Diastolic dysfunction: improved understanding using emerging imaging techniques

How non-alcoholic fatty liver disease and cirrhosis affect the heart

Liver diseases affect the heart and the vascular system. Cardiovascular complications appear to be a leading cause of death in patients with non-alcoholic fatty liver disease (NAFLD) and cirrhosis. The predominant histological changes in the liver range from steatosis to fibrosis to cirrhosis, which can each affect the cardiovascular system differently. Patients with cirrhotic cardiomyopathy (CCM) and NAFLD are at increased risk of impaired systolic and diastolic dysfunction and for suffering major cardiovascular events. However, the pathophysiological mechanisms behind these risks differ depending on the nature of the liver disease. Accurate assessment of symptoms by contemporary diagnostic modalities is essential for identifying patients at risk, for evaluating candidates for treatment, and prior to any invasive procedures. This review explores current perspectives within this field.

Reducing Cardiac Steatosis: Interventions to Improve Diastolic Function - A Narrative Review

Heart failure is one of the main causes of morbidity and mortality around the globe. Heart failure with preserved ejection fraction is primarily caused by diastolic dysfunction. Adipose tissue deposition in the heart has been previously explained in the pathogenesis of diastolic dysfunction. In this article, we aim to discuss the potential interventions that can reduce the risk of diastolic dysfunction by reducing cardiac adipose tissue. A healthy diet with reduced dietary fat content can reduce visceral adiposity and improve diastolic function. Aerobic and resistance exercises also reduce visceral and epicardial fat and ameliorate diastolic dysfunction. Some medications, include metformin, glucagon-like peptide-1 analogues, dipeptidyl peptidase-4 inhibitors, thiazolidinediones, sodium-glucose co-transporter-2, inhibitors, statins, ACE-Is, and ARBs, have shown different degrees of effectiveness in improving cardiac steatosis and diastolic function. Bariatric surgery has also shown promising results in this field.

Left and Right Ventricular Impairment Shortly After Correction of Tetralogy of Fallot

Surgical repair of Tetralogy of Fallot (ToF) is usually performed in the first months of life with low early postoperative mortality. During long-term follow-up, however, both right (RV) and left ventricular (LV) performances may deteriorate. Tissue Doppler imaging (TDI) and speckle tracking echocardiography (ST) can unmask a diminished RV and LV performance. The objective of the current study was to assess the cardiac performance before and shortly after corrective surgery in ToF patients using conventional, TDI and ST echocardiographic techniques. Thirty-six ToF patients after surgery were included. Transthoracic echocardiography including TDI and ST techniques was performed preoperatively and at hospital discharge after surgery (10 days to 4 weeks after surgery). Median age at surgery was 7.5 months [5.5-10.9]. Regarding the LV systolic function there was a significant decrease in interventricular septum (IVS) S' at discharge as compared to preoperatively (pre IVS S' = 5.4 ± 1.4; post IVS S' = 3.9 ± 1.2; p < 0.001) and in global longitudinal peak strain (GLS) (pre = - 18.3 ± 3.4; post = - 14.2 ± 4.1; p = 0.003); but not in the fractional shortening (FS). Both conventional and TDI parameters showed a decrease in diastolic function at discharge. Tricuspid Annular Plane Systolic Excursion and RV S' were significantly lower before discharge. When assessing the RV diastolic performance, only the TDI demonstrated a RV impairment. There was a negative correlation between age at surgery and postoperative LV GLS (R = - 0.41, p = 0.031). There seems to be an impairment in left and right ventricle performance at discharge after ToF corrective surgery compared to preoperatively. This is better determined with TDI and ST strain imaging than with conventional echocardiography.

Left ventricular concentric remodelling and functional impairment in women with ischaemia with no obstructive coronary artery disease and intermediate coronary flow reserve: a report from the WISE-CVD study

AIMS

Women with evidence of ischaemia but no obstructive coronary artery disease (INOCA) often have coronary microvascular dysfunction (CMD). Although invasively measured coronary flow reserve (CFR) is useful for the diagnosis of CMD, intermediate CFR values are often found of uncertain significance. We investigated myocardial flow reserve and left ventricular (LV) structural and functional remodelling in women with suspected INOCA and intermediate CFR.

METHODS AND RESULTS

Women's Ischemia Syndrome Evaluation-Coronary Vascular Dysfunction (WISE-CVD) study participants who had invasively measured intermediate CFR of 2.0≤ CFR ≤3.0 (n = 125) were included for this analysis. LV strain, peak filling rate (PFR) and myocardial perfusion reserve index (MPRI) were obtained by cardiac magnetic resonance imaging. Participants were divided: (i) Group 1 (n = 66) high MPRI ≥ 1.8, and (ii) Group 2 (n = 59) low MPRI < 1.8. The mean age was 54 ± 12 years and CFR was 2.46 ± 0.27. MPRI was significantly different but CFR did not differ between groups. LV relative wall thickness (RWT) trended higher in Group 2 and circumferential peak systolic strain and early diastolic strain rate were lower (P = 0.039 and P = 0.035, respectively), despite a similar LV ejection fraction and LV mass. PFR was higher in Group 1 and LV RWT was negatively related to PFR (r = -0.296, P = 0.001).

CONCLUSIONS

In women with suspected INOCA and intermediate CFR, those with lower MPRI had a trend towards more adverse remodelling and impaired diastolic LV function compared with those with higher MPRI. CFR was similar between the two groups. These findings provide evidence that both coronary microvessel vasomotion and structural and functional myocardial remodelling contribute to CMD.

A risk score for predicting atrial fibrillation in individuals with preclinical diastolic dysfunction: a retrospective study in a single large urban center in the United States

Background

Left ventricular diastolic dysfunction has been shown to associate with increased risk of atrial fibrillation (AF). We aimed to examine the predictors of AF in individuals with preclinical diastolic dysfunction (PDD) - diastolic dysfunction without clinical heart failure – and develop a risk score in this population.

Methods

Patients underwent echocardiogram from December 2009 to December 2015 showing left ventricular ejection fraction (LVEF) ≥ 50% and grade 1 diastolic dysfunction, without clinical heart failure, valvular heart disease or AF were included. Outcome was defined as new onset AF. Cumulative probabilities were estimated and multivariable adjusted competing-risks regression analysis was performed to examine predictors of incident AF. A predictive score model was constructed.

Results

A total of 9591 PDD patients (mean age 66, 41% men) of racial/ethnical diversity were included in the study. During a median follow-up of 54 months, 455 (4.7%) patients developed AF. Independent predictors of AF included advanced age, male sex, race, hypertension, diabetes, and peripheral artery disease. A risk score including these factors showed a Wolber’s concordance index of 0.65 (0.63–0.68, p <  0.001), suggesting a good discrimination.

Conclusions

Our study revealed a set of predictors of AF in PDD patients. A simple risk score predicting AF in PDD was developed and internally validated. The scoring system could help clinical risk stratification, which may lead to prevention and early treatment strategies.

Electronic supplementary material

The online version of this article (10.1186/s12872-019-1024-4) contains supplementary material, which is available to authorized users.

