Mario Lepera

Serum osteoprotegerin and carotid intima–media thickness in acute/chronic coronary artery diseases

Aims Osteoprotegerin (OPG) plays a key role in atherosclerosis progression and plaque destabilization. We investigated the relationship between intima–media thickness of the common carotid artery (CCA-IMT; an early marker of atherosclerosis) and OPG levels in patients with acute coronary syndrome (ACS) and chronic coronary artery disease (CAD). Methods We studied 133 consecutive patients, mean age 65 ± 9 years, referred to our department for coronary angiography. They were evaluated for cardiovascular risk factors, OPG levels and CCA-IMT and accordingly divided in two subgroups: ACS and chronic CAD. Results Except for age, the two groups were similar according to conventional cardiovascular risk factors. The chronic CAD group showed a CCA-IMT lower than the ACS group (0.86 ± 0.15 vs. 0.94 ± 0.22 mm, P = 0.027); there were no differences regarding the extension of coronary atherosclerosis on angiograms. The OPG levels were higher in chronic CAD patients than in ACS patients (5.36 ± 3.06 vs. 3.85 ± 2.96 pmol/l, P = 0.004). Moreover, the CCA-IMT was significantly correlated with the age of the patients (r = 0.5; P < 0.001). OPG values were not related either to age or to the CCA-IMT. At analysis of covariance, when adjusting the groups for age, the comparison of the two groups lost statistical significance for CCA-IMT (P = 0.41), whereas the OPG values remained significant after the correction (P = 0.001). Conclusion OPG levels are higher in chronic CAD patients. CCA-IMT confirmed its importance in predicting CAD, showing significantly higher values in the patients in the ACS group as compared with those in the chronic CAD group.

Cardiovascular risk evaluation and prevalence of silent myocardial ischemia in subjects with asymptomatic carotid artery disease

Introduction: Silent ischemia is an asymptomatic form of myocardial ischemia, not associated with angina or anginal equivalent symptoms, which can be demonstrated by changes in ECG, left ventricular function, myocardial perfusion, and metabolism. The aim of this study was to evaluate the prevalence of silent myocardial ischemia in a group of patients with asymptomatic carotid stenosis. Methods: A total of 37 patients with asymptomatic carotid plaques, without chest pain or dyspnea, was investigated. These patients were studied for age, sex, hypertension, diabetes, dyslipidemia, smoking, and family history of cardiac disease, and underwent technetium-99 m sestamibi myocardial stress-rest scintigraphy and echo-color Doppler examination of carotid arteries. Results: A statistically significant relationship (P = 0.023) was shown between positive responders and negative responders to scintigraphy test when both were tested for degree of stenosis. This relationship is surprising in view of the small number of patients in our sample. Individuals who had a positive scintigraphy test had a mean stenosis degree of 35% ± 7% compared with a mean of 44% ± 13% for those with a negative test. Specificity of our detection was 81%, with positive and negative predictive values of 60% and 63%, respectively. Conclusion: The present study confirms that carotid atherosclerosis is associated with coronary atherosclerosis and highlights the importance of screening for ischemic heart disease in patients with asymptomatic carotid plaques, considering eventually plaque morphology (symmetry, composition, eccentricity or concentricity of the plaque, etc) for patient stratification.

Detection, location, and severity assessment of left anterior descending coronary artery stenoses by means of contrast-enhanced transthoracic harmonic echo Doppler

AIMS Contrast-enhanced second harmonic Doppler (ED) is a new ultrasound modality that increases the feasibility of recording blood flow velocity (BFV) in the left anterior descending coronary artery (LAD) using a transthoracic approach. Blood flow velocity convective acceleration is a reliable marker of coronary stenosis and can be used to assess the percentage area reduction at the stenosis site by applying the continuity equation. To detect, locate, and assess the severity of significant stenosis throughout the LAD by means of an ED recording of BFV acceleration at the stenosis site. METHODS AND RESULTS Fifty-three consecutive patients undergoing coronary angiography (CA) underwent a colour-guided pulsed-wave ED recording of BFV in the proximal/mid and distal portions of the LAD, and maximal and reference BFV was obtained in each of the two arterial segments. Maximal velocity was much higher in the diseased segments (>or=50% lumen narrowing) than in the normal segments (143 +/- 84 vs. 38 +/- 20 cm/s; P < 0.001); as the reference velocity was similar (37 +/- 13 vs. 31 +/- 12; P = 0.03), the percentage increase in velocity was also higher (290 +/- 233 vs. 20 +/- 37%; P < 0.001). Using a cut-off value of an 82% increase in velocity, sensitivity and specificity vs. CA was, respectively, 86 and 95%. The reduction in the percentage area of stenosis calculated using the continuity equation agreed with that determined by means of quantitative CA (r = 0.7). CONCLUSION Blood flow velocity evaluation in the LAD by means of transthoracic ED is feasible and reliable in detecting, locating, and assessing the severity of LAD stenosis.

