial ischemia, as well as by severe left ventricular failure with intact coronary vessels. The literature on postoperative development of this disease is scarce. This paper presents three documented cases of takotsubo syndrome with favorable outcomes that developed just after the induction of general anesthesia.

Atlanto-occipital dislocation in a patient presenting with out-of-hospital cardiac arrest: a case report and literature review

BackgroundAtlanto-occipital dislocation is a rare and severe injury of the upper spine associated with a very poor prognosis.Case presentationWe report the case of a 59-year-old European man who suffered from out-of-hospital cardiac arrest following a motor vehicle accident. Cardiopulmonary resuscitation was initiated immediately by bystanders and continued by emergency medical services. After 30 minutes of cardiopulmonary resuscitation with a total of five shocks following initial ventricular fibrillation, return of spontaneous circulation was achieved. An electrocardiogram recorded after return of spontaneous circulation at the scene showed signs of myocardial ischemia as a possible cause for the cardiac arrest. No visible signs of injury were found. He was transferred to the regional academic trauma center.Following an extended diagnostic and therapeutic workup in the emergency room, including extended focused assessment with sonography for trauma ultrasound, whole-body computed tomography, and magnetic resonance imaging (of his head and neck), a diagnosis of major trauma (atlanto-occipital dislocation, bilateral serial rip fractures and pneumothoraces, several severe intracranial bleedings, and other injuries) was made. An unfavorable outcome was initially expected due to suspected tetraplegia and his inability to breathe following atlanto-occipital dislocation.Contrary to initial prognostication, after 22 days of intensive care treatment and four surgical interventions (halo fixation, tracheostomy, intracranial pressure probe, chest drains) he was awake and oriented, spontaneously breathing, and moving his arms and legs. Six weeks after the event he was able to walk without aid. After 2 months of clinical treatment he was able to manage all the activities of daily life on his own.It remains unclear, whether cardiac arrest due to a cardiac cause resulted in complete atony of the paravertebral muscles and caused this extremely severe lesion (atlanto-occipital dislocation) or whether cardiac arrest was caused by apnea due the paraplegia following the spinal injury of the trauma.ConclusionsA plausible cause for the trauma was myocardial infarction which led to the car accident and the major trauma in relation to the obviously minor trauma mechanism. With this case report we aim to familiarize clinicians with the mechanism of injury that will assist in the diagnosis of atlanto-occipital dislocation. Furthermore, we seek to emphasize that patients presenting with electrocardiographic signs of myocardial ischemia after high-energy trauma should primarily be transported to a trauma facility in a percutaneous coronary intervention-capable center rather than the catheterization laboratory directly.

Cardioprotective Effects of Remifentanil in a Sympathetic Hyperactivity Model in Rabbits.

In this study, the antiarrhythmic and anti-ischemic effects of a 6 μg kg(-1) min(-1) infusion dose of remifentanil are investigated in a central sympathetic hyperactivity model in rabbits. In this study, 18 New Zealand rabbits were used. The subjects were randomly divided into three groups (n=6) and received 10 μmol L(-1) glutamate intracerebroventricularly to provide the central sympathetic hyperactivity. In group 1, 10 μmol L(-1) glutamate was used; in group 2, 1 h before L-glutamate injection, 40 mg kg(-1) N (omega)-nitro-L-arginine methyl ester was intravenously (iv) administered; and in group 3, also 1 h before L-glutamate injection, 40 mg kg(-1) N (omega)-nitro-L-arginine methyl ester was iv administered. A 6 μg kg(-1) min(-1) dose of remifentanil infusion was administered 5 min before L-glutamate injection. Heart rate, systolic arterial pressure and mean arterial pressure were measured and recorded. Within 15 min of the intracerebroventricular L-glutamate injection, premature ventricular complexes, bigeminy ventricular arrhythmia, ventricular tachycardia, ST-segment shift and T-wave inversions were recorded. When incidences of heart rate, rate pressure product, premature ventricular complexes and bigeminy ventricular arrhythmia were compared between groups, significant differences were not determined. Mean arterial pressure was more significantly increased in group 2 than in the other groups (p<0.05). Ventricular tachycardia, ST-segment shift and T-wave inversions were significantly lower in group 3 than in groups 1 and 2 (p<0.05). Remifentanil (6 μg kg(-1) min(-1) for 5 min of infusion) prevented life-threatening ventricular tachycardia and electrocardiographic signs of myocardial ischemia in a model of arrhythmia resulting from the association of central sympathetic overactivity.

