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patients with metastatic cancer Christodoulos Stefanadis , Andreas Synetos , Dimitris Tousoulis ⁎, Eleftherios Tsiamis , Archontoula Michelongona , Flora Zagouri , Aristotle Bamias , Meletios Athanasios Dimopoulos , Stella Kyvelou , Ioannis Kapelakis , Konstantinos Toutouzas a a First Department of Cardiology, Athens Medical School, Athens, Greece b Third Department of Medical Oncology, “Agii Anargiri” Hospital, Athens, Greece c Department of Therapeutics, “Alexandra” Hospital, Athens Medical School, Athens, Greece d First Cardiology Department, Evangelismos Hospital, Athens, Greece

Objective Radial artery spasm may hinder completion of transradial angiography or PCI, leading to access site crossover, prolonged procedure times and complications. The aim of this study was to derive a radial artery spasm risk score in patients undergoing elective percutaneous coronary intervention (PCI), prospectively validate it, and apply it in a real-life clinical setting. Methods The study population consisted of 3 cohorts of patients undergoing elective PCI with transradial access: the derivation cohort (N=1006), the validation cohort (N=576) and the intervention cohort (N=140), consisting of patients with high risk score, in whom intensified spasm-preventive measures were applied. Results Multivariable analysis in the derivation cohort showed that 5 weighted factors could be used to construct a risk score for spasm: body-mass index, height, current smoking, hypertension and peripheral artery disease (c-statistic 0.945, with an optimal cut-off of 4). In the validation cohort, the cut-off of 4 predicted spasm with a sensitivity of 84.5% and a specificity of 74.7%. In the intervention cohort, which included only patients with a spasm-risk score of ≥4, the rate of spasm was drastically reduced (odds ratio 0.32, 95% confidence interval 0.17–0.61), compared to the corresponding high spasm risk subgroup of patients of the validation cohort. Conclusion A spasm risk score can be used to predict radial artery spasm during elective transradial PCI. Using this score, a high spasm risk patient subgroup can be identified, where intensive spasm-preventive measures can lead to a significant reduction in the frequency of spasm.

We sought to test the hypothesis that virtual histology characteristics of the culprit lesion in patients with ST-elevation myocardial infarction are associated with blood flow restoration after thrombolysis.Consecutive patients referred for coronary angiography after successful thrombolysis were included in this correlational cross-sectional study. Evaluation with intravascular ultrasound (IVUS) and virtual histology of the culprit arterial segment was performed in all cases.Forty-eight patients (60.5 ± 10.7 years) were included. TIMI flow grade 3 was found in 24 (50%). Diabetes was strongly associated with lower TIMI flow 3 rate (26.7% vs 60.6%; p = 0.029) and there was a significant difference in the time to thrombolysis (2.0 ± 0.8 hours in those with TIMI flow 3 vs 3.0 ± 0.7 hours in TIMI flow grades 1-2; p0.001). Patients with TIMI flow grades 3 and 1-2 had similar absolute total plaque volume (152.8 ± 59.3mm(3) vs 147.5 ± 92.3mm(3); p = 0.817) and absolute necrotic core (NC) volume (31.2 ± 13.9 mm(3) vs 33.6 ± 23.2mm(3); p = 0.671). However, there were significant differences in the relative NC content, both in proportion to the whole plaque volume (26.3% vs 29.9%; p = 0.016) and as an area fraction at the largest NC site (31.5% vs 40.3%; p0.001).The NC content of atherosclerotic plaques is meaningful for flow restoration after the occurrence of a coronary event. This finding highlights the importance of plaque composition, as studied with virtual histology, not only for the sequence of processes leading to an acute plaque-related event, but also for thrombus formation and lysis, following the occurrence of such an event.

The Osborn wave is a distinctive deflection occurring at the QRS-ST junction that appears characteristically in hypothermic patients after exposure to a cold environment.We present a critically ill hospitalized patient that developed Osborn waves in association with sepsis-induced hypothermia. A 56-year-old woman with metastatic breast cancer was admitted to our department with respiratory failure due to diaphragmatic paralysis. The arterial blood gas analysis on room air revealed hypercapnic and hypoxic respiratory acidosis with a pH of 7.30, PaO2 of 40.3 mm Hg, PaCO2 of 57.5mmHg, andHCO3 32.6mEq. The patient was transferred to the intensive care unit (ICU) and noninvasive positive pressure ventilation was started. Her hospital stay was complicated by superior vena cava syndrome and multiple nosocomial infections. During her hospitalization and while she was treated forCandida albicans peritonitis (diagnosed after ascitic fluid cultures), her rectal temperature decreased to 34.3 °C over the course of 3 h. She became hemodynamically unstable with blood pressure 92/ 35 mm Hg and heart rate 69 beats per minute. Prominent Osborn (J) waveswere noticed on themonitor's screen (Fig. 1). There was also a PR interval of borderline duration (200 ms) and a prolonged QT interval, (QTc 520 ms). Blood glucose level at that time was 90 mg/dl. White blood cell count was elevated (15,000/μl), while blood electrolyte levels were

