Rationale, design, methods and baseline characteristics of the Asklepios Study

Normative Values of Echocardiographic Chamber Size and Function in Older Healthy Adults: The Multi-Ethnic Study of Atherosclerosis

BACKGROUND

Echocardiographic (2-dimensional echocardiography) thresholds indicating disease or impaired functional status compared with normal physiological aging in individuals aged ≥65 years are not clearly defined. In the present study, we sought to establish standard values for 2-dimensional echocardiography parameters related to chamber size and function in older adults without cardiopulmonary or cardiometabolic conditions.

METHODS

In this cross-sectional study of 3032 individuals who underwent 2-dimensional echocardiography at exam 6 in the MESA (Multi-Ethnic Study of Atherosclerosis), 608 participants fulfilled our inclusion criteria of healthy aging, with normative values defined as the mean ± 1.96 standard deviation and compared across sex and race and ethnicity. Functional status measures included NT-proBNP (N-terminal pro-B-type natriuretic peptide), 6-minute walk distance, and Kansas City Cardiomyopathy Questionnaire. Prognostic performance using MESA cutoffs was compared with established guideline cutoffs using time-to-event analysis.

RESULTS

The normative aging cohort (69.5±7.0 years, 46.2% male, 47.5% White) had lower NT-proBNP, higher 6-minute walk distance, and higher (better) Kansas City Cardiomyopathy Questionnaire summary values. Women had significantly smaller chamber sizes and better biventricular systolic function. White participants had the largest chamber dimensions, whereas Chinese participants had the smallest, even after adjustment for body size. Current guidelines identified 81.6% of healthy older adults in MESA as having cardiac abnormalities.

CONCLUSIONS

Among a large, diverse group of healthy older adults, we found significant differences in cardiac structure and function by sex and race/ethnicity, which may signal sex-specific cardiac remodeling with advancing age. It is crucial for existing guidelines to consider the observed and clinically significant differences in cardiac structure and function associated with healthy aging. Our study highlights that existing guidelines, which grade abnormalities in echocardiographic cardiac chamber size and function based on younger individuals, may not adequately address the anticipated changes associated with normal aging.

Novel theory and potential applications of central diastolic pressure decay time constant

Central aortic diastolic pressure decay time constant ( τ ) is according to the two-element Windkessel model equal to the product of total peripheral resistance ( R ) times total arterial compliance ( C ). As such, it is related to arterial stiffness, which has considerable pathophysiological relevance in the assessment of vascular health. This study aimed to investigate the relationship of the constant τ with the product T MBP cPP , given by heart period ( T ) times the ratio of mean blood pressure (MBP) to central pulse pressure ( cPP ). The relationship was derived by performing linear fitting on an in silico population of n1 = 3818 virtual subjects, and was subsequently evaluated on in vivo data (n2 = 2263) from the large Asklepios study. The resulted expression was found to be τ = k ' T MBP cPP , withk ' = 0.7 (R2 = 0.9). The evaluation of the equation on the in vivo human data reported high agreement between the estimated and reference τ values, with a correlation coefficient equal to 0.94 and a normalized RMSE equal to 5.5%. Moreover, the analysis provided evidence that the coefficient k ' is age- and gender-independent. The proposed formula provides novel theoretical insights in the relationship between τ and central blood pressure features. In addition, it may allow for the evaluation of τ without the need for acquiring the entire central blood pressure wave, especially when an approximation of the cPP is feasible. This study adds to the current literature by contributing to the accessibility of an additional biomarker, such as the central diastolic pressure decay time constant, for the improved assessment of vascular ageing.

Normative Values of Echocardiographic Chamber Size and Function in Older Healthy Adults: The Multi-Ethnic Study of Atherosclerosis

Background

Echocardiographic (2DE) thresholds indicating disease or impaired functional status compared to normal physiologic aging in individuals ≥ 65 years are not clearly defined. In the present study, we sought to establish standard values for 2DE parameters related to chamber size and function in older adults without cardiopulmonary or cardiometabolic conditions.

