Echocardiography in the Era of Obesity

Obesity and Risk of Incident Left Ventricular Hypertrophy in Community-Dwelling Populations With Hypertension: An Observational Study

BACKGROUND

The aim of this study was to evaluate the association between obesity and risk of incident left ventricular hypertrophy (LVH) in community-dwelling populations with hypertension and investigate whether this association would be attenuated by a lower achieved systolic blood pressure (SBP).

METHODS AND RESULTS

We used the EMINCA (Echocardiographic Measurements in Normal Chinese Adults) criteria, which were derived from healthy Chinese populations to define LVH. A total of 2069 participants with hypertension and without LVH (obesity 20.4%) were included. The association between obesity and risk of incident LVH was evaluated using Cox proportional hazard models and stratified by achieved follow-up SBP levels (≥140, 130-139, and <130 mm Hg). These analyses were also assessed using the American Society of Echocardiography/European Association of Cardiovascular Imaging criteria, which were derived from European populations to define LVH. After a median follow-up of 2.90 years, the rates of incident LVH in the normal-weight, overweight, and obese groups were 13.5%, 20.3%, and 27.8%, respectively (P<0.001). In reference to normal weight, obesity was associated with increased risk of incident LVH (adjusted hazard ratio [aHR], 2.51 [95% CI, 1.91-3.29]), which was attenuated when achieved SBP was <130 mm Hg (aHR, 1.78 [95% CI, 0.99-3.19]). This association remained significant when achieved SBP was ≥140 mm Hg (aHR, 3.45 [95% CI, 2.13-5.58]) or at 130 to 139 mm Hg (aHR, 2.32 [95% CI, 1.23-4.36]). Differences in these findings were noted when LVH was defined by the American Society of Echocardiography/European Association of Cardiovascular Imaging criteria.

CONCLUSIONS

Obesity was associated with incident LVH and an SBP target <130 mm Hg might be needed to attenuate this risk in patients with hypertension and obesity.

Echocardiography as a Vital Tool in Assessing Shock: A Comprehensive Review

Shock is a critical condition characterized by inadequate tissue perfusion, leading to cellular hypoxia and organ dysfunction. Early and accurate assessment is crucial for timely intervention and improved patient outcomes. Echocardiography has emerged as a vital tool in the assessment of shock, offering real-time visualization of cardiac anatomy, function, and hemodynamics. This comprehensive review aims to elucidate the role of echocardiography in shock assessment by providing an overview of its principles, techniques, and clinical applications. We discuss the importance of early diagnosis, identification of underlying pathology, monitoring response to therapy, and prognostic value offered by echocardiography in managing shock. Furthermore, we explore its utility in different types of shock, including hypovolemic, cardiogenic, distributive, and obstructive shock. Challenges and limitations of echocardiography, as well as future directions and innovations, are also discussed. Through a synthesis of current evidence and clinical insights, this review underscores the significance of echocardiography in optimizing shock management and highlights areas for further research and development.

The weight of obesity in hypertrophic cardiomyopathy

Hypertrophic cardiomyopathy is one of the most frequently diagnosed primary conditions of the heart muscle. It is considered to be inherited, caused by genetic mutations encoding for sarcomere proteins. The marked heterogeneity in clinical manifestations and natural course of the disease, even among family members sharing the same genetic mutation, has raised the question of non-genetic environmental factors contributing to the phenotype. Obesity has been associated with worse cardiovascular outcomes in the general population. Its prevalence is increased in hypertrophic cardiomyopathy, and the two conditions share some similar pathophysiological and clinical characteristics. In this review, we aim to summarise the effects of obesity in the cardiac phenotype, the symptoms and management in patients with hypertrophic cardiomyopathy.

