Technical Validation of ARTSENS-An Image Free Device for Evaluation of Vascular Stiffness

Vascular stiffness is an indicator of cardiovascular health, with carotid artery stiffness having established correlation to coronary heart disease and utility in cardiovascular diagnosis and screening. State of art equipment for stiffness evaluation are expensive, require expertise to operate and not amenable for field deployment. In this context, we developed ARTerial Stiffness Evaluation for Noninvasive Screening (ARTSENS), a device for image free, noninvasive, automated evaluation of vascular stiffness amenable for field use. ARTSENS has a frugal hardware design, utilizing a single ultrasound transducer to interrogate the carotid artery, integrated with robust algorithms that extract arterial dimensions and compute clinically accepted measures of arterial stiffness. The ability of ARTSENS to measure vascular stiffness in vivo was validated by performing measurements on 125 subjects. The accuracy of results was verified with the state-of-the-art ultrasound imaging-based echo-tracking system. The relation between arterial stiffness measurements performed in sitting posture for ARTSENS measurement and sitting/supine postures for imaging system was also investigated to examine feasibility of performing ARTSENS measurements in the sitting posture for field deployment. This paper verified the feasibility of the novel ARTSENS device in performing accurate in vivo measurements of arterial stiffness. As a portable device that performs automated measurement of carotid artery stiffness with minimal operator input, ARTSENS has strong potential for use in large-scale screening.

Evaluation of the Beta Stiffness Index and Carotid Intima–Media Thickness in Asian Patients With Psoriasis

The risk of cardiovascular (CV) events is reportedly elevated in patients with psoriasis. Evaluation of the beta stiffness index (BSI) and carotid intima–media thickness (cIMT) are noninvasive methods of assessing arterial stiffness and subclinical atherosclerosis. We aimed to determine carotid arterial stiffness and cIMT, using high-resolution ultrasonography, in patients with psoriasis compared with controls, and to analyze whether psoriasis is an independent risk factor for atherosclerosis. A total of 54 consecutive patients with psoriasis and 60 age and gender-matched healthy controls were enrolled. Compared with control participants, patients with psoriasis exhibited a significantly higher BSI ( P < .001). The cIMT tended to be higher in patients with psoriasis but statistically not significant ( P = .076). BSI was positively correlated with age, systolic blood pressure, disease severity defined according to history of systemic treatment, and traditional CV risk factors. Also, psoriasis was independently associated with BSI. These findings suggest that psoriasis is an independent risk factor for arterial stiffness, and the BSI is an earlier indicator of atherosclerosis than cIMT in these patients.

Serum osteoprotegerin is associated with arterial stiffness assessed according to the cardio-ankle vascular index in hypertensive patients

AIM

Arterial stiffness is recognized to be an independent risk factor for cardiovascular morbidity and mortality. Recent studies have found that osteoprotegerin (OPG) is associated with increased pulse wave velocity and may reflect endothelial dysfunction. The aim of this study was to evaluate the relationship between the serum OPG level and arterial stiffness in hypertensive patients using the cardio-ankle vascular index (CAVI).

METHODS

Fasting blood samples were obtained from 115 hypertensive patients and 52 healthy participants. The CAVI value was derived using the waveform device (CAVI-VaSera VS-1000). The serum OPG levels were measured using a commercially available enzyme-linked immunosorbent assay. A CAVI value of ≥9 defined the high arterial stiffness group.

RESULTS

Sixty-five hypertensive patients (56.5%) were included in the high arterial stiffness group. Diabetes (p=0.032), smoking (p=0.044), age (p < 0.001), systolic blood pressure (p=0.001), diastolic blood pressure (p=0.024), pulse pressure (p=0.046) and the creatinine (p=0.013) and serum OPG (p < 0.001) levels were higher in the high arterial stiffness group than in the low arterial stiffness group, while the glomerular filtration rate (p=0.003) was lower in the high arterial stiffness group than in the low arterial stiffness group among the hypertensive patients. The results of the Spearman's rank correlation coefficient test also indicated a strong positive correlation between the OPG and CAVI values (r=0.484, p < 0.001) in the hypertensive patients. In addition, a multivariate logistic regression analysis showed that age (odds ratio: 1.162, 95% confidence interval (CI): 1.070-1.263, p < 0.001), diastolic blood pressure (odds ratio: 1.109, 95% CI: 1.033-1.190, p=0.004), and serum OPG level (odds ratio: 1.275, 95% CI: 1.030-1.580, p=0.026) were independent predictors of arterial stiffness in hypertensive patients.