Methods

In this cross-sectional study of 3032 individuals who underwent 2DE at Exam 6 in the Multi-Ethnic Study of Atherosclerosis (MESA), 608 participants fulfilled our inclusion criteria, with normative values defined as the mean value ± 1.96 standard deviations and compared across sex and race/ethnicity. Functional status measures included NT-proBNP, 6-minute walk distance [6MWD], and Kansas City Cardiomyopathy Questionnaire [KCCQ]. Prognostic performance using MESA cutoffs was compared to established guideline cutoffs using time-to-event analysis.

Results

Participants meeting our inclusion criteria (69.5 ± 7.0 years, 46.2% male, 47.5% White) had lower NT-proBNP, higher 6MWD, and higher (better) KCCQ summary values. Women had significantly smaller chamber sizes and better biventricular systolic function. White participants had the largest chamber dimensions, while Chinese participants had the smallest, even after adjustment for body size. Current guidelines identified 81.6% of healthy older adults in MESA as having cardiac abnormalities.

Conclusions

Among a large, diverse group of healthy older adults, we found significant differences in cardiac structure and function across sexes and races/ethnicities, which may signal sex-specific cardiac remodeling with advancing age. It is crucial for existing guidelines to consider the observed and clinically significant differences in cardiac structure and function associated with healthy aging. Our study highlights that existing guidelines, which grade abnormalities in echocardiographic cardiac chamber size and function based on younger individuals, may not adequately address the anticipated changes associated with normal aging.

Normalized Echocardiographic Values From Guideline-Directed Dedicated Views for Cardiac Dimensions and Left Ventricular Function

BACKGROUND

Continuous technologic development and updated recommendations for image acquisitions creates a need to update the current normal reference ranges for echocardiography. The best method of indexing cardiac volumes is unknown.

OBJECTIVES

The authors used 2- and 3-dimensional echocardiographic data from a large cohort of healthy individuals to provide updated normal reference data for dimensions and volumes of the cardiac chambers as well as central Doppler measurements.

METHODS

In the fourth wave of the HUNT (Trøndelag Health) study in Norway 2,462 individuals underwent comprehensive echocardiography. Of these, 1,412 (55.8% women) were classified as normal and formed the basis for updated normal reference ranges. Volumetric measures were indexed to body surface area and height in powers of 1 to 3.

RESULTS

Normal reference data for echocardiographic dimensions, volumes, and Doppler measurements were presented according to sex and age. Left ventricular ejection fraction had lower normal limits of 50.8% for women and 49.6% for men. According to sex-specific age groups, the upper normal limits for left atrial end-systolic volume indexed to body surface area ranged from 44 mL/m2 to 53 mL/m2, and the corresponding upper normal limit for right ventricular basal dimension ranged from 43 mm to 53 mm. Indexing to height raised to the power of 3 accounted for more of the variation between sexes than indexing to body surface area.

CONCLUSIONS

The authors present updated normal reference values for a wide range of echocardiographic measures of both left- and right-side ventricular and atrial size and function from a large healthy population with a wide age-span. The higher upper normal limits for left atrial volume and right ventricular dimension highlight the importance of updating reference ranges accordingly following refinement of echocardiographic methods.

In Vivo Material Properties of Human Common Carotid Arteries: Trends and Sex Differences

INTRODUCTION

In vivo estimation of material properties of arterial tissue can provide essential insights into the development and progression of cardiovascular diseases. Furthermore, these properties can be used as an input to finite element simulations of potential medical treatments.

MATERIALS AND METHODS

This study uses non-invasively measured pressure, diameter and wall thickness of human common carotid arteries (CCAs) acquired in 103 healthy subjects. A non-linear optimization was performed to estimate material parameters of two different constitutive models: a phenomenological, isotropic model and a structural, anisotropic model. The effect of age, sex, body mass index and blood pressure on the parameters was investigated.

