Rabih R. Azar

Duration of Abnormal SPECT Myocardial Perfusion Imaging Following Resolution of Acute Ischemia: An Angioplasty Model

OBJECTIVESnThis study was designed to determine how long nuclear myocardial perfusion imaging (MPI) remains abnormal following transient myocardial ischemia.nnnBACKGROUNDnAcute rest MPI identifies myocardial ischemia with a high sensitivity when the radionuclide is injected during chest pain. However, the sensitivity of this technique is uncertain when the radionuclide is injected following the resolution of symptoms.nnnMETHODSnForty patients undergoing successful coronary angioplasty were randomized into four equal groups. Tc-99m sestamibi was injected intravenously during the last balloon inflation (acute MPI) in 30 patients and then reinjected 1, 2, or 3 h later (delayed MPI). In a fourth group, the radiopharmaceutical was injected at 15 min following balloon deflation (delayed MPI). A final injection was performed at 24 to 48 h (late MPI) in 37 patients (93%).nnnRESULTSnA perfusion defect was detected in all 30 acute MPI studies; in 7/10 patients (70%) injected at 15 min; in 11/30 patients (37%) injected at 1, 2, or 3 h; and in 7/37 patients (19%) injected at 24 to 48 h. Perfusion scores were 13.0 +/- 9.2 on acute MPI, 5.1 +/- 2.8 at 15 min (p < 0.001 vs. acute MPI); 2.6 +/- 3.0 at 1, 2, and 3 h (p < 0.001 vs. acute MPI); and 1.3 +/- 2.4 at 24 to 48 h (p < 0.001 vs. acute MPI; p < 0.03 vs. delayed MPI).nnnCONCLUSIONSnMyocardial perfusion imaging may remain abnormal for several hours following transient myocardial ischemia even when normal flow is restored in the epicardial coronary artery.

Effects of Aspirin (325 mg/day) on Serum High- Sensitivity C-Reactive Protein, Cytokines, and Adhesion Molecules in Healthy Volunteers

In this study of healthy middle-aged and elderly subjects, we found that self-reported family history of premature heart attack and sudden death is independently associated with reduced HRV, suggesting that autonomic imbalance may be part of the complex of familial predisposition to premature heart attack.

Effect of Ezetimibe/Atorvastatin Combination on Oxidized Low Density Lipoprotein Cholesterol in Patients With Coronary Artery Disease or Coronary Artery Disease Equivalent

Ezetimibe is effective in providing additional low-density lipoprotein (LDL) cholesterol lowering when coadministered with statins, but its effect beyond LDL cholesterol lowering is unknown. Oxidized LDL (ox-LDL) is a better predictor of adverse cardiovascular events than standard lipid parameters. The objective of this study was to investigate the effect of ezetimibe on ox-LDL. A total of 100 patients with coronary artery disease or coronary artery disease equivalent were randomized to atorvastatin 40 mg/day and ezetimibe 10 mg/day or to atorvastatin 40 mg/day and placebo. LDL cholesterol, LDL cholesterol subfractions, and ox-LDL were measured at baseline and after 8 weeks of therapy. The ezetimibe group had a larger reduction in total LDL cholesterol compared to placebo. This was due mainly to a larger reduction in large buoyant LDL (24% vs 10%, p = 0.008). Ox-LDL level did not change in the placebo group (50 +/- 13 vs 51 +/- 13 U/L), while it decreased in the ezetimibe group, from 51 +/- 13 to 46 +/- 10 U/L (p = 0.01 vs baseline and p = 0.02 vs final level in placebo). The change in ox-LDL correlated significantly with those in total LDL and in large buoyant LDL (r = 0.6 and r = 0.5, respectively, p <0.01 for both), but not with that of small dense LDL, high-density lipoprotein, or very low density lipoprotein. In conclusion, this study demonstrates that ezetimibe decreases ox-LDL cholesterol through reductions in total LDL cholesterol and in large buoyant LDL cholesterol.

Prevalence, Awareness, Treatment, and Control of Hypertension in Lebanon

The prevalence and factors related to hypertension (HTN) treatment and control are well investigated in the Western world but remain poorly understood in the Middle East and in middle‐income countries such as Lebanon. In order to measure the prevalence, awareness, treatment, and control rates of HTN in Lebanon, the authors measured blood pressure (BP) in 1697 adults. The prevalence of optimal BP (<120/80 mm Hg) was 33% and that of pre‐HTN (BP ≥120/80 mm Hg but <140/90 mm Hg) was 30%. The prevalence, awareness, treatment, and control (among treated hypertensive) rates of HTN were 36.9%, 53%, 48.9%, and 54.2%, respectively. Overall, only 27% of patients with HTN had their BP under control. Awareness was the most important predictor of treatment. No predictor of control could be identified. The authors concluded that HTN is prevalent in Lebanon and its overall control is low. Improving awareness is the most important target for intervention.