Left Ventricular Diastolic Dysfunction in a Rat Model of Diabetic Cardiomyopathy using ECG-gated 18F-FDG PET

In diabetic cardiomyopathy, left ventricular (LV) diastolic dysfunction is one of the earliest signs of cardiac involvement prior to the definitive development of heart failure (HF). We aimed to explore the LV diastolic function using electrocardiography (ECG)-gated ¹⁸F-fluorodeoxyglucose positron emission tomography (¹⁸F-FDG PET) imaging beyond the assessment of cardiac glucose utilization in a diabetic rat model. ECG-gated ¹⁸F-FDG PET imaging was performed in a rat model of type 2 diabetes (ZDF fa/fa) and ZL control rats at age of 13 weeks (n = 6, respectively). Under hyperinsulinemic-euglycemic clamp to enhance cardiac activity, ¹⁸F-FDG was administered and subsequently, list-mode imaging using a dedicated small animal PET system with ECG signal recording was performed. List-mode data were sorted and reconstructed into tomographic images of 16 frames per cardiac cycle. Left ventricular functional parameters (systolic: LV ejection fraction (EF), heart rate (HR) vs. diastolic: peak filling rate (PFR)) were obtained using an automatic ventricular edge detection software. No significant difference in systolic function could be obtained (ZL controls vs. ZDF rats: LVEF, 62.5 ± 4.2 vs. 59.4 ± 4.5%; HR: 331 ± 35 vs. 309 ± 24 bpm; n.s., respectively). On the contrary, ECG-gated PET imaging showed a mild but significant decrease of PFR in the diabetic rats (ZL controls vs. ZDF rats: 12.1 ± 0.8 vs. 10.2 ± 1 Enddiastolic Volume/sec, P < 0.01). Investigating a diabetic rat model, ECG-gated ¹⁸F-FDG PET imaging detected LV diastolic dysfunction while systolic function was still preserved. This might open avenues for an early detection of HF onset in high-risk type 2 diabetes before cardiac symptoms become apparent.

Refractory Hypertension Is not Attributable to Intravascular Fluid Retention as Determined by Intracardiac Volumes

Refractory hypertension (RfHTN) is an extreme phenotype of antihypertensive treatment failure defined as lack of blood pressure control with ≥5 medications, including a long-acting thiazide and a mineralocorticoid receptor antagonist. RfHTN is a subgroup of resistant hypertension (RHTN), which is defined as blood pressure >135/85 mm Hg with ≥3 antihypertensive medications, including a diuretic. RHTN is generally attributed to persistent intravascular fluid retention. It is unknown whether alternative mechanisms are operative in RfHTN. Our objective was to determine whether RfHTN is characterized by persistent fluid retention, indexed by greater intracardiac volumes determined by cardiac magnetic resonance when compared with controlled RHTN patients. Consecutive patients evaluated in our institution with RfHTN and controlled RHTN were prospectively enrolled. Exclusion criteria included advanced chronic kidney disease and masked or white coat hypertension. All enrolled patients underwent biochemical testing and cardiac magnetic resonance. The RfHTN group (n=24) was younger (mean age, 51.7±8.9 versus 60.6±11.5 years; P=0.003) and had a greater proportion of women (75.0% versus 43%; P=0.02) compared with the controlled RHTN group (n=30). RfHTN patients had a greater left ventricular mass index (88.3±35.0 versus 54.6±12.5 g/m²; P<0.001), posterior wall thickness (10.1±3.1 versus 7.7±1.5 mm; P=0.001), and septal wall thickness (14.5±3.8 versus 10.0±2.2 mm; P<0.001). There was no difference in B-type natriuretic peptide levels and left atrial or ventricular volumes. Diastolic dysfunction was noted in RfHTN. Our findings demonstrate greater left ventricular hypertrophy without chamber enlargement in RfHTN, suggesting that antihypertensive treatment failure is not attributable to intravascular volume retention.

Direct comparison of high-temporal-resolution CINE MRI with Doppler ultrasound for assessment of diastolic dysfunction in mice

Diastolic dysfunction is a sensitive early indicator of heart failure and can provide additional data to conventional measures of systolic function. Transmitral Doppler ultrasound, which measures the one-dimensional flow of blood through the mitral valve, is currently the preferred method for the measurement of diastolic function, but the measurement of the left ventricular volume changes using high-temporal-resolution cinematic magnetic resonance imaging (CINE MRI) is an alternative approach which is emerging as a potentially more robust and user-independent technique. Here, we investigated the performance of high-temporal-resolution CINE MRI and compared it with ultrasound for the detection of diastolic dysfunction in a mouse model of myocardial infarction. An in-house, high-temporal-resolution, retrospectively gated CINE sequence was developed with a temporal resolution of 1 ms. Diastolic function in mice was assessed using a custom-made, open-source reconstruction package. Early (E) and late (A) left ventricular filling phases were easily identifiable, and these measurements were compared directly with high-frequency, pulsed-wave, Doppler ultrasound measurements of mitral valve inflow. A repeatability study established that high-temporal-resolution CINE MRI and Doppler ultrasound showed comparable accuracy when measuring E/A in normal control mice. However, when applied in a mouse model of myocardial infarction, high-temporal-resolution CINE MRI indicated diastolic heart failure (E/A = 0.94 ± 0.11), whereas ultrasound falsely detected normal cardiac function (E/A = 1.21 ± 0.11). The addition of high-temporal-resolution CINE MRI to preclinical imaging studies enhances the library of sequences available to cardiac researchers and potentially identifies diastolic heart failure early in disease progression.

Three-Dimensional Volumetric Assessment of Diastolic Function by Cardiac Magnetic Resonance Imaging: The Multi-Ethnic Study of Atherosclerosis (MESA)

Background:

Cardiac Magnetic Resonance is in need of a simple and robust method for diastolic function assessment that can be done with routine protocol sequences.

Objective:

To develop and validate a three-dimensional (3D) model-based volumetric assessment of diastolic function using cardiac magnetic resonance (CMR) imaging and compare the results obtained with the model with those obtained by echocardiography.

Methods:

The study participants provided written informed consent and were included if having undergone both echocardiography and cine steady-state free precession (SSFP) CMR on the same day. Guide points at the septal and lateral mitral annulus were used to define the early longitudinal relaxation rate (E'), while a time-volume curve from the 3D model was used to assess diastolic filling parameters. We determined the correlation between 3D CMR and echocardiography and the accuracy of CMR in classifying the diastolic function grade.

Results:

The study included 102 subjects. The E/A ratio by CMR was positively associated with the E/A ratio by echocardiography (r = 0.71, p < 0.0001). The early diastolic relaxation velocity by tissue Doppler and longitudinal relaxation rate for the lateral mitral annulus displacement were positively associated (p = 0.007), as were the ratio between Doppler E/e' and CMR E/E' (p = 0.01). CMR-determined normalized peak E (NE) and deceleration time (DT) were able to predict diastolic dysfunction (areas under the curve [AUCs] = 0.70 and 0.72, respectively). In addition, the lateral E/E' ratio showed good utility in identifying diastolic dysfunction (AUC = 0.80). Overall, echocardiography and CMR interobserver and intraobserver agreements were excellent (intraclass correlation coefficient range 0.72 - 0.97).

Conclusion:

3D modeling of standard cine CMR images was able to identify study subjects with reduced diastolic function and showed good reproducibility, suggesting a potential for a routine diastolic function assessment by CMR.

