Evaluating preload dependence of a novel Doppler application in assessment of left ventricular diastolic function during hemodialysis

BACKGROUND

Left ventricular (LV) diastolic dysfunction, commonly found in hemodialysis (HD) patients, is a major cause of intradialytic hypotension. Conventional Doppler interrogation of mitral flow velocities typically is load dependent. Tissue Doppler imaging (TDI) recently was proposed as a new and relatively load-independent approach to assess diastolic function. The aim of this study is to determine whether HD-related volume reduction affects mitral annular velocities in a large number of patients.

METHODS

One hundred twenty-eight uremic patients underwent Doppler echocardiography 1 hour before and after HD. Two-dimensional and M-mode echocardiography were used to analyze LV size, volume, mass, systolic function, and the inferior vena cava. Doppler signals were obtained from the mitral inflow and TDI of the mitral annulus to measure variations in hemodynamics and LV diastolic filling parameters.

RESULTS

After HD, LV size, volume, mass, stroke volume, and cardiac output were significantly decreased (all P < 0.001). Peak early (E) and late diastolic velocities (A) and E/A ratio decreased significantly after HD (all P < 0.001). Mitral annulus E' velocity and E'/A' ratio also changed significantly (both P < 0.001), whereas A' did not. Consequently, changes in E and A significantly differed with respect to the varying amount of ultrafiltration (both P < 0.05).

CONCLUSION

Our larger cohort study shows that the proposed technique of TDI is still volume dependent. Therefore, LV diastolic function in HD patients must be assessed carefully in a timely manner, even when the new Doppler application is used.

Prognostic Role of Alveolar-Arterial Oxygen Pressure Difference in Acute Pulmonary Embolism

BACKGROUND

This study investigated the utility of the alveolar - arterial oxygen pressure difference (AaDO (2)) in predicting the short-term prognosis of acute pulmonary embolism (PE).

METHODS AND RESULTS

This study retrospectively enrolled 114 consecutive patients with acute PE, diagnosed by either spiral computed tomography or high probability ventilation - perfusion lung scans. During the first 24 h of admission, all patients had initial artery blood gas collected under room air. Patient exclusion criteria were chronic lung disease, septic emboli, and moderate and low probability lung scans. Patients were assigned to 2 groups based on either 30-day death or a 30-day composite event. Receiver operating characteristic analyses was used to determine the AaDO(2) cut-off value for predicting primary and composite endpoints. Statistical analysis demonstrated significant differences in AaDO(2) between the 30-day composite endpoint group and the 30-day composite event-free survival group (p=0.012). The AaDO(2) had a strong trend between the 30-day death group and the survival group (p=0.062). The best cut-off value for AaDO(2) was 53 mmHg and using this, the positive predictive value for 30-day death was 25% and the negative predictive value was 92%. For the 30-day composite endpoint, the positive predictive value for AaDO(2) was 35%, and the negative predictive value was 84%. In this study, thrombocytopenia was also an indicator of poor prognosis for patients with acute PE.

CONCLUSION

The AaDO(2) measurement is a highly useful and simple measurement for predicting short-term prognosis in patients with acute PE. It has high negative predictive value and moderate positive predictive value for 30-day death and 30-day composite event. Aggressive thrombolytic treatment strategies should be considered for patients with an initial poor prognostic parameter (ie, AaDO(2) >or=53 mmHg).

Changes of the Cardiac Architectures and Functions for Chronic Hemodialysis Patients with Dry Weight Determined by Echocardiography

BACKGROUND/AIMS

Left ventricular hypertrophy (LVH) has long been known as an independent risk factor for cardiovascular deaths, in both dialysis and general populations. Numerous factors influence the pathophysiology of LVH. However, extracellular fluid may have a particularly important influence on this impact. Inferior vena cava diameter (IVCD) estimation is a non-invasive and relatively convenient method for obtaining a good correlation with the intravascular fluid status, and may obtain an optimal dry weight (DW) for chronic hemodialysis patients. This study estimates the DW of end-stage renal disease (ESRD) patients by echocardiographic measurement of the IVCD to observe changes in cardiac morphology and function.

