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Cardiovasc. Med., Volume 13, Issue 2 (02 2010) – 6 articles

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5 pages, 406 KB

Open AccessEditorial

Do We Need MR Conditional Pacemakers?

by Roger Luechinger and Firat Duru

Cardiovasc. Med. 2010, 13(2), 70; https://doi.org/10.4414/cvm.2010.01477 - 24 Feb 2010

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Abstract

Magnetic resonance imaging (MRI) is a widely accepted tool for the diagnosis of a variety of disease states. However, due to safety concerns the presence of an implanted cardiac pacemaker is considered to be a contraindication to MRI in most medical centres. The increasing number of implanted pacemakers and the estimated over 50% probability that a pacemaker patient may be a candidate for an MRI increase the need for safe scanning of pacemaker patients. Over the last ten years a major effort has been made to understand the potential risks. The influences from the three electromagnetic fields on pacemakers are versatile and will be summarised. The research in this area has helped to predict the risks of an MRI scan in patients with conventional pacemakers, and has also stimulated pacemaker manufacturers to improve their devices with the goal of providing MR conditional devices. Since autumn 2008 the first approved MR conditional pacemakers have been on the market and other devices are likely to follow this trend. However, the vast majority of devices are still not approved for MRI, a situation which will take several years to change. It is thus important that a solution be also found for these patients. Several studies including over 500 patients with a pressing need for MRI have been performed at different experienced centres. On the basis of those data various organisations in MRI fields have proposed guidelines for MRI in patients who fulfill given requirements. However, at present, non- MRI modalities should be considered, whenever possible, for diagnosis in pacemaker recipients with conventional devices. If other imaging modalities are not adequate, MRI with careful monitoring and preparation for adverse events may be considered only at experienced centres. With the wider availability of MR conditional devices, the risks of MRI are greatly reduced and non-tertiary centres will be able to perform these investigations. In any case, rapid progress in the field of MR conditional pacing is desirable. Full article

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Open AccessCase Report

Platinum Reward for Theft, or the Percutaneous Treatment of Coronary Steal Due to a Giant Coronary Artery Fistula

by Diego Arroyo and Stéphane Cook

Cardiovasc. Med. 2010, 13(2), 68; https://doi.org/10.4414/cvm.2010.01476 - 24 Feb 2010

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Abstract

An 89-year-old sister who presented with angina pectoris and signs of acute left ventricular failure had a history of chronic dyspnoea aggravated a few days prior to admission by orthopnoea and nycturia. [...] Full article

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4 pages, 190 KB

Open AccessCase Report

Troponin und Schmerz – Nicht Immer Kommt’s vom Herz

by Franziska Spitzner, Hans-Rudolf Schmid, Hans-Jürg Beer and Michael K. Neuhaus

Cardiovasc. Med. 2010, 13(2), 64; https://doi.org/10.4414/cvm.2010.01474 - 24 Feb 2010

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Abstract

We report the case of a 76-year-old woman with palpitations and chest discomfort, who presented with elevated concentrations of cardiac biomarkers (Troponin T and creatine kinase CK) but no ST elevation. A coronary angiogram showed no evidence of obstructive coronary artery disease, an echocardiography was normal. Myocarditis was suspected, and treatment with a non-steroidal anti-inflammatory drug was initiated. After three as well as after six months cardiac bio markers continued to be elevated; a repeat echocardiography remained normal without signs of regional wall motion abnormalities. Given the clinical course as well as the unchanged echocardiogram a non-cardiac cause of the elevated cardiac biomarkers appeared most likely. Troponin-I was taken and turned out negative. Hence, the elevated cardiac Troponin T and CK were unrelated to myocardial ischaemia, but instead were due to a rheumatic disease. Full article

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4 pages, 485 KB

Open AccessEditorial

Blutplättchenhemmer bei Koronarer Herzkrankheit

by Bernhard Meier

Cardiovasc. Med. 2010, 13(2), 60; https://doi.org/10.4414/cvm.2010.01478 - 24 Feb 2010

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Abstract

Platelet inhibition in coronary artery disease. Acetylsalicylic acid has been used for over 100 years but its potential to inhibit platelets has only been taken advantage of for about 30 years. For about 10 years the thienopyridines (initially ticlopidine and then clopidogrel) have been used as alternatives or complements (in particular in the context of coronary artery stents). Thienopyridines block the ADP receptor of the platelet which stimulates the GP IIb/IIIa receptors (subreceptor P2Y₁₂) to appear at the platelet surface and to permanently ligate to a fibrinogen molecule. Each fibrinogen molecule can attach to 2 GP IIb/IIIa receptors. If they belong to two individual platelets, the two are aggregated irreversibly. Recently a second thienopyridine (prasugrel) has come to market. It is a prodrug like clopidogrel but activated faster and more reliably. In the examined doses it has proved to be more efficacious but also more bleed prone than clopidogrel. Soon to come is another oral ADP antagonist (ticagrelor) which is ingested in the active form and binds to the receptor reversibly. This entails that it be given twice a day. Clinical results so far show enhanced efficacy compared with clopidogrel without a significant increase of bleeding risk. Future clinical use will show whether we will continue to use all three modern platelet inhibitiors in addition to acetylsalicylic acid, narrow it down to one or two of them, or perhaps drop acetylsalicylic acid. The quest to find an oral direct inhibitor of the GP IIb/IIIa receptor goes on as does the search for other indirect platelet inhibitors acting for instance on the thrombin receptor, the thromboxane A₂ receptor (also the target of acetylsalicylic acid), the epinephrine receptor, the serotonin receptor, or the collagen receptors. Full article

