Episodes Of ST-segment Depression Research Articles

Features of the course of stable exertional angina against the background of iron deficiency anemia in outpatient practice

Introduction. Iron-deficiency accompanies many diseases, including cardiovascular pathology, so timely diagnosis and correction of this condition is necessary. Aim. To study the features of the course of stable exertional angina against the background of iron deficiency anemia before and after correction with iron (III) polymaltose hydroxide in patients in primary health care using a computerized patient register. Materials and methods. 1210 patients with stable exertional angina aged 50–85 years (309 men, 901 women) were included. A special computer program was created for data analysis. In 500 out of 1210 patients, IDA was detected (385 women, 115 men). Mild anemia – 410 patients, moderate – 75, severe – 15. The main group – patients with stable exertional angina and Irondeficiency anemia (the first subgroup – patients treated with iron (III) polymaltose hydroxide and the second subgroup – patients who did not receive the drug iron (III) polymaltose hydroxide due to refusal of treatment or contraindications) and the control group – patients with stable exertional angina without Iron-deficiency anemia. All patients received standard therapy recommended for the treatment of stable exertional angina (the main group additionally received iron (III) polymaltose hydroxide). Results. In the first subgroup of the main group, after treatment with iron (III) hydroxide polymaltose, there was a statistically significant increase in hemoglobin levels by 11,7%, hematocrit by 5%, erythrocytes by 4%, serum iron by 112,8%, and an improvement in exercise tolerance by 48,7%, episodes of ST segment depression by 30,2%. In the second subgroup and the control group, there were no significant changes in the above parameters. Conclusion. Iron-deficiency anemia contributes to the severe course of stable exertional angina, which is confirmed by the high frequency of III-IV functional class exertional angina, a decrease in tolerance to exercise stress. Correction of Iron-deficiency anemia reduces the frequency of episodes of transient myocardial ischemia in the main group.

The impact of chronic exposure to air pollution on electrocardiographic parameters.

Chronic exposure to air pollution caused by particulate matter (PM) with aerodynamic diameters of <10 μm (PM10) and <2.5 μm (PM2.5), dependent on "low emissions" resulting from the combustion of solid fuels in households, significantly increases the risk of cardiovascular events. The aim of the study was to assess the impact of chronic exposure to air pollution in the place of residence on the occurrence of coronary artery disease, hypertension and the presence of electrocardiographic abnormalities in 24-hour Holter ECG recording. After considering the exclusion criteria, 100 consecutive patients of the cardiology outpatient clinic were enrolled in the study, including 50 patients living for ≥10 years in Warsaw districts with the lowest average concentrations of PM2.5 (group I) and 50 living in the districts with the highest recorded exposure (group II). All patients underwent clinical and physical examination, 12-lead ECG, 2D cardiac echo, and Holter ECG. To avoid the impact of acute exposure, the study was carried out in May - the month with statistically the lowest recorded PM2.5 concentrations. In the group of patients exposed to higher concentrations of PM2.5 in the place of residence, coronary artery disease and arterial hypertension were significantly more frequent, while in the Holter ECG examination, ventricular arrhythmias, conduction disturbances and ST-segment and T-wave changes were independently associated with exposure to air pollution. Chronic exposure to air pollution in the place of residence contributes to the occurrence of chronic coronary syndrome and hypertension. Chronic exposure to air pollution seems to be a significant factor increasing the incidence of ventricular arrhythmia, conduction disturbances and ST-segment depression episodes in Holter monitoring. Int J Occup Med Environ Health. 2022;35(3):353-60.