CONCLUSIONS

The serum OPG level is positively associated with arterial stiffness in hypertensive patients.

Echocardiographic elastic properties of ascending aorta and their relationship with exercise capacity in patients with non-ischemic dilated cardiomyopathy

Background

: Aortic stiffness, an independent predictor of mortality and cardiovascular events, is common among patients affected by non-ischemic dilated cardiomyopathy (NIDC) and heart failure (HF).

Methods

: A total of 55 patients with diagnosis of NIDC (aged 60 ± 11 years, mean ejection fraction (EF) 35.2% ± 7.7%) admitted consecutively to our department for mild to moderate HF (NYHA class II–III) underwent an echocardiographic study and cardiopulmonary exercise test (CPX). We evaluated elastic properties of ascending aorta, i.e. aortic stiffness and aortic distensibility (mm Hg^{− 1}), derived from ascending aorta systolic and diastolic diameter (mm/m²) measured 3 cm above the valvular plane through 2D-guided M-mode echocardiography.

Results

: Mean aortic stiffness was 15.63 ± 14.53 and aortic distensibility was 2.61 ± 2.39 mm Hg^{− 1}. Collected parameters at CPX were peak oxygen consumption (pVO₂) (ml/kg/min), anaerobic threshold (AT) and the slope of the relation between minute ventilation (VE) and carbon dioxide production (VCO₂). Mean pVO₂ was 15.4 ± 3.9 ml/kg/min, VE/VCO₂ ratio at AT was 36.1 ± 6.1. Functional capacity measured through peak VO₂ was found to be directly correlated with aortic distensibility (r = 0.47, p = − 0.0002) and negatively correlated to aortic stiffness index (r = − 0.51, p = − 0.0001). These results were the same at multivariate analysis, corrected by age, hypertension, diabetes mellitus and ejection fraction (respectively r = 0.27, p = 0.008 and r = − 1.75, p = 0.0002).

Conclusions

: HF patients due to NIDC elastic properties of ascending aorta, evaluated by echocardiography, are correlated with a reduced functional capacity.

Causes and pathophysiology of heart failure with preserved ejection fraction

Heart failure with preserved ejection fraction (HFPEF) is frequently associated with multiple disorders complicating both the clinical management and the understanding of the underlying mechanisms. This review focuses on the causes and pathophysiology of HFPEF and overviews how cellular and molecular changes related to various comorbidities may influence the age-dependent and gender-dependent hemodynamic alterations of diastolic ventricular function.

Fibulin-5 null mice with decreased arterial compliance maintain normal systolic left ventricular function, but not diastolic function during maturation

Abstract The large arteries serve as compliant vessels that store energy during systole and return it during diastole. This function is made possible by the elastic fibers in the arterial wall that are assembled during late embryonic and early postnatal development from various proteins, including fibulin-5. Mice and humans with insufficient amounts of fibulin-5 have reduced arterial compliance as adults. Reduced compliance of the large arteries is correlated with hypertension, reduced cardiac function, and an increased risk of death from cardiac and cardiovascular disease. The goal of this study was to quantify arterial compliance, blood pressure, and left ventricular (LV) function from early postnatal development to young adulthood in fibulin-5 null (Fbln5-/-) mice to determine the effects of reduced arterial compliance during this critical period of elastic fiber assembly. We find that ascending aorta compliance is reduced as early as postnatal day (P) 7 and carotid artery compliance is reduced by P21 in Fbln5-/- mice. We did not find significant increases in systolic blood pressure by P60, but pulse pressures are increased by P21 in Fbln5-/- mice. LV systolic function, as measured by ejection fraction and fractional shortening, is unaffected in Fbln5-/- mice. However, LV diastolic function, as measured by tissue Doppler imaging, is compromised at all ages in Fbln5-/- mice. We propose that Fbln5-/- mice represent a suitable model for further studies to determine mechanistic relationships between arterial compliance and LV diastolic function.

