EDUCATION IN HEART VOL 3 - PART 10 potx

RENAL ARTERY INTERVENTION FOR PRESERVATION OF RENAL FUNCTION There is increasing consensus that blood pressure can be managed medically in most patients with renal artery stenosis. Therefore the preservation/improvement of renal function has become the most important indication for renal revascularisation. Patients with generalised atherosclerosis may have a variety of conditions causing renal failure including (essential) hypertension, renal hypoperfusion due to congestive heart failure, atheroembolic disease, diabetes mellitus, radiocontrast nephrotoxicity from (repeat) percutaneous coronary interventions, and ischaemic nephropathy from arteriosclerotic renal artery disease. Recently it has been argued that many patients with renal artery stenosis do not have critical ischaemia/hypoxia of the renal parenchyma, but rather a relative hypoperfusion which limits the glomerular filtration rate without causing true tissue ischaemia. Therefore, the more appropriate term “chronic azotemic renovascular disease” has been proposed. 13 Compared with the excellent procedural results of renal artery stenting 8 the clinical outcome of this procedure is less certain. In particular, the impact on renal function is complex; in addition to the general risks of invasive arterial procedures, renal artery interventions themselves carry a significant renal risk, mainly related to radiocontrast nephropathy and cholesterol embolisation from atheromatous plaques. Hence it is not surprising that renal function often fails to improve, despite technically successful revascularisation; in a substantial portion of patients it may even deteriorate. The registry report on renal artery stenting in 1058 patients showed overall a significant reduction of the mean (SD) serum creatinine concen- tration from 1.7 (1.1) mg/dl (150 (97) µmol/l) to 1.3 (0.8) mg/dl (115 (71) µmol/l) over a four year follow up period, sug- gesting that renal artery revascularisation is beneficial in the long ter m in the majority of patients. 3 However, there are no published randomised controlled studies in which the effect of renal ar tery stenting is compared to optimal conservative treatment with modern antihypertensive agents. Such studies are very difficult to conduct, as patients with advanced renal dysfunction are more likely to die of other (cardiovascular) causes before a potential benefit of the renal revascularisation can be detected. On the other hand, patients with normal or only mild renal dysfunction may require very long follow up periods to show a significant benefit. The functional results of 10 descriptive studies have been reviewed by Isles and colleagues: renal function improved in 26%, remained stable in 48%, and deteriorated in 26% of stented patients. 14 In the large single centre series on primary renal artery stenting by Lederman and colleagues, renal function improved in 19% of patients with renal insufficiency before the intervention, remained stable in 54%, and decreased in 27%. 8 Thus, despite the 100% procedural success rate reported by this group, from the renal function point of viewtheprocedurewasdetrimentalinmorepatientsthanit was beneficial; in most patients it was inconsequential. Watson and associates published the results of a prospective studyonrenalarterystentingin33patientswithdeteriorat- ing renal function before the intervention. 15 Stenting was technically successful in all patients. During 20 (11) months of follow up, renal function improved in 18 patients and the deteriorationofrenalfunctionwasstoppedorslowedinthe remainder of the patients. The preservation/improvement of renal function was accompanied by a preservation of renal size. Another recent prospective study on the effect of renal artery stenting on renal function in 63 patients with renal insufficiency is consistent with these results, demonstrating that patients with declining renal function, but not with stable renal dysfunction, benefit from stenting. 16 However, in this study five patients reached end stage renal failure within six months of stent implantation, in two cases because of stent implantation. Patients with stable renal insufficiency derived no benefit from stenting during a median follow up period of 23 months. Taken together these studies suggest that renal revascularisation is most beneficial in patients with prog ressive renal failure. Its overall usefulness in patients with stable renal (dys)function is less certain, since the procedure itself is not innocuous and can cause a rapid deterioration of renal function. Hence, careful patient selection and meticulously documented infor med consent are important. Figure 34.2 Regulation of glomerular haemodynamics. Reduction of the glomerular perfusion pressure behind a stenosis of the renal artery induces dilatation of the afferent arteriole and constriction of the efferent arteriole. The decreased resistance of the afferent arteriole is mediated by vasodilatory prostaglandins, the constriction of the efferent vessel by angiotensin II. These changes result in the increase of the filtration pressure. The higher filtration fraction maintains the glomerular filtration rate despite the lower perfusion pressure. Afferent arteriole dilated Bowman's capsule Efferent arteriole constricted Renal artery stenosis Prostaglandins Glomerular filtration pressure GFR maintained Angiotensin II EDUCATION IN HEART * 244 WHO SHOULD BE EVALUATED FOR RENAL ARTERY STENOSIS? Generalscreeningofhypertensivepatientsforthepresenceof renal artery stenosis is not indicated for two reasons: (1) the prevalence of renal artery stenosis in the general hypertensive population is too low; and (2) even if renal artery stenosis is present, this finding does not need to influence patient management provided blood pressure is controlled by medication and renal size and function remain stable. Therefore only patients who potentially benefit from renal revascularisation should be worked up for renal artery revascularisation. There are several clinical clues to identify these patients (table 1). Unusually severe hypertension or hypertension refractory to more than three medications should prompt an evaluation for renal artery stenosis, especially if a renal ultrasound shows asymmetric and/or small kidneys. Patients with hypertension, other arteriosclerotic manifestations, and renal failure should have a work up for renal artery stenosis, particularly if the renal insufficiency is progressive and/or aggravated by ACE inhibitors or ang iotensin II antagonists. Patients with severe hypertension, good systolic left ventricular function, and recurrent “flash” pulmonary oedemaareadistinctsubgroupinwhomitisimportantto exclude renal artery stenosis. 