Avraham Caspi

Differential Effects of Coronary Artery Stenosis on Myocardial Function: The Value of Myocardial Strain Analysis for the Detection of Coronary Artery Disease

BACKGROUND Speckle-tracking imaging is a novel method for assessing left ventricular (LV) function and ischemic changes. The aim of this study was to assess the predictive value of two-dimensional longitudinal strain in the detection of longitudinal LV dysfunction and the identification of coronary artery disease (CAD) in patients hospitalized with angina. METHODS Two-dimensional strain software was extended to allow the analysis of numerous longitudinal strain traces in the entire left ventricle and generate a histogram of peak systolic strain (PSS) values for the left ventricle and for each coronary territory. In each histogram, the value of the 10% worst strain values (PSS(10%)) was determined. Global strain, segmental PSS, and PSS(10%) were analyzed in 97 patients hospitalized with angina and had normal LV function, who underwent coronary angiography, and 51 patients with low probability of CAD. Echocardiography was performed 2.9 ± 2 days after admission. RESULTS Sixty-nine patients had significant CAD on coronary angiography. Significant differences were observed in all strain parameters between patients with and without CAD. PSS(10%) showed the best accuracy in detecting CAD, with an area under the receiver operating characteristic curve of 0.85. The areas under the curve for global strain and segmental PSS were 0.80 and 0.76, respectively. The optimal cutoff for PSS(10%) was -13.9%, with sensitivity and specificity of 86% and 75%, respectively. PSS(10%) was better than segmental PSS in the detection of CAD in each coronary territory. CONCLUSIONS In patients hospitalized with angina who have significant CAD on coronary angiography, longitudinal systolic function is impaired. Histogram analysis improved the accuracy of longitudinal strain analysis in detecting global and regional impaired function.

Blood transfusion for acute decompensated heart failure—friend or foe?

BACKGROUND In acute coronary syndromes (ACSs), blood transfusion (BT) has been associated with worse outcomes. The impact of BT among patients with acute decompensated heart failure (ADHF) remains unknown. METHODS Propensity score analysis of patients with ADHF with and without BT in a national heart failure (HF) survey was used in this study. RESULTS Of the 4,102 enrolled patients, 2,335 had ADHF, of whom 166 (7.1%) received BT. These patients were older (75.6% vs 73.6%, P = .04), more likely to be females (54.8% vs 43.9%, P = .007), more likely to have diabetes (59.0% vs 51.1%, P = .04) and renal dysfunction (59.0% vs 40.2%, P < .001), and more likely to receive inotropes (16.9% vs 8.0%, P < .001), but they had similar rates of ACS (41.0% vs 39.4%, P = .69) and prior HF (64.5% vs 70.0%, P = .23). Nadir hemoglobin levels were commonly <10 g/dL in BT patients (92.7% vs 8.0%); 15 BT patients had bleeding complications, of which 10 are major bleeding. Major predictors for BT were ACS (OR 1.85, 95% CI 1.15-2.96), inotropes use (OR 2.36, 95% CI 1.22-4.55), and nadir hemoglobin (OR 0.18 per 1 g/dL increase, 95% CI 0.14-0.22). In-hospital, 30-day, 1-year, and 4-year unadjusted mortality rates were higher for BT patients (10.8% vs 5.2%, P = .02; 11.0% vs 8.5%, P = .27; 39.6% vs 28.5%, P = .03; 69.5% vs 59.5%, P = .01, respectively). However, in 103 propensity-matched pairs (c-statistic 0.97), short-term mortality tended to be lower with BT (8.7% vs 14.6%, P = .20; 9.7% vs 18.4%, P = .08; 38.8% vs 42.7%, P = .59; and 72.8% vs 76.7%, P = .52, respectively). CONCLUSIONS Acute decompensated HF patients receiving BT had worse clinical features and unadjusted outcomes, but BT per se seemed to be safe and perhaps even beneficial.

A high incidence of vitamin B12 deficiency in israeli patients undergoing coronary angiography

Sir, Treatment with a mixture of vitamin B12, vitamin B6 and folic acid has been shown to decrease the rate of restenosis after coronary angioplasty [1,2]. This is thought to be related to a decrease in the level of serum homocysteine [3]. This is loosely referred to as folate supplementation. The administration of folic acid alone in the presence of vitamin B12 deficiency may have consequences of neurological damage [4]. We decided to determine the prevalence of vitamin B12 deficiency in our population, in order to see whether a policy of pure folic acid administration would be feasible. One hundred thirty serial patients presenting for coronary angiography in the Heart Institute of Kaplan Medical Center were included in this study. A note was made of the number of vessels involved, presence of hypertension, smoking or hyperlipidemia (LDL cholesterol >130 mg/dL), CBC and MCV, vitamin B12, folic acid and whether angioplasty was performed or not. Significant coronary disease was defined as a greater than 50% diameter stenosis on multiple views. Vitamin B12 (cobalamin) was determined by the Access-Sanofi Pasteur System, France chemiluminescence assay and folic acid was also determined by chemiluminescence. We have chosen a level of 200 pg/ml as the lower limit of normal for vitamin B12 since this has been reported to have a specificity of 95–100% [5]. The mean vitamin B12 level of these patients was 308.34 ± 181.88 pg/mL. There were 39 patients (29.55%) with a level of vitamin B12 less than 200 pg/mL. The average vitamin B12 level of these patients was 145.1 ± 30.89 pg/mL and the folic acid level of these patients was 11.58 ± 7.26 pg/mL. There were 91 patients with a serum B12 level above 200 pg/mL. The average vitamin B12 level was 345.37 ± 151.46 pg/mL and the folic acid level of these patients was 14.41 ± 7.11 pg/mL. There was no difference between the groups with a B12 <200 pg/mL and >200 pg/mL in terms of number of coronary vessels involved, need for angioplasty, unstable angina, myocardial infarction or hypertension (t-test, χ2 test and Mann-Whitney test). This finding of a high prevalence of vitamin B12 deficiency in Israel has been found previously [6,7] but not in a population of coronary artery disease patients. This requires further evaluation but we suggest that folate supplementation should either include vitamin B12 or that a separate determination of vitamin B12 be performed. Since vitamin B12 deficiency can have deleterious effects, this latter approach is to be preferred.