Left ventricular twist and ventricular-arterial coupling in hypertensive patients

BACKGROUND

Left ventricular (LV) twist is usually influenced by LV hypertrophy resulting from hypertension or vascular stiffness. Vascular stiffness would increase arterial elastance (Ea), whereas LV end-systolic stiffness (Ees) could be influenced by LV hypertrophy. Therefore, in hypertensive patients, we assessed the extent to which ventricular-arterial coupling (VAC; Ea/Ees) affects LV twist, which may be a compensatory mechanism for systolic dysfunction.

METHODS

Hypertensive patients (n = 128) and healthy controls (n = 40) underwent conventional and speckle tracking echocardiography including LV twist. Ea and Ees were estimated noninvasively by echocardiography. Patients were divided into 3 tertiles according to the twist angle. Univariate and multivariate regression analyses were performed to test the influence of VAC on twist.

RESULTS

Patients in the lowest LV twist tertile had larger LV end-systolic volume, lower ejection fraction, lesser mid-wall fractional shortening (MWFS), and higher LV mass index (LVMI), compared to those with the highest tertile. They showed the lower septal tissue Doppler velocity, and global longitudinal and circumferential strain. With regard to VAC, Ea was similar among 3 groups, but Ees was significantly decreased in patient with lower tertile, resulting in increased VAC (1.1 ± 0.2 vs. 0.9 ± 0.1 vs. 0.7 ± 0.1, P < 0.001). While LV twist showed significant correlations with Ees, MWFS, and LVMI, VAC (β = -14.92, P < 0.001) was most associated with twist in a multivariate analysis.

CONCLUSIONS

LV twist was significantly associated with VAC in accordance with LV function; LV twist and VAC decreased progressively as LV systolic function deteriorated, while being enhanced during the well-compensated phase.

Arterial Stiffness: A Nexus between Cardiac and Renal Disease

Vascular disease is the leading cause of morbidity and mortality in the Western world, and vascular function is determined by structural and functional properties of the arterial vascular wall. Cardiorenal metabolic syndrome such as obesity, diabetes, hypertension, kidney disease, and aging are conditions that predispose to arterial stiffening, which is a pathological alteration of the vascular wall and ultimately results in target organ damage in heart and kidney. In this review, we provide new insights on the interactions between arterial stiffness, vascular resistance and pulse wave velocity as well as final end-organ damage in heart and kidney. Better understanding of the mechanisms of arterial functional and hemodynamic alteration may help in developing more refined therapeutic strategies aimed to reduce cardiovascular and chronic kidney diseases.

Perioperative transesophageal echocardiography for aortic dissection

PURPOSE

Aortic dissection is an infrequent but serious condition that often requires immediate operative intervention. We explore recent developments in the classification of aortic dissection and perioperative transesophageal echocardiography that assist with quantifying the severity of disease and facilitate its management.

PRINCIPAL FINDINGS

We describe the pivotal role of echocardiography in relation to key surgical considerations such as cannulation, aortic root surgery, perfusion in the aortic arch vessels, stenting in hybrid arch repair, and timing of preventative surgery.

CONCLUSION

Developments in the classification of aortic dissection have improved our perspective and understanding of the key presenting features that affect mortality. Improvements in patient outcome may be achieved in part by appropriately timed echocardiography-guided surgery.

Arterial stiffness changes in patients with cardiovascular risk factors but normal carotid intima-media thickness

AIMS

We aimed to evaluate, through an Echotracking system, the functional changes of carotid arteries with relation to the amount of cardiovascular risk factors in patients without structural atherosclerotic damage.

