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Angina
Kinds of Angina Terms modified by Angina Selected AbstractsEstimation of Coronary Flow Velocity Reserve Using Transthoracic Doppler Echocardiography and Cold Pressor Test Might Be Useful for Detecting of Patients with Variant AnginaECHOCARDIOGRAPHY, Issue 4 2010Hui-Jeong Hwang M.D. Purpose: The cold pressor test (CPT) has been used to detect variant angina, but its sensitivity in predicting vasospasm is low. The aim of this study was to determine whether estimates of the coronary flow velocity reserve (CFVR) in the distal left anterior descending coronary artery (dLAD) using transthoracic echocardiography (TTE) and CPT are useful tool to predict variant angina. Methods: 65 patients (mean age = 52 ± 10 years; male:female = 41:24) who had normal coronary artery on angiography and underwent acetylcholine provocation test were enrolled and divided into the spasm group (n = 31) and the no spasm group (n = 34). During CPT, the peak (PDV) and mean diastolic flow velocity (MDV) of the dLAD were estimated using TTE with a high-frequency transducer, and electrocardiography, blood pressures, heart rate, and symptoms were monitored every 30 seconds. CPT%PDV and CPT%MDV were defined as the percentage changes in PDV and MDV during CPT, respectively. Results: CPT%PDV was 4.99 ± 23.62% in the spasm group and 52.75 ± 24.78% in the no spasm group (P < 0.001). CPT%MDV was 6.83 ± 23.81% in the spasm group and 50.22 ± 27.83% in the no spasm group (P < 0.001). CPT%PDV<31.1% had a sensitivity of 93.5% and a specificity of 82.4% in predicting variant angina (95% confidence interval [CI]: 0.939,0.979, P < 0.001). CPT%MDV<30.55% had a sensitivity of 90% and a specificity of 76.5% in predicting variant angina (95% CI: 0.884,0.950, P < 0.001). Conclusion: The measurement of changes in the coronary flow velocity of the dLAD using TTE and CPT might be useful for the estimation of endothelial dysfunction in patients with variant angina. (ECHOCARDIOGRAPHY 2010;27:435-441) [source] Gender- and Age-Related Differences in Treatment and Control of Cardiovascular Risk Factors Among High-Risk Patients With AnginaJOURNAL OF CLINICAL HYPERTENSION, Issue 7 2005Katharine H. Hendrix PhD Dyslipidemic, hypertensive patients (N=48,863) were stratified by gender, age, and angina (n=2502) vs. nonangina (n=46,358) status. Comparing 95% confidence intervals yielded significant differences in treatment and cardiovascular risk factor control between subgroups. More men than women bad low-density lipoprotein cholesterol (LDL-C) <100 mg/dL (angina, 43.94-43.96 vs. 34.42-34.50; nonangina, 32.43-32.43 vs. 17.25-17.25) and 100-129 mg/dL (angina, 32.12-32.14 vs. 35.10-35.18; nonangina, 53.86-53.86 vs. 32.44-32.44). More women than men had LDL-C >130 mg/dL (angina, 27.68-27.72 vs. 23.91-23.93; nonangina, 38.70-38.70 vs. 35.38-35.39). Women were less likely than men to receive statins (angina, 69.95-69.99 vs. 82.11-82.13; nonangina, 59.80-59.80 vs. 63.72-63.72), any antilipidemic medication at all (angina, 25.93-25.97 vs. 13.48-13.48; nonangina, 36.73-36.73 vs. 30.73-30.73), or to have current cholesterol measurements (angina, 56.82-56.88 vs. 34.54-34.56; nonangina, 45.77-45.77 vs. 39.75-39.75). Primary care providers treat high-risk patients relatively aggressively; however, opportunities to forestall cardiovascular disease may be missed in hypertensive, dyslipidemic women whose LDL-C is often not measured and controlled. [source] Role of a Streamer-like Coronary Thrombus in the Genesis of Unstable AnginaJOURNAL OF INTERVENTIONAL CARDIOLOGY, Issue 3 2010YASUMI UCHIDA M.D. Introduction: It is generally believed that the coronary occlusion occurs at the site of plaque disruption in acute coronary syndromes. An exceptional mechanism of coronary occlusion, namely a streamer-like thrombus (SLT) originating in a nonstenotic lesion extended distally to obstruct a just distal nondisrupted stenotic segment, was found by angioscopy in patients with unstable angina (UA). This study was carried out to examine the incidence of this phenomenon and its relationship to the subtypes of UA. Methods: The culprit coronary artery was investigated by angioscopy in successive 48 patients (mean ± SE age, 61.0 ± 2.3 years; 10 females and 38 males) with UA. Results: SLT originating in a nonstenotic lesion extended distally, and obstructed the just distal most stenotic segment (DMSS) by its tail in 11 patients (eight with class III and three with class II according to Braunwald's classification). Recurrent anginal attacks were observed in all. The nonstenotic lesion in which the SLT originated was a disrupted yellow plaque in most cases. The SLT was frequently red and yellow in a mosaic pattern, indicating a mixture of fresh thrombus and plaque debris. The plaques that constructed the DMSS were not disrupted. Angiographically, the SLT was not detectable and the entry of the DMSS showed a "tapering" configuration. Conclusions: Obstruction of the DMSS by the tail of SLT originating in a nonstenotic lesion is another mechanism of UA. Therefore, treatment of both the nonstenotic lesion and DMSS is needed to prevent recurrent thrombus formation and consequent reattacks. (J Interven Cardiol 2010;23:216,222) [source] Timing of Death and Myocardial Infarction in Patients with Non-ST Elevation Acute Coronary Syndromes: Insights From Randomized Clinical TrialsJOURNAL OF INTERVENTIONAL CARDIOLOGY, Issue 5 2007M.S., RAJENDRA H. MEHTA M.D. Background: Adverse events occur following non-ST elevation acute coronary syndromes (NSTE ACS). However, the timing of these events in relation to index event is less clear. Methods: Accordingly, we evaluated 26,466 NSTE ACS patients from the Global Use of Strategies to Open Occluded Arteries in Acute Coronary Syndromes (GUSTO-IIb), Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy (PURSUIT), and Platelet IIb/IIIa Antagonism for the Reduction of Acute Coronary Syndrome Events in a Global Organization Network (PARAGON) A and B trials to ascertain the timing of adverse events. Outcomes of interest were death, myocardial infarction (MI), and death or MI at 180 days. Logistic regression modeling for death was used to categorize patients into low-, medium-, and high-risk groups. Results: At 6 months, 6.2% of patients died, 12.1% had MI, and 15.7% suffered death or MI. From 15% to 40% of these events occurred beyond 30 days. At 6 months, 3%, 4%, and 13% of patients died in low-, medium-, and high-risk groups, respectively. However, the proportion of patients dying beyond 30 days was similar in the three groups (44%, 43%, and 41% of death, respectively). Similarly, whereas death or MI increased with higher risk (11%, 14%, and 23%, respectively), the