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Markousis-Mavrogenis G, Bacopoulou F, Mavragani C, Voulgari P, Kolovou G, Kitas GD, Chrousos GP, Mavrogeni SI. Coronary microvascular disease: The "Meeting Point" of Cardiology, Rheumatology and Endocrinology. Eur J Clin Invest 2022; 52:e13737. [PMID: 34939183 DOI: 10.1111/eci.13737] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 12/19/2021] [Accepted: 12/20/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Exertional chest pain/dyspnea or chest pain at rest are the main symptoms of coronary artery disease (CAD), which are traditionally attributed to insufficiency of the epicardial coronary arteries. However, 2/3 of women and 1/3 of men with angina and 10% of patients with acute myocardial infarction have no evidence of epicardial coronary artery stenosis in X-ray coronary angiography. In these cases, coronary microvascular disease (CMD) is the main causative factor. AIMS To present the pathophysiology of CMD in Cardiology, Rheumatology and Endocrinology. MATERIALS-METHODS The pathophysiology of CMD in Cardiology, Rheumatology and Endocrinology was evaluated. It includes impaired microvascular vasodilatation, which leads to inability of the organism to deal with myocardial oxygen needs and, hence, development of ischemic pain. CMD, observed in inflammatory autoimmune rheumatic and endocrine/metabolic disorders, brings together Cardiology, Rheumatology and Endocrinology. Causative factors include persistent systemic inflammation and endocrine/metabolic abnormalities influencing directly the coronary microvasculature. In the past, the evaluation of microcirculation was feasible only with the use of invasive techniques, such as coronary flow reserve assessment. Currently, the application of advanced imaging modalities, such as cardiovascular magnetic resonance (CMR), can evaluate CMD non-invasively and without ionizing radiation. RESULTS CMD may present with a variety of symptoms with 1/3 to 2/3 of them expressed as typical chest pain in effort, more commonly found in women during menopause than in men. Atypical presentation includes chest pain at rest or exertional dyspnea,but post exercise symptoms are not uncommon. The treatment with nitrates is less effective in CMD, because their vasodilator action in coronary micro-circulation is less pronounced than in the epicardial coronary arteries. DISCUSSION Although both classic and new medications have been used in the treatment of CMD, there are still many questions regarding both the pathophysiology and the treatment of this disorder. The potential effects of anti-rheumatic and endocrine medications on the evolution of CMD need further evaluation. CONCLUSION CMD is a multifactorial disease leading to myocardial ischemia/fibrosis alone or in combination with epicardial coronary artery disease. Endothelial dysfunction/vasospasm, systemic inflammation, and/or neuroendocrine activation may act as causative factors and bring Cardiology, Rheumatology and Endocrinology together. Currently, the application of advanced imaging modalities, and specifically CMR, allows reliable assessment of the extent and severity of CMD. These measurements should not be limited to "pure cardiac patients", as it is known that CMD affects the majority of patients with autoimmune rheumatic and endocrine/metabolic disorders.
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Affiliation(s)
| | - Flora Bacopoulou
- University Research Institute of Maternal and Child Health and Precision Medicine, UNESCO Chair on Adolescent Health Care, National and Kapodistrian University of Athens, Aghia Sophia Children's Hospital, Athens, Greece
| | - Clio Mavragani
- Pathophysiology Department, University of Athens, Athens, Greece
| | | | - Genovefa Kolovou
- Onassis Cardiac Surgery Hospital, Athens, Greece.,Epidemiology Department, University of Manchester, Manchester, UK
| | - George D Kitas
- Epidemiology Department, University of Manchester, Manchester, UK
| | - George P Chrousos
- University Research Institute of Maternal and Child Health and Precision Medicine, UNESCO Chair on Adolescent Health Care, National and Kapodistrian University of Athens, Aghia Sophia Children's Hospital, Athens, Greece
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Gogakos AI, Gogakos T, Kita M, Efstathiadou ZA. Pituitary Dysfunction as a Cause of Cardiovascular Disease. Curr Pharm Des 2021; 26:5573-5583. [PMID: 33155896 DOI: 10.2174/1381612824999201105165351] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 08/16/2020] [Indexed: 11/22/2022]
Abstract
The hypothalamic-pituitary axis is responsible for the neuroendocrine control of several organ systems. The anterior pituitary directly affects the functions of the thyroid gland, the adrenal glands, and gonads, and regulates growth and milk production. The posterior hypophysis, through nerve connections with the hypothalamic nuclei, releases vasopressin and oxytocin responsible for water balance and social bonding, sexual reproduction and childbirth, respectively. Pituitary gland hormonal excess or deficiency results in dysregulation of metabolic pathways and mechanisms that are important for the homeostasis of the organism and are associated with increased morbidity and mortality. Cardiovascular (CV) disorders are common in pituitary disease and have a significant impact on survival. Hormonal imbalance is associated with CV complications either through direct effects on the heart structure and function and vasculature or indirectly by altering the metabolic profile. Optimal endocrine control can prevent or reverse CV defects and preserve survival and quality of life. In this review, we discuss the effects of pituitary hormone excess and deficiency on the CV system. Specifically, we assess the impact of Somatotroph, Corticotroph, Gonadotroph, and Lactotroph anterior pituitary axes on the CV system. The effect of posterior pituitary function on the CV system is also explored.
