Jan van Es

Assessment of the relation between initial culprit vessel patency in acute ST-elevation myocardial infarction and endothelial function

AIMS To assess whether better endothelial function increases the likelihood of patients with acute ST-elevation myocardial infarction (STEMI) having initially patent culprit vessels. Clinical data on the relation between endothelial function and culprit vessel patency in STEMI patients are scarce. METHODS AND RESULTS In this prospective cohort study in 71 patients with STEMI, endothelial function was non-invasively assessed by use of the reactive hyperaemia peripheral artery tonometry (RH-PAT) method at four to six weeks after the primary percutaneous coronary intervention (PPCI). The RH-PAT index measured on average 1.90±0.58. In patients with patent culprit vessels before PPCI (n=33, 46.5%), endothelial function was significantly better than in patients with occluded vessels (n=38, 53.5%) (RH-PAT index 2.08±0.34 vs. 1.75±0.35; p<0.007). Compared to patients with normal endothelial function, the patients with severe endothelial dysfunction had a fivefold higher risk of presenting with an occluded culprit vessel (OR 5.1, 95% CI: 1.8-14.2). Logistic regression analysis revealed that this relation between endothelial function and vessel patency became even stronger after adjustment for potential confounders (adjusted OR 7.1, 95% CI: 2.1-23.6). CONCLUSIONS In this series of patients with acute STEMI, better endothelial function was independently associated with a higher likelihood of presenting with an initially patent culprit vessel.

Extensive Left Ventricular Hemangioma

![Figure][1] [![Graphic][3] ][3][![Graphic][4] ][4][![Graphic][5] ][5] A 27-year-old man with no medical history presented with ventricular tachycardia at 160 beats/min with right bundle branch block and left axis. Transthoracic echocardiography showed an echogenic mass

Cardiac imaging in a symptomatic patient with multiple coronary artery–left ventricular microfistulae

We present the case of a 44-year-old woman with acute coronary syndrome and multiple coronary artery–left ventricular microfistulae at angiography. To evaluate the clinical significance of this observation and to obtain further insights into this rare disease, the patient was further examined with echocardiography and both magnetic resonance imaging and single-photon emission computed tomography, which showed considerable abnormalities.

Relationship between Framingham Risk Score and Left Ventricular Remodeling after Successful Primary Percutaneous Coronary Intervention in Patients with First Myocardial Infarction and Single Vessel Disease

Background: Limited data is available on the potential value of estimated cardiovascular event risk for prediction of left ventricular (LV) remodeling and size of infarcted tissue after ST-elevation myocardial infarction (STEMI). Methods: Therefore, we assessed in a consecutive series of patients with first STEMI, successful primary percutaneous coronary intervention (PCI), and single-vessel disease the potential relationship between the Framingham Risk Score and parameters of both LV remodeling and infarct tissue characteristics, as determined with contrast-enhanced (CE) cardiovascular magnetic resonance (CMR) 6 months after the index event. Parameters of LV remodeling were end-diastolic and end-systolic volumes, ejection fraction, and wall motion score index; infarct tissue characteristics comprised core, peri, and total infarct size, and transmural extent. Results: A total of 25 patients (21 men, 56 ± 10 years) were studied, and the mean Framingham Risk Score was 14.1 ± 5.8%. There was a significant relation between Framingham Risk Score and multiple parameters of LV remodeling: LV ejection fraction, end-diastolic volume, end-systolic volume, and wall motion score index after 6 months (r=-0.55-0.76; p=0.000 for all). Framingham Risk Score showed no relation with various infarct tissue characteristics (ns). Male gender was the only component of the Framingham Risk Score that correlated individually with a few parameters of LV remodeling: LV end-diastolic volume and end-systolic volume (p=0.000 for both). Conclusion: In a series of consecutive patients with first STEMI, successful primary PCI, and single-vessel coronary artery disease, we observed a significant relation between the Framingham Risk Score and several CMRbased parameters of LV remodeling. The results of our small hypothesis-generating study underline the supremacy of multifactorial risk scores as tools for prediction of unfavorable cardiovascular outcome. Additionally, the data support the hypothesis that there might be a future role for a novel and specific multifactorial risk score in predicting unfavorable LV remodeling, which finally could trigger risk-adjusted preventive measures.