РЕЗУЛЬТАТИ ДОБОВОГО МОНІТОРИНГУ ЕЛЕКТРОКАРДІОГРАМИ ЗАЛЕЖНО ВІД СТАНУ ЖОВЧНОГО МІХУРА

Gallbladder (GB) diseases are associated with structural and functional cardiac abnormalities. Biliary autonomous viscero-visceral cardioneuropathy (BAVVCNP) and post-biliary autonomous cardioneuropathy (PBACNP) are characterized by rhythm and conduction disorders, ST-segment depression, and signs of left ventricular hypertrophy in patients with various GB disorders. The aim of this study was to compare results of 24-hour electrocardiogram (ECG) monitoring in patients with BAVVCNP, PBACNP, and normal GB. 138 outpatients with cardiovascular and extracardiac disorders underwent 24-hour ECG monitoring. They were divided into three groups: intact GB (n=54); BAVVCNP (n=72); PBACNP (n=12). PBACNP patients were characterized by the absence of ST segment depressions, PR interval shortenings, paroxysmal supraventricular tachycardia, sympathoadrenal overdrive in the mornings, pacemaker migration, or sinus node dysfunction. BAVVCNP was characterized by the development of active ectopic foci in the myocardium, increased cardiac output, GB wall thickening, and elevated total bilirubin level. Patients with PBACNP differed from those without cardioneuropathy by faster nocturnal heart rate, absence of episodes of ST segment depression, shorter QRS duration, and lower blood monocyte count

The effect of SGLT2 inhibitors on silent myocardial ischemia

Abstract Background In large cardiovascular (CV) outcome trials, sodium-glucose co-transporter 2 (SGLT2) inhibitors reduced the development of heart failure (HF) in patients with type 2 diabetes (T2DM). Also it reduced CV death and worsening HF events in HFrEF patients. It is unknown whether SGLT2 inhibitors work through glucose-dependent mechanism or it could have other effects not related to glucose on cardiovascular morbidity and mortality in diabetic patients. Its effect on silent ambulatory myocardial ischemia (SAMI) has not been reported yet. In this study we report the effect of SGLT2 inhibitors on (SAMI). Treating silent myocardial ischemia has a prognostic effect and may improve long term mortality of chronic ischemic heart disease (CIHD). Methods We enrolled 44 type 2 diabetic patients with proven stable coronary artery disease (CAD) and at least one episode of on silent ambulatory myocardial ischemia (SAMI) on ambulatory ECG monitoring. All of them were receiving optimal therapy for CIHD and type 2 DM. 22 patients were randomized to receive Dapagliflozin 5mg qd and the other 22 patients received placebo. Ambulatory monitoring was repeated after 4 to 6 months of therapy. The two groups were comparable with respect to baseline characteristics, number of episodes of ST-segment depression, HgbA1c level, and baseline serum cholesterol levels. Holters were read by a blinded cardiologist. Results The Dapagliflozin group experienced a significant reduction in the number of episodes of ST-segment depression compared with the placebo group. ST-segment depression completely resolved in 8 of 22 patients (36%) in the Dapagliflozin group versus 3 of 22 (13%) in the placebo group and the Dapagliflozin group exhibited a highly significant reduction in (SAMI) (P&amp;lt;0.001). By logistic regression, treatment with Dapagliflozin was an independent predictor of (SAMI) resolution. Conclusions Therapy with SGLT2 inhibitors in type2 DM patients results in reduction or resolution of (SAMI) recorded as episodes of ST-segment depression in ambulatory monitoring of the ECG. A larger study is required to confirm this theory and to see the effect of SAMI reduction on long term mortality of CIHD in diabetics. Possible mechanisms for this beneficial effects of SGLT2i includes: Reduction in oxygen supply-demand mismatch, improvement in cardiac microvascular function, modulation of cardiac energy metabolism, reduction in glucotoxicity, reduction in sympathetic nervous system activation and reduction in blood pressure. Funding Acknowledgement Type of funding source: None

Therapy of patients with the high risk of arterial hypertension with the use of telmisartan

