Incidence Of Myocardial Ischemia Research Articles

Ineffective matching of oxygen supply to myocardial metabolism in primiparous compared to nulliparous swine

Maternal mortality rates in the United States are higher than any other developed country in the world. Most postpartum maternal deaths are directly related to adverse cardiovascular events and often occur in mothers who have had a healthy pregnancy. Although pregnancy is recognized as a cardiovascular stress test for the pregnant patient, understanding of how the longitudinal and dynamic cardiovascular adaptations during pregnancy contribute to augmented risk of cardiovascular complications through the postpartum period remains poorly understood. We propose that pregnancy-induced adaptations in the coronary circulation contribute to adverse cardiovascular outcomes, especially during the puerperium period (1-60 days following delivery). Accordingly, this study tested the hypothesis that the balance between coronary blood flow and myocardial metabolism is compromised in the puerperium heart. Experiments were performed in anesthetized, open-chest control nulliparous (control) and primiparous (postpartum) swine during the puerperium period (35-45 days post-delivery). Systemic and coronary hemodynamic responses were assessed under baseline conditions and in response to continuous intravenous infusion of dobutamine (1 – 30 μg/kg/min). Under baseline conditions, blood pressure averaged 107 ± 6 mmHg in both control and postpartum swine and was unaffected by dobutamine administration (P = 0.94). Heart rate increased from 77 ± 6 to 165 ± 9 beats/min in response to dobutamine in control swine vs. 52 ± 3 to 139 ± 13 beats/min in postpartum swine (P = 0.53). Coronary blood flow and myocardial oxygen delivery were significantly diminished by ~60 ± 8% at rest in postpartum swine, which is consistent with reduced myocardial oxygen consumption (MVO2). The relationship between coronary blood flow and heart rate (P < 0.0001) or MVO2 (P = 0.0002) showed a marked parallel downward shift in postpartum swine at rest and in response to dobutamine infusion. This reduction in myocardial perfusion was associated with significant reductions in myocardial lactate uptake at rest in postpartum vs. control (0.34 μmol/min/g vs. 0.08 μmol/min/g, P = 0.02). Dobutamine increased myocardial lactate uptake in control by ~47 ± 3% with little change in the postpartum group. Together, these results suggest an ineffective matching of myocardial oxygen supply to metabolism in postpartum swine. This imbalance is consistent with increased incidence of myocardial ischemia and cardiac deaths in postpartum puerperium period. This work was supported by AHA.23PRE101281, NIH R01 HL158723. This is the full abstract presented at the American Physiology Summit 2024 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

#6104 CLINICAL IMPACT OF UNDIAGNOSED HOSPITAL ACUTE KIDNEY INJURY

Abstract Background and Aims Hospital Acute kidney injury (H-AKI) is associated with an increased risk of complications and mortality. Despite attempts to uniform the diagnosis of AKI and point attention to this condition, in clinical practice, the recognition of AKI is often limited. In this study, we tried to evaluate the impact of underdiagnosed AKI in hospitalized patients. Method We collected data of patients hospitalized at IRCSS Policlinico San Martino, Genoa, Italy, between 1/1/2106 and 31/12/2019. We considered clinical data, serum creatinine (sCr), length of hospital stay, death, comorbidities, and primary diagnoses as codified in the hospital discharge form-HDF. Patients with CKD stage 4-5 were excluded. In the selected patients, we defined and graded AKI according to the KDIGO criteria, by comparing the peak sCr to the lowest sCr during hospitalization under the assumption that the lowest sCr would represent baseline kidney function. Then, we divided this cohort into 3 groups: 1) patients with no AKI at all, 2) AKI calculated by sCR changes and formally codified in HDF (diagnosed AKI), 3) AKI calculated by sCR changes but not codified in HDF (i.e., undiagnosed AKI). Finally, we compared the clinical characteristics and outcomes of these groups. Results We included 56,820 pts. The incidence of AKI was 24.5% (n = 13,920), evaluating the distribution among the 3 groups, we noticed that a small percentage of AKI was reported in HDF (Fig. 1). Only in 27% of cases in medical wards, 13% in surgical wards, and 19% in Intensive care Units AKI was formally reported in HDF, while in the emergency department, AKI was diagnosed in 78% of cases. Compared with No AKI patients, those with AKI (both diagnosed and undiagnosed) had a higher prevalence of comorbidities (diabetes mellitus, heart failure, atrial fibrillation) and incidence of myocardial ischemia and sepsis (Table 1). Moreover, patients with AKI had a significantly longer hospitalization and major mortality risk, at cox regression (HR 2.6, IC 2.4-2.8, p0.000) and Kaplan Meier (Fig. 2). The mortality risk augmented in all patients with AKI analyzed by both logistic regression univariate (OR 7.1, IC 6.7-7.6, p<0.001) and multivariate analysis corrected by age, gender, and comorbidities (OR 4,5, IC 4,2-4,9, p<0.001). Interestingly, these findings were confirmed also considering only the group of patients with undiagnosed AKI (univariate: OR 5.9, IC 4.2-4.9, p<0.001; multivariate: OR 4.6, IC 4.2-4.9, p<0.001). Conclusion Undiagnosed AKI is still very common in hospitalized patients, even if it identifies a category of patients with a high risk of complications and mortality. Proper recognition of H-AKI remains a problem to face.