Fundamento:

A ressonância magnética cardíaca necessita de um método simples e robusto para a avaliação da função diastólica que pode ser feito com sequências protocolares de rotina.

Objetivo:

Desenvolver e validar a avaliação volumétrica da função diastólica através de um modelo tridimensional (3D) com utilização de imagens de ressonância magnética cardíaca (RMC) e comparar os resultados obtidos com este modelo com os obtidos por ecocardiografia.

Métodos:

Os participantes do estudo assinaram um termo de consentimento e foram incluídos se tivessem sido submetidos no mesmo dia tanto à ecocardiografia quanto à cine RMC com precessão livre no estado estacionário (steady-state free precession, SSFP). Pontos-guia foram utilizados no anel mitral septal e lateral para definir a velocidade de estiramento no início da diástole (E'), enquanto curvas de volume-tempo do modelo 3D foram utilizadas para avaliar os parâmetros de enchimento diastólico. Foram determinadas a correlação entre a RMC 3D e a ecocardiografia, além da acurácia da RMC em classificar o grau de função diastólica.

Resultados:

Ao todo, 102 sujeitos foram incluídos no estudo. A razão E/A pela RMC esteve positivamente associada com a razão E/A obtida pela ecocardiografia (r = 0,71, p < 0,0001). Estiveram positivamente associadas a velocidade de relaxamento diastólico inicial ao Doppler tecidual e a velocidade de relaxamento longitudinal de deslocamento do anel mitral lateral (p = 0,007), bem como a razão entre E/e' por Doppler e E/E' pela RMC (p = 0,01). A velocidade normalizada de pico de enchimento (EM) determinada pela RMC e o tempo de desaceleração (TD) foram capazes de predizer a disfunção diastólica (áreas sob a curva [AUCs] = 0,70 e 0,72, respectivamente). Além disso, a razão E/E' lateral mostrou boa utilidade para a identificação da disfunção diastólica (AUC = 0,80). No geral, a ecocardiografia e a RMC apresentaram excelente concordância interobservador e intraobservador (coeficiente de correlação intraclasse 0,72 - 0,97).

Conclusão:

Uma modelagem 3D de imagens padrões de cine RMC foi capaz de identificar os indivíduos do estudo com função diastólica reduzida e mostrou uma boa reprodutibilidade, sugerindo ter potencial na avaliação rotineira da função diastólica por RMC.

Cardiac magnetic resonance assessment of diastolic dysfunction in acute coronary syndrome

Chest pain is an important presenting symptom. However, few cases of chest pain are diagnosed as acute coronary syndrome (ACS) in the acute setting. This results in frequent inappropriate discharge and major delay in treatment for patients with underlying ACS. The conventional methods of assessing ACS, which include electrocardiography and serological markers of infarct, can take time to manifest. Recent studies have investigated more sensitive and specific imaging modalities that can be used. Diastolic dysfunction occurs early following coronary artery occlusion and its detection is useful in confirming the diagnosis, risk stratification, and prognosis post-ACS. Cardiac magnetic resonance provides a single imaging modality for comprehensive evaluation of chest pain in the acute setting. In particular, cardiac magnetic resonance has many imaging techniques that assess diastolic dysfunction post-coronary artery occlusion. Techniques such as measurement of left atrial size, mitral inflow, and mitral annular and pulmonary vein flow velocities with phase-contrast imaging enable general assessment of ventricular diastolic function. More novel imaging techniques, such as T2-weighted imaging for oedema, T1 mapping, and myocardial tagging, allow early determination of regional diastolic dysfunction and oedema. These findings may correspond to specific infarcted arteries that may be used to tailor eventual percutaneous coronary artery intervention.

MRI Assessment of Cardiomyopathy Induced by β1-Adrenoreceptor Autoantibodies and Protection Through β3-Adrenoreceptor Overexpression

The cardiopathogenic role of autoantibodies (aabs) directed against β1-adrenoreceptors (β1-AR) is well established. In mouse models, they cause progressive dilated cardiomyopathy (DCM) whose characterization with echocardiography requires prolonged protocols with numerous animals, complicating the evaluation of new treatments. Here, we report on the characterization of β1-aabs-induced DCM in mice using 11.7T MRI. C57BL/6J mice (n = 10 per group) were immunized against the β1-AR and left ventricular (LV) systolic function was assessed at 10, 18 and 27 weeks. Increase in LV mass/tibial length ratio was detected as the first modification at 10 weeks together with dilation of cavities, thereby outperforming echocardiography. Significant impairment in diastolic index was also observed in immunized animals before the onset of systolic dysfunction. Morphometric and histological measurements confirmed these observations. The same protocol performed on β3-AR-overexpressing mice and wild-type littermates (n = 8–12 per group) showed that transgenic animals were protected with reduced LV/TL ratio compared to wild-type animals and maintenance of the diastolic index. This study demonstrates that MRI allows a precocious detection of the subtle myocardial dysfunction induced by β1-aabs and that β3-AR stimulation blunts the development of β1-aabs-induced DCM, thereby paving the way for the use of β3AR-stimulating drugs to treat this autoimmune cardiomyopathy.

Diagnostic approaches for diabetic cardiomyopathy

Diabetic cardiomyopathy (DCM) is a cardiac dysfunction which affects approximately 12% of diabetic patients, leading to overt heart failure and death. However, there is not an efficient and specific methodology for DCM diagnosis, possibly because molecular mechanisms are not fully elucidated, and it remains asymptomatic for many years. Also, DCM frequently coexists with other comorbidities such as hypertension, obesity, dyslipidemia, and vasculopathies. Thus, human DCM is not specifically identified after heart failure is established. In this sense, echocardiography has been traditionally considered the gold standard imaging test to evaluate the presence of cardiac dysfunction, although other techniques may cover earlier DCM detection by quantification of altered myocardial metabolism and strain. In this sense, Phase-Magnetic Resonance Imaging and 2D/3D-Speckle Tracking Echocardiography may potentially diagnose and stratify diabetic patients. Additionally, this information could be completed with a quantification of specific plasma biomarkers related to related to initial stages of the disease. Cardiotrophin-1, activin A, insulin-like growth factor binding protein-7 (IGFBP-7) and Heart fatty-acid binding protein have demonstrated a stable positive correlation with cardiac hypertrophy, contractibility and steatosis responses. Thus, we suggest a combination of minimally-invasive diagnosis tools for human DCM recognition based on imaging techniques and measurements of related plasma biomarkers.

3D Real-Time Echocardiography Combined with Mini Pressure Wire Generate Reliable Pressure-Volume Loops in Small Hearts

BACKGROUND

Pressure-volume loops (PVL) provide vital information regarding ventricular performance and pathophysiology in cardiac disease. Unfortunately, acquisition of PVL by conductance technology is not feasible in neonates and small children due to the available human catheter size and resulting invasiveness. The aim of the study was to validate the accuracy of PVL in small hearts using volume data obtained by real-time three-dimensional echocardiography (3DE) and simultaneously acquired pressure data.

METHODS

In 17 piglets (weight range: 3.6-8.0 kg) left ventricular PVL were generated by 3DE and simultaneous recordings of ventricular pressure using a mini pressure wire (PVL3D). PVL3D were compared to conductance catheter measurements (PVLCond) under various hemodynamic conditions (baseline, alpha-adrenergic stimulation with phenylephrine, beta-adrenoreceptor-blockage using esmolol). In order to validate the accuracy of 3D volumetric data, cardiac magnetic resonance imaging (CMR) was performed in another 8 piglets.