Recurrent myocardial ischaemia during combination antiviral therapy in a patient with chronic hepatitis C and normal aminotransferase levels

A 63-year-old man with chronic hepatitis C and persistently normal alanine aminotransferase levels was treated with peginterferon alpha-2a (180 μg weekly) and ribavirin (800 mg daily). Hepatitis C virus-ribonucleic acid was negative at week 4. After 12 weeks of therapy, haemoglobin levels had decreased by 3.5 mg/dL, and he developed a syncope episode with electrocardiographic signs of myocardial ischaemia. Antiviral treatment was stopped and the ischaemia-like electrocardiographic changes resolved completely within 2 months. Eight months later, because of the previous rapid virological response and patient motivation, he was treated again with peginterferon and ribavirin. Baseline and weekly electrocardiographic recordings were obtained during treatment. At week 4 hepatitis C virus-ribonucleic acid was negative. At week 8, when the haemoglobin levels had decreased by 3.4 mg/dL, the patient developed the same ischaemia-like changes that occurred during the previous treatment. Antiviral therapy was stopped and the electrocardiographic ischaemia-like changes disappeared after 1 month. The patient neither had a history of previous cardiovascular diseases, nor evidence of current disease at myocardial scintigraphy. However, a coronary microvessel spasm, possibly related to drug-toxicity and/or anaemia could not be excluded. This case indicates the need of strict electrocardiographic monitoring in elderly patients undergoing treatment with peginterferon and ribavirin.

The effect of double dose of omeprazole on the course of angina pectoris and treadmill stress test in patients with coronary artery disease — A randomised, double-blind, placebo controlled, crossover trial

Background Gastroesophageal reflux (GER) and coronary artery disease (CAD) frequently overlap, making the proper diagnosis of chest pain more difficult. GER symptoms may mistake anginal chest pain, and oesophageal acidification may induce myocardial ischaemia both in the rest and in the effort. Increase of oesophageal pH should prevent these conditions. Aim To estimate the effect of double omeprazole dose on the course of angina pectoris and treadmill stress test in patients with coronary artery disease (CAD), using double-blind, crossover randomised, placebo-controlled study design. Methods We studied 48 patients with angina pectoris symptoms and significant narrowing of coronary vessels in angiography. After baseline examination and treadmill stress test all subjects were randomised to treat either with omeprazole (20 mg b.i.d.) or placebo for 14 days, using a double-blind, crossover placebo controlled design. Results Seventeen (35%) subjects reported more than by half decrease in symptoms severity after omeprazole and 6 (12%) after placebo ( p = 0,01). Omeprazole significantly decreased the number of chest pain episodes and number of nitroglycerin doses taken in the second week of both study phases, as well as the percentage of subjects with significant decrease of ST interval during the stress test (64% vs. 73%, p < 0,05). However majority of other stress test parameters (i.e. test duration, DUKE index) have improved both after omeprazole and placebo administration (by 9–38%). Conclusion Double dose of omeprazole significantly decreased symptoms severity in 35% of patients with CAD, as well as frequency of some electrocardiographic signs of myocardial ischaemia during stress test.

Role of Inflammation and Endothelial Dysfunction in the Pathogenesis of Cardiac Syndrome X

Chest pain with normal coronary arteriograms represents a major diagnostic and therapeutic challenge to contemporary cardiology. Cardiac syndrome X (CSX), defined as typical angina-like chest pain, a positive response to exercise stress testing and normal coronary arteriograms, encompasses patients with a variety of pathogenic mechanisms. Cardiac ischemia has been documented in approximately 25% of CSX patients and is associated with endothelial dysfunction and microvascular vasodilator abnormalities. Increased endothelin-1, a powerful vasoconstrictor, has been suggested to play a pathogenic role. There is a high prevalence of postmenopausal women with CSX and thus estrogen deficiency has also been proposed to represent a possible pathogenic mechanism. Inflammatory mechanisms and endothelial dysfunction at the coronary microvascular level appear to be important in the pathogenesis of CSX. Treatment with agents that have protective effects on the vasculature and also anti-inflammatory properties, such as statins and angiotensin-converting enzyme inhibitors have been effective in improving both symptoms and electrocardiographic signs of myocardial ischemia in patients with CSX. This review discusses the roles for endothelial dysfunction and inflammation in the pathogenesis of CSX, as well as the potential therapeutic implications of these mechanisms.

