Ravindra Bhardwaj

Effect of intensive lifestyle changes on endothelial function and on inflammatory markers of atherosclerosis.

Intensive lifestyle changes have been shown to regress atherosclerosis, improve cardiovascular risk profiles, and decrease angina pectoris and cardiac events. We evaluated the influence of the Multisite Cardiac Lifestyle Intervention Program, an ongoing health insurance-covered lifestyle intervention conducted at our site, on endothelial function and inflammatory markers of atherosclerosis in this pilot study. Twenty-seven participants with coronary artery disease (CAD) and/or risk factors for CAD (nonsmokers, 14 men; mean age 56 years) were enrolled in the experimental group and asked to make changes in diet (10% calories from fat, plant based), engage in moderate exercise (3 hours/week), and practice stress management (1 hour/day). Twenty historically (age, gender, CAD, and CAD risk factors) matched participants were enrolled in the control group with usual standard of care. At baseline endothelium-dependent brachial artery flow-mediated dilatation (FMD) was performed in the 2 groups. Serum markers of inflammation, endothelial dysfunction, and angiogenesis were performed only in the experimental group. After 12 weeks, FMD had improved in the experimental group from a baseline of 4.23 + or - 0.13 to 4.65 + or - 0.15 mm, whereas in the control group it decreased from 4.62 + or - 0.16 to 4.48 + or - 0.17 mm. Changes were significantly different in favor of the experimental group (p <0.0001). Also, significant decreases occurred in C-reactive protein (from 2.07 + or - 0.57 to 1.6 + or - 0.43 mg/L, p = 0.03) and interleukin-6 (from 2.52 + or - 0.62 to 1.23 + or - 0.3 pg/ml, p = 0.02) after 12 weeks. Significant improvement in FMD, C-reactive protein, and interleukin-6 with intensive lifestyle changes in the experimental group suggests > or = 1 potential mechanism underlying the clinical benefits seen in previous trials.

Incremental Value of Live/Real Time Three-Dimensional Transthoracic Echocardiography in the Assessment of Right Ventricular Masses

This case series demonstrates the incremental value of three‐dimensional transthoracic echocardiography (3D TTE) over two‐dimensional transthoracic echocardiography (2D TTE) in the assessment of 11 patients with right ventricular (RV) masses or mass‐like lesions (three cases of RV thrombus, one myxoma, one fibroma, one lipoma, one chordoma, and one sarcoma and three cases of RV noncompaction, which are considered to be mass‐like in nature). 3D TTE was of incremental value in the assessment of these masses in that 3D TTE has the capacity to section the mass and view it from multiple angles, giving the examiner a more comprehensive assessment of the mass. This was particularly helpful in the cases of thrombi, as the presence of echolucencies indicated clot lysis. In addition, certainty in the number of thrombi present was an advantage of 3D TTE. Also, sectioning of cardiac tumors allowed more confidence in narrowing the differential diagnosis of the etiology of the mass. In addition, 3D TTE allowed us to identify precise location of the attachments of the masses as well as to determine whether there were mobile components to the mass. Another noteworthy advantage of 3D TTE was that the volumes of the masses could be calculated. Additionally, the findings by 3D TTE correlated well with pathologic examination of RV tumors, and some of the masses measured larger by 3D TTE than by 2D TTE, which was also validated in one case by surgery. As in the case of RV fibroma, another advantage was that 3D TTE actually identified more masses than 2D TTE. RV noncompaction was also well studied, and the assessment with 3D TTE helped to give a more definitive diagnosis in these patients.

Embolization of Atrial Septal Occluder Device into the Pulmonary Artery: A Rare Complication and Usefulness of Live/Real Time Three-Dimensional Transthoracic Echocardiography

Percutaneous closure of atrial septal defects (ASD) in adults has emerged as an alternative to surgery. We report a rare complication of an atrial septal occluder device embolization into the pulmonary artery which was detected by fluoroscopy and echocardiography. The potential usefulness of live/real time three‐dimensional transthoracic echocardiography in the management of patients undergoing percutaneous ASD occlusion is described. (ECHOCARDIOGRAPHY, Volume 26, July 2009)

Differential Diagnosis of Acute Pericarditis From Normal Variant Early Repolarization and Left Ventricular Hypertrophy With Early Repolarization: An Electrocardiographic Study

Background:Differentiation of ST-segment elevation on electrocardiogram (ECG) from acute pericarditis (AP), normal variant early repolarization (ER) and early repolarization of left ventricular hypertrophy (ERLVH) can be problematic. Hence, the authors evaluated the accuracy of the ST/T ratio in ECG to more optimally differentiate between AP, ST-segment elevation, ER and ERLVH. Methods:Between September 2006 and July 2010, 80 patients were enrolled in this study consisting of 25 individuals with AP, 27 with ER and 28 with ERLVH. Each ECG was analyzed in a systematic manner including the measurement of PR interval, QRS duration, QT-segment duration, PR-segment deviation, ST-segment deviation and the height of T wave. The ratio of the height of ST segment to the height of T wave was measured in leads I, II, III, aVF and V2 through V6. Results:The mean ages of the patients with AP, ER and ERLVH were 32 ± 16.5, 36 ± 15.4 and 53 ± 16 years, respectively. The ratio of the amplitude of ST segment to the amplitude of the T wave in leads I, V4, V5 and V6 proved to be a significant discriminator at a value of ≥0.25 (P < 0.05 for all). Conclusions:Leads I, V4, V5 and V6 can all be used to differentiate AP from ER and ERLVH. When ST elevation is present in lead I, the ST/T ratio has the best predictive value (0.82) to more accurately discriminate between AP, ER and ERLVH.