17 This clinical syndrome of recurrent episodes of sudden onset non-ischaemic pulmonary oedema can be caused by severe bilateral renal artery stenosis oracriticallystenosedarterytoasinglefunctioningkidney. Because of the compromised renal perfusion a rise in blood pressure is not accompanied by a pressure natriuresis. The ensuing hypertensive crisis induces pronounced diastolic dysfunction and pulmonary oedema. Correction of the stenosis permits the excretion of sodium and prevents the hypertensive crisis and the recurrence of the pulmonary oedema. The renal risk of angioplasty is increased in proportion to the severity of the renal insufficiency because of the greater susceptibility to radiocontrast nephropathy and possibly the greater arteriosclerotic burden, adding to the r isk of cholesterol embolisation. This increased risk has to be taken into account when obtaining informed consent, and patients should be warned that the interventional procedure can has- ten the course towards dialysis. On the other hand, there are several anecdotal reports that even patients with severe renal failure on dialysis may recover sufficient renal function from renal “salvage” revascularisation to discontinue renal replacement therapy. Therefore, treatment of renal artery disease should not be denied simply because a patient is on dialysis, particularly if kidney size is relatively preserved and renal replacement therapy has just begun. Since renal atrophy is irreversible, no significant functional improvement can be expected in atrophic kidneys, and patients with renal artery stenosis in kidneys < 7.5 cm should be treated conservatively (or by nephrectomy, if blood pressure cannot be controlled pharmacologically). 13 Recently Doppler ultrasound has been proposed as a valuable tool to discrimi- nate between patients who benefit from renal revascularisation and those who can be spared this potentially dangerous and expensive procedure. 18 However, the discriminating value of the Doppler sonographic renal resistance index in routine clinical practice is still uncertain. Other indicators of parenchymal renal disease, including a urinary protein excretion > 1 g/day, hyperuricaemia, and a creatinine clearance <40ml/min,mayidentifyasubgroupofpatientswhoareless likely to benefit from renal revascularisation. HOW IS RENAL ARTERY STENOSIS DIAGNOSED? The diagnosis of renal artery stenosis is established by functional and/or morphological studies. The current diagnostic gold standard is arterial digital subtraction angiography (DSA). Arterial DSA requires cannulation of the aorta and exposes the patient to potentially nephrotoxic iodinated radiocontrast agents. This is pertinent, since renal function is often compromised in these patients putting them at an increased risk of radiocontrast induced nephropathy. Spiral computed tomographic angiography allows the three dimensional reconstruction of the abdominal aorta and its branches, including the renal arteries. However, it requires about the same volume of intravenous iodinated radiocontrast material as arter ial DSA; therefore it also carr ies the risk of nephrotoxicity. Nuclear magnetic resonance angiography is becoming increasingly popular for imaging renal arteries, since it is relatively non-invasive and does not require iodinated radiocontrast agents. In addition to imaging the renal arteries, enabling direct detection of a stenosis, this technique allows the evaluation of renal function and perfusion. Hence it can provide information on the haemodynamic relevance of the stenosis. The assessment of perfusion is potentially useful for follow up after stent implantation, since imaging by magnetic resonance is usually not possible after stent implantation because of the metal artefact. A totally non-invasiv e tool for the diagnosis of renal artery stenosis is renal duplex ultrasonography. Howev er, even under optimal circumstances this technique is time consuming and in a substantial group of patients not satisfactory because of obes- ity, bowel gas, and other patient factors. Because duplex Table 1 Factors influencing the treatment decision of renal artery stenosis c Favouring renal revascularisation: Refractory hypertension despite >3 drugs Progressive azotemia Acute renal failure on ACE inhibitors (angiotensin II receptor blockers) Recurrent “flash” pulmonary oedema “Salvage” therapy in recent onset end stage renal disease c Favouring conservative treatment/watchful waiting: Hypertension controlled on <3 drugs Normal renal function Stable mild/moderate renal insufficiency Advanced renal atrophy (<7.5 cm) Doppler ultrasonographic renal resistance index >80 History or clinical evidence of cholesterol embolisation ACE, angiotensin converting enzyme. Arteriosclerotic renal artery stenosis: key points c Arteriosclerosis is the most common cause of renal artery stenosis c Hypertension can be treated safely and effectively with antihypertensive drugs in most patients with renal artery stenosis c The treatment of arteriosclerotic renal artery stenosis with angioplasty and stenting is safe and effective with a low risk of restenosis c Correction of arteriosclerotic renal artery stenosis generally fails to cure hypertension, but control of blood pressure requires fewer drugs c The preservation of renal function through the interventional treatment of arteriosclerotic renal artery stenosis is less certain; patients with deteriorating renal function seem to derive greater benefit than patients with stable renal insufficiency ARTERIOSCLEROTIC RENAL ARTERY STENOSIS: CONSERVATIVE VERSUS INTERVENTIONAL MANAGEMENT * 245 ultrasonography does not expose the patient to nephrotoxic contrast agents or ionising radiation it can be readily repeated and is the method of choice for follow up after renal artery interventions, including stent implanta tion in suitable patients. Renal scintigraphy, especially in combination with the administration of captopril, is a standard technique to evalu- ate renal perfusion for the diagnosis of renovascular hypertension. The captopril challenge is based on the substantial reduction of the glomerular filtration rate in the post-stenotic kidney after reducing angiotensin II by blocking the angiotensin converting enzyme (fig 2). Renal scintigraphy can be useful not only for the estimation of the functional signifi- cance of the stenosis, but also for follow up after interventions to exclude a haemodynamically relevant restenosis. A disadvantage of the method is that it does not provide anatomical information and has only a limited diagnostic accuracy, even when used in combination with captopril. Many patients with renal artery stenosis undergo coronary angiography. In selected patients it may be appropriate to pro- ceed directly to renal ar teriography after the coronary procedure with little additional risk, provided the radiocontrast volume stays within reasonable limits. However, most patients with morphological evidence of renal artery stenosis do not have renovascular hypertension and are not likely to benefit from angioplasty. Therefore the routine imaging of renal arteries during coronary angiography in all hypertensive patients as a screening tool for renal artery disease and especially immediate angioplasty/stenting is not indicated. CONCLUSIONS AND OUTLOOK Renal artery angioplasty with stent implantation has become a standard procedure in the management of patients with arteriosclerotic renal artery disease. The procedure is safe and effective and results in the reduction of blood pressure and/or medication requirement. With regards to renal function its benefitislessclear.Patientswithprogressiverenaldysfunc- tion appear to be more likely to benefit from the procedure than patients with stable renal failure. The procedure has a definite r isk of worsening renal function through radiocontrast nephrotoxicity and/or atheroembolism. Therefore patient selection is critical (table 1). In appropriately selected patients the diagnosis and treatment of renal artery stenosis is not only clinically beneficial, but also cost effective. 