Marker Of Myocardial Ischemia Research Articles

Is ischemia a disease or syndrome, the cause of angina, and now even a trial?

The clinical manifestations of myocardial ischemia are protean in nature and include a variable combination of typical or atypical angina symptoms, electrocardiographic changes, noninvasive findings of regional wall motion abnormalities, and reversible scintigraphic perfusion defects—the changes of which, importantly, may or may not be of epicardial coronary origin. Thus, mounting evidence indicates that the presence or absence of atherosclerotic coronary artery disease (CAD) should no longer be considered a surrogate marker for myocardial ischemia, as suggested by the high prevalence of minor or absent coronary obstruction among patients with proven myocardial ischemia. Whereas the management of CAD has been largely predicated on the plausible assumption that flow-limiting obstructions of the epicardial coronary arteries are the proximate cause of both angina and myocardial ischemia, there is scant evidence from many randomized trials and several meta-analyses that treating epicardial coronary obstructions in patients with stable CAD, particularly with percutaneous coronary intervention (PCI), reduces mortality and morbidity, as compared with optimal medical therapy (OMT). A crucial scientific question for which evidence has been lacking is whether more severe and extensive myocardial ischemia is the driver of adverse cardiovascular outcomes and whether an invasive strategy with myocardial revascularization would be superior to OMT alone in such patients. The results of the recent ISCHEMIA trial (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches), however, have failed to show—even in this higher-risk CAD subset—any incremental clinical benefit of revascularization as compared with OMT alone on cardiac event reduction.

Biochemical Markers of Sudden Cardiac Death

The possible use of biochemical markers in the postmortem diagnosis of sudden cardiac deaths is well known in the forensic setting, though several issues have limited its widespread adoption. The aim of the present study was to describe the discovery of cardiac troponin I (cTnI), myoglobin (MYO) and creatinine kinase MB (CK-MB) in femoral whole blood (FWB), pericardial fluid (PF) and vitreous humor (VH) samples, that were collected post-mortem, in various cases of death related to ischemic heart disease, using the rapid diagnostic test 'Cardiac Markers Combo Rapid Test Device'. The authors conducted a prospective study in which they analyzed a total of 100 autopsies performed at the Legal Medicine Clinical Service of Galați County. The results of the present study showed that cardiac markers can be determined using rapid diagnostic tests for blood from the femoral vein and pericardial fluid, but not for the vitreous humor. Using postmortem biochemical markers of myocardial ischaemia requires caution and flexibility, so that the forensic pathologist has to take into consideration, when interpreting the results, both the postmortem interval, and the type of biological sample. Keywords: sudden death, cardiac, markers, troponin, forensic pathology

P1549 The quantitative value of PSI and time interval between AV closure and regional peak longitudinal strain in the assessment of CAD severity by the use of resting 2D ST_TTE

Abstract Background Early detection of myocardial ischemia has important therapeutic and prognostic implications. Evidence of post-systolic shortening (PSS) on speckle tracking TTE is indicative of delayed myocardial contraction after aortic valve closure (AVC), and has been proposed to be a marker of myocardial ischemia. The pathologic post systolic strain index (PSI) only exists in patients with decreased systolic strain and thickening. Purpose To evaluate the PSI and time interval from AVC to regional PLS measured by using resting 2D speckle tracking TTE for detection of LV myocardial ischemic segments and lesion severity confirmed by coronary angiography. Methods A cross sectional study of patients with ischemic heart disease, underwent 2D speckle tracking TTE (Vivid E9, GE Healthcare) immediately before invasive coronary angiography. PSI, regional PLS and time interval from AVC to regional PLS in each LV segment were calculated. Results 63 stable patients, the mean age 55.6 (± 10.95) years and male: female ratio (2: 1). Coronary angiographic lesion ≥ 50% was detected in (334) LV segments of corresponding coronary artery territory. There were significant differences between LV segments with <50% CA lesion severity and LV segments with ≥50% CA lesion severity regarding both the PSI and Time interval from AVC to regional PLS. To identify the LV segments of the corresponding CA territory with ≥50% lesion severity, the receiver operator characteristic (ROC) curves for PSI and the time interval had areas under the curve (AUC) values 0.82 and 0.63 respectively which were statistically significant with best cut-off points of PSI was 15% (sensitivity 84%, specificity 68%) and for the Time interval was 85msec (sensitivity 68%, specificity 55%). Conclusion In ischemic patients with ≥50% coronary artery stenosis, as confirmed by invasive coronary angiography, the measurement of PSI and the time interval simultaneously on resting 2D ST_TTE, enabled the identification of LV segments of the corresponding coronary artery territory with pathologic (ischemic) PSS by using each appropriate threshold for PSI and time interval with excellent diagnostic accuracy. When both measures were significant, the sensitivity and specificity being (49 %, 69.8%) respectively which is better than using one measure alone. Best cut-off point of PSI & Time interva variable cut-off point sensitivity specificity PSI 15% 84% 68% Time Interval 68% 55% PSI & Time Interval 15% , 85 msec 49% 69.8%

