Stephanie Maciejewski

Effect of omega-3 fatty acid supplementation on the arachidonic acid:eicosapentaenoic acid ratio.

Study Objectives. To determine the baseline arachidonic acid: eicosapentaenoic acid (AA:EPA) ratio in patients with coronary artery disease and healthy subjects, and whether supplementation of omega‐3 fatty acids, administered as fish oil capsules, affects this ratio.

Pharmacological Management of Atrial Fibrillation following Cardiac Surgery

Atrial fibrillation (AF) is the most common complication following coronary artery bypass graft surgery (CABG). Post-CABG AF occurs most commonly on the second postoperative day and declines in incidence thereafter. A number of risk factors have been found to be associated with a higher frequency of post-CABG AF. These risk factors include advanced age, a prior history of AF, hypertension, and heart failure. Postoperative complications — including low cardiac output, use of an intra-aortic balloon pump, pneumonia, and prolonged mechanical ventilation — are also associated with higher rates of post-CABG AF. Post-CABG AF increases the risk of stroke, and the length and cost of hospitalization. Prophylactic administration of conventional ≤-adrenoceptor antagonists (≤-blockers) or sotalol produces a consistent and significant reduction in the incidence of post-CABG AF; however, results with prophylactic amiodarone or magnesium are less consistent. Termination of post-CABG AF, once it occurs, can be accomplished with a number of antiarrhythmic agents. Ibutilide has been the most widely studied agent for this indication. Sotalol is not indicated for cardioversion of AF and has not been studied in the post-CABG setting. Electrical cardioversion and biatrial pacing have also been used to terminate post-CABG AF. Ventricular rate is best controlled with ≤-blockers and calcium channel antagonists. Esmolol has a rapid onset of action and is easily titrated to effect. Digoxin can control the ventricular rate, but has a slow onset of action. There are limited data available to guide decisions regarding the optimal management of post-CABG AF.

Fibrate therapy in the management of dyslipidemias, alone and in combination with statins: role of delayed-release fenofibric acid

Importance of the field: Optimization of lipid management is a crucial aspect in the treatment of cardiovascular disease. Currently, HMG-CO reductase inhibitors (statins) are a mainstay of therapy. While this class of drugs has proven efficacy at lowering low-density lipoprotein cholesterol (LDL-C), their effects on other important lipid parameters, such as high-density lipoprotein cholesterol (HDL-C) and triglycerides, are less robust. Areas covered in this review: The current paper will address the significance of these secondary targets and review currently available therapies, including a new formulation of delayed-release fenofibric acid. A comprehensive MEDLINE search (1966 to September 2009) was performed. What the reader will gain: The reader will gain a comprehensive review of the importance of secondary cholesterol targets, as well as the effectiveness of currently available therapies to address non-LDL-C. The role of the newly released fenofibric acid will also be addressed, as well as its potential use in combination therapy with a statin. Take home message: Adequate treatment of lipid parameters beyond LDL-C is an essential component in the treatment of dyslipidemia. The fibrate class of drugs has proven efficacy in improving secondary targets; however, concerns regarding severe myopathy and rhabdomyolysis have limited their combination with statins. Recently, a new fibrate derivative, fenofibric acid, has become available. Studies to date reflect a positive safety and tolerability profile when combined with statins. This may offer a new tool to address the important secondary cholesterol targets that are becoming increasingly recognized as important contributors to cardiovascular outcomes.

Impact of left atrial volume in prediction of outcome after cardiac resynchronization therapy