METHODS

From a series of 260 asymptomatic consecutive patients we selected 75 patients (mean age: 47 ± 8 years) with normal intima-media thickness (IMT) and without atherosclerotic plaques. In these patients, local arterial stiffness parameters were evaluated using a simple Echotracking system. Patients were divided in three groups: group 1 (n = 25 patients without risk factors), group 2 (n = 23 patients with one risk factor) and group 3 (n = 27 patients with two or more risk factors).

RESULTS

Carotid IMT was similar in all groups (P = ns). On the contrary, stiffness parameters progressively increased according to the number of risk factors [pulse wave velocity (PWV) = 5.8 ± 1.1 m/s, 6.4 ± 1.2 m/s and 6.7 ± 1.4 m/s in Group 1, 2 and 3, respectively, P = 0.002; β-index = 7.5 ± 3.4, 8.5 ± 3.2 and 9.5 ± 4.7 in Group 1, 2 and 3, respectively, P = 0.047]. Furthermore, on multivariate linear regression analysis, PWV and β-index significantly correlated (P = 0.002 and P = 0.048, respectively) with the number of risk factors even when adjusted for age, gender and current therapy.

CONCLUSION

In a population with normal carotid IMT and without plaques, changes in arterial stiffness are significantly related to the number of risk factors. This information could be relevant for a more tailored primary prevention in patients with risk factors even in absence of structural atherosclerotic abnormalities.

Early identification of cardiovascular involvement in patients with β-thalassemia major

The aim of the present study was to evaluate left ventricular myocardial deformation and carotid arterial stiffness using 2-dimensional strain and echo-tracking in patients with asymptomatic β-thalassemia major (β-TM) without significant myocardial iron overload to determine whether early subclinical cardiovascular abnormalities would be detectable. We enrolled 32 patients with β-TM (23 women, mean age 35 ± 8 years) and 33 healthy volunteers (20 women, mean age 35 ± 6 years). All subjects underwent echocardiography with 2-dimensional strain analysis (XStrain) and ultrasonography of the carotid arteries with measurement of the stiffness parameters (ProSound Alpha 10). Cardiac magnetic resonance imaging using a T2* algorithm (37.7 ± 5.6 ms) for the assessment of myocardial iron overload was performed in each patient. The clinical and standard echocardiographic parameters were comparable between the patients and healthy subjects. The global left ventricular longitudinal strain was significantly impaired in the patients compared with the controls (-17.9 ± 3.5% vs -24.3 ± 3.4%, p = 0.002), although the radial and circumferential strain values were similar between the 2 groups (p = NS for both). The carotid intima-media thickness was comparable between the patients and healthy subjects (0.67 ± 0.20 mm vs 0.66 ± 0.15 mm, p = NS). In contrast, the arterial stiffness was significantly increased in the patients compared with the controls (stiffness index 6.16 ± 1.31 vs 4.65 ± 0.82, p <0.001; arterial compliance 1.10 ± 0.26 vs 1.28 ± 0.30 cm(2)/mm Hg, p = 0.027; elastic modulus 74.1 ± 19.5 vs 59.1 ± 12.1 mm Hg, p = 0.001). In conclusion, cardiovascular abnormalities, although often subclinical, occur at an early stage of β-TM and also in the absence of significant iron overload. Thus, 2-dimensional strain and echo-tracking might be more accurate than standard echocardiography and vascular parameters in the early identification of cardiovascular involvement.