19 All patients with ar teriosclerotic renal artery stenosis should be evaluated for coronary artery disease and most patients should receive an ACE inhibitor and a statin. The lat- ter not only reduces cardiac risk but may induce a regression of renal artery stenosis. 20 The role of pharmacological treatment in the management of renal artery disease is likely to increase in the future. REFERENCES 1 Allenberg J-R, Hupp T. Endovasculäre und offene rekonstruktive Chirurgie der Nierenarterienläsion. Chirurg 1995;66:101–11. 2 Weibull H, Bergqvist, Bergentz SE, et al . Percutaneous transluminal angioplasty versus surgical reconstruction of atherosclerotic renal artery stenosis: a prospective randomized study. J Vasc Surg 1993;18:841–52. c Important study showing that interventional treatment is as effective as surgery for the treatment of arteriosclerotic renal artery stenosis. 3 Dorros G, Jaff M, Mathiak L, et al . Multicenter Palmaz stent renal artery stenosis revascularization registry report: four-year follow-up of 1,058 successful patients. Catheter Cardiovasc Interv 2002;2:182–8. c Largest series on renal artery stenting. In patients with normal or only mildly impaired renal function renal artery stenting was beneficial for blood pressure control and preservation of renal function. Though not from a randomised study, this is pertinent information. 4 Plouin P-F, Rossignol P, Bobrie G. Atherosclerotic renal artery stenosis: to treat conservatively, to dilate, to stent, or to operate? J Am Soc Nephrol 2001;12:2190–6. c Excellent recent review of the subject focusing on the comparison between conservative and interventional treatment, including stents. 5 Gross CM, Kramer J, Waigand J, et al . Renovascular illness: prevalence and therapy in patients with coronary heart disease. Z Kardiol 2000;89:747–53. 6 Conlon PJ, Little MA, Pieper K, et al . Severity of renal vascular disease predicts mortality in patients undergoing coronary angiography. Kidney Int 2001;60:1490–7. 7 Fatica RA, Port FK, Young EW. Incidence trends and mortality in end-stage renal disease attributed to renvascular disease in the United States. Am J Kidney Dis 2001;37:1184–90. 8 Lederman RJ, Mendelsohn FO, Santos R, et al . Primary renal artery stenting: characteristics and outcomes after 363 procedures. Am Heart J 2001;142:314–23. c Largest single centre study on arteriosclerotic renal artery stenting: 363 renal artery stenoses were treated in 300 patients between 1993 and 1998 with a 100% procedural success rate. The overall restenosis rate during a m edian follow up of 16 months was 21%. There were no procedural deaths or surgical emergencies. 9 Johnson RJ, Herrera-Acosta J, Schreiner GF, et al . Mechanisms of disease: subtle acquired renal injury as a mechanism of salt-sensitive hypertension. N Engl J Med 2002;346:913–23. c Review article developing the pathophysiological concept that a variety of factors, including renal artery stenosis, induce subtle renal injury which can cause salt sensitive (essential) hypertension. 10 Webster J, Marshall F, Abdalla M, et al . Randomised comparison of percutaneous angioplasty vs continued medical therapy for hypertensive patients with atheromatous renal artery stenosis. Scottish and Newcastle renal artery stenosis collaborative group. J Hum Hypertens 1998;12:329–35. 11 Plouin PF, Chatellier G, Darne B, et al . Blood pressure outcome of angioplasty in atherosclerotic renal artery stenosis: a randomized trial. Essai Multicentrique medicaments vs angioplastie (EMMA) study group. Hypertension 1998;31:823–9. 12 van Jaarsveld BC, Krijnen P, Pieterman H, et al . The effect of balloon angioplasty on hypertension in atherosclerotic renal artery stenosis. N Engl JMed 2000;342:1007–14. c Important randomised study involving 106 patients treated either conservatively or by angioplasty. Interventional treatment had little advantage over drug therapy, but angioplasty resulted in a reduction of antihypertensive medication. There was a relatively high crossover rate of patients initially treated conservatively who later received angioplasty. 13 Textor SC, Wilcox CS. Renal artery stenosis: a common, treatable cause of renal failure? Annu Rev Med 2001;52:421–42. c Excellent review of renal artery stenosis and its effect on renal (dys)function. The term chronic azotemic renovascular disease describes the pathophysiology more accurately than ischaemic nephropathy, since there is usually no true tissue ischaemia. 14 Isles CG, Robertson S, Hill D. Management of renovascular disease: a review of renal artery stenting in ten studies. QJM 1999;92:159–67. c A useful meta-analysis of the outcome of renal artery stenting, particularly with respect to renal function. 15 Watson PS, Hadjipetrou P, Cox SV, et al . Effect of renal artery stenting on renal function and size in patients with atherosclerotic renovascular disease. Circulation 2000;102:1671–7. 16 Beutler JJ, van Ampting JMA, van de Ven PJG, et al . Long-term effects of arterial stenting on kidney function for patients with ostial atherosclerotic renal artery stenosis and renal insufficiency. J Am Soc Nephrol 2001;12:1475–81. 17 Missouris CG, Belli A-M, MacGregor GA. “Apparent” heart failure: a syndrome caused by renal artery stenosis. Heart 2000;83:152–5. 18 Radermacher J, Chavan A, Bleck J, et al . Use of doppler ultrasonography to predict the outcome of therapy for renal-artery stenosis. N Engl J Med 2001;344:410–17. c This study examines the value of renal Doppler ultrasound to distinguish patients who might benefit from renal revascularisation from those who do not. A renal resistance index > 80 identifies a subgroup of patients who do not benefit from renal revascularisation. Although still subject to validation in routine application, this finding may be included in clinical decision processes. 19 Nelemans PJ, Kessels AG, de Leeuw P, et al . The cost-effectiveness of the diagnosis of renal artery stenosis. Eur J Radiol 1998;27:95-107. c This study stresses the importance of a careful clinical evaluation, since the cost effectiveness of the diagnosis of renal artery stenosis is critically dependent on a pre-test likelihood > 20%. 20 Khong TK, Missouris CG, Belli AM, et al . Regression of atherosclerotic renal artery stenosis with aggressive lipid lowering therapy. JHum Hypertens 2001;15:431–3. Additional references appear on the Heart website– www.heartjnl.com EDUCATION IN HEART * 246 35 EFFECT OF PARTIAL COMPLIANCE ON CARDIOVASCULAR MEDICATION EFFECTIVENESS Joyce A Cramer T he typical assessment of mediation compliance by physicians is similar to the assessment of an iceberg from the ship captain’s window. The difference is that when a captain sees ice in the water, he assumes that what he sees might be only the “tip of the iceberg” requiring attention. In contrast, patients who inadvertently omit many doses and doctors who attribute poor control to lack of drug efficacy may have no concept that the underlying problem is poor compliance with the prescribed regimen. If the captain fails to recognise an iceberg in advance, he knows that he must turn his immense vessel rapidly to avoid disaster. Failing to recognise inadequate compliance as the source of the patient’s problem, the physician is unaware of the appropriate action to be taken. Instead, the physician typically prescribes even more medication as a higher dose, or an alternative or second drug. Unfortunately, the patient often remains on a potentially fatal collision course. Why is this scenario so common in medical practice? Inherent in the answers to these questions is a message for every clinician who prescribes medications: Look under the surface. Don’t assume that you know which patients take their medication regularly. Don’t assume that failure to control hypertension, hyperlipidaemia or other measures of cardiovascular disease is caused by lack of efficacy of the prescribed medications. In daily practice, after the physician determines the diagnosis and selects an appropriate treatment, the burden of achieving a good outcome is shifted to the patient. Depending on the setting, patients might be left to accomplish this important task of self management with little guidance. Both physicians and patients need to understand that key factors affecting outcome are “compliance” (that is, attempting to take the medication each day as prescribed) and “persistence” (that is, continuing to take the medication long term). 