Relation between aortic stiffness and left ventricular diastolic function in patients with hypertension, diabetes, or both

Transthoracic echocardiographic evaluation of aortic distensibility in a Takayasu's arteritis patient

Takayasu's arteritis (TA) is a chronic, nonspecific, rare, and segmental inflammatory disease that primarily affects the aorta and its main branches. In the present case, the aortic elastic properties were decreased (aortic distensibility was practically normal) suggesting that ascending aorta was not affected by TA. For preoperative assessment, a routine transthoracic echocardiography can be a valuable method for the noninvasive functional evaluation of ascending aorta in a patient with TA.

Relationship between impaired elastic properties of aorta with left ventricle geometric patterns and left ventricle diastolic functions in patients with newly diagnosed essential hypertension

The aim of this study was to investigate the association between elastic properties of aorta with left ventricle (LV) geometric patterns and LV diastolic functions in patients with newly diagnosed hypertension (HT). We studied 149 patients with newly diagnosed HT and 29 healthy control subjects. Echocardiographic examination was performed to all subjects. Ascending aorta (Ao) diameters (mm/m2) and Ao elastic indexes - namely, Ao strain [AS] (%), Ao distensibility [AD] (cm2 dyn(-1) x 10(-6)) were calculated. Four different geometric patterns were identified in hypertensive patients according to LV mass index (LVMI) and relative wall thickness (RWT). Tissue Doppler-derived Ea/Aa was determined from the all subjects. Patients vs. control subjects had lower mean AS and AD (p < 0.001 for both). Mean AS and AD of all geometric patterns significantly decreased compared with control group (p < 0.05 for all). Both AS and aortic AD of concentric remodelling (CR; p = 0.017 for both) and concentric hypertophic groups (p < 0.001 for both) were decreased compared with normal LV group. AS and AD of concentric hypertrophic pattern was lower than that of the CR group (p = 0.011 and 0.020 respectively) and the eccentric hypertrophic group (p < 0.001 and p = 0.002, respectively). Both AS and AD of the CR group were similar to that of the eccentric hypertrophic group (p > 0.05 for both). Both AS and AD were significantly correlated with age (beta = -0.178, p = 0.025, beta = -0.158, p = 0.029 respectively), LVMI (beta = -0.223, p = 0.022, beta = -263, p = 0.003 respectively), RWT (beta = -0.196, p = 0.019, beta = -0.189, p = 0.013 respectively) and Ea/Aa (beta = 0.174, p = 0.045, beta = 0.247, p = 0.002 respectively) in multiple linear regression analysis. Elastic properties of aorta were impaired in newly diagnosed HT. The degree of this impairment is different among various LV geometric patterns. In addition, impaired elastic properties of aorta were associated with RWT, LVMI and diastolic disfunctions, besides age, but not with LV geometry.

Elastic properties of the reconstructed aorta in hypoplastic left heart syndrome

BACKGROUND

Patients with repaired coarctation of the aorta retain abnormal elastic properties of the aorta. It is not known whether patients with hypoplastic left heart syndrome also manifest abnormal elastic properties after palliative surgery. The presence of such abnormalities may have important clinical implications as reduced aortic compliance might adversely impact single right ventricular function.

METHODS

We prospectively evaluated the elastic properties of the aorta in a cohort of patients with hypoplastic left heart syndrome who had undergone the Norwood procedure with aortic arch reconstruction and subsequent bidirectional Glenn or Fontan procedure. The hypoplastic left heart syndrome patients (n = 20) were compared with single-ventricle patients (n = 18) without history of arch reconstruction and patients with double-ventricular lesions (n = 22). Aortic elastic function was quantified by distensibility index and stiffness index. M-mode measurements of the transverse aortic arch were obtained with transesophageal echocardiography under general anesthesia. Patients were evaluated at a median age of 22.2 months with no age difference between patient subgroups.

RESULTS

Distensibility index was significantly less (p = 0.007) and stiffness index greater (p = 0.005) in the reconstructed arch of hypoplastic left heart syndrome patients compared with single-ventricle and double-ventricle patients.

CONCLUSIONS

Patients with hypoplastic left heart syndrome after Norwood palliation have increased aortic stiffness and decreased distensibility in the reconstructed transverse arch. As previous studies in adults have shown that decreased aortic compliance increases the energy cost of cardiac ejection, examination of modifications to the surgical technique that might improve elastic properties is warranted.