Left ventricular noncompaction: A rare disorder in adults and its association with 1p36 chromosomal anomaly†

We report on a case of a 25‐year‐old male with 1p36 deletion syndrome, who was diagnosed with left ventricular noncompaction (LVNC). The association of this rare chromosomal abnormality with LVNC is reported in the pediatric literature, but it has not previously been specifically reported in adults. It is important to diagnose this unclassified cardiomyopathy in the adult population with this chromosomal abnormality for appropriate management and treatment as highlighted in our case.

Diastolic dysfunction following HIV infection.

The development of myocardial dysfunction in patients following HIV infection continues to be widely reported [1–6]. Compelling evidence of surprisingly frequent diastolic dysfunction followed by systolic dysfunction is observed in both the pediatric and adult populations [1–6]. Basic mechanisms proposed to explain these clinical observations include direct effects of HIV proteins, or indirect effects of cytokines, co-infection, autoimmunity and antiretroviral toxicity [1,7]. The advent of highly active antiretroviral therapies (HAART) has prolonged survival, but has been considered a potential source of cardiovascular complications of HIV infection [1]. Recent clinical studies in countries lacking universal access to HAART have provided some insights into the relative importance of HIV infection as opposed to its pharmacotherapy in HIV cardiomyopathy. These recent studies indicate that HIV cardiomyopathy is more prevalent among patients with HIV alone compared with those patients with HIV who also received HAART [1–6]. Thus, HIV infection appears to contribute more to HIV cardiomyopathy than does its treatment. Human autopsy data identifying gp120 in the hearts of HIV cardiomyopathy patients prior to HAART also support its potential pathogenic role in this condition [8].

Two-Dimensional Echocardiographic Findings of Pulmonary Valve Cyst Secondary to Pulmonary Valvuloplasty

Real time two‐dimensional transthoracic and transesophageal echocardiography demonstrated a mobile echolucent mass attached to the pulmonary valve in a 25‐year‐old adult, 20 years following balloon pulmonary valvuloplasty. The mass was surgically excised and pathology showed it to be a cyst.

Comorbidities of Chronic Complete Right Bundle Branch Block and Correlations With Coronary Angiographic Findings

Background This is a prospective, observational review of medical records to investigate the associated comorbidities and angiographic anatomy in patients with chronic right bundle branch block (RBBB). Methods The analyses of 32,345 consecutive electrocardiograms (EKGs) between October 2010 and January 2012 revealed 583 patients with RBBB. The common comorbidities associated with RBBB were hypertension (82%), diabetes (42%), coronary artery disease (CAD) (44%), valvular heart disease (aortic—16% and mitral—17%) and pulmonary disease (33%). Demographic data including age, sex, EKG and associated comorbidities were analyzed from the medical records. Coronary angiograms within 6 months of EKG in patients with RBBB were available for 184 patients and were accordingly analyzed for significant obstructive CAD. Results In all, 33 patients had single‐vessel disease, 52 patients had 2‐vessel disease, and 87 patients had multivessel disease whereas 12 patients had no significant disease. Left anterior descending artery was the most frequent vessel involved (72%) followed by left circumflex (58%) and right coronary artery (53%). Conclusions In conclusion, in chronic RBBB, wherever the angiograms were available, CAD predominantly involved left anterior descending artery. Most common associated comorbidities in chronic RBBB were systemic hypertension and CAD.

Acute effects of diets rich in almonds and walnuts on endothelial function

Objective Omega-3 fatty acids, especially alpha-linolenic acid (ALA), which are present in nuts may reduce cardiovascular disease (CVD) risk, by changing vascular inflammation and improving endothelial dysfunction. The objective of the study was to evaluate the acute effects of two different diets, one containing walnuts and the other almonds on endothelial function. Methods Twenty-seven overweight volunteers underwent a randomized 2-period, crossover, controlled intervention study. The subjects were given either walnut or almond diets which varied in monounsaturated fatty acid (MUFA) and polyunsaturated fatty acid (PUFA) content. The walnut diet provided 23.1% energy from PUFA and the almond diet provided 7.6% energy from PUFA. Endothelial function was assessed physiologically by flow-mediated dilation (FMD) and biochemically by sVCAM (soluble vascular cell adhesion molecules). Results The walnut diet significantly improved FMD (p = 0.004) and decreased sVCAM (p = 0.009) whereas the almond diet tended to improve FMD (p = 0.06) and significantly decreased sVCAM (p = 0.004). Conclusion Both walnut and almond diets improved FMD and sVCAM and there was no significant difference in physiological and biochemical markers between the two diets.

ENHANCED EXTERNAL COUNTER PULSATION IMPROVES ENDOTHELIAL FUNCTION, INFLAMMATORY MARKERS AND DEPRESSION.

Background: Endothelial dysfunction is the earliest and most important factor in the pathogenesis of atherosclerosis. Inflammation has been shown to contribute to endothelial dysfunction. EECP has been shown to improve endothelial function besides symptomatic benefit in patients with refractory angina. In this patient population, depression has an unfavorable impact on mortality. We evaluated the effect of EECP on endothelial function, inflammatory markers of atherosclerosis and depression.