Athanasios J. Manolis

Prognostic significance of blood pressure response to exercise in patients with systolic heart failure

High systolic blood pressure (SBP) has been linked to worse cardiovascular outcomes. However, emerging data suggest that in patients with heart failure (HF), low SBP correlates with increased mortality. The purpose was to examine the impact of baseline and post-exercise systolic and diastolic blood pressure (DBP), as well as pulse pressure (PP), on cardiac mortality in patients with systolic HF. One hundred sixty patients with systolic HF (left ventricular ejection fraction 33xa0±xa08) were studied. Blood pressure (BP) levels were determined at rest and at peak exercise during a cardiopulmonary exercise test. Patients were followed up for a period of 2.5xa0±xa00.8xa0years. During this period 22 patients died and 5 subjects underwent heart transplantation. Patients with higher SBP and DBP at rest, and patients with SBP ≥160xa0mmHg and PP ≥75xa0mmHg at peak exercise had the most favorable prognosis. There was a fourfold increase in cardiac mortality risk for patients with SBP <160xa0mmHg at peak exercise (hazard ratio: 3.97, 95% confidence interval: 1.60–9.84) and a threefold increase for patients with PP <75xa0mmHg at peak exercise (hazard ratio: 2.96, 95% confidence interval: 1.29–6.82). There is an inverse relationship between SBP and cardiac mortality in patients with systolic HF. BP response to exercise could serve as a simple risk stratification model in HF patients.

Iatrogenic Giant Osborn Waves

A 57-year-old man was admitted after an out-of-hospital cardiac arrest. He received bystander basic life support followed by prolonged resuscitation at the emergency department and was subsequently transferred to the intensive care …

Native aortic valve endocarditis caused by Brevibacterium epidermidis in an immunocompetent patient.

Although Brevibacterium species used to be considered as nonpathogenic microorganisms until recently, it seems that they can cause a wide variety of clinical diseases by acting mostly as opportunistic pathogens. The present case is the second reported case of infective endocarditis by Brevibacterium species; however, it is the first reported infected native aortic valve in an immunocompetent patient.

Late traumatic aortic dissection

Traumatic dissection of the aorta is a well-documented entity with poor prognosis and broad spectrum of clinical presentations. We report a rare case of an asymptomatic late presentation of aortic dissection after a high-speed vehicle accident. This case highlights the importance of high clinical suspicion for the diagnosis of aortic dissection.

A Case of Acute Myocarditis Caused by Pandemic (H1N1) 2009 Influenza Virus

The new strain of swine-origin H1N1 influenza virus was initially described in April 2009, and the first cases of infection were reported in the Mexican state of Veracruz. As the disease spread rapidly to other countries, the World Health Organization declared the new strain of influenza virus as pandemic on June 11, 2009.1 Infection with this virus predominantly affects young patients in relatively good health, without documented underlying illnesses. Although the majority of them experience mild symptoms, severe complications associated with high mortality can occur. Acute myocarditis can cause substantial myocardial injury and lead to arrhythmia, atrioventricular block, cardiogenic shock and sudden cardiac death. The majority of myocarditis cases are of viral etiology and presentation can often mimic myocardial infarction, pulmonary embolism or acute heart failure. Although endomyocardial biopsy remains the gold standard, cardiac magnetic resonance imaging (CMRI) has recently been shown to be a powerful tool in the diagnosis of acute myocarditis. We present a rare case of acute myocarditis caused by H1N1 influenza virus in a young patient. An 18-year-old man of Greek origin was admitted with a 3-day history of fever, malaise, sore throat and dry cough, and a 5-hour history of central chest pain of sudden onset. The pain radiated to the left shoulder and was relieved when the patient leaned forward. The pain did not respond to sublingual glyceryl trinitrate. He was a smoker and had a history of spontaneous ventricular septal defect closure at the age of 3 years. On admission, his heart rate was 66 beats/min, oxygen saturation in room air was 98%, blood pressure was 115/75 mmHg, and axillary temperature was 37.1°C. Heart auscultation revealed normal heart sounds, a pericardial friction rub and no murmurs. Electrocardiography showed sinus rhythm, with incomplete right bundle branch block, ST segment elevation with biphasic T-waves in leads V3 and V4, and ST segment depression with biphasic T-waves in leads I, II and aVL. Chest radiography was normal. Echocardiography depicted normal left ventricular ejection fraction, with no regional wall motion abnormalities or pericardial effusion. White blood cell count was 12.5×109/L, C-reactive protein was 17.1 mg/L, and erythrocyte sedimentation rate was 17 mm/hr.