RESULTS AND CONCLUSION

Although both material models were able to model in vivo arterial behaviour, the structural model provided more realistic results in the supra-physiological domain. The phenomenological model predicted very high deformations for pressures above the systolic level. However, the phenomenological model has fewer parameters that were shown to be more robust. This is an advantage when only the physiological domain is of interest. The effect of stiffening with age, BMI and blood pressure was present for women, but not always for men. In general, sex had the biggest effect on the mechanical properties of CCAs. Stiffening trends with age, BMI and blood pressure were present but not very strong. The intersubject variability was high. Therefore, it can be concluded that finding a representative set of parameters for a certain age or BMI group would be very challenging. Instead, for purposes of patient-specific modelling of surgical procedures, we currently advise the use of patient-specific parameters.

Molecular Mechanisms of Vascular Health: Insights From Vascular Aging and Calcification

Cardiovascular disease is the most common cause of death worldwide, especially beyond the age of 65 years, with the vast majority of morbidity and mortality due to myocardial infarction and stroke. Vascular pathology stems from a combination of genetic risk, environmental factors, and the biologic changes associated with aging. The pathogenesis underlying the development of vascular aging, and vascular calcification with aging, in particular, is still not fully understood. Accumulating data suggests that genetic risk, likely compounded by epigenetic modifications, environmental factors, including diabetes and chronic kidney disease, and the plasticity of vascular smooth muscle cells to acquire an osteogenic phenotype are major determinants of age-associated vascular calcification. Understanding the molecular mechanisms underlying genetic and modifiable risk factors in regulating age-associated vascular pathology may inspire strategies to promote healthy vascular aging. This article summarizes current knowledge of concepts and mechanisms of age-associated vascular disease, with an emphasis on vascular calcification.

Wave reflection quantification analysis and personalized flow wave estimation based on the central aortic pressure waveform

Pulse wave reflections reflect cardiac afterload and perfusion, which yield valid indicators for monitoring cardiovascular status. Accurate quantification of pressure wave reflections requires the measurement of aortic flow wave. However, direct flow measurement involves extra equipment and well-trained operator. In this study, the personalized aortic flow waveform was estimated from the individual central aortic pressure waveform (CAPW) based on pressure-flow relations. The separated forward and backward pressure waves were used to calculate wave reflection indices such as reflection index (RI) and reflection magnitude (RM), as well as the central aortic pulse transit time (PTT). The effectiveness and feasibility of the method were validated by a set of clinical data (13 participants) and the Nektar1D Pulse Wave Database (4,374 subjects). The performance of the proposed personalized flow waveform method was compared with the traditional triangular flow waveform method and the recently proposed lognormal flow waveform method by statistical analyses. Results show that the root mean square error calculated by the personalized flow waveform approach is smaller than that of the typical triangular and lognormal flow methods, and the correlation coefficient with the measured flow waveform is higher. The estimated personalized flow waveform based on the characteristics of the CAPW can estimate wave reflection indices more accurately than the other two methods. The proposed personalized flow waveform method can be potentially used as a convenient alternative for the measurement of aortic flow waveform.

A NOVEL METHOD FOR DETERMINING THE ARRIVAL TIME OF REFLECTED WAVE AT SINGLE SITE: VALIDATION USING PHASE CONTRAST MAGNETIC RESONANCE DATA

Characterization of the wave reflection and mainly its return time has significant clinical value in detecting cardiovascular and cerebrovascular diseases. Indeed, the return time is an indicator which is used to evaluate the performance of peripheral perfusion and the propagation speed for arterial stiffness measurement. The study is aimed at implementing a novel model based on cepstral analysis for estimation of the arrival time of reflected wave ([Formula: see text]. The proposed method is specially based on cepstral analysis of the simulated blood velocity wave by using the Matlab software. To achieve this aim, we used a theoretical bidimensional model to simulate blood flow velocity, and we combined this model with clinical data acquired in two healthy subjects using phase contrast magnetic resonance imaging (PCMRI). Values of the arrival time of reflected wave measured are similar to the theoretical values. The suggested model is validated in vivo. We can conclude that the novel approach described in this paper offers a promising efficient and convenient method to determinate noninvasively arrival time of reflected wave.

