A case-control study comparing the incidence of early symptoms in pancreatic and biliary tract cancer

OBJECTIVES

Pancreatic ductal adenocarcinoma (PDAC) and biliary tract cancers (BTC) are often diagnosed late and at an advanced stage. Population-based screening programmes do not exist and diagnosis is primarily dependent on symptom recognition. Recently symptom-based cancer decision support tools (CDSTs) have been introduced into primary care practices throughout the UK to support general practitioners (GPs) in identifying patients with suspected PDAC. However, future refinement of these tools to improve their diagnostic accuracy is likely to be necessary.

SETTING

The Health Improvement Network (THIN) is a primary care database, which includes more than 11 million electronic patient records, from 562 GP practices in the UK.

PARTICIPANTS

All patients with a diagnosis of PDAC or BTC between 2000 and 2010 were included in the study along with six matched controls; 2773 patients with PDAC, 848 patients with BTC and 15,395 controls.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary aim of this study was to determine the early symptom profiles of PDAC and BTC. Secondary aims included comparing early symptom trends between BTC and PDAC, defining symptom onset in PDAC and evaluating trends in routine blood tests nearest to the time of diagnosis.

RESULTS

In the year prior to diagnosis, patients with PDAC visited their GP on a median of 18 (IQR 11-27) occasions. PDAC was associated with 11 alarm symptoms and BTC with 8. Back pain (OR 1.33 (95% CI 1.18 to 1.49) p<0.001), lethargy (1.42 (95% CI 1.25 to 1.62) p<0.001) and new onset diabetes (OR 2.46 (95% CI 2.16 to 2.80)) were identified as unique features of PDAC.

CONCLUSIONS

PDAC and BTC are associated with numerous early alarm symptoms. CDSTs are therefore likely to be useful in identifying these tumours at an early stage. Inclusion of unique symptoms, symptoms with an early onset and routinely performed blood tests is likely to further improve the sensitivity of these tools.

Serum aldosterone and death, end-stage renal disease, and cardiovascular events in blacks and whites: findings from the Chronic Renal Insufficiency Cohort (CRIC) Study

Prior studies have demonstrated that elevated aldosterone concentrations are an independent risk factor for death in patients with cardiovascular disease. Limited studies, however, have evaluated systematically the association between serum aldosterone and adverse events in the setting of chronic kidney disease. We investigated the association between serum aldosterone and death and end-stage renal disease in 3866 participants from the Chronic Renal Insufficiency Cohort. We also evaluated the association between aldosterone and incident congestive heart failure and atherosclerotic events in participants without baseline cardiovascular disease. Cox proportional hazards models were used to evaluate independent associations between elevated aldosterone concentrations and each outcome. Interactions were hypothesized and explored between aldosterone and sex, race, and the use of loop diuretics and renin-angiotensin-aldosterone system inhibitors. During a median follow-up period of 5.4 years, 587 participants died, 743 developed end-stage renal disease, 187 developed congestive heart failure, and 177 experienced an atherosclerotic event. Aldosterone concentrations (per SD of the log-transformed aldosterone) were not an independent risk factor for death (adjusted hazard ratio, 1.00; 95% confidence interval, 0.93-1.12), end-stage renal disease (adjusted hazard ratio, 1.07; 95% confidence interval, 0.99-1.17), or atherosclerotic events (adjusted hazard ratio, 1.04; 95% confidence interval, 0.85-1.18). Aldosterone was associated with congestive heart failure (adjusted hazard ratio, 1.21; 95% confidence interval, 1.02-1.35). Among participants with chronic kidney disease, higher aldosterone concentrations were independently associated with the development of congestive heart failure but not for death, end-stage renal disease, or atherosclerotic events. Further studies should evaluate whether mineralocorticoid receptor antagonists may reduce adverse events in individuals with chronic kidney disease because elevated cortisol levels may activate the mineralocorticoid receptor.