1 We know that the current treatment style does not work well because national surveys continue to demonstrate that only 23% of people with diagnosed hypertension have blood pressure measurements within the target range. Why is effectiveness so low? The diagnoses and prescribed treatments probably are appropriate. The patients heard the diagnosis and received the prescriptions. Why were the prescr iptions not filled, or refilled? Why were doses not taken daily or long term? Where is the weak link in the system? Compliance with medication regimens is the link between disease management and attainment of the desired treatment outcomes. Drugs don’t work for patients who don’t take them c DEFINITIONS Compliance in the medical setting can be defined as when a patient follows mutually agreeable instructions prescribed by a healthcare pro vider. Another aspect of compliance is treatment persistence, with a focus on long term continuation of treatment. Both definitions include the concept of partial compliance ranging from the occasional missed dose to the occasional extra dose. The pattern for partial compliance may be erratic, or it ma y be consistent but different from what the physician prescribed. Patients who are partial compliers are making an effort to participate in their treatment, b ut neither achieve their intention nor receive the full ef fect of their treatment. Common reasons are forgetfulness and feeling tha t treatment is not necessary. Persistence is an issue when patients feel that they no longer need medication. Some people test themselves by purposefully omit- ting doses, while others simply become lax about daily dosing. Medication compliance for symptomatic and asymptomatic disorders is highly variable among the adult population. Approximately three quarters of medication is taken as prescribed, 2 across a wide range of medical disorders. Simple dose regimens are easier to follow. Ho wev er, compliance ra tes are most highly cor- related with the number of doses rather than the number of medications or tablets that must be taken daily. The core issue for pa tients is: “How many times a day m ust I remember to take a dose?” MEASURING COMPLIANCE Physicians have been concerned about whether patients were following their medical instructions since the time of Hippocrates. Unfor tunately, the simple method of asking patients whether they * 247 took their medication is not a very accurate measure of compliance. Patients who know they have missed doses tend to tell physicians what they think the physician wants to hear to avoid embarrassment. 2 If forgetfulness about dosing has been the main problem, the patient might not realise the frequency of missed doses. Reporting good compliance is not deceit, but lack of awareness of the problem. Large medical centres have the capacity to assess compliance based on the frequency of prescription refills. Analyses of large databases can provide an estimate of overall compliance long term without the details of whether doses were omitted occasionally or whether the pattern included long periods with no doses. The newest technology to assess compliance is continuous electronic monitoring 3 (MEMS, Medication Event Monitoring Systems, AARDEX, Zug, Switzerland). These units use a standard prescription bottle that has a microprocessor in the cap to record the date and time whenever the bottle is opened. 34 Data from the units can be downloaded to a computer for a visual representation of how often the patient took the medication, the number of hours between doses, and periods of missed dosing. Electronic monitoring has given us a window on patient behaviour and the opportunity to study the link between compliance and treatment outcome. Most patients take approximately 50–90% of doses, although the overall range is 0–100%. On average, patients treated for a variety of medical disorders take approximately 75% of medication as prescribed, irrespective of the potential for negative consequences. 25 Neuropsychological correlates showed that compliance does not correlate with intelligence, memory, per- sonality disorder, age, or education. The number of drugs a patient takes also does not correlate with compliance. Patients who are prescribed several medications tend to take all types of drugs together (for example, three medications, six pills with breakfast) or forget all of them when they miss that dose. 2 The conclusion is that the number of medications is not as important as the number of times a day doses must be remembered. Electronic monitoring has proven the widely help belief that compliance diminishes when the number of doses per day increases. An overview of 76 reports using electronic monitoring showed mean (SD) compliance rates of 79 (14)% for once daily, 69 (15)% for twice daily, 65 (16)% for three times daily, and 51 (20)% for four times daily dosing (p < 0.001) for treatment of a variety of medical disorders. 1 . Precision of dosing was even lower with only 59% of doses taken at appropriate time intervals. A review of 13 studies showed that compliance rates for once daily antihypertensive medications ranged from 55–86%, averaging 76%. 5 People take approximately 75% of doses as prescribed, across a variety of medical disorders PATTERNS OF COMPLIANCE Cardiovascular disease is a chronic disorder, requiring long term treatment. Medication taking behaviour starts with the first prescription and continues for a lifetime. Prescriptions for antihypertensive and lipid lowering medications are often given to patients based on the assumption that people are reluctant to participate in lifestyle modification. Physicians seem to think that patients who will not diet and exercise to improve their health will be willing to take medication. The result is that even simple once daily medications are not taken regularly. 5 When blood pressure and lipids have been maintained at target levels for a long time, patients might feel that the medication is no longer necessary. A study of elderly patients newly treated for hypertension revealed that they filled prescriptions covering only 49% of days during the first year. 6 Studies of treatment persistence have shown that half of patients discontinue lipid lowering treatment within five years. 7 However, patients with comorbid diagnoses of hypertension, diabetes or coronary artery disease had significantly better compliance rates than those with only hyperlipidaemia. Patients who take medication can be categorised as near optimal compliers, partial compliers, or non-compliers. 