Aim. The study assesses the effects of therapy based on the use of telmisartan in patients with arterial hypertension and stable angina on the clinical and functional indicators of the cardiovascularvascular system. Material and methods. 52 patients with a combination of arterial hypertension (AH) I and II stages and coronary artery disease II with the mean age 63.5 ± 5.4 years (79% males and 21% of females) were enrolled in the trial. The duration of AH and CAD were 17.5±3.8 and 12.5±3.1 accordingly. All patients took a daily 80 mg dose of telmisartan. The efficacy of treatment was estimated in 3,6 and 12 months. Results. The use of telmisartan in complex treatment of high-risk patients with AH has led to decreasing blood pressure to the target level, increasing exercise tolerance (walking the distance from 315.5 m to 410.2 m in 6 minutes). 12 months of therapy based on telmisartan showed significant decrease in left hy‑ pertrophy ventricle (LV myocardial mass index on average by 10.4%), a decrease in the total duration of depression ST segment from 9.6±2.9 to 2.7±1.5 mm and a decrease in the depth of depression from 1.5±0.3 mm to 0.3±0.09 mm, with a trend towards decrease in the number of episodes of ST-segment depression, as well as the absence of a significant change in heart rate. After 12 months of en‑ dothelium-dependent vasodilation therapy, the condition of 31 (60%) patients improved, and 18 (35%) patients showed the tendency to improvement. The tests with reactive hyperemia conducted after 12 months of treatment revealed decreased linear velocity of blood flow in the brachial artery on average by 17%. Conclusion. The use of telmisartan in complex therapy improves the quality of life according to the EQ-VAS questionnaire by 25 points after 12 months of therapy, contributes to lowering blood pressure in 96% of patients, reduc‑ ing myocardial hypertrophy, endothelial dysfunction and severity of ischemic manifestations (reducing the need for nitroglycerin intake to an average of 0,5 inhalations, as well as a decrease in the ST segment depression of 40% after 12 months of therapy).

An Experience of Meldonium Use in Patients with Ventricular Arrhythmias of Ischemic Genesis

Under dynamic observation were 147 patients with IHD and VA (Lown II-IV functional class). The diagnosis of angina pectoris was confirmed by clinical, exercise bicycle ergometry, Holter ECG monitoring, and echocardiography data. Holter ECG monitoring was used for recording VA, heart rate, episodes of ST-segment depression. The levels of total cholesterol, triglycerides, low-density lipoprotein cholesterol (LDLC), high-density lipoprotein cholesterol were determined. All patients were randomly divided into 2 groups. The first group (81 patients) received standard antianginal and antiarrhythmic therapy plus meldonium for 2 months. The second (control) group (66 patients) received standard antianginal and antiarrhythmic therapy only. Statistical analysis of the data was carried out using the statistical package SPSS 13.0. A comparative analysis of the results showed that the use of meldonium in combination with basic therapy significantly improved clinical condition and quality of life indicators, increased exercise tolerance and improved systolic and diastolic dysfunction in patients with IHD and VA. The positive effect of meldonium on LDLC levels was observed. Moreover, the combination of basic antianginal and antiarrhythmic therapy and meldonium in patients with ischemic genesis VA promoted significant reduction of ischemic episodes and decrease of VA, in particular allorhythmia. Results of this study suggest that the use of meldonium in patients with IHD and VA helps to optimize myocardial energy metabolism in conditions of ischemia and reperfusion.

45. Ezetimibe and statins yields on silent holter ambulatory myocardial ischemia

Further cholestrol lowering may affect silent ischemia detected on holter monitoring. Cholesterol lowering is associated with a reduction in cardiovascular morbidity and mortality. Statins are the main drugs for cholesterol lowering. Ezetimibe when added to statins gives further reduction in cholesterol but its long-term effect on cardiovascular morbidity and mortality and ischemic events is not known. This study sought to determine whether further cholesterol lowering with ezitimibe will also results in a reduction of myocardial ischemia during daily life. We enrolled 50 patients with proven stable coronary artery disease (CAD) and at least one episode of ST-segment depression on ambulatory ECG monitoring. All of them were receiving optimal therapy for CAD including statin therapy for cholesterol reduction. 25 patients were randomized to continue their statin therapy (Statin only group) and 25 to recieve statin plus ezitimibe 10 mg/day (ezitimibe group). Serum cholesterol and LDL cholesterol levels and ambulatory monitoring were repeated after 4–6 months of therapy. The two groups were comparable with respect to baseline characteristics, number of episodes of ST-segment depression, and baseline serum cholesterol levels. The ezitimibe group had lower mean total and LDL cholesterol levels at study end and experienced a significant reduction in the number of episodes of ST-segment depression compared with the statin only group. ST-segment depression was completely resolved in 13 of 25 patients (52%) in the ezitimibe group versus 3 of 25 (12%) in the statin only group. The ezitimibe group exhibited a highly significant reduction in ambulatory ischemia (P < .001). By logistic regression, treatment with ezitimibe was an independent predictor of ischemia resolution. Further cholesterol lowering with ezitimibe can result in reduction or resolution of myocardial ischemia recorded as episodes of ST-segment depression in ambulatory monitoring of the ECG.