RESULTS

Correlation between CMR- and 3DE-derived volumes was good (enddiastolic volume: mean bias -0.03ml ±1.34ml). Computation of PVL3D in small hearts was feasible and comparable to results obtained by conductance technology. Bland-Altman analysis showed a low bias between PVL3D and PVLCond. Systolic and diastolic parameters were closely associated (Intraclass-Correlation Coefficient for: systolic myocardial elastance 0.95, arterial elastance 0.93, diastolic relaxation constant tau 0.90, indexed end-diastolic volume 0.98). Hemodynamic changes under different conditions were well detected by both methods (ICC 0.82 to 0.98). Inter- and intra-observer coefficients of variation were below 5% for all parameters.

CONCLUSIONS

PVL3D generated from 3DE combined with mini pressure wire represent a novel, feasible and reliable method to assess different hemodynamic conditions of cardiac function in hearts comparable to neonate and infant size. This methodology may be integrated into clinical practice and cardiac catheterization programs and has the capability to contribute to clinical decision making even in small hearts.

Echocardiographic evaluation of left ventricular diastolic function in cats: Hemodynamic determinants and pattern recognition

Left ventricular (LV) diastolic dysfunction is highly prevalent in cats and is a functional hallmark of feline cardiomyopathy. The majority of cats with hypertrophic, restrictive, and dilated cardiomyopathy have echocardiographic evidence of abnormal LV filling, even during the occult (preclinical) phase. Moderate and severe diastolic dysfunction is an indicator of advanced myocardial disease, is associated with clinical signs including exercise intolerance and congestive heart failure, affects outcome, and influences therapeutic decisions. Therefore, identification and quantification of LV diastolic dysfunction are clinically important. Surrogate measures of diastolic function determined by transthoracic two-dimensional, M-mode, and Doppler echocardiographic (DE) methods have been used widely for such purpose. Major functional characteristics of LV diastole, including global function, relaxation and untwist, chamber compliance, filling volume, and the resultant filling pressures can be semi-quantified by echocardiographic methods, and variables retrieved from transmitral flow, pulmonary vein flow, and tissue Doppler recordings are most frequently used. Although there is still a critical lack of well-designed studies in the field, knowledge has steadily accumulated over the past 20 years, reference ranges of diastolic echocardiographic variables have been determined, epidemiological studies have been conducted, and new treatments of diastolic dysfunction in cats have been evaluated. This report will give the reader a summary of the current status in the field of feline diastology with focus on the noninvasive diagnostic methods and interpretation of echocardiographic surrogate measures of LV diastolic function. Lastly, a grading system using a composite of left atrial size and various DE variables potentially useful in the functional classification of LV diastole in cats is introduced.

Diastolic dysfunction measured by cardiac magnetic resonance imaging in women with signs and symptoms of ischemia but no obstructive coronary artery disease

BACKGROUND

Women with chest pain and no obstructive coronary artery disease often have coronary microvascular dysfunction (CMD), diagnosed by invasive coronary reactivity testing (CRT). The relationship between CMD and diastolic function measured by cardiac magnetic resonance imaging (CMR) is not well described.

METHODS

41 women with suspected CMD underwent CRT and CMR. Left ventricular end-diastolic pressure (LVEDP), coronary flow reserve (CFR) and coronary blood flow (CBF) were measured invasively. Resting CMR of these women and 20 reference controls was assessed for LV mass, septal wall thickness, ejection fraction (LVEF), end-diastolic volume (EDV), peak filling rate (PFR) and time-to-peak-filling rate (tPFR). Pearson correlations and linear regression models were made.

RESULTS

Mean age was 55±9, all had LVEF≥50%, and 16/41 (40%) had LVEDP>15mmHg. CMD (CFR<2.5 or CBF<50%) was present in 34/41 (83%) women. tPFR (mean 178±110ms) and PFR (mean 3.2±0.64 EDV/s) were not significantly different in women with or without CMD. tPFR increased with age (r=0.37, p=0.017) and septal wall thickness (r=0.47, p=0.002), while PFR decreased with age (r=-0.45, p=0.003). There was an inverse relationship between CFR and tPFR (r=-0.3, p=0.058). Increasing mass was associated with decreasing CBF (p=0.02). Compared to controls, cases had lower LVEF (p=0.049) and lower EDV (p=0.0002).

CONCLUSION

In women with signs and symptoms of ischemia but no obstructive coronary artery disease, CMD and elevated LVEDP are prevalent. While non-endothelial dependent CMD may be related to diastolic dysfunction, further investigation is needed regarding links between CMD, diastolic dysfunction and the development of heart failure with preserved LVEF.

Improved diastolic function in type 2 diabetes after a six month liraglutide treatment

AIMS

To investigate whether liraglutide improves diastolic function in type 2 diabetes.

METHODS

Thirty-seven patients with type 2 diabetes who began liraglutide therapy between June 2013 and May 2014 were enrolled in this observational, prospective study. 26 patients received liraglutide therapy for at least 6months. The remaining 11 patients withdrew from liraglutide therapy during the first month, were started on other hypoglycaemic therapies and formed the control group. Anthropometric, metabolic and echocardiographic parameters including pulsed wave tissue Doppler imaging were evaluated at baseline and at 6months.

RESULTS

In the liraglutide group the early diastolic mitral annulus velocity on the lateral (e-lat) and medial (e-med) sides of the mitral annulus increased from 9.2±3.4 to 11.6±4.7cm/s (p<0.001) and from 6.9±1.7 to 8.4±2.6cm/s (p<0.003), respectively. The ratio of early-to-late velocities on the lateral and medial sides of the mitral annulus increased from 0.7±0.3 to 0.9±0.4 (p<0.001) and from 0.5±0.1 to 0.6±0.1 (p<0.02), respectively. The ratio of early diastolic mitral inflow velocity to early diastolic myocardial relaxation velocity decreased from 10.7±4.3 to 8.5±2.5 (p<0.005). No improvements in diastolic function was detected in the control group. Glucose control improved similarly in both groups: HA1bc -1.5% (-17mmol/mol) vs -1.3% (-14mmol/mol), p=0.67.

CONCLUSIONS

In patients with type 2 diabetes, 6months liraglutide treatment was associated with a significant improvement in diastolic function.

Assessing the Value of BMI and Aerobic Capacity as Surrogate Markers for the Severity of Left Ventricular Diastolic Dysfunction in Patients with Type 2 Diabetes Who Are Obese

Left ventricular diastolic dysfunction (LVDD) is one of the earliest signs for abnormal cardiac function in patients with type 2 diabetes (T2DM). It is important to explore the risk factors that will assist in identifying the severity of the LVDD in this population. We examined the influences of fitness and fatness on the level of left ventricular (LV) impairment in patients with T2DM. Twenty-five patients (age: 64.0 ± 2.5 years, body mass index [BMI] = 36.0 ± 1.5 kg/m(2), mean ± standard error of measurement) with T2DM and preserved systolic function, but impaired diastolic function, mitral valve (MV) E/e', participated in the study. LV function was assessed using a stress echocardiograph, aerobic power was assessed with a sign- and symptom-limited graded exercise test, and the fatness level was assessed using Dual-energy X-ray absorptiometry and BMI. Patients in the higher 50% of BMI had higher lateral and septal MV E/e' (∼34% and ∼25%, respectively, both P < 0.001), compared to those in the lower 50% of BMI, with no difference in LV ejection fraction (LVEF) (P > 0.05). In addition, a higher BMI correlated with a higher lateral (r = 0.62, P < 0.001) and septal (r = 0.56, P < 0.01) E/e'. There was no such relationship for VO2peak. BMI and VO2peak were not correlated with LV systolic function (ejection fraction). In individuals with T2DM and diastolic dysfunction, a higher BMI was associated with worsening diastolic function independent of their aerobic capacity. The data provide a simple and practical approach for clinicians to assist in the early identification and diagnostics of functional changes in the heart diastolic function in this population.