proportion of patients with this event beyond 30 days did not differ in the three strata (22%, 20%, and 25%, respectively). Conclusions: Our study provides important insights into the timing of adverse events and suggests that the substantial proportion of patients suffer subsequent adverse events after their index NSTE ACS. Thus, these data call for continuous surveillance for these events and efforts beyond the acute phase at increasing adherence to evidence-based therapies to improve the outcomes of these patients. [source] Sequence of Electrocardiographic and Acoustic Cardiographic Changes and Angina during Coronary Occlusion and Reperfusion in Patients Undergoing Percutaneous Coronary InterventionANNALS OF NONINVASIVE ELECTROCARDIOLOGY, Issue 2 2009A.N.P., Eunyoung Lee R.N., Ph.D. Background: Previous studies have suggested that ventricular function may be impaired without or prior to electrocardiographic changes or angina during ischemia. Understanding of temporal sequence of electrical and functional ischemic events may improve the detection of myocardial ischemia. Methods: A prospective study was performed in 21 subjects undergoing percutaneous coronary intervention (PCI) who had both ST amplitude changes >2 standard deviations above baseline on 12-lead electrocardiography (ECG), and new or increased third or fourth heart sound (S3 or S4) intensity measured by computerized acoustic cardiography. The sequence of the onset and resolution of these signs of ischemia were examined following coronary balloon inflation and deflation. Results: Electrocardiographic ST amplitude and diastolic heart sound changes occurred contemporaneously, shortly after coronary occlusion (mean onset from balloon inflation; ST changes, 21 ± 17 seconds; S4, 25 ± 26 seconds; S3, 45 ± 43 seconds). In 40% of patients, a new or increased S3 or S4 developed earlier than ST changes. Anginal symptoms occurred in only 2 of the 21 subjects during ischemia with a mean onset time of 68 seconds. ST-segment changes resolved earliest (33 seconds after balloon deflation) while diastolic heart sounds (89 ± 146 seconds) and angina (586 ± 653 seconds) resolved later. Conclusion: A new or intensified S3 and/or S4 occurred contemporaneously with electrocardiographic changes during ischemia. These diastolic heart sounds persisted longer than ST changes following coronary reperfusion. Acoustic cardiographic assessment of diastolic heart sounds may aid in the early detection of myocardial ischemia, particularly in those patients with an uninterpretable ECG. [source] Guideline Implementation Research: Exploring the Gap between Evidence and Practice in the CRUSADE Quality Improvement InitiativeACADEMIC EMERGENCY MEDICINE, Issue 11 2007Andra L. Blomkalns MD Translating research results into routine clinical practice remains difficult. Guidelines, such as the 2002 American College of Cardiology/American Heart Association Guidelines for the Management of Patients with Unstable Angina and non-ST-segment elevation myocardial infarction, have been developed to provide a streamlined, evidence-based approach to patient care that is of high quality and is reproducible. The Can Rapid Risk Stratification of Unstable Angina Patients Suppress ADverse Outcomes with Early Implementation (CRUSADE) Quality Improvement Initiative was developed as a registry for non,ST-segment elevation acute coronary syndromes to track the use of guideline-based acute and discharge treatments for hospitalized patients, as well as outcomes associated with the use of these treatments. Care for more than 200,000 patients at more than 400 high-volume acute care hospitals in the United States was tracked in CRUSADE, with feedback provided to participating physicians and hospitals regarding their performance over time and compared with similar institutions. Such access to data has proved important in stimulating improvements in non,ST-segment elevation acute coronary syndromes care at participating hospitals for delivery of acute and discharge guideline-based therapy, as well as improving outcomes for patients. Providing quality improvement methods such as protocol order sets, continuing education programs, and a CRUSADE Quality Improvement Initiative toolbox serve to actively stimulate physician providers and institutions to improve care. The CRUSADE Initiative has also proven to be a fertile source of research in translation of treatment guidelines into routine care, resulting in more than 52 published articles and 86 abstracts presented at major emergency medicine and cardiology meetings. The cycle for research of guideline implementation demonstrated by CRUSADE includes four major steps,observation, intervention, investigation, and publication,that serve as the basis for evaluating the impact of any evidence-based guideline on patient care. Due to the success of CRUSADE, the American College of Cardiology combined the CRUSADE Initiative with the National Registry for Myocardial Infarction ST-segment elevation myocardial infarction program to form the National Cardiovascular Data Registry,Acute Coronary Treatment & Intervention Outcomes Network Registry beginning in January 2007. [source] A historical overview of enhanced external counterpulsationCLINICAL CARDIOLOGY, Issue S2 2002Anthony N. Demaria M.D., MACC Chief Abstract Angina remains a significant health problem in the United States and the world. Although there are a variety of pharmacologic and interventional therapies to treat angina, many patients are not adequately helped by these treatments. Enhanced external counterpulsation (EECP) is an effective, noninvasive technique designed to decrease the frequency and duration of anginal episodes, as well as increase exercise duration in patients with acute angina. Since the early 1960s, the technology of EECP has been thoroughly refined. In addition, a number of important clinical trials have provided evidence for its effectiveness. Continuing research is needed to determine the best patients for EECP and its appropriate clinical application. [source] Management of patients with non,ST-segment elevation acute coronary syndromes: Insights from the pursuit trialCLINICAL CARDIOLOGY, Issue S5 2000Dan J. Fintel M.D The glycoprotein (GP) IIb-IIIa inhibitor eptifibatide (INTEGRILIN®, COR Therapeutics, Inc., South San Francisco, California, and Key Pharmaceuticals, Inc., Kenilworth, New Jersey) is a novel and highly potent antithrombotic agent indicated for the management of patients with non-ST-segment elevation acute coronary syndromes (ACS) and those undergoing percutaneous coronary intervention. The approval of eptifibatide for non-ST-segment elevation ACS was based on the positive results of the Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy (PURSUIT) trial. With enrollment of almost 11,000 patients, not only is the PURSUIT trial the largest trial of a GP IIb-IIIa inhibitor to date, but it is also the largest clinical study ever conducted in patients with non-ST-segment elevation ACS. The key feature of the PURSUIT trial is that patient management closely resembled standard clinical practice, because decisions about the use and timing of invasive cardiac procedures were made by the individual physicians rather than being prespecified in the study protocol. Eptifibatide therapy was associated with a significant reduction in the incidence of the primary endpoint,a composite of death or myocardial infarction at 30 days (14.2 vs. 15.7% in the placebo group; p = 0.042). Of importance is the fact that the beneficial effect of eptifibatide was independent of the management strategy pursued during study drug infusion (invasive or conservative), and it was achieved with few major safety concerns. These findings demonstrate that the use of eptifibatide should be considered for all patients presenting with signs and symptoms of intermediate- to high-risk non-ST-segment elevation ACS. [source] Prognostic significance of asymptomatic coronary artery disease in patients with diabetes and need for early revascularization therapyDIABETIC MEDICINE, Issue 9 2007E.-K. Choi Abstract Aims, Information on the clinical outcome of patients with diabetes with silent myocardial ischaemia is limited. We compared the clinical and angiographic characteristics, and the clinical outcomes of diabetic patients with asymptomatic or symptomatic coronary artery disease (CAD). Methods, Three hundred and ten consecutive diabetic patients with CAD were divided into two groups according to the presence of angina and followed for a mean of 5 years. Fifty-six asymptomatic patients with a positive stress test and CAD on coronary angiography were compared with 254 symptomatic patients, 167 with unstable angina and 87 with chronic stable angina. Results, Although the severity of coronary atherosclerosis was similar in asymptomatic and symptomatic patients, revascularization therapy was performed less frequently in the asymptomatic than the symptomatic patients (26.8 vs. 62.0%; P < 0.001). Asymptomatic patients experienced a similar number of major adverse cardiac events (MACEs; death, non-fatal myocardial infarction, and revascularization; 32 vs. 28%; P = 0.57), but had higher cardiac mortality than symptomatic patients (26 vs. 9%; P < 0.001). However, patients who underwent revascularization therapy at the time of CAD diagnosis in these two groups showed similar MACE and cardiac mortality (20.0 vs. 22.5%, 6.7 vs. 5.3%, respectively; all P > 0.05). Conclusions, This study suggests that diabetic patients with asymptomatic CAD have a higher cardiac mortality risk than those with symptomatic CAD, and that lack of revascularization therapy may be responsible for the poorer survival. [source] Interactive effect of retinopathy and macroalbuminuria on all-cause mortality, cardiovascular and renal end points in Chinese patients with Type 2 diabetes mellitusDIABETIC MEDICINE, Issue 7 2007P. C. Y. Tong Abstract Aims To examine the effect of albuminuria and retinopathy on the risk of cardiovascular and renal events, and all-cause mortality in patients with Type 2 diabetes. Methods A post-hoc analysis of 4416 Chinese patients without macrovascular complications at baseline (age 57.6 ± 13.3 years). Glomerular filtration rate (eGFR) was estimated by the abbreviated Modification of Diet in Renal Disease Study Group Formula, further adjusted for Chinese ethnicity. Clinical end points were all-cause mortality, cardiovascular events (heart failure or angina, myocardial infarction, lower limb amputation, re-vascularization procedures and stroke) and renal end points (reduction in eGFR by more than 50% or eGFR < 15 ml/min/1.73 m2 or death as a result of renal causes or need for dialysis). Results Compared with individuals without complications, subjects with retinopathy and macroalbuminuria had higher rates of cardiovascular events (14.1 vs. 2.4%), renal events (40.0 vs. 0.8%) and death (9.3 vs. 1.7%, P < 0.001). For composite event of death, cardiovascular and renal events, the presence of retinopathy, microalbuminuria alone, macroalbuminuria alone, retinopathy with microalbuminuria or retinopathy with macroalbuminuria increased the risk [hazard ratio (95% CI)] by 1.61 (1.05 to 2.47; P = 0.04), 1.93 (1.38 to 2.69; P < 0.001), 4.34 (3.02 to 6.22; P < 0.001), 2.59 [1.76 to 3.81; P < 0.001) and 6.83 (4.89 to 9.55; P < 0.001) fold, respectively. The relative excess risk as a result of interaction between retinopathy and macroalbuminuria was 15.31, implying biological interaction in the development of renal events. Conclusions In Chinese patients with Type 2 diabetes, retinopathy interacts with macroalbuminuria to increase the risk of composite cardio-renal events. [source] Myocardial perfusion imaging and cardiac events in a cohort of asymptomatic patients with diabetes living in southern FranceDIABETIC MEDICINE, Issue 4 2006A. Sultan Abstract Aims, To assess the association between abnormal stress myocardial perfusion imaging (MPI) and cardiac events (CE) in asymptomatic patients with diabetes and with , 1 additional risk factor. Predictors of abnormal stress MPI were also evaluated. Methods, Four hundred and forty-seven consecutive patients who underwent stress MPI were prospectively followed for 2.1 [0.5,4.1] years for the subsequent occurrence of hard CE (myocardial infarction and sudden or coronary death) and soft CE (unstable angina and ischaemic heart failure requiring hospitalization). Re-vascularization procedures performed as a result of the screening protocol were not included in the analysis. Results, Follow-up was successful in 419 of 447 patients (94%), of whom 71 had abnormal MPI at baseline. Medical therapy was intensified in all subjects and especially in those with abnormal MPI. Twenty-three patients with abnormal MPI underwent a re-vascularization procedure. CEs occurred in 14 patients, including six of 71 patients (8.5%) with abnormal MPI and eight of 348 patients (2.3%) with normal MPI (P < 0.005). Only two patients developed a hard CE and 12 a soft CE. In multivariate analysis, abnormal MPI was the strongest predictor for CEs [odds ratio (OR) (95% CI) = 5.6 (1.7,18.5)]. Low-density lipoprotein cholesterol , 3.35 mmol/l [OR (95% CI) = 7.3; 1.5,34.7] and age > median [OR (95% CI) = 6.0 (1.2,28.6)] were additional independent predictors for CE. The independent predictors for abnormal MPI were male gender, plasma triglycerides , 1.70 mmol/l, creatinine clearance < 60 ml/min and HbA1c > 8%, with