UNLABELLED Left atrial volume index (LAVI) as a predictor of mortality has not been well investigated in patients with cardiac resynchronization therapy (CRT). The purpose of this study is to evaluate the impact of LAVI in predicting mortality in CRT patients. METHODS We studied 100 consecutive patients who received CRT (male 73, age 69.9 ± 9.6 years). The follow-up duration of all echocardiographic measurements was 14.4 ± 10.5 months after CRT. LAVI was measured from apical views on two-dimensional echocardiography by bi-plane rule. A decrease of left ventricular end systolic volume ≥ 15% after CRT was defined as a positive response to CRT. RESULTS The mean LAVI at baseline was 59.9 ± 22.7 ml/m(2). LAVI in patients who died (78.2 ± 27.5 ml/m(2)) was significantly greater than those who survived (55.9 ± 19.5 ml/m(2), p<0.0001) during follow-up of 17 ± 10.6 months. The area under ROC curve (AUC) for LAVI predicting death was 0.77 (p=0.0001). The cutoff point for LAVI predicting death was LAVI>59.4 ml/m(2). LAVI>59.4 ml/m(2) was related to mortality by Cox proportional univariate regression [hazard ratio (HR)=5.15, 95% CI=1.48-17.93, p=0.01]. After adjustment for the variables with significant difference by univariate regression, LAVI>59.4 ml/m(2) was continuously related to mortality by multivariate regression (HR=4.56, 95% CI, 1.30-15.97, p=0.02). LAVI>59.4 ml/m(2) was associated with a near 5-fold increase in mortality during follow-up of 17 ± 10.6 months. CONCLUSION Patients who have LAVI>59.4 ml/m(2) continue to have increased mortality despite CRT.

Effectiveness of a fenofibrate 145-mg nanoparticle tablet formulation compared with the standard 160-mg tablet in patients with coronary heart disease and dyslipidemia.

Study Objective. To compare the effectiveness of a fenofibrate 145‐mg nanoparticle tablet formulation with the standard 160‐mg tablet in patients with dyslipidemia and coronary heart disease.

Thoracic aortic atheroma severity predicts high-risk coronary anatomy in patients undergoing transesophageal echocardiography.

Introduction We hypothesized a relationship between severity of thoracic aortic atheroma (AA) and prevalence of high-risk coronary anatomy (HRCA). Material and methods We investigated AA diagnosed by transesophageal echocardiography and HRCA diagnosed by coronary angiography in 187 patients. HRCA was defined as ≥ 50% stenosis of the left main coronary artery or significant 3-vessel coronary artery disease (≥ 70% narrowing). Results HRCA was present in 45 of 187 patients (24%). AA severity was grade I in 55 patients (29%), grade II in 71 patients (38%), grade III in 52 patients (28%), grade IV in 5 patients (3%), and grade V in 4 patients (2%). The area under receiver operating characteristic curve for AA grade predicting HRCA was 0.83 (p = 0.0001). The cut-off points of AA to predict HRCA was > II grade. The sensitivity and specificity of AA > grade II to predict HRCA were 76% and 81%, respectively. After adjustment for 10 variables with significant differences by univariate regression, AA > grade II was related to HRCA by multivariate regression (odds ratio = 7.5, p< 0.0001). During 41-month follow-up, 15 of 61 patients (25%) with AA >grade II and 10 of 126 patients (8%) with AA grade ≤ 2 died (p= 0.004). Survival by Kaplan-Meier plot in patients with AA > grade II was significantly decreased compared to patients with AA ≤ grade II (p= 0.002). Conclusions AA > grade II is associated with a 7.5 times increase in HRCA and with a significant reduction in all-cause mortality.

Randomized, double-blind, crossover comparison of amlodipine and valsartan in african-americans with hypertension using 24-hour ambulatory blood pressure monitoring.

Study Objective. To compare the efficacy of amlodipine and valsartan in African‐American patients with hypertension using ambulatory blood pressure monitoring (ABPM).

Evaluation of left ventricular dyssynchrony using combined pulsed wave and tissue Doppler imaging

