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 147,016 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Atrial fibrillation is a common disorder and the incidence increases with each decade of life. Previously, rheumatic mitral valve disease has been the condition most highly associated with atrial fibrillation. However, with the decreasing incidence of rheumatic heart disease, other conditions have assumed greater importance and now congestive cardiac failure, coronary artery disease, and hypertension are the most commonly associated conditions. Nonrheumatic atrial fibrillation is associated with an approximately five-fold increase in the risk of ischemic stroke and a 5% to 7% yearly risk that increases with age. In addition, atrial fibrillation is associated with an increased incidence of silent cerebral infarction and increased mortality. However, whether atrial fibrillation is independently associated with the risk of stroke or is a marker of underlying cardiac disease is contentious. Until recently, the use of preventive therapy has been controversial. However, data from four recently published, prospective randomized studies clearly support the use of warfarin prophylaxis in nonrheumatic atrial fibrillation. Within the diverse group of patients with nonrheumatic atrial fibrillation there are high and low risk subgroups and identification of these may influence decisions regarding antithrombotic prophylaxis. With a few exceptions, however, this remains an area in which there are contradictory findings in the literature. The role of aspirin for prophylaxis in nonrheumatic atrial fibrillation remains unclear and further evaluation awaits the publication of ongoing studies.
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PMID:Atrial fibrillation: epidemiology and the risk and prevention of stroke. 138 92

Congestive heart failure (CHF) is a common manifestation of hypertension, coronary artery disease, and dilated cardiomyopathy. The Framingham study showed that the incidence of CHF increases twofold with each decade of age. The presence of CHF increases the age-adjusted death rate 5.5-fold for women and 8-fold for men, and it increases the sudden death rate 5.5-fold in both men and women. Ventricular arrhythmias are a common accompaniment of CHF. Ambient ventricular premature complexes occur in most of these patients, and nearly one half of all CHF patients will have nonsustained ventricular tachycardia on a 24-h ambulatory electrocardiographic (Holter) recording. In addition, low left ventricular ejection fraction (LVEF) predicts inducible sustained ventricular tachycardia on electrophysiologic study. One-year mortality increases with worsening New York Heart Association (NYHA) Functional Class and decreasing LVEF. As the overall yearly mortality increases, the proportion of patients who die of arrhythmias decreases. The precise mechanism of death is frequently difficult to assess. Nonarrhythmic causes of death include CHF, shock, electromechanical dissociation, and myocardial rupture. Arrhythmic causes are most commonly due to ventricular tachycardia/ventricular fibrillation. Bradycardic events (asystole or heart block) are usually associated with progressively worsening CHF. Noncardiac causes that may confuse classification include pulmonary embolus and cerebrovascular accident. Because many patients have ischemic heart disease as the etiology of the CHF, a recurrent ischemic event can likewise make classification difficult. Overall, approximately one half of all deaths in CHF are arrhythmic and one half are nonarrhythmic.
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PMID:Clinical significance and management of arrhythmias in the heart failure patient. 139 10

Echocardiographic predictors of clinical outcome were examined in subjects from the Framingham Heart Study with overt coronary artery disease. The study population consisted of 185 men and 147 women with coronary artery disease who underwent M-mode echocardiography and were followed for a mean of 3.90 years. At baseline, 37 men (18.4%) and 16 women (10.9%) had reduced fractional shortening, 43 men (23.2%) and 28 women (19%) had left ventricular (LV) dilatation, and 76 men (41%) and 76 women (51.7%) had LV hypertrophy. During the follow-up period new cardiovascular disease events (coronary disease, stroke, transient ischemic attack, claudication, heart failure and deaths from cardiovascular disease) occurred in 60 men (32%) and 58 women (39%). With use of age-adjusted proportional hazards analyses, LV mass/height in men (relative risk [RR] = 1.25/50 g/m increment, 95% confidence interval [CI] 1.01 to 1.55) and LV end-diastolic diameter in women (RR = 1.36/5 mm increment, 95% CI 1.05 to 1.76) were predictors of new cardiovascular disease events. Cardiovascular risk was also associated with LV end-systolic diameter in both sexes (in men RR = 1.28/1 SD increment, 95% CI 1.02 to 1.63; in women RR = 1.40/1 standard deviation increment, 95% CI 1.09 to 1.82). Reduced fractional shortening alone (RR = 1.91, 95% CI 1.11 to 3.31) and in combination with LV dilatation (RR = 2.13, 95% CI 1.13 to 4.02) was associated with the incidence of new cardiovascular disease outcomes in men.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:Echocardiographic determinants of clinical outcome in subjects with coronary artery disease (the Framingham Heart Study). 141 14