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Affiliation(s)
- Apostolos I Gogakos
- Department of Endocrinology, "Hippokration" General Hospital of Thessaloniki, Thessaloniki, Greece
| | - Tasos Gogakos
- Department of Pathology, Massachusetts General Hospital, Boston, MA 02114, United States
| | - Marina Kita
- Department of Endocrinology, "Hippokration" General Hospital of Thessaloniki, Thessaloniki, Greece
| | - Zoe A Efstathiadou
- Department of Endocrinology, "Hippokration" General Hospital of Thessaloniki, Thessaloniki, Greece
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3
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Pingle SR, Shah T, Mosleh W, Kim AS. Cushing syndrome cardiomyopathy: an unusual manifestation of small-cell lung cancer. ESC Heart Fail 2020; 7:3189-3192. [PMID: 32573943 PMCID: PMC7524218 DOI: 10.1002/ehf2.12860] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 05/31/2020] [Accepted: 06/09/2020] [Indexed: 01/12/2023] Open
Abstract
Cushing syndrome is a rare cause of dilated cardiomyopathy and heart failure with reduced ejection fraction. Cases describing this association are scarce. We describe a patient presenting with acute heart failure, new cardiomyopathy, refractory hypokalaemia, severe hyperglycaemia, and uncontrolled hypertension who was found to have hypercortisolism secondary to an ectopic adrenocorticotropic hormone‐secreting primary lung neoplasm. This case highlights the effects of hypercortisolism on the myocardium. The finding of a non‐dilated cardiomyopathy in this case is unique because the majority of previously reported Cushing syndrome cardiomyopathy cases have described left ventricular dilatation or significant left ventricular hypertrophy. In addition, small‐cell lung cancer with adrenocorticotropic hormone production causing Cushing syndrome cardiomyopathy is rare.
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Affiliation(s)
- Srinath-Reddi Pingle
- Department of Medicine, University of Connecticut School of Medicine, 263 Farmington Avenue, Farmington, CT, 06030-2202, USA
| | - Tanvi Shah
- Department of Medicine, St. Vincent's Hospital, Worcester, MA, USA
| | - Wassim Mosleh
- Calhoun Cardiology Center, University of Connecticut School of Medicine, 263 Farmington Avenue, Farmington, CT, 06030-2202, USA
| | - Agnes S Kim
- Department of Medicine, University of Connecticut School of Medicine, 263 Farmington Avenue, Farmington, CT, 06030-2202, USA.,Calhoun Cardiology Center, University of Connecticut School of Medicine, 263 Farmington Avenue, Farmington, CT, 06030-2202, USA
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4
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Tona F, Boscaro M, Barbot M, Maritan L, Famoso G, Dal Lin C, Montisci R, Fallo F, Iliceto S, Scaroni C. New insights to the potential mechanisms driving coronary flow reserve impairment in Cushing's syndrome: A pilot noninvasive study by transthoracic Doppler echocardiography. Microvasc Res 2020; 128:103940. [DOI: 10.1016/j.mvr.2019.103940] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 10/30/2019] [Accepted: 10/30/2019] [Indexed: 01/06/2023]
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Dal Lin C, Tona F, Osto E. The Heart as a Psychoneuroendocrine and Immunoregulatory Organ. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1065:225-239. [PMID: 30051388 DOI: 10.1007/978-3-319-77932-4_15] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
The heart can be viewed not just as muscle pump but also as an important checkpoint for a complex network of nervous, endocrine, and immune signals. The heart is able to process neurological signals independently from the brain and to crosstalk with the endocrine and immune systems. The heart communicates with the psyche through the neuro-endocrine-immune system in a highly integrated way, in order to maintain the homeostasis of the whole body with peculiarities specific to males and females.