Abstract 15913: Statin And Ezetimibe in Silent Ambulatory Myocardial Ischemia (SESAMI Trial)

Introduction: Cholesterol lowering is associated with a reduction in cardiovascular morbidity and mortality. Statins are the main drugs for cholesterol lowering. Ezetimibe when added to statins gives further reduction in cholesterol but its long-term effect on cardiovascular morbidity and mortality and ischemic events is not known. This study sought to determine whether further cholesterol lowering with ezitimibe will also results in a reduction of myocardial ischemia during daily life. Hypothesis: Further cholestrol with ezetimibe lowering may reduce silent ischemia. Methods: We enrolled 50 patients with proven stable coronary artery disease (CAD) and at least one episode of ST-segment depression on ambulatory ECG monitoring. All of them were receiving optimal therapy for CAD including statin therapy for cholesterol reduction. 25 patients were randomized to continue their statin therapy (Statin only group) and 25 to recieve statin plus Ezitimibe 10mg/day (ezitimibe group). Serum cholesterol and LDL cholesterol levels and ambulatory monitoring were repeated after 4 to 6 months of therapy. The two groups were comparable with respect to baseline characteristics, number of episodes of ST-segment depression, and baseline serum cholesterol levels. Holters were read by a blinded cardiologist. Results: The ezitimibe group had lower mean total and LDL cholesterol levels at study end and experienced a significant reduction in the number of episodes of ST-segment depression compared with the statin only group. ST-segment depression was completely resolved in 13 of 25 patients (52%) in the ezitimibe group versus 3 of 25 (12%) in the statin only group. The ezitimibe group exhibited a highly significant reduction in ambulatory ischemia (P&lt;.001). By logistic regression, treatment with ezitimibe was an independent predictor of ischemia resolution. Conclusions: Further cholesterol lowering with ezitimibe can result in reduction or resolution of myocardial ischemia recorded as episodes of ST-segment depression in ambulatory monitoring of the ECG. A larger study is required to confirm this results. This may be translated into long term mortality reduction for CAD by adding ezetimibe.

Evaluation of chest pain by holter monitoring in patients of hypertrophic cardiomyopathy

Background: Patients with hypertrophic cardiomyopathy frequently complain of pain chest during daily activities even despite normal resting ECG and normal coronary angiogram. It seems to be related to myocardial ischemia which may lead to progressive left ventricular remodeling and fibrosis. These morphological changes may produce intractable symptoms and life threatening arrhythmia. The aim of the study is to evaluate the chest pain and clinical significance of ST-segment depression during daily normal activities in the patients with hypertrophic Cardiomyopathy as a noninvasive marker of ischemia. Methods: Continuous 48 hours Holter monitoring was perform in 106 patients aged (40 ±12 years) with hypertrophic Cardiomyopathy. 92 patients’ (86%) Holter recording were suitable for ST-segment analysis. Results: A total of 97 episodes of ST-segment depression ( > 1 mm from baseline) were recorded in 26 patients (Male 21, Female 5). In patients 30 years) were correlated between ST-segment desperation and history of exertional chest pain (9 of 15 vs 1 of 21, P- 0011) and dyspnea NYHA II/III ( 9 of 14 vs 1 of 22 P-004). There was no correlation between ST-segment depression and risk factors for sudden death, such as family history of sudden death, sustained and non sustained ventricular tachycardia and history of syncope. Conclusions: In Holter monitoring ST-segment depression is common in younger patients with history of typical pain chest of cardiac origin and dyspnea.

