Novel potential targets for prevention of arterial restenosis: insights from the pre-clinical research

Restenosis is the pathophysiological process occurring in 10-15% of patients submitted to revascularization procedures of coronary, carotid and peripheral arteries. It can be considered as an excessive healing reaction of the vascular wall subjected to arterial/venous bypass graft interposition, endarterectomy or angioplasty. The advent of bare metal stents, drug-eluting stents and of the more recent drug-eluting balloons, have significantly reduced, but not eliminated, the incidence of restenosis, which remains a clinically relevant problem. Biomedical research in pre-clinical animal models of (re)stenosis, despite its limitations, has contributed enormously to the identification of processes involved in restenosis progression, going well beyond the initial dogma of a primarily proliferative disease. Although the main molecular and cellular mechanisms underlying restenosis have been well described, new signalling molecules and cell types controlling the progress of restenosis are continuously being discovered. In particular, microRNAs and vascular progenitor cells have recently been shown to play a key role in this pathophysiological process. In addition, the advanced highly sensitive high-throughput analyses of molecular alterations at the transcriptome, proteome and metabolome levels occurring in injured vessels in animal models of disease and in human specimens serve as a basis to identify novel potential therapeutic targets for restenosis. Molecular analyses are also contributing to the identification of reliable circulating biomarkers predictive of post-interventional restenosis in patients, which could be potentially helpful in the establishment of an early diagnosis and therapy. The present review summarizes the most recent and promising therapeutic strategies identified in experimental models of (re)stenosis and potentially translatable to patients subjected to revascularization procedures.

The REFLO-STEMI trial comparing intracoronary adenosine, sodium nitroprusside and standard therapy for the attenuation of infarct size and microvascular obstruction during primary percutaneous coronary intervention: study protocol for a randomised controlled trial

BACKGROUND

Microvascular obstruction (MVO) secondary to ischaemic-reperfusion injury is an important but underappreciated determinant of short- and longer-term outcome following percutaneous coronary intervention (PCI) treatment of ST-elevation myocardial infarction (STEMI). Several small studies have demonstrated a reduction in the degree of MVO utilising a variety of vasoactive agents, with adenosine and sodium nitroprusside (SNP) being most evaluated. However, the evidence base remains weak as the trials have had variable endpoints, differing drug doses and delivery. As such, the results regarding benefit are conflicting.

METHODS

The REperfusion Facilitated by LOcal adjunctive therapy in STEMI (REFLO-STEMI) trial is a multicentre, prospective, randomised, controlled, open label, study with blinded endpoint analysis: Patients presenting within 6 h of onset of STEMI and undergoing planned primary PCI (P-PCI) with TIMI 0/1 flow in the infarct-related artery (IRA) and no significant bystander coronary artery disease on angiography, are randomised into one of three groups: PCI with adjunctive pharmacotherapy (intracoronary adenosine or SNP) or control (standard PCI). All receive Bivalirudin anticoagulation and thrombus aspiration. The primary outcome is infarct size (IS) (determined as a percentage of total left ventricular mass) measured by cardiac magnetic resonance imaging (CMRI) undertaken at 48 to 72 h post P-PCI. Secondary outcome measures include MVO (hypoenhancement within infarct core) on CMRI, angiographic markers of microvascular perfusion and MACE during 1-month follow-up. The study aims to recruit 240 patients (powered at 80% to detect a 5% absolute reduction in IS).

DISCUSSION

The REFLO-STEMI study has been designed to address the weaknesses of previous trials, which have collectively failed to demonstrate whether adjunctive pharmacotherapy with adenosine and/or SNP can reduce measures of myocardial injury (infarct size and MVO) and improve clinical outcome, despite good basic evidence that they have the potential to attenuate this process. The REFLO-STEMI study will be the most scientifically robust trial to date evaluating whether adjunctive therapy (intracoronary adenosine or SNP following thrombus aspiration) reduces CMRI measured IS and MVO in patients undergoing P-PCI within 6 h of onset of STEMI.

TRIAL REGISTRATION

Trial registered 20th November 2012: ClinicalTrials.gov Identifier NCT01747174.

Left atrial emptying fraction predicts limited exercise performance in heart failure patients

AIM

We aimed in this study to assess the role of left atrial (LA), in addition to left ventricular (LV) indices, in predicting exercise capacity in patients with heart failure (HF).

METHODS

This study included 88 consecutive patients (60 ± 10 years) with stable HF. LV end-diastolic and end-systolic dimensions, ejection fraction (EF), mitral and tricuspid annulus peak systolic excursion (MAPSE and TAPSE), myocardial velocities (s', e' and a'), LA dimensions, LA volume and LA emptying fraction were measured. A 6-min walking test (6-MWT) distance was performed on the same day of the echocardiographic examination.

RESULTS

Patients with limited exercise performance (≤ 300 m) were older (p = 0.01), had higher NYHA functional class (p = 0.004), higher LV mass index (p = 0.003), larger LA (p = 0.002), lower LV EF (p = 0.009), larger LV end-systolic dimension (p = 0.007), higher E/A ratio (p = 0.03), reduced septal MAPSE (p < 0.001), larger LA end-systolic volume (p = 0.03), larger LA end-diastolic volume (p = 0.005) and lower LA emptying fraction (p < 0.001) compared with good performance patients. In multivariate analysis, only the LA emptying fraction [0.944 (0.898-0.993), p = 0.025] independently predicted poor exercise performance. An LA emptying fraction < 60% was 68% sensitive and 73% specific (AUC 0.73, p < 0.001) in predicting poor exercise performance.

CONCLUSION

In heart failure patients, the impaired LA emptying function is the best predictor of poor exercise capacity. This finding highlights the need for routine LA size and function monitoring for better optimization of medical therapy in HF.

Early ventricular remodeling and dysfunction in obese children and adolescents

OPINION STATEMENT

Obesity is an independent predictor of heart failure in adults. Obese individuals have increased hemodynamic load and neuro-hormonal activation that contribute, but cannot entirely explain the reported changes in ventricular structure and function leading to heart failure. There are intrinsic alterations in the myocardium that are independent of load. Insulin resistance promotes alterations in myocardial substrate metabolism that may play a role in the pathogenesis of decreased myocardial efficiency and cardiac dysfunction in obese individuals. The prevalence of obesity in childhood and adolescence has increased significantly over the last decade. Obese children and adolescents have left ventricular remodeling that transpires into adulthood, and subclinical systolic and diastolic dysfunction despite normal conventional parameters of ventricular function. These findings suggest that obesity has an early impact in the cardiovascular health of obese adolescents. Life-style modifications causing weight loss can reverse the ventricular dysfunction observed in this young population and must be strongly encouraged.