The Impact of Race on the Prognosis of Preclinical Diastolic Dysfunction: A Large Multiracial Urban Population Study

BACKGROUND

This study was performed to assess the impact of race on the incidence of heart failure and survival in patients with preclinical diastolic dysfunction.

METHODS

All adults during a 5-year period with grade 1 diastolic dysfunction on echocardiogram, left ventricular ejection fraction ≥ 50%, and no diagnosis of heart failure were included in this study. Clinical endpoints were new diagnosis of heart failure (International Classification of Diseases-Ninth Revision code 428.0) and all-cause mortality. A total of 7878 patients: 20.8% non-Hispanic White, 35.8% non-Hispanic Black, and 31.0% Hispanic individuals (mean age was 68 ± 12 years, 37% men) were included in the study. Non-Hispanic Whites were older, more frequently male, and had a higher mean socioeconomic status and more antecedent myocardial infarction.

RESULTS

Non-Hispanic Blacks and Hispanics had more hypertension, diabetes, renal disease, and cerebrovascular disease. After a median follow-up time of 6 years, 1356 patients developed heart failure and 2078 patients died. The 10-year cumulative probabilities of heart failure and all-cause mortality were 23.9% and 32.6%, respectively. Time to incident heart failure was similar among the 3 racial groups. However, non-Hispanic Blacks (hazard ratio 0.80, P = .002) and Hispanics (hazard ratio 0.67, P < .001) experienced lower mortality compared with non-Hispanic Whites, which was confirmed on a propensity-scored sensitivity analysis.

CONCLUSIONS

Time to heart failure was similar among the 3 racial groups, however, non-Hispanic Whites experienced worse survival compared with non-Hispanic Blacks and Hispanics, despite their higher burden of risk factors. The reasons for worse survival in the non-Hispanic white population need to be further explored.

A Novel Integrated Score Index of Echocardiographic Indices for the Evaluation of Left Ventricular Diastolic Function

Background

We propose a novel integrated score index, which could be used to quantify and grade left ventricular (LV) diastolic function.

Methods

We enrolled 629 participants [393 healthy subjects, 145 with hypertension (HTN), 24 with hypertrophic cardiomyopathy (HCM), and 67 with coronary artery disease (CAD)]. This score index was with a score of 1 for an E/A ratio < 1, a score of 1 for a septal e’/a’ ratio ≤ 0.8, a score of 2 for a lateral e’/a’ ratio ≤ 1, a score of 2 for a septal E/e’ ratio ≥10–15, a score of 3 for a lateral E/e’ ratio ≥8–15, and a score of 1 for a deceleration time >240 ms. The sum of each score was considered as the final value in this scoring method (either a septal or a lateral E/e’ ratio > 15 was given a total score of 10, regardless of the other measurements).

Results

After analysis, the AUROC of this integrated score index for predicting any diastolic dysfunction (discriminated by the American Society of Echocardiography guidelines) was 0.962, and the AUROC of the method from the logistic regression was 0.970. The mean values of the score index for the groups were 3.81 ± 0.12 in healthy, 6.48 ± 0.19 in HTN, 7.35 ± 0.46 in HCM, and 6.62 ± 0.29 in CAD. Using the score index, the healthy subjects obtained lower scores compared with those of HTN (p = 0.00), HCM (p = 0.00), and CAD (p = 0.00). Therefore, this score index could discriminate patients with diseases with impaired diastolic function from the healthy subjects when the total sum of the score was equal to or greater than 4.

Conclusions

If the presently used methods cannot allow the clear diagnosis of LV diastolic dysfunction, this integrated score index might be helpful for discriminating diseases with impaired diastolic function.

Can emergency physicians diagnose and correctly classify diastolic dysfunction using bedside echocardiography?

OBJECTIVES

The goal of this study was to determine if emergency physicians (EPs) can correctly perform a bedside diastology examination (DE) and correctly grade the level of diastolic function with minimal additional training in echocardiography beyond what is learned in residency. We hypothesize that EPs will be accurate at detecting and grading diastolic dysfunction (DD) when compared to a criterion standard interpretation by a cardiologist.

METHODS

We conducted a prospective, observational study on a convenience sample of adult patients who presented to an urban emergency department with a chief concern of dyspnea. All patients had a bedside echocardiogram, including a DE, performed by an EP-sonographer who had 3 hours of didactic and hands-on echocardiography training with a cardiologist. The DE was interpreted as normal, grade 1 to 3 if DD was present, or indeterminate, all based on predefined criteria. This interpretation was compared to that of a cardiologist who was blinded to the EPs' interpretations.

RESULTS

We enrolled 62 patients; 52% had DD. Using the cardiology interpretation as the criterion standard, the sensitivity and specificity of the EP-performed DE to identify clinically significant diastolic function were 92% (95% confidence interval [CI], 60-100) and 69% (95% CI, 50-83), respectively. Agreement between EPs and cardiology on grade of DD was assessed using κ and weighted κ: κ = 0.44 (95% CI, 0.29-0.59) and weighted κ = 0.52 (95% CI, 0.38-0.67). Overall, EPs rated 27% of DEs as indeterminate, compared with only 15% by cardiology. For DEs where both EPs and cardiology attempted an interpretation (indeterminates excluded) κ = 0.45 (95% CI, 0.26 to 0.65) and weighted κ = 0.54 (95% CI, 0.36-0.72).

CONCLUSION

After limited diastology-specific training, EPs are able to accurately identify clinically significant DD. However, correct grading of DD, when compared to a cardiologist, was only moderate, at best. Our results suggest that further training is necessary for EPs to achieve expertise in grading DD.

The (dys)functional extracellular matrix

The extracellular matrix (ECM) is a major component of the biomechanical environment with which cells interact, and it plays important roles in both normal development and disease progression. Mechanical and biochemical factors alter the biomechanical properties of tissues by driving cellular remodeling of the ECM. This review provides an overview of the structural, compositional, and mechanical properties of the ECM that instruct cell behaviors. Case studies are reviewed that highlight mechanotransduction in the context of two distinct tissues: tendons and the heart. Although these two tissues demonstrate differences in relative cell-ECM composition and mechanical environment, they share similar mechanisms underlying ECM dysfunction and cell mechanotransduction. Together, these topics provide a framework for a fundamental understanding of the ECM and how it may vary across normal and diseased tissues in response to mechanical and biochemical cues. This article is part of a Special Issue entitled: Mechanobiology.