Nonalcoholic fatty liver disease is associated with myocardial ischemia by CT myocardial perfusion imaging, independent of clinical and coronary CT angiography characteristics.

The aim of this study was to evaluate whether patients with nonalcoholic fatty liver disease (NAFLD) have more myocardial malperfusion on CT myocardial perfusion imaging (CT-MPI), as well as to further assess if NAFLD is a predictor of myocardial ischemia independently. A total of 310 consecutive patients were included for analysis. All patients were divided into two groups according to the presence or absence of NAFLD, which was diagnosed by noncontrast cardiac CT partially covered liver and spleen. Clinical characteristics as well as imaging features including coronary artery calcium score, CCTA, and CT-MPI findings were analyzed. Univariable and multivariable logistic regression analyses were used to find out the relationship between NAFLD and myocardial ischemia. NAFLD (unadjusted hazard ratio [HR]: 2.4, 95% confidence interval [CI]: 1.2 to 4.4, p = 0.008), male (HR: 2.6, 95% CI: 1.5 to 4.5, p = 0.001), obstructive CAD (HR: 2.3, 95% CI: 1.3 to 4.2, p = 0.004), and FAI ≥ -70.1 HU (HR: 3.1, 95% CI: 1.8 to 5.5, p < 0.001) were associated with myocardial ischemia in univariable analysis. After adjusting for traditional CAD risk factors and CT characteristics in the multivariable regression analysis, NAFLD (HR: 2.3, 95% CI: 1.2 to 4.4, p = 0.016) was an independent predictor of myocardial ischemia. Our data suggest that myocardial ischemia was more prevalent in patients with NAFLD, and NAFLD is a predictor of myocardial ischemia independent of traditional cardiovascular risk factors and CCTA characteristics. • NAFLD patients had higher calcium score, incidence of obstructive coronary artery disease, grade of CAD-RADS, quantitative plaque characteristics, and incidence of fat attenuation index ≥ -70.1 HU. • NAFLD patients had a higher incidence of myocardial ischemia, myocardial hypoperfusion, and hypoperfusion myocardial segments ratio. • NAFLD was a predictor of myocardial ischemia, independent of traditional cardiovascular risk factors, and CCTA characteristics.

Correlation of High BMI and Hyperlipidemia with Myocardial Ischemia

Background: Myocardial ischemia is considered as one of most common cause of mortality worldwide. Several Risk factors are linked to an increased incidence of Myocardial Ischemia. The most common risk factors are hypertension, hypercholesterolemia, diabetes mellitus, high BMI, physical inactivity, smoking, age and gender predisposition and socioeconomic status. Aim: To inspect and compare incidence of myocardial ischemia in cases with hyperlipidemia and elevated BMI. Methods: 102 patients were selected for our research study and cases were split up into 2 groups of 51 patients each. Group A comprised cases with standard normal lipid profile and BMI with suspected myocardial ischemia. Group B contained 51 patients with hyperlipidemia and high BMI with suspected myocardial ischemia. The study data was then analyzed by SPSS 21st version. The Probability Value (P- Value) of ≤0.05 was coined as statistically convincing value. Results: The serum Cholesterol levels were 148 ± 11 in first group A and 268 ± 41 in other group B. The triglycerides serum values were 129± 13 in A group and 220± 13 in B group. The serum Low density Lipoproteins values were 109±10 in A group and 179±22 in B group. The serum HDL values were 39±10 in A group and 20±08 in B group. An independent/unpaired samples T- statistical test was used Using a two-tailed 0.05 criterion, the test indicated a statistically convincing difference among the two research groups (p value was &lt;0.05) in relation to cholesterol, triglycerides, HDL, LDL and BMI. Conclusion: Hyperlipidemia and High BMI contribute significantly to development of acute myocardial ischemia Keywords: Myocardial Ischemia, Hyperlipidemia, Body Mass index

Colchicine for Secondary Prevention of Coronary Artery Disease: A Meta-Analysis of Randomised Controlled Trials