Data mining of atherosclerotic plaque transcriptomes predicts STAT1-dependent inflammatory signal integration in vascular disease

Atherosclerotic plaque development involves multiple extra- and intra-cellular signals engaging cells from the immune system and from the vasculature. Pro-inflammatory pathways activated by interferon gamma (IFNγ) and toll-like receptor 4 (TLR4) ligands are profoundly involved in plaque formation and have been shown to involve cross-talk in all atheroma-interacting cell types leading to increased activation of signal transducer and activator of transcription-1 (STAT1) and elevated expression of pro-inflammatory mediators. Here we demonstrate that in Gene Expression Omnibus repository (GEO) deposited microarray datasets, obtained from human coronary and carotid atherosclerotic plaques, a significant increase in expression of pro-inflammatory and immunomodulatory genes can be detected. Moreover, increased expression of multiple chemokines, adhesion molecules and matrix-remodeling molecules was commonly detected in both plaque types and correlated with the presence of putative STAT1 binding sites in their promoters, suggesting strong involvement of STAT1 in plaque development. We also provide evidence to suggest that STAT1-nuclear factor kappa-light-chain-enhancer of activated B cells (NFκB) or STAT1-interferon-regulated factor (IRF) regulatory modules are over-represented in the promoters of these inflammatory genes, which points to a possible contribution of IFNγ and TLR4 cross-talk in the process of atherogenesis. Finally, a subset of these genes encodes for secreted proteins that could serve as a basis of a non-invasive diagnostic assay. The results of our in silico analysis in vitro provide potential evidence that STAT1-dependent IFNγ-TLR4 cross-talk plays a crucial role in coronary and carotid artery plaque development and identifies a STAT1-dependent gene signature that could represent a novel diagnostic tool to monitor and diagnose plaque progression in human atherosclerosis.

Vulnerable plaques in the contralateral carotid arteries in symptomatic patients: a detailed ultrasound analysis

BACKGROUND AND AIM

Carotid plaques may represent a generalized atherosclerotic syndrome or a localized disease. The aim of this study was to assess the morphological and textural features of carotid plaques located contralateral to the symptomatic side and compare them with the symptomatic side and with plaques from asymptomatic patients.

METHODS

We studied 66 arteries in 39 patients (mean age 70 ± 7 year, 33% females). Arterial plaques were classified as either symptomatic (n = 30), contralateral to symptomatic (n = 25) or asymptomatic (n = 11). We compared several plaque features between these groups including the mean values of the grey scale median (GSM), entropy, juxtaluminal black area (JBA) without visible echogenic cap, GSM of the JBA and surface irregularity.

RESULTS

The plaques contralateral to symptomatic arteries had similar morphological and textural features to those in the symptomatic arteries. In contrast, they had more vulnerable morphological and textural features than those in asymptomatic arteries: less smooth plaques (12% vs. 55%) and instead more often mildly irregular (60% vs 36%) or markedly irregular (28% vs. 9%; p = 0.03), lower GSM (26.2 ± 8 vs. 49.4 ± 14, p < 0.001) and lower GSM of the JBA (5.0 ± 3.6 vs. 11.4 ± 2.1, p = 0.008). The frequency of entropy and plaque calcification was similar in all groups.

CONCLUSION

Symptomatic patients with carotid artery disease seem to have similar morphological and textural features of vulnerability in the symptomatic and the contralateral carotid arteries, which are profound compared with asymptomatic carotid arteries. These findings support the concept of generalized carotid atherosclerotic pathology rather than incidental unilateral disease, and also emphasize a need for aggressive measures for plaque stabilization, particularly in symptomatic patients.

Activation of the proapoptotic unfolded protein response in plaques of the human carotid artery

OBJECTIVE

To analyze expression of keystone markers of apoptosis and the proapoptotic signaling pathway "unfolded protein response" (UPR) in rupture-prone plaques of the human carotid artery.

METHODS

Plaque specimens were obtained during endarterectomy for high-grade carotid stenosis, and were formalin-fixed. Ten specimens were identified that exhibited criteria of advanced rupture-prone atherosclerotic plaques, and histological and immunohistological analysis of markers of apoptosis (cleaved Caspase-3, TUNEL) and UPR (KDEL, ATF3, CHOP, CHAC-1) was performed. In addition, co-localization of apoptosis and UPR-activation was assessed by double-immunohistochemistry.

RESULTS

The mean size of the necrotic core was 44 ± 7% and the mean minimum/representative thicknesses of the fibrous cap were 129 ± 39 μm/280 ± 60 μm, respectively. Each specimen fulfilled at least two of the criteria for rupture-prone plaques. Semi-quantitative analysis of immunohistochemistry showed a significant increase in cleaved Caspase-3-positive (1923 ± 93 cells/mm(2)) and TUNEL-positive cells (1387 ± 66 cells/mm(2)) when compared with control tissue. Furthermore, expression of UPR-markers KDEL, AFT3 and CHOP was significantly increased (1175 ± 40 cells/mm(2), 1971 ± 69 cells/mm(2) and 2173 ± 120 cells/mm(2), respectively). Co-localization of UPR-activation with apoptosis was confirmed by double-immunohistochemistry, and lesional macrophages were identified as the primary cell-type involved.

CONCLUSION

For the first time, activation of the proapoptotic signaling pathway UPR has been identified in advanced rupture-prone plaques of the human carotid artery. This provides additional evidence for adding UPR to the potential targets for controlling plaque apoptosis and thereby preventing plaque progression/rupture.

How predictors and patterns of stroke recurrence after a TIA differ during the first year of follow-up

The highest risk of subsequent stroke after a TIA occurs within the first week after the index event. However, the risk of stroke recurrence (SR) remains high during the first year of follow-up. We studied the temporal pattern and predictors of SR (at 7 days and from 7 days to 1-year follow-up). Between April 2008 and December 2009, we included 1,255 consecutive TIA patients from 30 Spanish stroke centers (PROMAPA study). We determined the short-term (at 7 days) and long-term (from 8 days to 1 year) risk of SR. Patients who underwent short-term recurrence and long-term recurrence were compared with regard to clinical findings, vascular territories, and etiology. Enough information (clinical variables and extracranial vascular imaging) was assessed in 1,137 (90.6 %) patients. The 7-day stroke risk was 2.6 %. 32 (3.0 %) patients had an SR after 7-day follow-up. Multiple TIA (HR 3.50, 1.67-7.35, p = 0.001) and large artery atherosclerosis (HR 2.51, 1.17-5.37, p = 0.018) were independent predictors of early SR, whereas previous stroke (HR 1.40, 1.03-1.92, p = 0.034) and coronary heart disease (2.65, 1.28-5.50, p = 0.009) were independent predictors of late SR. Notoriously, 80 % of SR happened in the same territory of the index TIA at 7-day follow-up, whereas only 38 % during the long-term follow-up (p < 0.001). Different predictors of SR were identified throughout the follow-up period. Moreover, the ischemic mechanism differed in early and late stroke recurrences.

Comparative survey of the six-minute walk test on the treadmill and on the corridor in cardiac patients

Introduction The six minute walk test (6MWT) is considered an important tool in the evaluation of physical capacity, monitoration and the effectiveness of treatment in cardiac patients.Objective To compare the 6MWT on the treadmill and corridor in cardiac patients.Methods Participated 24 cardiac patients, being 12 male and 12 female with 56.7 ± 12.7 years age average, submitted to the six-minute walk test on the treadmill (6MWTT) and on the corridor (6MWTC) in an interval of seven days. The analyzed variables were: walked distance, respiratory rate (RR), heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP) and oxygen saturation (SatO2).Results It was statistically significant difference in the comparison between the tests for the variables: walked distance, SBP, DBP and SatO2 (p > 0.05). The only statistically significant variable was the HR after the test application (p = 0.03).Conclusion After the two tests application, there was similarity in the variables: walked distance, SBP, DBP and SatO2 with no significant statistical differences. Only the HR presented statistical significance between groups at the end of the tests.