Follow-up of Patients with Resistant Hypertension

Resistant hypertension (RH) is defined as failure to reach goal blood pressure (BP) in spite of concurrent treatment with maximum tolerated doses of three antihypertensive agents of different classes, including a diuretic. Several trials have demonstrated that achievement of BP goals is still poor despite the use of several protocol-defined treatment regimens. Follow-up of these patients seems to be even more difficult since there are practically no data regarding long-term surveillance of patients with RH. This article provides an overview on the assessment and follow-up of patients with resistant hypertension.

Prognostic Value of NT-proBNP at Rest and Peak Exercise in Patients With Impaired Left Ventricular Function

We aimed to identify whether N-terminal fragment of pro-brain natriuretic peptide (NT-proBNP) at peak exercise can provide incremental clinical information over resting levels. A total of 90 patients with systolic heart failure were prospectively studied. Levels of plasma NT-proBNP were assessed at rest and at peak exercise during a cardiopulmonary exercise test. Patients were followed-up for 30 ± 10 months. Levels of NT-proBNP at baseline and peak exercise were significantly correlated with left ventricular ejection fraction ([LVEF] r = −.629, P < .001 and r = −.630, P < .001, respectively) and peak oxygen uptake ([Vo 2] r = −.752, P < .001 and r = −.740, P < .001, respectively). Levels of plasma NT-proBNP at peak exercise demonstrated similar predictive ability for the detection of patients with low peak Vo 2 and LVEF <28%. Levels of plasma NT-proBNP can detect low-functional class patients and patients who may be the candidates for heart transplantation with high sensitivity and specificity. At baseline and peak exercise, NT–proBNP demonstrates similar prognostic and predictive ability.

Twiddler's syndrome.

An 82-year-old woman with severely impaired mental status, presented to the Emergency department aft er sustaining a femoral fracture following syncope. She had a history of sick sinus syndrome treated with a dual chamber pacemaker 11 months earlier and has been lost to follow-up since. On clinical examination she was agitated and disorientated. ECG depicted under-sensing and non-capture of both electrodes. Chest radiography demonstrated coiling of both pacing leads within the generator pocket and displacement of their tips into the right atrium-superior vena cava junction (Figure 1). Patient was immediately transferred to the electrophysiology laboratory and underwent lead removal and successful re-implantation of two new pacing leads. Lead dislodgment is a serious complication and usually occurs within the fi rst six weeks post pacemaker implantation (1). Twiddler ’ s syndrome is the most commonly described mechanism of dislodgment due to conscious or

Comorbidities Often Associated with Brain Damage in Hypertension: Diabetes, Coronary Artery Disease, Chronic Kidney Disease and Obstructive Sleep Apnoea

Several comorbidities are often associated to patients with essential hypertension. The coexistence of different risk factors and diseases such as diabetes mellitus (DM), chronic kidney disease (CKD) and coronary artery disease (CAD) can increase the incidence of brain damage. Moreover, obstructive sleep apnoea syndrome (OSAS) is also associated with an increased risk of stroke and other cardiovascular diseases. This chapter will address the associations between these diseases and conditions and hypertension and the mechanisms involved in the acceleration of the stroke-related and cognitive decline burden induced by high blood pressure values in these patients.

Comorbidities Often Associated with Brain Damage in Hypertension: Dyslipidaemia

Brain function is directly and indirectly associated with lipoprotein levels and function. Thus, overproduction or deficiency of lipids and/or lipoproteins can significantly affect brain homeostasis. Although the development and progression of atheroma plaques represents probably the most recognized mechanism of stroke, dyslipidaemia can induce or aggravate stroke also through other mechanisms. In this chapter, we discuss how dyslipidaemia can affect the brain through several different pathways leading to brain deterioration and damage and how treatment with statins and cholesterol reduction may improve stroke outcomes.