The anti-ischemic efficacy of diltiazem may improve with increments in dosage and with additional beta-blocking therapy. However, the combined administration could lead to adverse effects through amplification of negative inotropic and chronotropic properties. To evaluate hemodynamic tolerability and safety of high-dose intravenous diltiazem in patients with coronary artery disease receiving long-term metoprolol treatment, 9 such patients were studied for 30 minutes after onset of intravenous diltiazem administration (0.5 mg/kg for 5 minutes, followed by 15 mg/hour). Diltiazem plasma levels peaked at 5 minutes (641 +/- 74 micrograms/liter), decreasing to 177 micrograms/liter at 30 minutes. Average metoprolol levels (43 +/- 12 micrograms/liter) did not change. Diltiazem immediately decreased systemic vascular resistance, left ventricular systolic and mean aortic pressures (29, 21 and 20%, respectively, at 5 minutes), and they remained significantly reduced at 30 minutes. Heart rate initially increased by 11% during the bolus infusion (p < 0.05). Concomitantly, contractility indexes Vmax and Vce40, measured at fixed heart rates, also increased significantly by 11%. Both heart rate and contractility indexes returned to baseline levels thereafter. Cardiac output increased by 10% (p = not significant), stroke index remained unchanged, but stroke work decreased significantly by 20%. Also, the tension-time index was significantly reduced (23%). Diltiazem induced moderate negative lusitropic effects, the first derivative of negative left ventricular pressure decline decreased by 12% and Tau 2 lengthened by 13%. Concomitantly, left ventricular filling pressure increased from 19 +/- 2 to 23 +/- 3 mm Hg, but only at 5 and 15 minutes. PQ, QRS and QTc intervals were not affected.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:Acute hemodynamic and electrophysiologic effects and safety of high-dose intravenous diltiazem in patients receiving metoprolol. 141 18

Despite substantial progress in cardiovascular disease prevention, stroke and myocardial infarction remain the leading causes of death throughout the industrialized world. Treatment of high blood pressure, while contributing importantly to this progress, remains inefficient and less than optimally effective, particularly in regard to coronary artery disease events. Therapeutic intervention in the renin-angiotensin system offers promise of progress on both these fronts. Renin-sodium profiles have been shown to permit prognostic stratification of otherwise indistinguishable hypertensive patients. Indeed, low renin subjects, without other cardiovascular risk factors, have a particularly favorable prognosis. Now, the pharmacologic ability to mute the pathologic effects of angiotensin II also offers the genuine possibility that the cardioprotective value of antihypertensive therapy may be significantly improved.
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PMID:Prevention of myocardial infarction. 141 21

We have analyzed results in 54 consecutive patients with recurrent ventricular tachycardia and coronary artery disease in whom we used an aggressive surgical approach involving map-directed ventricular tachycardia ablation, scar excision and left ventricular remodeling, and coronary artery bypass grafting, as well as staged mitral valve replacement when necessary. We have previously shown age greater than 65 years to be an independent predictor of mortality and have excluded such patients from this series. Average age was 56 +/- 7 years. All patients had a previous myocardial infarction; 24% of the infarctions (13/54) were posterior in location. Symptoms included syncope or presyncope in 83% of the patients (45/54), angina in 54% (29/54), and congestive heart failure in 52% (28/54). Extensive coronary artery disease was found in 78% (42/54), and 89% (48/54) had serious compromise of left ventricular function (ejection fraction < 0.40; average ejection fraction, 0.28 +/- 0.12). Only 63% (34/54) appeared to have a resectable left ventricular aneurysm on the preoperative angiogram. Ablation techniques included endocardial excision in 82% (44/54), with the addition of cryoablation in 60% (32/54), and balloon electric shock ablation in 22% (12/54); coronary artery bypass grafting was performed in 85% (46/54). There were four hospital deaths (7%). The surgical cure rate (no inducible VT at postoperative electrophysiologic study was 72% (39/54). During follow-up (mean, 50 +/- 31 months) there have been six late deaths (1 sudden death, 1 stroke, 4 congestive heart failures with or without mitral regurgitation). Four patients with progressive congestive heart failure and serious mitral regurgitation have undergone repeat operation for mitral valve replacement.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:Late results of operation for ventricular tachycardia. 141 72