State of the Art of Low‐density Lipoprotein Apheresis in the Year 2003

Low-density lipoprotein (LDL) apheresis is a last-resort treatment for hypercholesterolemic patients resistant to conservative lipid-lowering therapy. In the extracorporeal circuit, LDL, Lp(a) and coagulation factors are selectively eliminated, while the beneficial proteins like high-density lipoprotein, albumin and immunoglobulins are returned to the patient. Clinical effects of LDL apheresis comprise improvement of symptoms like angina and exercise tolerance, reduction of clinical coronary events like unstable angina, need for angioplasty or bypass operation, myocardial infarction and ultimately coronary mortality. The reduction of atherogenic lipoproteins and of coagulation factors by LDL apheresis (LA) positively influences hemorheology, endothelial function and coronary reserve. In the controlled LAARS, LA significantly improved the electrocardiographic signs of myocardial ischemia in the treadmill test. In angiographically controlled trials such as LARS and L-CAPS, a reduction of progression of coronary lesions was observed; in favorable cases, regression of the stenoses could be documented. In addition, in the LDL apheresis coronary morphology trial, LA decreased the coronary plaque area. The Hokuriku trial documented a 72% decrease of coronary events (MACE) in the LA group vs. controls treated only by statins. In longitudinal studies, the incidence of MACE after regular LA decreased compared with the preapheresis period in the same patients. Apart from coronary heart disease, recent studies indicate a positive effect of LA also on carotid artery stenoses and peripheral vascular disease. Prospective randomized studies showed the beneficial effects of cascade filtration on age-related macular degeneration and of heparin-induced LDL precipitation apheresis on acute inner ear deafness.

Testosterone and atherosclerosis.

Hypoandrogenemia in men and hyperandrogenemia in women are associated with increased risk of coronary artery disease but also with visceral obesity, insulin resistance, low high-density lipoprotein (HDL) cholesterol, elevated triglycerides, low-density lipoprotein (LDL) cholesterol and plasminogen activator inhibitor (PAI-1). These gender differences and confounders render the precise role of endogenous androgens in atherosclerosis unclear. Exogenous androgens, on the other hand, induce both apparently beneficial and deleterious effects on cardiovascular risk factors by decreasing serum levels of HDL-C, PAI-1 (apparently deleterious), Lp(a), fibrinogen, insulin, leptin and visceral fat mass (apparently beneficial) in men as well as women. However, androgen-induced declines in circulating HDL-C should not automatically be assumed to be pro-atherogenic, since it may reflect accelerated reverse cholesterol transport instead.Short-term application of supraphysiological doses of exogenous T can reduce the severity and frequency of angina pectoris and improve the electrocardiographic signs of myocardial ischaemia; long-term effects have not been investigated. Nonetheless, interpretations of the effects of pharmacological doses of androgens on arterial compliance and flow-mediated dilatation in particular must be treated with circumspection also because at physiological concentrations, beneficial, neutral, and detrimental effects on vascular reactivity can be observed.Testosterone exerts 'pro-atherogenic' effects on macrophage function by facilitating the uptake of modified lipoproteins and an 'anti-atherogenic' effect by stimulating efflux of cellular cholesterol to HDL. In the majority of animal experiments, exogenous testosterone exerted neutral or beneficial effects on the development of atherosclerosis. In conclusion, the overall effect of administration of testosterone on cardiovascular-disease risk is difficult to assess because androgens have such an extraordinary array of effects in vivo. When dealing with a complex multifactorial condition such as CAD, it is premature to assume that clinical benefits can be derived from manipulation of the sex steroid milieu - even when these assumptions are based on biologically plausible mechanisms or, indeed, on cross-sectional risk-factor observational data. Neither needs the therapeutic use of testosterone in men be restricted by concerns regarding cardiovascular side effects.