Arterial Wave Reflections Are Associated With Left Ventricular Diastolic Dysfunction in Adamantiades-Behçet's Disease

BACKGROUND

Adamantiades-Behçet's disease (ABD) is characterized by systemic vasculitis. We investigated whether aortic distensibility and arterial wave reflections are linked to left ventricular (LV) diastolic dysfunction in ABD.

METHODS AND RESULTS

Eighty-two patients and 40 controls with similar atherosclerotic risk factors were examined by applanation tonometry of the radial artery (SphygmoCor) and echocardiography. Augmentation index (AI%) and arrival time (Deltat, ms) of reflected arterial waves as well as aortic distensibility (AoD) assessed by echocardiography were estimated. Doppler diastolic abnormalities were defined as proposed by the European Study Group on Diastolic Heart Failure by measurement of E/A ratio, isovolumic relaxation time, deceleration time, and flow propagation velocity. Patients had impaired central augmentation index (CAI), Deltat, and AoD compared with controls (P > .05). After adjusting for age, atherosclerotic risk factors, left ventricular mass, and medication the odds-ratio of AoD and CAI for left ventricular diastolic dysfunction was 0.664 (95%CI 0.449-0.982), P = .04, and 1.073 (95% CI 1.014-1.140), P = .001, respectively. The addition of CAI to the multivariable model including AoD significantly increased the power of the model for prediction of left ventricular diastolic dysfunction (-2 Log likelihood change = 18.8, P for change > .01).

CONCLUSION

Augmentation index has a complementary value to aortic distensibility in the assessment of left ventricular diastolic dysfunction in ABD.

The determinants of right ventricular function in patients with atrial septal defect

OBJECTIVE

The purpose of this study was to ascertain the determinants of right ventricular (RV) systolic and diastolic functions in patients with atrial septal defect.

METHODS

Thirty-three patients with atrial septal defect having left to right shunt were enrolled in this study. RV function parameters were assessed echocardiographically. RV systolic function was assessed using tricuspid tissue Doppler S velocity (St). With regard to RV diastolic function parameters, E/A ratio, deceleration time (DT), E/Et ratio (Et = tissue Doppler E velocity), RV isovolumetric relaxation time (RVIVRT) were assessed. RV myocardial performance index (MPI) was calculated as an index of both systolic and diastolic function. Pulmonary artery stiffness (PAS) was also calculated. After echocardiography, right and left heart catheterization was performed. Mean pulmonary artery pressure (MPAP), mean right atrial pressure (MRAP), systemic flow (Qs), pulmonary flow (Qp), systemic vascular resistance (SVR), and pulmonary vascular resistance (PVR) were obtained using the data of invasive measurements.

RESULTS

In multivariate analysis, MPAP was found to be the parameter closest related to RVIVRT (r = 0.73, p < 0.001) and E/Et (r = 0.66, p < 0.001), while PAS was found to be the parameter closest related to MPI (r = 0.53, p = 0.002). In addition, St velocity was found the only parameter related to PVR (r = -0.39) in univariate analysis. There was no relationship between QP/QS and any of the RV function parameters.

CONCLUSION

The pulmonary vascular bed appears to be the predictor of the RV functions in patients with atrial left to right shunts, and the amount of the shunt seems to have no direct adverse influence on the RV functions.

Left ventricular diastolic function and endothelial function in patients with erectile dysfunction

The aim of this study was to assess left ventricular diastolic function and forearm endothelial function in patients with erectile dysfunction (ED) without overt cardiovascular disease. Forearm endothelial function and diastolic Doppler parameters, including tissue Doppler imaging, were studied in 32 men with ED and 27 age-matched, healthy, male control subjects. Left ventricular diastolic function in patients with ED and the relation between endothelium-dependent vasodilation and the Doppler parameters of left ventricular diastolic function, including tissue Doppler imaging, were assessed. Endothelium-dependent vasodilation (4.1+/-3.3% vs 9.7+/-4.2%, p<0.001) as well as the mitral inflow E velocity (0.66+/-0.17 vs 0.80+/-0.16 m/s, p=0.01), the E/A ratio (the ratio of mitral inflow E velocity to mitral inflow A velocity; 0.91+/-0.3% vs 1.22+/-0.26%, p<0.001), and the E/Em ratio (the ratio of mitral A-wave velocity to early diastolic velocity in the annulus derived by tissue Doppler imaging; 7.4+/-2.7% vs 6.6+/-1.6%, p=0.03) were smaller in the ED group than in the control group. Deceleration time (228.6+/-61.6 vs 192.9+/-44.6 ms, p=0.03) and isovolumetric relaxation time (112.8+/-18 vs 94+/-15.9 ms, p<0.001) were also prolonged in the ED group compared with the control group. The mitral E-wave velocity (r=0.40, p=0.022), the E/A ratio (r=0.40, p=0.027), and the E/Em ratio (r=-0.52, p= 0.003) were related to endothelium-dependent vasodilation by nivariate analysis. Only the E/Em ratio was correlated with endothelium-dependent vasodilation by multivariate analysis. In conclusion, this study indicates that endothelial function and left ventricular diastolic function are impaired in patients with ED without overt cardiovascular disease.