Update on the management of cholangiocarcinoma

Cholangiocarcinoma (CC) is a rare cancer arising from the epithelium of the biliary tree, anywhere from the small peripheral hepatic ducts to the distal common bile duct. Classification systems for CC typically group tumours by anatomical location into intrahepatic, hilar or extrahepatic subtypes. Surgical resection or liver transplantation remains the only curative therapy for CC, but up to 80% of patients present with advanced, irresectable disease. Unresectable CC remains resistant to many chemotherapeutic agents, although gemcitabine, particularly in combination with other agents, has been shown to improve overall survival. Ongoing investigation of biological agents has also yielded some promising results. Several novel interventional and endoscopic techniques for the diagnosis and management of non-operable CC have been developed: initial results show improvements in symptoms and progression-free survival, but further randomised studies are required to establish their role in the management of CC.

John Sutton M, Wolf M, Feldman H, Reese P, Anderson C, Townsend R, Deo R, Lo J, Gadegbeku C, Carlow D, Sulik MJ, Leonard MB. FGF23 modifies the relationship between vitamin D and cardiac remodeling

BACKGROUND

There is growing evidence to support an important role for vitamin D and related hormones, parathyroid hormone and fibroblast growth factor 23 (FGF23), on cardiac remodeling in chronic kidney disease. Our objective was to determine the relationships between vitamin D and cardiac remodeling in chronic kidney disease and the effects of parathyroid hormone and FGF23 on these associations.

METHODS AND RESULTS

In 1431 participants from the Chronic Renal Insufficiency Cohort study, we measured 25-hydroxyvitamin D (25(OH)D), 1,25-dihydroxyvitamin D (1,25(OH)2D), FGF23, and parathyroid hormone and performed quantitative echocardiography. Using linear regression methods, we determined significant negative interactions between 25(OH)D and FGF23 on left ventricular (LV) mass (P=0.016), end-diastolic volume (P=0.029), and end-systolic volumes (P=0.021). In participants with an FGF23 level greater than the median of 123.5 RU/mL, each doubling of 25(OH)D was associated with a 2.5% (95% confidence interval, -4.8, -0.2) lower LV mass. This association was less pronounced with FGF23 levels less than the median (0.4%; 95% confidence interval, -1.9, 2.7). Conversely, in participants with deficient 25(OH)D levels <20 ng/mL, each doubling of FGF23 was associated with a 3.4% (95% confidence interval, 1.2, 5.6) greater LV mass compared with only a 1.6% (95% confidence interval, -0.2, 3.5) difference in participants with sufficient 25(OH)D. Similar findings were observed with 25(OH)D and volumes (P<0.05), and 1,25(OH)2D and LV mass and volumes (P<0.005). There was no effect modification by parathyroid hormone.

CONCLUSIONS

We identified significant interactions among 25(OH)D, 1,25(OH)2D, and FGF23 on cardiac remodeling. Increased LV mass and cavity dilatation were observed with low 25(OH)D and high FGF23. Our findings suggest that consideration of both hormones is crucial to understanding the role of either in cardiac remodeling, and may have important therapeutic implications.

Comparison of transcatheter and surgical aortic valve replacement in severe aortic stenosis: a longitudinal study of echocardiography parameters in cohort A of the PARTNER trial (placement of aortic transcatheter valves)

OBJECTIVES

This study sought to compare echocardiographic findings in patients with critical aortic stenosis following surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR).

BACKGROUND

The PARTNER (Placement of Aortic Transcatheter Valves) trial randomized patients 1:1 to SAVR or TAVR.

METHODS

Echocardiograms were obtained at baseline, discharge, 30 days, 6 months, 1 year, and 2 years after the procedure and analyzed in a core laboratory. For the analysis of post-implantation variables, the first interpretable study (≤6 months) was used.

