Vladimír Kincl

Association of coronary artery disease, erectile dysfunction,and endothelial nitric oxide synthase polymorphisms

The purpose of this study was to determine the relationship between erectile dysfunction (ED), coronary artery disease (CAD), and T−786C and intron 4 a/b endothelial nitric oxide synthase (eNOS) polymorphisms in 419 patients with suspected or known CAD referred for coronary angiography. The patients had a high prevalence of risk factors for both CAD and ED: hypercholesterolemia (64%), hypertension (74%), diabetes mellitus (25%), obesity (30%), and smoking (63%). Three hundred and twenty-one patients had significant coronary atherosclerosis (luminal diameter narrowing of 50% or more of at least 1 coronary artery), 41 had insignificant coronary stenoses, and 57 patients were found to have coronary arteries without the evidence of atherosclerosis. The prevalence of ED in these groups was 79%, 76%, and 67% (P = NS), respectively. As compared to patients without ED, those with ED exhibited significantly higher probability of having significant coronary atherosclerosis (69% vs 79%, P = 0.04), higher number of significant coronary stenoses (median, 1 vs 2, P = 0.004), and a higher prevalence of a triple-vessel disease (12% vs 25%, P = 0.004). We did not find any relationship between T−786C and intron 4 a/b polymorphisms and the manifestation of coronary atherosclerosis or the presence of ED. In conclusion, in patients with numerous cardiovascular risk factors referred for coronary angiography, there was a high prevalence of ED in patients with both the presence and the absence of coronary atherosclerosis. The coincidence of CAD and ED identified patients at increased risk of severe forms of CAD.

Matrix metalloproteinase 13 genotype in rs640198 polymorphism is associated with severe coronary artery disease.

Atherosclerosis as a main etiopathogenetic source for coronary artery disease (CAD) development is intimately related to dynamic changes in the extracellular matrix (ECM). Elevated levels of MMP-13 have been observed in human atherosclerotic plaques which could also involve variability in MMP-13 gene. The aim of the study was to associate rs640198 polymorphism with CAD and/or with its severity. The study comprised 1071 consecutive patients with suspected or known coronary artery disease (CAD), confirmed by coronary angiography. Genotyping for the rs640198 polymorphism in MMP-13 gene was performed using Taqman® assay. The TT and TG genotypes of rs640198 polymorphism in MMP-13 gene confer the significantly increased risk of triple vessel disease compared to patients without atherosclerotic lesions in coronary arteries (odds ratio = 1.64, Pcorr = 0.05). Furthermore, an increased risk of having 5 and more stenoses (odds ratio = 1.90, Pcorr = 0.004) was observed in TT and TG carriers (sensitivity of 0.613 and a specificity of 0.544; power of the test is 0.87). The T allele of MMP-13 intron polymorphism rs640198 is associated with the severity of coronary artery disease, represented by the number of affected arteries as well as by the number of stenoses confirmed by coronarography.

The prognostic impact of myocardial late gadolinium enhancement.

Cardiovascular magnetic resonance using late gadolinium enhancement (LGE) provides a unique opportunity to assess myocardial tissue in vivo. LGE enables tissue characterization in ischemic and nonischemic cardiomyopathies and other cardiac diseases. LGE is associated with adverse clinical outcomes across a range of different cardiac conditions and may improve risk stratification for death, sudden cardiac death, or serious adverse events beyond traditional prognostic markers. Generally, matching data for the prognostic impact of LGE are frequently reached in cardiac disorders. In other diseases, only a limited number of trials are available, but it is anticipated that the prognostic impact of delayed enhancement will become evident. The development and validation of new cardiovascular magnetic resonance methods for diffuse myocardial fibrosis measurements would even improve the prognostic impact of LGE. The evaluation of diffuse myocardial fibrosis has a great potential in large-scale diseases, including their initial phases, with the possibility to identify patients at risk for subsequent development of clinical heart failure, to assess repeatedly the stage and progression of cardiac diseases, and to monitor the effect of treatment.

The unique value of cardiovascular magnetic resonance in patients with suspected acute coronary syndrome and culprit-free coronary angiograms

BackgroundPatients with chest pain, elevated troponin, and unobstructed coronary disease present a clinical dilemma. The purpose of this study was to investigate the incremental diagnostic value of cardiovascular magnetic resonance (CMR) in a cohort of patients with suspected acute coronary syndrome (ACS) and unobstructed coronary arteries.ResultsData files of patients meeting the inclusion criteria in two cardiology centres were searched and analysed. The inclusion criteria included: 1) thoracic pain suspected with ACS; 2) a significant increase in the high-sensitive Troponin T value; 3) ECG changes; 4) coronary arteries without any significant stenosis; 5) a CMR examination included in the diagnostic process; 6) an uncertain diagnosis before the CMR exam; and 7) the absence of known CMR and contrast media contraindications. Special attention was paid to the benefits of CMR in determining the final diagnosis.In total, 136 patients who underwent coronary angiography for chest pain were analysed. The most frequent underlying causes were myocarditis (38%) and perimyocarditis (18%), followed by angiographically unrecognised acute myocardial infarction (18%) and Takotsubo cardiomyopathy (15%). The final diagnosis remained unclear in 6% of the patients. The contribution of CMR in determining the final diagnosis determination was crucial in 57% of the patients. In another 35% of the patients, CMR confirmed the suspicion and, only 8% of the CMR examinations did not help at all and had no influence on diagnosis or treatment.ConclusionCMR provided a powerful incremental diagnostic value in the cohort of patients with suspected ACS and unobstructed coronary arteries. CMR is highly recommended to be incorporated as an inalienable part of the diagnostic algorithms in these patients.