A 10-year experience with pediatric asphyxiation secondary to near hanging

Background: Pediatric (especially preadolescent) asphyxiation secondary to near hanging is a seldom reported entity and tends to be predominantly accidental in nature.Objective: The objective of the study was to assess and report the course during the intensive care unit (ICU) stay and the unique problems that are pertinent to pediatric near-hanging injuries.Methodology: A 10-year retrospective analysis (2009–2019) was conducted after obtaining ethical approval.Results: Eleven patients presented to our pediatric ICU over the past 10 years, with pediatric asphyxiation secondary to near hanging. Among these children, most of them had saree swing as the mode of hanging; this subgroup had a higher morbidity and mortality. They tend to have higher markers of myocardial ischemia (high troponin T and creatine kinase). About half of the patients required fluid boluses, inotropic requirement, and ventilation at admission. Patients with pulmonary edema tended to have low oxygen saturation (SpO2), even without respiratory distress at admission, and higher ventilator and inotropic requirement. Only half of the patient population admitted were discharged with good neurological outcome (Glasgow Coma Scale: 15/15 at discharge).Conclusion: The nature of complications secondary to hanging necessitates ICU monitoring, with pediatric ENT and anesthesia backup. The presence of low SpO2at admission in this setting should alert the clinician to possibility of pulmonary edema. Parents should be made aware that saree swing can lead to accidental asphyxiation. It is important to raise awareness to prevent this entity as it is associated with poor outcome.

Protective effect of ulinastatin on myocardial injury after cardiopulmonary resuscitation in pigs

Objective To evaluate the protective effect of ulinastatin (UTI) on myocardial injury after post-cardiac arrest syndrome (PCAS) of cardiopulmonary resuscitation in pigs. Methods Twelve male 3-4 months pigs were randomly divided into two groups, UTI group and control group. The ventricular fibrillation (VF) animal model was replicated by programmed stimulation method. Among the 12 pigs, 11 pigs were successfully resuscitated by CPR after 5 min VF, of which, 6 pigs were in the UTI group and 5 pigs in the control group. Immediately after resuscitation, pigs in the UTI group was given 100 kU dissolved in 5 mL normal saline with slowly injection every 3 h until 24 h after recovery (no drug was given at 24 h). In the control group, 5 mL normal saline was given with same delivery time and frequency as that in the UTI group. The venous blood of the pigs was collected at VF, 2, 4, 6, 12, and 24 h after ROCS, and tumor necrosis factor -α (TNF-α), interleukin-6 (IL-6), superoxide dismutase (SOD), malondialdehyde (MDA), and ischemia modified albumin (IMA) were measured by enzyme-linked immunosorbent assay (ELISA) method. Because IMA was sensitive and increased rapidly, venous blood was detected at 1 h after ROSC, and the rest test time were same with the rest of the blood factors. Statistical analysis was performed using LSD-t test and variance analysis. The pigs were sacrificed 24 h after ROSC, and specimens from heart tissue were taken for HE staining. Results Before ventricular fibrillation in three groups, there was no significant difference in serum levels of inflammatory cytokines, oxidative stress indexes, and myocardial ischemia markers between the two groups (P>0.05). At 2 h after ventricular fibrillation, the levels of TNF-α and IL-6 level in the UTI group was significantly lower than those in the control group. At 4 h, MDA level in the UTI group was significantly lower than that in the control group (P 0.05). HE staining results showed that the damage degree of myocardial tissue in the UTI group was significantly lower than that in the control group at 24 h after ROSC. Conclusions UTI can significantly antagonize inflammatory response, reduce oxidative stress, and improve the myocardial tissue injury after resuscitation. It can protect myocardial injury after cardiopulmonary resuscitation. Key words: Ulinastatin; Cardiopulmonary resuscitation; Post-cardiac arrest syndrome; Tumor necrosis factor -αInterleukin-6; Superoxide dismutase; Ischemia modified albumin

Postsystolic shortening on echocardiography as a gateway to cardiac computed tomography in patients with suspected stable angina pectoris.

