Marina N. Vernalis

ARBITER: Arterial Biology for the Investigation of the Treatment Effects of Reducing Cholesterol A Randomized Trial Comparing the Effects of Atorvastatin and Pravastatin on Carotid Intima Medial Thickness

Background—Whether marked LDL reduction to levels well below 100 mg/dL would further reduce the burden of cardiovascular disease is controversial. We compared the effects of 2 statins with widely differing potencies for LDL reduction (pravastatin 40 mg/d and atorvastatin 80 mg/d) on carotid intima-media thickness (CIMT). Methods and Results—This was a single-center, randomized, clinical trial of 161 patients (mean age, 60 years; 71.4% male; 46% with known cardiovascular disease) that met National Cholesterol Education Program (NCEP) II criteria for lipid-lowering therapy. The effects of atorvastatin (80 mg/d; n=79) and pravastatin (40 mg/d; n=82) on CIMT were compared using blinded, serial assessments of the far wall of the distal common carotid artery. Baseline CIMT and other characteristics were similar between study groups. As anticipated, atorvastatin was substantially more potent for LDL reduction after 12 months: in the atorvastatin group, LDL cholesterol was 76±23 mg/dL after 12 months (−48.5%); LDL cholesterol was 110±30 mg/dL in the pravastatin group (−27.2%;P <0.001). Atorvastatin induced progressive CIMT regression over 12 months (change in CIMT, −0.034±0.021 mm), whereas CIMT was stable in the pravastatin group (change of 0.025± 0.017 mm;P =0.03). Conclusions—Marked LDL reduction (<100 mg/dL) with a high-potency statin provides superior efficacy for atherosclerosis regression at 1 year. This early effect on CIMT, a surrogate for clinical benefit, suggests that marked LDL reduction with synthetic statins may provide enhanced reduction in clinical coronary event rates.

Anomalous origin and course of coronary arteries in adults: Identification and improved imaging utilizing transesophageal echocardiography

Anomalous origin of a coronary artery is rare, but may represent a clinically significant abnormality, since some anomalies are associated with myocardial ischemia, infarction, and sudden death. Diagnosis may elude routine screening procedures, and even when an anomalous vessel is identified angiographically, it may be difficult to delineate its true course on the basis of angiography alone. The purpose of this study was to determine whether transesophageal echocardiography (TEE) is of value in making the diagnosis and outlining the course of anomalous coronary arteries. Five adult patients with anomalous origin of a coronary artery were studied by monoplane TEE and selective coronary angiography. Transthoracic echocardiography (TTE) was also performed in four of these five patients. Anomalous coronary ostia were visualized in four of five patients utilizing TEE, but in none of four patients by TTE. A proximal segment of the anomalous coronary vessel was identified in all five patients by TEE, and in only two of four patients by TTE. TEE images were consistently of superior diagnostic quality. TEE is a valuable tool for the echocardiographic identification of anomalous coronary arteries, and is superior to TTE in adult patients.

Perceived stress correlates with disturbed sleep: a link connecting stress and cardiovascular disease.

The association between stress and cardiovascular disease (CVD) risk is becoming established. A mechanistic link clarifying the intermediate steps between the experience of stress and the development of CVD would support this association. We sought to examine the role of perceived stress as a factor associated with disturbed sleep with the goal of providing an explanation for the stress–CVD connection. We performed a cross-sectional analysis of data recorded by subjects at entry to our CVD prevention program. Data collection included questionnaire surveys, anthropometrics, and a CVD-relevant laboratory panel. Of 350 consecutively enrolled subjects (mean age 54.4 ± 12.4 [SD] years, 138 men, 39%), 165 (47%) scored above the mean for stress measures. These high-stress subjects displayed an increased cardiovascular risk profile including elevated body mass index (mean ± SD 31.1 ± 5.9 vs. 29.0 ± 5.9, rs = 0.175), increased waist circumference (102 ± 17 cm vs. 98 ± 14, rs = 0.135), and elevated high-sensitivity serum C-reactive protein (0.384 mg/dl vs. 0.356, rs = 0.109). High-stress subjects also demonstrated greater daytime sleepiness (Epworth Sleepiness Scale: 10.4 ± 5.0 vs. 7.8 ± 4.8, rs < 0.316), greater fatigue (fatigue scale: 5.4 ± 2.2 vs. 3.4 ± 2.4, rs = 0.484), poorer sleep quality (Pittsburgh Sleep Quality Index: 8.5 ± 4.4 vs. 5.9 ± 4.0, rs = 0.416), and shorter sleep duration (20 min less/24 h, rs = negative 0.177) with a higher risk for sleep apnea (60% at high risk vs. 40%, p = 0.003) than low-stress subjects. High stress was associated with significant disturbances in sleep duration and sleep quality. Stress levels also correlated with daytime consequences of disturbed sleep. The stress–sleep connection may be an important mechanistic mediator of the association between stress and CVD.

Echocardiographic evaluation of papillary fibroelastoma: A case report and review of the literature

Papillary fibroelastomas comprise approximately 7.9% of benign primary cardiac tumors. Although papillary fibroelastomas were at first discovered incidentally at autopsy or during heart surgery, these tumors are increasingly being identified by echocardiography. This article reviews those papillary fibroelastomas detected by transthoracic or transesophageal echocardiography and discusses the echocardiographic features of these tumors, associated symptoms, and management. Echocardiography is important in influencing management decisions regarding excision, valve replacement, and valve repair.

