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Current Cardiology Reviews
ISSN: 1573-403X
Current Cardiology Reviews
Volume 3, Number 3, August 2007
Contents
Integrating Coronary Calcium into Risk Prediction:
Current Approaches and Future Directions Pp. 165-175
Alan Boyar
[Abstract]
Myocardial Quantitative Analysis in Physiological
and Pathological Ventricular Hypertrophy: The Increasing Role
of Doppler Myocardial Imaging Pp. 176-184
Antonello D’Andrea, Raffaella Scarafile, Gemma Salerno,
Lucia Riegler, Claudia Mita, Filomena Allocca, Giuseppe De
Corato, Chiara Sordelli, Sergio Cuomo and Raffaele Calabrò
[Abstract]
Hybrid Stress Testing by Adenosine Infusion and Exercise
Myocardial Perfusion Imaging: A Critical Appraisal
Pp. 185-189
Todd A. Dorfman and Ami E. Iskandrian
[Abstract]
Which are the Best Follow-Up Strategies for Patients
Who Undergo Percutaneous Coronary Interventions?
Pp. 190-198
Alfredo R. Galassi, Salvatore Azzarelli, Salvatore Davide
Tomasello, Giombattista Barrano, Miriam Cumbo and Corrado
Tamburino
[Abstract]
Therapeutic Hypothermia for Cardiopulmonary Resuscitation:
Why, When and How Pp. 199-206
Ala Nozari, Neli Azimi and Theodore A. Alston
[Abstract]
The Role of HLA-Directed Antibodies in Cardiac Transplant
Immunology Pp. 207-220
Anat R. Tambur
[Abstract]
Diagnosis and Management of Chronic Coronary Artery
Disease Pp. 221-231
Filippos Triposkiadis, Randall C. Starling and Christodoulos
Stefanadis
[Abstract]
Abstracts
[Back to top]
Integrating Coronary Calcium into Risk Prediction: Current
Approaches and Future Directions
Alan Boyar
The CT coronary calcium score is a predictor of risk
for cardiovascular events. Individuals without detectable
coronary calcium are at very low risk for events whereas individuals
with large amounts of coronary calcium have annual event rates
of 4.8%. In the USA the Framingham scoring system is the most
widely used method for calculating cardiovascular event risk.
To date at least four approaches have been proposed to combine
risk determined from the CT coronary calcium score with the
Framingham scoring system risk. These include: 1) adjustment
of age points in the Framingham scoring system based on CT
coronary calcium age-sex percentile rank (determined from
a nonogram of CT coronary calcium scores); 2) age replacement
in the Framingham scoring system in which an “arterial
age” determined by the CT coronary calcium score replaces
chronological age; 3) a likelihood or hazard ratio approach;
and 4) Bayesian methods for risk combination. This review
will discuss methods and merits of each of these approaches.
With the exception of the age-sex percentile rank method which
suffers from specific intrinsic problems, none of the other
approaches is necessarily superior; ultimately, the one that
is easiest to use and most reliable will probably be the one
adopted for clinical use.
[Back to top]
Myocardial Quantitative Analysis in Physiological
and Pathological Ventricular Hypertrophy: The Increasing Role
of Doppler Myocardial Imaging
Antonello D’Andrea, Raffaella Scarafile, Gemma Salerno,
Lucia Riegler, Claudia Mita, Filomena Allocca, Giuseppe De
Corato, Chiara Sordelli, Sergio Cuomo and Raffaele Calabrò
Athlete’s heart is a left ventricular adaptation to
long-term, intensive training which includes changes as increased
cavity diameter, wall thickness and mass. Even if the standard
2-dimensional echocardiography represents an irreplaceable
method in the evaluation of cardiac adaptations to physical
exercise, the data currently available suggests the usefulness
of Doppler Myocardial Imaging (DMI) in the assessment of the
myocardial systolic and diastolic function of the athlete’s
heart. In particular, DMI analysis in the trained subject
has demonstrated interesting prospective for : 1) the differential
diagnosis from pathological left ventricular hypertrophy due
to Hypertrophic Cardiomyopathy (HCM); 2) the prediction of
cardiac performance during physical effort; 3) the evaluation
of the bi-ventricular interaction; 4) the analysis of the
myocardial adaptations to various training protocols; 5) the
early identification of specific genotypes associated with
cardiomyopathies. Such a combined use of standard 2-D echo
and DMI may be taken into account for a valid non-invasive
and easy-repeatable evaluation of both physiological and pathological
ventricular hypertrophy.
[Back to top]
Hybrid Stress Testing by Adenosine Infusion and Exercise
Myocardial Perfusion Imaging: A Critical Appraisal
Todd A. Dorfman and Ami E. Iskandrian
Approximately, 10 million stress myocardial perfusion images
(MPI) are performed each year in the Unites States for the
diagnosis of coronary artery disease (CAD) and risk assessment.
Pharmacologic stress accounts for nearly 40% of these studies,
and adenosine is the most widely used stress agent at present.
The relative role of adenosine versus the newer and as of
yet unapproved selective A-2 agonist is currently under intense
study. The purpose of this review is to critically assess
the role and utility of combined exercise and adenosine, so
called hybrid stress testing (HST). The discussion will focus
on adenosine, because HST of other combinations is well accepted
such as dobutamine plus atropine and exercise combined with
dipyridamole.
[Back to top]
Which are the Best Follow-Up Strategies for Patients
Who Undergo Percutaneous Coronary Interventions?