Postsystolic shortening (PSS) by speckle-tracking echocardiography (STE) is a marker of myocardial ischemia and may improve diagnostic strategy. We sought to evaluate if PSS is associated with the coronary artery calcium score (CACS) and stenosis by computed tomography angiography (CTA) in patients with suspected stable angina pectoris (SAP). We retrospectively studied 437 SAP patients (age 58 ± 11years, 41% male) who underwent STE, evaluation of CACS and assessment of significant stenosis (≥ 50%) by CTA. The postsystolic index (PSI) was defined as follows: 100x([peak negative strain cardiac cycle - peak negative strain systole])/peak negative strain cardiac cycle. A wall had PSS if any segment within the wall had a PSI ≥ 20%. We defined categories for walls with PSS: 0, 1, 2 and ≥ 3, and CACS: 0, 1-100, 101-400 and > 400. Each additional wall with PSS was associated with a 43% relative increase in CACS (95%CI +9% to +87%, P = 0.010), while each 1% absolute increase in the PSI was associated with a 9% relative increase in CACS (95%CI +1% to +18%, P = 0.031). Walls with PSS (OR 1.81 per 1 wall increase, 95%CI 1.27-2.59, P = 0.001) and the PSI (OR 1.12 per 1% increase, 95%CI 1.04-1.21, P = 0.004) were associated withthe occurrence of CACS > 400. Additionally, walls with PSS (OR 1.53 per 1 wall increase, 95%CI 1.21-1.93, P < 0.001) was a predictor of significant stenosis by CTA. PSS is associated with CACS and significant stenosis by CTA in patients with SAP and may aid in the selection of patients referred for cardiac computed tomography.

Assessment of Myocardial Ischemic Memory Using Three-Dimensional Speckle-Tracking Echocardiography: A Novel Integrated Analysis of Early Systolic Lengthening and Postsystolic Shortening

Persistence of subtle abnormal myocardial deformation such as postsystolic shortening (PSS) after transient ischemia can be used to diagnose a history of myocardial ischemia (myocardial ischemic memory). Furthermore, early systolic lengthening (ESL) has recently attracted attention as another marker of myocardial ischemia. However, it is unclear whether the persistence of such abnormal deformation can be detected by three-dimensional (3D) speckle-tracking echocardiography, which has relatively low spatial and temporal resolution compared with two-dimensional echocardiography. The aim of this study was to evaluate the diagnostic accuracy of myocardial ischemic memory and its spatial extent using 3D speckle-tracking echocardiography. The left circumflex coronary artery was occluded for 2min, followed by reperfusion, in 33 dogs. Their hemodynamic and 3D echocardiographic data were chronologically acquired. Peak systolic strain, early systolic strain index as a parameter of ESL, postsystolic strain index as a parameter of PSS, and myocardial dysfunction index as a combined parameter of ESL and PSS were analyzed in all left ventricular segments. At the center of the risk area, early systolic strain index and postsystolic strain index significantly increased until 20min after reperfusion compared with baseline, although peak systolic strain recovered by 20min. Myocardial dysfunction index significantly increased for >20min after reperfusion and allowed better diagnostic accuracy of ischemic memory than the other parameters. In the 147 risk segments, abnormal values of myocardial dysfunction index remained in 49 segments (33%) at 20min after reperfusion, whereas abnormal peak systolic strain was observed in only 13 segments (9%). ESL and PSS persisted after transient ischemia and could be detected by 3D speckle-tracking echocardiography. Integrated analysis of ESL and PSS provided higher diagnostic accuracy of ischemic memory. This method may be useful for detecting transient ischemic insults in patients after the disappearance of anginal attack.

MRNA expression patterns in human myocardial tissue, pericardial fluid and blood, and its contribution to the diagnosis of cause of death

Gene expression has become an interesting research area in forensic pathology to investigate the process of death at the molecular level. The aims of this study were to analyze changes in gene expression patterns in relation to the cause of death, and to propose new molecular markers of myocardial ischemia of potential use for the postmortem diagnosis of early ischemic heart damage in cases of sudden cardiac death (SCD). We determined mRNA levels of five proteins related with ischemic myocardial damage and repair – TNNI3, MYL3, TGFB1, MMP9 and VEGFA – in specific sites of the myocardium, blood and pericardial fluid in samples from 30 cadavers with different causes of death (SCD, multiple trauma, mechanical asphyxia, and other natural deaths). TNNI3 expression in blood, and MMP9 expression in pericardial fluid, were significantly higher when the cause of death was mechanical asphyxia, probably because of the more sensitive response of these proteins to acute systemic hypoxia/ischemia. Specifically, among SCD cases, increased MYL3, VEGFA and MMP9 values in the anterior wall of the right ventricle were found when the confirmed cause of death was acute myocardial infarction (AMI). Higher TGFB1 expression was found in the interventricular septum when AMI was not the cause of death, most likely as a reflection of the short duration of ischemia. Molecular biology techniques can provide complementary tools for the forensic diagnosis of early ischemic myocardial damage and AMI, and may make it possible to determine the duration and severity of myocardial ischemia.