METHODS

A total of 88 patients, ranging from 26 to 90 (59.4 +/- 13.3) years of age, were involved in this study. The patients were divided into study (n = 48) and control (n = 40) groups. All patients received IVCD assessment via echocardiography bi-monthly for 1 year. In the study group patients, DW was adjusted according to the IVCD by echocardiography. Meanwhile, in the control group patients, DW was adjusted based on traditional clinical parameters. All patients underwent cardiac examinations and measurements, including left ventricular mass (LVM), wall thickness, chamber size and left ventricular systolic function by echocardiography, at the beginning and end of the study.

RESULTS

Both groups displayed comparable clinical and biochemical parameters. The IVCD index correlated well with the cardiac parameters estimated by echocardiography. The LVM and left ventricular mass index (LVMI) was reduced significantly in the study group patients (from 200 +/- 64.2 to 187 +/- 63.2 g, p = 0.021; from 132 +/- 37.6 to 123 +/- 37.3 g/m(2), p = 0.014, respectively). Furthermore, the study group patients with fluid overload, named study subgroup A, displayed significant differences not only in LVM and LVMI, but also in septal wall thickness, left ventricular end-diastolic dimension and left atrial dimension. In contrast, the control group displayed no changes in these cardiac architectures during the study period.

CONCLUSION

Adjusting DW via the IVCD measured by echocardiography for hemodialysis patients may prevent the progression of chamber dilatation and LVH, especially for patients with fluid overload.

The Role of Cardiac Fibrosis in Diabetic Cardiomyopathy: From Pathophysiology to Clinical Diagnostic Tools

Diabetes mellitus (DM) is a chronic metabolic disorder characterized by hyperglycemia due to inadequate insulin secretion, resistance, or both. The cardiovascular complications of DM are the leading cause of morbidity and mortality in diabetic patients. There are three major types of pathophysiologic cardiac remodeling including coronary artery atherosclerosis, cardiac autonomic neuropathy, and DM cardiomyopathy in patients with DM. DM cardiomyopathy is a distinct cardiomyopathy characterized by myocardial dysfunction in the absence of coronary artery disease, hypertension, and valvular heart disease. Cardiac fibrosis, defined as the excessive deposition of extracellular matrix (ECM) proteins, is a hallmark of DM cardiomyopathy. The pathophysiology of cardiac fibrosis in DM cardiomyopathy is complex and involves multiple cellular and molecular mechanisms. Cardiac fibrosis contributes to the development of heart failure with preserved ejection fraction (HFpEF), which increases mortality and the incidence of hospitalizations. As medical technology advances, the severity of cardiac fibrosis in DM cardiomyopathy can be evaluated by non-invasive imaging modalities such as echocardiography, heart computed tomography (CT), cardiac magnetic resonance imaging (MRI), and nuclear imaging. In this review article, we will discuss the pathophysiology of cardiac fibrosis in DM cardiomyopathy, non-invasive imaging modalities to evaluate the severity of cardiac fibrosis, and therapeutic strategies for DM cardiomyopathy.

Prognostic Role of Right Ventricular Dilatation and Troponin I Elevation in Acute Pulmonary Embolism

Acute pulmonary embolism continues to cause significant morbidity and mortality despite advances in diagnosis and treatment. This retrospective analysis aimed to determine whether the combination of elevated troponin I and right ventricular dilatation (RVD) could provide a more powerful predictor for risk evaluation. The study data comprised records of 110 patients with either high-probability ventilation/perfusion lung scan or positive spiral computed tomography. All cause 100-day mortality was 18.2%. The hypotension and RVD variables significantly influenced 100-day mortality. For the combination of RVD and raised troponin I, the 100-day mortality rate was 31%. Notably, the group with elevated troponin I and no RVD had a 100-day mortality rate of only 3.7%. The combination of RVD and elevated troponin had a positive predictive value of 31% and a negative predictive value of 88% for 100-day mortality. Compared with existing reports, conflicting conclusions for the individual prognostic role of elevated troponin I, cancer, and heart failure were obtained. These conflicting conclusions most likely resulted from inappropriate cut-off troponin I values and the modest sample size. In conclusion, the combination of elevated troponin and RVD was able to identify a subset of patients most likely to benefit from aggressive therapy.

Ankle-arm index as a predictor of lesion morphology and risk classification for coronary artery disease undergoing angioplasty

BACKGROUND

Low ankle-arm systolic blood pressure index is strongly correlated with various cardiovascular risk factors. However, although the potential hazards of resulting coronary artery disease (CAD) are well established, no data is available regarding how ankle-arm index (AAI) and CAD severity are related.