Alfredo R. Galassi, Salvatore Azzarelli, Salvatore Davide
Tomasello, Giombattista Barrano, Miriam Cumbo and Corrado
Tamburino
Percutaneous coronary intervention has become a mainstay in
the treatment of patients with coronary artery disease in
recent years. However, restenosis, incomplete revascularization,
and progression of disease continue to cause a need for a
clinical functional assessment in order to reduce morbidity.
Angiographic systematic follow-up should nowadays be considered
a valuable approach only to monitor small groups of very high
risk patients. Although coronary CT angiography seems able
to non-invasively image the coronary artery lumen, but the
presence of a stent could limit visualization of coronary
morphology. Recurrence of symptoms itself has low sensitivity
and specificity for detection of restenosis and myocardial
ischemia. Exercise testing may provide useful information
on symptoms and functional capacity of the patient; however,
it is poorly diagnostic of restenosis and myocardial ischemia
with a low level of sensitivity and specificity. Conversely,
the significantly increased sensitivity and specificity obtained
by stress nuclear, echocardiographic or magnetic resonance
imaging provide great advantage for clinical assessment of
these patients. Additional advantages of stress imaging are
the ability to assess location and extent of myocardial ischemia
regardless of symptoms as well as to evaluate patients who
are unable to exercise or who have an uninterpretable electrocardiogram.
Furthermore, the clear superiority of stress imaging with
regard to specificity and predictive value for postrevascularization
events makes this functional approach of paramount importance
for assessing prognosis of such patients.
[Back to top]
Therapeutic Hypothermia for Cardiopulmonary Resuscitation:
Why, When and How
Ala Nozari, Neli Azimi and Theodore A. Alston
Therapeutic hypothermia has been shown to improve neurological
outcome in comatose survivors of cardiac arrest. Uncontrolled
hypothermia is, however, potentially deleterious because of
its effects on various organ systems and physiologic functions.
Clinicians are concerned that improper application of this
treatment or overzealous cooling of their patients may result
in serious complications and may increase the overall morbidity
and mortality in that population. Induced hypothermia has,
consequently, not achieved widespread use, despite an advisory
statement from the International Liaison Committee on Resuscitation
to cool comatose survivors of cardiac arrest. In this report,
we critically review the literature on therapeutic hypothermia
in individuals who have experienced cardiac arrest and the
risks and complications associated with that treatment. Technical
aspects and optimal timing for this intervention are also
discussed, and appropriate monitoring of physiologic parameters
is suggested.
[Back to top]
The Role of HLA-Directed Antibodies in Cardiac Transplant
Immunology
Anat R. Tambur
Over the last few years heart transplant physicians have encounted
more allograft rejection episodes that are not responsive
to conventional treatment. The role of B cells and alloantibodies
in organ transplant outcome becomes more apparent. More centers
recognize the role of humoral rejection and the involvement
of HLA-directed antibodies specifically. In fact, new guidelines
to diagnose antibody mediated rejection have just recently
been published and are reviewed in this context.
This review summarizes our data as well as other published
manuscripts related to the involvement of pre-formed as well
as de-novo HLA-directed antibodies in determining allograft
outcome. Special emphasis is given to the rapid advancements
in antibody detection methodologies and the use of solid phase
based techniques. We further discuss cutting edge opportunities
to overcome prior sensitization of patients awaiting heart
transplantation (“Desensitization protocols”).
Utilizing recent advances in HLA-directed antibody detection
methods and progress in immunosuppression protocols, patients
previously not considered to be transplant candidates now
have an opportunity to receive a life-saving allograft.
[Back to top]
Diagnosis and Management of Chronic Coronary Artery
Disease
Filippos Triposkiadis, Randall C. Starling and Christodoulos
Stefanadis
Coronary artery disease (CAD) usually coexists with atherosclerosis
of other arterial trees and is accelerated by several risk
factors. It may remain asymptomatic for a long period affecting
the vessel wall with no lumen encroachment. However, its course
may change dramatically when complicated by thrombosis arising
from ruptured atherosclerotic plaques leading to myocardial
infarction or sudden death, which are often the first manifestations.
Alternatively, thrombosis may remain clinically silent yet
contributing to the natural history of plaque progression
and ultimately luminal stenosis resulting in symptomatic or
asymptomatic myocardial ischemia. Thus, chronic CAD may be
classified as: 1) Asymptomatic/non-ischemic (subclinical)
including asymptomatic patients without stress-induced myocardial
ischemia and one or more of the following: a) non-coronary
forms of atherosclerotic disease, b) diabetes, c) high Framingham
Risk Score (FRS) or European Heart Score (EHS), and d) intermediate
FRS or EHS and either a coronary artery calcium score =100
or a carotid intima-media thickness score = 1mm; 2) Asymptomatic/ischemic,
including asymptomatic patients with a positive stress-test
and one or more of the following: a) non-coronary forms of
atherosclerosis, b) diabetes, and c) intermediate or high
FRS or EHS; 3) Symptomatic/ ischemic, including patients
with effort angina and stress test-induced myocardial ischemia.
Lifestyle modification, aspirin, and lipid lowering with statins,
are the mainstay of treatment in all patients with chronic
CAD. Antiischemic pharmacotherapy should be considered in
patients with evidence of myocardial ischemia and reperfusion
treatment in selected patients with obstructive lesions in
coronary angiography.
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