RESULTS

Both groups showed a decrease in aortic valve gradients and increase in effective orifice area (EOA) (p < 0.0001), which remained stable over 2 years. Compared with SAVR, TAVR resulted in larger indexed EOA (p = 0.038), less prosthesis-patient mismatch (p = 0.019), and more total and paravalvular aortic regurgitation (p < 0.0001). Baseline echocardiographic univariate predictors of death were lower peak transaortic gradient in TAVR patients, and low left ventricular diastolic volume, low stroke volume, and greater severity of mitral regurgitation in SAVR patients. Post-implantation echocardiographic univariate predictors of death were: larger left ventricular diastolic volume, left ventricular systolic volume and EOA, decreased ejection fraction, and greater aortic regurgitation in TAVR patients; and smaller left ventricular systolic and diastolic volumes, low stroke volume, smaller EOA, and prosthesis-patient mismatch in SAVR patients.

CONCLUSIONS

Patients randomized to either SAVR or TAVR experience enduring, significant reductions in transaortic gradients and increase in EOA. Compared with SAVR, TAVR patients had higher indexed EOA, lower prosthesis-patient mismatch, and more aortic regurgitation. Univariate predictors of death for the TAVR and SAVR groups differed and might allow future refinement in patient selection. (THE PARTNER TRIAL: Placement of AoRTic TraNscathetER Valve Trial; NCT00530894).

Proteomic profiling of bovine M. longissimus lumborum from Crossbred Aberdeen Angus and Belgian Blue sired steers varying in genetic merit for carcass weight

Bovine skeletal muscle is a tissue of significant value to the beef industry and global economy. Proteomic analyses offer the opportunity to detect molecular mechanisms regulating muscle growth and intramuscular fat accumulation. The current study aimed to investigate differences in protein abundance in skeletal muscle tissue of cattle from two breeds of contrasting maturity (early vs. late maturing), adiposity, and muscle growth potential, namely, Belgian Blue (BB) × Holstein Friesian and Aberdeen Angus (AA) × Holstein Friesian. Twenty AA (n = 10) and BB (n = 10) sired steers, the progeny of sires of either high or low genetic merit, expressed as expected progeny difference for carcass weight (EPDcwt), and bred through AI, were evaluated as 4 genetic groups, BB-High, BB-Low, AA-High, and AA-Low (n = 5 per treatment). Chemical composition analysis of M. longissimus lumborum showed greater protein and moisture and decreased lipid concentrations for BB-sired compared with AA-sired steers. To investigate the effects of both sire breed and EPDcwt on M. longissimus lumborum, proteomic analysis was performed using 2-dimensional difference gel electrophoresis followed by mass spectrometry. Proteins were identified from their peptide sequences, using the National Center for Biotechnology Information (NCBI) and Swiss-prot databases. Metabolic enzymes involved in glycolysis (glycogen phosphorylase, phosphoglycerate mutase) and the citric acid cycle (aconitase 2, oxoglutarate dehydrogenase) were increased in AA- vs. BB-sired steers. Expression of proteins involved in cell structure, such as myosin light chain isoforms and troponins I and T, were also altered due to sire breed. Furthermore, heat shock protein β-1 and peroxiredoxin 6, involved in cell defense, had increased abundance in muscle of AA-sired relative to BB-sired steers. Protein abundance of glucose-6-phosphate isomerase, enolase-3, and pyruvate kinase was greater in AA-sired animals of High compared with Low EPDcwt. Changes in the expression of these proteins were supported by gene expression analysis using quantitative real-time PCR. This information will aid in our understanding of genetic influences controlling muscle growth and fat accumulation and could contribute to future breeding programs to increase lean tissue gain of beef cattle.

Left ventricular remodeling in human heart failure: quantitative echocardiographic assessment of 1,794 patients

BACKGROUND

The left ventricle (LV) undergoes significant architectural remodeling in heart failure (HF). However, the fundamental associations between cardiac function and LV size and performance have not been thoroughly characterized in this population. We sought to define the adaptive remodeling that occurs in chronic human HF through the detailed analyses of a large quantitative echocardiography database.