METHODS

This study enrolled 477 patients and all patients underwent coronary angiography and AAI measurements. Based on AAI values, patients were divided into study (AAI value of <0.9, 126 patients) and control groups (AAI value of >or=0.9, 351 patients).

RESULTS

Among baseline characteristics, the study group showed a significantly older and higher female ratio than the control group. The presence of hypertension, diabetes mellitus (DM), current smoking status and LDL-cholesterol level differed significantly between these two groups. Mean number of lesions and target vessel involvement were significant different between the study and control group (2.6+/-1.1 vs. 1.9+/-1.0, p<0.0001; 2.0+/-0.8 vs. 1.6+/-0.7, p<0.0001). Percentages of lesion sites on ostial and proximal portions were markedly high in the study group than in the control group. Significant differences also emerged in the complex stenotic lesions (B2 or C) and lesion morphology (calcified, chronic total occlusion, irregular, bifurcation and diffuse) of these two groups. Multivariate logistic regression analysis, showed that AAI is a statistically significant independent predictor for lesion site, complex stenotic lesions and lesion morphology with Odds ratios (ORs) of, respectively, 1.728, 2.880 and 2.71.

CONCLUSIONS

The AAI is a useful non-invasive tool for the prediction of CAD severity.

Clinical events occurrence and the changes of quality of life in chronic haemodialysis patients with dry weight determined by echocardiographic method

The maintenance of circulating blood volume within an optimal range is necessary for haemodialysis patients to avoid circulating complications, including over-hydration and dehydration. Inferior vena cava diameter (IVCD) estimation is a non-invasive method to obtain a well correlation with the intravascular fluid status, and it may get a reliable ideal dry weight (DW) for chronic haemodialysis patients. We try to analysis the life quality changes and circulating complication in chronic haemodialysis patients who adjust DW with this tool in comparing with the traditional method. A total of 100 chronic haemodialysis patients, ranging from 26 to 77 years old, were involved in this study. They are randomly divided into study (n = 50) and control group (n= 50). All of them received the IVCD estimation by echocardiography every month for 3 months. The patients in the study group adjusted the DW with the IVCD estimated by echocardiographic method, however, patients in the control group with the traditional method. The quality of life (QOL) was evaluated with the short form 36 questionnaire (SF-36) in the beginning and the end of the study. The scores of physical functioning (PF), role limitation-physical (RP), general health (GH) and role limitation-emotional (RE) have much improvement in the patients of the study group than those in the control group. Besides, the occurrence of clinical events due to circulating complications during the study period showed significant reduction in the extents of hypotension, gastrointestinal upset, discontinuation of haemodialysis, muscular cramps, tinnitus, headache and chest discomforts with electrocardiographic changes; and these effects, especially, are significant in the patients with over-dehydrated status, which with the IVCD < 8 mm/m2 detected by echocardiographic method. The study demonstrated that ideal DW estimated by echocardiographic method not only improved the QOL but also reduced the circulating complications during haemodialysis for chronic haemodialysis patients.

Relationship between resistant hypertension and arterial stiffness assessed by brachial-ankle pulse wave velocity in the older patient

Background

Resistant hypertension (RH) is a common clinical condition associated with increased cardiovascular mortality and morbidity in older patients. Several factors and conditions interfering with blood pressure (BP) control, such as excess sodium intake, obesity, diabetes, older age, kidney disease, and certain identifiable causes of hypertension are common in patients resistant to antihypertensive treatment. Arterial stiffness, measured by brachial-ankle pulse wave velocity (baPWV), is increasingly recognized as an important prognostic index and potential therapeutic target in hypertensive patients. The aim of this study was to determine whether there is an association between RH and arterial stiffness.

Methods

This study included 1,620 patients aged ≥65 years who were referred or self-referred to the outpatient hypertension unit located at a single cardiovascular center. They were separated into normotensive, controlled BP, and resistant hypertension groups. Home BP, blood laboratory parameters, echocardiographic studies and baPWV all were measured.

Results

The likelihood of diabetes mellitus was significantly greater in the RH group than in the group with controlled BP (odds ratio 2.114, 95% confidence interval [CI] 1.194–3.744, P=0.010). Systolic BP was correlated in the RH group significantly more than in the group with controlled BP (odds ratio 1.032, 95% CI 1.012–1.053, P=0.001). baPWV (odds ratio 1.084, 95% CI 1.016–1.156, P=0.015) was significantly correlated with the presence of RH. The other factors were negatively correlated with the existence of RH.

