Treatment of heart failure: guidelines compared to clinical practice

Last decade brought great development in the treatment of patients with heart failure (HF). General use of angiotensin-converting-enzyme inhibitors (ACE-I) in patients with asymptomatic left ventricular dysfunction or with HF significantly reduced morbidity and mortality. The aim of this study was to assess how the specialists from Cardiology Department and Gastroenterology Department think that heart failure should be managed, how they implement their knowledge and if it is consistent with the recommendation of European Society of Cardiology (ESC) and whether differences exists in practice between specialists. In the first phase the specialists, cardiologists and diabetologists, answered the questions about the management of different stages of HF. In second phase we analysed medical documentation of 345 patients aged between 38 and 98 years, hospitalised in Cardiology and Gastroenterology Departments from October 2000 to February 2002 by reason of coronary artery disease, hypertension and dilated cardiomyopathy. In the third phase we compared the knowledge of heart failure management from questionnaire and its implementation, the compliance with ESC recommendation and finally whether differences in clinical practice exist between cardiologist and diabetologists. RESULTS: ACE-I were prescribed in all NYHA classes of HF. In over 50% patients in II NYHA class to 94% in IV NYHA class in Cardiology Department. Differences between the Departments in prescribing of ACE-I were observed. Beta-blockers (BB) were used with the same frequency in all NYHA classes, more often in Cardiology Department. Frequency of the administration of digoxin, diuretics, aldosterone receptor blocker was increasing starting with II NYHA class. The highest compliance between declarations from questionnaire and clinical practice concerned the use of BB and ACE-I combination.     

IgG from patients with antiphospholipid syndrome binds to platelets without induction of platelet activation

The clinical manifestations of the antiphospholipid syndrome (APLS) include arterial and venous thrombosis, thrombocytopenia and fetal loss, but the pathogenic mechanisms remain unclear. It has been hypothesized that platelet activation by autoantibody may be a pathogenic mechanism. We studied IgG binding, microparticle (mp) formation and P-selectin expression by flow cytometry in normal platelets after incubation in serum from 11 patients with antiphospholipid antibodies and that from 10 normal healthy subjects. Levels of platelet-associated IgG were significantly higher after incubation in patient sera (mean 17.2, range 2.0–75.0%) compared with normal sera (mean 2.0, range 1.2–3.7%, P  < 0.05). Incubation of normal platelets in serum led to increased microparticle formation ( P  < 0.01) and P-selectin expression ( P  < 0.05), compared with unstimulated platelets. There was no significant difference, however, between microparticle formation nor P-Selectin expression induced by patient serum (mp 3.0 (1.6–5.0)%; P-selectin 8.0 (4.0–16.6)%) versus normal serum (mp 3.2 (2.1–4.5)%; P-selectin 10.1 (4.0–15.6); median (range)). Pre-activation of platelets with subthreshold ADP concentrations or thrombin receptor activator peptide resulted in a small increase in microparticle formation, but there was still no significant difference between the effects of patient and control sera. Despite the presence of platelet membrane binding IgG in serum from 5/11 patients with antiphospholipid antibodies, there was no evidence for associated enhanced platelet-activating ability. This study supports antiplatelet reactivity in antiphospholipid syndrome, but not a direct platelet-activating role for platelet-directed autoantibodies.     

Association of the ScaI atrial natriuretic peptide gene polymorphism with nonfatal myocardial infarction and extent of coronary artery disease

Background There is growing evidence from recent studies that atrial natriuretic peptide (ANP) plays an important part in coronary blood flow regulation and in atherosclerosis. Transition T2238→C in the atrial natriuretic peptide (ANP) precursor gene, which leads potentially to the translation of ANP with 2 additional arginines, has been suggested to be associated with salt-sensitive hypertension. According to our knowledge, this study is the first to look for the potential association of the ScaI ANP gene polymorphism with the history of nonfatal myocardial infarction and the extent of coronary artery disease (CAD).Methods The study was performed in 847 consecutive, white patients (719 men and 128 women) with significant coronary artery stenosis confirmed by means of elective coronary angiography (at least 1 coronary artery with ≥50% lumen narrowing). Screening for the T2238→C substitution was performed by means of polymerase chain reaction of genomic DNA, followed by ScaI digestion and agarose gel electrophoresis.Results We found a significant association of the A2A2 ScaI ANP genotype with a higher incidence of positive history of nonfatal myocardial infarction (odds ratio 1.85, 95% CI 1.33-2.58) and multiple-vessel CAD (odds ratio 1.45, 95% CI 1.02-2.06). The ScaI ANP genotype distribution did not differ with age, sex, body mass index, plasma lipids, hypertension, diabetes mellitus, and family history of CAD in studied groups.Conclusions Our results suggest that the ScaI ANP polymorphism may be associated with nonfatal myocardial infarction and the extent of CAD. However, the precise mechanism of this association remains to be determined. (Am Heart J 2003;145:125-31.)     