C-reactive protein after stroke in arterial hypertension

OBJECTIVE

To evaluate the relationship between plasma high-sensitivity C-reactive protein level and the risk of recurrent coronary and cerebral ischemic events after ischemic stroke in patients with arterial hypertension.

METHODS

102 patients with mild-to-moderate arterial hypertension (67 male, aged 56-68 years) were enrolled in the study. Serum high-sensitivity C-reactive protein was determined on study entry only. Clinical interviews were performed every 3 months during 1 year after blood sampling. Clinical events included confirmed ischemic stroke or transient ischemic attack, coronary ischemic events, sudden death, diabetes mellitus, and all cardiovascular events including chronic heart failure and hospitalization.

RESULTS

Patients in the highest quartile of high-sensitivity C-reactive protein levels had a significantly higher adjusted odds ratio for clinical events compared to those in the first quartile (odds ratio = 7.46, 95% confidence interval: 1.55-19.6, p = 0.001). A receiver operating characteristic curve detected a plasma high-sensitivity C-reactive protein cutoff level of 5.58 mg·L(-1) (76.7% sensitivity, 80.3% specificity). A Cox regression model identified high-sensitivity C-reactive protein >5.58 mg·L(-1) as an independent predictor of further cardiovascular events (hazard ratio = 7.14, 95% confidence interval: 1.15-12.6, p = 0.009).

CONCLUSION

We suggest that high-sensitivity C-reactive protein levels >5.58 mg·L(-1) strongly predict increased risk of cumulative cardiovascular events after ischemic stroke in hypertensive patients.

Dysregulation of Mfn2 and Drp-1 proteins in heart failure

Therapeutic approaches for cardiac regenerative mechanisms have been explored over the past decade to target various cardiovascular diseases (CVD). Structural and functional aberrations of mitochondria have been observed in CVD. The significance of mitochondrial maturation and function in cardiomyocytes is distinguished by their attribution to embryonic stem cell differentiation into adult cardiomyocytes. An abnormal fission process has been implicated in heart failure, and treatment with mitochondrial division inhibitor 1 (Mdivi-1), a specific inhibitor of dynamin related protein-1 (Drp-1), has been shown to improve cardiac function. We recently observed that the ratio of mitofusin 2 (Mfn2; a fusion protein) and Drp-1 (a fission protein) was decreased during heart failure, suggesting increased mitophagy. Treatment with Mdivi-1 improved cardiac function by normalizing this ratio. Aberrant mitophagy and enhanced oxidative stress in the mitochondria contribute to abnormal activation of MMP-9, leading to degradation of the important gap junction protein connexin-43 (Cx-43) in the ventricular myocardium. Reduced Cx-43 levels were associated with increased fibrosis and ventricular dysfunction in heart failure. Treatment with Mdivi-1 restored MMP-9 and Cx-43 expression towards normal. In this review, we discuss mitochondrial dynamics, its relation to MMP-9 and Cx-43, and the therapeutic role of fission inhibition in heart failure.

Perioperative assessment of myocardial deformation

Evaluation of left ventricular performance improves risk assessment and guides anesthetic decisions. However, the most common echocardiographic measure of myocardial function, the left ventricular ejection fraction (LVEF), has important limitations. LVEF is limited by subjective interpretation that reduces accuracy and reproducibility, and LVEF assesses global function without characterizing regional myocardial abnormalities. An alternative objective echocardiographic measure of myocardial function is thus needed. Myocardial deformation analysis, which performs quantitative assessment of global and regional myocardial function, may be useful for perioperative care of surgical patients. Myocardial deformation analysis evaluates left ventricular mechanics by quantifying strain and strain rate. Strain describes percent change in myocardial length in the longitudinal (from base to apex) and circumferential (encircling the short-axis of the ventricle) direction and change in thickness in the radial direction. Segmental strain describes regional myocardial function. Strain is a negative number when the ventricle shortens longitudinally or circumferentially and is positive with radial thickening. Reference values for normal longitudinal strain from a recent meta-analysis by using transthoracic echocardiography are (mean ± SD) -19.7% ± 0.4%, while radial and circumferential strain are 47.3% ± 1.9% and -23.3% ± 0.7%, respectively. The speed of myocardial deformation is also important and is characterized by strain rate. Longitudinal systolic strain rate in healthy subjects averages -1.10 ± 0.16 s. Assessment of myocardial deformation requires consideration of both strain (change in deformation), which correlates with LVEF, and strain rate (speed of deformation), which correlates with rate of rise of left ventricular pressure (dP/dt). Myocardial deformation analysis also evaluates ventricular relaxation, twist, and untwist, providing new and noninvasive methods to assess components of myocardial systolic and diastolic function. Myocardial deformation analysis is based on either Doppler or a non-Doppler technique, called speckle-tracking echocardiography. Myocardial deformation analysis provides quantitative measures of global and regional myocardial function for use in the perioperative care of the surgical patient. For example, coronary graft occlusion after coronary artery bypass grafting is detected by an acute reduction in strain in the affected coronary artery territory. In addition, assessment of left ventricular mechanics detects underlying myocardial pathology before abnormalities become apparent on conventional echocardiography. Certainly, patients with aortic regurgitation demonstrate reduced longitudinal strain before reduction in LVEF occurs, which allows detection of subclinical left ventricular dysfunction and predicts increased risk for heart failure and impaired myocardial function after surgical repair. In this review, we describe the principles, techniques, and clinical application of myocardial deformation analysis.

Mandatory oral glucose tolerance tests identify more diabetics in stable patients with chronic heart failure: a prospective observational study

BACKGROUND

Many patients with chronic heart failure (CHF) are believed to have unrecognized diabetes, which is associated with a worse prognosis. This study aimed to describe glucose tolerance in a general stable CHF population and to identify determinants of glucose tolerance focusing on body composition and skeletal muscle strength.

METHODS

A prospective observational study was set up. Inclusion criteria were diagnosis of CHF, stable condition and absence of glucose-lowering medication. Patients underwent a 2 h oral glucose tolerance test (OGTT), isometric strength testing of the upper leg and dual energy x-ray absorptiometry. Health-related quality of life and physical activity level were assessed by questionnaire.

RESULTS

Data of 56 participants were analyzed. Despite near-normal fasting glucose values, 55% was classified as prediabetic, 14% as diabetic, and 20% as normal glucose tolerant. Of all newly diagnosed diabetic patients, 79% were diagnosed because of 2 h glucose values only and none because of HbA1c. Univariate mixed model analysis revealed ischaemic aetiology, daily physical activity, E/E', fat trunk/fat limbs and extension strength as possible explanatory variables for the glucose curve during the glucose tolerance test. When combined in one model, only fat trunk/fat limbs and E/E' remained significant predictors. Furthermore, fasting insulin was correlated with fat mass/height2 (r = 0.51, p < 0.0001), extension strength (r = -0.33, p < 0.01) and triglycerides (r = 0.39, p < 0.01).