Conclusion

In patients aged ≥65 years, the patients with RH have elevated vascular stiffness more than the well controlled hypertension group. baPWV increased with arterial stiffness and was correlated with BP levels. Strict BP control is necessary to prevent severe functional and structural vascular changes in the course of hypertensive disease.

Ankle-arm index is a useful test for clinical practice in outpatients with suspected coronary artery disease

BACKGROUND

Although a low ankle-arm index (AAI) has been reported to be associated with increased risk of cardiovascular mortality in several populations, no data exist concerning the impact of AAI for outpatients with suspected coronary artery disease (CAD) in the clinical setting.

METHODS AND RESULTS

The present study enrolled 840 outpatients (age range 35-87 years, mean age 63.9+/-10.2) with suspected CAD. All patients underwent AAI measurements and coronary angiography, and based on the AAI values, they were divided into group A (AAI <0.9; n=191; CAD positive, 181) and group B (AAI >or=0.9; n=649; CAD positive, 509). Metabolic syndrome (MS), obesity, and level of the inflammatory biomarker high sensitive C-reactive protein (hsCRP) were compared between the 2 groups. The sensitivity, specificity, positive and negative predictive values in predicting CAD with an AAI value <0.9 in all patients were 26.2%, 93.3%, 94.8% and 21.6%, respectively. The patients in group A was significantly older and there was a higher female-to-male ratio than in group B. The presence of hypertension and diabetes mellitus, current smoking status, and levels of low density lipoprotein (LDL)-cholesterol level, uric acid and hsCRP differed significantly between the 2 groups. Group A had a higher percentage of high LDL-cholesterol level, high waist-to-hip ratio and more positive cases of MS than group B. Multivariate logistical regression analysis showed that AAI was related to MS, high levels of hsCRP (>3 mg/L) and uric acid (>7 mg/dl) with odds ratios of 1.769, 3.907 and 2.580, respectively.

CONCLUSIONS

The AAI test is an effective tool in predicting CAD in outpatients in clinical practise.

Liver X Receptor/Retinoid X Receptor Pathway Plays a Regulatory Role in Pacing-Induced Cardiomyopathy

Background

The molecular mechanisms through which high‐demand pacing induce myocardial dysfunction remain unclear.

Methods and Results

We created atrioventricular block in pigs using dependent right ventricular septal pacing for 6 months. Echocardiography was performed to evaluate dyssynchrony between pacing (n=6) and sham control (n=6) groups. Microarray and enrichment analyses were used to identify differentially expressed genes (DEGs) in the left ventricular (LV) myocardium between pacing and sham control groups. Histopathological and protein changes were also analyzed and an A cell pacing model was also performed. Pacing significantly increased mechanical dyssynchrony. Enrichment analysis using Ingenuity Pathway Analysis and the activation z‐score analysis method demonstrated that there were 5 DEGs (ABCA1, APOD, CLU, LY96, and SERPINF1) in the LV septum (z‐score=−0.447) and 5 DEGs (APOD, CLU, LY96, MSR1, and SERPINF1) in the LV free wall (z‐score=−1.000) inhibited the liver X receptor/retinoid X receptor (LXR/RXR) pathway, and 4 DEGs (ACTA2, MYL1, PPP2R3A, and SNAI2) activated the integrin‐linked kinase (ILK) pathway in the LV septum (z‐score=1.000). The pacing group had a larger cell size, higher degree of myolysis and fibrosis, and increased expression of intracellular lipid, inflammatory cytokines, and apoptotic markers than the sham control group. The causal relationships between pacing and DEGs related to LXR/RXR and ILK pathways, apoptosis, fibrosis, and lipid expression after pacing were confirmed in the cell pacing model. Luciferase reporter assay in the cell pacing model also supported inhibition of the LXR pathway by pacing.

Conclusions

Right ventricular septal‐dependent pacing was associated with persistent LV dyssynchrony–induced cardiomyopathy through inhibition of the LXR/RXR pathway.

Enhancement of quality of life with adjustment of dry weight by echocardiographic measurement of inferior vena cava diameter in patients undergoing chronic hemodialysis

BACKGROUND/AIMS

Ideal dry weight (DW) can serve as a marker of good quality of life (QOL) in patients receiving chronic hemodialysis. The size of the inferior vena cava (IVC) reflects the intravascular fluid status, and the diameter of IVC correlates indirectly with DW in these patients. Adjusting DW using echocardiographic measurement of the diameter of the IVC thus may be useful in maintenance of a better QOL in patients receiving chronic hemodialysis.