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Affiliation(s)
- Carlo Dal Lin
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Francesco Tona
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Elena Osto
- Laboratory of Translational Nutrition Biology, Federal Institute of Technology Zurich ETHZ, Zurich, Switzerland. .,Center for Molecular Cardiology, University of Zurich and University Heart Center, Cardiology, University Hospital Zurich, Zurich, Switzerland.
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6
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Guarnotta V, Amato MC, Pivonello R, Arnaldi G, Ciresi A, Trementino L, Citarrella R, Iacuaniello D, Michetti G, Simeoli C, Colao A, Giordano C. The degree of urinary hypercortisolism is not correlated with the severity of cushing's syndrome. Endocrine 2017; 55:564-572. [PMID: 26965912 DOI: 10.1007/s12020-016-0914-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 03/01/2016] [Indexed: 12/29/2022]
Abstract
Cushing syndrome (CS) is characterized by increased morbidity and mortality compared to the general population. However, there are patients who have more clinical aggressive forms than others. Aim of the study is to evaluate whether the degree of hypercortisolism, defined by the number of times urinary free cortisol (UFC) levels exceed the upper limit of the normal range (ULN), is related to the worsening of phenotypic features, as well as metabolic and cardiovascular parameters, in a cohort of CS patients. A cross-sectional study was conducted on 192 patients with active CS, consecutively presenting at the outpatients' clinic of the University Hospitals of Ancona, Naples, and Palermo. Patients were grouped into mild (UFC not exceeding twice the ULN), moderate (2-5 times the ULN), and severe (more than 5 times the ULN) hypercortisolism. Thirty-seven patients (19.3 %) had mild, 115 (59.8 %) moderate, and 40 (20.9 %) severe hypercortisolism. A significant trend of increase among the three groups was demonstrated for 8-, 16-, and 24-h serum cortisol levels (p < 0.001) and serum cortisol after low dose of dexamethasone suppression test (p = 0.001). No significant trend of increase was found regarding phenotype and comorbidities. The degree of hypercortisolism by itself does not appear to be a sufficient parameter to express the severity of CS. Therefore, estimating the severity of CS according to biochemical parameters remains a challenge, while the clinical phenotype and the associated comorbidities might be more useful to assessing the severity of the CS.
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Affiliation(s)
- Valentina Guarnotta
- Dipartimento Biomedico di Medicina Interna e Specialistica (Di.Bi.M.I.S), Sezione di Endocrinologia, Diabetologia e Malattie Metaboliche, Università degli Studi di Palermo, Palermo, Italy
| | - Marco C Amato
- Dipartimento Biomedico di Medicina Interna e Specialistica (Di.Bi.M.I.S), Sezione di Endocrinologia, Diabetologia e Malattie Metaboliche, Università degli Studi di Palermo, Palermo, Italy
| | - Rosario Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Giorgio Arnaldi
- Clinica di Endocrinologia e del Metabolismo, Azienda Ospedaliero-Universitaria Ospedali Riuniti di Ancona, Ancona, Italy
| | - Alessandro Ciresi
- Dipartimento Biomedico di Medicina Interna e Specialistica (Di.Bi.M.I.S), Sezione di Endocrinologia, Diabetologia e Malattie Metaboliche, Università degli Studi di Palermo, Palermo, Italy
| | - Laura Trementino
- Clinica di Endocrinologia e del Metabolismo, Azienda Ospedaliero-Universitaria Ospedali Riuniti di Ancona, Ancona, Italy
| | - Roberto Citarrella
- Dipartimento Biomedico di Medicina Interna e Specialistica (Di.Bi.M.I.S), Sezione di Endocrinologia, Diabetologia e Malattie Metaboliche, Università degli Studi di Palermo, Palermo, Italy
| | - Davide Iacuaniello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Grazia Michetti
- Clinica di Endocrinologia e del Metabolismo, Azienda Ospedaliero-Universitaria Ospedali Riuniti di Ancona, Ancona, Italy
| | - Chiara Simeoli
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Annamaria Colao
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Carla Giordano
- Dipartimento Biomedico di Medicina Interna e Specialistica (Di.Bi.M.I.S), Sezione di Endocrinologia, Diabetologia e Malattie Metaboliche, Università degli Studi di Palermo, Palermo, Italy.