8 The proportion of patients who have been prescribed an antihypertensive or lipid lowering medication but do not fill or refill the prescription is unknown, but assumed to be large. Among compliers, dosing can vary from day to day, or month to month, resulting in periods without treatment. I found that compliance was significantly higher during five day periods before and after medical appointments, compared to 30 days after a visit, 9 a phenomenon I call “white-coat compliance”. These data suggest that attention to dosing was enhanced in anticipation of the visit when health behaviour was a promi- nent issue. This behaviour was maintained for at least a brief period after the visit. Fading of health behaviour was associated with erratic compliance within a few weeks and the potential for medical problems because of under dosing. Thus, blood pressure readings in the medical office are likely to be the result of recent dosing but might not reflect a steady state measurement. Similarly, lipid concentrations might reflect careful dieting for a few days before the blood test. Did the drug fail, or did the patient f ail to take the drug? COMPLIANCE AND OUTCOMES The relation between compliance with lipid lowering drugs and cardiovascular risk was demonstrated in the Lipid Research Clinic’s coronary primary prevention trial. 10 The more doses taken, the lower the cardiovascular risk, with the greatest benefit achieved for patients who took full doses of cholestyramine daily. These data are included in the medication label to explain the value of full compliance. The Helsinki heart study demonstrated that lipid reductions were linearly related to gemfibrozil compliance. 11 Effectiveness was greatly reduced among patients who took less than 70% of prescribed doses. Other studies have shown that patients readmitted to the hospital because of uncontrolled blood pressure had used significantly less medication than patients who were not readmitted (26% v 9% of days without medications). 12 A small study with electronic monitoring showed a significant correlation between ambulatory diastolic blood pressure and mean compliance. 13 CONSEQUENCES OF ERRATIC COMPLIANCE Stopping and restarting an antihypertensive medication can be dangerous. Studies have demonstrated that omission of dose of a short acting calcium channel blocker or β blocker resulted in significantly increased systolic and diastolic pressure and heart rate during the following two days, with three patients developing rebound hypertension. 14 Abrupt dis- continuation of non-intrinsic sympathomimetic activity blockers can also result in rebound hypertension. 15 Doxazosin, a per ipheral vasodilator, can cause severe problems if doses are omitted for several days. The risk of a cardiovascular event was fourfold higher among patients who took less than 80% of EDUCATION IN HEART * 248 their β blocker medication, and twofold higher among those taking 80–90% of doses than patients who took more than 90% of doses. 16 Note also that some cardiac antiarrhythmic drugs have a proarrhythmic effect when not taken as directed. This is an important lesson when prescribing medication that might do more transient harm than the overall beneficial effect of treatment for patients who are erratic compliers. What can doctors do? Teach your patients simple skills on how to follow a dosing plan, and reinforce the message at every visit STRATEGIES FOR IMPROVING MEDICATION COMPLIANCE Some of the essential aspects of prescribing that will enhance patient compliance are: c selecting the fewest number of doses to be taken daily c taking into consideration other medications the patient must take c schedulingwhendosesaretobetaken c helping the patient select a reminder cue. 17 A cue can be any activity that patients perform regularly that can be mentally associated with a scheduled dose. Basic cues are clock times, meal times, or daily rituals. For example, recommend that patients select specific clock times as dose times (for example, 7 am and 7 pm), or plan to take doses with meals (if they eat meals regularly). Other good cues are shav- ing, fixing one’s hair, walking the dog, or listening to the news broadcast. Making the suggestion at the time the prescription is written will emphasise the importance of regular dosing, and takes minimal extra time. Everyone in the clinic or practice should reinforce the need for daily dosing with every patient, at every visit. Ask patients about their cue and how well it reminds them to take their medication. If the cue is not helping, suggest they choose another type of reminder. The message should stress the need for long term treatment to maintain persistence. A combination of reminder cues and visual feedback of compliancedatafromelectronicmonitorsisaneffective method for improving compliance. I developed a Medication Usage Skills for Effectiveness Program as a rapid, simple teaching programme that can be initiated by non-medical personnel spending a few minutes with the patient. 18 The Figure 35.1 Example of initially good compliance, followed by erratic dose timing and many dose omissions (PowerView software, AARDEX Ltd, Zug, Switzerland). 03:00 AM 11:00 PM 07:00 PM 03:00 PM 11:00 AM 07:00 AM 03:00 AM Jan 23 Jan 25 Jan 27 Jan 29 Jan 31 Feb 02 Feb 04 Feb 06 Feb 08 Feb 10 Feb 12 Feb 14 Feb 16 Good Start 03:00 AM 11:00 PM 07:00 PM 03:00 PM 11:00 AM 07:00 AM 03:00 AM Feb 20 Feb 22 Feb 24 Feb 26 Feb 28 Mar 01 Mar 03 Mar 05 Mar 07 Mar 09 Mar 11 Mar 13 Mar 15 Slowly becoming erratic 03:00 AM 11:00 PM 07:00 PM 03:00 PM 11:00 AM 07:00 AM 03:00 AM Mar 19 Mar 21 Mar 23 Mar 25 Mar 27 Mar 29 Mar 31 Apr 02 Apr 04 Apr 06 Apr 08 Apr 10 Apr 12 Too many missed doses Table 35.1 Electronic dosing record for a patient prescribed a medication to be taken three times a day. The calendar plot reveals erratic compliance on weekdays, and neglect on weekends Sunday Monday Tuesday Wednesday Thursday Friday Saturday 332 3 21 1333 2 20 0032 2 21 0222 2 10 0012 0 EFFECT OF PARTIAL COMPLIANCE ON CARDIOVASCULAR MEDICATION EFFECTIVENESS * 249 patients sees a record of all doses taken on a computer screen in a calendar format listing the number of doses taken each day, the dose times, or a figure showing dosing over several months. The report (fig 35.1 and table 35.1) is reviewed with the patient, asking about special problems on days when doses were missed, and how reminders can be used to improve compliance. This technique takes only minutes by any staff person to teach skills that might be useful for a lifetime. Patients should develop a personalised plan to take their medication every day, 365 day a year, including holidays SUMMARY Physicians can picture themselves in the role of the ship’s captain who sees ice in the water. Having learned about the high incidence of inadequate compliance and persistence, it is clear that every ice floe must be investigated to avoid potential disaster. We do not have the sonar system that helps the ship’s captain scan under the water, but we can use other methods to avoid problems. We know that: c taking three quarters of doses as prescribed leaves a wide window for potential cardiac disaster that is further increased when treatment is discontinued c interruptions in the pharmacodynamic action of antihypertensive medications may compromise health in the short term or long term c efficacy of some lipid lowering drugs is dose related. The collision course includes target organ damage over time. The Amer ican Heart Association has recommended use of strategies to enhance compliance to decrease morbidity and mortality from cardiovascular disease and stroke. 