The relation between silent ischemia and coronary artery disease severity in diabetics

The aim of this work was to examine the relation between the severity of silent ischemic episodes detected by ambulatory ECG recording and the angiographic severity of coronary artery disease (CAD). Fifty patients with chronic stable angina pectoris and type 2 diabetes mellitus were enrolled in the study.Among the study group, there were 33 males and 17 females; and their mean age was 61 ± 6.5 years. All patients were submitted to 24-hours ambulatory ECG recording and coronary angiography with estimation of Gensini score. According to the frequency of silent ST-segment depression episodes, patients were classified into two groups. Group I: 24 patients with ST-segment depression frequency <8. Group II: 26 patients with ST-segment depression frequency ⩾8. In patients with ST-segment depression frequency ⩾8, there were significantly higher number of left main coronary artery (LMCA) disease, and significantly higher Gensini score (Table 1). Sensitivity of ST-segment depression frequency ⩾8 in predicting Gensini score ⩾20 was 60%, specificity was 56%, positive predictive value was 58%, negative predictive value was 58%, and overall accuracy was 58% (Kappa = 0.412, p = 0.014). Gensini score showed significant positive correlation with ST-segment depression frequency (r = 0.391, p = 0.005), with maximum ST-segment depression (r = 0.346, p = 0.014), and with total ST-segment depression duration (r = 0.495, p = 0.0003). Patients with type 2 diabetes mellitus who had more frequent silent myocardial ischemia by ambulatory ECG recording were found to have angiographically more extensive CAD as assessed by Gensini score. Gensini score was found to be significantly correlated to the frequency of silent ST-depression, maximum ST-depression, and total ST-depression duration.

Statin and ezetimibe in silent ambulatory myocardial ischemia (sesami trial)

Background Cholesterol lowering is associated with a reduction in cardiovascular morbidity and mortality. Statins are the main drugs for cholesterol lowering. Ezetimibe when added to statins gives further reduction in cholesterol but its long-term effect on cardiovascular morbidity and mortality and ischemic events is not known. This study sought to determine whether further cholesterol lowering with ezitimibe will also results in a reduction of myocardial ischemia during daily life. Methods We enrolled 50 patients with proven stable coronary artery disease (CAD) and at least one episode of ST-segment depression on ambulatory ECG monitoring. All of them were receiving optimal therapy for CAD including statin therapy for cholesterol reduction. 25 patients were randomized to continue their statin therapy (Statin only group) and 25 to recieve statin plus ezitimibe 10 mg/day (ezitimibe group). Serum cholesterol and LDL cholesterol levels and ambulatory monitoring were repeated after 4–6 months of therapy. The two groups were comparable with respect to baseline characteristics, number of episodes of ST-segment depression, and baseline serum cholesterol levels. Holters were read by a blinded cardiologist. Results The ezitimibe group had lower mean total and LDL cholesterol levels at study end and experienced a significant reduction in the number of episodes of ST-segment depression compared with the statin only group. ST-segment depression was completely resolved in 13 of 25 patients (52%) in the ezitimibe group versus 3 of 25 (12%) in the statin only group. The ezitimibe group exhibited a highly significant reduction in ambulatory ischemia ( P Conclusions Further cholesterol lowering with ezitimibe can result in reduction or resolution of myocardial ischemia recorded as episodes of ST-segment depression in ambulatory monitoring of the ECG.

Cardiovascular Safety of One-Year Escitalopram Therapy in Clinically Nondepressed Patients With Acute Coronary Syndrome