Endothelial function after ST-elevation myocardial infarction in patients with high levels of high-sensitivity CRP and Lp-PLA2 : A substudy of the RESPONSE randomized trial

BACKGROUND The combination of high levels of high-sensitive C-reactive protein (hs-CRP) and lipoprotein-associated phospholipase-A2 (Lp-PLA2) was recently shown to correlate with increased cardiovascular risk. Endothelial dysfunction is also known to be a risk factor for cardiovascular events. AIM To test among patients with previous ST-elevation myocardial infarction (STEMI) the hypothesis that high levels of both hs-CRP and Lp-PLA2 may be associated with impaired endothelium-dependent vasodilatation. METHODS In this substudy of the RESPONSE randomized trial, we used reactive hyperemia peripheral artery tonometry (RH-PAT) 4 to 6weeks after STEMI and primary percutaneous coronary intervention (PPCI) to non-invasively assess endothelial function (RH-PAT index <1.67 identified endothelial dysfunction). Reliable measurements of RH-PAT, hs-CRP, and Lp-PLA2 were obtained in 68 patients, who were classified as high-risk if levels of both hs-CRP and Lp-PLA2 were in the upper tertile (≥3.84mg/L and >239μg/L, respectively). RESULTS Patients were 57.4±9.7years and 53 (77.9%) were men. 11 (16%) patients were classified as high-risk and 57 (84%) as low-to-intermediate-risk. The RH-PAT index was 1.68±0.22 in high-risk and 1.95±0.63 in low-to-intermediate-risk patients (p=0.17). Endothelial dysfunction was present in 8 (72.7%) high-risk and 26 (45.6%) low-to-intermediate-risk patients (p=0.09). Framingham risk score, NT-proBNP and fibrinogen levels were higher in high-risk patients (p≤0.03). CONCLUSION In this population of patients with recent STEMI and PPCI, we observed between patients with high hs-CRP and Lp-PLA levels and all other patients no more than numerical differences in endothelial function that did not reach a statistical significance. Nevertheless, further research in larger study populations may be warranted.

The Use of Contrast-Enhancement Cardiovascular Magnetic Resonance Imaging in Cardiomyopathies

The clinical applications of cardiovascular magnetic resonance imaging (CMR), are expanding as the result of the development in hardware, pulse sequence and the ability of post-processing techniques. As the result of the flexibility of CMR to use different pulsesequences, with or without the use of Gadolinium, CMR has developed as a powerful tool for clinical relevant tissue characterization. CMR in combination with the contrastenhancement (CE) technique was initially developed to distinguish viable from non-viable myocardium following myocardial infarction. Nowadays, CE-CMR is increasingly used for tissue characterization in ischemic as well as non-ischemic cardiomyopathies to determine the exact etiology, guide proper treatment, and predict outcome and prognosis. In this chapter, we would like to discuss and illustrate the value of CE-CMR imaging in various cardiomyopathies.

Preservation of the relation between infarct characteristics and left ventricular remodeling following successful early revascularization for myocardial infarction: an observational study with contrast-enhanced cardiovascular MRI

Left ventricular (LV) remodeling following myocardial infarction (MI) is the result of complex interactions between various factors, including presence or absence of early revascularization. Cardiovascular Magnetic Resonance (CMR) imaging with contrast-enhancement (CE) permits assessment of myocardial tissue and LV dimensions and function, but the impact of early revascularization on the relationship between infarct tissue characteristics and LV remodeling has not yet been investigated.

Infarct tissue characteristics of patients with versus without early revascularization for acute myocardial infarction: a contrast enhancement cardiovascular magnetic resonance imaging study

Histopathological studies have suggested that early revascularization for acute myocardial infarction (MI) limits the size, transmural extent, and homogeneity of myocardial necrosis. However, the long-term effect of early revascularization on infarct tissue characteristics is largely unknown. Cardiovascular magnetic resonance (CMR) imaging with contrast enhancement (CE) allows non-invasive examination of infarct tissue characteristics and left ventricular (LV) dimensions and function in one examination. A total of 69 patients, referred for cardiac evaluation for various clinical reasons, were examined with CE-CMR >1 month (median 6, range 1–213) post-acute MI. We compared patients with (n = 33) versus without (n = 36) successful early revascularization for acute MI. Cine-CMR measurements included the LV end-diastolic and end-systolic volumes (ESV), LV ejection fraction (LVEF, %), and wall motion score index (WMSI). CE images were analyzed for core, peri, and total infarct size (%), and for the number of transmural segments. In our population, patients with successful early revascularization had better LVEFs (46 ± 16 vs. 34 ± 14%; P 0.05 for all comparisons); only transmural extent (P = 0.07) and infarct age (P = 0.06) tended to be larger in patients without early revascularization. CMR wall motion abnormalities are significantly better after revascularization; these differences are particularly marked later after infarction. The difference in scar size is more subtle and does not reach significance in this study.