Cardiology Opinion Research Articles

Current World Literature

Current Opinion in Cardiology: July 2011 - Volume 26 - Issue 4 - p 356-361 doi: 10.1097/HCO.0b013e328348da50

Current World Literature

Current Opinion in Cardiology: March 2011 - Volume 26 - Issue 2 - p 165-173 doi: 10.1097/HCO.0b013e328344b569

Pre-operative echocardiogram in hip fracture patients with cardiac murmur- an audit

BackgroundAll hip fracture patients with a cardiac murmur have an echocardiogram as a part of their preoperative work-up in our unit. We performed a retrospective audit to assess the impact of obtaining a pre-operative echocardiogram on the management of hip fracture patients.MethodsAll hip fracture patients (N = 349) between 01/06/08 and 01/06/09 were included in the study. 29 patients had pre-operative echocardiogram (echo group). A computer generated randomised sample of 40 patients was generated from N, 'non-echo' group. Data was obtained from medical records and the Hospital Information Support System (HISS). The groups were compared using Student's t test. Approval was obtained locally from the clinical governance department for this project.ResultsAge and gender distribution were similar in both groups. Indication for echo was an acute cardiac abnormality in 4 cases. 25 patients had echo for no new cardiac problem (indication being cardiac murmur in 23 patients and extensive cardiac history in 2 cases). Cardiology opinion was sought in 5 cases. No patient required cardiac surgery or balloon angioplasty preoperatively. Patients having pre-operative echo had significant delay to surgery (average 2.7 days, range 0-6 days) compared to 'non-echo' group (average 1.1 days, range 0-3 days), (p < 0.001). There was no significant difference in length of stay (p = 0.14) and mortality at 30 days (p = 0.41) between the groups.ConclusionWe have developed departmental guidelines for expediting echo requests in hip fracture patients with cardiac murmur. A liaison has been established with our cardiology department to prioritise such patients on the Echocardiography waiting list, to prevent unnecessary avoidable delay. Careful patient selection for pre-operative echocardiography is important to avoid unnecessary delay to surgery.

Current World Literature

Current Opinion in Cardiology: November 2010 - Volume 25 - Issue 6 - p 639-653 doi: 10.1097/HCO.0b013e3283406f73

Current World Literature

Current Opinion in Cardiology: September 2010 - Volume 25 - Issue 5 - p 522-533 doi: 10.1097/HCO.0b013e32833e3300

Chlorthalidone: Don’t Call It “Thiazide-Like” Anymore

Recently, there has been growing interest in the idea that chlorthalidone should be preferred over thiazides when it comes to selecting a nonloop diuretic for treatment of hypertension.1–4 Depending on how these drugs are dosed, it is believed that the nonthiazide diuretic chlorthalidone might provide greater cardiovascular protection than thiazide diuretics because of its more potent and prolonged effects on blood pressure. However, given that the chemical structure of chlorthalidone is clearly distinct from the basic chemical structure of the thiazides (Figure), it is possible that the nonthiazide chlorthalidone might also differ from thiazides with respect to effects on determinants of cardiovascular disease other than just blood pressure. Yet, few if any studies have ever directly compared the effects of the nonthiazide chlorthalidone versus thiazides on potential cellular or molecular mechanisms of cardiovascular morbidity and mortality independent of blood pressure. Figure. The nonthiazide diuretic chlorthalidone and the thiazides, including hydrochlorothiazide, have sulfonamide groups (denoted within the unshaded ovals) that interact with the Zn(II) ion in the active site cleft of CA and with amino acid residues in the enzyme as well. A sulfonamide moiety is also present in the nonthiazide diuretics metolazone and indapamide (not shown), and these agents are also known to affect CA activity. However, the nonthiazide diuretics chlorthalidone, metolazone, and indapamide do not have the benzothiadiazine dioxide scaffold that is characteristic of the thiazides (denoted within the shaded oval). The structures of the nonthiazide diuretics beyond the sulfonamide group are clearly different from those of the thiazides and contribute to different effects of the various diuretics on CA isozyme activity profiles and perhaps to different effects on cardiovascular outcomes as well. In this issue of Hypertension , Woodman et al5 report novel in vitro experiments in which chlorthalidone was found to reduce epinephrine-induced platelet aggregation …

Lipid-lowering drugs and heart failure: where do we go after the statin trials?