Selective serotonin reuptake inhibitors are commonly used for treatment of depression in patients with cardiac diseases. However, evidence of cardiovascular (CV) safety from randomized trials is based on studies of no longer than 6-month duration. We examined the CV safety of 1-year treatment with Selective serotonin reuptake inhibitor escitalopram compared with placebo in patients with recent acute coronary syndrome (ACS). The DECARD (DEpression in patients with Coronary ARtery Disease) trial assessed the prophylactic effect of escitalopram on depression after ACS. Two hundred forty patients were randomized to escitalopram 10-mg daily or matching placebo for 1 year. Serial measures of CV safety including clinical and biochemical parameters, 24-hour electrocardiogram monitor, resting electrocardiogram, and echocardiographic assessment were obtained. Escitalopram and placebo groups were comparable at baseline with regard to age, gender, sociodemography, depression score, risk factor profile, severity of heart disease, and medications. Dropout rates defined as withdrawal for any reason or lost to follow-up during the 12-month study period was 27.2% in the escitalopram group and 23.4% in the placebo group (NS). There were no statistically significant differences between intervention groups in any of CV safety measures including the incidence of ventricular arrhythmia and episodes of ST-segment depression, length of QTc, and systolic and diastolic echocardiographic measures at the 12-month follow-up between groups. After 12 months, 16 and 13 major adverse events (death, recurrent ACS, or acute revascularization) were recorded in the escitalopram and placebo group, respectively (NS). One-year escitalopram treatment was safe and well tolerated in patients with recent ACS.

Clinical trial: chest pain caused by presumed gastro‐oesophageal reflux in coronary artery disease – controlled study of lansoprazole vs. placebo

Gastro-oesophageal reflux (GER) and coronary artery disease commonly co-exist. Coronary artery disease patients may mistake GER-induced pain for cardiac pain or GER might provoke angina. To investigate if GER might contribute to nocturnal/rest chest pain among coronary artery disease patients. Double-blind placebo-controlled crossover study investigating effect of lansoprazole on chest pain; 125 patients with angiographically proven coronary artery disease enrolled with at least one weekly episode of nocturnal/rest pain, randomized to lansoprazole 30 mg daily or placebo with crossover after 4 weeks. Symptoms recorded and QOL assessed by Nottingham Health Profile Questionnaire; ST segment depression episodes counted from 24 h electrocardiographic monitoring in final week of both periods. ANCOVA with period and carryover analysis. In all, 108 patients completed the study. There was a modest increase in pain-free days on lansoprazole vs. placebo (P < 0.02), with fewer days with pain at rest (P < 0.05) and at night (P < 0.009) on lansoprazole vs. placebo, but no significant differences in ST segment depression episodes (P = 0.64). There was a trend for reduction in the 'physical pain' QOL domain. Among coronary artery disease patients, lansoprazole modestly increases pain-free days and reduces rest/nocturnal pain. As lansoprazole did not affect ST segments, this may be by suppression of GER-provoked pain misinterpreted as angina, rather than acid-provoked ischaemia.

ECG changes in epilepsy patients.

To investigate the frequency of ECG abnormalities suggestive of myocardial ischaemia in patients with severe drug resistant epilepsy and without any indication of previous cardiac disease, assuming that these changes may be of significance for the group of epileptic patients with sudden unexpected death. Twelve patients with medically intractable epilepsy were investigated with simultaneous long ECG and EEG recordings while attending either epilepsy surgery investigational procedures or the investigational programme for diagnostic purposes, and one while having an episode of status epilepticus. The ECG recording failed in 1 patient. This patient had chest pain and minor yet morphologically conspicuous changes in the ECG, suggestive of myocardial infarction. He died in heart arrest. Eight epilepsy patients had episodes of ST segment depression in the ECG, many of which coincided with video- and EEG documented epileptic seizures. Two patients experiencing simple partial seizures and 1 patient experiencing absence seizures had no ST segment depressions in the ECG. One patient had an episode of status epilepticus secondary to brain damage and no ST segment deviation was seen during the ECG recording which continued until 3 h before the patient died. Patients with severe drug resistant epilepsy have episodes of ST segment changes, some of which are closely related to epileptic seizures. Further studies are needed to confirm the present results and to investigate the nature of these changes and document the effect of prophylactic treatment with cardioactive drugs to reduce the risk of sudden death.