METHODS

This study included 119 patients with ages ranging between 27 and 90 years (mean +/- standard deviation of 58.3 +/- 12.8). All of the patients received the IVC diameter (IVCD) measurement by echocardiography every 2 months for 1 year. The study group included 68 patients in whom the DW were adjusted by echocardiographic measurement of the IVCD, while the control group included 51 patients in whom the DW was adjusted by the conventional method. QOL was evaluated using the short form 36 questionnaire (SF-36) at the beginning and at the end of the study. Besides, the Kt/V(urea) value, a parameter of total urea clearance, was measured at the beginning and at the end of the study in patients of both groups.

RESULTS

The scores of physical functioning, physical role functioning, general health and physical component summary showed a prominent improvement in the study group but not in the control group. The impact of periodic echocardiographic evaluation also demonstrated a significant change in the scores of physical functioning, physical role functioning and physical component summary in the study group. Furthermore, the Kt/V(urea) value, a parameter of total urea clearance, also increased significantly in the study group.

CONCLUSION

Ideal DW is better adjusted by periodic echocardiographic measurement of the IVCD in patients undergoing chronic hemodialysis. Maintenance of a better DW leads to improve hemodialysis quality and QOL in these patients.

Effects of statin therapy on cerebrovascular and renal outcomes in patients with predialysis advanced chronic kidney disease and dyslipidemia

BACKGROUND

Treatment with statin may be beneficial for patients with chronic kidney disease (CKD). However, the debate over the clinical importance of statin in patients with predialysis advanced CKD remains unresolved.

OBJECTIVES

The objective of the article was to evaluate the effect of statin on mortality, cerebrovascular, and renal outcomes in patients with predialysis advanced CKD and dyslipidemia.

METHODS

Data on predialysis advanced CKD patients were retrieved from the National Health Insurance Research Database based on the guidelines for prescribing regular erythropoietin-stimulating agent in CKD patients. Patients with dyslipidemia were further selected and divided into 2 groups by their statin use after the prescribed erythropoietin-stimulating agent. All-cause mortality and cerebrovascular and renal outcomes were analyzed after propensity score matching.

RESULTS

There were 2016 and 14,412 patients in the statin and nonstatin groups. Their average follow-up periods were 3.7 and 3.0 years, respectively. After 1:2 propensity score matching, the annual all-cause mortality rate was higher in the nonstatin than in the statin group (143.99 vs 109.50 per 1000 person-years; P < .001; hazard ratio: 0.73; 95% confidence interval: 0.68-080). The annual risk of ischemic stroke (P = .186) and intracranial hemorrhage (P = .322) were not significantly different between the 2 groups. The nonstatin group had a higher risk of dialysis than the statin group (1269.45 vs 1095.00 per 1000 person-years; P = .002). Adverse events were not significant between the 2 groups.

CONCLUSIONS

Statins may reduce the all-cause mortality and reduced the risk of dialysis in patients with predialysis advanced CKD and dyslipidemia. However, statins have no impact on ischemic-hemorrhage stroke.

Gout, not hyperuricemia alone, impairs left ventricular diastolic function

Introduction

Gout is a common metabolic disorder characterized by hyperuricemia and chronic inflammation. Previous studies show that hyperuricemia accelerates the occurrence and worsening of cardiovascular disease due to LV remodeling. However, it is still unclear whether hyperuricemia is the sole contributor to organic heart remodeling in patients with gout. In addition, there is a paucity of data regarding the association between LV diastolic function and gout. The objective of this study was to investigate the effects of gout on LV diastolic function.

Methods

A total of 173 patients were divided into tertiles based on the following serum uric acid (UA) levels: 1) serum UA ≤ 6.5 mg/dL (n = 54), 2) serum UA >6.5 to ≤8.5 mg/dL (n = 59), and 3) serum UA > 8.5 mg/dL (n = 60).Patients underwent a comprehensive Doppler-echocardiography examination to evaluate LV volume, systolic and diastolic function, and left atrial (LA) volume.