Effects of alcohol septal ablation on left ventricular diastolic filling patterns in obstructive hypertrophic cardiomyopathy

Alcohol septal ablation (ASA) has been shown to improve left ventricular (LV) diastolic function in patients with obstructive hypertrophic cardiomyopathy (HCM). However, its beneficial effect on diastolic function assessed by cardiac magnetic resonance (CMR) has not been reported. We investigated the mid-term changes of diastolic function by CMR combined with echocardiography in HCM patients after ASA at a median of 14-month follow-up. CMR parameters of diastolic function including peak filling rate (PFR), and time to peak filling rate (TPFR) were evaluated in 43 patients (aged 48 ± 9 years). LV diastolic function improved significantly measured by echocardiography with the decrease in ratio of transmitral early LV filling velocity (E) to early diastolic mitral lateral annular velocity (E') (14.20 ± 1.17 to 11.58 ± 1.16, p < 0.001) and E-wave deceleration time (194.04 ± 19.30 to 168.45 ± 12.58 ms, p < 0.001). PFR increased significantly with associated decrease in TPFR after ASA (both p < 0.001) at follow-up. Furthermore, patients with larger decrease in LVOT gradients had a greater improvement of LV diastolic function, as measured by the reduction of E/E' (p < 0.001) and increase of PFR (p < 0.001). In conclusion, this study demonstrated that successful ASA results in both echocardiographic and CMR indices of diastolic function improvement after ASA at 14-month follow-up. ASA therapy can significantly reduce LVOT gradient and mitral regurgitation, both of which may contribute to the improvement of diastolic function.

Assessment of atrial diastolic function in patients with hypertrophic cardiomyopathy by cine magnetic resonance imaging

PURPOSE

This study was conducted to assess the role of atrial function by cardiac magnetic resonance (CMR) for the evaluation of diastolic physiology in patients with hypertrophic cardiomyopathy (HCM) compared to healthy controls.

MATERIALS AND METHODS

We enrolled 23 consecutive patients affected by HCM and 43 healthy subjects as age-matched control cases (CC). CMR was performed through acquisition of cine steady-state free precession sequences using a 1.5-T scanner. Image postprocessing was carried out using Tracking Tool software.

RESULTS

Atrial volumes were significantly higher in patients with HCM compared to CC: maximum atrial volume (p = 0.007) and minimum atrial volume (p = 0.01). A statistically significant difference was also observed in atrial ejection fraction in patients with HCM (p < 0.0001). The atrial volume curves defined as cavity volume over time (dV/t) showed significant differences: early atrial peak emptying rate (PERE) (maximum rate of emptying independent of atrial contraction) in HCM was -146 ± 53 ml/s versus -227 ± 86 ml/s in CC (p < 0.0001); active atrial peak emptying rate (PERA) (maximum rate of emptying secondary to atrial contraction) in HCM was -256 ± 80 ml/s versus -216 ± 104 ml/s in CC (p = 0.05); the atrial PER E/A ratio in HCM was 0.6 ± 0.2 versus 1.05 ± 0.5 in CC (p < 0.0001).

CONCLUSIONS

This study demonstrated that in HCM patients with early diastolic dysfunction the parameters of left atrial function assessed by CMR are impaired before the ventricular diastolic indexes such as the early peak filling rate and the active peak filling rate.

Diastolic dysfunction

Despite the growing number of patients affected, the understanding of diastolic dysfunction and heart failure with preserved ejection fraction (HFpEF) is still poor. Clinical trials, largely based on successful treatments for systolic heart failure, have been disappointing, suggesting that HFpEF has a different pathology to that of systolic dysfunction. In this review, general concepts, epidemiology, diagnosis, and treatment of diastolic dysfunction are summarized, with an emphasis on new experiments suggesting that oxidative stress plays a crucial role in the pathogenesis of at least some forms of the disease. This observation has lead to potential new diagnostics and therapeutics for diastolic dysfunction and heart failure caused by diastolic dysfunction.

Diagnosing acute heart failure in patients with undifferentiated dyspnea: a lung and cardiac ultrasound (LuCUS) protocol

OBJECTIVES

The primary goal of this study was to determine accuracy for diagnosing acutely decompensated heart failure (ADHF) in the undifferentiated dyspneic emergency department (ED) patient using a lung and cardiac ultrasound (LuCUS) protocol. Secondary objectives were to determine if US findings acutely change management and if findings are more accurate than clinical gestalt.

METHODS

This was a prospective, observational study of adult patients presenting to the ED with undifferentiated dyspnea. The intervention consisted of a 12-view LuCUS protocol performed by experienced emergency physician sonographers. The primary objective was measured by comparing US findings to the final diagnosis independently determined by two physicians blinded to the LuCUS result. Acute treatment changes based on US findings were tracked in real time through a standardized data collection form.

RESULTS

Data on 99 patients were analyzed; ADHF was the final diagnosis in 36%. The LuCUS protocol had sensitivity of 83% (95% confidence interval [CI] = 67% to 93%), specificity of 83% (95% CI = 70% to 91%), positive likelihood ratio of 4.8 (95% CI = 2.7 to 8.3), and negative likelihood ratio of 0.20 (95% CI = 0.09 to 0.42). Forty-seven percent of patients had changes in acute management, and 42% had changes in acute treatment. Observed agreement for the LuCUS protocol was 93% between coinvestigators. Overall, accuracy improved by 20% (83% vs. 63%, 95% CI = 8% to 31% for the difference) over clinical gestalt alone.

CONCLUSIONS

The LuCUS protocol may accurately identify ADHF and may improve acute clinical management in dyspneic ED patients. This protocol has improved diagnostic accuracy over clinical gestalt alone.

Human internal jugular valve M-mode ultrasound characterization

In humans the mechanism governing the internal jugular vein (IJV) valve opening and closure is still unclear. M-mode is used in echo-cardiology for the heart valves assessment. Sometimes it was performed also in deep peripheral veins and in vena cava assessment, but never in the IJV valve. Aim of the present study is to investigate the IJV valves physiology in healthy volunteers, by means of both B and M-mode ultrasound.

Eighty-three (83) healthy volunteers (35 Male, 48 Female, 25.7±6.7 y.o.), for a total of 166 IJVs, were enrolled. The entire cohort underwent IJVs high-resolution B and M-mode evaluation, in standardized postural and respiratory conditions. Presence, motility, and number of cusps, as well as their opening and closure mechanism have been assessed.

Bilateral valve absence occurred in 13/83 (16%), whereas at least a one side absence was recorded in 38/83 (46‰ of the cohort) (p<0.0356). Valve leaflets were always mobile and respectively bi-cusps in 34%, or mono-cusp in 27%. The latter was significantly more frequent on the left side (35%) than on the right side (19%) (p<0.0013).

In supine, M-mode valve opening was synchronous with the cardiac cycle.

To the contrary, in an upright position, the valve remained always open and saddled to the wall, independently from the cardiac cycle.

In healthy subjects, the IJV valve leaflets are always mobile, but the significant rate of mono and bilateral absence could suggest a progressive phylogenetic importance loss of such apparatus. M-mode ultrasound enhances the characterization of IJV valve, for this reason it should be taken into consideration to routinely add it to the cerebral venous return investigation.

