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Query: UMLS:C0022116 (ischemia)
 91,303 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

The authors describe a rare case of pulmonary thromboembolism with unusual clinical findings and emphasized the large difficulty encountered in formuling a correct diagnosis in a reasonable time. A man, 60 years old, was admitted to a Medical Division of our hospital for the appearance of chest pain and epigastric pain during effort in the last year. He smoked 20 cigarettes a day and drank wine (1 or 2 litres a day). He was affected by hypercholesterolemia and in the past reported relapsed thrombophlebitis in the left leg. Four years before admission to our hospital he underwent large and small left saphenectomy. He had no cardiac events in the past. After a non significant exercise stress test the patient was treated with nitrates and asa and was discharged from the hospital. At home the symptoms increased and after 8 months the patient was admitted again to the Cardiologic Division of the hospital. At admission he reported dyspnea and chest pain at rest, not only during effort and the ECG showed negative T waves in anterior and inferior leads. Intravenous heparine, nitrates and calcium antagonists stabilized the clinical picture. The following examinations revealed: reduction of the T wave negativity at the ECG registered during chest pain; mild enlargement of the heart at the chest roentgenogram; normal value of the left ventricle and apical and midseptal by ipokinesia at the transthoracic echocardiogram; normal coronary artery at the coronary arteriography. "Vasospastic angina" was diagnosed and the patient was discharged after 20 days, asymptomatic. After 15 days he returned to the hospital again for chest pain, dyspnea, hypotension and syncope despite therapy. At physical examination he showed a painful left tibio-tarsal tumefaction, an increased and splitting second heart sound in the pulmonary area and a systolic murmur in the third and fourth left interspace. The ECG showed a severe anterior ischemia, while a new transthoracic echocardiogram revealed a considerable dilatation of the right atrium, right ventricle and the main pulmonary artery with severe tricuspid regurgitation and pulmonary hypertension (mean PAP about 50 mmHg). The following pulmonary perfusion scintigraphy confirmed the diagnosis of pulmonary embolism and the selective right and left pulmonary arteriography exhibited multiple thrombi and large intravascular filling defects. The right heart catheterization confirmed a chronic precapillary pulmonary hypertension (mean PAP = 55 mmHg). About 24 hours after these examinations the patient died because of a cardiac arrest with electromechanical dissociation. Pulmonary thromboembolism is a potentially fatal disease characterized by a largely variable clinical presentation. Frequently pulmonary embolism diagnosis is difficult especially when clinical findings are unusual. In the case observed the "typical" chest and epigastric pains associated with the electrocardiographic findings directed diagnosis towards myocardial ischemia. Also after the coronary arteriography that showed normal coronary artery, the erroneous diagnosis persisted. Pulmonary embolism was correctly diagnosed too late to begin an effective therapy. These unusual clinical findings and diagnostic mistakes are stressed and critically reviewed in the article.
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PMID:[Pulmonary thromboembolism. A clinical case with unusual presentation]. 871 Jan 39

Impaired vasomotor function has been suggested as playing a role in the pathophysiology of hypertension, diabetes, hypercholesterolemia, and atherosclerosis, all of which are common in cardiovascular surgery patients. In addition to chronic vasomotor dysfunction, alterations in vasomotor tone can result in acute arterial spasm, microcirculatory ischemia, and wide variations in systemic blood pressure. Changes in the health of the vascular endothelium may also impact the late patency of coronary artery bypass grafts, the progression of atherosclerosis in the native coronary circulation, and the long-term success of cardiac transplants. In the resting state the endothelium produces several substances that promote vascular relaxation and inhibition of platelet function, thus assuring the unhindered flow of blood through the capillaries. In response to injury, the endothelium loses some capacity to relax and also releases powerful vasoconstrictive agents. Attempting to understand the contributions that these substances play in the vasomotor dysfunction seen after cardiothoracic surgery is an area of active investigation.
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PMID:Endothelial cell injury in cardiovascular surgery: the pathophysiology of vasomotor dysfunction. 882 28

