Ventricular dysrhythmias, left ventricular hypertrophy, and sudden death

Left ventricular myocardial mass index and its correlates as an early marker of cardiovascular risk among nonobese normotensive Indian women with polycystic ovary syndrome: lessons from a cross-sectional study

OBJECTIVE

To quantitate left ventricular mass index (LVMI) and correlate it with inflammation, insulin resistance (IR) and serum androgen levels among nonobese normotensive women with polycystic ovary syndrome (PCOS).

DESIGN

Cross-sectional study SETTING: Tertiary care institute in North India PATIENTS: A total of 260 drug-naive women qualifying the Rotterdam 2003 criteria for diagnosis of PCOS and 250 apparently healthy women matched for age and body mass index (BMI).

INTERVENTIONS

Clinical, biochemical, hormonal, and inflammatory marker assessment was followed by estimation of LVM and LVMI by 2-dimensional echocardiography.

MAIN OUTCOME MEASURES

LVM and LVMI in nonobese, normotensive women with PCOS and its correlation with subinflammation, IR, and androgen excess.

RESULTS

Mean ages (28.08 ± 4.18 vs. 29.44 ± 6.33 years) and BMI (24.43 ± 4.15 vs. 23.92 ± 4.21 kg/m²) of cases vs. controls were comparable, as was blood pressure and plasma glucose (1 hour after oral glucose tolerance test [OGTT]). Women with PCOS had fewer menstrual cycles per year and higher Ferriman-Gallwey scores, plasma insulin, homeostasis model assessment of IR, total testosterone, plasma glucose (fasting and 2 hours after OGTT), serum high-sensitive C-reactive protein, tumor necrosis factor-α, and interleukin-6 than did the controls (P<.001). Significant differences were observed in LVM (101.50 ± 30.19 vs. 89.35 ± 27.57 g) and LVMI (63.60 ± 16.67 vs. 56.32 ± 10.84 g/m²) between women with PCOS and the controls (P<.001). Multivariate analysis revealed that proinflammatory markers and IR rather than hyperandrogenism correlated with LVMI.

CONCLUSION

We conclude that normotensive nonobese women with PCOS were more likely to have elevated mean LVMI than were healthy controls and it was positively correlated with proinflammatory markers and IR but not with androgen excess. Well-designed long-term follow-up studies with a larger cohort of subjects with comprehensive cardiovascular risk assessment are warranted to conclusively answer the question.

The relationship between left ventricular mass and insulin resistance in obese patients

Objective

In this study, we investigated the relationship between left ventricular mass and insulin resistance in obese patients.

Methods

A total of 90 subjects, 66 women, and 24 men, with an age range from 24 to 56 years, were enrolled in the study. Forty-nine patients were in the obesity group whose body mass index (BMI) was >29.9 kg/m² and 41 subjects were in the control group with a BMI <25 kg/m². All of them were normotensive, nondiabetic, and did not have any cardiovascular disease. They were not taking any medication. Weight, height, and waist circumference were measured and BMI was calculated. Plasma glucose, insulin, serum total, high-density lipoprotein (HDL) and low-density lipoprotein (LDL) cholesterol, and triglyceride levels were measured, and insulin resistance was calculated via homeostasis model of assessment-estimated insulin resistance (HOMA-IR). Subjects were examined by echocardiography and left ventricular mass (LVM) and index (LVMI) were calculated with Devereux formula.

Results

Insulin levels, HOMA-IR, LVM, and LVMI were significantly higher in obesity group (p < 0.01). Fasting glucose, triglyceride, fasting insulin levels, and waist circumference did not correlate with LVMI.

Conclusion

In conclusion, though findings of the present study suggest increased left ventricular hypertrophy (LVH) in obese subjects compared to controls, it appears that the increased LVM or LVH is not linked to BMI and insulin resistance in this study population.

Left ventricular hypertrophy on long-term cardiovascular outcomes in patients with ST-elevation myocardial infarction

BACKGROUND

Left ventricular hypertrophy (LVH) had been associated with increased adverse cardiovascular events in hypertensive patients. Prognostic significance of LVH in patients with ST-elevation myocardial infarction (STEMI) is not established. This study aimed to investigate prognostic impact of LVH on the patients with STEMI.

METHODS

We analyzed the data and clinical outcomes of 30-day survivors with STEMI who underwent successful coronary intervention from 2003 to 2009. Definition of LVH was LV mass index (LVMI) >115 g/m(2) in male and >95 g/m(2) in female. Patients were classified into a LVH group and a non-LVH group. Occurrence of major adverse cardiovascular events (MACE; death, recurrent MI, target vessel revascularization (TVR)) within 5 years was evaluated.

RESULTS

We enrolled 418 patients and mean follow-up duration was 43 ± 17 months. Two hundred and fourteen patients (51%) had LVH. The survival of the patients with LVH was significantly worse than the patients without LVH (log-rank p = 0.024). In a multivariate regression model, the presence of LVH was independently associated with increased risk for all-cause mortality (OR, 2.37; 95% CI, 1.096-5.123, p = 0.028). When the end points were analyzed based on LVH severity, all-cause mortality was significantly correlated with LVH severity (p = 0.011). The severe LVH was independently associated with increased risk for all-cause mortality (OR, 5.110; 95% CI, 1.454-17.9, p = 0.001).

CONCLUSION

LVH was associated with increased rate of adverse clinical outcomes in 30-day survivors after STEMI, who underwent successful coronary intervention.

Left ventricular hypertrophy increases cardiovascular risk independently of in-office and out-of-office blood pressure values

OBJECTIVES

Previous studies have shown that left ventricular hypertrophy (LVH) represents a cardiovascular risk factor independently of clinic blood pressure (BP). The present study was aimed at determining the impact of LVH on the incidence of cardiovascular morbid and fatal events taking into account not only classical risk factors but also home and ambulatory BP values, which have been shown to have an important independent prognostic impact.