19 The first task should be to help partial compliers develop better dosing habits to help to achieve this goal. Physicians who routinely discuss compliance and dose schedules, and who help patients select personalised cue reminders, can engage patients in their own care. 20 Attentiontocomplianceisasimplewayto demonstrate special attention to patient care as well as improve medical success. REFERENCES 1 Claxton AJ, Cramer JA, Pierce C. Medication compliance: the importance of the dosing regimen. Clin Therapeutics 2001;23:1296–310. c Overview of 76 studies with electronic compliance monitoring describes dose taking and dose timing deficits across a wide variety of medical disorders. 2 Cramer JA,MattsonRH,PreveyML, et al . How often is medication taken as prescribed? A novel assessment technique. JAMA 1989;261:3273–7. c The first report of variable compliance using electronic monitoring demonstrated that compliance was imperfect despite potentially disastrous consequences. 3 Cramer JA. Microelectronic systems for monitoring and enhancing patient compliance with medication regimens. Drugs 1995;49:321–7. c Spending a few minutes to show patients how to tailor their medication regimens to fit into their schedules enhances compliance. Electronic monitoring systems allow clinicians to better understand patient dose taking behaviours, and to utilise those data to help patients develop schedules that meet individual lifestyles. 4 Cramer JA. Medication use by the elderly: enhancing patient compliance in the elderly: role of packaging aids and monitoring. Drugs & Aging 1998;12:7–15. 5 Cramer JA. Consequences of intermittent treatment for hypertension: the case for medication compliance and persistence. Am J Managed Care 1999;4:1563–8. 6 Monane M, Bohn R, Gurwitz J, et al . Compliance with antihypertensive therapy among elderly medicaid enrollees: the roles of age, gender, and race. Am J Public Health 1996;86:1805–8. c Despite the efficacy of antihypertensive treatment, non-compliance may contribute to suboptimal cardiovascular outcomes. 7 Avorn J, Monette J, Lacour A, et al . Persistence of use of lipid-lowering medications: a cross-national study. JAMA 1998;279:1458–62. c A comparison of US and Canadian populations for persistence with lipid lowering medications. 8 Rudd P. Compliance with antihypertensive therapy: a shifting paradigm. Cardiol Rev 1994;25:230–40. 9 Cramer JA, Scheyer RD, Mattson RH. Compliance declines between clinic visits. Arch Intern Med 1990;150:1509–10. 10 Coronary Drug Project Research Group. Influence of adherence to treatment and response of cholesterol on mortality in the coronary drug project. N Engl J Med 1980;303:1038–41. c Demonstration of the link between compliance and cardiovascular benefit from lipid lowering treatment. 11 Manninen V, Elo MO, Frick H, et al . Lipid alterations and decline in the incidence of coronary heart disease in the Helsinki heart study. JAMA 1988;260:641–51. 12 Maronde RF, Chan LS, Larsen FJ, et al . Underutilization of antihypertensive drugs and associated hospitalization. Med Care 1989;27:1159–66. 13 Burnier M, Schneider MP, Chiolero A, et al . Electronic compliance monitoring in resistant hypertension: the basis for rational therapeutic decisions. J Hypertension 2001;19:335–41. c A demonstration of the usefulness of compliance intervention to bring previously uncontrolled hypertension under control. 14 Johnson BF, Whelton A. A study design for comparing the effects of missing daily doses of antihypertensive drugs. Am J Therapeutics 1994;1:260–7. c A controlled simulation of the effect of missing a few doses of antihypertensive medication. 15 Rangno RE, Langlois S. Comparison of withdrawal phenomena after propranolol, metroprolol, and pindolol. Br J Clin Pharmacol 1982;13(suppl 2):345S–51S. 16 Psaty BM, Koepsell TD, Wagner EH, et al . The relative risk of incident coronary heart disease associated with recently stopping use of beta blockers. JAMA 1990;263:1653–7. 17 Cramer JA. Overview of methods to measure and enhance patient compliance. In: Cramer JA, Spilker B, eds. Patient compliance in medical practice and clinical trials. New York: Raven Press, 1991. 18 Cramer JA, Rosenheck R. Enhancing medication compliance for people with serious mental illness. J Nervous Mental Dis 1999;187:52–4. c Patients randomised to a brief compliance feedback programme had significantly higher compliance rates than those assigned to usual care. 19 Miller NH, Hill M, Kottke T, et al . The multilevel compliance challenge. Recommendations for a call to action: a statement for healthcare professionals. Circulation 1997;95:1085–90. 20 Waeber B, Burnier M, Brunner HR. How to improve adherence with prescribed treatment in hypertensive patients? J Cardiovasc Pharmacol 2000;35(suppl 3):S23–6. c Various strategies to improve compliance concludes that the “motivation of the patient to follow the treatment requires the doctor to be equally motivated”. EDUCATION IN HEART * 250 36 MYOTONIC DYSTROPHY AND THE HEART G Pelargonio, A Dello Russo, T Sanna, G De Martino, F Bellocci M yotonic dystrophy (dystrophia myotonica, DM) is the most frequently inherited neuromuscular disease of adult life. DM is a multisystem disease with major cardiac involvement. Core features of myotonic dystrophy are myotonia, muscle weakness, cataract, and cardiac conduction abnormalities. Classical DM (first described by Steinert and called Steinert’s disease or DM1) has been identified as an autosomal dominant disorder associated with the presence of an abnormal expansion of a CTG trinucleotide repeat on chromosome 19q13.3 (the DM 1 locus). A similar but less common disorder was later described as proximal myotonic myop- athy, caused by alterations on a different gene on chromosome 3q21 (the DM2 locus). This article will mainly focus on DM1. It will provide an insight into the epidemiology and genetic alterations of the disease and provide up-to-date infor mation on postmortem and clinical findings and on diagnostic and therapeutic options in patients presenting cardiac involvement. c EPIDEMIOLOGY AND CLASSIFICATION OF DM1 The incidence of DM1 is estimated to be 1 in 8000 births and its worldwide prevalence ranges from 2.1 to 14.3/100 000 inhabitants. 1 Based on the age of onset and on its clinical features, DM1 can be divided into three forms: congenital, classical, and minimal, which may occur in the same kindred. Congenital DM1 presents at birth or during the first year of life in a severe form. It is characterised by neonatal hypotonia, facial diplegia, joint contractures, frequent and often fatal respiratory failure, feeding difficulties, and developmental delay. The risk of dying from congenital DM1 in the neonatal period is high. 1 Patients who survive exhibit non-progressive psychomotor retardation and may subsequently exhibit the features of the adult-type, classical form of DM1. In the classical form, which is the most common, symptoms become evident between the second and the fourth decade of life, showing a slow progression over time (table 36.1). The key feature of the disease is myotonia, which is characterised by delayed relaxation after muscular contraction (fig 36.1A,B); progressive muscular weakness (dystrophy) and wasting are also typical findings; facial, axial, semi-distal, and distal compartments are predominantly involved. DM1 is, however, a multisystem disorder; indeed, affected patients can manifest abnormalities of other organs and systems including the eye (cataract), the endocrine system (diabetes, thyroid dysfunction, hypogonadism), the central nervous system (cognitive impairment, mental retardation, attention disorders), the gastrointestinal system (dysphagia, constipation, gallbladder stones, pseudo- obstruction), and the heart (table 36.2). Minimal DM1 begins later in life, usually after 50 years of age, with a very mild degree of muscle weakness and myotonia or only cataracts, associated with a normal lifespan. GENETIC ALTERATIONS OF DM1 DM1 is an autosomal dominant disorder with incomplete penetrance and variable phenotypic expression. The genetic basis of DM1 is known to include mutational expansion of a repetitiv e trinucleotide sequence (CTG) in the 3′-untranslated region of the DMPK gene (m y otonic dystrophy protein kinase gene) on chromosome 19q13.3. While 5-34 CTG repeats are observed in normal alle- les, their number may reach 50–2000 in DM1. 