A new proof for the relationship between erectile dysfunction and atherosclerosis: fragmented QRS?

In patients with coronary artery disease (CAD), fragmented QRS (fQRS) is a practical marker of myocardial ischemia evaluated on electrocardiography (ECG).The current study investigated the connection between FQRS and erectile dysfunction (ED), which is commonly accepted as an early sign and independent predictor of CAD. The study consisted of a 190 ED patients; 47 of them having severe, 44 moderate, 49 mild-to-moderate, and 50 mild ED, and a control group of 51 otherwise healthy adult men. None of the participants had a history of cardiac disease. There was a significant difference among the groups in terms of fQRS; severe, moderate, and mild-to-moderate ED groups had significantly higher rates of fQRS presence on ECG (27.5%, 23.5%, and 22.5%, respectively) in comparison with those of mild ED and the control groups (13.7% and 12.7%, respectively) (p < 0.001). In patients presenting with ED complaints, a fQRS finding on a simple ECG recording may serve as a first sign of the presence of CAD. As far as we know, the present study is the first in the literature assessing the possible relationship between ED and fQRS. On the ECG, the existence of fQRS was considered to be connected with ED; thus, including this basic parameter into the clinical decisions for ED patients may initiate an extensive diagnostic approach for their underlying cardiovascular diseases.

Importance of Strain Echocardiography and Cardiac Magnetic Resonance for the Early Diagnosis of Myocarditis

Introduction: Myocarditis (MC) can result from a variety of infectious and non-infectious causes, and the secondary MC due to viral infection is the most prevalent form. Acute and nonfatal MC, on the other hand, has a more indolent presentation with mortality up to 20.0% in the first year and 55.0% at 11 years based on the initial diagnosis of acute MC. The diagnostic evaluation of MC is done initially through clinical suspicion, together with non-invasive diagnostic methods. In this sense, we highlight the Echocardiography with Strain. Objective: to present the importance of the early diagnosis of myocarditis through the images obtained by the Strain Echocardiography and Cardiac Magnetic Resonance. Case report: The CBB patient, 25 years old, female, with no known diagnosis, reports that two weeks ago the patient had started upper airway infection with partial improvement after specific antimicrobial treatment. The hemogram revealed normocytic and normochromic anemia and leukocytosis with predominance of segmented. C-reactive protein was elevated and markers of myocardial ischemia were also altered. Strain echocardiography revealed segmental alterations of the endomyocardial deformation with reduction of the longitudinal Strain in the middle inferolateral and middle anterolateral segments. Cardiac magnetic resonance revealed late focal mesoepicardial enhancement, of small extension, in the midbasal inferolateral segment, suggestive of MC. Final considerations: In conclusion the study made it possible to know that the early diagnosis of myocarditis through the image obtained by the Strain Echocardiography showed the inflammatory process in the same region observed by cardiac magnetic resonance imaging. This was added to the hemogram, reactive protein, and to the markers of myocardial ischemia.

Effect of Intractable Epilepsy on the Physiological Cardiac Performance Parameters and the Serum Levels of Cardiac Fatty Acid Binding Protein in Pediatrics

AbstractBackground: Multiple cardiac changes and various abnor-malities have been linked to epileptic fits. The assessment of cardiac changes and serum biomarkers level are commonly accepted methods to evaluate autonomic disturbances during epileptic fits which is very closely associated with some cardiovascular events especially the sudden unexpected cardiac death.Aim of Study: To evaluate ictal and inter-ictal cardiac changes and plasma levels of heart type fatty acid binding protein (H-FABP) in pediatric patients with treatment resistant epilepsy.Patients and Methods: 32 seizure attacks were recorded in 23 children with intractable seizures. Simultaneous Holter-ECG and video-EEG recordings were done with evaluation of changes in Heart Rate (HR), parameters of Heart Rate Variability (HRV), as well as serum levels of H-FABP as a marker of myocardial ischemia in the ictal and inter-ictal periods and compared with a control group.Results: The recorded HR changes included Ictal Tachy-cardia (IT) (96.87%), Ictal Bradycardia (IB) (3.13%), Prema-ture Atrial Contractions (PAC) (18.75%) and Premature Ventricular Contractions (PVC) (28.13%) in the first post-ictal hour. Significant HR increase was observed in the pre-ictal hour and ictal values compared to basal values and remained high 2 hours post-ictally. Basal HR and serum levels of the H-FABP protein were significantly higher while time domain HRV parameters were significantly lower in the patients compared to controls.Conclusion: Significant cardiac changes may occur even before the seizure onset in cases with intractable epilepsy. The increased levels of H-FABP may indicate the presence of autonomic instability and myocardial ischemia even in asymptomatic patients.