Erectile dysfunction as a generalized vascular dysfunction

OBJECTIVE

We hypothesize that generalized vascular dysfunction may be the underlying cause in patients with erectile dysfunction (ED) without atherosclerosis and its major risk factors.

METHODS

In all, 30 outpatients with ED and 25 healthy volunteers as a control group were enrolled for this study. Aortic stiffness was calculated from data obtained by echocardiographic examination, which was performed using commercially available equipment with a 2.5- to 3.5-MHz transducer. Endothelium-dependent flow-mediated dilation (FMD) of the brachial artery was assessed using a high-resolution ultrasound system with a 10-MHz linear-array vascular transducer. Shear stress and nitroglycerin was used as a stimulus for assessing endothelium-dependent FMD and nonendothelium-dependent dilation of the brachial artery.

RESULTS

FMD was significantly decreased in the ED group compared with control group (4.1 +/- 3.1% vs 9.7 +/- 3.5%, P < .001). Nonendothelium-dependent dilation was statistically insignificant in patients with ED compared with control subjects (13 +/- 3.9% vs 15.4 +/- 3.8%, P = .55). The relationship between ED and FMD was significant (r = -0.66, P < .001), whereas no relationship was found between ED and nonendothelium-dependent dilation (r = -0.23, P > .05). Aortic strain (3.7 +/- 2.7% vs 9.5 +/- 3.2%, P < .001) and distensibility (1.5 +/- 1.0 vs 4.7 +/- 2.9 cm2.dyne(-1).10(-3), P < .001) were found significantly lower in the ED group than in the control group. The relationship between ED and aortic stiffness was also significant (for aortic strain; r = -0.62, P < .001 and for aortic distensibility; r = -0.60, P < .001).

CONCLUSION

Aortic and brachial artery functions are impaired in men with ED without cardiovascular disease or its major risk factors, indicating a more generalized vascular disease.

Comparison of percutaneous coronary intervention and coronary artery bypass grafting after acute myocardial infarction complicated by cardiogenic shock: results from the Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock (SHOCK) trial

BACKGROUND

The Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock (SHOCK) trial demonstrated the survival advantage of emergency revascularization versus initial medical stabilization in patients developing cardiogenic shock after acute myocardial infarction. The relative merits of coronary artery bypass grafting (CABG) versus percutaneous coronary intervention (PCI) in patients with shock have not been defined. The objective of this analysis was to compare the effects of PCI and CABG on 30-day and 1-year survival in the SHOCK trial.

METHODS AND RESULTS

Of the 302 trial patients, 128 with predominant left ventricular failure had emergency revascularization. The selection of revascularization procedures was individualized. Eighty-one patients (63.3%) had PCI, and 47 (36.7%) had CABG. The median time from randomization to intervention was 0.9 hours (interquartile range [IQR], 0.3 to 2.2 hours) for PCI and 2.7 hours (IQR, 1.3 to 5.5 hours) for CABG. Baseline demographics and hemodynamics were similar, except that there were more diabetics (48.9% versus 26.9%; P=0.02), 3-vessel disease (80.4% versus 60.3%; P=0.03), and left main coronary disease (41.3% versus 13.0%; P=0.001) in the CABG group. In the PCI group, 12.3% had 2-vessel and 2.5% had 3-vessel interventions. In the CABG group, 84.8% received > or =2 grafts, 52.2% received > or =3 grafts, and 87.2% were deemed completely revascularized. The survival rates were 55.6% in the PCI group compared with 57.4% in the CABG group at 30 days (P=0.86) and 51.9% compared with 46.8%, respectively, at 1 year (P=0.71).