Results

LV diastolic parameters, including diastolic peak early transmitral flow velocity (E), late transmitral flow velocity (A), E/A, peak early diastolic mitral annular velocity (Em), late diastolic annular velocity (Am), Em/Am, E/Em, maximal LA volume index (LAVi) and prevalence of moderate to severe LV diastolic dysfunction were not significantly different between the three groups. Among the population being studied, 108 individuals received a gout diagnosis. Gout patients had greater LV end-systolic dimensions (27.08 ± 4.38 mm, p = 0.006), higher LV mass index (107.18 ± 29.51 g/m², p < 0.001), higher E/Em (10.07 ± 2.91, p = 0.008), and larger maximal LAVi (16.96 ± 7.39 mL/m², p < 0.001) than patients without gout. The prevalence of moderate to severe LV diastolic dysfunction was higher in patients with gout (23 %, p = 0.02).

Conclusions

Gout, not hyperuricemia alone, is associated with LV diastolic dysfunction and LA volume enlargement.

Neck Circumference as a Predictive Indicator of CKD for High Cardiovascular Risk Patients

Background. Neck circumference (NC) is an anthropometric measure of obesity for upper subcutaneous adipose tissue distribution which is associated with cardiometabolic risk. This study investigated whether NC is associated with indicators of chronic kidney disease (CKD) for high cardiometabolic risk patients. Methods. A total of 177 consecutive patients who underwent the outpatient departments of cardiology were prospectively enrolled in the study. The patients were aged >20 years with normal renal function or with stages 1–4 CKD. A linear regression was performed using the Enter method to present an unadjusted R², standardized coefficients, and standard error, and the Durbin-Watson test was used to assess residual independence. Results. Most anthropometric measurements from patients aged ≧65 were lower than those from patients aged <65, except for women's waist circumference (WC) and waist hip ratio. Female NC obtained the highest R² values for 24 hr CCR, uric acid, microalbuminuria, hsCRP, triglycerides, and HDL compared to BMI, WC, and hip circumference. The significances of female NC with 24 hr CCR and uric acid were improved after adjusted age and serum creatinine. Conclusions. NC is associated with indicators of CKD for high cardiometabolic risk patients and can be routinely measured as easy as WC in the future.

Percutaneous coronary intervention versus coronary artery bypass graft surgery for the treatment of unprotected left main coronary artery stenosis: in-hospital and one year outcome after emergent and elective treatments

This study attempts to compare the risks and benefits of provisional stenting with drug eluting stents and bypass surgery for left main coronary artery (LMCA) stenosis. Recent improvements in interventional technologies have increased interest in percutaneous treatment of LMCA stenosis. However, application of percutaneous techniques to LMCA has been sporadic and controversial. In-hospital and one year outcomes of coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI) cases were compared. From September, 2003 to June, 2005, a total of 59 consecutive patients with de novo unprotected LMCA stenosis were treated with either CABG or PCI. Twenty patients received non-intravascular ultrasound-guided PCI with a stent in the LMCA. Thirty-nine patients underwent CABG. At 30-day follow-up, the major adverse cardiac and cerebrovascular event (MACE) rates of mortality, myocardial infarction, cerebral vascular accident, and target vessel revascularization were 25.6% in the CABG group and 5% in the PCI group (P=0.054). At one year follow-up, the MACE rates were 33.3% in the CABG group and 5% in the PCI group. One year MACE for the CABG group significantly differed from that of the PCI group (P=0.015). The odds ratio (OR) of one year MACE-free survival was 0.75 (P<0.001) in the CABG group versus the PCI group. Further analysis demonstrated there was a significant difference in in-hospital MACE and one year MACE between the elective CABG group and elective PCI group (P=0.045). However, there was no significant difference between the emergent CABG group and emergent PCI group (P=1.000 for in-hospital MACE; P=0.486 for one year MACE). PCI on unprotected LM offers an alternative option in patients with high surgical risk and appropriate lesion morphology.

Effect of initiating statin therapy on long-term outcomes of patients with dyslipidemia after intracerebral hemorrhage

BACKGROUND AND AIMS

Intracerebral hemorrhage (ICH) has a higher mortality than ischemic stroke. Statin is beneficial for stroke, but high potency statin treatment has been associated with the risk of hemorrhagic stroke. The aim of this study was to assess the impact of initiating statin therapy after ICH on cardiovascular outcomes.

METHODS

Dyslipidemic patients were retrieved from the ICH population from the National Health Insurance Research Database in Taiwan. We retrospectively compared patients prescribed with and without statin treatment after ICH. Outcomes of interest were mortality, myocardial infarction, ischemic stroke, and hemorrhagic stroke during 5 years of follow-up.