Percutaneous peripheral interventions in patients with non-ST elevation acute coronary syndromes performed by interventional cardiologists: rationale and results

BACKGROUND: The coexistence of peripheral artery disease (PAD) and multilevel atherosclerosis increases death and stroke rates in patients with coronary artery disease (CAD). Due to many comorbidities these patients are often treated conservatively without revascularisation. AIM: To investigate whether complex percutaneous cardiovascular interventions for CAD and PAD may improve prognosis and long-term outcome in this group of patients. METHODS: We studied consecutive patients treated for symptomatic CAD who also had chronic PAD. The primary cause of hospital admission for all our patients was non-ST elevation acute coronary syndrome (NSTE ACS). All percutaneous peripheral interventions were performed during one hospital stay (index hospitalisation). Major adverse cardio- and cerebrovascular events (MACCE) during follow-up were defined as follows: death (cardiac and non-cardiac), myocardial infarction (MI), urgent revascularisation (surgical or repeat PCI, peripheral percutaneous intervention), stroke/TIA or amputation. RESULTS: We performed 109 interventions in 78 consecutive patients with chronic peripheral artery stenoses and occlusions. The average age was 61.5+/-8.6 years and the majority were males (80%). Preinterventional angiography showed occlusions that involved the common iliac artery in 28 (36%) patients, the external iliac artery in 16 (21%) patients, internal iliac artery in 2 (3%) patients, and superficial femoral artery in 63 (81%) patients. Stenting was performed in half of the patients with a mean stent length of 69.6+/-50.3 mm. An average number of 1.24+/-0.55 stents was used for each lesion. During a mean follow-up of 18 months (range 4 to 42), there were 4 deaths, 3 MIs, 13 repeated percutaneous peripheral interventions due to restenosis in previously treated peripheral lesions, two urgent coronary interventions, two ischaemic strokes, two TIAs and one amputation. The combined follow--up MACCE end-point occurred in 32% of patients. CONCLUSIONS: Patients with concomitant CAD and PAD could safely undergo percutaneous cardiovascular and peripheral interventions. Multilevel intervention is associated with a promising long-term follow-up.     

The Shear Stress Determination in Tubular Specimens under Torsion in the Elastic–Plastic Strain Range from the Perspective of Fatigue Analysis

The comparison of shear stress determination methods in tubular specimens under torsion is presented in this paper. Four methods were analyzed: purely elastic solutions, purely plastic solutions, the midsection approach, and the Chaboche nonlinear kinematic hardening model. Using experimental data from self-designed and conducted fatigue experiments, an interesting insight on this problem was obtained that is not often tackled in the literature. It was shown that there are differences in determined shear stress values, and their level depends on a few factors. The midsection approach and purely plastic solution gave values of surface shear stress very close to the values obtained using the Chaboche nonlinear kinematic hardening model for high strain levels. The purely elastic solution gave proper results for the low strain ranges, close to the cyclic yield limit. Since none of the methods can be trusted in the full range of loading, an important conclusion from these analyses regards the formulated ranges of their applicability. It was also shown that the calculated values of shear stress and plastic and elastic strain energy density determined on this basis have a strong impact on fatigue life predictions. Finally, the influence of predicted values of shear stresses on the interpretation of cyclic hardening phenomena was also presented.     

Induction of immediate early genes expression in the mouse striatum following acute administration of synthetic cathinones

BackgroundSynthetic cathinones (SCs) form one of the most prominent group of the New Psychoactive Substances. SCs enhance central dopaminergic and noradrenergic neurotransmission, and are used as substitutes for illicit psychostimulants, namely cocaine, amphetamine, and methamphetamine. Changes in the expression of immediate early genes (IEGs) in the striatum underlie the addictive potential of drugs of abuse belonging to distinct pharmacologic groups. This work was aimed to assess the impact of acute administration of the prominent SCs on the mRNA levels of IEGs in the mouse striatum.MethodsEffects of 3,4-MDPV, 2,3-MDPV, α-PVP, PV8, PV9, methcathinone (MC) and 3-fluoromethcathinone (3-FMC) on the mRNA levels of ten IEGs, one and two hours after exposure, were measured in the mouse striatum using the quantitative RT-PCR technique.ResultsAll SCs used in the study produced increased mRNA levels of the following IEGs: Areg, c-fos, Csrnp1, Dusp1, Dusp14, Egr2, Egr4 and FosB. Additionally, the majority of SCs increased the expression of Homer1 and c-jun. The magnitude of observed changes varied by the drug, analyzed gene and, in many cases, by time after administration.ConclusionsThis study demonstrates that SCs increase the expression of IEGs in the mouse striatum, which may lead to a plethora of effects, as proteins encoded by the analyzed genes are involved in diverse actions, including an acute response to the drug and the neuroplasticity underlying the development of addiction.