Colchicine has become prominent as an anti-inflammatory therapy for secondary cardiovascular prevention in patients with coronary artery disease (CAD). This meta-analysis was performed to evaluate the efficacy and safety of colchicine in patients with CAD. Randomised controlled trials (RCTs) that compare major adverse cardiovascular events (MACEs) between patients with CAD randomised to colchicine versus placebo (or no colchicine) were included. Random effect risk ratios (RRs) were calculated for clinical outcomes. A total of 12,071 patients in seven RCTs were included in the meta-analysis. Compared with placebo or no colchicine, colchicine was associated with a significantly lower incidence of MACEs (RR 0.64, 95% CI 0.51-0.80, p<0.01). The reduction in MACEs in the colchicine group was driven by statistically significant reductions in the incidence of myocardial ischaemia (RR 0.74, 95% CI 0.58-0.95, p=0.02), coronary revascularisation (RR 0.61, 95% CI 0.42-0.89, p=0.01), and stroke (RR 0.48, 95% CI 0.28-0.83, p=0.01). However, there was no statistically significant difference for cardiovascular death (RR 0.82, 95% CI 0.55-1.22, p=0.33). All-cause and non-cardiovascular mortality, gastrointestinal events, infection, and cancer were not significantly different between the colchicine and control groups. Colchicine is a reasonably efficacious and safe drug that could be successfully utilised for the secondary prevention of CAD.

Effect of perioperative levosimendan administration on postoperative N-terminal pro-B-type natriuretic peptide concentration in patients with increased cardiovascular risk factors undergoing non-cardiac surgery: protocol for the double-blind, randomised, placebo-controlled IMPROVE trial

IntroductionElevated N-terminal pro-brain natriuretic peptide (NT-pro-BNP) after non-cardiac surgery is a strong predictor for cardiovascular complications and reflects increased myocardial strain. NT-pro-BNP concentrations significantly rise after non-cardiac surgery within the...

Association of coronary perivascular fat attenuation index, the parameters of plaque and fractional flow reserve

Objective: To explore the association of coronary perivascular fat attenuation index (FAI), the parameters of plaque and fractional flow reserve (FFR). Methods: A total of 113 patients (with 141 plaques) (78 males and 35 females, age from 40 to 83 years) with stable coronary artery disease were retrospectively collected from Jingling Hospital and Shanghai Sixth People's Hospital. All the patients underwent coronary CT angiography and invasive FFR examinations. The quantitative and qualitative parameters of plaque and vessel (such as the length and volume of plaque, the characteristics of plaque and high-risk plaque) and the FAI around the plaque were measured. The patients were divided into positive FAI group (n=46) and negative FAI group (n=66) according to the standard of whether the threshold of FAI≥ -70 HU. The quantitative indexes, including age, the length and volume of plaque, minimal lumen area (MLA) and FAI, as well as the qualitative indexed, including the characteristics of plaque, the number and characteristic of high-risk plaque and the number of patients and plaque with positive FFR were compared between the two groups. Further, logistic regression analysis was performed to analyze the correlation among myocardial ischemia, age, the length of plaque, minimal lumen area (MLA), FAI and so on. ROC curve was used for evaluating the performance of each parameter. Results: Compared to the negative FAI group, positive FAI group had lower MLA (2.00±1.33 mm2 vs 4.13±2.41 mm2, P<0.001). The proportion of patients and vessels with FFR<0.75 in positive FAI group were significantly higher than that in negative FAI group (21.3% vs 4.5%, P=0.006; 23.2% vs 8.2%, P=0.016). The FAI between high-risk plaque and non-high-risk plaque had no significant difference (21.2% vs 16.1%, P=0.451). FAI predicted myocardial ischemia (AUC=0.666, P=0.021) and significantly improved the prediction efficiency of complex model(0.915 vs 0.951,P=0.033). Conclusion: Lower MLA and higher incidence of myocardial ischemia were associated with patients with higher FAI. In addition, FAI has a certain prediction efficiency and can provide incremental value for the determination of myocardial ischemia.

Increased C-reactive protein concentrations in patients admitted to the emergency department with troponin level elevations decreases the probability of myocardial ischemia

