Mahdi Sareban

Effect of Cocoa Products on Blood Pressure: Systematic Review and Meta-Analysis

BACKGROUND Cocoa products such as dark chocolate and cocoa beverages may have blood pressure (BP)-lowering properties due to their high content of plant-derived flavanols. METHODS We performed a meta-analysis of randomized controlled trials assessing the antihypertensive effects of flavanol-rich cocoa products. The primary outcome measure was the change in systolic and diastolic BP between intervention and control groups. RESULTS In total, 10 randomized controlled trials comprising 297 individuals were included in the analysis. The populations studied were either healthy normotensive adults or patients with prehypertension/stage 1 hypertension. Treatment duration ranged from 2 to 18 weeks. The mean BP change in the active treatment arms across all trials was -4.5 mm Hg (95% confidence interval (CI), -5.9 to -3.2, P < 0.001) for systolic BP and -2.5 mm Hg (95% CI, -3.9 to -1.2, P < 0.001) for diastolic BP. CONCLUSIONS The meta-analysis confirms the BP-lowering capacity of flavanol-rich cocoa products in a larger set of trials than previously reported. However, significant statistical heterogeneity across studies could be found, and questions such as the most appropriate dose and the long-term side effect profile warrant further investigation before cocoa products can be recommended as a treatment option in hypertension.

Diagnostic Performance of CMR Imaging Compared With EMB in Patients With Suspected Myocarditis

OBJECTIVES The goal of this study was to assess the diagnostic performance of cardiac magnetic resonance (CMR) compared with endomyocardial biopsy in patients with suspected acute myocarditis (AMC) and chronic myocarditis (CMC). BACKGROUND Several studies have reported an encouraging diagnostic performance of CMR in myocarditis. However, the comparison of CMR with clinical data only and the use of preselected patient populations are important limitations of the majority of these reports. METHODS One hundred thirty-two consecutive patients with suspected AMC (defined by symptoms ≤ 14 days; n = 70) and CMC (defined by symptoms >14 days; n = 62) were included. Patients underwent cardiac catheterization with left ventricular endomyocardial biopsy and CMR, including T(2)-weighted imaging for assessment of edema, T(1)-weighted imaging before and after contrast administration for evaluation of hyperemia, and assessment of late gadolinium enhancement. CMR results were considered to be consistent with the diagnosis of myocarditis if 2 of 3 CMR techniques were positive. RESULTS Within the total population, myocarditis was the most common diagnosis on endomyocardial biopsy analysis (62.9%). Viral genomes were detected in 30.3% (40 of 132) of patients within the total patient population and significantly more often in patients with AMC than CMC (40.0% vs. 19.4%; p = 0.013). For the overall cohort of patients with either suspected AMC or CMC, the diagnostic sensitivity, specificity, and accuracy of CMR were 76%, 54%, and 68%, respectively. The best diagnostic performance was observed in patients with suspected AMC (sensitivity, 81%; specificity, 71%; and accuracy, 79%). In contrast, diagnostic performance of CMR in suspected CMC was found to be unsatisfactory (sensitivity, 63%; specificity, 40%; and accuracy, 52%). CONCLUSIONS The results of this study underline the usefulness of CMR in patients with suspected AMC. In contrast, the diagnostic performance of CMR in patients with suspected CMC might not be sufficient to guide clinical management.

Low vs. Higher-Dose Dark Chocolate and Blood Pressure in Cardiovascular High-Risk Patients

BACKGROUND Dark chocolate may have blood pressure-lowering properties. We conducted a prospective randomized open-label blinded end-point design trial to study a potential dose dependency of the presumed antihypertensive effect of dark chocolate by directly comparing low vs. higher doses of dark chocolate over the course of 3 months. METHODS We enrolled a total of 102 patients with prehypertension/stage 1 hypertension and established cardiovascular end-organ damage or diabetes mellitus. Patients were randomly assigned to receive either 6 or 25 g/day of flavanol-rich dark chocolate for 3 months. The difference in 24-h mean blood pressure between groups was defined as the primary outcome measure. RESULTS Significant reductions in mean ambulatory 24-h blood pressure were observed between baseline and follow-up in both groups (6 g/day: -2.3 mm Hg, 95% confidence interval -4.1 to -0.4; 25 g/day: -1.9 mm Hg, 95% confidence interval -3.6 to -0.2). There were no significant differences in blood pressure changes between groups. In the higher-dose group, a slight increase in body weight was noted (0.8 kg, 95% confidence interval 0.06 to 1.6). CONCLUSIONS The findings are consistent with the hypothesis that dark chocolate may be associated with a reduction in blood pressure (BP). However, due to the lack of a control group, confounding may be possible and the results should be interpreted with caution.