Introduction The combination of pulsed wave (PW) and tissue Doppler imaging (TDI) has been proposed as a new method to assess left ventricular (LV) mechanical dyssynchrony (LVMD), but results have not been validated. We investigated the correlation of a combination of PW and TDI with a positive response to cardiac resynchronization therapy (CRT). Material and methods We studied 108 consecutive patients who received CRT. Patients with atrial fibrillation were excluded. The time difference (TPW-TDI) between onset of QRS to the end of LV ejection by PW (TPW) and onset of QRS to the end of the systolic wave in LV basal segments with greatest delay by TDI (TTDI) was measured before CRT and during short-term and long-term follow-up. Results The TPW-TDI interval before CRT was 74 ±48 ms. Intra-observer variabilities for TPW and TTDI were 1.5 ±0.24% and 1 ±0.17%. Inter-observer variabilities for TPW and TTDI were 1 ±0.36% and 1 ±0.64%, respectively. TPW-TDI > 50 ms was defined as the cutoff value for diagnosis of LVMD by receiver operating curve (ROC) analysis. During follow-up of 15 ±11 months, the sensitivity and specificity of TPPW-TDI to predict a positive response to CRT were 98% and 82%, respectively. The area under the ROC curve was 0.92. There was a significant agreement between LVMD determined by TPW-TDI and the positive response to CRT (κ=0.80). Conclusions Left vertricular dyssynchrony detected by the method combining PW and TDI demonstrated a high reproducibility, sensitivity, specificity and agreement with a positive response to CRT.

A new baseline scoring system may help to predict response to cardiac resynchronization therapy

Introduction The PROSPECT trial reported no single echocardiographic measurement of dyssynchrony is recommended to improve patient selection for cardiac resynchronization therapy (CRT). Material and methods In 100 consecutive patients who received CRT, we analyzed 27 ECG and echocardiographic variables to predict a positive response to CRT defined as a left ventricular (LV) end systolic volume decrease of ≥ 15% after CRT. Results Right ventricular (RV) pacing-induced left bundle branch block (LBBB), time difference between LV ejection measured by tissue Doppler and pulsed wave Doppler (TTDI-PW), and wall motion score index (WMSI) were significantly associated with positive CRT response by multivariate regression. We assigned 1 point for RV pacing-induced LBBB, 1 point for WMSI ≤ 1.59, and 2 points for TTDI-PW > 50 ms. Overall mean response score was 1.79 ±1.39. Cutoff point for response score to predict positive response to CRT was > 2 by receiver operating characteristic (ROC) analysis. Area under ROC curve was 0.97 (p = 0.0001). Cardiac resynchronization therapy responders in patients with response score > 2 and ≤ 2 were 36/38 (95%) and 7/62 (11%, p < 0.001), respectively. After age and gender adjustment, the response score was related to CRT response (OR = 45.4, p < 0.0001). Conclusions A response score generated from clinical, ECG and echocardiographic variables may be a useful predictor for CRT response. However, this needs to be validated.

Are the extent, location, and score of segmental wall motion abnormalities related to cardiac resynchronization therapy response?

Background: We hypothesized that segmental wall motion abnormalities (WMAs) are related to cardiac resynchronization therapy (CRT) response. Methods: We studied 108 patients who received CRT, 69 with ischemic and 39 with nonischemic heart disease. A wall motion score index (WMSI) was analyzed using a 17‐segment model and calculated by the total score/number of segments analyzed. A decrease of left ventricular end systolic volume ≥15% after CRT was defined as a positive response to CRT. Results: Of 108 patients, 1,054/1,836 segments (57%) had WMAs. The mean WMSI was 2.06 in patients with ischemic heart disease and 1.04 in patients with nonischemic heart disease (P < 0.0001). The area under the receiver operating characteristic curve for a WMSI predicting a positive response to CRT was 0.70 (P = 0.0001). The cutoff point was a WMSI ≤2 for prediction of a positive response to CRT. After adjustment for age, gender, and clinical features, the WMSI persistently related to CRT responders (P = 0.01). During 15‐month follow‐up, the percentage of CRT nonresponders in patients with a WMSI >2 was significantly higher (82%) compared to patients with a WMSI ≤2 (47%, P = 0.005) and nonischemic heart disease (36%, P < 0.001). In 59 patients with left ventricular mechanical dyssynchrony, the percentage of negative responders to CRT in patients with a WMSI >2, ≤2, and nonischemic heart disease were 53% (8 of 15), 16% (3 of 19) and 0% (0 of 25), respectively (P < 0.001). Conclusions: A large extent of WMAs and a WMSI >2 predicted a poorer CRT response. (ECHOCARDIOGRAPHY, Volume 26, November 2009)