Abstract Funding Acknowledgements Type of funding sources: None. Background Patients frequently present to the emergency department (ED) with chest pain, dyspnea, or other symptoms with elevated troponin level. This finding prompts a provisional diagnosis of myocardial ischemia and raises the need to exclude this possibility. However, elevated blood troponin may be the result of a systemic inflammatory or infectious state merely representing cardiac injury and not myocardial ischemia. Purpose We hypothesized that the ratio of CRP/troponin could reflect the extent of the systemic inflammatory state that induces an attendant cardiac injury, which if sufficiently high could exclude myocardial ischemia. Methods Study population included 10774 patients admitted to the ED during the years 2016-2019 with cTn level higher &amp;gt; 14 ng/liter. CRP level was measured in all patients and CRP/troponin ratio was assessed against discharge diagnosis of myocardial ischemia, in order to evaluate its ability to exclude ischemic etiology of symptoms. The incidence of myocardial ischemia among study patients decreased with increasing CRP/troponin value. Results The prevalence of myocardial ischemia was 760/2694 patients (28.2%), 415/2694 (15.4%), 294/2695 (10.9%) and 130/2694 (4.8%) with 1st-4th CRP/troponin quartile, respectively (p &amp;lt; 0.0001). Logistic regression has shown that the probability of myocardial ischemia decreased by 53%, 68%, and 87% in the second to fourth CRP/troponin quartile compared with the first quartile, respectively (p &amp;lt; 0.0001). Conclusion The present study has shown that increased CRP level seems to modulate the specificity of simultaneous troponin as a marker of ischemia. As CRP level increases, so increases the likelihood that concomitant elevated troponin is due to myocardial injury and not due to myocardial ischemia. The clinical implication is that in the presence of a high CRP/troponin ratio, admission to the cardiology department and coronary investigation are unnecessary, whereas appropriate investigation of the actual medical problem is warranted.

Importance of myocardial ischemia detected with protocol-based measurements of high-sensitivity troponin, ECG and echocardiography in critically ill patients without acute coronary syndrome—a prospective study

Elevated cardiac troponin is detected in the majority of critically ill patients. This study aimed to evaluate the prognostic value of protocol-guided detection of myocardial ischemia (MI) (serial 12-lead electrocardiograms (ECG), high-sensitivity troponin T (hsTnT) measurements, and echocardiography) and compare it with a retrospective cohort with only clinically driven detection of MI. In a prospective observational study, 95 patients hospitalized ≥48 hours for reasons other than acute coronary syndrome in medical or surgical intensive-care unit (ICU) were enrolled. A protocol-based approach, with regular 12-lead ECG recordings, hsTnT measurements and admission echocardiography was conducted. All events possibly indicating MI were documented, and ECG, hsTnT, echocardiography were repeated. The protocol-based approach was compared to a retrospective group with only clinically driven detection of MI. In the prospective group, 95.8% of patients had at least one elevated hsTnT value. A hsTnT ＞70 ng/L was associated with the use of inotropes (OR 3.35 (95% CI: 1.184, 9.472), p = 0.022), left ventricular ejection fraction &lt;30% (OR 9.65 (95% CI: 1.172, 76.620), p = 0.035), regional wall motion abnormalities (OR 3.87 (95% CI: 1.032, 14.533), p = 0.045), ICU mortality (OR 8.38 (95% CI: 1.004, 69.924), p = 0.0495), hospital mortality (OR 3.05 (95% CI: 1.133, 8.230), p = 0.027) and 1-year mortality (OR: 5.43 (95% CI: 2.1099, 13.971), p = 0.005). The incidence of MI was higher in the prospective, as compared to the retrospective group (22.1% vs 5.3%; p = 0.001). MI, compared to the high “hsTnT positive only” group, predicted hospital mortality (OR 3.33 (95% CI: 1.190, 9.329), p = 0.02) and 1-year mortality (OR 4.66 (95% CI: 1.647, 13.222), p = 0.0037). A protocol-based compared to a clinically driven approach for the detection of MI reveals more patients with MI. The majority of critically ill patients have elevated hsTnT levels. Detected MI additionally stratifies patients with elevated hsTnT to higher hospital and 1-year mortality.

Myocardial ischemia by radionuclide imaging and long-term outcomes after kidney transplantation.

We examined the incidence of myocardial ischemia (MI) in kidney transplant recipients (KTR) using myocardial perfusion imaging (MPI), and its association with long-term outcomes after transplantation. A retrospective observational study was conducted of asymptomatic KTRs who underwent post-transplant MPI screening for MI, as defined by moderate to severe myocardial perfusion defects, post-stress myocardial stunning or balanced ischemia. A composite outcome of all-cause mortality, graft loss, and major adverse cardiovascular events (MACE) was examined over minimum 5years. We studied 135 KTRs who underwent 226 MPIs, with follow-up duration of 10 (7-13) years. 110 (81%) patients had normal MPIs, 11 (8%) had mild perfusion defects, and 14 (10%) had MI. Correspondingly, composite outcome developed in 6%, 27%, and 43% (p = 0.04), and MACE occurred in 7%, 0%, and 21% (p = 0.11), of the respective subgroups. Twenty-six patients developed the composite outcome after 5 (3-7) years post-transplantation, including 11 patients with MACE. On multivariate analysis, MI, higher low-density lipoprotein levels, and proteinuria > 0.3g/day independently predicted the composite outcome; only MI predicted MACE (all p < 0.05). Ninety-one patients had two serial MPIs, which increased the positive predictive value for MACE from 17 to 25%. Absence of MI had negative predictive value of 83% for MACE and 93% for the composite outcome. MI that is detected early post-kidney transplantation predicts long-term mortality, graft loss, and MACE in KTRs, with excellent negative but poor positive predictive values.