male gender the strongest [OR (95% CI) = 4.0 (1.8,8.8)]. Conclusions, Asymptomatic patients with diabetes in this study had a very low hard cardiac event rate over an intermediate period. This could be explained by the effects of intervention or by the low event rate in the background population. Randomized studies of cardiac heart disease screening are required in asymptomatic subjects with diabetes to determine the effectiveness of this intervention. Diabet. Med. (2006) [source] Nephropathy, but not retinopathy, is associated with the development of heart disease in Type 1 diabetes: a 12-year observation study of 462 patientsDIABETIC MEDICINE, Issue 6 2005O. Torffvit Abstract Aims To study the occurrence of heart disease and death in Type 1 diabetic patients and evaluate whether presence of microangiopathy, i.e. nephropathy and retinopathy, was associated with the outcome. Methods A 12-year observation study of 462 Type 1 diabetic patients without a previous history of heart disease at baseline who were treated under routine care in a hospital out-patient clinic. Results A total of 85 patients developed signs of heart disease, i.e. myocardial infarction (n = 41), angina (n = 23), and heart failure (n = 17) and 56 patients died. The mortality for patients without signs of heart disease during the observation period was 7.6% compared with 51% in patients with myocardial infarction (P < 0.001), 26% in patients with angina (P < 0.01) and 65% in patients with heart failure (P < 0.001). The relative risk for death was 9.0 (P < 0.001) and 2.5 (P < 0.05) times higher in patients with macroalbuminuria and microalbuminuria, respectively. The risk for cardiovascular death was 18.3 times (P < 0.001) higher in patients with macroalbuminuria compared with patients with normoalbuminuria. In patients with sight-threatening retinopathy, the relative risk for death was 7.0 times higher (P < 0.01) and the risk for coronary heart disease events 4.4 times higher (P < 0.05) compared with patients with no retinopathy. However, when retinopathy was adjusted for presence of macroalbuminuria, this association disappeared. Conclusion This study shows a high incidence of heart disease in patients with Type 1 diabetes. The worse prognosis was seen in patients with sight-threatening retinopathy and macroalbuminuria and microalbuminuria at baseline. Macroalbuminuria and microalbuminuria were independently associated with a high risk for heart disease and death while the association with sight-threatening retinopathy only occurred in the presence of nephropathy. [source] The effect of diabetes on heart rate and other determinants of myocardial oxygen demand in acute coronary syndromesDIABETIC MEDICINE, Issue 9 2004K. Foo Abstract Aims To compare major determinants of myocardial oxygen demand (heart rate, blood pressure and rate pressure product) in patients with and without diabetes admitted with acute coronary syndromes. Methods A cross-sectional study of the relation between diabetes and haemodynamic indices of myocardial oxygen demand in 2542 patients with acute coronary syndromes, of whom 1041 (41.0%) had acute myocardial infarction and 1501 (59.0%) unstable angina. Results Of the 2542 patients, 701 (27.6%) had diabetes. Major haemodynamic determinants of myocardial oxygen demand were higher in patients with than without diabetes: heart rate 80.0 ± 20.4 vs. 75.2 ± 19.2 beats/minute (P < 0.0001); systolic blood pressure 147.3 ± 30.3 vs. 143.2 ± 28.5 mmHg (P = 0.002); rate-pressure product 11533 ± 4198 vs. 10541 ± 3689 beats/minute × mmHg (P < 0.0001). Multiple regression analysis confirmed diabetes as a significant determinant of presenting heart rate [multiplicative coefficient (MC) 1.05; 95% confidence interval (CI) 1.03,1.07; P < 0.0001], rate pressure product (MC 1.09; CI 1.05,1.12; P < 0.0001) and systolic blood pressure, which was estimated to be 3.9 mmHg higher than in patients without diabetes (P = 0.003). These effects of diabetes were independent of a range of baseline variables including acute left ventricular failure and mode of presentation (unstable angina or myocardial infarction). Conclusions In acute coronary syndromes, heart rarte and other determinants of myocardial oxygen demand are higher in patients with than without diabetes, providing a potential contributory mechanism of exaggerated regional ischaemia in this high-risk group. [source] SPONTANEOUS COLONIC HEMATOMA: ENDOSCOPIC APPEARANCEDIGESTIVE ENDOSCOPY, Issue 2 2007Marcus Martins Dos Santos Intramural colonic hematoma is a rare complication of anticoagulation therapy. We report a patient under therapy with acetylsalicylic acid, low-molecular-weight heparin and clopidogrel for unstable angina, who presented with massive lower gastrointestinal bleeding secondary to spontaneous intramural colonic hematoma, with unremarkable coagulation tests. Diagnosis was promptly made by colonoscopy, and the patient was successfully managed with a conservative approach, with complete resolution of symptoms after 7 days. This is the first report of spontaneous intramural colonic hematoma presumed to be related to acetylsalicylic acid, enoxaparin and clopidogrel. [source] Estimation of Coronary Flow Velocity Reserve Using Transthoracic Doppler Echocardiography and Cold Pressor Test Might Be Useful for Detecting of Patients with Variant AnginaECHOCARDIOGRAPHY, Issue 4 2010Hui-Jeong Hwang M.D. Purpose: The cold pressor test (CPT) has been used to detect variant angina, but its sensitivity in predicting vasospasm is low. The aim of this study was to determine whether estimates of the coronary flow velocity reserve (CFVR) in the distal left anterior descending coronary artery (dLAD) using transthoracic echocardiography (TTE) and CPT are useful tool to predict variant angina. Methods: 65 patients (mean age = 52 ± 10 years; male:female = 41:24) who had normal coronary artery on angiography and underwent acetylcholine provocation test were enrolled and divided into the spasm group (n = 31) and the no spasm group (n = 34). During CPT, the peak (PDV) and mean diastolic flow velocity (MDV) of the dLAD were estimated using TTE with a high-frequency transducer, and electrocardiography, blood pressures, heart rate, and symptoms were monitored every 30 seconds. CPT%PDV and CPT%MDV were defined as the percentage changes in PDV and MDV during CPT, respectively. Results: CPT%PDV was 4.99 ± 23.62% in the spasm group and 52.75 ± 24.78% in the no spasm group (P < 0.001). CPT%MDV was 6.83 ± 23.81% in the spasm group and 50.22 ± 27.83% in the no spasm group (P < 0.001). CPT%PDV<31.1% had a sensitivity of 93.5% and a specificity of 82.4% in predicting variant angina (95% confidence interval [CI]: 0.939,0.979, P < 0.001). CPT%MDV<30.55% had