Leveraging the potential of machine learning for assessing vascular ageing: state-of-the-art and future research

Vascular ageing biomarkers have been found to be predictive of cardiovascular risk independently of classical risk factors, yet are not widely used in clinical practice. In this review, we present two basic approaches for using machine learning (ML) to assess vascular age: parameter estimation and risk classification. We then summarize their role in developing new techniques to assess vascular ageing quickly and accurately. We discuss the methods used to validate ML-based markers, the evidence for their clinical utility, and key directions for future research. The review is complemented by case studies of the use of ML in vascular age assessment which can be replicated using freely available data and code.

Genetic investigation of fibromuscular dysplasia identifies risk loci and shared genetics with common cardiovascular diseases

Fibromuscular dysplasia (FMD) is an arteriopathy associated with hypertension, stroke and myocardial infarction, affecting mostly women. We report results from the first genome-wide association meta-analysis of six studies including 1556 FMD cases and 7100 controls. We find an estimate of SNP-based heritability compatible with FMD having a polygenic basis, and report four robustly associated loci (PHACTR1, LRP1, ATP2B1, and LIMA1). Transcriptome-wide association analysis in arteries identifies one additional locus (SLC24A3). We characterize open chromatin in arterial primary cells and find that FMD associated variants are located in arterial-specific regulatory elements. Target genes are broadly involved in mechanisms related to actin cytoskeleton and intracellular calcium homeostasis, central to vascular contraction. We find significant genetic overlap between FMD and more common cardiovascular diseases and traits including blood pressure, migraine, intracranial aneurysm, and coronary artery disease.

On the assessment of arterial compliance from carotid pressure waveform

In a progressively aging population, it is of utmost importance to develop reliable, noninvasive, and cost-effective tools to estimate biomarkers that can be indicative of cardiovascular risk. Various pathophysiological conditions are associated to changes in the total arterial compliance (C_T), and thus, its estimation via an accurate and simple method is valuable. Direct noninvasive measurement of C_T is not feasible in the clinical practice. Previous methods exist for indirect estimation of C_T, which, however, require noninvasive, yet complex and expensive, recordings of the central pressure and flow. Here, we introduce a novel, noninvasive method for estimating C_T from a single carotid waveform measurement using regression analysis. Features were extracted from the carotid wave and were combined with demographic data. A prediction pipeline was adopted for estimating C_T using, first, a feature-based regression analysis and, second, the raw carotid pulse wave. The proposed methodology was appraised using the large human cohort (N = 2,256) of the Asklepios study. Accurate estimates of C_T were yielded for both prediction schemes, namely, r = 0.83 and normalized root mean square error (nRMSE) = 9.58% for the feature-based model, and r = 0.83 and nRSME = 9.67% for the model that used the raw signal. The major advantage of this method pertains to the simplification of the technique offering easily applicable and convenient C_T monitoring. Such an approach could offer promising applications, ranging from fast and cost-efficient hemodynamical monitoring by the physician to integration in wearable technologies.NEW & NOTEWORTHY This article introduces a novel artificial intelligence method to estimate total arterial compliance (C_T) via exploiting the information provided by an uncalibrated carotid blood pressure waveform as well as typical clinical variables. The major finding of this study is that C_T, which is usually acquired using both pressure and flow waveforms, can be accurately derived by the use of the pressure wave alone. This method could potentially facilitate easily applicable and convenient monitoring of C_T.

Left ventricular mechanical dispersion in a general population: Data from the Akershus Cardiac Examination 1950 study

AIMS

Increased left ventricular mechanical dispersion by 2D speckle tracking echocardiography predicts ventricular arrhythmias in ischaemic heart disease and heart failure. However, little is known about mechanical dispersion in the general population. We aimed to study mechanical dispersion in the general population and in diseases associated with increased risk of cardiovascular disease.

