Allan Zelinger

High coronary artery calcium scores pose an extremely elevated risk for hard events

OBJECTIVES We sought to assess the natural history of a cohort of asymptomatic individuals with very high (> or = 1,000) calcium scores (CSs) on a screening electron beam tomography (EBT) not submitted to further testing after the initial scan. We also compared the outcome of our prospective cohort with that of historical controls with severe abnormalities on myocardial perfusion imaging (MPI). BACKGROUND Coronary calcium detected on EBT imaging has been shown to correlate with the total plaque burden. However, there is still controversy as to the prognostic significance of calcium, as some investigators believe that the presence of coronary calcification may stabilize the atherosclerotic plaque. METHODS Ninety-eight asymptomatic subjects (mean age: 62 +/- 10) were followed for an average of 17 +/- 11 months (range: 4 to 36 months) after undergoing EBT screening for the occurrence of hard coronary events (HCEs), defined as myocardial infarction or coronary death. All patients had an initial CS > or = 1,000, and in none did the results of the EBT screening lead to further invasive or non-invasive testing. RESULTS During the follow-up period, 35 patients (36%) suffered an HCE. All events were recorded in the first 28 months of follow-up. Subjects with HCEs had higher initial CSs than subjects not suffering HCEs (1,561 +/- 270 vs. 1,199 +/- 200, p < 0.001). The annualized event rate in subjects with a CS > or = 1,000 was significantly greater than that of historical controls with severe perfusion abnormalities on MPI (25% vs. 7.4%, respectively; p < 0.0001). CONCLUSIONS A high CS (> or = 1,000) on a screening EBT in an asymptomatic person portends a very high risk of an HCE in the short term. This risk appears to be greater than the risk associated with a severe perfusion abnormality on MPI.

Relation between brachial artery reactivity and noninvasive large and small arterial compliance in healthy volunteers