Evaluation of the comparative influence of magnesium sulfate single and combination with ritodrine hydrochloride in the prevention of preterm delivery

This project was designed to explore the effects of ritodrine hydrochloride combined with magnesium sulfate in the prevention of preterm delivery of patients with threatened premature birth. 128 cases of threatened premature birth were randomly divided into two groups according to the number table method. The control group was treated with magnesium sulfate, while the study group was treated with ritodrine hydrochloride combined with magnesium sulfate. The d(p&gt;0.05). ata was analyzed using SPSS 18.0 and was subjected to Chi-square and t test. The onset time and prolonged gestation time of the study group were shorter than those of the control group (p&lt;0.05). There was no difference in the incidence of myocardial ischemia between the study group and the control group (p&gt;0.05). The heart rate per minute of the study group was higher than that of the control group (p&lt;0.05). There was no difference in blood pressure between the study group and the control group Nevertheless, the neurological function, pregnancy outcome and neonatal status of the group were better than those of the control group (p&lt;0.05).&#x0D;

High thoracic epidural decreases perioperative myocardial ischemia and improves left ventricle function in aortic valve replacement alone or in addition to cabg surgery even with increased left ventricle mass index.

Introduction:High thoracic epidural (HTE) may reduce perioperative tachyarrhythmias, respiratory complications and myocardial ischemia (MI) and it may increase coronary perfusion and myocardial oxygen balance through sympatholysis and pain control. The aim of this study is to investigate the benefit of HTE in patients undergoing aortic valve replacement (AVR) alone or in addition to coronary artery bypass graft (CABG).Methods:This prospective randomized controlled study was conducted on 80 patients (40 with increased left ventricular mass index (LVMI) and 40 with normal LVMI) who were equally randomised (n = 40) to receive either GA with HTE (HTE group) or GA alone (GA group). Heart rate (HR), mean arterial blood pressure (MAP) and the incidence of ischemic ECG changes were recorded. LV functions (preoperative and postoperative by transthoracic echocardiography and intraoperative by transoesophageal echocardiography) were measured preoperative, intraoperative and till 48 H postoperative.Results:There was no significant difference in the baseline values of all measurements. HR and MAP were lower, and LV functions were improved in HTE group intraoperatively and postoperatively. Ischemic ECG changes were significantly lower in HTE group; with 42.9% intraoperative risk reduction (95% CI: 0.195-0.943) and 46.6% postoperative risk reduction (95% CI 0.227-0.952) as compared to GA group. The risk of ischemia was significantly higher in patients with increased LVMI in GA group (2.25 times compared to normal LVMI patients with 95% CI: 1.195-4.236), but it wasn't increased in HTE group. LV functions were significantly improved from the induction to 48 H postoperative in HTE group as compared to GA group.Conclusion:HTE reduced the incidence of MI and improved the LV function, even with increased LVM, in patients undergoing AVR alone or in addition to CABG.

Quantification of plaque characteristics detected by dual source computed tomography angiography to predict myocardial ischemia as assessed by single photon emission computed tomography myocardial perfusion imaging.

We aim to evaluate the relationship between quantitative plaque characteristics detected by dual-source computed tomography angiography (DSCTA) and myocardial ischemia as assessed by single photon emission computed tomography myocardial perfusion imaging (SPECT-MPI). In this study, 460 consecutive patients with suspected coronary artery disease (CAD) underwent DSCTA and stress/rest SPECT-MPI, and 179 patients with coronary artery plaques were quantitatively analyzed. Quantitative coronary artery plaque measurements including total plaque volume, the volume of non-calcified plaque, calcified plaque volume, low-density noncalcified plaque volume, total plaque burden, calcified plaque burden, non-calcified plaque burden, low-density non-calcified plaque (LDNCP) burden, remodeling index, plaque length, maximum diameter stenosis were provided by the automated software (Release 5.6.5, Circle Cardiovascular Imaging, Canada). Univariate and multivariate logistic regression analysis was performed to assess the correlation between quantitative plaque characteristics and myocardial ischemia to determine if plaque characteristics were independent of clinical risk factors and significant CAD. One hundred and seventy-nine patients (65% males) with suspected-CAD, undergoing DSCTA and stress/rest SPECT-MPI and single vessel ischemia were considered. There were significant correlations between quantitative assessment of plaque features and myocardial ischemia with details as follow: total plaque volume [25.2 (17.8-37.8) vs. 15.6 (10.3-24.9) mm3, P<0.001], calcified plaque volume (1.6±7.1 vs. 2.3±6.4 mm3, P=0.019), non-calcified plaque volume [23.6 (16.6-35.9) vs. 14.6 (10.3-22.8) mm3, P<0.001)], LDNCP volume [4.9 (2.1-8.2) vs. 2.2 (1.0-5.5) mm3, P=0.003], total plaque burden (47.6%±17.1% vs. 36.2%±17.3%, P=0.002), calcified plaque burden (1.5%±5.5% vs. 2.9%±6.9%, P=0.014), non-calcified plaque burden (46.1%±18.8% vs. 33.3%±16.4%, P=0.001), LDNCP burden [12.3% (6.4-17.7) vs. 3.3% (1.6-5.3), P<0.001], remodeling index [1.2 (1.1-1.4) vs. 1.0 (1.1-1.2), P<0.001], plaque length [4.0 (3.2-6.1) vs. 3.3 (2.8-3.8) mm, P=0.009], maximum diameter stenosis [18.1% (10.0-52.9) vs. 12.9% (6.5-18.5), P=0.011]. In a multivariate analysis, low-density noncalcified plaque burden (OR 1.33; 95% CI, 1.16-1.53, P<0.001) remained a significant predictor of myocardial ischemia after adjusting for stenosis ≥50% and gender. The area under curve (AUC) of the model containing LDNCP burden, stenosis ≥50% and gender was 0.875 (95% CI, 0.812-0.938), which was significantly better than the model with stenosis ≥50% and gender (AUC 0.729; 95% CI, 0.633-0.825). Quantitative plaque characteristics detected by DSCTA are independently correlated with the incidence of myocardial ischemia by SPECT-MPI in patients with suspected CAD.