GHOSTS AFTER LEAD REMOVAL: ETIOLOGY AND PROGNOSTIC IMPACT. A REPORT OF AN INTRACARDICAC AND TRANSESOPHAGEAL ECHOCARDIOGRAPHIC STUDY

Ghosts are new mass lesions in the right cardiac chamber after leads extraction, whose clinical significance is not clear. Because we do not know the true origin of ghosts, prolonged hospitalization and antibiotic therapy are considered necessary. Sixteen patients scheduled for leads removal

Sudden cardiac death in a woman with clinical evidence of coronary vasospastic disease and myocardial stunning. A necrospy insight into the etiology

This case shed some light on the etiology of severe coronary vasospastic disease. A 54 years old lady with metabolic syndrome had a terminal ventricular fibrillation after an episode of acute ischemia caused by a coronary spasm. At the autopsy study an inflammatory perivascular and mainly perineural infiltration of the autonomic fibres of the cardiac nerves, confirmed at immunohistochemistry, could suggest a potential susceptibility of the nervous fibres to evoke an intense coronary vasospastic response as a consequence of non-specific events. Correspondence to: Carlo Caiati, Unità Operativa di Cardiologia Universitaria, Policlinico di Bari, Piazza G. Cesare, Italy, Tel: +39-080-5592750; Fax: +39-0805478796; E-mail: carlo.caiati@uniba.it Received: November 07, 2016; Accepted: December 05, 2016; Published: December 08, 2016 Background The etiology of vasospatic angina is not well known [1]. Coronary endodothelium and autonomic nerves dysfunction have been indicated as a possible mechanism of coronary vasospasm but these studies have had little clinical impact as no causes of this dysfunction if any, has been demonstrated [2-7].

DISTINGUISHING ISCHEMIC FROM NONISCHEMIC LEFT BUNDLE BRANCH BLOCK BY TRANSTHORACIC ENHANCED CORONARY ECHO DOPPLER IN CONVERGENT COLOR DOPPLER MODE

Thanks to new technological advances (convergent color Doppler mode) and new tomographic planes, transthoracic enhanced echo Doppler of coronaries (CED) has the potential to detect both mild and critical coronary stenoses over the entire left anterior descending coronary artery (LAD), by detecting

TRANSTHORACIC ENHANCED DOPPLER ECHOCARDIOGRAPHY-ASSESSED ABSENCE OF ATHEROSCLEROSIS IN THE LEFT ANTERIOR DESCENDING CORONARY ARTERY RULES OUT CRITICAL RIGHT AND/OR CIRCUMFLEX CORONARY ARTERY DISEASE

Background: The left anterior descending coronary artery (LAD) is the coronary most frequently affected by atherosclerosis (CAD) and it is reasonable to expect that advanced CAD already causing a significant obstructing plaque of the right (RCA) and/or circumflex (LCX) coronary arteries will, at least minimally, involve the LAD. LAD CAD, both critical and subcritical, can be reliably assessed by transthoracic enhanced echo Doppler of the coronaries (CED) in convergent color Doppler mode. This approach consists of recording LAD blood flow velocity in order to detect any acceleration at the stenosis site over the entire LAD. We aimed at verifying the value of atherosclerotic plaques (either mild or critical) in predicting significant CAD (>50% diameter lumen narrowing) of the LCX and/or RCA, as assessed by CED over the entire LAD.

THE SLOW CORONARY FLOW PHENOMENON IS NOT A GOOD PREDICTOR OF CORONARY MICROCIRCULATORY DYSFUNCTION AS ASSESSED BY ABSOLUTE CORONARY FLOW RESERVE IN PATIENTS WITH ANGIOGRAPHICALLY NORMAL CORONARY ARTERIES

The meaning of the slow coronary flow phenomenon (SCF) as visualized in patients (pts) with angiographically normal coronary arteries, is controversial. Non-invasively assessed absolute coronary flow reserve (CFR) in the left anterior descending coronary artery (LAD) by transthoracic colour guided