CONCLUSIONS

Among SHOCK trial patients randomized to emergency revascularization, those treated with CABG had a greater prevalence of diabetes and worse coronary disease than those treated with PCI. However, survival rates were similar. Emergency CABG is an important component of an optimal treatment strategy in patients with cardiogenic shock, and should be considered a complementary treatment option in patients with extensive coronary disease.

What role do extracellular matrix changes contribute to the cardiovascular disease burden of diabetes mellitus?

Matrix metalloproteinases (MMP) and their inhibitors (TIMP) are central factors in the control of extracellular matrix turnover. They are important in normal physiology and also during a range of pathological states. In this review, we have systematically identified clinical articles relevant to cardiovascular disease in diabetes from the last 10 years. Our aim was to outline the structure, function and regulation of metalloproteinases and their key roles in cardiomyopathy and vasculopathy in diabetes. We also explore the effects of drug intervention on both human subjects with diabetes and experimental animal models. The modulation of MMP and TIMP activity using drugs that affect the expression and function of these proteins may provide us with new ways to treat this serious and disabling disease, and we explore potential mechanisms and treatments.

The epidemiology of left ventricular hypertrophy in type 2 diabetes mellitus

AIMS/HYPOTHESIS

Patients with type 2 diabetes mellitus are at greater cardiovascular risk than the general population. Although it is widely acknowledged that diabetes is a risk factor for coronary artery disease, the increased prevalence of potentially lethal left ventricular abnormalities in this population is less well appreciated.

METHODS

We carried out an echocardiographic study of 500 subjects with type 2 diabetes mellitus to assess the prevalence of left ventricular hypertrophy (LVH) and left ventricular systolic dysfunction (LVSD). We also assessed whether abnormalities in diastolic filling parameters were present.

RESULTS

Of the 371 patients in whom left ventricular mass could be successfully assessed, 264 had LVH (71%). Left ventricular systolic dysfunction was much less common, being present in 16/385 patients (4.2%). Long axis contraction was abnormal in 29/429 patients (6.8%). Diastolic filling abnormalities were present in 178/435 (41%) of patients who could be classified using the selected criteria.

CONCLUSIONS

We conclude that left ventricular abnormalities are common in type 2 diabetic patients. As medical therapy is available for both LVH and LVSD and has been demonstrated to reduce cardiovascular death, these left ventricular abnormalities could be ideal targets for screening, followed by selective therapeutic intervention.

Left ventricular diastolic dysfunction is accompanied by increased aortic stiffness in the early stages of essential hypertension: a TDI approach

OBJECTIVE

To investigate the inter-relationship between aortic stiffness and left ventricular (LV) diastolic function in subjects with newly diagnosed uncomplicated essential hypertension.

METHODS

We studied 106 consecutive newly diagnosed subjects (aged 51 years, 80 males) with stage I-II essential hypertension, and 50 normotensives matched for age, sex and body mass index. LV diastolic function was estimated by pulsed tissue Doppler imaging (TDI) echocardiography, averaging diastolic mitral annular velocity measurements (Emav, Amav, Emav/Amav ratio) from four separate sites (basal septal, lateral, anterior, and inferior LV wall). Moreover, aortic stiffness was evaluated by non-invasive carotid-femoral pulse wave velocity (c-f PWV) measurement.

RESULTS

Hypertensives compared with normotensives exhibited greater LV mass index and Amav (110 versus 95 g/m and 10 versus 8.8 cm/s, respectively, P < 0.001 for both cases), and greater c-f PWV (8.47 versus 7.48 m/s, P < 0.03), as well as lower Emav and Emav/Amav values, (8.4 versus 10 cm/s and 0.82 versus 1.15, respectively, P < 0.001 for both cases). In the group of hypertensives, a univariate analysis revealed that c-f PWV was negatively associated with Emav (r = -0.305, P = 0.005), as well as with Emav/Amav ratio (r = -0.437, P < 0.001). Moreover, a multivariate analysis showed that the TDI-derived Emav/Amav ratio was significantly associated with age (P = 0.001), relative wall thickness (P = 0.006) and c-f PWV (P = 0.03), while the conventional Doppler-derived E/A ratio was significantly associated only with age (P = 0.001).