a sensitivity of 90% and a specificity of 76.5% in predicting variant angina (95% CI: 0.884,0.950, P < 0.001). Conclusion: The measurement of changes in the coronary flow velocity of the dLAD using TTE and CPT might be useful for the estimation of endothelial dysfunction in patients with variant angina. (ECHOCARDIOGRAPHY 2010;27:435-441) [source] An Uncommon Cause of Coronary Artery Ostial Obstruction: Papillary FibroelastomaECHOCARDIOGRAPHY, Issue 3 2010D.E.A.A., Gabor Erdoes M.D. Cardiac papillary fibroelastoma is a benign tumor that mainly affects cardiac valves. The tumor has the potential to cause angina and myocardial infarction due to embolization of tumor fragments. We describe a rare case of right coronary artery ostial obstruction by a 12 × 19 mm sized papillary fibroelastoma located in the sinus of Valsalva. The report underlies the importance of echocardiography in diagnosis and intraoperative treatment of this type of cardiac mass. (Echocardiography 2010;27:337-340) [source] Correlation between NT-pro BNP Levels and Early Mitral Annulus Velocity (E,) in Patients with Non,ST-Segment Elevation Acute Coronary SyndromeECHOCARDIOGRAPHY, Issue 4 2008Marcia M. Barbosa M.D., Ph.D. Acute coronary syndromes in the absence of ST-segment elevation (NSTE-ACS) are a heterogeneous entity in which early risk stratification is essential. Diastolic dysfunction is precocious and associated with poor prognosis. BNP has been recognized as a biochemical marker of ventricular dysfunction and ischemia. Objective: To investigate if there is correlation of NT pro-BNP levels with diastolic dysfunction in patients with NSTE-ACS. Methods: Fifty-two patients with NSTE-ACS admitted to the coronary unit were included. NT-pro brain natriuretic hormone (BNP) levels and a Doppler echocardiogram were obtained in all and systolic and diastolic functions were analyzed. Their Doppler indexes were compared with those of 53 age- and sex-matched controls, without heart failure symptoms and with normal ejection fraction (EF) and normal NT-pro BNP levels. Results: Twenty-four patients (46%) with unstable angina and 28 patients (54%) with acute myocardial infarction (AMI) were included. Mean EF was 55.9 ± 10.7% and mean NT-pro BNP level was 835 ± 989 pg/ml. No mitral or pulmonary venous flow parameters of diastolic function correlated with NT-pro BNP levels. E,/A, correlated with NT-pro BNP level in univariate analysis but, in a multivariate analysis, only the EF and the E, showed negative correlation with the peptide level (r =,0.33, P = 0.024 and r =,0.29, P = 0.045, respectively). Thirteen patients presented with stage II diastolic dysfunction but the NT-pro BNP level in these patients did not differ from the level in stage I patients. Conclusion: NT-pro BNP levels are elevated in acute coronary syndromes, even in the absence of significant necrosis. Of all echocardiographic parameters investigated, only E, and the EF correlated with the levels of NT-pro BNP in this group of patients. [source] Clinical and Echocardiographic Aspects of Mid-Ventricular Hypertrophic CardiomyopathyECHOCARDIOGRAPHY, Issue 6 2005Francisco Martínez Baca-López M.D. Three cases of patients with hypertropic cardiomyopathy, apical aneurysm, and mid-ventricular obstruction are presented. Two patients were diagnosed first by two-dimensional and Doppler echocardiography, which showed mid-ventricular obliteration, characteristic hourglass image, and paradoxic jet flow. One patient with suboptimal echocardiogram was necessary to perform contrast echocardiogram. Clinical picture was characterized by angina and dyspnea. Thallium myocardial imaging revealed perfusion abnormalities in apical region, ischemia or necrosis. Cardiac catheterism showed mid-ventricular obliteration and significant intraventricular gradient and coronary arteries angiography without lesions. [source] Prognostic Value of 12-Lead Electrocardiogram During Dobutamine Stress EchocardiographyECHOCARDIOGRAPHY, Issue 5 2000Milind R. Dhond M.D. The aim of this study was to assess the prognostic value of the 12-lead electrocardiogram (ECG) obtained during dobutamine stress echocardiography (DSE) in predicting subsequent cardiac events. We retrospectively analyzed 345 patients undergoing DSE in 1992,1994 and selected those patients with negative echo results for ischemia. Of the 200 patients with negative DSE results, a separate analysis of their ECG data was performed with results reported as either positive, negative, or nondiagnostic for ischemia. Follow-up was performed through a physician chart review and direct telephone contact. Event rates were determined for hard (myocardial infarction or cardiac death) and soft (hospitalization for angina and/or congestive heart failure, coronary angioplasty, or coronary artery bypass graft surgery) cardiac events occurring after the negative DSE for up to 6 years after the test. Death was also determined by referencing the patients' data with mortality data available on the Internet. There were 143 patients with ECG data reported as negative and 40 patients with ECG data reported as positive for ischemia. The hard and soft event rates were 1.5% and 9% per patient per year in the ECG negative group and 2% and 11% in the ECG positive group. There were no statistical differences in event rates between the two groups during the 5-year follow-up period. Our results suggest that the ECG result obtained during DSE does not confer any incremental prognostic value over the echo result. [source] How does variability in alcohol consumption over time affect the relationship with mortality and coronary heart disease?ADDICTION, Issue 4 2010Annie Britton ABSTRACT Objective To examine the relationship between alcohol consumption and risk of mortality and incident coronary heart disease (CHD), taking account of variation in intake during follow-up. Method Prospective cohort study of 5411 male civil servants aged 35,55 years at entry to the Whitehall II study in 1985,88. Alcohol consumption was reported five times over a 15-year period. Mortality, fatal CHD, clinically verified incident non-fatal myocardial infarction and definite angina were ascertained during follow-up. Results We found evidence that drinkers who vary their intake during follow-up, regardless of average level, have increased risk of total mortality (hazard ratio of high versus low variability 1.52: 95% CI: 1.07,2.17), but not of incident CHD. Using average consumption level, as opposed to only a baseline measure, gave slightly higher risk estimates for CHD compared to moderate drinkers at the extremes of the drinking range. Conclusions Multiple repeated measures are required to explore the effects of variation in exposure over time. Caution