METHODS AND RESULTS

The present cross-sectional study consists of 2529 subjects born in 1950 included in the Akershus Cardiac Examination (ACE) 1950 study. Global longitudinal strain (GLS) was assessed from 17 strain segments, and mechanical dispersion calculated as the standard deviation of contraction duration of all segments. The cohort was divided according to the median value of mechanical dispersion, and multivariable linear regression models were performed with mechanical dispersion as the dependent variable. The prevalence of coronary artery disease (CAD), hypertension, obesity, and diabetes (P < 0.01 for all) was significantly higher in subjects with supra-median mechanical dispersion. In a multivariable clinical model, CAD (B = 7.05), hypertension (B = 4.15; both P < 0.001), diabetes (B = 3.39), and obesity (B = 1.89; both P < 0.05) were independently associated with increasing mechanical dispersion. When echocardiographic indices were added to the multivariable model, CAD (B = 4.38; P < 0.01) and hypertension (B = 2.86; P < 0.001) remained significant in addition to peak early diastolic tissue velocity e' (B = -2.00), GLS (B = 1.68), and ejection fraction (B = 0.22; P < 0.001 for all).

CONCLUSION

In a general middle-aged population, prevalent CAD and hypertension were associated with increasing mechanical dispersion, possibly indicating elevated risk of fatal arrhythmias and sudden cardiac death. Albeit weaker, systolic and diastolic dysfunction, were also associated with increasing mechanical dispersion.

Framingham Heart Study: JACC Focus Seminar, 1/8

The Framingham Heart Study is the longest-running cardiovascular epidemiological study, starting in 1948. This paper gives an overview of the various cohorts, collected data, and most important research findings to date. In brief, the Framingham Heart Study, funded by the National Institutes of Health and managed by Boston University, spans 3 generations of well phenotyped White persons and 2 cohorts comprised of racial and ethnic minority groups. These cohorts are densely phenotyped, with extensive longitudinal follow-up, and they continue to provide us with important information on human cardiovascular and noncardiovascular physiology over the lifespan, as well as to identify major risk factors for cardiovascular disease. This paper also summarizes some of the more recent progress in molecular epidemiology and discusses the future of the study.

Feasibility and cost of FH cascade screening in Belgium (BEL-CASCADE) including a novel rapid rule-out strategy

BACKGROUND

Familial hypercholesterolaemia (FH) is underdiagnosed in most countries. We report our first experience from a national pilot project of cascade screening in relatives of FH patients.

METHODOLOGY

Participating specialists recruited consecutive index patients (IP) with Dutch Lipid Clinic Network (DLCN) score ≥6. After informed consent, the relatives were visited by the nurses to collect relevant clinical data and perform blood sampling for lipid profile measurement. FH diagnosis in the relatives was based on the DLCN and/or MEDPED FH (Make-Early-Diagnosis-to-Prevent-Early-Deaths-in-FH) criteria.

RESULTS

In a period of 18 months, a total of 127 IP (90 with definite FH and 37 with probable FH) were enrolled in 15 centres. Out of the 270 relatives visited by the nurses, 105 were suspected of having FH: 31 with DCLN score >8, 33 with DLCN score 5-8 and 41 with MEDPED FH criteria. In a post-hoc analysis, another set of MEDPED FH criteria established in the Netherlands and adapted to Belgium allowed to detect FH in 51 additional relatives.

CONCLUSION

In a country with no national FH screening program, our pilot project demonstrated that implementing a simple phenotypical FH cascade screening strategy using the collaboration of motivated specialists and two nurses, allowed to diagnose FH in 127 index patients and an additional 105 of their relatives over the two-year period. Newly developed MEDPED FH cut-offs, easily applicable by a nurse with a single blood sample, might further improve the sensitivity of detecting FH within families.

Sex differences in the association between arterial hypertension, blood pressure, and sleep apnea in the general population

STUDY OBJECTIVES

To assess sex-related differences in the relationship between hypertension (HT), blood pressure (BP), and sleep apnea in the general population.