Thyroid Hormone Replacement Therapy in Critically Ill Patients: Lack of Promising Evidence for Physiologically Sound Approaches

The sick euthyoid syndrome, also known as nonthyroidal illness syndrome, refers to changes seen in patient thyroid function tests administered in the medical intensive care unit during episodes of critical illness(1). Low serum T3 is the most common abnormality in euthyroid sick syndrome. Both low T3 and low T4 syndrome are reported in critically ill patients and low serum T4 is related with worst outcome. These features in laboratory findings of sick euthyroid patients have been explained by circulating thyroid binding hormone inhibitor (2). Thyroid hormone signalling regulates crucial biological functions, including energy expenditure, thermogenesis, development and growth. Fliers et al. (3), in their review “Thyroid function in critically ill patients”, concluded that routine thyroid hormone replacement therapy is not recommended in non-thyroid illness syndrome in critically ill patients. As we know, decreased plasma concentrations of thyroid hormones, especially T3, in critically ill patients represent the severity of the disorder and are associated with poor outcomes. On the other hand, thyroid hormone administration has been reported to be associated with improved hemodynamics, increased cardiac output, decreased ICU length of stay, reduced need for inotropic agents and mechanical devices, decreased incidence of myocardial ischaemia and decreased incidence of atrial fibrillation and pacemaker therapy (4-6). There are some studies reported the link between low levels of thyroid hormone and sarcopenia which leads to critical ill weakness (7.8). So it may be a rational to use hormone replacement therapy in selected critically ill patients with sick euthyroid syndrome.Not to implement physiologically sound approaches just because “evidence is lacking” might be disadvantageous for these patients over time as it might probably take years until clinical evidence become available. Subsequently, based on previous trials that have introduced effectiveness or at least no effects of hormone replacement therapy for non-thyroid illness syndrome, it seems that critically ill patients without limiting conditions such as advanced age or cardiac dysfunction (e.g. CHF or ACS) might benefit from thyroid replacement therapy and depriving these patients from what they might have benefited seems unethical.As we mentioned sick euthyroid syndrome occurs with different faces in critically ill patients with some good and some bad characteristics. Tolerating the early onset hibernation response with its concomitant changes in thyroid hormone parameters seems to be beneficial and safe. But the other type of sick euthyroid syndrome which develops later during prolong ICU admission may have a different face and needs some interventions as it has impact on patients outcome.

Lack of Cardiac Improvement After Cardiosphere-Derived Cell Transplantation in Aging Mouse Hearts.