Role of Echocardiography in Diabetic Cardiomyopathy: From Mechanisms to Clinical Practice

It has been well established that diabetes mellitus (DM) is considered as a core risk factor for the development of cardiovascular diseases. However, what is less appreciated is the fact that DM may affect cardiac function irrespective of cardiac pathologies to which it contributes, such as coronary artery disease and hypertension. Although echocardiography provides accurate and reproducible diagnostic and prognostic data in patients with DM, its use in these patients is still underappreciated, resulting in progression of DM-related heart failure in many patients. Hence, in the present review, we aimed to discuss the role of echocardiography in the contemporary management of diabetic cardiomyopathy (DCM), as well as the role of emerging echocardiographic techniques, which may contribute to earlier diagnosis and more appropriate management of this complication of DM. In order to improve outcomes, focus must be placed on early diagnosis of this condition using a combination of echocardiography and emerging biomarkers, but perhaps the more important thing is to change perspective when it comes to the clinical importance of DCM.

Supradiaphragmatic central venous catheter malposition detection using the parasternal long-axis echocardiographic view and dextrose 50% contrast solution: A pilot study

Background

Contrast-enhanced ultrasonography (CEUS) using saline was studied to detect supradiaphragmatic central venous catheter malposition. Commonly used echocardiographic views are apical 4-chamber (A4c) and subcostal views. However, this standard method is not feasible in certain situations. We explored the feasibility of the right ventricle inflow parasternal long axis (RVI-PLAX) echocardiographic view and dextrose 50% (D50%) contrast solution for detecting supradiaphragmatic central venous catheter malposition.

Method

This pilot study screened 60 patients who underwent ultrasound-guided supradiaphragmatic central venous catheter insertion. We compared the investigators' guidewire's J-tip detection, D50% rapid atrial swirl sign (RASS) findings on the RVI-PLAX view and the central venous catheter tip on chest radiograph. We also compared the mean capillary blood sugar level before and after the 5 ml D50% flush.

Results

No guidewire J-tips were detected from the RVI-PLAX view. The first and second investigators' diagnosis of central venous catheter malposition detected on RVI-PLAX CEUS achieved an almost perfect agreement (κ = 1.0 (95% confidence interval (CI): 0.90 to 1.0), p < .0001). The RVI-PLAX CEUS was not able to detect two central venous catheter malpositions (one atrial malposition and one left brachiocephalic vein venous catheter malposition). The capillary blood sugar was significantly elevated (8.96 mmol/L vs. 9.75 mmol/L) after D50% flush (p < 0.005) with no complications reported within 30 minutes after the D50% flush.

Conclusion

RVI-PLAX view should not be used for guidewire detection. CEUS using D50% and RVI-PLAX view are potentially useful tools in detecting central venous catheter malposition. Further studies comparing them with conventional methods are needed.

Comparison of the Quality of Echocardiography Imaging Between the Left Lateral Decubitus and Supine Positions

Introduction It is commonly taught that positioning the patient in the left lateral decubitus (LLD) position will improve transthoracic echocardiography (TTE) image quality. Despite this, no previous studies have been performed that study this practice. Our goal was to quantify the difference in image quality of TTE views between the supine and LLD positions.  Methods This was a prospective study in a single academic Emergency Department (ED) of a convenience sample of 30 patients. Three separate ED physicians performed TTE views in both the supine and LLD position on each patient. The order of position was randomized. Images were then reviewed on a previously validated TTE image quality scale by two blinded ED physicians with specialized training in ultrasound. The scale used a 0 to 5 (highest quality) metric for quality assessment. Interpretability of right ventricular and left ventricular function was also assessed. Results The mean image quality for the supine position was 2.85 (standard deviation {SD} 1.1) and 3.05 (SD 1.2) for the LLD position (p=0.044). In the subset of parasternal and apical windows, the mean quality for the supine position was 2.87 (SD 1.1) and 3.23 (SD 1.1) for the LLD position (p=0.003). The number of studies in which right ventricular function was interpretable was significantly higher in the LLD position (62% versus 42%, p=0.044). Conclusions There was a statistically significant increase in image quality when TTE was performed in the LLD position as compared to supine. This was especially pronounced in the apical four and parasternal windows.