Aortic root dimensions and stiffness in healthy subjects

The aim of the present study was to investigate the full range of aortic root diameters and stiffness in a group of subjects without known cardiovascular risk factors and/or overt cardiovascular disease. Four hundred and twenty-two healthy subjects (mean age 44.35 ± 16.91 years, range 16 to 90, 284 men [67%]) underwent comprehensive transthoracic echocardiography. The leading edge method was used for the end-diastolic aortic root diameters measured at 4 locations (1) the aortic annulus, (2) the sinuses of Valsalva, (3) the sinotubular junction, and (4) the maximum diameter of the proximal ascending aorta. Aortic wall stiffness was assessed using 2-dimensional guided M-mode evaluation of systolic and diastolic aortic diameter, 3 cm above the aortic valve. The absolute aortic root diameters increased with age in both genders. Aortic measurements were significantly greater in men than in women at all levels, whereas body surface area-indexed values were similar in men and women, except for the ascending aorta for which women tended to have greater values. Multivariable regression analysis using age and body size (weight, height, and body surface area) predicted all aortic diameters, whereas blood pressure indexes predicted only the distal part of the aorta. Aortic stiffness increased with age in men and women with no differences between genders; only age predicted aortic stiffness. The increment in aortic diameter with age was lesser when adjusted for aortic stiffness. In conclusion, we define the physiologic range of aortic root diameters and related stiffness in healthy subjects stratified by age and gender. Moreover, aortic stiffness should also be taken into account when the increase of aortic diameter is considered.

Comparison of sequentially measured Aloka echo-tracking one-point pulse wave velocity with SphygmoCor carotid-femoral pulse wave velocity

Objectives:

Recently, echo-tracking-derived measures of arterial stiffness have been introduced in clinical practice for the assessment of one-point pulse wave velocity. The purpose of this study was to find a relation between carotid–femoral pulse wave velocity and one-point carotid pulse wave velocity, and to find a value of one-point carotid pulse wave velocity that predicts carotid–femoral pulse wave velocity higher than 12 m/s.

Methods:

A total of 160 consecutive subjects (112 male/48 female, mean age = 51.5 ± 14.1 years; 96 healthy, 44 hypertensives, 13 with aortic valve disease, and 7 with left ventricular dysfunction) were studied. Carotid–femoral pulse wave velocity was measured with the SphygmoCor system and one-point carotid pulse wave velocity with high-definition echo-tracking system (ProSound Alpha10; Aloka, Tokyo, Japan).

Results:

Both carotid–femoral pulse wave velocity and one-point carotid pulse wave velocity correlated significantly with each other (r = 0.539, p < 0.001) and with age (one-point carotid pulse wave velocity r = 0.618, carotid–femoral pulse wave velocity r = 0.617, p < 0.0001 for both). Median value of carotid–femoral pulse wave velocity (7.2 m/s, 95% confidence interval = 6.2–8.9) was systematically higher than that of one-point carotid pulse wave velocity (5.8 m/s, 95% confidence interval = 5–6.6). The area under the receiver operating characteristic curve was 0.85, identifying the cutoff for one-point pulse wave velocity of 6.65 m/s as the best predictor of carotid–femoral pulse wave velocity more than 12 m/s (sensitivity = 0.818, specificity = 0.819).

Conclusions:

One-point carotid pulse wave velocity correlates with carotid–femoral pulse wave velocity, and the cutoff of 6.65 m/s was the best predictor of carotid–femoral pulse wave velocity over 12 m/s.

Arterial stiffness and walk time in patients with end-stage renal disease

BACKGROUND

End-stage renal disease patients experience increased prevalence of cardiovascular disease. Heart-artery interaction may be shifted, impacting blood pressure lability, and exercise tolerance. The coupling ratio consists of the ratio of indexed arterial elastance (EaI, arterial load) to ElvI, a measure of cardiac contractility or stiffness. Our purpose was to explore the relationship between elastances and functional capacity. We hypothesized that arterial stiffness (central pulse wave velocity, PWV) and elastances would be correlated to shuttle walk time.

METHODS

We used applanation tonometry, ultrasonography, and a shuttle walk test to evaluate our hypothesis. Spearman's correlations were used to assess relationships between variables. Block regression was also performed.