is needed when interpreting risks of exposures measured only once at baseline, without consideration of changes over time. [source] Increased coronary sinus blood temperature: correlation with systemic inflammationEUROPEAN JOURNAL OF CLINICAL INVESTIGATION, Issue 4 2006K. Toutouzas Abstract Background, Recent studies have shown that patients with single vessel coronary artery disease (CAD) suffering from acute coronary syndromes (ACS) have increased coronary sinus (CS) blood temperature compared with the right atrium (RA). The aim of this study was to investigate whether there is a correlation between systemic inflammatory indexes and CS temperature and whether there is a difference in CS temperature between patients with single vs. multivessel disease. Materials and methods, We included consecutive patients scheduled for coronary angiography for recent-onset chest pain evaluation. We measured C-reactive protein (CRP) levels in the study population. Coronary sinus and RA blood temperature measurements were performed by a 7F thermography catheter. ,, was calculated by subtracting the RA from the CS blood temperature. Results, The study population comprised 53 patients with ACS, 25 patients with stable angina (SA) and 22 subjects without CAD (control group). ,, was greater in patients with ACS and with SA compared with the control group (0·22 ± 0·10 °C, 0·18 ± 0·04 °C vs. 0·14 ± 0·07 °C, P < 0·01 for both comparisons). The ACS group had greater ,, compared with the SA group, although the difference did not reach statistical significance (P = 0·09). Eighteen (39·1%) out of 46 patients with multivessel disease had three-vessel disease and 28 (60·8%) had two-vessel disease. ,, between patients with multivessel and single vessel disease was similar (0·22 ± 0·01 °C, 0·19 ± 0·01 °C, P = 0·17). The levels of CRP were well correlated with ,, (R = 0·35b, P < 0·01). Conclusions, Systemic inflammation is well correlated with CS temperature; thus, an inflammatory process could be the underlying mechanism for increased heat production from the myocardium. [source] Plasma matrix metalloproteinase-3 level is an independent prognostic factor in stable coronary artery diseaseEUROPEAN JOURNAL OF CLINICAL INVESTIGATION, Issue 9 2005T. C. Wu Abstract Background, Recent evidence suggests the important role of matrix metalloproteinases (MMPs) in the progression of atherosclerosis and development of clinical events. We assessed the prognostic value of different plasma MMPs in patients with stable coronary artery disease (CAD). Materials and methods, A total of 165 consecutive nondiabetic patients with angiographically significant CAD (n = 150) or normal coronary angiograms despite exercise-induced myocardial ischemia (cardiac syndrome X, n = 15) and 17 normal subjects were evaluated. In each subject, plasma inflammatory markers including high sensitivity C-reactive protein (hsCRP) and MMP-2, 3 and 9 were measured. In CAD patients, major cardiovascular events including cardiac death, nonfatal myocardial infarction, unscheduled coronary revascularization and hospitalization as a result of unstable angina were prospectively followed up for more than 6 months. Results, Plasma levels of MMPs were significantly higher in CAD patients than in those with cardiac syndrome X and in normal subjects (MMP-2: 914·76 ± 13·20 vs. 830·79 ± 31·95 vs. 783·08 ± 28·40 ng mL,1, P = 0·002; MMP-3: 129·59 ± 4·21 vs. 116·86 ± 8·09 vs. 91·71 ± 9·55 ng mL,1, P = 0·011; MMP-9: 31·42 ± 2·84 vs. 11·40 ± 5·49 vs. 6·71 ± 2·89 ng mL,1, P = 0·006). In CAD patients, there were 48 major cardiovascular events during a mean follow-up period of 17·74 ± 0·85 months. The numbers of diseased vessels (HR = 2·19, 95% CI 1·20,1·02, P = 0·011), plasma hsCRP (HR = 2·21, 95% CI 1·18,4·11, P = 0·013) and MMP-3 level (HR = 2·46, 95% CI = 1·15,5·28, P = 0·021) were associated with the development of cardiovascular events. However, only the plasma MMP-3 level was an independent predictor of the adverse events in CAD patients (HR = 2·47, 95% CI 1·10,5·54, P = 0·028). Conclusions, Plasma MMP levels were increased in CAD patients. Plasma MMP-3 level, rather than hsCRP, was an independent prognostic marker for future cardiovascular events, suggesting its potential role in risk stratification and clinical management of stable CAD. [source] Measurement of the soluble angiopoietin receptor tie-2 in patients with coronary artery disease: development and application of an immunoassayEUROPEAN JOURNAL OF CLINICAL INVESTIGATION, Issue 7 2003N. A. Y. Chung Abstract Background The angiopoietin family has emerged as a group of crucial growth factors to normal angiogenesis. They are essential to the development of the mature vessel wall and interact with the endothelium via endothelial cell-specific tyrosine kinase receptors, tie-1 and tie-2. The role of the tie-2 receptor has been extensively examined in neovascularization associated with malignancy, but little is known about the role it may play in atherosclerosis, a condition whose pathophysiology also involves angiogenesis. Soluble tie-2 has been detected in the plasma of healthy controls, but this has yet to be applied to patients in the clinical setting. Materials and methods We developed an ELISA to detect plasma tie-2 levels and applied these to a clinical setting. The intra- and interassay coefficients of variation for the assay were 4·7% and 9·6%, respectively. We then measured levels of tie-2, vascular endothelial growth factor (VEGF), another factor associated with angiogenesis, and the soluble VEGF receptor Flt-1 (sFlt-1) in 75 patients with coronary artery disease [25 with acute myocardial infarction (AMI), 25 with acute coronary syndromes (ACS) and 25 with stable angina] and 25 healthy controls. Results Median [IQR, interquartile range] levels of tie-2 were significantly higher in the coronary artery disease patients (AMI 12 [10,17] ng mL,1, ACS 10 [9,14] ng mL,1, stable angina 9 [3,11] ng mL,1) when compared with the controls (7·5 [7,9] ng mL,1P = 0·004). As expected, levels of VEGF and sFlt were significantly different from those in the healthy controls (P = 0·011 and P < 0·001, respectively). Significant correlations were found between levels of tie-2 and VEGF (Spearman r = 0·59, P < 0·001), tie-2 and sFlt-1 (r = 0·45, P < 0·001) and VEGF and sFlt-1 (r = 0·56, P < 0·001) in the whole study group. Conclusion We suggest that tie-2 may be potentially used as a marker of angiogenesis in atherosclerosis and may help elucidate the role of the angiopoietin/tie-2 system in atherogenesis. [source] Elective coronary angioplasty with 60 s balloon inflation does not cause peroxidative injuryEUROPEAN JOURNAL OF CLINICAL INVESTIGATION, Issue 3 2002K. Cedro Abstract Background