The timing of carotid endarterectomy (CEA) and coronary revascularization (CABG) for concomitant disease is controversial. Results of combined CEA/CABG in 127 patients (age range, 46 to 82 years; mean age, 65 years; 61% male) from 1978 to 1991 were reviewed. Ninety-five patients (75%) were in New York Heart Association functional class III or IV, 48 (38%) had left main coronary artery disease, and 32 (28%) had depressed ejection fraction ( < 0.50). Forty (32%) had asymptomatic bruits, 61 (48%) transient ischemic attacks, and 26 (20%) prior strokes. Seventy-five (59%) had bilateral carotid stenosis, including 20 (16%) with contralateral occlusions. Perioperative mortality was 7 of 127 (5.5%), and all deaths were cardiac related. Myocardial infarctions occurred in 6 of 127 patients (4.7%) and were nonfatal in 3 (2.3%). Permanent strokes occurred in 7 of 127 (5.5%) and were ipsilateral in 5 (3.9%). Perioperative stroke did not occur in the asymptomatic group, but the risk was higher in those with prior stroke (19%) or with contralateral carotid occlusion (15%). The stroke risk for our patients with carotid disease having CABG without CEA is not known, but the literature reports rates as high as 14%. For our patients without known concomitant disease, the risk of permanent stroke was 1.0% (31/3012) for isolated CABG and 1.5% (7/482) for isolated CEA. The late results after CEA/CABG revealed a 5-year survival of 70% +/- 5%, which correlated with ejection fraction ( > or = 0.50, 81% +/- 5%; < 0.50, 45% +/- 11%; p < 0.003). Freedom from late permanent ipsilateral stroke was 97% +/- 2% at 8 years. Freedom from stroke at 5 years was lower among patients with a previous stroke (71% +/- 10%) compared with transiently symptomatic (90% +/- 4%) and asymptomatic (96% +/- 4%) patients (p < 0.03). Combined CEA/CABG is a useful option in this high-risk group of patients with extensive atherosclerosis; avoids a subsequent hospitalization, anesthetic, and delay period; and provides long-term protection from ipsilateral stroke.
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PMID:Combined carotid and coronary revascularization: the preferred approach to the severe vasculopath. 144 93

Hypertension is a very frequent condition in individuals with non-insulin dependent diabetes mellitus (NIDDM) in Japan and has affected the occurrence of late diabetic complications, especially stroke and nephropathy. Despite similar characteristics of hypertension among Japanese and white patients, the effect of hypertension on the development of coronary artery disease (CAD) in these two populations is strikingly different. In white NIDDM patients, hypertension is one of the major risk factors for the development of CAD. However, CAD is an infrequent complication in NIDDM patients in Japan, even though they have hypertension, lipid abnormalities, and renal complications.
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PMID:Hypertension and the development of complications in patients with non-insulin dependent diabetes mellitus in Japan. 145 54

The natural history of peripheral arterial occlusive disease is discussed. Severe limb-threatening ischemia is the most serious consequence of chronic arterial occlusive disease. Severe ischemia and amputation can be considered as an endpoint in peripheral vascular disease. Severe limb ischemia is relatively uncommon in isolated aortoiliac disease and this is more than twice in patients with either femoropopliteal or multisegmental disease. Subsequent studies have also demonstrated that both smoking and diabetes are associated with a substantial risk for sudden ischemia. A clear majority of about 50% deaths are caused by associated coronary artery disease, 15% to stroke and 10% to vascular disease in the abdomen. Ankle systolic blood pressure is one of the most significant factors in the progression of peripheral arterial occlusive disease and also for cardiovascular mortality. In the future, men need to know how therapies as exercise, during regimens would influence the most frequent complications besides severe limb ischemia, namely brain infarction and coronary artery disease.
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PMID:Natural history and evolution of peripheral obstructive arterial disease. 146 Mar 49

Doppler echocardiography and radionuclide angiography were shown to provide valuable tools with comparable functional parameters for the noninvasive assessment of left ventricular (LV) diastolic function in patients with coronary artery disease or LV hypertrophy. In order to examine the influence of an impaired systolic function on both methods, we studied LV filling simultaneously by Doppler echocardiography and radionuclide angiography in 47 patients with idiopathic dilated cardiomyopathy and stable sinus rhythm. The Doppler echocardiographic peak velocities (VE, VA) and radionuclide angiographic peak filling rates (PFRFF, PFRA) normalized to either left ventricular enddiastolic volume or stroke volume were measured and systolic function was assessed by obtaining the ejection fraction (EF) with the radionuclide angiography. Patients were divided into two groups with moderately (group 1: EF > or = 35%) or severely impaired (group 2: EF < 35%) systolic function. In group 2 the PFRFF (1.8 +/- 0.5 vs. 3.3 +/- 0.8 SV/s; p < 0.01) and PFRA (1.2 +/- 0.6 vs. 2.5 +/- 1.0 SV/s; p < 0.01) were both lower than in group 1, as was the Doppler echocardiographic VA (0.44 +/- 0.20 vs. 0.63 +/- 0.17 m/s; p < 0.01). However, VE was increased with reduced systolic function (0.75 +/- 0.20 vs. 0.53 +/- 0.16 m/s; p < 0.01). No relation was found between PFRFF and VE and only a weak relation between the atrial filling parameters of Doppler echocardiography and radionuclide angiography. The peak filling rates were closely correlated with the systolic function (PFRFF:r = 0.86; p < 0.001) and were reduced with an impaired systolic function.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:[Differences in the non-invasive assessment of left ventricular filling in patients with dilated cardiomyopathy using Doppler echocardiography and radionuclide angiography]. 149 39


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