2 The process which leads from abnormal expansion of CTG repeats in a non-coding region of DMPK gene to cellular dysfunction is still incompletely under- stood. Howev er, the localisation of DMPK in the heart muscle at the level of intercalated discs, com- bined with the observation that DMPK reduction in animal models compromise conduction both at the level of the atriov entricular node and of the His-Purkinje system, 3 suggest impairment of intercellular impulse propaga tion as a possible mechanism of disease. Pathologic expansion of the CTG repeats is unstable both during mitotic and meiotic divisions. Mitotic instability explains the presence of somatic mosaicism, a common feature of DM1. Meiotic instability represents the mechanism underlying the phenomena of “anticipation” and “reverse mutation” observed during parent-to-child transmission in DM1 pedigrees. “Anticipation” occurs in earlier onset and a greater severity of symptoms in succeeding generations is caused by a meiotic increase in the size of CTG repeats, while the less common “reverse mutation”, possibly * 251 accounting for incomplete penetrance of DM1, is caused by a meiotic regression in the size of the expansion bringing the number of the CTG repeats towards normal range. 2 Many attempts have been made to find a possible correlation between the number of CTG repeats and severity of clinical manifestations of DM1. Despite earlier controversial results, evidence is accumulating in favour of a correlation between cardiac involvement and CTG expansion. 245 Indeed, the number of CTG repeats seems on average to influence the timing of cardiac complications, 6 to predict the presence and the progression of ECG abnormalities, 5 and the risk of major cardiac events, 7 but it does not predict abnormal findings at electrophysiological study (EPS). 8 Analysis of CTG repeats is, however, of limited predictive value in individual patients because of the overlap between expansion sizes seen in different phenotypic groups, somatic mosaicism, and current analysis of CTG repeats from peripheral blood leucocyte DNA instead of skeletal and cardiac muscle DNA. 2 CARDIAC INVOLVEMENT IN DM1 Pathology and mechanisms of cardiac death Endomyocardial biopsies and postmortem studies performed on patients with DM1 have documented various degrees of non-specific changes, such as interstitial fibrosis, fatty infiltration, hypertrophy of myocardiocytes, and focal myocar- ditis. A selective and extensive impairment of the conduction system is the most common finding. 9 Duringa10yearfollowupstudyof367DM1patients, 1 mortality was 7.3 times higher than that in an age matched referencepopulation,withameanageatdeathof53yearsand a positive correlation between age at onset of DM1 and age of death. In this series, respiratory failure and cardiovascular disease were the most prevalent causes of death, accounting for about 40% and 30% of fatalities, respectively. Cardiac mortality occurred because of progressive left ventricular dysfunction, ischaemic hear t disease, pulmonary embolism, or as a result of unexpected sudden death. 1 Relative contribution of sudden death ranges from about 2–30% in different published series, according to selection criteria. The hypothesis that cardiac arrhythmias may represent the most prevalent cause of sudden death in DM1 patients is supported by the absence of other causes of sudden death at necropsy studies. Sudden cardiac death may be caused by ventricular asystole, degeneration of ventricular tachycardia (VT), ventricular fibr illation (VF) or electromechanical dissociation. The consistent evidence of the degeneration of the conduction system in DM generated the hypothesis that bradyarrhythmias might represent the most prevalent mechanism of SD. However, ventricular tachyarrhythmias are increasingly recognised as a common finding in these patients (fig 36.2A,B), possibly explaining some cases of sudden death after pacemaker implant. Clinical presentation Heart disease is common in DM1 but its prevalence is difficult to estimate precisely, as different definitions have been used in the literature. Neuromuscular alterations are usually the initial clinical manifestation of DM1 (with or without subclinical cardiac involvement), but cardiac symptoms may be occasionally the first to appear. Cardiac involvement is characterised by conduction system abnormalities, supraventricular and ventricular arrhythmias and, less frequently, myocardial dysfunction and ischaemic heart disease (table 36.3). At variance with other neuromuscular diseases, patients with DM1 rarely present overt clinical manifestations of cardiomyopathy (“myotonic” heart disease). 10 Table 36.1 Muscular manifestations of myotonic dystrophy (DM1) Myotonia c Active and evoked Muscular dystrophy and wasting c Facial and masticatory muscles (facies myotonica) c Axial compartment c Semidistal compartment c Distal compartment c Pharyngeal muscles (nasal speech, dysphagia ) c Respiratory muscles Central nervous system c Cognitive impairment c Mental retardation c Attentive disorders Table 36.2 Systemic involvement in DM1 Eye c Cataract Endocrine system c Diabetes c Thyroid dysfunction c Hypogonadism Gastrointestinal tract c Dysphagia c Constipation c Gallbladder stones c Pseudo-obstruction Central nervous system c Cognitive impairment c Mental retardation c Attentive disorders Heart Figure 36.1 The grip test is a quick and easy way to determine the presence of active myotonia. After contraction of the fist (A) the patient is unable to relax the muscles of the hand (B). Photographs courtesy of Dr Gabriella Silvestri, Unione Italiana Lotta alla Distrofia Muscolare, Sezione Lazio, Italy. EDUCATION IN HEART * 252 Conduction system defects Conduction system abnormalities are commonly observed in DM1. Any part of the conduction system may be affected, but the His-Purkinje system is most frequently involved. Minor conduction defects are often present in 12 lead ECG in asymptomatic DM1 patients in the early stages of disease; their progression towards more severe conduction defects may cause shor tness of breath, dizziness, fainting, syncope, and sudden death. Rate of progression of conduction abnor mali- ties is usually slow, 11 but fast progression has been occasionally observed thus making the clinical course of individual patients rather unpredictable. Delayed impulse propagation along the conduction system can be associated with a long PR interval (prevalence ranging from 20–40% in different studies, depending on patient selection criteria) and/or with a wide QRS complex (prevalence ranging from 5–25% in different studies, depending on patient selection criteria). Unfortu- nately, the presence of a long PR interval does not give any clue as to the site of the conduction delay, as it may occur at any level from the atrium to the His bundle, through the atrioventricular node. However, when a wide QRS is also present (for example, right or left bundle brunch block), the probability of an infrahissian (below the His bundle) conduction impairment is higher. Of note, prolongation of the HV interval has been observed in about half of unselected patients with DM1. 