Abstract 16624: Association of Subclinical Atherosclerosis and Echocardiographic Indices of Cardiac Remodeling: The Framingham Study

Subclinical atherosclerosis, a marker of myocardial ischemia, may impact cardiac remodeling indices; yet this association has not been evaluated. We hypothesized that higher coronary artery calcium (CAC) burden is associated with alterations of cardiac remodeling in individuals free of congestive heart failure (CHF) and myocardial infarct (MI). We related CT-based CAC score to echocardiographic (echo) indices in 2,650 Framingham Study participants (mean age 52 yrs, 48% women; 39% had CAC&gt;0). We examined the following echo indices (log-transformed dependent variables): left ventricular (LV) mass index (LVMi), LV ejection fraction (LVEF), E/e’, global longitudinal strain (GLS), left atrial ejection fraction (LAEF) and aortic root diameter (AoR). Using multivariable-adjusted generalized linear models to account for relatedness, we modeled CAC score (independent variable) as a log-transformed continuous [ln(CAC+1)] or categorical (0, 1-100, and ≥101) variable. Adjusting for standard risk factors, higher CAC burden was associated with higher LVMi, E/e’ and AoR, and with lower LAEF. Those with CAC score≥101 had lower LAEF and higher E/e’ and AoR compared to those with CAC=0 ( P &lt;0.05 for all, Figure). We observed effect modification by sex and age (interaction P &lt;0.05) for the association of CAC score with LAEF and with AoR, respectively. In stratified analysis, higher CAC values were associated with lower LAEF values only in women ( P &lt;0.003), and with higher AoR in older participants (&gt;median age of 58 yrs; P &lt;0.007). Conclusions: Subclinical atherosclerosis is associated with cardiac remodeling indices, consistent with the potential adverse impact of subclinical ischemia on myocardial and aortic remodeling in individuals free of CHF and MI. The prognostic significance of these associations warrant evaluation in future studies.

Cardiovascular resistance to thrombosis in 13-lined ground squirrels.

13-lined ground squirrels (Ictidomys tridecemlineatus) enter hibernation as a survival strategy during extreme environmental conditions. Typical ground squirrel hibernation is characterized by prolonged periods of torpor with significantly reduced heart rate, blood pressure, and blood flow, interrupted every few weeks by brief interbout arousals (IBA) during which blood flow fluctuates dramatically. These physiological conditions should increase the risk of stasis-induced blood clots and myocardial ischemia. However, ground squirrels have adapted to survive repeated bouts of torpor and IBA without forming lethal blood clots or sustaining lethal ischemic myocardial damage. The purpose of this study was to determine if ground squirrels are resistant to thrombosis and myocardial ischemia during hibernation. Blood markers of coagulation, fibrinolysis, thrombosis, and ischemia, as well as histological markers of myocardial ischemia were measured throughout the annual hibernation cycle. Hibernating ground squirrels were also treated with isoprenaline to induce myocardial ischemia. Thrombin-antithrombin complex levels were significantly reduced (p < 0.05) during hibernation, while D-dimer level remained unchanged throughout the annual cycle, both consistent with an antithrombotic state. During torpor, the ground squirrels were in a hyperfibrinolytic state with an elevated ratio of tissue plasminogen activator complexed with plasminogen activator inhibitor to total plasminogen activator inhibitor (p < 0.05). Histological markers of myocardial ischemia were reversibly elevated during hibernation with no increase in markers of myocardial cell death in the blood. These data suggest that ground squirrels do not form major blood clots during hibernation through suppression of coagulation and a hyperfibrinolytic state. These animals also demonstrate myocardial resistance to ischemia.

Myocardial Scar But Not Ischemia Is Associated With Defibrillator Shocks and Sudden Cardiac Death in Stable Patients With Reduced Left Ventricular EjectionFraction.