METHODS

Baseline echocardiograms were performed in 1,794 patients with HF across a broad range of ejection fraction (EF), from less than 10% to greater than 70%. Core lab measurements of LV volumes and length were made, from which EF, mass, sphericity indices, stroke volume (SV), and stroke work were derived. Spearman correlation coefficients and linear regression methods were used to determine the relationships between remodeling parameters.

RESULTS

The median EF was 28.6% (IQR 21.9-37.0). Across a multitude of parameters of cardiac structure and function, indexed end-systolic volumes (ESVs) explained the greatest proportion of the variance in EF (R =-0.87, P < 0.0001). Systolic sphericity index and LV mass were also strongly correlated with EF (R =-0.62 and -0.63, P < 0.0001), reflective of the alterations in LV shape and size that occur as EF declines. SV was rigorously maintained across a broad spectrum of EF, until the EF fell below 20%, at which point SV decreased significantly (P < 0.0001).

CONCLUSIONS

In chronic HF, the LV undergoes extensive structural adaptive remodeling in order to maintain SV across a broad range of EF. However, when the EF falls below 20%, further modulation of SV is no longer possible through alterations in ventricular architecture.

Cardiovascular disease among hispanics and non-hispanics in the chronic renal insufficiency cohort (CRIC) study

BACKGROUND AND OBJECTIVES

Hispanics are the largest minority group in the United States. The leading cause of death in patients with chronic kidney disease (CKD) is cardiovascular disease (CVD), yet little is known about its prevalence among Hispanics with CKD.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We conducted cross-sectional analyses of prevalent self-reported clinical and subclinical measures of CVD among 497 Hispanics, 1638 non-Hispanic Caucasians, and 1650 non-Hispanic African Americans, aged 21 to 74 years, with mild-to-moderate CKD at enrollment in the Chronic Renal Insufficiency Cohort (CRIC) and Hispanic CRIC (HCRIC) studies. Measures of subclinical CVD included left ventricular hypertrophy (LVH), coronary artery calcification (CAC), and ankle-brachial index.

RESULTS

Self-reported coronary heart disease (CHD) was lower in Hispanics compared with non-Hispanic Caucasians (18% versus 23%, P = 0.02). Compared with non-Hispanic Caucasians, Hispanics had a lower prevalence of CAC >100 (41% versus 34%, P = 0.03) and CAC >400 (26% versus 19%, P = 0.02). However, after adjusting for sociodemographic factors, these differences were no longer significant. In adjusted analyses, Hispanics had a higher odds of LVH compared with non-Hispanic Caucasians (odds ratio 1.97, 95% confidence interval, 1.22 to 3.17, P = 0.005), and a higher odds of CAC >400 compared with non-Hispanic African Americans (odds ratio, 2.49, 95% confidence interval, 1.11 to 5.58, P = 0.03). Hispanic ethnicity was not independently associated with any other CVD measures.

CONCLUSIONS

Prevalent LVH was more common among Hispanics than non-Hispanic Caucasians, and elevated CAC score was more common among Hispanics than non-Hispanic African Americans. Understanding reasons for these racial/ethnic differences and their association with long-term clinical outcomes is needed.