The aim of this study was to evaluate the ongoing controversial issue of whether ischemia/reperfusion during elective coronary angioplasty evokes myocardial peroxidative injury. Design We measured indicators of free radical damage to lipids (free malondialdehyde) and proteins (sulphydryl groups) in coronary sinus blood in 19 patients with stable angina who were undergoing elective angioplasty for isolated stenosis of the proximal left anterior descending coronary artery. Ischemia induced by 60 s balloon inflations was confirmed by lactate washout into coronary sinus after deflation, with immediate and 1 min samples. Peroxidative injury was assessed from washout of (a) malondialdehyde measured directly by high performance liquid chromatography and (b) reduced sulphydryl groups, inverse marker of protein oxidative stress. Results Mean lactate concentration immediately after each deflation increased by 120,150% of the initial value, confirming ischemia and showing that blood originated largely from the ischemic region. Lack of myocardial production of malondialdehyde was confirmed by (a) no arteriovenous differences in individual basal concentrations (aortic, range 0·33,12·03 nmol mL,1, mean 7·82; coronary sinus blood, range 0·52,15·82 nmol mL,1, mean 8·18), and (b) after deflations, mean concentrations were not significantly different from preocclusion value. There was no decrease in concentration of sulphydryl groups throughout angioplasty. Conclusion Elective coronary angioplasty with 60 s balloon inflations is a safe procedure that does not induce peroxidative myocardial injury as assessed by methods used in the present study. [source] Effects of trimetazidine, a partial inhibitor of fatty acid oxidation, on ventricular function and survival after myocardial infarction and reperfusion in the ratFUNDAMENTAL & CLINICAL PHARMACOLOGY, Issue 4 2010Frederic Mouquet Abstract Trimetazidine (TMZ), a partial inhibitor of fatty acid oxidation, has been effective in treating chronic angina, but its effects on the development of post-myocardial infarction (MI) left ventricular remodeling are not defined. In this study, we tested whether chronic pre-MI administration of TMZ would be beneficial during and after acute MI. Two-hundred male Wistar rats were studied in four groups: sham + TMZ diet (n = 20), sham + control diet (n = 20), MI + TMZ diet (n = 80), and MI + control diet (n = 80) splitted into one short-term and one long-term experiments. Sham surgery consisted of a thoracotomy without coronary ligation. MI was induced by coronary occlusion followed by reperfusion. Left ventricle (LV) function and remodeling were assessed by serial echocardiography throughout a 24-week post-MI period. LV remodeling was also assessed by quantitative histological analysis of post-MI scar formation at 24 weeks post-MI. During the short-term experiment, 10/80 rats died after MI, with no difference between groups (MI + control = 7/40, MI + TMZ = 3/40, P = 0.3). In the long-term experiment, the deaths occurred irregularly over the 24 weeks with no difference between groups (MI + control = 16% mortality, MI + TMZ = 17%, P = 0.8). There was no difference between groups as regard to LV ejection fraction (MI + control = 36 ± 13%, MI + TMZ = 35 ± 13%, P = 0.6). In this experimental model, TMZ had no effects on the post-MI occurrence of LV dysfunction or remodeling. Further investigations are warranted to assess whether the partial inhibition of fatty acid oxidation may limit the ability of the heart to respond to acute severe stress. [source] Increased serum anandamide level at ruptured plaque site in patients with acute myocardial infarctionFUNDAMENTAL & CLINICAL PHARMACOLOGY, Issue 3 2009Naotaka Maeda Abstract Inflammation caused by activated macrophages and T lymphocytes may trigger plaque rapture in acute coronary syndrome (ACS). Anandamide and 2-arachidonylglycerol (2-AG) are macrophage-derived signal lipids and may be involved in the pathogenesis of ACS, but no clinical relevant data have been reported. In 43 acute myocardial infarction (AMI) patients (66 ± 2 years), blood samples were obtained from the aortic root and the infarct-related coronary artery (IRA) using a PercuSurge system during primary percutaneous coronary intervention (PCI). In six patients with stable effort angina (SEA) (56 ± 6 years), blood samples were obtained from the site of stenosis during elective PCI. In 25 of the 43 AMI patients, anandamide was detected in the serum. Serum anandamide level was 35 ± 20 pmol/mL in the aorta and was significantly increased to 401 ± 134 pmol/mL in the IRA (P < 0.01). 2-AG was undetectable in most of the patients. In patients with SEA, neither anandamide nor 2-AG was detected in the serum at the plaque site. In AMI patients with anandamide detected, left ventricular ejection fraction at 2 weeks after PCI was increased by 3.7 ± 2.1% compared with that at the acute phase, while it was decreased by 3.0 ± 1.8% in those without anandamide detected (P < 0.05). The serum anandamide level at the culprit lesion was elevated compared with the systemic level in a significant number of AMI patients, indicating the synthesis of anandamide at the IRA. Anandamide was suggested to be derived from ruptured plaque and may exert beneficial effects in humans. [source] Metabolic therapy in the treatment of ischaemic heart disease: the pharmacology of trimetazidineFUNDAMENTAL & CLINICAL PHARMACOLOGY, Issue 2 2003William C. Stanley Abstract The primary result of myocardial ischaemia is reduced oxygen consumption and adenosine triphosphate (ATP) formation in the mitochondria, and accelerated anaerobic glycolysis, lactate accumulation and cell acidosis. Classic pharmacotherapy for demand-induced ischaemia is aimed at restoring the balance between ATP synthesis and breakdown by increasing the oxygen delivery (i.e. with long acting nitrates or Ca2+ channel antagonist) or by decreasing cardiac power by reducing blood pressure and heart rate (i.e. with , -blocker or Ca2+ channel antagonist). Animal studies show that fatty acids are the primary mitochondrial substrate during moderate severity myocardial ischaemia, and that they inhibit the oxidation of carbohydrate and drive the conversion of pyruvate to lactate. Drugs that partially inhibit myocardial fatty acid oxidation increase carbohydrate oxidation, which results in reduced lactate production and a higher cell pH during ischaemia. Trimetazidine (1-[2,3,4-trimethoxibenzyl]-piperazine) is the first and only registered drug in this class, and is available in over 90 countries world-wide. Trimetazidine selectively inhibits the fatty acid , -oxidation enzyme 3-keto-acyl-CoA dehydrogenase (3-KAT), and is devoid of any direct haemodynamic effects. In