Altered coronary flow properties in diffuse coronary artery ectasia

Objectives The purpose of this study was to investigate coronary blood flow properties in patients with diffuse coronary artery ectasia (CAE) associated with exercise-induced myocardial ischemia. Methods Seventeen patients with diffuse CAE and without coexisting coronary artery stenosis were enrolled in the study (CAE group). CAE was defined as luminal dilatation 1.5 to 2 times that of the adjacent normal coronary artery segment or the diameter of the corresponding coronary artery of the control group when there was no normal segment. The age- and sex-matched control group (n = 20) comprised patients with normal epicardial coronary arteries. Coronary blood flow velocities were obtained invasively by use of Doppler scanning flow wire. Coronary flow reserve (CFR) was measured by administration of intracoronary papaverine as the hyperemic stimulus. Volumetric coronary blood flow was estimated by multiplying the velocity time integral of coronary blood flow with the cross-sectional area of the coronary artery and the heart rate. Results Fifteen patients with CAE, but none of the patients in the control group, had electrocardiographic signs of myocardial ischemia at peak exercise on ergometry. Baseline average peak velocities (APVs) of coronary blood flow were similar in the 2 groups. Peak hyperemic APVs of coronary blood flow were lower in the CAE group than in the control group (17.5 ± 7.4 cm/s vs 41.5 ± 12.6 cm/s, respectively, P < .001). Volumetric coronary blood flow was significantly higher in the CAE group than in the control group, both at rest and at hyperemia (146.3 ± 71.2 cm 3/min vs 45.1 ± 16.1 cm 3/min, respectively, P < .001, and 202 ± 87.3 cm 3/min vs 104.1 ± 37.6 cm 3/min, respectively, P < .003). The mean CFR of the CAE group was significantly reduced compared with that of the control group (1.51 ± 0.31 vs 2.67 ± 0.52, respectively, P < .001). Conclusions The CFR is significantly reduced in patients with diffuse CAE compared to a matched control group. Although volumetric coronary blood flow is significantly higher in CAE, microcirculatory dysfunction that is reflected as depressed CFR may be the underlying cause of exercise-induced myocardial ischemia. (Am Heart J 2003;145:66-72.)

Reperfusion Arrhythmias and Sudden Cardiac Death

The observation that ventricular fibrillation may occur within seconds after restoration of blood flow to myocardium turned ischemic by a period of coronary occlusion (reperfusion) was originally made in the experimental laboratory in the 19th century by Cohnheim and Von Schulthess-Rechberg1 and later confirmed in the early 20th century by Tennant and Wiggers.2 In fact, it was found in subsequent laboratory experiments that ventricular fibrillation may occur more frequently after reperfusion than after coronary artery occlusion.3 It took until the latter part of the 20th century for these early laboratory studies to be translated to clinical medicine. It was noticed that only a minority of those individuals who have been successfully resuscitated from sudden ventricular fibrillation associated with coronary artery disease subsequently developed a myocardial infarction,4,5 suggesting that, if indeed myocardial ischemia caused by coronary occlusion was involved, it was transient. Reperfusion must have occurred. This proposed relationship between transient ischemia, reperfusion, and arrhythmias was corroborated by studies in patients with transient coronary artery spasm in whom ventricular arrhythmias, including ventricular fibrillation, occurred within minutes after the beginning of electrocardiographic signs of myocardial ischemia caused by the spasm6 but also after ST segment changes had returned to normal, when reperfusion had occurred.6–9 What is the mechanism responsible for this occurrence of fibrillation? This is a subject that has been pursued in more than a century of experimentation with slow but continued progress. The most recent advance, now in the 21st century, is the article by Cascio et al10 in this issue of Circulation Research . The initial information on mechanisms of reperfusion arrhythmias came from experiments on in situ hearts of large animals subjected to periods of coronary artery occlusion followed by release of the occlusion that allowed reperfusion. In these experiments, the …

Continuous Monitoring of Global Left Ventricular Ejection Fraction During Percutaneous Transluminal Coronary Angioplasty

Continuous monitoring of left ventricular (LV) function during percutanous transluminal coronary angioplasty (PTCA) was performed in 40 patients (53 ± 2 years) with a miniature, nuclear detector system after labeling the patients’ red blood cells with technetium-99m. Balloon dilation (113 seconds, range 60 to 240) induced on average a 0.12 ejection fraction (EF) unit (19%) decrease in the LVEF, which was explained by a 34% increase in end-systolic counts. Balloon dilation of the left anterior descending artery (n = 23) produced a decrease in the LVEF of 0.17 ± 0.13 EF units compared with the decrease of 0.06 ± 0.07 EF units in patients undergoing dilation of the left circumflex artery (n = 9) and 0.05 ± 0.04 EF units in patients treated for a stenosis of the right coronary artery (n = 8), (p = 0.02). Balloon deflation was associated with an immediate return to pre-PTCA levels. In 10 patients with 2 identical balloon occlusions, the second occlusion led to a significantly less decrease in the LVEF ( 0.41 ± 0.14 vs 0.44 ± 0.15 ) and electrocardiographic ST-segment deviation (88 ± 54 μV vs 65 ± 42 μV ) than the first. We conclude that PTCA is associated with an abrupt transient decrease in the LVEF. The effect of balloon occlusion of the left anterior descending artery is more pronounced than balloon occlusion of the left circumflex and the right coronary arteries. Neither single nor multiple balloon occlusions were associated with post-PTCA global LV dysfunction, whereas the lesser degree of LV dysfunction and electrocardiographic signs of myocardial ischemia during the second of 2 identical balloon occlusions suggests that preconditioning can be induced during PTCA.