This study sought to investigate the association of myocardial scar and ischemia with major arrhythmic events (MAEs) in patients with left ventricular ejection fraction (LVEF)≤35%. Although myocardial scar is a known substrate for ventricular arrhythmias, the association of myocardial ischemia with ventricular arrhythmias in stable patients with left ventricular dysfunction is less clear. A total of 439 consecutive patients (median age, 70 years; 78% male; 55% with implantable cardioverter defibrillator [ICD]) referred for stress/rest positron emission tomography (PET) and resting LVEF≤35% were included. Primary outcome was time-to-first MAE defined as sudden cardiac death, resuscitated sudden cardiac death, or appropriate ICD shocks for ventricular tachyarrhythmias ascertained by blinded adjudication of hospital records, Social Security Administration's Death Masterfile, National Death Index, and ICD vendor databases. Ninety-one MAEs including 20 sudden cardiac deaths occurred in 75 (17%) patients during a median follow-up of 3.2 years. Transmural myocardial scar was strongly associated with MAEs beyond age, sex, cardiovascular risk factors, beta-blocker therapy, and resting LVEF (adjusted hazard ratio per 10% increase in scar, 1.48 [95% confidence interval: 1.22 to 1.80]; p< 0.001). However, non transmural scar/hibernation or markers of myocardial ischemia on PET including global or peri-infarct ischemia, coronary flow reserve, and resting or hyperemic myocardial blood flows were not associated with MAEs in univariable or multivariable analysis. These findings remained robust in subgroup analyses of patients with ICD (n= 223), with ischemic cardiomyopathy (n= 287), and in patients without revascularization after the PET scan (n= 365). Myocardial scar but not ischemia was associated with appropriate ICD shocks and sudden cardiac death in patients with LVEF≤35%. These findings have implications for risk-stratification of patients with left ventricular dysfunction who may benefit from ICD therapy.

Stress perfusion Cardiac Magnetic Resonance in Patients with Antiphospholipid Syndrome.

Background:Antiphospholipid syndrome (APS) is characterized by the combination of recurrent arterial and venous thrombotic events and detection of persistently elevated antiphospholipid antibody titers in the serum or plasma. APS clinical manifestations also include non-thrombotic complications from various organ systems, mainly the CNS, kidneys, and heart. Cardiac manifestations of APS include valvulopathy, myocardial infarction and angina (stable, unstable, and Pritzmental angina). A previously published case series of cardiac magnetic resonance (CMR) in patients with APS has revealed a high rate of asymptomatic myocardial necrosis and scarring, but the prevalence of myocardial ischemia identified as CMR perfusion defects prior to development of necrosis is unknown.Aims of the study:To detect CMR imaging markers of myocardial ischemia in APS patients without symptoms of cardiovascular disease (CVD).Methods:We will scan fifty APS patients without symptoms of CVD stress-perfusion CMR in a 1.5 Tesla tomographer, after intravenous infusion of adenosine and gadolinium. In addition to markers of cardiac anatomy and function, we will record imaging markers of ischemia and scarring, namely perfusion defects (PDs), and late gadolinium enhancement (LGE). We will perform parametrics using dedicated software in order to derive each patient’s myocardial perfusion reserve index (MPRI). Scans will be reviewed independently by two experienced reviewers, with evaluation of inter- and intra-observer reliability. Statistical hypotheses will be examined using Student’s test and Pearson’s correlation coefficient, or non-parametric equivalents (Kruskall-Wallis and Spearman) for continuous variables, and Fisher’s exact test for binary variables. Linear or logistic regression analyses will be used to investigate APS-related determinants of subclinical myocardial ischemia.Anticipated benefits:We expect to identify CMR imaging patterns characteristic of APS, which will allow proactive therapeutic interventions for primary prevention of CVD and guide further research into the pathogenesis of APS cardiac manifestations.

Heart-type fatty acid binding protein levels in elderly diabetics without known cardiovascular disease.