The Valsalva maneuver can misdiagnose 'normal' as 'pseudonormal': a word of caution for an echocardiographic evaluation of diastolic function

OBJECTIVES

To identify differences in cardiac hemodynamic changes between the Valsalva maneuver and nitroglycerin (NTG) administration.

METHODS

Fifty-three subjects (37 men, 43 ± 12 years) with normal cardiac function [left ventricular ejection fraction ≥55%, early to late mitral inflow velocity ratio (E/A) ≥1, left atrial volume index ≤34 ml/m(2) and early diastolic mitral annulus velocity (E') ≥8 cm/s] were enrolled. Doppler parameters were determined at rest, during the Valsalva maneuver and after NTG administration.

RESULTS

Decreased E, A and E/A were observed both during the Valsalva maneuver and after NTG administration (p < 0.0001 for all). However, the reduction in E (ΔEValsalva: -30 ± 16 cm/s vs. ΔENTG: -17 ± 17 cm/s) and E/A (ΔE/AValsalva: -0.37 ± 0.28 vs. ΔE/ANTG: -0.19 ± 0.25) and the prolongation of the deceleration time (DT) of E (ΔDTValsalva: 105 ± 74 ms vs. ΔDTNTG: 83 ± 63 ms) were more prominent during the Valsalva maneuver than with NTG administration (p < 0.0001 for all). Particularly, a greater decrease in E' was observed during the Valsalva maneuver (ΔE'Valsalva: -3 ± 2 cm/s vs. ΔE'NTG: -2 ± 2 cm/s, p < 0.0001). Eighteen subjects (34%) showed ΔE/A ≥0.5 during the Valsalva maneuver; thus, they were mislabeled as 'pseudonormal', while only 3 subjects (6%) showed ΔE/A ≥0.5 after NTG administration.

CONCLUSIONS

The Valsalva maneuver not only decreases preload but also affects myocardial performance, thus, its use can result in the mislabeling of normal subjects as pseudonormal.

Diastolic function assessed by cardiac MRI using longitudinal left ventricular fractional shortening

INTRODUCTION

Diastolic dysfunction contributes significantly to diastolic heart failure. We examined the use of cardiac magnetic resonance imaging (CMR) using midwall longitudinal fractional shortening (MLFS) in the evaluation of transthoracic echocardiogram (TTE)-evidenced diastolic dysfunction.

METHODS

A total of 80 patients with CMR within 6 months of TTE and normal ejection fraction were identified. MLFS was calculated as percentage change in distance from the anterior mitral leaflet base to the apical endocardium in systole and diastole.

RESULTS

MLFS of grade II/III [0.14 (0.12-0.16)] was significantly lower than that of grade 0/I [0.20 (0.19-0.21)], P=.001. MLFS detected age-related changes with grade 0 [0.22 (0.21-0.23)] significantly lower than grade I [0.18 (0.16-0.20)], P=.001.

CONCLUSION

TTE-evidenced diastolic dysfunction can be reliably identified by CMR using MLFS.

Regular cocaine use is associated with increased systolic blood pressure, aortic stiffness and left ventricular mass in young otherwise healthy individuals

BACKGROUND

The cardiovascular impact of cocaine use in otherwise healthy individuals who consider themselves 'social' users is not well established.

METHODS/RESULTS

Twenty regular cocaine users and 20 control subjects were recruited by word-of-mouth. Cardiovascular magnetic resonance was performed to assess cardiac and vascular structure and function. Cocaine users had higher systolic blood pressure compared to non-users (134±11 vs 126±11 mmHg, p = 0.036), a finding independent of age, body surface area, smoking and alcohol consumption. Cocaine use was associated with increased arterial stiffness - reflected by reduced aortic compliance (1.3±0.2 vs 1.7±0.5 cm2×10-2.mmHg-1, p = 0.004), decreased distensibility (3.8±0.9 vs 5.1±1.4 mmHg-1.10-3, p = 0.001), increased stiffness index (2.6±0.6 vs 2.1±0.6, p = 0.005), and higher pulse wave velocity (5.1±0.6 vs 4.4±0.6 m.s-1, p = 0.001). This change in aortic stiffness was independent of vessel wall thickness. Left ventricular mass was 18% higher in cocaine users (124±25 vs 105±16 g, p = 0.01), a finding that was independent of body surface area, and left atrial diameter was larger in the user group than controls (3.8±0.6 vs 3.5±0.3 cm, p = 0.04). The increased left ventricular mass, systolic blood pressure and vascular stiffness measures were all associated with duration and/or frequency of cocaine use. No late gadolinium enhancement or segmental wall motion abnormalities were seen in any of the subjects.

CONCLUSIONS

Compared with the non-user control cohort, cocaine users had increased aortic stiffness and systolic blood pressure, associated with greater left ventricular mass. These measures are all well known risk factors for premature cardiovascular events, highlighting the dangers of cocaine use, even in a 'social' setting, and have important public health implications.

Ventricular performance after surgery for a congenital heart defect as assessed using advanced echocardiography: from doppler flow to 3D echocardiography and speckle-tracking strain imaging

A varying degree of impairment of ventricular performance is observed over the long-term after surgery for a congenital heart defect (CHD). Impaired ventricular performance has been shown to be of prognostic value for increased risk of cardiovascular events in adult CHD patients. This emphasizes the importance of delineating the timing and cause of this postoperative impairment. Impairment of ventricular performance could develop over time as a consequence of residua, sequelae and complications of the CHD or surgical procedure. Yet, impaired ventricular performance has also been observed immediately after surgery and can persist and/or worsen over time. This postoperative impairment of ventricular performance is the focus of this review. This article provides an overview of echocardiographic techniques currently used to assess ventricular performance. Furthermore, we review current literature describing ventricular performance, as assessed using echocardiography, after correction of a CHD. In general, a decrease in ventricular performance is observed directly after surgery for CHD’s. Subsequent follow-up of ventricular performance is characterized by a varying degree of postoperative recovery. A consistent observation is the persistent impairment of right-ventricular performance after repair in several different subgroups of CHD patients ranging from ventricular septal defect repair to surgery for Tetralogy of Fallot.

Predictors and outcomes of infection-related hospital admissions of heart failure patients

Background

Infections are one of the most common causes for hospitalization of patients with heart failure (HF). Yet, little is known regarding the prevalence and predictors of different types of acute infections as well as their impact on outcome among this growing population.

Methods and Results

We identified all patients aged 50 or older with a major diagnosis of HF and at least one echocardiography examination who had been hospitalized over a 10-year period (January 2000 and December 2009). Infection-associated admissions were identified according to discharge diagnoses. Among 9,335 HF patients, 3530 (38%) were hospitalized at least once due to infections. The most frequent diagnoses were respiratory infection (52.6%) and sepsis/bacteremia (23.6%) followed by urinary (15.7%) and skin and soft tissue infections (7.8%). Hospitalizations due to infections compared to other indications were associated with increased 30-day mortality (13% vs. 8%, p<0.0001). These higher mortality rates were predominately related to respiratory infections (OR 1.28 [95% CI 1.09, 1.5]) and sepsis\bacteremia (OR 3.13 [95% CI 2.6, 3.7]). Important predictors for these serious infections included female gender, chronic obstructive pulmonary disease, past myocardial infarction and echocardiography-defined significant right (RV) but not left ventricular dysfunction.