Myocardial ischaemia in patients with peripheral arterial disease

To study the relation between myocardial ischemia assessed with different techniques in patients with peripheral arterial disease (PAD) in comparison with a matched control group. Ninety-nine male patients with PAD and 94 age- and sex-matched control subjects without PAD or ischaemic heart disease performed a exercise treadmill test, dipyridamole Tc-99m sestamibi myocardial perfusion SPECT (MPS) (43 controls) and 48-h ambulatory ECG (AECG)-monitoring (43 controls). Thirteen of 99 patients had irreversible and 24 of 99 had reversible perfusion defects in MPS in comparison with 0 of 43 and six of 43 of control subjects respectively (P<0.01). Thirteen of 84 evaluable patients experienced a total of 36 episodes of ST-depression in AECG in comparison with two episodes in two of 42 control subjects (P = 0.07). Out of 13 patients with ST-depression episodes only three had reversible ischaemia in MPS. Most PAD patients with episodes of ST-segment depression have no reversible ischaemia as assessed with dipyridamole-stress MPS. Episodes of ST-segment depression may reflect types of myocardial ischaemia that are different from those detected by MPS.

Cardiac Rhythm Disturbances and ST-Segment Depression Episodes in Patients With Obstructive Sleep Apnea-Hypopnea Syndrome and Its Mechanisms

Cardiac Rhythm Disturbances and ST-Segment Depression Episodes in Patients With Obstructive Sleep Apnea-Hypopnea Syndrome and Its Mechanisms

Does gastro-esophageal reflux provoke the myocardial ischemia in patients with CAD?

Background Gastro-esophageal reflux disease (GERD) may cause chest pain. The aim was to determine the correlation between ischemia and gastro-esophageal reflux in patients with CAD and to assess the influence of short-term “anti-reflux” therapy on the ischemia in patients with GERD and CAD. Methods Fifty patients with angiographically proven CAD underwent simultaneous 24-h continuous ECG and esophageal pH monitoring. We assessed the number of ST-segment depression episodes (ST dep.) and total duration of ischemic episodes, expressed as total ischemic burden (TIB). In pH-metry, we assessed: time percentage of pH lower than 4, total time of pH lower than 4 and the number of pathological refluxes (PR). Patients fulfilling the GERD criteria received a 7-day therapy with omeprazol 20 mg bid. On the 7th day of therapy, simultaneous Holter and esophageal pH monitoring was repeated. Results Total number of 224 PRs in 42 patients (84%) was recorded during esophageal pH-metry. GERD criteria were fulfilled in 23 patients (46%). Out of 218 episodes of ST dep., 45 (20.6%) correlated with PR. GERD patients had larger TIB and higher number of ST dep. ( p<0.015 and p<0.035, respectively). The anti-reflux therapy reduced all analyzed parameters of esophageal pH monitoring ( p<0.0022) as well as the number of ST dep. ( p<0.012) and TIB ( p<0.05). Conclusions Gastro-esophageal reflux disease is common in patients with CAD and may provoke myocardial ischemia. Short-term proton pump inhibitors therapy that restores normal esophageal pH significantly reduces myocardial ischemia, possibly due to elimination of acid-derived esophago-cardiac reflex compromising coronary perfusion—the phenomenon known as “linked angina”.

Effect of spinal cord stimulation on spontaneous and stress-induced angina and ‘ischemia-like’ ST-segment depression in patients with cardiac syndrome X

A significant number of patients with cardiac syndrome X (CSX) present frequent episodes of severe chest pain, refractory to maximal multi-drug therapy. A few, small, uncontrolled data suggested that spinal cord stimulation (SCS) may have favourable clinical benefits in these patients. We studied 10 CSX patients who were being treated by SCS for refractory angina pectoris for 17+/-16 months (median 8). Patients were randomized to either continue or withdraw SCS for a period of 3 weeks and were then crossed over to the other condition for a further 3-week period. During each 3-week period patients kept a detailed diary of angina episodes occurring in the last 2 weeks of each phase. Furthermore, at the end of each 3-week period, angina status was also assessed by Seattle Angina Questionnaire (SAQ), a 0-100 visual analogue scale (VAS), and patients underwent 24-h Holter monitoring (HM) and echocardiographic dobutamine stress test (DST). Compared with the withdrawal phase, SCS reduced the number (P=0.01), duration (P=0.022), and severity (P=0.011) of angina episodes, and nitrate consumption (P=0.042). SAQ scores (P< or =0.013 for all) and VAS (P<0.001) were also improved, the number of episodes of ST-segment depression on HM was decreased (P=0.014), and time to angina (P=0.045) and to 1 mm ST-segment depression (P=0.04) during DST were both prolonged by SCS. Our data point out that SCS may be an effective form of treatment in patients with CSX suffering from frequent angina episodes significantly impairing quality of life (QOL) and refractory to maximally tolerated drug therapy.