Echocardiographic measurements of the left heart chambers size in a large cohort of subjects: comparison of body surface area and height indexation to account for effects of obesity

BACKGROUND

The assessment of cardiac chamber size in the obese population is a challenging subject. Values usually indexed to body surface area (BSA) are smaller in obese subjects and prone to overcorrection. This study aimed to find reference thresholds to account for effects of obesity from a large cohort of patients and to evaluate the indexation by height as an alternative to BSA.

METHODS

The last 10-years records of our Echocardiography Unit were retrospectively analyzed and 14,007 subjects without known cardiac disease were included (45±15 years, 54% women, 20% obese). Measurements included left atrial diameter, area and volume (LAD, LAA and LAV), left ventricular (LV) end-diastolic (LVEDD) and end-systolic diameters (LVESD), aortic root diameter (ARD) and LV mass (LVM). Absolute, BSA and height indexed maximum thresholds (mean+1.96.SD) were calculated. An allometric indexation of the form variable/Height^β was tested. Correlation coefficients between indexed and absolute values were calculated to evaluate their proportional association (ideally r=1). Correlations between indexed values and body size represented residual associations to be minimized (ideally r=0).

RESULTS

The strongest association of echocardiographic measurements with body size was observed for BSA (r=0.36-0.63), whereas the isometric and allometric height models showed lower comparable values (r=0.28-0.48). Positive correlations with BMI were mostly observed for LA size (r≈0.36) and LVM (r≈0.36) measurements. Scaling exponents β for the allometric height indexation were 1.72 for LAV and 2.33 for LVM. Correlations between indexed and absolute values were higher for height than BSA (0.80-0.98 vs 0.44-0.92). Correlations between indexed values and height were closer to zero than for BSA, particularly using the allometric model. The overcorrection observed with increasing obesity class after BSA indexation was avoided after height indexation.

CONCLUSIONS

Unlike BSA, height indexing provided an adequate body size scaling of left heart chambers size avoiding overcorrection using allometric models in particular.

Transthoracic echocardiography of patients in prone position ventilation during the COVID-19 pandemic: an observational and retrospective study

Mechanical ventilation in prone position is a strategy that increases oxygenation and reduces mortality in severe ARDS. The hemodynamic and cardiovascular assessment of these patients is essential. Transthoracic echocardiography (TTE) is a widely used tool to assess hemodynamics in critical care, but the prone position is thought to limit adequate TTE views and goal-oriented measurements. The aim of this study is to show the feasibility of the hemodynamic assessment by transthoracic echocardiography during prone position ventilation (PPV). This is a retrospective, observational study, carried out in the intensive care unit (ICU) of a tertiary-care center in Buenos Aires, Argentina. We included all the adult patients admitted to the ICU between March 2020 and August 2021 who had a TTE examination in PPV due to ARDS. During the study period, we evaluated by TTE a total of 35 patients requiring PPV. The vast majority of the patients had COVID-19 pneumonia (91.4%). In 33 out of 35 (94.3%) cases, it was able to achieve an adequate apical four chamber view. We assessed qualitatively the systolic function of left ventricle (LV) and right ventricle (RV) in all of the successfully evaluated patients. We measured the RV basal diameter (94.3%), RV/LV ratio (77.1%), tricuspid annular plane systolic excursion (TAPSE) (91.4%), and septal mitral annular plane systolic excursion (MAPSE) (88.5%) in most of them. Also, we quantified the left ventricle outflow tract velocity time integral (LVOT VTI) in a large part (68.5%) of the examinations. Transthoracic echocardiography is a useful tool for the hemodynamic assessment of patients in prone position under mechanical ventilation.

The Influence of Obesity on Care of Adults with Cardiovascular Disease

Obesity is a strong independent predictor of cardiovascular disease. In this article, we briefly review the physiologic effects of obesity on the cardiovascular system, discuss how obesity influences history taking, physical assessment, diagnostic testing, and treatment of patients with common cardiovascular conditions such as hypertension, coronary heart disease, and chronic heart failure. Implications for nursing practice will be shared with a focus on lifestyle modifications to be included in patient education.