BackgroundCardiovascular disease (CVD) is reported to be higher in elderly diabetics. Serum heart-type fatty acid binding protein (H-FABP) is a serum marker of myocardial ischemia. We aimed to investigate the association between serum H-FABP level and conventional cardiovascular risk factors, inflammatory markers and subclinical atherosclerosis in elderly diabetics without overt CVD.Patients and methodsA total of 50 elderly diabetic patients without overt CVD and 30 age-, sex- and body mass index (BMI)-matched healthy controls were enrolled. Anthropometric and biochemical parameters, serum H-FABP, high-sensitivity C-reactive protein (hs-CRP), fibrinogen and carotid intima-media thickness (CIMT) were measured. Logistic regression analyses (adjustments for age, sex, hypertension, smoking, diabetes, BMI, blood pressure, lipid, blood glucose, hemoglobin A1c, hs-CRP and fibrinogen) were performed to evaluate the association between H-FABP and cardiovascular risk factors and atherosclerosis indices.ResultsSerum fibrinogen (421.50±85.52 mg/dL vs 319.17±30.77 mg/dL, p=0.023), CIMT (0.70±0.12 mm vs 0.59±0.06 mm, p<0.001) and hs-CRP (5.72±4.50 mg/dL vs 1.60±0.72 mg/dL, p<0.001) were significantly higher in diabetic patients than controls. The mean serum H-FABP level did not differ between groups (1571.79±604.60 ng/mL vs 1500.25±463.35 ng/mL, p=0.905). H-FABP was positively correlated with fibrinogen (r2=0.473, p<0.001), hs-CRP (r2=0.323, p=0.003) and CIMT (r2=0.467, p<0.001). After full adjustments, the serum H-FABP level was independently associated with an increase in the fibrinogen level (odds ratio [OR] =4.21, 95% confidence level [CI] =1.49–11.90).ConclusionSerum H-FABP was similar in the elderly diabetic patients without known CVD when compared with the nondiabetic control group. H-FABP does not possess a high diagnostic value as a cardiovascular marker when used alone; however, it may add supplementary information in patients with a high fibrinogen level.

Prognostic Significance of Cardiac Troponin in Acute Gastrointestinal Bleeding

Introduction: Acute gastrointestinal bleeding (AGIB) is responsible for over 300,000 hospitalizations annually. Cardiovascular-related deaths accounts for 30% of the patients surviving the initial episode of AGIB. The purpose of this study is to identify the impact of elevated troponin on short-term mortality and length of stay (LOS) of these patients. Methods: From July 2013 to July 2016, 290 patients admitted with a diagnosis of AGIB and who had cardiac troponin I measured within 24 hours of presentation were retrospectively reviewed. Clinical variables including 30-day mortality, 30-day readmission and LOS were then compared between the groups of troponin elevation and no troponin elevation. Results: The overall 30-day mortality among patients with AGIB was 6.5% (19/290). Cardiac troponin was elevated in 10% of patients (29/290). Among patients with normal troponin, 5% (13/261) died within 30 days. In patients with troponin elevation, 21% died in the same period (6/29), P=0.001. The LOS was also higher in patients with troponin elevation (4.88 vs 5.45, P=0.02). There was no difference in 30-day readmission among the two groups. Past history of Coronary artery disease, Congestive Heart Failure, Hypertension, aspirin use and elevated creatinine were more common in patients with troponin elevation troponin elevation. On multivariate analysis, troponin elevation on presentation is associated with increased mortality (Odds 5.50, [CI: 1.73-17.47], P=0.004). Conclusion: Cardiac troponin I is the sensitive marker for myocardial ischemia, especially in assessing acute coronary syndromes. Elevated troponin can occur in non-cardiac conditions including AGIB and represent cardiac injury. Diminished oxygen delivery secondary to anemia and hypotension and increased oxygen demand due to tachycardia are the main reasons for myocardial ischemia and subsequent troponin elevation in GI bleeding. The severity of AGIB is usually assessed by Rockall and Blatchford score, with higher scores associated with higher mortality. Given association of troponin with higher mortality in AGIB, it can be used as a biomarker to risk-stratify the patients on admission, especially in those with pre-existing cardiovascular disease as elevated levels are associated with poor outcomes and higher utilization of resources. This study suggest 30-day mortality and length of stay are higher among patients with troponin elevation.Table: Table. Results of Univariate Tests between Patients with troponin elevation and those with normal troponin

Early markers of myocardial ischemia: from the experimental model to forensic pathology cases of sudden cardiac death.