FGF23 induces left ventricular hypertrophy

Chronic kidney disease (CKD) is a public health epidemic that increases risk of death due to cardiovascular disease. Left ventricular hypertrophy (LVH) is an important mechanism of cardiovascular disease in individuals with CKD. Elevated levels of FGF23 have been linked to greater risks of LVH and mortality in patients with CKD, but whether these risks represent causal effects of FGF23 is unknown. Here, we report that elevated FGF23 levels are independently associated with LVH in a large, racially diverse CKD cohort. FGF23 caused pathological hypertrophy of isolated rat cardiomyocytes via FGF receptor-dependent activation of the calcineurin-NFAT signaling pathway, but this effect was independent of klotho, the coreceptor for FGF23 in the kidney and parathyroid glands. Intramyocardial or intravenous injection of FGF23 in wild-type mice resulted in LVH, and klotho-deficient mice demonstrated elevated FGF23 levels and LVH. In an established animal model of CKD, treatment with an FGF-receptor blocker attenuated LVH, although no change in blood pressure was observed. These results unveil a klotho-independent, causal role for FGF23 in the pathogenesis of LVH and suggest that chronically elevated FGF23 levels contribute directly to high rates of LVH and mortality in individuals with CKD.

Vascular responses to drug-eluting and bare metal stents in diabetic/hypercholesterolemic and nonatherosclerotic porcine coronary arteries

BACKGROUND

Animal models used to gain insight into the vascular response to drug-eluting stents are generally juvenile and nonatherosclerotic, whereas stents are placed in patients with complex atherosclerosis and comorbidities. Hence, models reflecting these complexities are needed to help elucidate the vascular effects of drug-eluting stents. We compared the vascular responses with bare metal stent (BMS) and paclitaxel-eluting stent (PES) implantation in a diabetic/hypercholesterolemic (DM/HC) porcine model of advanced coronary atherosclerosis with the standard juvenile porcine model.

METHODS AND RESULTS

Two studies using similar stent procedural protocols were performed in either DM/HC (n=20) or domestic swine (non-DM/HC, n=20). Animals pretreated with dual-antiplatelet therapy, underwent BMS or PES implantation (1/artery, 2 stents per animal) and were euthanized 30 or 90 days later. DM/HC resulted in a 24% increase in platelet aggregation (P=0.05 versus baseline), whereas dual-antiplatelet therapy reduced platelet aggregation in both groups (P<0.0001). DM/HC pigs developed substantially greater neointimal area versus non-DM/HC pigs, regardless of stent type, (P=0.004 for BMS at 30 days and P=0.002 at 90 days, P=0.005 for PES at 30 days, P=0.002 at 90 days). Compared with non-DM/HC pigs, reendothelialization was delayed in DM/HC pigs, more so after PES implantation. Increased para-strut leukocytes were observed for PES compared with BMS in the DM/HC pigs at both 30 days (P=0.023) and 90 days (P=0.04). As well, increased T-lymphocyte infiltration was seen in the DM/HC pigs.

CONCLUSIONS

Stent implantation in a DM/HC swine model provides a metabolic environment closer to human disease, including hyperglycemia, hypercholesterolemia, and increased platelet aggregation. This model augmented differences in the vascular response between PES and BMS that are not as clearly evident in the non-DM/HC swine, including increased neointimal area, delayed reendothelialization, and greater, persistent vascular inflammation.

Effect of sire breed and genetic merit for carcass weight on the transcriptional regulation of the somatotropic axis in longissimus dorsi of crossbred steers