Heart failure is an important cause of disease burden in aging societies. Although HMG-CoA reductase inhibitors (statins) prevent important causative factors for heart failure, myocardial damage and ischemia, the benefits of statins and low-density lipoprotein (LDL) lowering in heart failure patients have been questioned. The role of other types of dyslipidemia [low high-density lipoprotein (HDL), high triglycerides] and their modification has received less attention in heart failure thus far. In patients with coronary artery disease (CAD), or at high risk thereof, statin treatment prevents heart failure. Moreover, intensive statin treatment is better than usual doses. However, initiation of even an effective statin in patients with established, and especially advanced, heart failure has not improved prognosis. Statin treatment may, however, reduce complications and, importantly, has not proved to be harmful in randomized trials. Variables related to HDL metabolism are associated with heart failure in several studies, but trial evidence of HDL or triglyceride-modifying therapies is scant. Whereas statins are important in preventing or postponing heart failure in the first place, their initiation in established heart failure does not improve prognosis. On the contrary, discontinuation of statin treatment is not indicated due to development of heart failure. Combination therapies of both LDL and HDL may offer more effective possibilities for heart failure prevention.

Current World Literature

Current Opinion in Cardiology: July 2010 - Volume 25 - Issue 4 - p 411-421 doi: 10.1097/HCO.0b013e32833bf995

Implantação de um sistema de telecardiologia em Minas Gerais: projeto Minas Telecardio

Although cardiovascular diseases are the main cause of morbimortality in Brazil, the access of small-town populations to electrocardiography and cardiology assessment is limited. The use of telecardiology to assist the access of distant towns to electrocardiography and a second opinion in cardiology is promising; however, it has not been formally assessed.To assess the feasibility of implementing a low-cost public telecardiology system in small Brazilian towns.A total of 82 towns in the state of Minas Gerais, with a population < 10,500 inhabitants, presenting > 70% coverage by the Family Health Program (Programa Saude da Familia-PSF), local government compliance and internet access, were selected. Each town was supplied with digital electrocardiography (ECG) device and a team was trained. The implementation was coordinated by HC/UFMG, together with four university hospitals in the state of Minas Gerais (UFU, UFTM, UFJF and UNIMONTES). The ECG assessments were carried out in the towns and sent through the Internet for prompt analysis by an on-duty telecardiology team. Online and offline discussions on the medical cases were carried out through the Internet, as well as refreshment courses.During the implementation period, a total of 253 health professionals were trained. From July 2006 to November 2008, the project assisted 42,664 patients, with a total of 62,865 ECG assessments being performed. A total of 2,148 emergency cases were treated, as well as 420 teleconsultations. The intermediate evaluation showed good acceptance of the implemented technology and a 70% decrease in patient referrals to other reference centers.The use of the customary resources in informatics to assist the access of small-town populations to electrocardiography and specialized cardiology assessment is feasible.

Évaluation des pratiques professionnelles (EPP) : prise en charge (PEC) de la douleur thoracique aiguë aux urgences

