Reviews in Cardiovascular Medicine

Multi-slice computed tomography (MSCT) coronary angiography is an imaging modality that can identify patients with both soft and hard plaque, supplementing the information gleaned from an ordinary coronary calcium scan and classic risk-factor assessment. Clinicians now have the tools to identify the presence of coronary artery disease (CAD) in the presymptomatic phase, as well as those needed to help identify the etiology of pain syndromes in patients presenting with atypical or obscure symptoms and who may be suffering from obstructive CAD, aortic dissection, pulmonary emboli, or other pathologic processes. There is considerable training and practice involved in developing the skills necessary to convert raw information from a CT scanner to optimal diagnostic images; however, MSCT provides important diagnostic information in a faster, less expensive, more patient-friendly, and safer manner than conventional coronary angiography. The following 2 cases describe the use of MSCT coronary angiography in patients with atypical symptoms and exemplify the use of this technology in a clinical setting.

Finding a simple blood test that would aid in the diagnosis and management of patients with CHF would clearly have a favorable impact on the staggering costs associated with the disease. B-type natriuretic peptide (BNP) may be the first potential "white count" for heart failure. The fact that a point-of-care, rapid assay for BNP has recently been approved by the FDA gives the clinician an opportunity to explore its potential usefulness. Data suggest that serial point-of-care testing of BNP will be of immense help in patients presenting to urgent care clinics with dyspnea. Additionally, BNP might serve as a screen for patients referred for echocardiography, and might also be an effective way to improve the in-hospital management of patients admitted with decompensated CHF. Finally, the role of BNP in the outpatient cardiac or primary care clinic may be one of critical importance in titration of therapies as well as assessment of the state of the patient's neurohormonal compensation.

Approximately 20% of coronary artery anomalies produce sudden death or life-threatening symptoms, including arrhythmias, syncope, and myocardial infarction. The most common clinical symptom of coronary artery anomaly is angina or exertional syncope. Physical examination is usually unrevealing in the absence of myocardial infarction or symptoms of ongoing ischemia. The rapid advent of cardiac computed tomography (CT) technology has made it an important adjunct to the diagnosis of coronary anomalies by angiography. The authors describe the case of a 54-year-old white man who presented with gangrenous toes. He had severe peripheral vascular disease, a femoral-popliteal bypass graft, residual hemiparesis from an ischemic stroke, hypertension, deep vein thrombosis, and a recent myocardial infarction. He underwent a 64-slice cardiac CT angiogram, which showed an interarterial course of the left main coronary artery between the aorta and the pulmonary trunk.

The IIb/IIIa receptor inhibitors have been shown to improve outcomes following percutaneous coronary intervention (PCI), particularly by decreasing periprocedural myocardial necrosis. Abciximab has been subject to multiple studies, demonstrating consistent improved early and late outcomes in multiple patient populations, including a mortality advantage in diabetics, but there has been concern about the possibility of anaphylaxis, thrombocytopenia, and reduced clinical efficacy with repeat administration of abciximab. Results of the ReoPro Readministration Registry, a prospective, phase IV, multicenter registry of 500 patients undergoing PCI who were treated with abciximab at least 7 days after a previous treatment with this same drug, support the contention that abciximab readministration is both safe and clinically efficacious and that there is no significant increase in the incidence of thrombocytopenia as compared with historical controls of trials of first abciximab administration. However, profound thrombocytopenia did occur with increased frequency as compared with historical controls, suggesting a shift from mild to profound thrombocytopenia with abciximab readministration.

Statins, angiotensin-converting enzyme inhibitors, and combination therapies have been shown to reduce the cardiovascular event rate in susceptible individuals, albeit with remaining significant residual risk. Some of the sources of residual risk, such as genetics and epigenetic phenomena, are not easily modifiable. Still, the risk imposed by these factors may be lowered by implementation of dietary, behavioral, and pharmacologic interventions. Abdominal obesity has emerged as one element in the cluster of factors linked to increased propensity for cardiovascular disease and type 2 diabetes. It is a potential therapeutic target to reduce residual cardiometabolic risk. Waist circumference has been shown to be a strong correlate of abdominal obesity, and measurement is a useful tool for the assessment of cardiometabolic risk.

Atrial fibrillation (AF) contributes to considerable morbidity, with increasing risk of stroke, complications from anticoagulation, and exacerbation of heart failure. AF ablation has become a commonly performed procedure in many hospitals as the procedural techniques evolve rapidly with improved success. Here we discuss the interventional options of catheter-based AF ablation for rhythm control, which offers the benefit of mortality reduction associated with normal sinus rhythm but without medication complications.

Patients with severely symptomatic hypertrophic obstructive cardiomyopathy (HOCM) have several alternatives when drugs do not help. Surgical septal myotomymyectomy, though effective, is an open-heart surgical procedure and can be associated with some complications. The less invasive dual chamber pacing has not lived up to its early promise. Percutaneous transluminal septal myocardial ablation (PTSMA) is a relatively simple, less complicated nonsurgical procedure that can provide an effective and sustained relief of left ventricular outflow tract (LVOT) obstruction. Should it gain wider acceptance?

A variety of cardiomyopathies are due to familial disease. Most are primarily associated with cardiac involvement and can lead to hypertrophic, dilated, or restrictive cardiomyopathy. Myotonic dystrophy (MD) is a multisystem disease with autosomal dominant inheritance and variable penetrance. Cardiac diseases are important causes of morbidity and mortality in MD patients. Patients with primary MD should be carefully investigated with an electrocardiogram, stress test, and an echocardiogram to identify preclinical cardiac involvement and to prevent life-threatening complications. Any new onset of atrial flutter or atrial fibrillation in a young patient without any underlying cardiac abnormality should be investigated for underlying myopathy. The authors report on a male adolescent with MD who presented with atrial flutter. The patient had been diagnosed with MD at birth. He had an impaired ejection fraction of 38% to 45%. The patient described sharp chest pain in the retrosternal area, with no radiation, that was induced by exercise.