Aging is one of the most significant risk factors for cardiovascular diseases, and the incidence of myocardial ischemia increases dramatically with age. Some studies have reported that cardiosphere-derived cells (CDCs) could benefit the injured heart. Nevertheless, the convincing evidence on CDC-induced improvement of aging heart is still limited. In this study, we tested whether the CDCs isolated from neonatal mice could benefit cardiac function in aging mice. We evaluated cardiac function of PBS- (n=15) and CDC-injected (n=19) aging mice. Echocardiography indicated that left ventricular (LV) ejection fraction (57.46%±3.57% versus 57.86%±2.44%) and LV fraction shortening (30.67%±2.41% versus 30.51%±1.78%) showed similar values in PBS- and CDC-injected mice. The diastolic wall thickness of LV was significantly increased after CDC injection, resulting in reduced diastolic LV volume. The pulse-wave Doppler and tissue Doppler imaging indicated that aging mice receiving PBS or CDC injection presented similar values of the peak early transmitral flow velocity, the peak late transmitral flow velocity, the ratio of the peak early transmitral flow velocity to the peak late transmitral flow velocity, and the ratio of the peak early transmitral flow velocity to the peak early diastolic mitral annular velocity, respectively. Pressure-volume loop experiment indicated that the LV end-diastolic pressure-volume relationship and end-systolic pressure-volume relationship were comparable in both PBS- and CDC-injected mice. Postmortem analysis of aging mouse hearts showed similar fibrotic degree in the 2 groups. In addition, the aging markers showed comparable expression levels in both PBS- and CDC-injected mice. The systemic aging performance measures, including exercise capacity, hair regrowth capacity, and inflammation, showed no significant improvement in CDC-injected mice. Finally, the telomere length was comparable between PBS- and CDC-injected mice. Together, these results indicate that CDCs do not improve heart function and systemic performances in aging mice.

Cardiovascular risk in rheumatoid arthritis: An update for general practitioners

Rheumatoid arthritis (RA) is a chronic inflammatory articular pathology which affects almost 1% of the general population and which is ranked among the top 15% of diseases causing major disability worldwide. RA shares some pathologic features, genetic predisposition and risk factors with atherosclerosis. Inflammation plays a central pathophysiologic role in both diseases. As compared with the general population, in RA the prevalence of cardiovascular events is increased to an extent comparable to that of type 2 diabetes mellitus. RA-Patients have a higher incidence of myocardial ischemia and infarction, cardiac failure, valvular heart disease, pericarditis, myocarditis and, to a lesser extent, venous complications. The occurrence of sudden cardiac death is two-fold increased and that of major adverse cardiovascular events is augmented to almost 50%. Cardiovascular deaths increase seven years following symptoms onset. Control of the joint pathology remains the principal therapeutic aim in RA, but the impact of cardiovascular complications should not be forgotten. Patients with RA who are at high cardiovascular risk should be given the best available therapies to reduce the cardiovascular complications. There are things we know that we know. There are known unknowns. That is to say, there are things that we know that we don’t know. But there are also unknown unknowns. There are things we don’t know we don’t know. Donald Rumsfeld

Effect of anesthesia methods on postoperative major adverse cardiac events and mortality after non-cardiac surgeries: a systematic review and meta-analysis.

Postoperative major adverse cardiac events (MACEs) are the main cause of postoperative mortality, and controversies exist regarding the effects of anesthesia methods on postoperative MACEs and mortality in high-risk cardiac patients after non-cardiac surgeries. A Meta-analysis about the effect of anesthesia methods on postoperative MACEs and mortality in high-risk cardiac patients undergoing intermediate- or high-risk non-cardiac surgeries was conducted; Chinese databases (SinoMed, CNKI, Wanfang, and VIP) and English databases (Medline, EMBASE, PubMed, Springer, Ovid, the Cochrane Library, and Google scholar) were searched. Twenty-seven randomized controlled trials (RCTs) were included and 35340 patients were involved. The cardiac troponin I level (cTnI) on postoperative day 1 (MD: -0.39, 95% CI: -0.45--0.34, P<0.00001) and the incidence of myocardial ischaemia (OR: 0.43, 95% CI: 0.27-0.68, P=0.0004) within 3 postoperative days were significantly lower after sevoflurane anesthesia than propofol anesthesia. There were no differences in postoperative MACEs or in mortality within either 30 days or 1 year between sevoflurane and propofol anesthesia, or between N2O and non-N2O anesthesia. The cTnI on postoperative day 3 was significantly lower from epidural anesthesia combined with general anesthesia (GA) than from GA alone (MD: -0.61, 95% CI: -0.75--0.47, P<0.00001). However, there were no differences in myocardial infarction or mortality between epidural anesthesia combined with GA and GA alone, or between spinal anesthesia alone and GA alone. Sevoflurane anesthesia, or epidural combined with general anesthesia can provide short-term myocardial protective effect in high-risk cardiac patients undergoing intermediate- or high-risk non-cardiac surgeries.