Summary The chest pain (CP) is a motive for frequent admissions in emergency departments requiring an optimal medical care of the patient according to the recommendations of the good professional practices. The objective looked for by the medical teams is to reduce the number of the useless admissions and to improve the quality of the care. It is imperative all the more quickly and exactly in the suspicions of acute coronary syndromes (ACS) received at the emergency departments. We evaluated the practices for this important care for the patients. The guideline used for the study is the one of the HAS of 2007. The reserved method is the clinical audit. The evaluation of files was manually realized by second reading over a period of 1 week from 1st till 7 June 2008 on a sample of 42 files extracted on the motive for “chest pain”. The statistical studies on the rate of troponin T positive (TnT+) and the average for turn around time (TAT) were made from the base Infocentre® of the laboratory. One hundred percent of the physicians answered the survey, the good guideline is quoted in 57% of the cases, the clinical examination + electrocardiogram + TnT are quoted in 100%, and the cardiological opinion is drawn in 50% of the answers. The estimated TAT of the laboratory by the physician (1 hour) is in accordance with the reality at 80%, the notion of decision-making threshold in 99th percentile for the interpretation of the TnT is quoted only by 40%. The patients are 22 men (average age: 67 years) and 20 women (average age: 78 years). The number of suspicions ACS is 18. All are ST−, 13 had an interpreted and formalized electrocardiogram (ECG), five ECG were not formalized, 24 had another motive for CP. Factors of cardiovascular risk (FCVR) were looked for and noted seven times on 13 suspect patients of ACS and only five times on 29 with CP for another motive. Forty-seven percent of the patients were hospitalized. All the 42 patients had prescribed a TnT as the only marker of cardiac damage, 13% had a TnT > 0,1 μg/L. The average of TnT TAT is 54 minutes. In conclusion, no lack of diagnosis of ACS was detected in the second reading of 42 files; the interpretation of ECG and FCVR is not systematically formalized. At the conclusion of this study several actions of improvement were organized and indicators of TnT TAT and rate of TnT+ were positioned.

Regulating Viral Myocarditis: Allografted Regulatory T Cells Decrease Immune Infiltration and Viral Load

Coxsackievirus was first discovered as a filterable agent associated with a paralytic syndrome, so named for its identification in Coxsackie, New York (coxsackievirus type A).1 Coxsackievirus type B (CVB) was isolated the following year from patients with aseptic meningitis,2 and by the mid-1950s, an association with acute myocarditis in humans was becoming clear.3–6 Many other viruses have since been shown to cause myocarditis and its long-term sequelae, arrhythmias, dilated cardiomyopathy, and heart failure. By example, adenovirus, herpesviruses, and influenza can cause myocarditis in humans and models of heart failure. Because immune cell infiltration is an easily seen feature of myocarditis, it is perhaps not surprising that the inflammatory response would be posited as a major cause of tissue injury during viral myocarditis. However, the virus itself has lytic and destructive potential, and a range of data indicate both viral and immune contributions to cardiomyocyte and interstitial damage during myocarditis. The question is often posed: Is damage primarily virus-mediated or more so the product of an overzealous immune response and autoimmunity? Perhaps the greatest error in the discussion has been approaching these 2 facets of the disease process in a mutually exclusive manner. Shi et al7 now show in this issue of Circulation that virus replication and the immune response are exquisitely intertwined in myocarditis pathogenesis. Article see p 2624 Over the last 3 decades, it has become apparent that viral load is a primary determinant of viral myocarditis severity,8–11 the virus causing extensive, early, direct injury to the myocardium through its replication. Results cited here all indicate significant injury to the myocardium before cardiac immune infiltration, supporting the view that considerable damage to the heart is directly mediated by the virus alone. An argument has been made previously for the importance of chronic virus replication …

Genotyping, Clopidogrel Metabolism, and the Search for the Therapeutic Window of Thienopyridines

It is somewhat remarkable to note that not until recently, nearly 12 years and tens of millions of treated patients after its initial approval, has the metabolism of clopidogrel, an inactive prodrug, begun to be more fully understood. Although this lack of knowledge may not be unique among common cardiovascular drugs, there are 4 characteristics of clopidogrel therapy that make this gap in understanding disconcerting: The potential for life-threatening complications (bleeding or thrombosis) at both ends of its therapeutic spectrum; the fact that 1 dose is supposed to fit all; the lack of a measureable, proven end point (such as blood pressure for antihypertensive drugs) that allows for titration to a target response; and the nearly mandatory need by many patients for clopidogrel, with no acceptable alternative until recently. Article see p 512 Historically, understanding the metabolism of a drug has been critical in identifying those patients most likely to benefit from and, more important, potentially be harmed by that drug. This is especially true for drugs with relatively narrow therapeutic windows, such as phenytoin, warfarin, and others. Although it seems safe to assume, on the basis of our extensive clinical experience, that the therapeutic window of clopidogrel is unlikely to be narrow, this certainly does not represent the depth of knowledge we would hope for after so much clinical experience and research. What we do know is that P2Y12 inhibition with thienopyridines is beneficial in preventing arterial thrombotic events, presumably requiring the achievement of some minimal level of receptor inhibition that may or may not vary on the basis of the patient and clinical scenario. We also know that it is associated with a significant increase in serious bleeding events, with higher levels of inhibition associated with greater bleeding. In the present and future practice environment, with a growing …