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7
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Avenatti E, Rebellato A, Iannaccone A, Battocchio M, Dassie F, Veglio F, Milan A, Fallo F. Left ventricular geometry and 24-h blood pressure profile in Cushing's syndrome. Endocrine 2017; 55:547-554. [PMID: 27179657 DOI: 10.1007/s12020-016-0986-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2016] [Accepted: 05/06/2016] [Indexed: 12/17/2022]
Abstract
Cushing's syndrome (CS) is associated with cardiovascular disease. The impact of the hemodynamic load on left ventricular mass (LVM) in patients with CS is not well known. In fact, the effects of 24-h blood pressure (BP) load and BP circadian rhythm on cardiac structure and function have not been studied. Aim of the present study has thus been to assess the presence of cardiac remodeling in patients with newly diagnosed CS, combining evaluation of cardiac remodeling and assessment of BP burden derived by 24-h ambulatory blood pressure monitoring (ABPM). 25 patients (4 M, 21 F) with CS underwent echocardiography in order to assess cardiac morphology and geometry (relative wall thickness-RWT). As controls, 25 subjects similar for demographic characteristics and 24-h BP were used. CS Patients were similar to controls by age, sex, mean 24-h BP, and body mass index. There was a significant increase in left ventricular mass (LVM; 44.4 ± 14.7 vs. 36.9 ± 10 g/m2.7, p = 0.03) and a significant increase in RWT (0.46 ± 0.07 vs. 0.41 ± 0.08, p = 0.02) in CS patients compared to controls. The prevalence of CS patients with pressure non-dipping profile was greater than that of controls (56 vs. 16 %, p < 0.05), with no significant association with LVM or geometry. 24-h urinary cortisol was not associated with LVM (r = 0.1, p = 0.5) or RWT (r = 0.02, p = 0.89) in the CS group. In conclusion, LVM and the concentric pattern of the left ventricle are relatively independent from 24-h BP load and profile (dipping/non-dipping) in CS patients.
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Affiliation(s)
- Eleonora Avenatti
- Internal Medicine and Hypertension Division, Department of Medical Sciences, University Hospital AOU Città della Salute e della Scienza di Torino, University of Torino, Via Genova 3, 10126, Turin, Italy
| | - Andrea Rebellato
- Department of Medicine-DIMED, University of Padova, Padua, Italy
| | - Andrea Iannaccone
- Internal Medicine and Hypertension Division, Department of Medical Sciences, University Hospital AOU Città della Salute e della Scienza di Torino, University of Torino, Via Genova 3, 10126, Turin, Italy
| | | | - Francesca Dassie
- Department of Medicine-DIMED, University of Padova, Padua, Italy
| | - Franco Veglio
- Internal Medicine and Hypertension Division, Department of Medical Sciences, University Hospital AOU Città della Salute e della Scienza di Torino, University of Torino, Via Genova 3, 10126, Turin, Italy
| | - Alberto Milan
- Internal Medicine and Hypertension Division, Department of Medical Sciences, University Hospital AOU Città della Salute e della Scienza di Torino, University of Torino, Via Genova 3, 10126, Turin, Italy.
| | - Francesco Fallo
- Department of Medicine-DIMED, University of Padova, Padua, Italy
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8
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Ferraù F, Korbonits M. Metabolic comorbidities in Cushing's syndrome. Eur J Endocrinol 2015; 173:M133-57. [PMID: 26060052 DOI: 10.1530/eje-15-0354] [Citation(s) in RCA: 110] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 06/09/2015] [Indexed: 12/12/2022]
Abstract
Cushing's syndrome (CS) patients have increased mortality primarily due to cardiovascular events induced by glucocorticoid (GC) excess-related severe metabolic changes. Glucose metabolism abnormalities are common in CS due to increased gluconeogenesis, disruption of insulin signalling with reduced glucose uptake and disposal of glucose and altered insulin secretion, consequent to the combination of GCs effects on liver, muscle, adipose tissue and pancreas. Dyslipidaemia is a frequent feature in CS as a result of GC-induced increased lipolysis, lipid mobilisation, liponeogenesis and adipogenesis. Protein metabolism is severely affected by GC excess via complex direct and indirect stimulation of protein breakdown and inhibition of protein synthesis, which can lead to muscle loss. CS patients show changes in body composition, with fat redistribution resulting in accumulation of central adipose tissue. Metabolic changes, altered adipokine release, GC-induced heart and vasculature abnormalities, hypertension and atherosclerosis contribute to the increased cardiovascular morbidity and mortality. In paediatric CS patients, the interplay between GC and the GH/IGF1 axis affects growth and body composition, while in adults it further contributes to the metabolic derangement. GC excess has a myriad of deleterious effects and here we attempt to summarise the metabolic comorbidities related to CS and their management in the perspective of reducing the cardiovascular risk and mortality overall.