CONCLUSIONS

Our data confirm that a large majority of CHF patients have impaired glucose tolerance. This glucose intolerance is related to fat distribution and left ventricular end-diastolic pressure.

Left ventricular twisting modifications in patients with left ventricular concentric hypertrophy at increasing after-load conditions

AIMS

Left ventricular hypertrophy (LVH) develops as a result of several clinical conditions, such as intensive training, hypertension, aortic valve stenosis. Aim of this study was to analyze the left ventricular twist (LVT) modifications in LVH patients with increasing after-load conditions.

METHODS

A total of 131 patients were enrolled: 17 healthy sedentary people (Hg), without concentric LVH; 45 water polo players (ATg); 22 patients with hypertensive cardiopathy (HPg); 47 patients with different degrees of aortic stenosis (ASg); all patients had concentric LVH, ejection fraction (EF) >54%, and were age-matched. The left ventricular end-systolic wall stress (LV-ESWS) was used as index of after-load.

RESULTS

Left ventricular twist value showed a progressive increase from ATg to ASg, according to increasing after-load. Longitudinal left ventricular function by tissue Doppler imaging (TDI) and speckle tracking echocardiography (STE) was reduced in HPg and ASg. There was a negative correlation between LVT and longitudinal systolic function at TDI and STE (r = -0.4; P < 0.001; -0.23; P < 0.05). E/A ratio was lower in HPg and ASg than ATg and Hg. LVT was linearly related to LV-ESWS (r = 0.36; P < 0.01), E/A ratio (r = -0.59; P < 0.001), E/E' ratio (r = 0.43; P < 0.001), age (r = 0.5; P < 0.001), relative wall thickness (RWT) (r = 0.38; P < 0.01), heart rate (HR) (r = 0.3; P < 0.05), maximum (G. max), and mean transvalvular gradient (G. mean) in ASg (r = 0.37; P < 0.01, r = 0.4; P < 0.01). RWT, E/A ratio, and HR were independent predictor of LVT (β = 0.23; P = 0.007; -0.44; P = 0.001; 0.17; P = 0.049). Only in ASg, G. mean was independent predictor of LVT (β = 0.44; P = 0.01).

CONCLUSION

Left ventricular twist showed a linear trend at increasing after-load values to compensate the reduction in systolic longitudinal function in pathological LVH patients.

Preclinical impairment of myocardial function in rheumatoid arthritis patients. Detection of myocardial strain by speckle tracking echocardiography

OBJECTIVES

The incidence of heart failure is higher in patients with rheumatoid arthritis (RA) than in the general population and contributes to elevated cardiovascular mortality and morbidity rates. Impaired myocardial function can be detected by a novel echocardiographic method, speckle tracking echocardiography (STE), when conventional methods have yielded normal findings. The aim of our study was to investigate the effect of disease duration on myocardial strain and strain rate parameters in patients with RA.

METHODS

This cross-sectional study included 37 RA patients [n=16, female gender n=16, mean age, 45.7 ± 9 years in the early-stage disease (ESD); n= 21, female gender n=19, 45.7 ± 16.8 years in the advanced-stage disease (ASD) group] who were compared according to early disease duration and advanced-stage disease (2.8 ± 1.2 vs. 14.6 ± 6.8 years, respectively). Hypertension, diabetes mellitus, and other cardiovascular risk factors were excluded. Offline analysis of STE was performed and data between the two groups were compared.

RESULTS

RS, RSR-E, and RSR-E/A values were statistically significantly lower in patients with ASD. Circumferential strain and strain rate were similar between the two groups. Except for LSR-E/A values, LS, LSR-S, LSR-E, and LSR-A values were decreased in patients with ASD.

CONCLUSION

RA patients without clinical evidence of cardiovascular disease and in the absence of traditional cardiovascular risk factors can be followed up with STE. In this way, early impairment of myocardial deformation can be detected before the appearance of any clinical evidence of cardiac involvement.

Diabetic cardiomyopathy: mechanisms and new treatment strategies targeting antioxidant signaling pathways

Cardiovascular disease is the primary cause of morbidity and mortality among the diabetic population. Both experimental and clinical evidence suggest that diabetic subjects are predisposed to a distinct cardiomyopathy, independent of concomitant macro- and microvascular disorders. 'Diabetic cardiomyopathy' is characterized by early impairments in diastolic function, accompanied by the development of cardiomyocyte hypertrophy, myocardial fibrosis and cardiomyocyte apoptosis. The pathophysiology underlying diabetes-induced cardiac damage is complex and multifactorial, with elevated oxidative stress as a key contributor. We now review the current evidence of molecular disturbances present in the diabetic heart, and their role in the development of diabetes-induced impairments in myocardial function and structure. Our focus incorporates both the contribution of increased reactive oxygen species production and reduced antioxidant defenses to diabetic cardiomyopathy, together with modulation of protein signaling pathways and the emerging role of protein O-GlcNAcylation and miRNA dysregulation in the progression of diabetic heart disease. Lastly, we discuss both conventional and novel therapeutic approaches for the treatment of left ventricular dysfunction in diabetic patients, from inhibition of the renin-angiotensin-aldosterone-system, through recent evidence favoring supplementation of endogenous antioxidants for the treatment of diabetic cardiomyopathy. Novel therapeutic strategies, such as gene therapy targeting the phosphoinositide 3-kinase PI3K(p110α) signaling pathway, and miRNA dysregulation, are also reviewed. Targeting redox stress and protective protein signaling pathways may represent a future strategy for combating the ever-increasing incidence of heart failure in the diabetic population.

Left ventricular diastolic dysfunction in patients with dermatomyositis without clinically evident cardiovascular disease

OBJECTIVE

To assess left ventricular (LV) diastolic function in patients with dermatomyositis (DM) without clinically evident cardiovascular (CV) disease and to estimate whether there is an association between the duration of DM and LV diastolic dysfunction (LVDD).

METHODS

The study included 51 patients with DM (43 women and 8 men) who had no clinically evident CV disease and 51 age-matched and sex-matched healthy controls. Echocardiographic and Doppler studies were conducted in all patients and controls. Early diastolic flow velocity/mitral annular early diastolic velocity (E/Em) was considered a marker for diastolic dysfunction.

RESULTS

E/Em was elevated in 39 patients (76.5%) versus 27 controls (52.9%; p < 0.05). There were significant differences between patients versus control group in late diastolic flow velocity (A), E/A ratio, Em, Em/Am (mitral annular late diastolic velocity) ratio, E/Em ratio, and deceleration time (DT; p < 0.05). There was a weak correlation with disease duration between A (r = 0.373, p = 0.007), E/A ratio (r = -0.467, p = 0.001), Em (r = -0.474, p < 0.001), Em/Am ratio (r = -0.476, p < 0.001), E/Em ratio (r = 0.320, p = 0.022), and DT (r = 0.474, p < 0.001). Disease duration was associated with E/Em after controlling for age, sex, and other factors (p < 0.05).