Performance of Whole-Genome Amplified DNA Isolated from Serum and Plasma on High-Density Single Nucleotide Polymorphism Arrays

Defining genetic variation associated with complex human diseases requires standards based on high-quality DNA from well-characterized patients. With the development of robust technologies for whole-genome amplification, sample repositories such as serum banks now represent a potentially valuable source of DNA for both genomic studies and clinical diagnostics. We assessed the performance of whole-genome amplified DNA (wgaDNA) derived from stored serum/plasma on high-density single nucleotide polymorphism arrays. Neither storage time nor usage history affected either DNA extraction or whole-genome amplification yields; however, samples that were thawed and refrozen showed significantly lower call rates (73.9 +/- 7.8%) than samples that were never thawed (92.0 +/- 3.3%) (P < 0.001). Genotype call rates did not differ significantly (P = 0.13) between wgaDNA from never-thawed serum/plasma (92.9 +/- 2.6%) and genomic DNA (97.5 +/- 0.3%) isolated from whole blood. Approximately 400,000 genotypes were consistent between wgaDNA and genomic DNA, but the overall discordance rate of 4.4 +/- 3.8% reflected an average of 11,110 +/- 9502 genotyping errors per sample. No distinct patterns of chromosomal clustering were observed for single nucleotide polymorphisms showing discordant genotypes or homozygote conversion. Because the effects of genotyping errors on whole-genome studies are not well defined, we recommend caution when applying wgaDNA from serum/plasma to high-density single nucleotide polymorphism arrays in addition to the use of stringent quality control requirements for the resulting genotype data.

Unruptured sinus of Valsalva aneurysm presenting with embolization.

15. Hiatt .JR, Yeatman LA, Child +JS. The value of echocardiopraphy in blunt chest trauma. J Trauma 1988:28:914-P?. King RM, Mucha P, Seward .JB. Cardiac contusion: a new diagnostic approach utilizing two-dimensional echocardiography. J Trauma 1983:23:610-X3. Wisner DH, Reed WH, Riddick RS. Suspected myocardial contusion. Ann Surg 1990;213:82-6. Kertes P, Westlake G, Luxton M. Multiple peripheral emholi after cardiac trauma. Br Heart J 1983;49:187-9. Pomerantz M, Delgado F. Eiseman B. Unsuspected depressed cardiac output following blunt thoracic or abdominal trauma. Sureerv 1971:70:8&i-71. ” “-~ ,

Effects of cardiovascular lifestyle change on lipoprotein subclass profiles defined by nuclear magnetic resonance spectroscopy

BackgroundLow-density lipoprotein (LDL) cholesterol lowering is a primary goal in clinical management of patients with cardiovascular disease, but traditional cholesterol levels may not accurately reflect the true atherogenicity of plasma lipid profiles. The size and concentration of lipoprotein particles, which transport cholesterol and triglycerides, may provide additional information for accurately assessing cardiovascular risk. This study evaluated changes in plasma lipoprotein profiles determined by nuclear magnetic resonance (NMR) spectroscopy in patients participating in a prospective, nonrandomized lifestyle modification program designed to reverse or stabilize progression of coronary artery disease (CAD) to improve our understanding of lipoprotein management in cardiac patients.ResultsThe lifestyle intervention was effective in producing significant changes in lipoprotein subclasses that contribute to CAD risk. There was a clear beneficial effect on the total number of LDL particles (-8.3%, p < 0.05 compared to matched controls), small dense LDL particles (-9.5%, p < 0.05), and LDL particle size (+0.8%; p < 0.05). Likewise, participants showed significant improvement in traditional CAD risk factors such as body mass index (-9.9%, p < 0.01 compared to controls), total cholesterol (-5.5%, p < 0.05), physical fitness (+37.2%, p < 0.01), and future risk for CAD (-7.9%, p < 0.01). Men and women responded differently to the program for all clinically-relevant variables, with men deriving greater benefit in terms of lipoprotein atherogenicity. Plasma lipid and lipoprotein responses to the lifestyle change program were not confounded by lipid-lowering medications.ConclusionIn at risk patients motivated to participate, an intensive lifestyle change program can effectively alter traditional CAD risk factors and plasma lipoprotein subclasses and may reduce risk for cardiovascular events. Improvements in lipoprotein subclasses are more evident in men compared to women.

Taking Aim at Nurse Stress: A Call to Action

The study investigates stress levels and related behaviors of nurses in a military medical center during wartime. In 2007, nurses completed a questionnaire survey with objective validation of data in a subsample using actigraphy over 12 weeks. Of 270 nurses, 255 (94%) returned surveys. A total of 81% reported moderately high or high stress with sources listed as work (66%) and fatigue (39%). Many reported coming to work despite feeling ill and/or stressed (13.6 days/3 months). In contrast, morale was high or moderately high in 71%. Nurses reported an average of 5.5 hours of sleep/night, 8.8 h/wk taken for self, and 3.8 h/wk for exercise. Actigraphy data showed an average of 6.0 hours of sleep/night. These findings highlight a mismatch between stress levels and coping perceptions indicating an inability to properly care for self. To manage the effects of chronic stress, nurse leaders should implement systems targeting healthy life balance.

Nongenital pelvic leiomyosarcoma metastatic to the heart.

A patient who had a 5-year history of a low-grade nongenital pelvic leiomyosarcoma was evaluated for worsening dyspnea, hypertension, and jugular venous distension. An echocardiogram revealed a large right atrial mass. At surgical exploration, metastatic leiomyosarcoma was found within the inferior vena cava extending from below the renal veins up into the right atrium. Using cardiopulmonary bypass with profound hypothermia and circulatory arrest, the inferior vena cava was opened below the renal veins, and the tumor was transected. That portion of the tumor above this transection was then extracted through a right atriotomy. Resection of the pelvic tumor was not thought to be feasible. The patient remains asymptomatic with stable pelvic tumor 1 year after the procedure.