The somatotropic axis plays an important role in postnatal growth, development, and differentiation of skeletal muscle. The aim of this study was to examine the effect of sire breed and sire EPD for carcass weight (EPD(cwt)) on the expression of components of the somatotropic axis in LM of beef cattle at slaughter. Crossbred Aberdeen Angus (AA; n = 17) and Belgian Blue (BB; n = 16) steers born to Holstein-Friesian dams and sired by bulls with either high (H) or low (L) EPD(cwt) were used in the study. Thus, there were 4 genetic groups [i.e., BBH (n = 8), BBL (n = 8), AAH (n = 8), and AAL (n = 9)]. Blood samples were collected via jugular venipuncture at regular intervals for analysis of plasma concentrations of IGF-1 and insulin. Total RNA was isolated from LM collected at slaughter, and the mRNA expression of IGF-1, IGF-2, their receptors (IGF-1R; IGF-2R), 6 IGFBP, acid labile subunit (ALS), and GH receptor (GHR) was measured by real-time reverse-transcription quantitative PCR. There was no effect of either sire breed or EPD(cwt) on concentrations of circulating IGF or insulin (P > 0.05). Gene expression of IGF-1R and IGFBP3 was upregulated in AA (P < 0.001) compared with BB, whereas IGF-1 was upregulated in H compared with L animals (P < 0.01). Correlation analysis indicated moderate positive associations between gene expression of IGFBP3 and IGF-1 (r = 0.54; P < 0.001) and IGF-1R (r = 0.48; P < 0.01). In addition, correlation analysis revealed that mRNA expression of IGFBP3 was moderately negatively associated with LM area per kilogram of carcass weight (r = -0.40; P < 0.05). Greater gene expression of IGF-1 and reduced transcript abundance of IGFBP3 in muscle may have a role in increased muscle growth potential in steers during the finishing period. These data will contribute to a better understanding of the molecular control of muscle growth at a tissue level in cattle.

Akt pathway is hypoactivated by synergistic actions of diabetes mellitus and hypercholesterolemia resulting in advanced coronary artery disease

Atherosclerosis is an inflammatory process leading to enhanced cellular proliferation, apoptosis, and vasa vasorum (VV) neovascularization. While both diabetes mellitus (DM) and hypercholesterolemia (HC) predispose to atherosclerosis, the precise interaction of these risk factors is unclear. Akt is a central node in signaling pathways important for inflammation, and we hypothesized that DM/HC would lead to aberrant Akt signaling and advanced, complex atherosclerosis. DM was induced in pigs by streptozotocin and HC by a high-fat diet. Animals were randomized to control (non-DM, non-HC), DM only, HC only, and DM/HC groups. Coronary artery homogenates were analyzed by immunoblotting for proteins involved in the Akt pathway, including phosphorylated (p)-Akt (Ser473), p-GSK-3beta (Ser9), activated NF-kappaB p65, and VEGF. Immunohistochemical staining for Ki67 (cell proliferation), terminal deoxynucleotidyltransferase-mediated dUTP nick end labeling (TUNEL) (apoptosis), and von Willebrand factor (vWF) (neovascularization) was performed. Neovascularization was visualized with micro-computerized tomography (CT). Only DM/HC animals developed advanced atherosclerosis and showed decreased p-Akt (Ser473) and p-GSK-3beta (Ser9) levels (P < 0.01 and P < 0.05, respectively). DM/HC arteries demonstrated increased cellular proliferation (P < 0.001), apoptosis (P < 0.01), and activation of NF-kappaB p65 (P < 0.05). Induction of DM/HC also resulted in significant VV neovascularization by enhanced VEGF expression (P < 0.05), increased vWF staining (P < 0.01), and increased density by micro-CT. In conclusion, DM and HC synergistically resulted in complex atherosclerosis associated with attenuated p-Akt (Ser473) levels. Aberrant Akt signaling correlated with increased inflammation, cellular proliferation, apoptosis, and VV neovascularization. Our results revealed a synergistic effect of DM and HC in triggering abnormal Akt signaling, resulting in advanced atherosclerosis.

John Sutton MG, Keane MG, Wiegers SE, Shannon RP, Kirkpatrick JN. Effect of right ventricular function and venous congestion on cardiorenal interactions during the treatment of decompensated heart failure