Hypercholesterolemia impairs arteriolar dilatation, but whether the vascular abnormalities accompanying this condition include large artery function is unknown. We addressed this issue in 13 normotensive subjects with familial hypercholesterolemia (serum cholesterol 401.6 +/- 16.9 mg/dl, mean +/- S.E., FHC) and no evidence of atherosclerotic lesions, in whom radial artery (RA) diameter and blood pressure (BP) were measured beat to beat by an echotracking and a Finapres device, respectively. RA compliance (RAC) was derived from the diameter/BP relationship and expressed over the systo-diastolic BP range, both at baseline and after a 12-min brachial artery occlusion. RAC was expressed also as the area under the RAC/BP curve divided for pulse BP. Measurements included maximal forearm blood flow (plethysmography) and minimal forearm vascular resistance (FVR) which were obtained from the values following the 12-min brachial arterial occlusion. Data were collected before and after 6- and 24-month lipid lowering treatment (simvastatin 40 mg/day). Ten age-matched normotensive normocholesterolemic healthy subjects (N) served as controls. Compared to N, baseline RAC was strikingly reduced in FHC (-53.5%, P < 0.01). After ischemia RAC increased significantly and markedly in N (+38.7, P < 0.01), while only a modest and non-significant increase was observed in FHC. Minimal FVR was markedly higher in FHC than in N (3.5 +/- 0.9 vs 1.6 +/- 0.1 units, P < 0.01). In FHC (7 subjects) RAC remained unchanged after 6 months of lipid lowering treatment, but increased markedly (+55.2%, p < 0.05) when treatment was prolonged to 24 months. Lipid lowering treatment also reduced minimal FVR, the effect being significant both after 6 and after 24 months. No changes in RAC and minimal FVR were seen after 6 months in controls. Thus, in subjects with a marked increase in serum cholesterol due to FHC, not only arteriolar dilatation, but also RAC and distensibility are markedly impaired. This impairment can be favourably affected by an effective lipid lowering treatment of long duration.
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PMID:Impaired radial artery compliance in normotensive subjects with familial hypercholesterolemia. 883 Sep 37

To evaluate the effects of short-term cholesterol-lowering treatment on myocardial effort ischemia, 22 patients with stable effort ischemia and mild to moderate hypercholesterolemia (low density lipoprotein [LDL] cholesterol 160 to 220 mg/dl) were randomly allocated at baseline (TO) in 2 groups. Group A included 12 patients treated with simvastatin 10 mg bid; group B included 10 patients treated with placebo. All patients underwent a treadmill electrocardiography (ECG) test; total cholesterol, HDL and LDL cholesterol, triglycerides, plasma, and blood viscosity were measured. All tests were repeated after 4 and 12 weeks. For 18 of the same patients (11 taking simvastatin, 7 receiving placebo), forearm strain-gouge plethysmography was performed at baseline and after 4 weeks, both at rest and during reactive hyperemia. At 4 and 12 weeks, group A showed a significant reduction in total cholesterol (p <0.05) and LDL (p <0.05), with unchanged HDL, triglycerides, blood, and plasma viscosity. Effort was unmodified, ST-segment depression at peak effort and ischemic threshold were significantly improved after 4 and 12 weeks (all p <0.05) with unchanged heart rate x systolic blood pressure product. A significant increase in the excess flow response to reactive hyperemia was detected in group A (p <0.03); group B showed no changes in hematochemical and ergometric parameters. These data suggest that cholesterol-lowering treatment is associated with an improvement in myocardial effort ischemia; this might be explained by a more pronounced increase of coronary blood flow and capacity of vasodilation in response to effort.
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PMID:Effects of short-term reduction in serum cholesterol with simvastatin in patients with stable angina pectoris and mild to moderate hypercholesterolemia. 885 79