CONCLUSION

Our study confirms a high frequency of LVDD in DM patients without evident CV disease. The association between transmitral flow alteration and disease duration may suggest a subclinical myocardial involvement with disease progression.

Whole body bone tissue and cardiovascular risk in rheumatoid arthritis

Introduction. Atherosclerosis and osteoporosis share an age-independent bidirectional correlation. Rheumatoid arthritis (RA) represents a risk factor for both conditions. Objectives. The study aims to evaluate the connection between the estimated cardiovascular risk (CVR) and the loss of bone tissue in RA patients. Methods. The study has a prospective cross-sectional design and it includes female in-patients with RA or without autoimmune diseases; bone tissue was measured using whole body dual X-ray absorptiometry (wbDXA); CVR was estimated using SCORE charts and PROCAM applications. Results. There were 75 RA women and 66 normal women of similar age. The wbDXA bone indices correlate significantly, negatively, and age-independently with the estimated CVR. The whole body bone percent (wbBP) was a significant predictor of estimated CVR, explaining 26% of SCORE variation along with low density lipoprotein (P < 0.001) and 49.7% of PROCAM variation along with glycemia and menopause duration (P < 0.001). Although obese patients had less bone relative to body composition (wbBP), in terms of quantity their bone content was significantly higher than that of nonobese patients. Conclusions. Female patients with RA and female patients with cardiovascular morbidity have a lower whole body bone percent. Obese female individuals have higher whole body bone mass than nonobese patients.

Coronary and carotid atherosclerosis: how useful is the imaging?

The recent advancement of imaging modalities has made possible visualization of atherosclerosis disease in all phases of its development. Markers of subclinical atherosclerosis or even the most advanced plaque features are acquired by invasive (IVUS, OCT) and non-invasive imaging modalities (US, MRI, CTA). Determining plaques prone to rupture (vulnerable plaques) might help to identify patients at risk for myocardial infarction or stroke. The most accepted features of plaque vulnerability include: thin cap fibroatheroma, large lipid core, intimal spotty calcification, positive remodeling and intraplaque neovascularizations. Today, research is focusing on finding imaging techniques that are less invasive, less radiation and can detect most of the vulnerable plaque features. While, carotid atherosclerosis can be visualized using noninvasive imaging, such as US, MRI and CT, imaging plaque feature in coronary arteries needs invasive imaging modalities. However, atherosclerosis is a systemic disease with plaque development simultaneously in different arteries and data acquisition in carotid arteries can add useful information for prediction of coronary events.

Gender related predictors of limited exercise capacity in heart failure

AIM

The aim of this study was to investigate the impact of gender on the prediction of limited exercise capacity in heart failure (HF) patients assessed by 6 minute walk test (6-MWT).

METHODS

In 147 HF patients (mean age 61 ± 11 years, 50.3% male), a 6-MWT and a Doppler echocardiographic study were performed in the same day. Conventional cardiac measurements were obtained and global LV dyssynchrony was indirectly assessed using total isovolumic time - t-IVT [in s/min; calculated as: 60 - (total ejection time - total filling time)] and Tei index (t-IVT/ejection time). Patients were divided into two groups according to gender, which were again divided into two subgroups based on the 6-MWT distance (Group I: ≤ 300 m, and Group II: > 300 m).

RESULTS

Female patients were younger (p = 0.02), and had higher left ventricular (LV) ejection fraction - EF (p = 0.007) but with similar 6-MWT distance to male patients (p = 68). Group I male patients had lower hemoglobin level (p = 0.02) and lower EF (p = 0.03), compared with Group II, but none of the clinical or echocardiographic variables differed between groups in female patients. In multivariate analysis, only t-IVT [0.699 (0.552-0.886), p = 0.003], and LV EF [0.908 (0.835-0.987), p = 0.02] in males, and NYHA functional class [4.439 (2.213-16.24), p = 0.02] in females independently predicted poor 6-MWT distance (< 300 m).

CONCLUSION

Despite similar limited exercise capacity, gender determines the pattern of underlying cardiac disturbances; ventricular dysfunction in males and subjective NYHA class in female heart failure patients.

Cardiopulmonary involvement in Puumala hantavirus infection

BACKGROUND

Hantavirus infections cause potentially life-threatening disease in humans world-wide. Infections with American hantaviruses may lead to hantavirus pulmonary syndrome characterised by severe cardiopulmonary distress with high mortality. Pulmonary involvement in European Puumala hantavirus (PUUV) infection has been reported, whereas knowledge of potential cardiac manifestations is limited. We aimed to comprehensively investigate cardiopulmonary involvement in patients with PUUV-infection.

METHODS

Twenty-seven hospitalised patients with PUUV-infection were examined with lung function tests, chest high-resolution CT (HRCT), echocardiography including speckle tracking strain rate analysis, ECG and measurements of cardiac biomarkers N-terminal pro-B-type natriuretic peptide (NT-ProBNP) and troponin T. Patients were re-evaluated after 3 months. Twenty-five age and sex-matched volunteers acted as controls for echocardiography data.

RESULTS

Two-thirds of the patients experienced respiratory symptoms as dry cough or dyspnoea. Gas diffusing capacity was impaired in most patients, significantly improving at follow-up but still subnormal in 38%. HRCT showed thoracic effusions or pulmonary oedema in 46% of the patients. Compared to controls, the main echocardiographic findings in patients during the acute phase were significantly higher pulmonary vascular resistance, higher systolic pulmonary artery pressure, lower left ventricular ejection fraction and impaired left atrial myocardial motion. Pathological ECG, atrial fibrillation or T-wave changes, was demonstrated in 26% of patients. NT-ProBNP concentrations were markedly increased and were inversely associated with gas diffusing capacity but positively correlated to pulmonary vascular resistance. Furthermore, patients experiencing impaired general condition at follow-up had significantly lower gas diffusing capacity and higher pulmonary vascular resistance, compared to those feeling fully recovered.

CONCLUSIONS

In a majority of patients with PUUV-infection, both cardiac and pulmonary involvement was demonstrated with implications on patients' recovery. The results demonstrate vascular leakage in the lungs that most likely is responsible for impaired gas diffusing capacity and increased pulmonary vascular resistance with secondary pulmonary hypertension and right heart distress. Interestingly, NT-ProBNP was markedly elevated even in the absence of overt ventricular heart failure. The method of simultaneous investigations of important cardiac and respiratory measurements improves the interpretation of the underlying pathophysiologic mechanisms.