Recent reports have demonstrated the adverse effects of venous congestion on renal function (RF) and challenged the assumption that worsening RF is driven by decreased cardiac output (CO). We hypothesized that diuresis in patients with right ventricular (RV) dysfunction, despite decreased CO, would lead to a decrease in venous congestion and resultant improvement in RF. We reviewed consecutive admissions with a discharge diagnosis of heart failure. RV function was assessed by multiple echocardiographic methods and those with >or=2 measurements of RV dysfunction were considered to have significant RV dysfunction. Worsening RF was defined as an increase in creatinine of >or=0.3 mg/dl and improved RF as improvement in glomerular filtration rate >or=25%. A total of 141 admissions met eligibility criteria; 34% developed worsening RF. Venous congestion was more common in those with RV dysfunction (odds ratio [OR] 3.3, p = 0.009). All measurements of RV dysfunction excluding RV dilation correlated with CO (p <0.05). Significant RV dysfunction predicted a lower incidence of worsening RF (OR 0.21, p <0.001) and a higher incidence of improved RF (OR 6.4, p <0.001). CO emerged as a significant predictor of change in glomerular filtration rate during hospitalization in those without significant RV dysfunction (r = 0.38, p <0.001). In conclusion, RV dysfunction is a strong predictor of improved renal outcomes in patients with acute decompensated heart failure, an effect likely mediated by relief of venous congestion.

Arterial pulsatile hemodynamic load induced by isometric exercise strongly predicts left ventricular mass in hypertension

Although resting hemodynamic load has been extensively investigated as a determinant of left ventricular (LV) hypertrophy, little is known about the relationship between provoked hemodynamic load and the risk of LV hypertrophy. We studied central pressure-flow relations among 40 hypertensive and 19 normotensive adults using carotid applanation tonometry and Doppler echocardiography at rest and during a 40% maximal voluntary forearm contraction (handgrip) maneuver. Carotid-femoral pulse wave velocity (CF-PWV) was measured at rest. Hypertensive subjects demonstrated various abnormalities in resting and induced pulsatile load. Isometric exercise significantly increased systemic vascular resistance, aortic characteristic impedance (Zc), induced earlier wave reflections, increased augmentation index, and decreased total arterial compliance (TAC; all P < or = 0.01). In hypertensive subjects, CF-PWV was the strongest resting predictor of LV mass index (LVMI) and remained an independent predictor after adjustment for age, gender, systemic vascular resistance, reflection magnitude, aortic Zc, and TAC (beta = 2.52 m/s; P < 0.0001). Age, sex, CF-PWV, and resting hemodynamic indexes explained 48% of the interindividual variability in LVMI. In stepwise regression, TAC (beta = -17.85; P < 0.0001) during handgrip, Zc during handgrip (beta = -150; P < 0.0001), and the change in the timing of wave reflections during handgrip (beta = -0.63; P = 0.03) were independent predictors of LVMI. A model that included indexes of provoked hemodynamic load explained 68% of the interindividual variability in LVMI. Hemodynamic load provoked by isometric exercise strongly predicts LVMI in hypertension. The magnitude of this association is far greater than for resting hemodynamic load, suggesting that provoked testing captures important arterial properties that are not apparent at rest and is advantageous to assess dynamic arterial load in hypertension.

Intracoronary delivery of mesenchymal stem cells at high flow rates after myocardial infarction improves distal coronary blood flow and decreases mortality in pigs

OBJECTIVES

Evaluate the effects of pressure and duration of intracoronary (IC) infusion of mesenchymal stem cells (MSCs) on delivery efficiency and safety after myocardial infarction (MI).

BACKGROUND

Standard IC delivery of MSCs can lead to intravascular plugging and reduced coronary blood flow. The optimal delivery pressure and duration is unknown.

METHODS

Immediately after MI pigs were randomized to 1 of 3 delivery protocols of 5 x 10(7) iron-fluorescent microspheres labeled MSCs, control received 2 ml infusions at 1 ml/min (five times), very high flow rate (VHFR) a single 10 ml infusion at 60 ml/min and the high flow rate (HFR) group a single 10 ml infusion at 20 ml/min. TIMI grade flow was assessed throughout the procedure and at sacrifice (day 14). MSCs distribution was analyzed in isolated hearts by 4.7T MRI. Delivery efficiency was quantified via fluorescent microsphere recovery using a magnetic separation technique and by light microscopy.