Acute coronary syndromes are responsible for more than half a million hospital admissions each year in the United States alone. Plaque rupture is the precipitating pathophysiologic event. The degree of narrowing of plaques that rupture is not necessarily severe, in the range of 30% to 70% diameter stenosis. Plaques containing large lipid pools with only thin fibrous caps are most at risk. The site of rupture is most often at the shoulder of the plaque, where stress is highest. Clusters of macrophages are often seen at these points. Most plaque ruptures heal without causing symptoms, perhaps leaving a narrowing somewhat more severe than before. Plaque ruptures that expose larger areas of thrombogenic intramural debris to flowing blood in areas of high turbulence are most likely to provoke more extensive thrombosis. Risk factors, particularly smoking and hypercholesterolemia, cause increased thrombin deposition at the site of deep arterial injury. Thrombin deposition causes local coronary vasoconstriction that may contribute to the development of ischemia. Whether plaque rupture with thrombosis causes infarction, unstable angina, or no symptoms at all depends on the site of the lesion, its severity, and whether the jeopardized myocardium is served by collaterals. Aspirin, heparin, and, potentially, the newer agents provide benefit in each of the acute coronary syndromes.
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PMID:Pathophysiology and initial management of the acute coronary syndromes. 887 45

In 80 patients (pts) with an uncomplicated myocardial infarction (MI) the rate of major cardiac events (MACE) including cardiac death, non-fatal myocardial infarction and recurrent ischemia requiring hospitalization was prospectively assessed over a mean follow-up period of 17 +/- 9 months and related to clinical, angiographic and scintigraphic findings, the latter obtained from adenosine Tc-99m sestamibi SPECT imaging. Decision for revascularization was mainly based on angiographic data and was carried out in a total of 50 patients (angioplasty in 34 pts and cardiac surgery in 16 pts). The overall MACE rate was 24% with a mortality and myocardial infarction rate of 4% and 5%, respectively. Early (< 2 months) revascularization seemed to have a beneficial effect on clinical outcome as was suggested by the following findings: 1) Cardiac events (MACE) were not significantly different in patients with versus without revascularization (MACE 24% versus 23%) although the former constituted a subgroup at higher risk for ischemic events because of a more extensive coronary artery disease state. 2) In the subset of patients with at least one significant coronary artery stenosis the clinical outcome was significantly better in those who were revascularized than in those who underwent no revascularization (MACE 24% vs 47%, p < 0.05. Among a variety of factors, including the scintigraphic and angiographic extent of coronary artery disease and post-MI treatment strategy, multivariate analysis selected hypercholesterolemia (> 240 mg%) as the only independent predictor of MACE with a more than fourfold increase in risk for development of MACE. These data suggest that the natural history, especially the rate of recurrent ischemic events, can be favourably changed by an elective and early revascularization, strategically oriented by the results of the angio-graphic study. Furthermore, our data emphasized the deleterious role of hypercholesterolemia on clinical outcome in patients with a recent MI.
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PMID:Clinical outcome of patients with an uncomplicated myocardial infarction: effect of revascularization. 888 92

Fluid filtration rate (Jv/S) from individual mesenteric capillaries in normocholesterolemic and hypercholesterolemic rats was measured before and after 30 min each of ischemia and reperfusion (I/R). The median I/R-induced increase in Jv/S (I/R vs. baseline) was 44% in normocholesterolemic rats (n = 11) and 97% in hypercholesterolemic rats (n = 11). A positive correlation slope of 0.20% per mg/dl resulted when the percent Jv/S increase vs. plasma cholesterol concentration (P = 0.02) was plotted, demonstrating that hypercholesterolemia enhances the capillary response to I/R. Because microvascular pressure did not change significantly after I/R in either group of rats, the increments in Jv/S likely reflect increased capillary permeability. In hypercholesterolemic rats rendered neutropenic with antineutrophil serum, I/R did not elicit a significant increase in Jv/S, suggesting that activated neutrophils mediate the exaggerated endothelial barrier dysfunction associated with hypercholesterolemia.
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PMID:Neutrophil enhancement of reperfusion-induced capillary fluid filtration associated with hypercholesterolemia. 894 88