Abnormal systolic and diastolic myocardial function in obese asymptomatic adolescents

Structural and functional cardiac changes are known in obese adults. We aimed to assess the relationship between body mass index (BMI) and cardiac function in overweight and obese asymptomatic adolescents. Ninety three healthy adolescents, aged 12.6 ± 1.2 years, received weight, height, BMI, waist, hips, waist/hips ratio assessment, hematology and biochemistry tests and an echocardiogram. Based on BMI, subjects were divided into: lean (L, n=32), overweight (Ov, n=33) and obese (Ob, n=32). Interventricular septal and LV posterior wall thickness were increased parallel to the BMI (L: 0.84 ± 0.1cm, Ov: 0.88 ± 0.1cm, Ob: 0.96 ± 0.1cm, p<0.001, and L: 0.78 ± 0.1cm, Ov: 0.8 ± 0.1cm, Ob: 0.94 ± 0.1cm, p<0.001, respectively) as were relative wall thickness (RWT) and mass index (LVMI) (L: 0.34 ± 0.05, Ov: 0.34 ± 0.05, Ob: 0.40 ± 0.04, p<0.001, and L: 47.7 ± 8.4 g/m(2), Ov: 51.9 ± 8.3g/m(2), Ob: 65.2 ± 13.3g/m(2), p=0<001, respectively). LV early diastolic (E') lateral and septal velocities (L: 15.3 ± 3.9 cm/s, Ov: 13.6 ± 4 cm/s, Ob: 10.5 ± 3.4 cm/s, p<0.001, and L: 12.2 ± 2.3 cm/s, Ov: 11.1 ± 2.4 cm/s, Ob: 9.8 ± 3.1cm/s, p=0.003, respectively), and systolic (S') velocities (L: 9.2 ± 1.4 cm/s, Ov: 9.3 ± 2.3 cm/s, Ob: 8.04 ± 1.5 cm/s, p=0.018, and L: 9.05 ± 2.3 cm/s, Ov: 9 ± 2.4 cm/s, Ob: 7.6 ± 1.1cm/s, p=0.014, respectively) were all reduced, only in obese adolescents. LV lateral E' (r=-0.44, p<0.001) and S' (r=-0.29, p=0.005) correlated with BMI. In asymptomatic adolescents, LV wall is thicker and diastolic function impaired and correlate with BMI. These findings demonstrate early cardiac functional disturbances which might explain the known obesity risk for cardiac disease.

Diastolic function is associated with quality of life and exercise capacity in stable heart failure patients with reduced ejection fraction

Exercise capacity and quality of life (QOL) are important outcome predictors in patients with systolic heart failure (HF), independent of left ventricular (LV) ejection fraction (LVEF). LV diastolic function has been shown to be a better predictor of aerobic exercise capacity in patients with systolic dysfunction and a New York Heart Association (NYHA) classification ≥II. We hypothesized that the currently used index of diastolic function E/e' is associated with exercise capacity and QOL, even in optimally treated HF patients with reduced LVEF. This prospective study included 44 consecutive patients aged 55±11 years (27 men and 17 women), with LVEF<0.50 and NYHA functional class I-III, receiving optimal pharmacological treatment and in a stable clinical condition, as shown by the absence of dyspnea exacerbation for at least 3 months. All patients had conventional transthoracic echocardiography and answered the Minnesota Living with HF Questionnaire, followed by the 6-min walk test (6MWT). In a multivariable model with 6MWT as the dependent variable, age and E/e' explained 27% of the walked distance in 6MWT (P=0.002; multivariate regression analysis). No association was found between walk distance and LVEF or mitral annulus systolic velocity. Only normalized left atrium volume, a sensitive index of diastolic function, was associated with decreased QOL. Despite the small number of patients included, this study offers evidence that diastolic function is associated with physical capacity and QOL and should be considered along with ejection fraction in patients with compensated systolic HF.

Accumulation of epicardial fat rather than visceral fat is an independent risk factor for left ventricular diastolic dysfunction in patients undergoing peritoneal dialysis

BACKGROUND

Symptoms of heart failure with preserved left ventricular systolic function are common among patients undergoing peritoneal dialysis (PD). Epicardial fat (EpF) is an ectopic fat depot with possible paracrine or mechanical effects on myocardial function. The aim of our current study is to assess the association between EpF and Left ventricular diastolic dysfunction (LVDD) in patients undergoing PD and to clarify the relationships among EpF, inflammation, and LVDD in this population.

METHODS

This was a cross-sectional study of 149 patients with preserved left ventricular systolic function who were undergoing PD. LVDD was diagnosed (according to the European Society of Cardiology guidelines) and EpF thickness measured by echocardiography. The patients without LVDD were used as controls. The serum inflammatory biomarker high-sensitivity C-reactive protein (hsCRP) was measured. The location and amount of adipose tissue were assessed by computed tomography (CT) at the level of the fourth lumbar vertebra.

RESULTS

Subjects with LVDD had higher levels of hsCRP, more visceral and peritoneal fat, and thicker EpF (all p < 0.001) than controls. Visceral adipose tissue, hsCRP, and EpF all correlated significantly (p < 0.05) with LVDD. Multivariate regression analysis rendered the relationship between visceral adipose tissue and LVDD insignificant, whereas EpF was the most powerful determinant of LVDD (odds ratio = 2.41, 95% confidence interval = 1.43-4.08, p < 0.01). EpF thickness also correlated significantly with the ratio of transmitral Doppler early filling velocity to tissue Doppler early diastolic mitral annular velocity (E/e'; r = 0.27, p < 0.01).

CONCLUSION

EpF thickness is significantly independently associated with LVDD in patients undergoing PD and may be involved in its pathogenesis.

Chemotherapy for testicular cancer induces acute alterations in diastolic heart function

BACKGROUND

After treatment with cisplatin-based chemotherapy for testicular cancer (TC), patients have higher prevalence of cardiovascular complications after long-term follow up. Little is known about acute cardiovascular effects of cisplatin-based chemotherapy. The aim of this study was to explore acute effects of chemotherapy on cardiac function in patients treated for TC.

METHODS

Fourteen TC patients (age 34.6 ± 12.3 years) were studied before and 3 months after start with cisplatin-based chemotherapy. Cardiac function was assessed with magnetic resonance imaging. Fasting glucose and insulin levels were measured and insulin sensitivity, reflected by the quantitative insulin sensitivity index (Quicki index), was calculated.

RESULTS

Left ventricular (LV) end-diastolic volume and LV stroke volume (SV) significantly decreased from 192 ± 27 to 175 ± 26 ml (P<0.05) and 109 ± 18 to 95 ± 16 ml (P<0.05), respectively. The ratio of early and atrial filling velocities across the mitral valve, a parameter of diastolic heart function, decreased after chemotherapy from 1.87 ± 0.43 to 1.64 ± 0.45 (P<0.01). Metabolic parameters were unfavourably changed, reflected by a decreased Quicki index, which reduced from 0.39 ± 0.05 to 0.36 ± 0.05 (P<0.05).

CONCLUSION

Chemotherapy for TC induces acute alterations in diastolic heart function, paralleled by unfavourable metabolic changes. Therefore, early after chemotherapy, metabolic treatment may be indicated to possibly reduce long-term cardiovascular complications.