METHODS

In 1716 patients belonging to the 'Pressioni Arteriose Monitorate E Loro Associazioni' population of Monza, we quantified left ventricular mass index and identified LVH by standard cutoff values. We also measured clinic, home and 24-h ambulatory BPs together with serum glucose and lipids.

RESULTS

During a follow-up of 148 months, the rate of fatal and nonfatal (hospitalizations) cardiovascular events as well as of all-cause death was markedly greater (four-fold to five-fold) in patients as compared with those without LVH. In LVH individuals, the increased risk remained significant even when data were adjusted for a large number of other confounding factors including home BP, 24-h mean BP and ambulatory BP. Results were similar when left ventricular mass was indexed by height and body surface area. A 10% increase in left ventricular mass index was associated with a significant increase in cardiovascular risk or all-cause deaths. In multivariate analysis, left ventricular mass index was always an independent predictor of cardiovascular events and death for any cause.

CONCLUSION

Our data provide evidence that LVH is an important risk factor even when the contribution of different BPs to risk is fully taken into account.

Survival after aortic valve replacement for aortic stenosis: does left ventricular mass regression have a clinical correlate?

AIM

The effects of post-operative left ventricular mass regression (LVMR) on clinical outcome after aortic valve surgery remains to be established. This study was intended to establish the impact of patient characteristics on post-operative survival in patients referred for aortic valve replacement (AVR), with particular regard to LVMR.

METHODS AND RESULTS

Two hundred and sixty consecutive cases submitted to aortic valve replacement for valvular stenosis were prospectively followed for a mean of 28+/-9 months. Baseline, characteristics and extent of LVMR were tested for association with survival by uni- and multivariable analysis. Ten deaths occurred during hospital stay and 52 during out-of-hospital follow-up. Mean left ventricular mass decreased from 190+/-43 to 158+/-70 g/m2 (P<0.001). Older age, advanced functional class, hypertension, reduced left ventricle ejection fraction, and high pre-operative left ventricular mass index were associated with reduced survival. Overall the extent of LVMR did not influence the clinical results, while only early (<6 months) LVMR was weakly associated with mid-term outcome.

CONCLUSION

Survival after aortic valve surgery is mainly determined by the pre-operative functional cardiac and systemic status. The extent of LVMR does not correlate with clinical outcome, whereas aggressive treatment of hypertension may improve post-operative survival.

Fatal overdosage with sildenafil citrate (Viagra): first report and review of the literature

A fatal case of sildenafil citrate (Viagra) overdosage is presented. The deceased was a 56-year old male found dead at home, with a past history of diabetes mellitus, hypertension, chronic alcoholism, anxio-depressive disorders, and erectile dysfunction. The main autopsy findings were cardiomegaly (650 g) with dilated cardiomyopathy, diffuse coronary atherosclerosis with no sign of acute ischaemic disease, and extensive fibrosis of the myocardium, especially affecting the cardiac conducting tissue. As measured by HPLC/MS, sildenafil concentration in postrmortem blood (6.27 microg/mL) exceeded at least four times the highest therapeutic levels previously reported. The results are discussed in the light of the literature about the cardiovascular side effects of sildenafil, with special emphasis on the recently evidenced arrhythmogenic potential of the drug. This is the first report of a fatality caused by sildenafil overdosage.

Drug treatment of hypertension complicating diabetes mellitus

Hypertension and diabetes mellitus are both common conditions associated with a high morbidity and mortality. When the two conditions occur together, as they do in 50% of diabetic individuals, the result is a 7.2-fold increase in mortality. If hypertension occurs in association with diabetes mellitus and diabetic nephropathy, mortality rises to 37-fold above that of a healthy population. Despite the increase in incidence of nephropathy, cardiovascular disease remains the major cause of death in diabetic individuals. Therapy should therefore take into consideration the results of large, placebo-controlled trials which have shown reduction in cardiovascular morbidity and mortality as a result of active treatment. Although studies with the newer antihypertensive agents such as calcium antagonists and angiotensin converting enzyme (ACE) inhibitors are ongoing, only diuretics and beta-adrenoceptor antagonists have been clearly shown to reduce cardiovascular risk. Despite concerns regarding adverse metabolic effects and loss of hypoglycaemic awareness, beta-blockers and diuretics do have a role in the management of diabetic patients. While it is clear that ACE inhibitors reduce the progression of diabetic nephropathy, evidence suggests that diuretics may be just as effective. However, unlike diuretics or beta-blockers, ACE inhibitors have no proven benefit in the prevention of stroke of myocardial infarction. Despite the claims of metabolic neutrality made for many antihypertensive agents there appears to be no advantage in their use in the majority of hypertensive diabetic patients, except where there exist specific contraindications to established therapies.

Evolving concepts in the management of hypertension

Currently, a plethora of antihypertensive medications exists. One concern about the long-term use of many of these agents is that adverse effects may offset their benefits. Despite the availability of many newer agents, blood pressure continues to be inadequately controlled in the majority of treated hypertensive patients, and many still remain at higher risk of premature death than the general population. More than 60% of treated hypertensive patients fail to attain blood pressures of < 140/90 mmHg. The major factors that permit a rational choice of medication include demographic considerations such as race and age, coexisting disease, safety, patient acceptance (quality of life), potential drug interactions, and additional salutary effects. The role of nondiuretic monotherapy is an integral component of this discussion. Preliminary data indicate that the use of calcium-channel blockers, converting-enzyme inhibitors, and AII-receptor antagonists constitutes excellent therapy in many patients. The effects of medication on the metabolic and lipid profiles are also considered.