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Affiliation(s)
- Francesco Ferraù
- Centre for Endocrinology William Harvey Research Institute, Barts and the London School of Medicine, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
| | - Márta Korbonits
- Centre for Endocrinology William Harvey Research Institute, Barts and the London School of Medicine, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
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Abstract
INTRODUCTION Cushing's syndrome is associated with a number of clinical manifestations and co-morbidities which may not resolve even after long-term remission leading to excessive mortality. MATERIALS AND METHODS This review summarizes the main manifestations of Cushing's syndrome (active or in remission) with particular focus on data from recently published literature. CONCLUSION Obesity and metabolic alterations, hypertension and cardio/cerebrovascular complications, hypercoagulability/thromboembolism, neuropsychiatric, muscle/skeletal and immune consequences remain the most challenging. Cardiovascular consequences and immunosuppression determine the main causes of death in Cushing's syndrome necessitating early intervention when possible.
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Affiliation(s)
- Georgia Ntali
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Old Rd, Headington, Oxford, OX3 7LJ, UK
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Barahona MJ, Resmini E, Viladés D, Fernández-Real JM, Ricart W, Moreno-Navarrete JM, Pons-Lladó G, Leta R, Webb SM. Soluble TNFα-receptor 1 as a predictor of coronary calcifications in patients after long-term cure of Cushing's syndrome. Pituitary 2015; 18:135-41. [PMID: 24728972 DOI: 10.1007/s11102-014-0566-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE Increased cardiovascular (CV) risk persists in Cushing's syndrome (CS), despite remission of hypercortisolism. The aim of this study was to evaluate prevalence of coronary artery disease in CS patients and its correlation with classical CV risk factors and inflammatory markers. METHODS Cardiac multidetector computed tomography (MDCT) was performed in 41 patients (7 men, 31 of pituitary origin, 29 cured, mean age: 48.6 ± 13 years), using 64-slice Toshiba Aquilion systems. Coronary atherosclerotic plaques were detected and coronary calcifications quantified by the Agatston score (AS). Clinical and biochemical parameters were correlated with the AS to identify possible surrogate markers of coronary disease. Normal values for clinical and biochemical parameters were obtained from a gender- and age-matched normal reference population (n = 82). RESULTS CS patients with calcifications (AS > 0) (N = 13, 32%) had higher levels of sTNF-R1, homocysteine, triglycerides, blood pressure and body mass index than patients without calcifications (AS = 0) and those of normal reference population. Both groups of CS patients (AS > 0 and AS = 0) had elevated trunk fat mass and IL-6 compared to reference values. Patients with AS > 0 had less adiponectin and higher insulin, HOMA and fibrinogen than those found in normal reference population. sTNF-R1 correlated positively with AS and remained significant after adjusting for confounding factors. The same result was observed when we considered only cured CS patients. CONCLUSION In our cohort of CS patients sTNF-R1 was a predictor of coronary calcifications. Since MDCT is an expensive technique not readily available in daily clinical practice, increased sTNF-R1 could be a marker of CV risk even in cured CS.