Accuracy and long-term prognostic value of pacing stress echocardiography compared with dipyridamole tl201 emission computed tomography in patients with a permanent pacemaker and known or suspected coronary artery disease.

Objectives: Myocardial ischemia is difficult to assess by noninvasive methods in patients with a permanent pacemaker. Pacing stress echocardiography (PASE) has been used successfully in the detection of coronary artery disease (CAD). However, there are no data comparing PASE and other methods. Methods: We compared agreement and accuracy of PASE and radionuclide tomography (SPECT) in detecting CAD in 58 patients, mean age 75 ± 7 years, with a permanent pacemaker and known or suspected CAD. Thirty-nine patients underwent coronary angiography. The prognostic value of these tests was determined by prediction of cardiac events and cardiac death. Results: PASE and SPECT were positive in 39 and 43 patients, respectively. The agreement between the tests was 75%; kappa value 0.64. The sensitivity was 87 and 96% and the specificity 78 and 57%, respectively. With median follow-up of 51 months, there were 24 cardiac events and 8 cardiac deaths. Multivariable analysis determined that positive PASE was the only independent predictive factor associated with cardiac events and cardiac death. Conclusions: PASE is a feasible and effective method for detection of significant CAD in patients with permanent-pacemaker and allows effective risk stratification. PASE merits further study in larger prospective comparative studies.

Hemochromatosis mutations are not linked to dilated cardiomyopathy in Israeli patients

AIMS Hemochromatosis is a condition in which iron loading impairs the function of many organs, including the heart. Congestive heart failure with left ventricular dilatation is commonly found in patients with hemochromatosis. Two missense mutations (C282Y and H63D) have been shown to be responsible for the majority of cases of hemochromatosis. METHODS AND RESULTS We examined 156 patients with congestive heart failure due to dilated cardiomyopathy. Details were recorded of clinical and echocardiographic parameters. DNA was extracted from peripheral blood and checked for the presence of the C282Y and H63D mutations by a commercially available single nucleotide primer extension assay. A control group of 98 healthy blood donors was also checked for the presence of these mutations. Of the 157 patients, 42 (26.75%) had at least one mutation. Five (3.65%) were homozygotic for the H63D mutation and 37 (23.6%) were heterozygotic for the H63D mutation. The C282Y mutation was not present. In a control population of 98 healthy blood donors, 27 (27.6%) were heterozygous for the H63D population and none had the C282Y mutation (no significant difference between the patients with cardiomyopathy and the healthy blood donors, chi(2) test 0.754). There was a non-significant trend to a difference in the prevalence of homozygotic H63D between the cardiomyopathy patients and the healthy blood donors (3.18% vs. 0%, P=0.076, chi(2) test). There was no statistically significant difference between the cardiomyopathy patients with and without the mutations in terms of age, gender, hemoglobin, iron, transferrin, ferritin, presence of diabetes mellitus, hypertension and previous coronary artery bypass grafting. CONCLUSION In our population of patients with dilated cardiomyopathy, there was no evidence for hemochromatosis being an important etiology.

Delayed percutaneous transluminal coronary angioplasty after acute myocardial infarction

The value of delayed percutaneous transluminal coronary angioplasty (> 12 h from admission or after thrombolytic therapy) following acute myocardial infarction is controversial. We compared the short- and long-term prognosis of 1940 consecutive patients after acute myocardial infarction, of whom 188 underwent delayed percutaneous transluminal coronary angioplasty. Delayed percutaneous transluminal coronary angioplasty was more frequently done in patients treated with thrombolysis (12%) than among patients excluded from thrombolytic therapy (8%; P=0.005). Patients in the delayed percutaneous transluminal coronary angioplasty group were younger, included more men and smokers and had less in-hospital complications in comparison to patients who did not undergo delayed percutaneous transluminal coronary angioplasty. The crude 30-day and 1-year mortality rates were 3 and 6% among patients who underwent percutaneous transluminal coronary angioplasty vs. 14 and 21% (P<0.01 for each) among those without percutaneous transluminal coronary angioplasty, respectively. After multivariate analysis adjusted for confounding factors, delayed percutaneous transluminal coronary angioplasty was associated with 65 (RR=0.35; 90% CI 0.14-0.88) and 50% (RR=0.50; 90% CI 0.27-0.92) mortality risk reduction after 30 days and 1 year, respectively. In conclusion, delayed percutaneous transluminal coronary angioplasty applied to selected post-myocardial infarction patients upon clinical indication is safe and beneficial for the treatment of acute myocardial infarction in the community.