V endothelium secretes vasodilators and constrictors, which interact to regulate vascular tone, and reportedly includes response of an arterial segment to incremental blood flow. Endothelial dysfunction represents an early stage of atherosclerosis preceding the formation of plaques, and causes the inability to release the endothelium-derived relaxing factor, which results in impairment of vasorelaxation and paradoxic vasoconstriction. Brachial artery reactivity or flow-mediated vasodilation is an established noninvasive method believed to reflect endothelial function using high-resolution ultrasonography, but this method is time consuming, subject to measurement error, and requires technical expertise. New methods of measuring vascular compliance are noninvasive, easy to perform, and may also reflect aspects of vascular function, which may parallel or represent endothelial function. Furthermore, early identification of abnormal vascular compliance may provide the opportunity to reduce risk factors and delay or reverse the disease process, which emphasizes the need for developing a simple method to measure it. The aim of our study was to evaluate and compare a noninvasive computer-based measurement of arterial compliance with brachial artery reactivity. • • • Twenty-six healthy volunteers, 10 women and 16 men, age range 25 to 51 years (mean age 31) were enrolled in the study (Table 1). None of the participants had any signs, symptoms, or risk factors for coronary artery disease, cerebrovascular disease, or peripheral vascular disease and none used vasoactive medications. Each participant rested supine on an examining table for 5 minutes before the test was performed. A manual blood pressure cuff was placed on the left arm and baseline blood pressure at rest was recorded. Baseline images of the brachial artery approximately 5 cm proximal to the brachial bifurcation were obtained with a 6.0-MHz linear array transducer (Acuson, Sequoia C-256, Mountain View, California) and the anteroposterior diameter was recorded. The cuff was then inflated to 50 mm Hg above the patient’s systolic blood pressure for 5 minutes. Images of the brachial artery were obtained at the same level for 30 and 60 seconds after deflation of the cuff and the anteroposterior diameter of the artery was re-recorded. Brachial artery reactivity was calculated as the percent change between baseline and 60 seconds after cuff deflation. All the studies were performed under identical conditions by a single sonographer. Measurement of arterial compliance of the same subjects was performed on a separate day of the same week by a single investigator. The acquisition of radial artery blood pressure waveform data involved use of a blood pressure cuff placed on participant’s left arm and a sensor placed over the right wrist with the participant lying supine. A wrist stabilizer was placed at the bend of right wrist and wrapped firmly. The piezoelectric sensor was positioned on the right wrist over the maximum pulsation along the longitudinal axis as well as perpendicular to the radial artery and secured using a loop strap. The knob at the top of the shaft holding the sensor was turned to place light pressure over the artery to obtain optimal signal strength. Blood pressure measurements and the radial waveform data were recorded, analyzed, and stored using the CardioVascular Profiling Instrument (CVPI) (CVPI model CR 2000, Hypertension Diagnostics Inc, Eagan, Minnesota). Pulse-wave analysis summarizes the pulse contour analysis performed on a 30-second collection of the radial artery blood pressure waveforms. The machine’s results are based on the use of an electrical analog model (based on a modified Windkessel model) that represents the vasculature as consisting of a capacitative compliance element (large artery elasticity compliance), a reflective compliance element (small artery elasticity compliance), and an inductance and a resistance (systemic vascular resistance) during the diastolic portion of the cardiac cycle (Table 1). These elements were similarly recorded for each participant. Standard linear regression analysis was performed to determine the relation between the arterial compliance and changes in brachial artery diameter. Baseline brachial artery diameter ranged from 3.2 to 5.4 mm (mean 4.01 0.6). After 60 seconds of hyperemic flow the mean brachial artery diameter increased by an average of 0.67 mm, corresponding to a percent increase in brachial artery diameter ranging from 4.2% to 42% (mean 17.81 10.9%). Large artery compliance ranged from 6.8 to 21 ml/mm Hg (mean 13.2 4.1) and small artery compliance ranged From the Department of Medicine, Office of Clinical Research and The Heart Failure Institute, Advocate Christ Hospital and Medical Center, Oak Lawn, Illinois. Dr. Silver’s address is: Department of Medicine, Heart Failure Institute, Advocate Christ Hospital and Medical Center, 4440 W 95th Street, Suite 428 S, Oak Lawn, Illinois 60453. E-mail: marc.silver@advocatehealth.com. Manuscript received May 15, 2001; revised manuscript received and accepted November 30, 2001.

Frequency and pattern of left ventricular dysfunction in potential heart donors: implications regarding use of dysfunctional hearts for successful transplantation.

To the Editor: Cardiac transplantation is a widely accepted treatment for patients with advanced heart failure. Unfortunately only 1 in 8 hearts offered for donation is accepted for transplantation ([1][1]). Some donor hearts may be rejected due to left ventricular systolic dysfunction (LVSD) noted

Neurogenic stress cardiomyopathy in heart donors.

Cardiac transplantation is severely restricted by donor availability. Left ventricular dysfunction due to neurogenic stress cardiomyopathy is often seen during donor evaluation and often presents a clinical dilemma for procurement. We report a case of a 23-year-old man with severe left ventricular dysfunction whose heart was successfully procured for transplantation. The brief case report is followed by an extensive review of neurogenic stress cardiomyopathy as well as donor evaluation for cardiac transplantation in the setting of such cardiomyopathy.

Calcified Amorphous Tumor of the Left Ventricular Outflow Tract

We report a very rare case of a calcified amorphous tumor presenting atypically as a mobile left ventricular outflow tract mass in a 69-year-old female who was admitted for shortness of breath.

Massive aortic thrombus in patient with mechanical prosthetic valve supported with left ventricular assist device

A 54-year-old left ventricular assist device (LVAD)-supported patient with mechanical prosthetic valves was planned for LVAD exchange using cardiac computed tomography(CCT) for preoperative evaluation. The CCT revealed massive thrombus in the ascending aorta. The surgery was done without thromboembolic complications. We reinforces the utility of CCT as a preoperative assessment in this specific case.