Ischemia modified albumin (IMA), as measured using the albumin cobalt binding test, is currently the most promising biomarker for early detection of ischemia before the onset of irreversible cardiac injury. This paper reviews the information available on IMA, including its pathophysiology, analysis, clinical applications and future perspectives. The data provided was identified by a search of MEDLINE using the terms IMA, biomarkers and ischemia. IMA may be useful to cover the complete diagnostic window of patients presenting with acute coronary syndromes (ACS) in the Emergency Department, along with the electrocardiogram and cardiac troponins. Preliminary data regarding the significance of IMA in the prognosis of either ACS or following revascularization need further study.

(Br Heart3 1994;71:196-201) There is still no consensus on the most suitable heart valve replacement for women of childbearing age. Mechanical valves carry a risk of thromboembolism and the need for anticoagulation whereas bioprostheses have a lower thromboembolic risk but are not as durable, particularly in the young. There is controversy about the safest anticoagulant regimen during pregnancy. Early reports of pregnancy in women with mechanical valves were usually of anecdotal cases: they were inspired by disaster rather than by success. Most of these reports came from the United States where overanticoagulation was the rule because of the use of thromboplastins of low responsiveness.' There is still no universal adoption of the International Normalised Ratio (INR)

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Summary:To examine whether QTc and QTc dispersion across the leads of a surface electrocardiogram (ECG) are different in patients with hypertrophic cardiomyopathy (HCM) compared with normal subjects, we measured QT and calculated QTc in all 12 leads of a surface ECG in 24 patients with HCM and in 20 age-and sex-matched normal control subjects. Maximal QTc was prolonged in HCM patients (465 f 24 ms) compared with controls (410f20 ms) (p < 0.001). QTc dispersion defined as the difference of maximum-minimum QTc was also greater in HCM patients (71 f21 ms) compared with normals (35 f l l ms) (p <0.001). A correlation was found between the degree of left ventricular hypertrophy expressed by the maximal wall thickness and maximal QTc (r =0.48, p < 0.02). However, QTc dispersion did not correlate with maximal wall thickness. Thus, patients with HCM show a prolonged QTc (>440 ms) and increased QTc dispersion compared with normal subjects. In addition, the degree of left ventricular hypertrophy correlates with maximal QTc. The presence of a prolonged QT with increased regional dispersion may be associated with the occurrence of serious ventricular arrhythmia and sudden death in HCM.

The IMA plasma levels change significantly during exercise testing in patients with coronary artery disease, but there is no difference between positive and negative stress tests; this possibly implies that the observed changes do not reflect myocardial ischemia.

Administration of estrogen promotes angiogenesis and perfusion in ischemic rabbit hindlimbs. Thus, estrogen may represent a new therapeutic modality in the management of arterial insufficiency.

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