CONCLUSIONS

TDI-detected LV diastolic dysfunction is accompanied by increased aortic stiffness in newly diagnosed essential hypertension, suggesting that there may be a common pathophysiological pathway linking these two entities.

Assessment of aortic stiffness and ventricular diastolic functions in patients with Behçet’s disease

BACKGROUND

Behçet's disease is a systemic vasculitis in which studies have given conflicting results about ventricular diastolic functions. However, tissue Doppler echocardiography has never been used in any of these studies. Aortic stiffness, a cardiovascular risk factor, may also precede ventricular dysfunction.

OBJECTIVES

The aim of this study was to assess aortic stiffness and biventricular diastolic functions in patients with Behçet's disease.

METHODS

A total of 26 patients with Behçet's disease (mean age; 33+/-10 years) and 20 age- and sex-matched controls (mean age; 33+/-7 years) were included. Aortic stiffness was evaluated by aortic strain and distensibility. Ventricular diastolic functions were evaluated with both conventional and tissue Doppler echocardiography. Mitral E and A wave, E/A ratio of E wave, deceleration time, and isovolumic relaxation time were calculated.

RESULTS

There was no significant difference in diastolic Doppler parameters between patients and controls. Similarly, there was no significant difference in mitral annular E and A velocities between these two groups. Aortic strain in patients with Behçet's disease was found to be significantly less than in the controls (8.3+/-4.9% and 15.7+/-2.7% respectively, p<0.001). Aortic distensibility was also significantly low in patients with Behçet's disease when compared to controls (0.45+/-0.28 and 0.78+/-0.13 respectively, p<0.001). Beta index values were significantly high in Behçet's patients (7.23+/-5.93 and 2.69+/-0.55 respectively, p<0.001).

CONCLUSION

No significant diastolic dysfunction was found in left and right ventricles in patients with Behçet's disease by using both conventional and tissue Doppler echocardiography. However, an increase in aortic stiffness was found, suggesting an inflammatory involvement of proximal aorta.

Diabetic cardiomyopathy: mechanisms, diagnosis and treatment

Independent of the severity of coronary artery disease, diabetic patients have an increased risk of developing heart failure. This clinical entity has been considered to be a distinct disease process referred to as 'diabetic cardiomyopathy'. Experimental studies suggest that extensive metabolic perturbations may underlie both functional and structural alterations of the diabetic myocardium. Translational studies are, however, limited and only partly explain why diabetic patients are at increased risk of cardiomyopathy and heart failure. Although a range of diagnostic methods may help to characterize alterations in cardiac function in general, none are specific for the alterations in diabetes. Treatment paradigms are very much limited to interpretation and translation from the results of interventions in non-diabetic patients with heart failure. This suggests that there is an urgent need to conduct pathogenetic, diagnostic and therapeutic studies specifically in diabetic patients with cardiomyopathy to better understand the factors which initiate and progress diabetic cardiomyopathy and to develop more effective treatments.

Impaired elastic properties of ascending aorta in patients with giant cell arteritis

OBJECTIVE

To investigate the elastic properties of the ascending aorta in untreated patients with giant cell arteritis compared with age and sex matched normal controls.

METHODS

Distensibility of the ascending aorta and aortic strain were measured in 22 patients with a recent diagnosis of giant cell arteritis (documented by a positive temporal artery biopsy) before initiation corticosteroid treatment, and in 44 age and sex matched healthy subjects. Aortic distensibility was calculated as 2x[pulsatile change in aortic diameter]/[(diastolic aortic diameter)x(aortic pulse pressure)], and aortic strain as [pulsatile change in aortic diameter]/[diastolic aortic diameter]. Aortic diameters were measured by echocardiography. Aortic pressures were obtained by external sphygmomanometry.

RESULTS

Distensibility of the ascending aorta and aortic strain were both lower in patients with giant cell arteritis than in the controls (p<0.01). In the patients with giant cell arteritis, aortic distensibility was inversely correlated with white blood cell count (p<0.05), but not with erythrocyte sedimentation rate or C reactive protein.

CONCLUSIONS

Compared with healthy subjects, aortic distensibility and aortic strain are decreased in patients with giant cell arteritis before initiation of corticosteroid treatment. There was an association between the degree of reduction of aortic distensibility and the white blood cell count in the patient group.