912 In patients with DM1, analysis of late potentials has unique implications. Late potentials are expression of delayed myocardial activation usually caused by abnormal tissue (for example, myocardial fibrosis or necrosis, as typically observed in ischaemic heart disease after myocardial infarction), and are considered predictors of ventricular arrhythmias. Delayed myocardial activation in DM1 is not a consequence of inhomogeneous conduction through scattered areas of fibrosis butratherofdelayedactivationalongtheHis-Purkinje system. 13 In DM1, abnormal late potentials are thus an expression of a conduction defect, and represent an important non-invasivecluetothepresenceofalongHVinterval.QRS duration > 100 ms and low amplitude signals in the last 40 ms of QRS complex > 36 ms can predict a prolonged HV interval at EPS with good sensitivity and specificity (80% and 83.3%, respectively). Tachyarrhythmias In DM1 patients, supraventricular tachyarrhythmias are a common finding on 12 lead ECG or dur ing 24 hour Holter monitoring, and may be asymptomatic. Most common arrhythmias are atrial flutter or fibrillation, observed in up to 25% of patients both as unsustained and sustained forms. Atrial flutter, atrial fibrillation, and atrial tachycardia are also easily inducible at EPS even in the absence of previously documented spontaneous episodes, but the clinical implications of these findings are still uncertain. Figure 36.2 (A) Intracardiac electrograms (EGM) of a spontaneous episode of sustained ventricular tachycardia as recorded from the cardioverter-defibrillator (ICD) implanted in a 32 year old male patient affected by DM1. From top to bottom the tracings show the atrial EGM, the ventricular EGM, and a pseudo-surface lead II derived from signals recorded between the shock coils and the ICD. Atrioventricular dissociation, enabling a diagnosis of ventricular tachycardia, is evident. (B) Resumption of sinus rhythm after a 17 J biphasic DC shock. MYOTONIC DYSTROPHY AND THE HEART * 253 [...]... (ISHLT) Registry 44, 49 intervention trials, applicability of outcomes 225 InTime-II 22 intra-aortic balloon counterpulsation 36 , 38 intra-aortic balloon pump (IABP) 36 , 37 , 38 , 39 intra-atrial re-entrant tachycardia 1 03 4, 106 intracellular proteins 218 intracranial bleeding 6, 22 intraluminal bodies 8 intrapericardial thrombus 166 intrauterine pulmonary vascular disease 1 53 intravascular ultrasound... nicorandil 13 nifedipine 85, 155 nisoldipine 12 nitrates 83, 86 nitric oxide 11, 13, 150–1, 152, 1 53, 154 nitric oxide inhibitor 39 nitroprusside 13, 37 , 83 non-coding exons 197 non-compliers, research trials 224 non-contact endocardial mapping 120–2 non-Hodgkin lymphoma 44 non-invasive testing 17, 192, 245 “non-negligent loser” 212 non-obstructive HCM 66–7 non-pulsatile flow, CBP 29 non-steroidal anti -in ammatory... sudden death 144 infections 47, 48, 84, 139 in ammatory response 29, 107 inhibitor of apoptosis proteins 218, 220, 221 insulin 39 , 46 insulin-like growth factor 1 receptor (IGF-1R) 220 Index Integrilin 22 intercellular adhesion molecule-1 (ICAM-1) 11, 154 interferon γ 219 interleukins 46, 219 International Mechanical Circulatory Support Device Database 49 International Society for Heart and Lung Transplantation... secondary interatrial communication 237 secondary septal structure 240 Senning procedure 104 , 106 , 107 septal myectomy 66 septum secundum 235 , 238 , 239 , 240 serine elastase inhibitors 154 serotonin 11, 1 53 serum cholesterol 15, 1 83 serum creatinine 244 serum myoglobin 10 serum response factor 199 serum triglycerides 17 settlement, claims against NHS 212 Sheffield table 184 SHOCK 21, 34 , 35 , 36 , 37 , 38 , 39 ... 2002;88:54 4-5 0 30 Bennett MR Apoptosis in the cardiovascular system Heart 2002;87:48 0-7 SECTION VI: CONGENITAL HEART DISEASE 31 31 Furberg CD To whom do the research findings apply? Heart 2002;87:57 0-4 20 Burch M Heart failure in the young Heart 2002;88:19 8-2 02 32 Dean JCS Management of Marfan syndrome Heart 2002;88:9 7-1 00 21 Wren C Sudden death in children and adolescents Heart 2002;88:426 -3 1 33 Anderson... tomographic imaging with intravascular ultrasound Heart 2002;88:9 1-6 36 Pelargonio G, Russo AD, Sanna T, De Martino G, Belloci F Heart 2002;88:66 5-7 0 265 Thank you for purchasing Education in Heart Volume III This purchase entitles you to online access to ALL Education in Heart material on the Heart website—www.heartjnl.com—for one year (US$50 value) Education in Heart was launched in January 2000... childbearing age 92 3 helix-loop-helix transcription factor (HIF-1) 199 heparin 22, 36 , 92 heroin 53 heterotaxy syndromes 107 high density lipoprotein (HDL) 15, 16 high pressure stent deployment 1 63 His-Purkinje system 2 53 histone acetylases 199 histone proteins 197 Hodgkin lymphoma 44 Holter monitoring 67, 68–9, 106 , 254 homeobox factor 199 homocysteine concentrations 17 homocystinuria 230 homogeneity,... defects, HCM 69 thallium testing, risk assessment 192 thioflavin S 10 thrombi 11, 12, 166 thromboembolism 89–90, 91, 92, 93, 125, 129 thromboplastin 91 thrombosis 104 , 105 thromboxane 11, 1 53 thymine 197 thyroid hormone receptor α1 (TRα1) 199 ticlopidine 4 time delay, angioplasty and fibrinolysis 23 TIMI- 0-2 9, 170 TIMI-0 9 TIMI -3 9, 22, 23, 170 TIMI-14 22, 23 TIMI 23 TIMI frame count 10 tissue disorders 156... streak involvement, aorta and coronary arteries 16 fear, ICD patients 111 fetal cardiomyocytes, transplantation of 48 fibrillin mutations 228, 230 , 231 –2 fibrinogen 17 fibrinolysis AMI 20, 21 compared with angioplasty 23 5 new infusive schemes 22 3 ST elevation MI 36 fibrinopeptide A 1 53 fibroadipose tissue 238 , 239 filter-based arrays 205 flap valve 238 , 239 , 240 flecainide 84, 98, 101 , 125, 126, 128, 132 FLIPs... atrial septum Heart 2002;88 :10 4-1 0 22 Haworth SG Pulmonary hypertension in the young Heart 2002;88:65 8-6 4 34 Haller C Arteriosclerotic renal artery stenosis: conservative versus interventional management Heart 2002;88:1 9 3- 7 SECTION VII: IMAGING TECHNIQUES 35 Cramer JA Effect of partial compliance on cardiovascular medication effectiveness Heart 2002;88:2 0 3- 6 23 Schoenhagen P Nissen S , Understanding coronary . outcomes 225 InTime-II 22 intra-aortic balloon counterpulsation 36 , 38 intra-aortic balloon pump (IABP) 36 , 37 , 38 , 39 intra-atrial re-entrant tachycardia 1 03 4, 106 intracellular proteins 218 intracranial. proteins 218, 220, 221 insulin 39 , 46 insulin-like growth factor 1 receptor (IGF-1R) 220 Index 260 Integrilin 22 intercellular adhesion molecule-1 (ICAM-1) 11, 154 interferon γ 219 interleukins. 154 nitric oxide inhibitor 39 nitroprusside 13, 37 , 83 non-coding exons 197 non-compliers, research trials 224 non-contact endocardial mapping 120–2 non-Hodgkin lymphoma 44 non-invasive testing 17, 192,