Nature’s Genetic Gradients and the Clinical Phenotype

When God created the earth, he placed (modern) mankind in East Africa ≈200 000 years ago, as suggested by the phylogenetic and archeological studies.1,2 These hunter-gatherers populated the land and started to migrate, first to the west and southern tip of Africa and then north toward North Africa. Mankind gradually crossed the Arabian Peninsula to the Middle East and Eurasia. Then, over thousands of years of northerly movement, man crossed the Bering land bridge that connected Siberia to Alaska and migrated down to the Americas. This out-of-Africa migration took thousands of generations. It was interrupted by the Ice Age, which led to depopulation and isolation of the surviving population followed by the new waves of migrations, resulting in multiple founding populations.3 Articles see pages 552 and 558 At the genetic level, the tree of life was produced through replication of the genome. For the genome to replicate, cells are equipped with DNA polymerases to copy the parental DNA, which they do at blazing speeds.4 However, “no protein is perfect,” and neither are the DNA polymerases. So, the DNA polymerases commit occasional errors in copying the template (parental) DNA and incorporate wrong nucleotides into the new DNA strands. To correct the errors, nature afforded the cells with DNA repair enzymes, which are assigned the task of maintaining the integrity of the nucleotide pools before replication.5 Nevertheless, the process of DNA replication and editing, although exceedingly precise, is imperfect. The error rate of the DNA replication and editing machinery is estimated to be at 10−6 to 10−10 nucleotides incorporated into the new strand of DNA.6,7 The inheritance is forward. Therefore, the misincorporated nucleotides are passed on to the next generation, and with each generation, new errors in DNA replication are introduced. The occasional “errors of …

Current World Literature

Current Opinion in Cardiology: September 2009 - Volume 24 - Issue 5 - p 496-508 doi: 10.1097/HCO.0b013e32833099f8

Letter by Settergren et al Regarding Article, “Evidence for Statin Pleiotropy in Humans: Differential Effects of Statins and Ezetimibe on Rho-Associated Coiled-Coil Containing Protein Kinase Activity, Endothelial Function, and Inflammation”

To the Editor: It is well established that statins improve the prognosis of patients with coronary artery disease. However, it is still unclear whether the protective effects of statins relate to lipid lowering only or whether other so-called pleiotropic effects may contribute. Experimental data support the pleiotropic effects of statins, but knowledge on their clinical relevance is limited. We read with great interest the recent article by Liu et al.1 The authors compared the effect of simvastatin 40 mg/d, and the combination of simvastatin 10 mg and ezetimibe 10 mg …