The purpose of this study was to explore the effect of ischemia on the Na(+)-K(+)-ATPase activity and ouabain receptor of the myocardial sarcolemma in hypercholesterolemic rabbits. Male New Zealand white rabbits were fed with either standard chow or standard chow supplemented with 0.5% (w/w) cholesterol and 10% (w/w) coconut oil. After an 8 week feeding period, the rabbits underwent a thoracotomy and myocardial ischemia was induced by occlusion of the coronary artery. Myocardial samples from the ischemic and non-ischemic regions of the left ventricle of control and cholesterol-fed rabbits were taken for study. The cholesterol-fed group showed a decrease in both Na(+)-K(+)-ATPase activity and [3H]ouabain binding sites as compared to the control group. Ischemia caused a reduction in both Na(+)-K(+)-ATPase activity [3H]ouabain bindings sites in both control and cholesterol-fed rabbits. The combination of ischemia and hypercholesterolemia produced an additive effect, with a further decrease in both Na(+)-K(+)-ATPase activity and [3H]ouabain binding sites. Neither the activity of Mg+(+)-ATPase nor the binding affinity for [3H]ouabain was affected by either hypercholesterolemia or ischemia. These findings indicate that hypercholesterolemia may exaggerate certain aspects of functional deterioration arising during myocardial ischemia.
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PMID:Ischemia-induced alteration of myocardial Na(+)-K(+)-ATPase activity and ouabain binding sites in hypercholesterolemic rabbits. 900 5

L-arginine is the physiological precursor of nitric oxide (NO) which is formed in endothelial cells by the activity of the constitutive NO synthase isoenzyme. NO is tonically released from the endothelium, thus maintaining an active vasodilator tone and inhibiting platelet aggregation, leukocyte adhesion, and vascular smooth muscle cell proliferation. In experimental hypercholesterolemia and atherosclerosis as well as in hypercholesterolemic patients, NO-mediated responses have been shown to be impaired. Whether decreased formation and/or enhanced oxidative inactivation are involved in this process, is still unclear. Chronic dietary administration of L-arginine has been shown to exert anti-atherosclerotic effects in hypercholesterolemic rabbits. Intravenous infusion of L-arginine induces NO-dependent peripheral vasodilatation and inhibits platelet aggregation in healthy humans as well as in patients with severe limb ischemia and generalized atherosclerosis. Whether L-arginine may induce therapeutic effects in peripheral vascular disease, still remains unclear.
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PMID:[Pathogenetic aspects of the L-arginine-NO metabolic pathway in arteriosclerosis and possible therapeutic aspects]. 903 7

The objective of this study was to define the influence of hypercholesterolemia on ischemia-reperfusion (I/R)-induced leukocyte-endothelial cell adhesion and albumin leakage in rat mesenteric venules. The microvascular alterations normally elicited by I/R (leukocyte adherence and emigration, albumin leakage, and platelet aggregation) were more pronounced in hypercholesterolemic rats (compared with control rats). Monoclonal antibodies against the adhesion glycoproteins CD11/CD18 and intercellular adhesion molecule-1 attenuated the I/R-induced leukocyte adherence and emigration and albumin leakage. Leukocyte adherence, but not albumin leakage, was diminished in animals pretreated with a P-selectin-specific antibody. Platelet aggregation was reduced by antibodies directed against either P-selectin, CD18, or intercellular adhesion molecule-1, as well as a GPIIb-IIIa antagonist. These results indicate that the enhanced reperfusion-induced albumin leakage in hypercholesterolemic rats is dependent on leukocyte-endothelial cell adhesion. Furthermore, P-selectin- and CD11/CD18-dependent heterotypic and GPIIb-IIIa-mediated homotypic platelet aggregation appear to influence the extravasation of both leukocytes and albumin in postischemic venules of hypercholesterolemic rats.
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PMID:Reperfusion-induced leukocyte adhesion and vascular protein leakage in normal and hypercholesterolemic rats. 927 3


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