Abstract P326: Myocardial Ischemia and Mobilization of Circulating Progenitor Cells

Background: Circulating progenitor cells (CPCs) are involved in vascular repair and regeneration. Low levels of CPCs in patients with CAD have been linked to adverse cardiovascular outcomes. The response of CPCs to transient myocardial ischemia in patients with CAD has not been studied before. We aimed to investigate the CPC response to exercise provoked myocardial ischemia (demand ischemia), and compare it to myocardial ischemia detected during pharmacological stress test (flow mismatch). Methods: 570 patients with stable CAD underwent 99mTc sestamibi myocardial perfusion imaging during exercise (69%), or pharmacological stress (31%). myocardial ischemia was defined as a new or worsening impairment in myocardial perfusion using a 17-segment model. CD34+ CPCs were enumerated by flow cytometry at rest and 30 min after stress testing. The change in CPC count was compared between patients with and without myocardial ischemia using mixed linear models. Results: Mean age was 63±9 years, 76% males, 36% with previous myocardial infarction. The incidence of myocardial ischemia was 31% and 41% during exercise and pharmacological stress test, respectively. No difference was observed in resting CPC between patients undergoing exercise vs pharmacological stress test, nor between patients with or without myocardial ischemia. However, patients who developed myocardial ischemia during exercise stress had a significant decrease in CPC with stress in comparison to those without myocardial ischemia (-12% vs 4%, respectively, p=0.006). Furthermore, the change in CPCs was inversely correlated with the magnitude of myocardial ischemia (R=-0.13, p=0.023), suggesting a greater CPC reduction with larger ischemic burden. These findings remained significant even after adjustment for age, gender, race, BMI, previous myocardial infarction, resting levels of CPCs and hematocrit change with stress. No difference was observed in CPC response to pharmacological stress test (change of -1% vs 3%, for patients with and without myocardial ischemia, respectively, p=0.96). Conclusion: Exercise stress-induced myocardial ischemia is associated with a decrease in CPC counts, likely due to increased homing of stem cells to the ischemic myocardium. Whether the extent of CPC uptake has prognostic implication, or whether the CPC response can be altered with intervention needs further investigation.

Insuficiencia cardiaca aguda en el anciano: características clínicas y mortalidad según la fracción de eyección ventricular izquierda

MotivationTo describe and analise the clinical features of heart failure in the elderly, as well as the influence in mortality according to their left ventricular ejection fraction. MethodEcological multigroup descriptive study in 115 patients who had been hospitalised due to acute heart failure with a one year follow-up period. Depending on their left ventricular ejection fraction, patients were divided into two groups: preserved or non preserved left ventricular ejection fraction, if they showed ≥ 50% or <50%, respectively. Mortality rate one year after discharge was registered and Cox regression model was used for survival analysis. ResultsAverage age was 83.9 years and 40% were men. The left ventricular ejection fraction was preserved in 76 (66%) of patients. 35 (30.4%) died after one year. The preserved left ventricular ejection fraction group consisted of women predominantly, and they had more comorbidities, such as high blood pressure, diabetes mellitus, atrial fibrillation and chronic obstructive pulmonary disease, whereas their incidence of myocardial ischemia was lower. Despite mortality being higher in the non preserved left ventricular ejection fraction group, statistical significance was not reached (38.5% vs. 26.3%; p=0.180). ConclusionsMortality rate after one year of old patients with heart failure is high, and they also have a higher proportion of preserved left ventricular ejection fraction, which in turn is associated to a higher number of comorbidities and a higher tendency to survival after one year in comparison to non preserved left ventricular ejection fraction.

Prevention of Perioperative Cardiac Events Using Clonidine in Patients with Coronary Artery Disease Undergoing Noncardiac Surgery: A Meta-Analysis

Background: Clonidine may help prevent cardiac events in patients with coronary artery disease (CAD) undergoing noncardiac surgery by sympatholysis. This study aims to provide a systematic review of randomized controlled trials (RCTs) that assessed the efficacy of low-dose clonidine in preventing cardiac events perioperatively. Methods: The authors independently searched the online sites of Medline, PubMed and the Cochrane Database of Systematic Reviews for RCTs involving human participants. The search terms clonidine, prevention, myocardial ischemia, myocardial infarction, and noncardiac surgery were used. Results: Five trials comprising 10,618 participants were analyzed for the efficacy of low-dose clonidine in preventing cardiac events among patients with CAD undergoing noncardiac surgery. Low dose clonidine significantly reduced the incidence of myocardial ischemia in patients undergoing noncardiac surgery (RR 0.64; 95% CI, 0.50, 0.81), but it was not associated with any significant reduction in the risk of myocardial infarction (RR 1.09; 95% CI, 0.94, 1.27), congestive heart failure (RR 1.24; 0.83, 1.85), cardiac arrhythmia (RR 1.10; 95% CI, 0.84, 1.45), and death (RR 0.93; 95 % CI, 0.67, 1.29). Significantly more patients in the clonidine group had hypotension compared to placebo (RR 1.28; 95 % CI, 1.22, 1.34). Conclusion: The meta-analysis suggests that perioperative low-dose clonidine reduced myocardial ischemia in patients at risk of CAD. However, it increased the risk of hypotension. The trend in reduction of mortality using low-dose clonidine was not statistically significant. The use of low-dose clonidine did not affect the risk of perioperative myocardial infarction, congestive heart failure and cardiac arrhythmia.