double-blind placebo-controlled trials trimetazidine significantly improved symptom-limited exercise performance in stable angina patients when used either as monotherapy or in combination with , -blockers or Ca2+ channel antagonists. Given available evidence, trimetazidine is an excellent alternative to classic haemodynamic agents, and is unique in its ability to reduce symptoms of angina when used in patients resistant to a haemodynamic treatment as vasodilators, , -blockers or Ca2+ channel antagonists. [source] Are Migraine and Coronary Heart Disease Associated?HEADACHE, Issue 2004An Epidemiologic Review In evaluating the cardiovascular risks of triptans (5-HT1B/1D agonists) for the treatment of migraine, the possible relationship between migraine and cardiovascular disease warrants careful assessment. The vascular nature of migraine is compatible with the possibility that migraine is a manifestation of cardiovascular disease or is linked to cardiovascular disease via a common mechanism. If so, then migraine itself,independent of the use of triptans,may be associated with an increased risk of cardiac events. This article considers the epidemiologic literature pertinent to evaluating the association of migraine with coronary heart disease. The research reviewed herein fails to support an association between migraine and coronary heart disease. First, data from several large cohort studies show that the presence of migraine does not increase risk of coronary heart disease. Furthermore, although migraineurs are generally more likely than nonmigraineurs to report chest pain, the presence of chest pain in most studies did not predict serious cardiac events such as myocardial infarction. That the gender- and age-specific prevalence of migraine does not overlap with that of coronary heart disease is also consistent with a lack of association between migraine and atherosclerotic cardiovascular disease. While migraine appears not to be associated with coronary heart disease, preliminary evidence suggests a possible link of migraine with vasospastic disorders such as variant angina and Raynaud's phenomenon. These results warrant further investigation in large prospective studies. [source] Outpatient Intravenous Dihydroergotamine for Refractory Cluster HeadacheHEADACHE, Issue 3 2004E. Magnoux MD Objective.,To evaluate the efficacy and safety of outpatient intravenous dihydroergotamine (DHE) for treatment of refractory cluster headache. Method.,Medical records were retrospectively reviewed of all patients with cluster headache who received outpatient intravenous DHE for treatment of refractory cluster headache between January 1992 and May 2000. Results.,One hundred four treatments were identified in 70 patients. There were 7 dropouts. Of the 97 completed treatments, 60 were for episodic cluster headache and 37 were for chronic cluster headache. Results for all treatments showed complete resolution of pain during the intravenous phase at 1 month in 61 (63%) of 97 cases, partial resolution in 13 cases (15%), and failure in 23 cases (24%). For the treatment of episodic cluster headache, there was complete resolution in 44 (73%) of 60 cases, partial resolution in 9 cases (13%), and failure in 7 cases (12%). For treatment of chronic cluster headache, there was complete resolution in 17 (46%) of the 37 cases, partial resolution in 4 cases (11%), and 16 failures (43%). As regards side effects and safety, the treatment triggered chest pain suspected of being vasospastic angina in 1 patient on day 7 of the treatment, when she was in the subcutaneous phase. Two patients dropped out due to fear of the injection, 1 because of palpitations, 1 because of chest tightness, and 2 others because of leg cramps, nausea, and diarrhea. Conclusions.,Outpatient intravenous DHE is a safe treatment. It is useful for refractory cluster headache, is more effective for the episodic form than the chronic form, and has a rapid onset of action. It did not change the evolution of the episodic form, but it did appear to induce remission in the chronic form or transform it to the episodic form. We advance a hypothesis to explain this. [source] Uremic hyperhomocysteinemia: A randomized trial of folate treatment for the prevention of cardiovascular eventsHEMODIALYSIS INTERNATIONAL, Issue 2 2007Areuza C. A. VIANNA Abstract Homocysteine is a risk factor for atherosclerosis in the general population, and serum homocysteine levels are almost universally elevated in chronic renal failure patients. When such patients are treated with dialysis, cardiovascular disease accounts for more than 50% of their mortality, which, in some proportion, may be pathophysiologically related to the elevated serum homocysteine levels. From April 2003 to March 2005, we conducted a 2-year, double-blind, randomized, placebo-controlled trial of 186 patients with end-stage kidney disease due to any cause, who were older than 18 years and stable on hemodialysis. Patients were assigned to receive either oral folic acid 10 mg 3 times a week immediately after every dialysis session under nurse supervision or an identical-appearing placebo for the entire study. On admission, plasma total homocysteine (tHcy) levels were above 13.9 ,mol/L in 96.7% of patients (median 25.0 ,mol/L, range 9.3,104.0 ,mol/L). In the placebo group, tHcy levels remained elevated at 6, 12, and 24 months, while oral folate significantly decreased tHcy to a median value of 10.5 (2.8,20.3) ,mol/L, (p<0.01). During the study, 38 patients (folic acid group 17 vs. placebo group 21; p=0.47) died from cardiovascular disease. Kaplan,Meier life table analysis dealing with the incidence of cardiovascular events, both fatal and nonfatal (myocardial infarction, arrhythmias, angina, heart failure, cerebrovascular accident), showed that 2 years of folic acid treatment and the lowering of the homocysteine blood levels had no effect on cardiovascular events (p=0.41; hazard ratio 1.24, 95% CI 0.74,2.10). However, the carotid artery intima-media wall thickness measured in a blinded fashion decreased from 1.94 ± 0.59 mm to 1.67 ± 0.38 mm (p<0.01) after 2 years of folate therapy. In this short-term study of uremic patients, 2 years of folic acid supplementation normalized the tHcy blood levels in 92.3% of patients but did not change the incidence of cardiovascular events compared with the control group. However, ultrasonography of the common carotid arteries performed at entry and 24 months later showed a significant decrease in intima-media thickness with folate supplementation. This suggests that early folate supplementation may benefit patients with chronic renal failure by preventing cardiovascular deterioration. [source] | ||||||||||||||||||||||||||||||||||