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10 pages, 887 KB

Open AccessEditorial

From Pacemaker to Cardiac Rhythm and Disease Management

by Lukas Kappenberger

Cardiovasc. Med. 2010, 13(2), 50; https://doi.org/10.4414/cvm.2010.01475 - 24 Feb 2010

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Abstract

The first artificial pacemaker was implanted 51 years ago. Considerable progress has been made in recent decades and pacemakers have become fully automated cardiac rhythm management (CRM) systems representing a new, growing, and important set of therapies constituting a challenge for cardiologists and family practitioners. In the 25th year since the first implant of an automatic defibrillator (ICD) in Switzerland the present review puts the key CRM developments into perspective and is intended as a contribution to improved understanding and thereby management of patients under electrical therapy of the heart, a growing domain that is evolving towards a tool for full cardiac (and other) disease management. With the initial aim of preventing Adams-Stokes attacks by implanting a pacemaker with an electrode sutured on the heart, pacemakers have evolved to become devices able to automatically sense, analyse, and deliver appropriate electrical therapy against cardiac arrhythmias in their different forms. Automatic atrial and/or ventricular pacing, cardiac resynchronisation for correction of heart failure, and defibrillation for primary or secondary prevention of sudden cardiac death have demonstrably improved clinically important endpoints such as quality of life, symptom relief, hospitalisation rate and mortality. The increasing number of studies with documented endpoint reductions has resulted in corresponding treatment recommendations in the form of guidelines. The complexity of the indications and individual CRM programming possibilities, combined with the growing prevalence of patients seen to be benefiting from CRM in daily practice, has revealed the need for practising physicians to stay abreast of latest developments and be able to counsel their patients adequately. New ways of controlling vital signs via multiple sensors open the way to automatic remote and permanent assessment of many patient- or device-related parameters and thereby remind us of the importance of understanding the basic physiology of haemodynamics and cardiac function. Full article

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9 pages, 1093 KB

Open AccessProceeding Paper

Cardiovascular Pathology in the Land of the Doges

by Gaetano Thiene

Cardiovasc. Med. 2010, 13(2), 41; https://doi.org/10.4414/cvm.2010.01479 - 24 Feb 2010

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Abstract

This manuscript covers the history of Cardiovascular Pathology and the tradition of the study of the cardiovascular system since the Renaissance time, when the University of Padua was the Gymnasium of the Republic of Venice. The anatomy of the heart was described by Andreas Vesalius in 1543. Realdo Colombo published the discovery of the small circulation in 1559 by dissecting dogs in vivo. Fabrici ab Aquapendente built a permanent Anatomical Theatre in 1594, which may be considered the first Laboratory of investigation in the History of Medicine. William Harvey studied in Padua in 1599–1602 and, inspired by the venous valves dissected by Fabrici, put forward the theory of blood circulation. In the same period (1592–1610), Galileo Galilei was professor of Maths at the School of Medicine in Padua and founded the experimental method, according to which science is measure. Giovanni Battista Morgagni, by publishing the book De Sedibus et Causis Morborum per Anatomen Indagatis in 1761, introduced the method of clinico-pathologic correlations and established pathological anatomy as a science. The policy of the Venice Republic was to provide smart lecturers: only men of demonstrated excellence were given the charge over the education of the young. Major advances have been made in the current era with the advent of cardiac surgery, interventional cardiology and cardiac imaging. The mission of the pathologist moved from the anatomical to the surgical theatre and more recently to the molecular laboratory. Dissemination of knowledge of surgical and clinical anatomy of congenital heart diseases contributed to a sharp decline in operative mortality. Surgical pathology, with the use of light and electron microscopy, became a daily job to examine any native tissue resected at surgery from heart and vessels and even endovascular prostheses. Cardiac transplantation and endomyocardial biopsy resulted in a novel development of cardiovascular pathology history. The sudden death mystery was cleared up with concrete, preventive results. Application of molecular biology and genetic techniques makes it possible to nowadays gain a precise diagnosis even at mortem (“molecular autopsy”), with the opportunity to investigate the etiopathogenesis, in addition to the substrate of cardiovascular diseases. The position of the cardiovascular pathologist, between the bench and the bedside, allows him to play a key role in the study of cardiovascular disease. Full article

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