Recurrent Polymorphic Ventricular Tachycardia Complicating Radiofrequency Catheter Ablation of the Atrioventricular Junction

Recurrent ventricular tachycardia and ventricular fibrillation were observed immediately after RF ablation of the AV junction in a 64‐year‐old man. This arrhythmia was preceded by ventricular bigeminy and a long‐short sequence. It was not associated with prolongation of the QT interval compared to baseline, and recurred 3 months later despite ventricular pacing at 90 beats/min. This is the first reported case of sustained ventricular arrhythmia complicating RF AV junction ablation despite rapid ventricular pacing, and recurring 3 months after discharge. It may explain the rare cases of sudden death complicating this procedure.

Comparison of the effects of combination atorvastatin (40 mg) + ezetimibe (10 mg) versus atorvastatin (40 mg) alone on secretory phospholipase A2 activity in patients with stable coronary artery disease or coronary artery disease equivalent.

Secretory phospholipase A2 (sPLA2) is an enzyme that plays an important role in the pathogenesis of atherosclerosis and of adverse cardiovascular events. It is currently the target of emerging therapeutic agents. Our study was designed to investigate the effect of aggressive lowering of low-density lipoprotein (LDL) cholesterol with ezetimibe and atorvastatin on sPLA2 activity. We randomized 100 patients with stable coronary artery disease (CAD) or CAD equivalent (diabetes, stroke, or peripheral vascular disease) to receive ezetimibe 10 mg/day in association with atorvastatin 40 mg/day (combination therapy group) versus atorvastatin 40 mg/day and placebo (monotherapy group). Patients on statin therapy before inclusion were allowed to enter the study as long as the potency of the statin was lower than atorvastatin 40 mg/day. Lipid profile, high-sensitivity C-reactive protein (hs-CRP), and sPLA activity were measured at baseline and after 8 weeks of therapy. The decrease in LDL cholesterol was more significant in the combination therapy group, but the decrease in hs-CRP was similar. sPLA2 activity significantly decreased in the ezetimibe/atorvastatin group from 29 U/ml (interquartile range 23 to 35) to 26 U/ml (23 to 29, p = 0.001) but remained similar in the placebo/atorvastatin group (23 U/ml, 19 to 32, vs 22 U/ml, 19 to 28, p = NS). In a multivariate stepwise linear regression model, change in sPLA2 correlated with change in hs-CRP (p <0.001), baseline LDL cholesterol level (p = 0.001), body mass index (p = 0.003), diabetes mellitus (p = 0.04) and combination therapy with ezetimibe/atorvastatin (p = 0.05). In conclusion, this study demonstrates that coadministration of ezetimibe and atorvastatin decreases sPLA2 activity.

Diffuse Coronary Spasm in a Patient With a Recent Stent

The patient is a 65-year-old man who was complaining of chest pain induced by heavy exercise but sometimes occurring at rest. An exercise stress test was mildly positive electrically (1 mm ST-segment depression at 9 min of exercise and at a heart rate of 92% of the maximally predicted heart rate for

Acute effects of waterpipe smoking on blood pressure and heart rate: a real-life trial

Abstract Background: Waterpipe smoking is becoming a popular way of tobacco use in the world. Its acute effects on the cardiovascular system are not well investigated. Materials and methods: This is a trial designed to evaluate the acute effects of waterpipe smoking on blood pressure (BP) and heart rate (HR) in healthy adults. Individuals who ordered waterpipe in 6 Lebanese restaurants were enrolled (cases) and were compared to controls who consisted of subjects who were sitting at the same table of smokers but who did not smoke (passive smokers) and of subjects who were sitting in nonsmoking sections (nonsmokers). BP and HR were measured immediately before and 15u2009min after smoking or at baseline and 15u2009min later in controls. Results: A total of 194 subjects were enrolled: 101 waterpipe smokers, 51 passive smokers, and 42 nonsmokers. Systolic and diastolic BP and HR significantly increased after 15u2009min of smoking in cases (mean 3.1u2009mm Hg (95% CI 0.8–5.5; pu2009=u20090.009) for systolic BP, 2.1u2009mm Hg (95% CI 0–4.2; pu2009=u20090.053) for diastolic BP, and 6.3 beats/minute (95% CI 4.3–8.3; pu2009<u20090.001) for HR, but did not change in controls. Conclusions: Waterpipe smoking for duration as short as 15u2009min has acute hemodynamic effects and significantly increases systolic BP and HR.

The Curse of Target Lesion Calcification Still Active After All These Years

At the dawn of interventional cardiology, Andreas Gruntzig remarked that balloon angioplasty was limited by anatomic factors such as fibrotic or calcified stenoses [(1)][1]. Subsequently, in large series of patients undergoing balloon angioplasty, coronary calcification was one of the factors

Performance Deficiencies in the Treatment of ST-Elevation Myocardial Infarction in Québec: "Tis But a Part We See, and Not a Whole".

Editorial Performance Deficiencies in the Treatment of ST-Elevation Myocardial Infarction in Quebec: “Tis But a Part We See, and Not a Whole” Rabih R. Azar, MD, MPH, FACC, Zena Kadri, MD, and David D. Waters, MD, FACC Hotel Dieu de France Hospital and the St Joseph University School of Medicine, Beirut, Lebanon San Francisco General Hospital and the University of California San Francisco, San Francisco, California, USA