Relationships among HIV infection, metabolic risk factors, and left ventricular structure and function

Our objective was to determine if the presence of metabolic complications (MC) conveyed an additional risk for left ventricular (LV) dysfunction in people with HIV. HIV⁺ and HIV⁻ men and women were categorized into four groups: (1) HIV⁺ with MC (43±7 years, n=64), (2) HIV⁺ without MC (42±7 years, n=59), (3) HIV⁻ with MC (44±8 years, n=37), or (4) HIV⁻ controls without MC (42±8 years, n=41). All participants underwent two-dimensional (2-D), Doppler, and tissue Doppler echocardiography. Overall, the prevalence of systolic dysfunction (15 vs. 4%, p=0.02) and LV hypertrophy (9 vs. 1%, p=0.03) was greater in HIV⁺ than in HIV⁻ participants. Participants with MC had a greater prevalence of LV hypertrophy (10% vs. 1%). Early mitral annular velocity during diastole was significantly (p<0.005) lower in groups with MC (HIV⁺/MC⁺: 11.6±2.3, HIV⁻/MC⁺: 12.0±2.3 vs. HIV⁺/MC⁻: 12.4±2.3, HIV⁻/MC⁻: 13.1±2.4 cm/s) and tended to be lower in groups with HIV (p=0.10). However, there was no interaction effect of HIV and MC for any systolic or diastolic variable. Regardless of HIV status, participants with MC had reduced LV diastolic function. Although both the presence of MC and HIV infection were associated with lower diastolic function, there was no additive negative effect of HIV on diastolic function beyond the effect of MC. Also, HIV was independently associated with lower systolic function. Clinical monitoring of LV function in individuals with metabolic risk factors, regardless of HIV status, is warranted.

Prognostic value of the six-minute walk test in heart failure patients undergoing cardiac surgery: a literature review

Background. The prognostic value of cardiopulmonary exercise testing (CPET) is known, but the predictive value of 6MWT in patients with heart failure (HF) and patients undergoing coronary artery bypass grafting (CABG) is not established yet. Objective. We conducted a systematic review exploring the prognostic value of 6MWT in HF patients undergoing cardiac surgery. The aim was to find out whether the change in the distance walked during follow-up visits was associated with prognosis. Data Source. We searched "PubMed" from January 1990 to December 2012 for any review articles or experimental studies investigating the prognostic value of 6MWT in HF patients and patients undergoing cardiac surgery. Results. 53 studies were included in the review, and they explored the role of 6MWT in cardiology, cardiac surgery, and rehabilitation. The results did not show the relation between the six-minute walk distance and adverse events after CABG. The predictive power of the distance walked for death in HF patients undergoing cardiac surgery was not found. It is not yet proved if the change in the six-minute walk distance is associated with prognosis. The predictive power of the six-minute walk distance for death in HF patients undergoing cardiac surgery remains unclear.

What Is the Meaning of Increased Myocardial Injury Enzymes during Hemodialysis? A Tissue Doppler Imaging Study

BACKGROUND

Cardiovascular death is decreasing in the general population; however, it appears in still higher rates and even increases gradually in hemodialysis (HD) patients. This situation has led to a debate about cardiovascular adverse effects of HD which lead to significant changes in cardiac and hemodynamic events. It is known that troponins are often elevated in HD patients, and high levels of troponin are associated with increased mortality. Therefore, it is difficult to interpret the value of elevations in chronic kidney disease patients.

METHODS

Echocardiographic and biochemical parameters of 41 patients treated with HD were evaluated before and after a HD session.

RESULTS

HD led to an increased heart rate, and tissue Doppler imaging parameters such as early diastolic mitral peak velocity (E)/early diastolic myocardial peak velocity (é) and septal é decreased significantly after HD. HD caused an increase in troponin I, myoglobin and cardiac creatine kinase (CK MB) levels (p = 0.019, p < 0.001 and p = 0.018, respectively). A decrease in the left ventricular peak systolic myocardial (LV S') velocity (p = 0.011) was detected in patients with increased levels of cardiac damage markers (group 2) compared to those without increased levels of cardiac damage markers (group 1) in HD.

CONCLUSION

A decrease in LV S' velocity was found to be an independent predictor of an increase of myocardial injury enzymes in HD (odds ratio = 1.099; p = 0.039). We concluded that HD may lead to significant acute stress upon the myocardium.

Targeting the upregulation of reactive oxygen species subsequent to hyperglycemia prevents type 1 diabetic cardiomyopathy in mice

Cardiac oxidative stress is an early event associated with diabetic cardiomyopathy, triggered by hyperglycemia. We tested the hypothesis that targeting left-ventricular (LV) reactive oxygen species (ROS) upregulation subsequent to hyperglycemia attenuates type 1 diabetes-induced LV remodeling and dysfunction, accompanied by attenuated proinflammatory markers and cardiomyocyte apoptosis. Male 6-week-old mice received either streptozotocin (55mg/kg/day for 5 days), to induce type 1 diabetes, or citrate buffer vehicle. After 4 weeks of hyperglycemia, the mice were allocated to coenzyme Q10 supplementation (10mg/kg/day), treatment with the angiotensin-converting-enzyme inhibitor (ACE-I) ramipril (3mg/kg/day), treatment with olive oil vehicle, or no treatment for 8 weeks. Type 1 diabetes upregulated LV NADPH oxidase (Nox2, p22(phox), p47(phox) and superoxide production), LV uncoupling protein UCP3 expression, and both LV and systemic oxidative stress (LV 3-nitrotyrosine and plasma lipid peroxidation). All of these were significantly attenuated by coenzyme Q10. Coenzyme Q10 substantially limited type 1 diabetes-induced impairments in LV diastolic function (E:A ratio and deceleration time by echocardiography, LV end-diastolic pressure, and LV -dP/dt by micromanometry), LV remodeling (cardiomyocyte hypertrophy, cardiac fibrosis, apoptosis), and LV expression of proinflammatory mediators (tumor necrosis factor-α, with a similar trend for interleukin IL-1β). Coenzyme Q10's actions were independent of glycemic control, body mass, and blood pressure. Coenzyme Q10 compared favorably to improvements observed with ramipril. In summary, these data suggest that coenzyme Q10 effectively targets LV ROS upregulation to limit type 1 diabetic cardiomyopathy. Coenzyme Q10 supplementation may thus represent an effective alternative to ACE-Is for the treatment of cardiac complications in type 1 diabetic patients.

The association and predictive value analysis of metabolic syndrome on diastolic heart failure in patients at high risk for coronary artery disease

BACKGROUND

The purpose of the present study was to evaluate the effect and predictive value of metabolic syndrome (MetS) and its components on diastolic heart failure (DHF) in patients at high risk for coronary artery disease (CAD).

MATERIALS AND METHODS

We enrolled 261 patients with normal left ventricular ejection fraction (≥50%) who were scheduled to undergo coronary angiography for suspected myocardial ischemia. They were categorized into three groups (non-MetS, pre-MetS and MetS) based on the number of MetS criteria. Echocardiography was used to assess left ventricular (LV) diastolic function. The association between MetS and DHF was assessed by multivariate logistic regression (MLR) analysis (non-DHF patients as reference group) after controlling for confounders. The predictive performance of the MetS severity score (MSS) was evaluated using the area under the receiver-operating characteristic curve (AUC).

RESULTS

A tendency toward increased DHF prevalence with increasing MSS was found (p < 0.001). MLR analysis showed that in patients with an MSS of 1, the odds ratio (OR) of DHF was 1.60 (95% confidence interval-CI, 1.19-2.16; p = 0.02) compared to non-DHF patients; in patients with MSS ≥4, the OR was 6.61 (95% CI, 4.90-8.90; p < 0.001) compared to non-DHF patients. MSSs strongly predicted DHF (AUC = 0.73, 95% CI, 0.66-0.78, p < 0.001). MLR with MetS components as binary variables showed that blood pressure (BP) and triglycerides (TGs) were significantly associated with DHF (P = 0.001 and 0.043, respectively).