Prognostic significance and magnetic resonance imaging findings in aborted myocardial infarction after primary angioplasty.

BACKGROUND Aborted myocardial infarction (MI) is defined by major (> or =50%) ST-segment resolution and a lack of subsequent cardiac enzyme rise > or =2 the upper normal limit. This ultimate myocardial salvage has been observed in approximately 15% of ST-elevation MI (STEMI) patients after fibrinolysis. So far, the prognostic significance and magnetic resonance imaging (MRI) findings of an aborted MI after primary angioplasty have not been evaluated appropriately. METHODS We examined 420 consecutive STEMI patients undergoing primary angioplasty within 12 hours after symptom onset. All patients underwent MRI within 1 to 4 days. Clinical end points were major adverse cardiovascular events within 6 months after the index event. RESULTS Of the 420 STEMI patients, 58 (14%) fulfilled aborted MI criteria. As compared with true MI, patients with aborted MI had a significant lower infarct size, shorter pain-to-balloon time, and better left ventricular ejection fraction (P < .001, respectively). Aborted MI patients had a 6-month major adverse cardiovascular event rate of 1.7% versus 19.6% of true MI patients (P = .001). In aborted MI patients, MRI detected no myocardial scar in 30 (56%), and a minor necrosis/scar formation in 24 patients (44%). CONCLUSION The proven prognostic relevance of aborted MI makes it a meaningful end point and therapeutic target in future MI studies. MRI can further distinguish between true aborted MI with absence of myocardial scar and aborted MI with scar formations.

Effect of Coronary Collaterals on Microvascular Obstruction as Assessed by Magnetic Resonance Imaging in Patients With Acute ST-Elevation Myocardial Infarction Treated by Primary Coronary Intervention

The aim of this study was to determine whether angiographically visible collaterals before reperfusion are associated with beneficial effects on infarct size, microvascular obstruction, and left ventricular function as measured by magnetic resonance imaging (MRI) in patients with ST-elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI). We examined 235 patients with STEMI and symptoms <12 hours. All patients had Thrombolysis In Myocardial Infarction grade < or =1 flow before PCI. Collateral flow was graded according to Rentrop classification. Patients were divided in 2 groups; group A had absent or weak collateral flow and group B had significant flow. In 166 patients there was absent or weak collateral flow, whereas 69 had significant flow. Extent of microvascular obstruction was significantly smaller in group B at early MRI (3.3% vs 2.1% of left ventricle, p = 0.009). Infarct size measured by peak creatine kinase release showed smaller infarcts in group B (p = 0.02), whereas MRI infarct size showed a weak trend (p = 0.20). At 6 months, a strong trend toward a lower rate of death or nonfatal reinfarction could be seen in group B (4.5% vs 12.2%, p = 0.07). In conclusion, well-developed collaterals before reperfusion by PCI in patients with STEMI are associated with a protective effect on coronary microcirculation.

Effects of physical exercise versus rosiglitazone on endothelial function in coronary artery disease patients with prediabetes

We conducted a three‐arm, parallel‐group, randomized, controlled trial to compare the effects of rosiglitazone and physical exercise on endothelial function in patients with coronary artery disease and impaired fasting glucose or impaired glucose tolerance over a 6‐month period. Group A received rosiglitazone tablets 8 mg daily (n = 16), group B underwent a structured physical exercise programme (n = 15) and group C served as a control group (n = 12). At baseline and after 6 months, brachial artery ultrasound imaging was performed to assess reactive flow‐mediated dilation (FMD). Rosiglitazone treatment and exercise both led to significant improvements in insulin resistance at 6 months, whereas no change was observed in control patients. FMD improved significantly in physical exercise patients, whereas no change could be observed in patients receiving rosiglitazone or in the control group. Between‐group comparisons also showed a significant relative improvement in FMD in exercise patients compared with rosiglitazone.