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Affiliation(s)
- María-José Barahona
- Department of Endocrinology, Hospital Universitari Mútua de Terrassa, Pl Dr Robert 5, 08221, Terrassa, Barcelona, Spain,
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Dal Lin C, Tona F, Osto E. Coronary Microvascular Function and Beyond: The Crosstalk between Hormones, Cytokines, and Neurotransmitters. Int J Endocrinol 2015; 2015:312848. [PMID: 26124827 PMCID: PMC4466475 DOI: 10.1155/2015/312848] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Revised: 03/10/2015] [Accepted: 03/16/2015] [Indexed: 01/18/2023] Open
Abstract
Beyond its hemodynamic function, the heart also acts as a neuroendocrine and immunoregulatory organ. A dynamic communication between the heart and other organs takes place constantly to maintain cardiovascular homeostasis. The current understanding highlights the importance of the endocrine, immune, and nervous factors to fine-tune the crosstalk of the cardiovascular system with the entire body. Once disrupted, this complex interorgan communication may promote the onset and the progression of cardiovascular diseases. Thus, expanding our knowledge on how these factors influence the cardiovascular system can lead to novel therapeutic strategies to improve patient care. In the present paper, we review novel concepts on the role of endocrine, immune, and nervous factors in the modulation of microvascular coronary function.
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Affiliation(s)
- Carlo Dal Lin
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Via Giustiniani 2, 35100 Padua, Italy
| | - Francesco Tona
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Via Giustiniani 2, 35100 Padua, Italy
| | - Elena Osto
- Centre for Molecular Cardiology, University of Zurich and University Heart Center, Department of Cardiology, University Hospital, Raemistrasse 100, 8091 Zurich, Switzerland
- *Elena Osto:
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Rebellato A, Grillo A, Dassie F, Sonino N, Maffei P, Martini C, Paoletta A, Fabris B, Carretta R, Fallo F. Ambulatory blood pressure monitoring-derived short-term blood pressure variability is increased in Cushing's syndrome. Endocrine 2014; 47:557-63. [PMID: 24408053 DOI: 10.1007/s12020-014-0164-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Accepted: 01/02/2014] [Indexed: 11/29/2022]
Abstract
Cushing's syndrome is associated with high cardiovascular morbility and mortality. Blood pressure (BP) variability within a 24-h period is increasingly recognized as an independent predictor of cardiovascular risk. The aim of our study was to investigate the short-term BP variability indices in Cushing's syndrome. Twenty-five patients with Cushing's syndrome (mean age 49 ± 13 years, 4 males; 21 Cushing's disease and 4 adrenal adenoma patients) underwent 24-h ambulatory BP monitoring (ABPM) and evaluation of cardiovascular risk factors. Cushing patients were divided into 8 normotensive (NOR-CUSH) and 17 hypertensive (HYP-CUSH) patients and were compared with 20 normotensive (NOR-CTR) and 20 hypertensive (HYP-CTR) age-, sex-, and BMI-matched control subjects. Short-term BP variability was derived from ABPM and calculated as the following: (1) standard deviation (SD) of 24-h, daytime, and nighttime BP; (2) 24-h weighted SD of BP; and (3) average real variability (ARV), i.e., the average of the absolute differences between consecutive BP measurements over 24 h. In comparison with controls, patients with Cushing's syndrome, either normotensive or hypertensive, had higher 24-h and daytime SD of BP, as well as higher 24-h weighted SD and ARV of BP (P = 0.03 to P < 0.0001). No difference in metabolic parameters was observed between NOR-CTR and NOR-CUSH or between HYP-CTR and HYP-CUSH subgroups. ABPM-derived short-term BP variability is increased in Cushing's syndrome, independent of BP elevation. It may represent an additional cardiovascular risk factor in this disease. The role of excess cortisol in BP variability has to be further clarified.