RESULTS

TIMI grade flow did not change following MI (all groups TIMI 3). However, following MSCs delivery only 18% (2/11) of control animals had TIMI 3 blood flow vs. 56% (5/9) in VHFR and 67% (4/6) in HFR (P = 0.03). As a consequence, 63% of control animals died within 24 hr, 33% in VHFR and none in HFR (P = 0.02). MSCs delivery in the infarct tissue did not differ between the groups (P = 0.06).

CONCLUSIONS

A single MSCs infusion at 20 ml/min resulted in improved coronary blood flow and decreased mortality, without sacrificing delivery efficiency.

Application of appropriateness criteria in outpatient transthoracic echocardiography

BACKGROUND

Appropriateness criteria were applied to outpatient transthoracic echocardiographic (TTE) studies.

METHODS

Indications were rated as appropriate, inappropriate, or unclassifiable, considering provider-stated indications, previous TTE studies, symptom changes, and patient-stated indications. Clinically important new or unexpected findings were recorded.

RESULTS

Of 368 TTE studies, 206 (56%) were appropriate, 31 (8%) were inappropriate, and 131 (35%) were unclassifiable. Appropriateness was not correlated with patient or provider demographics. In 288 cases with prior TTE studies, there were 92 (32%) important new findings and 63 (22%) unexpected findings, of which 20% were from inappropriately ordered and 31% from unclassifiable TTE studies. Appropriateness was not associated with new (odds ratio, 1.23; 95% confidence interval, 0.48-3.18) or unexpected (odds ratio, 1.15; 95% confidence interval, 0.38-3.52) findings. Provider type and level of training were not correlated with new or unexpected findings.

CONCLUSIONS

Many indications for TTE studies were unclassifiable. A high percentage of inappropriately ordered TTE studies yielded important information. Care must be taken in judging the value of TTE studies solely on the basis of appropriateness criteria.

Future potential of echocardiography in heart failure

Echocardiography represents a convenient, portable and noninvasive method to provide important anatomic and physiologic information to inform the management of heart failure patients. Traditional echo assessments include diagnostic, etiologic and prognostic data from ventricular size, geometry and performance. Newer echocardiographic techniques are receiving greater utilization, however, and promise to further enhance diagnostic abilities in heart failure. This article reviews traditional anatomic assessments, echo-based cardiac hemodynamics, 3D echocardiography, quantification of myocardial tissue mechanics and hand-carried echocardiography. These developments in echocardiography underlie future trends toward echo objectivity, improved imaging of patients with poor acoustic windows, miniaturization and simplicity in focused exams and the expanded application of old and new techniques.

John Sutton MG, Ferrari VA, Scott CH, Wiegers SE. Failure of digital echocardiography to accurately diagnose intracardiac shunts

BACKGROUND

Intravenous agitated saline injection during transthoracic echocardiography assists in the detection of right to left intracardiac and intrapulmonary shunts. Whether digital echocardiography offers comparable sensitivity and specificity to analog tape recording to assess shunts is unknown. Technical differences between methods could lead to significant differences in shunt detection.

METHODS

Agitated saline was injected intravenously at rest and with Valsalva in 189 consecutive patient studies (406 injections). Echocardiographers assessed presence and degree of left ventricle contrast on simultaneously recorded analog tape and digital echocardiography images in blinded fashion.

RESULTS

Digital echocardiography had low overall sensitivity (rest 0.50, valsalva 0.63, late 0.39) compared to analog tape. Longer clip lengths improved sensitivity for detection of late contrast passage (rest 0.50, valsalva 0.67, late 0.46).

CONCLUSION

Digital echocardiography saline contrast studies have poor sensitivity for assessment of intracardiac shunts versus analog tape, and increasing clip length only modestly increases sensitivity. Joint Photographic Experts Group digital compression losses may be an important cause of failure to detect intracardiac shunts, including patent foramen ovale.