Blue episodes in a neonate

In September, 2007, a 9-day-old baby girl presented to the emergency department with increased respiratory eff ort and weight loss. She was delivered by elective caesarean section for breech presentation. At birth, she was fl oppy, cyanosed, and bradycardic. Her Apgar score was 5 and 9 at 1 and 5 min, respectively. On examination she had a grade II systolic murmur. Blood pressure and oxygen saturation were normal. On day 3, she was noted to have some weight loss due to poor feeding. Following successful supervised feeding and some weight gain, she was discharged the following day, in good condition, with an echocardiogram planned for day 9. On day 6, however, the mother raised concerns about her baby’s rapid breathing and continuing feeding diffi culties but was reassured by the community midwife. When we saw the baby in the emergency department she was cyanosed (SaO2 88% on room air), with a respiratory rate of 30–40/min, intercostal recession, and grunting. She had noisy breathing with intermittent episodes of desaturation and bradycardia. Her nasal passages were patent. The rest of the clinical examination was unremarkable. Capillary blood gas showed respiratory acidosis (ph 7·28, PO2 6·5 kPa, PCO2 9·1 kPa, HCO3 31 mmol/L, and base excess +1·6 mmol/L). Septic screen was negative. Chest radiography showed a boot shaped heart, suggestive of congenital cyanotic heart disease. She was transferred immediately to a specialist unit for a cardiology opinion. Echocardiography showed a small posteromuscular ventricular septal defect which did not account for the clinical presentation. Her noisy breathing was attributed to inspiratory stridor, and subsequent microlaryngoscopy and bronchoscopy (MLB) showed a large cyst arising from the vallecula (fi gure A). Aspiration of the cyst failed because of the viscosity of the contents; the cyst was incised and de-roofed successfully (fi gure B). Histological examination showed a squamous epi thelium lined cyst with a smooth muscle-containing wall. She was discharged home on the 10th post-operative day with intermittent soft stridor, and on demand feeds. When the baby was reviewed 6 weeks later in clinic, she had gained weight and was well, with no stridor or breathing diffi culty, and feeding well. Congenital tumours of the oropharynx are rare. Laryngeal cysts are broadly classifi ed as ductal (75%) or saccular (25%). Ductal cysts arise because of obstruction in the collecting ducts; vallecular cysts are a form of ductal cyst. The vallecula is the groove between the epiglottis and the base of the tongue; during swallowing food enters the vallecula and passes around the epiglottis either side into the pyriform aperture and then into the oesophagus. Although vallecular cysts are benign, a mortality rate of 40% has been reported because of major airway obstruction. They arise because of obstruction in mucous glands at the base of the tongue. Vallecular cysts can be detected in pregnancy as early as 25 weeks’ gestation. They can present antenatally as polyhydramnios, tracheal compression, or compression of cervical vessels or hypoglossal nerve. Postnatally, they can present as respiratory distress. Other clinical features are intercostal recession, failure to thrive, cough, dysphonia, dysphagia, and cyanosis. MLB and rigid endoscopy are the mainstay of diagnosis. A fi bre-optic review of the upper airway and bronchus is mandatory to rule out laryngo/bronchomalacia. The defi nitive treatment of these cysts is marsupialisation with CO2 laser or electrocautery. The prognosis is generally good with no risk of recurrence. Cyanosis in neonates is often caused by congential heart problems or lung pathology; our case shows that investigating non-cardiac causes of cyanosis in neonates can be a life-saving measure.

Looking back over my professional life

Looking back over my professional life

Aortic dissection in Turner syndrome

Turner syndrome is a relatively common disorder of female development with cardinal features of short stature and congenital cardiovascular defects (CHD). Turner syndrome is the most common established cause of aortic dissection in young women, but has received little attention outside pediatric literature. This review focuses on emerging knowledge of the characteristics of aortic disease in Turner syndrome in comparison with Marfan-like syndromes and isolated aortic valve disease. The incidence of aortic dissection is significantly increased in individuals with Turner syndrome at all ages, highest during young adult years and in pregnancy. Pediatric patients with dissection have known congenital cardiovascular defects (CHD), but adults often have aortic valve and arch abnormalities detected only by screening cardiac magnetic resonance. Thoracic aortic dilation in Turner syndrome must be evaluated in relation to body surface area. Dilation is most prominent at the ascending aorta, similar to the pattern seen in nonsyndromic bicuspid aortic valve, is equally prevalent (20-30%) in children and adults, and does not seem to be rapidly progressive. Cardiovascular anomalies and risk for aortic dissection in Turner syndrome are strongly linked to a history of fetal lymphedema, evidenced by the presence of neck webbing and shield chest. Risk for acute aortic dissection is increased by more than 100-fold in young and middle-aged women with Turner syndrome. Monitoring frequency and treatment modalities are decided on an individual basis until more information on outcomes becomes available.

Current World Literature

Current Opinion in Cardiology: July 2008 - Volume 23 - Issue 4 - p 407-429 doi: 10.1097/HCO.0b013e3283081beb

A Statement on Ethics from the HEART Group

Current Opinion in Cardiology: July 2008 - Volume 23 - Issue 4 - p 289-291 doi: 10.1097/HCO.0b013e328305be9d