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Affiliation(s)
- Andrea Rebellato
- Department of Medicine-DIMED, Clinica Medica 3, University of Padova, Via Giustiniani 2, 35128, Padua, Italy
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Kamenický P, Redheuil A, Roux C, Salenave S, Kachenoura N, Raissouni Z, Macron L, Guignat L, Jublanc C, Azarine A, Brailly S, Young J, Mousseaux E, Chanson P. Cardiac structure and function in Cushing's syndrome: a cardiac magnetic resonance imaging study. J Clin Endocrinol Metab 2014; 99:E2144-53. [PMID: 25093618 PMCID: PMC4223435 DOI: 10.1210/jc.2014-1783] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Patients with Cushing's syndrome have left ventricular (LV) hypertrophy and dysfunction on echocardiography, but echo-based measurements may have limited accuracy in obese patients. No data are available on right ventricular (RV) and left atrial (LA) size and function in these patients. OBJECTIVES The objective of the study was to evaluate LV, RV, and LA structure and function in patients with Cushing's syndrome by means of cardiac magnetic resonance, currently the reference modality in assessment of cardiac geometry and function. METHODS Eighteen patients with active Cushing's syndrome and 18 volunteers matched for age, sex, and body mass index were studied by cardiac magnetic resonance. The imaging was repeated in the patients 6 months (range 2-12 mo) after the treatment of hypercortisolism. RESULTS Compared with controls, patients with Cushing's syndrome had lower LV, RV, and LA ejection fractions (P < .001 for all) and increased end-diastolic LV segmental thickness (P < .001). Treatment of hypercortisolism was associated with an improvement in ventricular and atrial systolic performance, as reflected by a 15% increase in the LV ejection fraction (P = .029), a 45% increase in the LA ejection fraction (P < .001), and an 11% increase in the RV ejection fraction (P = NS). After treatment, the LV mass index and end-diastolic LV mass to volume ratio decreased by 17% (P < .001) and 10% (P = .002), respectively. None of the patients had late gadolinium myocardial enhancement. CONCLUSION Cushing's syndrome is associated with subclinical biventricular and LA systolic dysfunctions that are reversible after treatment. Despite skeletal muscle atrophy, Cushing's syndrome patients have an increased LV mass, reversible upon correction of hypercortisolism.
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Colao A, Boscaro M, Ferone D, Casanueva FF. Managing Cushing's disease: the state of the art. Endocrine 2014; 47:9-20. [PMID: 24415169 DOI: 10.1007/s12020-013-0129-2] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Accepted: 11/21/2013] [Indexed: 12/28/2022]
Abstract
Cushing's disease is a rare chronic disease caused by a pituitary adenoma, which leads to excess secretion of adrenocorticotropic hormone (ACTH). The over-production of ACTH leads to hyperstimulation of the adrenal glands and a chronic excess of cortisol, resulting in the signs and symptoms of a severe clinical state (Cushing's syndrome) that leads to significant morbidity, negative impacts on the patient's quality of life, and, if untreated, increased mortality. The management of patients with Cushing's disease is complicated by the heterogeneity of the condition, with signs and symptoms that overlap with those of other diseases, and high subclinical incidence rates. Controversies surrounding the tests used for screening and identifying patients with Cushing's disease add to the challenge of patient management. Surgical intervention to remove the adenoma is the first-line treatment for patients with Cushing's disease, but medical therapies are useful in patients who relapse or are unsuitable for surgery. The recent introduction of pasireotide, the first pituitary-directed medical therapy, expands the number of treatment options available for patients with Cushing's disease. This state-of-the-art review aims to provide an overview of the most recent scientific research and clinical information regarding Cushing's disease. Continuing research into improving the diagnosis and treatment of Cushing's disease will help to optimize patient management.
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Affiliation(s)
- Annamaria Colao
- Dipartimento di Medicina Clinica e Chirurgia, Università Federico II di Napoli, Via S. Pansini 5, 80131, Naples, Italy,
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Abstract
It was assumed that resolution of hypercortisolism in Cushing syndrome (CS) was followed by normalization of morbidity; however, in the last decade evidence is accumulating that patients with cured CS still have increased morbidity and mortality after the biochemical control of hypercortisolism. Patients with CS have an increased cardiovascular and metabolic risk and persistent accumulation of central fat, with an unfavorable adipokine profile, not only during the active phase of the disease but also long after biochemical remission. Clinical management should be particularly careful in identifying global cardiovascular risk, as a primary goal during the followup of these patients, aimed at improving global vascular morbidity. Moreover bone mass is reduced not only due to the endogenous hypercortisolism but also due to duration and dose of exogenous glucocorticoid (GC) replacement therapy after surgery. Thus, therapy in operated patients with inhibition of the hypothalamic-pituitary-adrenal axis should be reduced to the lowest dose and duration possible. Specific treatments should be considered in patients with decreased bone mass, aimed at reducing the increased fracture incidence. Finally, cognitive and health related quality of life impairments, described in active disease, are still abnormal after endocrine cure. Thus, residual morbidity persists in cured CS, suggesting irreversibility of GC-induced phenomena, typical of chronic hypercortisolism.