Cardiac Rhythm Disturbances and ST-Segment Depression Episodes in Patients With Obstructive Sleep Apnea-Hypopnea Syndrome and Its Mechanisms

<h3>Study objectives</h3> To compare the frequency of daytime and nocturnal cardiac arrhythmias and ST-segment depression episodes among patients with obstructive sleep apnea-hypopnea syndrome (OSAHS), snoring subjects, and healthy subjects, and to analyze the relationship between the cardiac disturbances, sleep characteristics, and sympathetic tone in patients with OSAHS. <h3>Patients and interventions</h3> Twenty-one consecutive patients with OSAHS, 12 snorers without hypersomnolence, and 15 healthy subjects were selected. Polysomnography, 24-h Holter ECG recording, and urinary catecholamine determination were simultaneously performed on all subjects. <h3>Results</h3> Patients with OSAHS had more daytime and nocturnal episodes of sinus and supraventricular arrhythmias and couplets than the snoring and control groups. Moreover, nocturnal ST-segment depression episodes were more frequent in the OSAHS group than in control subjects (0.565 ± 0.826/h vs 0 ± 0/h [mean ± SD]). In patients with OSAHS, arousal index and daytime epinephrine levels were related to daytime and nocturnal ST-segment depression episodes, whereas minimum arterial oxygen saturation was related to nocturnal sinus bradycardia and supraventricular tachycardia. Epinephrine and norepinephrine urinary concentrations correlated with sinus and supraventricular arrhythmias. <h3>Conclusions</h3> Patients with OSAHS have a higher frequency of cardiac rhythm disturbances and ST-segment depression episodes than snoring and control subjects. Moreover, ST-segment changes are related to sympathetic tone and sleep fragmentation, whereas most of the rhythm disturbances in patients with OSAHS are associated with sleep fragmentation, nocturnal hypoxemia, and sympathetic tone.

Silent Myocardial Ischemia

Silent myocardial ischemia is defined as objective documentation of myocardial ischemia in the absence of angina or anginal equivalents. Since its original description in the 1970s, it has undergone intensive investigation, and its clinical significance is now well established. This review will serve as an update on the pathophysiology, detection, prevalence, prognosis, and treatment of silent ischemia in both asymptomatic patients and those with angina, whether stable or unstable. ### Pain Studies No discussion of silent ischemia is complete without consideration of the cardiac pain mechanism. Although much has been learned about this subject, much is still uncertain. The afferent fibers that run in the cardiac sympathetic nerves are usually thought of as the essential pathway for the transmission of cardiac pain (Figure 1). The atria and ventricles are abundantly supplied with sympathetic sensory innervation; from the heart, the sensory nerve endings connect to afferent fibers in cardiac nerve bundles, which in turn connect to the upper 5 thoracic sympathetic ganglia and the upper 5 thoracic dorsal roots of the spinal cord. Within the spinal cord, impulses mediated by this sympathetic afferent route probably converge with impulses from somatic thoracic structures onto the same ascending spinal neurons. This would be the basis for cardiac pain referred to the chest, wall, arm, back etc. In addition to this “convergence-projection theory,” the contribution of vagal afferent fibers must be acknowledged for an explanation of cardiac pain referred to the jaw and neck. How these vagal fibers are activated remains unclear. Furthermore, somatic localization of ischemic pain cannot predict the site of myocardial ischemia (anterior, inferior, or lateral) from one patient to the next. Figure 1. Mechanisms of cardiac pain. From Droste and Roskamm (used with permission).4 The actual “trigger” that stimulates the sensory nerve endings remains elusive. If a chemical pain stimulus is involved, …