Left atrium assessment: the evolving role of MRI.

The left atrium plays an integral role in cardiac performance. Data regarding the left atrial size, volume, function, and structure are clinically important in the management of patients with different diagnoses. Moreover, left atrial size and function were recognized as robust predictors of poor outcome across a broad range of cardiac diseases. These data are usually obtained using echocardiography. MRI can be used as an alternative tool or in clinical or experimental situations when more exact and detailed assessment is required. In the left atrial functional analysis, MRI is considered to be a gold standard technique that overcomes many of the limitations associated with echocardiographic assessment. In comparison with the other techniques, late gadolinium enhancement provides a unique opportunity to assess left atrial myocardial tissue in vivo. Complex cardiac magnetic resonance data may help to make a diagnosis, determine a prognosis and provide an impact on therapeutic actions. This review summarizes the potential role of cardiac magnetic resonance in left atrium assessment, with special emphasis on recent data and the potential future research directions.

The Relation between eNOS -786 C/T, 4 a/b, MMP-13 rs640198 G/T, Eotaxin 426 C/T, -384 A/G, and 67 G/A Polymorphisms and Long-Term Outcome in Patients with Coronary Artery Disease.

Aim. The purpose of this study is to determine the association between eotaxin 426 C/T, −384 A/G, 67 G/A, eNOS −786 T/C, 4 a/b, and MMP-13 rs640198 G/T and prognosis of patients with known CAD. Methods. From total of 1161 patients referred to coronary angiography, 532 patients with angiographically confirmed CAD were selected. Their long-term outcome was followed up using hospital database. Subsequent events were assessed in this study: death or combined endpoint-myocardial infarction, unstable angina pectoris, revascularization, heart failure hospitalization, and cardioverter-defibrillator implantation. Results. The multivariate Cox regression model identified age, smoking, and 3-vessel disease as significant predictors of all-cause death. Further analysis showed that eotaxin 67 G/A (GA + AA versus GG) and eotaxin −384 A/G (GG versus GA + AA) were significant independent prognostic factors when added into the model: HR (95% CI) 2.81 (1.35–5.85), p = 0.006; HR (95% CI) 2.63 (1.19–5.83), p = 0.017; eotaxin −384 A/G was significantly associated with the event-free survival, but it did not provide the prognostic information above the effect of two- or three-vessel disease. Conclusion. The A allele in eotaxin 67 G/A polymorphism is associated with worse survival in CAD patients.

Prognostic value of stress-only and stress-rest normal gated SPECT imaging: higher incidence of cardiac hard events in diabetic patients who underwent full stress-rest imaging.

BACKGROUND The European procedural guidelines for cardiac gated SPECT imaging demonstrate considerable variability in recommended administered radiopharmaceutical activity and imaging protocols. This study compared stress-only and stress-rest protocols to evaluate the safety of stress-only imaging, and to identify characteristics of patients who need full stress-rest imaging. METHODS Patients referred for a chest pain were scheduled for stress-rest gated SPECT imaging. If the stress images were interpreted as normal according to the perfusion and left ventricular function, the examination of patients was finished and patients did not undergo the rest imaging. A total number of 1063 patients was included (mean age 61 ± 11 years). These patients have been followed for hard cardiac events, i.e. cardiac deaths or nonfatal myocardial infarction. RESULTS During a follow-up of 3.2 ± 2.5 years, hard events occurred in 12 patients with normal SPECT and 59 with abnormal SPECT had hard events (0.7 vs. 3.6% /year, P < 0.001). Among the 536 patients with normal study, there was no significantly lower incidence of hard events in the subgroup of patients with stress-only imaging (0.6 vs. 0.8% /year, P = 0.641). Diabetes mellitus was an independent predictor of hard events in patients with normal SPECT (1.3 vs. 0.5%/year, P < 0.001). We found a higher incidence of hard events in diabetic patients with normal study with the necessity of full stress-rest imaging in comparison with those with stress-only imaging (1.7 vs. 0.7% /year, P < 0.001). CONCLUSIONS Our results support the good prognosis of normal stress-only study. Diabetes mellitus was an independent predictor of hard events in patients with normal SPECT. Diabetic patients with normal results who required additional rest imaging had significant adverse outcome.

Assessment of the severity of acute pulmonary embolism using CT pulmonary angiography parameters.