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Neary NM, Booker OJ, Abel BS, Matta JR, Muldoon N, Sinaii N, Pettigrew RI, Nieman LK, Gharib AM. Hypercortisolism is associated with increased coronary arterial atherosclerosis: analysis of noninvasive coronary angiography using multidetector computerized tomography. J Clin Endocrinol Metab 2013; 98:2045-52. [PMID: 23559084 PMCID: PMC3644598 DOI: 10.1210/jc.2012-3754] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Observational studies show that glucocorticoid therapy and the endogenous hypercortisolism of Cushing's syndrome (CS) are associated with increased rates of cardiovascular morbidity and mortality. However, the causes of these findings remain largely unknown. OBJECTIVE To determine whether CS patients have increased coronary atherosclerosis. DESIGN A prospective case-control study was performed. SETTING Subjects were evaulated in a clinical research center. SUBJECTS Fifteen consecutive patients with ACTH-dependent CS, 14 due to an ectopic source and 1 due to pituitary Cushing's disease were recruited. Eleven patients were studied when hypercortisolemic; 4 patients were eucortisolemic due to medication (3) or cyclic hypercortisolism (1). Fifteen control subjects with at least one risk factor for cardiac disease were matched 1:1 for age, sex, and body mass index. PRIMARY OUTCOME VARIABLES Agatston score a measure of calcified plaque and non-calcified coronary plaque volume were quantified using a multidetector CT (MDCT) coronary angiogram scan. Additional variables included fasting lipids, blood pressure, history of hypertension or diabetes, and 24-hour urine free cortisol excretion. RESULTS CS patients had significantly greater noncalcified plaque volume and Agatston score (noncalcified plaque volume [mm(3)] median [interquartile ranges]: CS 49.5 [31.4, 102.5], controls 17.9 [2.6, 25.3], P < .001; Agatston score: CS 70.6 [0, 253.1], controls 0 [0, 7.6]; P < .05). CS patients had higher systolic and diastolic blood pressures than controls (systolic: CS 143 mm Hg [135, 173]; controls, 134 [123, 136], P < .02; diastolic CS: 86 [80, 99], controls, 76 [72, 84], P < .05). CONCLUSIONS Increased coronary calcifications and noncalcified coronary plaque volumes are present in patients with active or previous hypercortisolism. Increased atherosclerosis may contribute to the increased rates of cardiovascular morbidity and mortality in patients with glucocorticoid excess.
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Affiliation(s)
- Nicola M Neary
- Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20892, USA
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Barahona MJ, Resmini E, Viladés D, Pons-Lladó G, Leta R, Puig T, Webb SM. Coronary artery disease detected by multislice computed tomography in patients after long-term cure of Cushing's syndrome. J Clin Endocrinol Metab 2013; 98:1093-9. [PMID: 23393183 DOI: 10.1210/jc.2012-3547] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Increased cardiovascular risk persists in Cushing's syndrome (CS), despite remission of hypercortisolism. The aim of this study was to evaluate the prevalence of coronary artery disease in patients after long-term cure of CS. METHODS Cardiac multidetector computed tomography was performed in 29 cured CS patients (5 men, 21 of pituitary origin, 50 ± 13 y, mean time of "cure" 11 ± 6 y), using 64-slice Toshiba Aquilion systems (Toshiba Medical Systems, Otawara, Japan). Noncontrast acquisitions were performed to detect coronary calcifications and, after injection of an iodinated contrast agent, for coronary angiography. Calcium was quantified by the Agatston score. Cured patients were compared with 48 gender-matched and age-matched healthy controls. RESULTS Cured CS patients had more hypertension and smoked less than controls (P < .05). The prevalence of coronary calcifications (31% vs 21%) and noncalcified plaques (20% vs 7.8%) tended to be higher in cured CS patients than controls. When only women were analyzed (24 CS and 34 controls), more abnormal multidetector computed tomography results were found (42% vs 18%; P < .05). When patients and controls in the youngest tertile (<45 y) were compared, cured CS patients had significantly more noncalcified plaques than controls (30% vs 0%, P = .01); this difference persisted when hypopituitary or dyslipidemic CS patients were excluded. CONCLUSION Despite long-term biochemical "cure" of CS, patients exhibit more coronary artery disease, especially in women and in those aged <45 years, in comparison to healthy matched controls.
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Affiliation(s)
- María-José Barahona
- Department of Endocrinology, Hospital Universitari Mútua de Terrassa, Plaça Doctor Robert 5, 08221 Terrassa, Barcelona, Spain.
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