RESULTS

Forty-two subjects on maintenance hemodialysis participated. Average age=44±5 years, body surface area=2.01 kg/m(2). Mean EaI=4.45 and mean ElvI=6.89; the coupling ratio=0.82. Mean aortic pulse pressure=51 mmHg and PWV=9.6 m/s. PWV(r=-0.385) and EaI (r=-0.424) were significantly and inversely related to walking time while stroke volume index (SVI) was positively correlated to shuttle walk time (r=0.337), p<0.05 for all.

CONCLUSIONS

We conclude that, like other clinical populations, both arterial and heart function predict walking ability and represent potential targets for intervention; arterial stiffness and SVI are strongly related to shuttle walk time in patients with ESRD.

The Ventricular-Arterial Coupling: From Basic Pathophysiology to Clinical Application in the Echocardiography Laboratory

The interplay between cardiac function and arterial system, which in turn affects ventricular performance, is defined commonly ventricular-arterial coupling and is an expression of global cardiovascular efficiency. This relation can be expressed in mathematical terms as the ratio between arterial elastance (EA) and end-systolic elastance (EES) of the left ventricle (LV). The noninvasive calculation requires complicated formulae, which can be, however, easily implemented in computerized algorithms, allowing the adoption of this index in the clinical evaluation of patients. This review summarizes the up-to-date literature on the topic, with particular focus on the main clinical studies, which range over different clinical scenarios, namely hypertension, heart failure, coronary artery disease, and valvular heart disease.

The correlation of carotid artery stiffness with heart function in hypertensive patients

BACKGROUND

The strength of each heart beat and the stiffness of large arteries contribute to blood pressure (BP). When the large arteries are stiff and their resistance greater, the afterload increases and this may change the function of the heart. However, the relation between common carotid artery stiffness and heart function in hypertensive patients has not been clarified.

METHODS

Two hundred and twenty hypertensive patients underwent transthoracic and carotid echocardiography. Measurements of local arterial stiffness were taken at the right common carotid artery level and stiffness parameter (β), pressure-strain elasticity modulus and intima-media thickness were calculated. Brachial cuff BP was measured just before starting the carotid study. The patients with any cardiovascular disease, diabetes mellitus, stroke, transient ischemic attack, or carotid stenosis were excluded.

RESULTS

Carotid artery stiffness parameter (β) was correlated with age and left ventricular mass index (p < 0.005). Even though β was not correlated with LV systolic function, it was inversely correlated with diastolic function as measured by early mitral annular velocity. When the artery was stiffer, early mitral annular velocity (e') decreased (p < 0.001) and the index of left atrial (LA) pressure (early diastolic mitral inflow E velocity/e') increased (p = 0.001). In logistic regression, diastolic dysfunction was affected by age (beta -0.385, p = 0.001), LA volume index (beta 0.175, p = 0.013) and β (beta -0.273, p = 0.019).

CONCLUSION

In hypertensive patients, changes in carotid artery stiffness can affect the diastolic function, independent of age and LA volume index. Therefore, measurements and control of carotid stiffness can play an important role in the prevention of diastolic heart failure.

NAD(P)H oxidase p22(phox) polymorphism and cardiovascular function in amateur runners

AIM

NAD(P)H system represents the major source of superoxide production at cardiovascular (CV) level. It has several genetic variants: in particular, the C242T polymorphism of its p22(phox) subunit is associated with a different oxidase activity, being the T allele related to a lower superoxide production. Although several authors investigated the protective effect of T allele in CV diseases, only few data are available on its functional role in physiological conditions. The aim of our study was to investigate the relationship between the p22(phox) C242T polymorphism and CV function in amateur runners.

METHODS

Seventy-three male amateur runners were screened for CYBA polymorphism. CV analysis was performed by echocardiographic-Doppler examination and by PulsePen tonometer assessment.

RESULTS

The genetic subgroups (CC and CT/TT) did not differ for VM O(2max) and cardiac dimension. Nevertheless, T carriers (n = 40) were characterized by a more efficient myocardial contraction and left ventricular (LV) filling, as evidenced by significant higher values of the midwall fractional shortening, systolic excursion of the tricuspid annular plane and of early/late diastolic wave velocities ratio and by a lower E wave deceleration time. Pulse wave velocity and augmentation index, parameters related to the arterial stiffness, were higher in CC subjects compared with CT/TT also when the analysis was adjusted for weight and diastolic pressure.