included. d) Only short-term follow-up was available. In conclusion, in successfully treated hyperthyroidism, autoimmune myocarditis can be identified and CMR is of diagnostic value even in the absence of other clinical and/or laboratory findings. However, further studies are needed to assess the clinical implications of these results. The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology [10]. There is no conflict of interest related to this work.

T cells are involved in the process of endothelial dysfunction contributing to plaque destabilization [1] and several studies have shown that the predominant population of T cells that infiltrates atherosclerotic plaques is CD4+ T cells [2]. An increased number of CD4+ T cells have already been found in the peripheral blood of patients presenting with acute coronary syndromes [3]. Particularly, a subset of CD4+ T cells characterized by a loss of the CD31 molecule seems to have a crucial role in plaque destabilization and thrombotic complications. Furthermore, an increased number of CD4+ T lymphocytes characterized by a defective cell surface expression of CD28 have been detected in patients with unstable angina (UA). CD4+CD28null T cells were found to expand in the peripheral blood of patients with UA and infiltrate unstable coronary plaques, where they undergo clonal expansion, probably due to their activation by specific antigens [4]. Therefore, we aimed to investigate whether CD4+CD31null and CD4+CD28null T cell subpopulations contribute to vascular function in patients with UA. We enrolled 61 patients with UA admitted to our Coronary Care Unit with UA Braunwald's class IIIB and 23 healthy individuals without overt cardiovascular disease who were screened in our outpatients' clinic for cardiovascular prevention. Endothelial function was evaluated by estimating the flow-mediated dilation (FMD) in the brachial artery, while flow cytometry was used to determine both the number of T-cells present as well as the frequencies of the various T-cell subsets of interest. We have found that endothelial function was significantly impaired in patients with UA compared to healthy controls (4.76 ± 0.24 vs 8.4 ±0.52, p b 0.001, Fig. 1A), while further analysis among the genders of the 2 groups did not reveal any significant differences in FMD (p = 0.631 for males and p= 0.767 for females). Similarly, FMD was not age related. More specifically, after dividing patients into two subgroups according to age, using as a cut-off point the age of 60 years, we observed no significant differences (p = 0.453 and p = 0.562 respectively). Importantly, we have shown that T cell population as marked by CD4+ was elevated in UA patients compared to healthy controls (42.07 ± 1.58 vs 35.43 ± 3.1, p = 0.046). Interestingly, a significant difference was detected between the two groups when the T cell subpopulation CD4+CD31null was examined. A significant increase of these circulating cells were found in the UA group (37.33 ± 1.5 vs 28.98 ± 3.1, p = 0.016, Fig. 1B). Similarly, UA patients presented with a significantly elevated frequency of CD4+CD28null T cells (9.49 ± 0.69 vs 6.69 ± 1.19, p = 0.018, Fig. 1C). However, no significant difference between groups was observed in the frequency

of three CoreValve prostheses George Latsios , Kostantinos Toutouzas , Dimitris Tousoulis ⁎, Andreas Synetos , Antonios Mastrokostopoulos , Konstantinos Stathogiannis , Themis Spyridopoulos , Ulrich Gerckens , Christodoulos Stefanadis a a 1st Department of Cardiology, “Hippokration” Hospital, University of Athens, Greece b Department of Radiology, “Penteli” Hospital, Greece c Gemeinschaftskrankenhaus Bonn, Germany

Dobutamine stress echocardiography (DSE) has been proposed as a tool for risk stratification of patients with acute chest pain (ACP). In this single-center study, we evaluated the negative predictive value of DSE in 178 patients who presented with low-risk ACP (normal or inconclusive electrocardiogram and negative markers of myocardial damage) and were discharged following a maximal DSE that did not reveal ischemia. During the follow-up (median 321 days), 2 of the 178 patients were admitted with an acute coronary syndrome and were diagnosed with obstructive coronary artery disease at angiography. In the time frame of the study, the negative predictive value of a normal and maximal DSE for an adverse cardiac event was 98.9% (95% CI: 96.0–99.8%). Thus, a normal DSE has a high negative predictive value and comprises a safe and effective tool for early risk stratification of patients who present with acute chest pain of low risk.