Inhaled budesonide does not prevent acute mountain sickness after rapid ascent to 4559 m

Recent studies showed that inhaled budesonide (200 µg twice per day) reduced the incidence of acute mountain sickness (AMS) after passive ascent to 3700 and 3900 m [1, 2]. These findings raised the possibility that mediators released from the hypoxic lung transmit signals to the brain which contribute to the cerebral processes leading to AMS [3]. Because neither of these studies reflect alpine-style climbing, the present study was performed to test whether inhalation of budesonide at two different doses (200 and 800 µg twice per day) prior to active and rapid ascent (<20 h) to 4559 m prevents AMS in this high-risk setting. Prophylactic inhalation of budesonide does not prevent acute mountain sickness after rapid ascent to high-altitude http://ow.ly/Bc9p30dOz46

Intra- and Interobserver Variability of different CMR-ratios for the detection of myocardial inflammation in patients with suspected acute viral myocarditis

Introduction Myocarditis is a diagnostic challenge in clinical cardiology with endomyocardial biopsy (EMB) being the gold standard. Cardiac magnetic resonance imaging (CMR) has the potential to serve as a non-invasive diagnostic tool in patients with suspected myocarditis. Recently, it was reported that a combination of CMR sequences had the best diagnostic accuracy in patients suspected of having acute inflammation. However, the used sequences and established signal intensity ratios do not always provide robust and reliable results.

Speckle tracking-derived bi-atrial strain before and after eleven weeks of training in elite rowers

The left (LA) and right (RA) atria undergo adaptive remodeling in response to hemodynamic stress not only induced by endurance exercise but also as part of several cardiovascular diseases thereby confounding differential diagnosis. Echocardiographic assessment of the atria with novel speckle tracking (STE)-derived variables broadens the diagnostic spectrum compared to conventional analyses and has the potential to differentiate physiologic from pathologic changes. The purpose of this study was to assess and categorize baseline values of bi-atrial structure and function in elite rowers according to recommended cutoffs, and to assess the cardiac changes occurring with endurance training. Therefore, fifteen elite rowers underwent 2D-echocardiographic analysis of established variables of cardiac structure and function as well as STE-derived variables of bi-atrial function. Measurements were performed at baseline and after eleven weeks of extensive training. 40% of athletes displayed mildly enlarged LA and 47% mildly enlarged RA at baseline, whereas no athlete fell below the lower reference values of LA and RA reservoir strain. Average power during a 2000 m ergometer rowing test (P2000 m) improved from 426 ± 39 W to 442 ± 34 W (p = 0.010) but there were no changes of echocardiographic variables following training. In elite rowers, longitudinal bi-atrial strain assessment indicates normal resting function of structurally enlarged atria and thereby may assist to differentiate between exercise-induced versus disease-associated structural cardiac changes in which function is commonly impaired.

Diagnosing Acute Mountain Sickness.

Diagnosing Acute Mountain Sickness To the Editor The systematic review by Dr Meier and colleagues1 demonstrated that most research on acute mountain sickness (AMS) conducted during the last 2 decades used either the self-reported Lake Louise Questionnaire Score (LLQS) or the Acute Mountain Sickness-Cerebral (AMS-C) score for diagnosing AMS. Because no criterion standard exists, the authors used the LLQS as a reference for comparison with the AMS-C score. Compared with an LLQS of 5 or greater, using an AMS-C score of 0.7 or greater to indicate AMS had a sensitivity of 67% and a specificity of 92%, with a positive likelihood ratio (LR) of 8.2 and a negative LR of 0.36. Two recent field studies found better agreement of the AMS-C score with the LLQS.2,3 In the first study, 235 participants completed both questionnaires at an altitude of 3450 m; the sensitivity of the AMS-C score was 91%, specificity was 94%, positive LR was 15.2, and negative LR was 0.1.3 In the second study, 191 participants answered questionnaires at an altitude of 4559 m; the sensitivity of the AMS-C score was 80%, specificity was 98%, positive LR was 40, and negative LR was 0.2.2 In contrast to the pooled data analysis from Meier et al,1 which showed significant data heterogeneity (I2 = 98%), data from the 2 studies were obtained by the same investigators with the same methods and in comparable study populations.2,3 The data further suggest that sensitivity and specificity of the AMS-C score compared with an LLQS of 5 or greater as reference changed with altitude. This finding is in line with previous studies in which data were collected from 490 climbers at various altitudes (range, 2850 m-4559 m).4,5 The change in diagnostic accuracy of a given AMS criterion score with altitude was not addressed by Meier et al1 but should be considered when the rate of AMS at various altitudes is investigated. It is unlikely that the increase of AMS prevalence with altitude is linear as concluded by Meier et al.1