CONCLUSION

In amateur runners, CYBA variants may influence both systolic and diastolic function and arterial stiffness. We suppose that the lower oxidative activity that characterizes 242T subjects may positively influence the excitation-contraction and arterial-ventricular coupling mechanisms, thus leading to a more efficient CV function.

Impact of diabetes on postinfarction heart failure and left ventricular remodeling

Diabetes mellitus, the metabolic syndrome, and the underlying insulin resistance are increasingly associated with diastolic dysfunction and reduced stress tolerance. The poor prognosis associated with heart failure in patients with diabetes after myocardial infarction is likely attributable to many factors, important among which is the metabolic impact from insulin resistance and hyperglycemia on the regulation of microvascular perfusion and energy generation in the cardiac myocyte. This review summarizes epidemiologic, pathophysiologic, diagnostic, and therapeutic data related to diabetes and heart failure in acute myocardial infarction and discusses novel perceptions and strategies that hold promise for the future and deserve further investigation.

Contrast stress echocardiography in hypertensive heart disease

Hypertension is associated with atherosclerosis and cardiac and vascular structural and functional changes. Myocardial ischemia may arise in hypertension independent of coronary artery disease through an interaction between several pathophysiological mechanisms, including left ventricular hypertrophy, increased arterial stiffness and reduced coronary flow reserve associated with microvascular disease and endothelial dysfunction. The present case report demonstrates how contrast stress echocardiography can be used to diagnose myocardial ischemia in a hypertensive patient with angina pectoris but without significant obstructive coronary artery disease. The myocardial ischemia was due to severe resistant hypertension complicated with concentric left ventricular hypertrophy and increased arterial stiffness.

Diabetes and the risk of heart failure

Prevalence of diabetes and heart failure are increasing exponentially worldwide. Diabetes is well-known to increase the risk of heart failure independent of other traditional risk factors and ischemia. Current evidence indicates the presence of several biochemical and molecular changes associated with diabetes that lead to diastolic dysfunction or American Heart Association stage B heart failure. Some, if not all, changes may also predate the development of frank diabetes. In this review, the authors present some of the epidemiologic evidence and a brief description of major mechanistic pathways that favor the development of heart failure in prediabetic and diabetic states.

Arterial-cardiac interaction: the concept and implications

Vascular stiffening of the large arteries is a common feature of human aging. Increased aortic stiffness with age may contribute to pathological changes in the left ventricle and this can induce ventricular stiffening. Vascular-ventricular stiffening combined with abnormal arterial-cardiac interaction is considered an important pathophysiology of heart failure with a preserved ejection fraction. Here, I briefly review the concept and implications of arterial-cardiac interaction and this will pave the way to understanding and controlling heart failure with a preserved ejection fraction, which is more prevalent in the elderly.

Incremental Value of Arterial Stiffness Over Traditional Risk Factors in Predicting Subclinical Cardiovascular Remodeling in Patients With Moderate Chronic Renal Failure

Cardiovascular remodeling in chronic kidney disease (CKD) is responsible for the high mortality found in this condition. A total of 89 consecutive outpatients with stage III CKD and 52 patients with stage II CKD with similar degree of traditional atherosclerotic risk factors underwent routine echocardiographic and carotid Doppler examination, evaluating vascular and cardiac remodeling (intima—media thickness [IMT] and left ventricular mass index [LVMi]), and its relation with arterial stiffness, determined in the same examination, using an echo-tracking technique. Also the absolute values of LVMi and IMT were statistically similar between the 2 groups, their determinants were completely different, only in stage III the markers of renal impairment and arterial stiffness being independent predictors of cardiac and vascular modifications. We concluded that macroanatomical measurements do not fully describe cardiovascular remodeling in this setting. Arterial stiffness echo-tracking derived could add valuable information, being an easy-to-perform parameter during a routine examination.