CONCLUSION

Our findings signify that MetS and its components of BP or TG were associated with DHF in high-risk CAD patients. DHF prevalence tends to increase with increasing MSS that has a high value in predicting DHF in high-risk CAD patients.

Dissecting the mechanisms of left ventricular diastolic dysfunction and inflammation in peritoneal dialysis patients

OBJECTIVE

Patients with symptoms of heart failure and preserved left ventricular (LV) systolic function are commonly encountered in clinical practice especially in peritoneal dialysis (PD) patients. We hypothesized that adiposity might influence LV diastolic function through systemic inflammation in this specific group.

METHODS

We designed a cross-sectional study in 173 prevalent PD patients. LV diastolic dysfunction was diagnosed by echocardiography. PD patient without LV diastolic dysfunction served as the control group. Serum inflammatory biomarkers were examined including tissue necrosis factor-alpha (TNF-α) and interleukin-6 (IL-6). The location and amount of adipose tissue were assessed by computerized tomography (CT) at the level of the fourth lumbar vertebra.

RESULTS

Subjects with LV diastolic dysfunction had higher levels of the pro-inflammation cytokines and more visceral and peritoneal fat (all P<0.001) than control subjects. A significant correlation was found between visceral adipose tissue and pro-inflammatory cytokines (r = 0.70; P<0.001). Multivariable regression analysis found that the relationship between visceral adipose tissue and LV diastolic dysfunction became insignificant when either TNF-α or IL-6 were introduced into the model, although TNF-α and IL-6 were both significantly associated with LV diastolic dysfunction even after adjusting for visceral fat (OR = 1.51; 95% CI = 1.09-2.02; P = 0.033 and OR = 1.62; 95% CI = 1.09-1.82; P = 0.031, respectively).

CONCLUSIONS

Larger amounts of adipose tissue were associated with higher serum pro-inflammatory levels in PD patients, which might be related to the development of LV diastolic dysfunction. Modulating inflammatory reactions in PD patients can be a useful therapeutic approach for managing LV diastolic dysfunction.

Emerging role of echocardiographic strain/strain rate imaging and twist in systolic function evaluation and operative procedure in patients with aortic stenosis

Systolic function of the left ventricle is vital for patients with aortic stenosis. Unfortunately, the most widely used clinical parameter, the left ventricular ejection fraction, is not sensitive enough, especially for patients with left ventricular hypertrophy. Echocardiographic strain/strain rate and twist are emerging parameters for left ventricular systolic and diastolic function evaluation. Aortic stenosis could reduce strain/strain rate while magnifying twist. Furthermore, strain/strain rate correlates well with the prognosis of patients with aortic stenosis. Most importantly the circumferential strain, strain rate and twist also play a role in differentiating cardiac compensation or decompensation. In any case, these parameters could normalize after successful surgical aortic valve replacement or transcatheter aortic valve replacement. Regardless of these advantages, clinical evidence is needed to ensure their usefulness.

Intra- and interscan reproducibility using Fourier Analysis of STimulated Echoes (FAST) for the rapid and robust quantification of left ventricular twist

PURPOSE

To assess the intra- and interscan reproducibility of LV twist using FAST. Assessing the reproducibility of the measurement of new MRI biomarkers is an important part of validation. Fourier Analysis of STimulated Echoes (FAST) is a new MRI tissue tagging method that has recently been shown to compare favorably with conventional estimates of left ventricular (LV) twist from cardiac tagged images, but with significantly reduced user interaction time.

MATERIALS AND METHODS

Healthy volunteers (N = 10) were scanned twice using FAST over 1 week. On day 1, two measurements of LV twist were collected for intrascan comparisons. Measurements for LV twist were again collected on day 8 for interscan assessment. LV short-axis tagged images were acquired on a 3 Tesla (T) scanner to ensure detectability of tags during early and mid-diastole. Peak LV twist is reported as mean ± SD. Reproducibility was assessed using the concordance correlation coefficient (CCC) and the repeatability coefficient (RC) (95% confidence interval [CI] range).

RESULTS

Mean peak twist measurements were 13.4 ± 4.3° (day 1, scan 1), 13.6 ± 3.7° (day 1, scan 2), and 13.0 ± 2.7° (day 8). Bland-Altman analysis resulted in intra- and interscan bias and 95% CI of -0.6° [-1.0°, 1.6°] and 1.4° (-1.0°, 3.0°), respectively. The Bland-Altman RC for peak LV twist was 2.6° and 4.0° for intra- and interscan, respectively. The CCC was 0.9 and 0.6 for peak LV twist for intra- and interscan, respectively.

CONCLUSION

FAST is a semi-automated method that provides a quick and quantitative assessment of LV systolic and diastolic twist that demonstrates high intrascan and moderate interscan reproducibility in preliminary studies.

Giant left atrial myxoma mimicking severe mitral valve stenosis and severe pulmonary hypertension

Myxoma is the most common primary tumor of the heart and can arise in any of the cardiac chambers. This paper reports A 50 -year-old woman without medical history and any cardiovascular risk factors was hospitalized for exertional dyspnea and palpitations from three months and signifiant weight loss. Transthoracic echocardiogram showed a giant left atrial myxoma mobile confined to the left atrium in systole, in diastole the tumor was seen prolapsing across the mitral valve into the left ventricle and partially obstructing it and causing severe functional mitral stenosis with a mean gradient of 21,3 mmHg. Severe pulmonary hypertension was confirmed by Doppler PAPs =137 mmHg. The patient was scheduled for cardiac surgery with good outcome.

Early impairment of contractility reserve in patients with insulin resistance in comparison with healthy subjects

Background

Insulin resistance (IR) is currently considered a crucial cardiovascular (CV) risk factor, which seems to play a dominant role in the evolution toward cardiac and vascular impairment. Early IR-induced cardiac dysfunction can be assessed by Doppler-derived myocardial systolic strain rate (SR) index, measured at baseline and after dobutamine stress echocardiography (DSE).

Methods

Thirty IR patients (HOMA-IR = 7 ± 5.2, age 52.6 ± 2.1 years), and 20 healthy, age and sex matched controls were studied. IR had been diagnosed in all patients in the 3 months preceding the study. Dobutamine echocardiography was performed in all subjects to exclude ischemic heart disease, and left ventricular contractile reserve (LVCR) was then assessed. LVCR was evaluated as an increase in the peak of an average longitudinal SR, measured in the basal and mid segments of 2 and 4 chamber ventricular walls.

Results

No significant differences between the 2 groups were revealed by baseline echocardiography. In contrast, after DSE a significant decrease of Delta SR was found in the IR group in comparison to the controls (0.54 ± 0.31 s⁻¹vs 1.14 ± 0.45 s⁻¹; p < 0.0001).

Conclusions

Our results show that IR, even if isolated and arising within a short time period, not only represents the initial phase of future diabetes, but may adversely affect heart function, as evidenced by the depressed LVCR. Our data strengthen the need for attention to be paid to IR state and for an early therapeutic approach.