The goal of this study was to assess whether early markers of myocardial ischemia, identified in a previous experimental work, can be applied in forensic pathology cases of sudden, ischemic cardiac death. These markers include desphosphorylated connexin 43 (Cx43), JunB, TUNEL assay, myoglobin, and troponin T. Fourteen cases of sudden cardiac death with gross and/or histological signs of myocardial infarction and 14 cases of sudden cardiac death with signs of early ischemia at histology and positive immunoreactions for fibronectin and C5b-9 were investigated. The control group was represented by 15 hanging (global hypoxia) cases. Immunohistochemical reactions were classified into four degrees and compared among groups. Cx43 and JunB were significantly more expressed in hanging than in ischemia/infarction, but they showed a different distribution in the tissue (sub-endocardial in ischemia/infarction, diffuse in hanging) and a different intensity of the signal. TUNEL assay was significantly more expressed in the group of early ischemia than in myocardial infarction. Myoglobin and troponin T did not show any significantly different expression among the three groups. Depletion markers have a limited application in forensic cases, and this is mostly because positive (depleted) areas are difficult to distinguish from artifactually paler areas. Nuclear markers (JunB and TUNEL), on the other hand, require a well-trained eye and a high magnification in order to be distinguished. Cx43, JunB, and TUNEL assays were confirmed to be early, sensitive markers for myocardial ischemia. Nonetheless, they are not specific, as they are expressed in global hypoxia as well, but with a different tissular distribution.

Assessment of Ischemia Modified Albumin and Cardiac Troponin (I) as an Early Diagnostic Markers of Myocardial Ischemia among Patients with Acute Chest Pain

Cardiac biomarkers have been emphasized as central to the diagnosis and risk stratification strategy for AMI by numerous clinical practice guidelines. Aim: To assess the diagnostic value of Ischemia -modified albumin (IMA) with standard biomarkers (CK-MB, LDH, and AST) troponin I [cTnI] in the early diagnosis of cardiac ischemia. Method: This is cross-sectional study was done 150 with patient’s acute chest pain as target population patients attending to the emergency department of Al Shab Hospital Khartoum. Every case was reviewed by a cardiologist. A clinical diagnosis of ischemia was assigned and correlated with biomarker test results. Results: 127 (84.7%) had myocardial ischemia. Receiver operating characteristic curves demonstrated IMA as highly sensitive but somewhat low specific for the presence of ischemia (area under curve, 0.878; P = .00). With a cut point of 88.16 U/mL, the IMA test had 84.6% sensitivity and 81% specificity for diagnosing ischemia and a negative predictive value of 77.9%. IMA was positive in 127 of 96 patients with electrocardiographic (ECG) evidence of ischemia and 31 of 127 patients with coronary ischemia but negative ECG. Among the same patients, the ECG and cTnI triad had a sensitivity of 64% and 24% respectively. The combination of IMA and ECG increased the sensitivity to (94.5%), and IMA, ECG, cTnI to 95.8%for detecting ischemia. IMA is highly sensitive and has a high negative predictive value, which might improve the usefulness of standard biomarkers of myocardial ischemia. Conclusion: Ischemia Modified Albumin has evaluated as highly sensitive, early diagnostic marker of among acute chest pain patients.

Myocardial ischemia in neonate with perinatal asphyxia: Electrocardiographic, echocardiographic and enzymatic correlation

Objective: The objective of this study is to evaluate the presence and severity of cardiac involvement in asphyxiated neonates and to established which clinical and laboratory parameters (electrocardiogram [ECG], echocardiography [ECHO], and cardiac enzyme) are reliable predictors of myocardial ischemia. Design: Nested case–control study. Setting: Neonatology unit of tertiary care institute. Materials and Methods: The study group consist of 90 term neonates who had APGAR score &lt;7 at 5 min as cases and 90 term neonate who had APGAR score &gt;9 at 5 min as controls. On the 2nd day of life (between 24 and 36 h), all neonate underwentECG, ECHO, and enzyme estimation (CK-MB). Result: The cases were divided into three groups according to SARNAT scale andGroup I consist 25, Group II - 54, and Group - III, 11 neonates. The mean gestational age was 36.97±0.35 and 37.12±0.46 week for cases and controls respectively while mean birth weight was 2.79±0.36 kg and 2.68±0.76 kg for cases and controls, respectively. ECG changes were present in 70 (77.7%) of cases. ECG changes of Grade 3 and 4 were present in only Group III neonates and all neonates with Grade 4 changes were died in 1st week of life. Fractional shortening (FS) decreased progressively from Group I to Group III (p&lt;0.001) and showed a significant difference between cases and controls as well as in different groups except in controls versus Group I. Peak aortic velocity behaved similarly. Concerning mean acceleration, the significant difference wasobserved between control and cases (all 3 groups). CK-MB activity increased from Group I to Group III and statistically significant difference was seen in controls and different Groups as well as in between different groups except in Controls versus Group I. Conclusion: Severe ECG changes (Grades 3 and 4), CK-MB elevation and reduced FS can be considered as reliable marker of myocardial ischemia in perinatal asphyxia.