Diagnosis and management of left ventricular diastolic dysfunction in the hypertensive patient

The progression of hypertensive involvement toward heart failure includes myocardial fibrosis and changes of left ventricular (LV) geometry. In the presence of these abnormalities, diastolic abnormalities occur and are defined as LV diastolic dysfunction (DD). They include alterations of both relaxation and filling, precede alterations of chamber systolic function and can induce symptoms of heart failure even when ejection fraction is normal. The prevalence of heart failure with normal ejection fraction (HFNEF) increased over time whereas the rate of death from this disorder remained unchanged. In this view, diagnosis, prognosis, and therapeutic management of DD and HFNEF in hypertensive patients is a growing public health problem. DD may be asymptomatic and identified occasionally during a Doppler-echocardiographic examination. This tool has gained, therefore, important clinical position for diagnosis of DD. Comprehensive assessment of diastolic function should be done not by a simple classification of DD progression but by estimating the degree of LV filling pressure (FP), a true determinant of symptoms and prognosis. This can be obtained by different ultrasound maneuvers/tools but the ratio between transmitral E velocity and pulsed tissue Doppler-derived early diastolic velocity (E/e' ratio) is the most feasible and accurate. The identification of left atrial enlargement may be useful in uncertain cases. The recommended management of DD in hypertensive patients should correspond to blood pressure (BP) lowering and to the attempt of reducing LV mass and normalizing LV geometry. Prospective studies with well-defined entry criteria are needed to establish whether this approach could reflect a better prognosis.

Early Identification of Vascular Damage in Patients With Systemic Sclerosis

Vascular involvement in systemic sclerosis (SSc) plays a key role in the pathogenesis of fibrosis. We assessed arterial stiffness using a new echo-tracking technique in patients with SSc asymptomatic for cardiovascular diseases. We enrolled 22 patients (21 female, 63 ± 14 years) and 20 controls (12 female, 62 ± 3 years). Carotid intima-media thickness (IMT) was comparable between the 2 groups (1.1 ± 0.3 vs 1.0 ± 0.4 mm, P = ns), whereas the stiffness parameters were significantly increased in patients (β: 9.5 ± 4.2 vs 5.8 ± 1.1, P = .001; pulse wave velocity [PWV]: 6.5 ± 1.5 vs 5.2 ± 0.6 m/sec, P = .003). A correlation between stiffness parameters, anti-Scl-70 antibodies (β: r = .46, P = .03; PWV: r = .50, P = .02), and anticentromere antibodies (β: r = -.54, P = .020; PWV: r = -.53, P = .023) was found. Echo-tracking technique may be valuable in early identification of vascular involvement in patients with SSc.

Aortic distensibility associates with increased ascending thoracic aorta diameter and left ventricular diastolic dysfunction in patients with coronary artery ectasia

Coronary artery ectasia is usually linked to coronary atherosclerosis. Its primary defect is a destruction of vascular media, which leads to coronary dilatation. The aim of the present study is to evaluate whether ascending aorta present anatomical and functional wall changes in patients with coronary ectasia compared with patients without ectasia. Forty patients with known coronary ectasia (group A) underwent echocardiography in order to study aortic lumen diameter and wall properties (distensibility and stiffness index). Twenty-five patients with coronary artery disease (group B) and 40 individuals with normal coronary arteries (group C) served as control groups. Both ascending aorta diameter and ascending aorta index were significantly increased in group A compared with groups B and C (P < 0.05 and P < 0.001, respectively). Furthermore, in patients with ectatic coronary arteries ascending aorta index, systolic blood pressure and diastolic dysfunction independently associate with aortic distensibility. In patients with coronary artery ectasia, ascending aortic diameter could be enlarged while aortic stiffness is related to diastolic dysfunction. We suggest that coronary ectasia is not an isolated lesion but a reflection of a generalized vascular media defect, and should not be recognized as a benign entity.