RESULTS

Of 17,980 adult patients with ICH and dyslipidemia, 8927 were eligible for analysis over the study period, including 1613 patients receiving statin therapy and 7314 patients not taking statins. After propensity score matching, the mean age was 61.2 ± 12.2 years in the statin group and 61.6 ± 13.0 years in the non-statin group. Hypertension was dominant, followed by diabetes mellitus, and the mean estimated NIHSS score was 12.9. The patients who received statin therapy were associated with lower risks of all-cause mortality (12.7% vs. 21.3%; hazard ratio [HR], 0.54; 95% confidence interval [CI], 0.45-0.65), cardiovascular death (4.0% vs. 7.1%; HR, 0.54; 95% CI, 0.39-0.75) and ICH (5.4% vs. 8.5%; HR, 0.62; 95% CI, 0.46-0.83) compared to those who did not receive statins.

CONCLUSIONS

Initiating statin therapy after ICH was associated with a decreased risk of recurrent ICH and mortality for dyslipidemia patients.

Platelet Glycoprotein IIb/IIIa Inhibitor Tirofiban Ameliorates Cardiac Reperfusion Injury

There are many published articles on the effects of the antithrombolytic function of platelet glycoprotein IIb/IIIa inhibitors (GP IIb/IIIa inhibitors) in myocardial infarction. However, few studies have explored the effects and optimal concentration of tirofibans in diminishing the extent of myocardial reperfusion injury (RI).Rats received 120 minutes of coronary ligation and 180 minutes of reperfusion. The rats were then divided into 7 groups based on the concentration of tirofiban administered intravenously 30 minutes prior to coronary reperfusion to the end of reperfusion. The ratio of myocardial necrotic area to area at risk (AAR), and myocardial malondialdehyde (MDA) and plasma myeloperoxidase (MPO) activities were measured. The apoptotic index (AI) was the percentage of myocytes positive for terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick-end labeling (TUNEL) out of all myocytes stained by 4', 6-diamidino-2-phenylindole (DAPI).The ratio of myocardial necrotic area to AAR significantly decreased in all tirofiban subgroups. The MDA activity for tirofiban concentrations of 2 and 5 ug/kg/minute showed a slight reduction. MPO activity was significantly decreased at a tirofiban concentration of 2 ug/kg/minute. The AI was significantly decreased at a tirofiban concentration of ≥ 0.4 ug/kg/minute.The results indicate that a tirofiban can significantly ameliorate the cardiac RI and myocyte apoptosis in rats.

The effects of gout on left atrial volume remodelling: a prospective echocardiographic study

OBJECTIVE

The aim of the present study was to investigate the effect of gout on left ventricular (LV) diastolic function and left atrial volume (LAV).

METHODS

A total of 173 patients were divided into four groups: control (n = 35), asymptomatic hyperuricaemia (n = 30), gouty arthritis without tophi (n = 58) and gouty tophi (n = 50). Patients underwent a comprehensive Doppler echocardiography examination to evaluate LV volume, systolic and diastolic function and LAV and function.

RESULTS

Serum uric acid levels were not significantly different in the asymptomatic hyperuricaemia, gouty arthritis without tophi and gouty tophi groups. However, the ratio of the transmitral and myocardial peak early diastolic velocities (E/e') and LAV index (LAVi) progressively increased from the control group to the gouty tophi group. The tophi group had significantly higher E/e' [10.5 (s.d. 3.2) vs 8.6 (s.d. 2.1), P = 0.008] and larger maximal, pre-contraction and minimal LAVi [29.6 ml/m(2) (s.d. 9.9) vs 20.1 ml/m(2) (s.d. 4.8); 19.1 ml/m(2) (s.d. 8.5) vs 11.5 ml/m(2) (s.d. 3.4); 9.6 ml/m(2) (s.d. 4.2) vs 6.1 ml/m(2) (s.d. 2.2); all P < 0.001] than the control group. By binary logistic analysis, maximal LAVi was an independent predictor for the development of tophi in gout patients, with an odds ratio of 1.068 (95% CI 1.02, 1.118; P = 0.005).

CONCLUSION

The severity of gout had a significant effect on LV diastolic dysfunction and LA enlargement in gout patients. Additionally, a high maximal LAVi predicted the development of tophi and may be a predictor of adverse cardiovascular events related to LA and LV remodelling in this clinical setting.