AIM To evaluate the association between computed tomography parameters and clinical signs in patients with acute pulmonary embolism. METHODS 109 patients retrospectivelly selected from hospital database with acute pulmonary embolism verified by CT pulmonary angiography. The following parameters were assessed: pulmonary artery diameter to aorta diameter ratio (PA/Ao), normalized pulmonary artery diameter (nPA), right ventricular to left ventricular diameter ratio from CT (RV CT/LV CT), normalized end-diastolic right ventricular diameter (nRVD echo) and right to left ventricular end diastolic diameter ratio (RV echo/LV echo) from echocardiography. RESULTS Multivariate regression analysis showed a significant association between PA/Ao and thrombolysed (0.99) to non-thrombolysed (0.90) patients, OR=1.56 P=0.012, and also RV CT/LV CT and thrombolysed 1.5 to non-thrombolysed (0.94) patients OR=1.24 P=0.002. The significant difference was also found in intensive care unit hospitalization necessity (ICU-Y/N) and RV CT/LV CT ratio (ICU-Y 1.42, ICU-N 0.91) OR=1.26 P=0.003, and RV echo/LV echo (ICU-Y 0.82, ICU-N 0.65) OR=1.83 P=0.033. CONCLUSION From the CT pulmonary angiography parameters, the RV CT/LV CT showed a significant association with both thrombolysis administration and ICU hospitalization. The PA/Ao had relation only to thrombolytic therapy as well as RV echo/LV echo only to ICU hospitalization.

The long-term effects of individual cardiac rehabilitation in patients with coronary artery disease

Uvod: Pozitivni vliv kardiorehabilitace byl opakovaně popsan a je dobře znam z hlediska kratko- a střednědobeho casoveho useku. Meně je znamo o dlouhodobých ucincich u pacientů s chronickou stabilni ischemickou chorobou srdecni.Cil: Cilem prace bylo vyhodnoceni dlouhodobeho ucinku individualni kardiorehabilitace u pacientů s ischemickou chorobou srdecni.Metodika: Sto padesat dva pacientů se stabilni ischemickou chorobou srdecni bylo retrospektivně rozděleno do dvou skupin podle dodržovani doporuceni stran individualni fyzicke aktivity, bez ohledu na absolvovani vedeneho treninku kardiorehabilitace. Skupina IT+, ktera provaděla individualni trenink podle doporuceni, byla srovnavana s pacienty, kteři toto odmitli (skupina IT-). Průměrna delka sledovani dosahovala 12,7 roku.Výsledky: Individualni trenink neměl žadný vliv na delku přežiti po upravě na dalsi faktory, ale multivariantni analýza ukazala významnou souvislost mezi výskytem kardialnich přihod, jako jsou infarkt myokardu, nestabilni angina pectoris, koronarni revaskularizace a hospitalizace pro srdecni selhani: HR (95 % CI) 0,51 (0,30-0,89); p = 0,017.Zavěr: Domaci kardiorehabilitace a pravidelna fyzicka aktivita významně snižuji dlouhodobou kardialni morbiditu u pacientů s chronickou ischemickou chorobou srdecni.

Prognostic value of myocardial perfusion imaging and coronary artery calcium measurements in patients with end-stage renal disease.

OBJECTIVE Coronary artery disease (CAD) is highly prevalent in patients with end-stage renal disease (ESRD), owing to clustering of traditional and uremic-specific risk factors. However, in this population asymptomatic course of CAD is common and it has been reported that myocardial perfusion imaging (MPI) with single-photon emission tomography (SPET) has lower sensitivity. In the current study, we assessed the value of MPI gated-SPET and its combination with coronary artery calcium (CAC) score measurements in risk stratification of ESRD patients. MATERIALS AND METHODS MPI gated-SPET was performed with dual-headed SPET camera and CAC score measured by multi-detector computed tomography (MDCT) system.There were tested 77 ESRD individuals. During the follow-up study, cardiac events (CE) defined as cardiac death or nonfatal myocardial infarction (MI) or the necessity for coronary revascularization were recorded. Univariate and stepwise multivariable Cox proportional hazards-models were used to identify the predictors of CE. RESULTS Eighteen CE were recorded during the follow-up. They were significantly associated with higher summed stress scores on MPI, higher percentage of ischaemic myocardium, higher occurrence of defects in multiple territories and higher CAC score (all with P<0.05). Univariate Cox proportional hazard-models showed that severe perfusion abnormalities as well as CAC score ≥1000 were significantly associated with cardiac events (P<0.0001, P=0.0056). In stepwise Cox proportional hazards-models considering age, gender, history of diabetes mellitus, post-stress left ventricular stunning, the degree of perfusion abnormality and CAC score, only severe perfusion abnormalities and CAC score ≥1000 were independent predictors of CE. There was no CE in patients with normal perfusion, normal function and zero CAC score. CONCLUSION This study suggests that combined evaluation of MPI and CAC can predict the outcome in ESRD individuals, while severe perfusion abnormality on gated-SPET and high CAC score ≥1000 are predictors of future cardiac events.