Conclusions

Major infection-related hospitalizations are frequent among patients with HF and are associated with increased mortality rates. Elderly female patients with multiple comorbidities and those with severe RV dysfunction are at higher risk for these infections.

The late effects of anticancer therapy after childhood Wilm's tumor: the role of diastolic function and ambulatory blood pressure monitoring

OBJECTIVE

Wilms' tumor, or nephroblastoma, is the most common primary malignant renal tumor of childhood. The excellent outcome now expected for most children with this tumor is attributed to the combination of effective adjuvant chemotherapy, improved surgical and anesthetic techniques and also the radiosensitivity of the tumor. The numerous organ systems are subject to the late effects of anticancer therapy. The aim of this study was to investigate the blood pressure profile and ambulatory blood pressure monitoring, and also cardiac diastolic functions and pulmonary venous flow in 25 children with unilateral Wilms' tumor in remission.

METHODS

The patient group consists of 25 patients who successfully completed anticancer treatment for unilateral Wilms' tumor. Thirty-three age-, weight- and height-matched healthy children were considered as a control group for an echocardiographic study. Also, 20 age-, weight- and height-matched healthy children were considered as a control group for the ambulatory blood pressure monitoring study.

RESULTS

In our study, 24 h, daytime and night-time systolic blood pressure and night-time diastolic blood pressure measurements were found to be significantly increased in the patient group compared with healthy children. We detected diastolic filling pattern abnormalities. We also found increase in pulmonary venous flow (systolic and diastolic) in Wilms' tumor group.

CONCLUSIONS

We suggest the regular follow-up of survivors of Wilms' tumor for care and prevention of cardiovascular diseases.

Gender-related differences in hospitalized heart failure patients

AIMS

The burden of heart failure (HF)-related hospitalization and mortality of female patients with HF is substantial. Currently, several gender-specific distinctions have been recognized amongst HF patients, but their relationships to outcomes have not been fully elucidated. Accordingly, in the current work, we aimed to explore gender-specific clinical and echocardiographic measures and to assess their potential impact on outcome.

METHODS AND RESULTS

We studied all consecutive HF patients, aged 50 or older, who had been hospitalized between January 2000 and December 2009, and had undergone at least one echocardiography study. A comparative analysis of clinical and echocardiographic findings was performed between 5228 males and 4107 females. Patients were followed for a mean of 2.8 ± 2.6 years. Females compared with males had less ischaemic heart disease, prior stroke, chronic renal failure, and COPD, and higher rates of hypertension, AF, obesity, valvular abnormalities, and pulmonary hypertension. Unadjusted 30-day and 1-year mortality rates were higher among women, while age-adjusted rates were similar. Predictors of outcomes varied between genders. Female-specific predictors of mortality included aortic stenosis, pulmonary hypertension, and malignancy, whereas diastolic dysfunction and chronic renal failure were found to be male-specific predictors.

CONCLUSIONS

Age-adjusted mortality rates of male and female hospitalized HF patients are similarly high. Predictors of mortality, however, are gender distinctive, and these measures may allow a better identification of high-risk HF patients.

An update on diastolic dysfunction

Diastolic dysfunction refers to abnormal diastolic filling properties of the left ventricle regardless of whether systolic function is normal or the patient has symptoms. Diastolic heart failure (HF), or more accurately, HF with preserved systolic function, is a distinct clinical entity characterized by the presence of the triad of impaired diastolic function, normal systolic function (left ventricular ejection fraction > 50%), and symptoms of HF. Patients with HF with preserved systolic function are frequently symptomatic from both acute and chronic elevations in left ventricular end-diastolic pressure and/or left atrial pressure.

Overweight female rats selectively breed for low aerobic capacity exhibit increased myocardial fibrosis and diastolic dysfunction

The statistical association between endurance exercise capacity and cardiovascular disease suggests that impaired aerobic metabolism underlies the cardiovascular disease risk in men and women. To explore this connection, we applied divergent artificial selection in rats to develop low-capacity runner (LCR) and high-capacity runner (HCR) rats and found that disease risks segregated strongly with low running capacity. Here, we tested if inborn low aerobic capacity promotes differential sex-related cardiovascular effects. Compared with HCR males (HCR-M), LCR males (LCR-M) were overweight by 34% and had heavier retroperitoneal, epididymal, and omental fat pads; LCR females (LCR-F) were 20% heavier than HCR females (HCR-F), and their retroperitoneal, but not perireproductive or omental, fat pads were heavier as well. Unlike HCR-M, blood pressure was elevated in LCR-M, and this was accompanied by left ventricular (LV) hypertrophy. Like HCR-F, LCR-F exhibited normal blood pressure and LV weight as well as increased spontaneous cage activity compared with males. Despite normal blood pressures, LCR-F exhibited increased myocardial interstitial fibrosis and diastolic dysfunction, as indicated by increased LV stiffness, a decrease in the initial filling rate, and an increase in diastolic relaxation time. Although females exhibited increased arterial stiffness, ejection fraction was normal. Increased interstitial fibrosis and diastolic dysfunction in LCR-F was accompanied by the lowest protein levels of phosphorylated AMP-actived protein kinase [phospho-AMPK (Thr(172))] and silent information regulator 1. Thus, the combination of risk factors, including female sex, intrinsic low aerobic capacity, and overweightness, promote myocardial stiffness/fibrosis sufficient to induce diastolic dysfunction in the absence of hypertension and LV hypertrophy.

Diagnostic accuracy of NT-proBNP ratio (BNP-R) for early diagnosis of tachycardia-mediated cardiomyopathy: a pilot study

BACKGROUND

When heart failure and tachycardia occur simultaneously, a useful diagnostic tool for early discrimination of patients with benign tachycardia-mediated cardiomyopathy (TMC) versus major structural heart disease (MSHD) is not available. Such a tool is required to prevent unnecessary and wearing diagnostics in patients with reversible TMC. Moreover, it could lead to early additional diagnostics and therapeutic approaches in patients with MSHD.

METHODS

A total of 387 consecutive patients with supraventricular arrhythmia underwent assessment at a single center. Of these patients, 40 fulfilled the inclusion criteria with a resting heart rate ≥100 bpm and an impaired left ventricular ejection fraction <40%. In all patients, successful electrical cardioversion was performed. At baseline, day 1 and weekly for 4 weeks, levels of NT-proBNP and echocardiographic parameters were evaluated. An NT-proBNP ratio (BNP-R) was calculated as a quotient of baseline NT-proBNP/follow-up NT-proBNP. After 4 weeks, cardiac catheterization was performed to identify patients with a final diagnosis of TMC versus MSHD.

RESULTS

Initial NT-proBNP concentrations were elevated and consecutively decreased after cardioversion in all patients. Multivariate regression and ROC analysis revealed that BNP-R discriminated between patients with TMC versus MSHD independent and superior to all other variables. The area under the ROC curve for BNP-R to detect TMC was 0.90 (95% CI 0.79-1.00; p < 0.001) after 1 week and 0.995 (95% CI 0.99-1.00; p < 0.0001) after 4 weeks. One week after cardioversion already, a BNP-R cutoff ≥2.3 was useful for TMC diagnosis indicated by an accuracy of 90%, sensitivity of 84% and specificity of 95%.

CONCLUSION

BNP-R was found to be highly accurate for the early diagnosis of TMC.