METHODS

We performed home polygraphy in a cohort of 1809 men and women in the general population. Office BP was measured. Presence of HT (drug-treated, physician-diagnosed, or high BP during study visit) was also recorded. HT rate and BP were assessed over a range of 7 sleep apnea severity categories based on the respiratory event index (REI).

RESULTS

The age-adjusted HT prevalence rate increased with higher REI in both sexes. After additional adjustment for obesity the association remained significant in women but not in men. In participants not treated with antihypertensive medications, age-adjusted BP increased with REI. Remarkably, the association was already significant within the normal range (REI < 5 events/h). The REI threshold for higher BP was situated at a distinctly lower cutoff point in women compared to men. After additional adjustment for obesity, the associations remained significant for diastolic but not systolic BP.

CONCLUSIONS

Significant increases in the age-adjusted BP and HT rate in the general population were present at lower REI cutoffs in women compared to men. Even a very low number of respiratory events was associated with higher BP and HT prevalence. Adjustment for obesity attenuated these associations, especially in men. Sex differences in BP susceptibility across the sleep apnea spectrum may be present.

Personalized physiologic flow waveforms improve wave reflection estimates compared to triangular flow waveforms in adults

Central aortic pressure waveforms contain valuable prognostic information in addition to central systolic pressure. Using pressure-flow relations, wave separation analysis can be used to decompose aortic pressure waveforms into forward- (Pf) and backward-traveling (Pb) components. Reflection magnitude, the ratio of pressure amplitudes (RM = Pb/Pf), is a predictor of heart failure and all-cause mortality. Aortic flow can be measured via Doppler echocardiography or estimated using a triangular flow waveform; however, the latter may underestimate the flow waveform convexity and overestimate Pb and RM. We sought to determine the accuracy of a personalized synthetic physiologic flow waveform, compared with triangular and measured flow waveforms, for estimating wave reflection indices in 49 healthy young (27 ± 6 yr) and 29 older adults [66 ± 6 yr; 20 healthy, 9 chronic kidney disease (CKD)]. Aortic pressure and measured flow waveforms were acquired via radial tonometry and echocardiography, respectively. Triangular and physiologic flow waveforms were constructed from aortic pressure waveforms. Compared with the measured flow waveform, the triangular waveform underestimated Pf in older, but not young, adults and overestimated Pb and RM in both groups. The physiologic waveform was equivalent to measured flow in deriving all wave reflection indices and yielded smaller mean absolute biases than the triangular waveform in all instances (P < 0.05). Lastly, central pulse pressure was associated with triangular, but not physiologic, mean biases for Pb and RM independent of age or central arterial stiffness (P < 0.05). These findings support the use of personalized physiologic flow waveforms as a more robust alternative to triangular flow waveforms when true flow cannot be measured.NEW & NOTEWORTHY We demonstrate that triangular flow waveforms overestimate wave reflection indices, particularly at higher central pulse pressures independent of age or carotid-femoral pulse wave velocity. In contrast, personalized physiologic flow waveforms provide equivalent wave reflection estimates as measured flow waveforms, thereby offering a more robust alternative to triangulation when aortic flow cannot be measured.

Longitudinal Changes of Input Impedance, Pulse Wave Velocity, and Wave Reflection in a Middle-Aged Population: The Asklepios Study

[Figure: see text].

Impact of varying diastolic pressure fitting technique for the reservoir-wave model on wave intensity analysis

The reservoir-wave model assumes that the measured arterial pressure is made of two components: reservoir and excess. The effect of the reservoir volume should be excluded to quantify the effects of forward and backward traveling waves on blood pressure. Whilst the validity of the reservoir-wave concept is still debated, there is no consensus on the best fitting method for the calculation of the reservoir pressure waveform. Therefore, the aim of this parametric study is to examine the effects of varying the fitting technique on the calculation of reservoir and excess components of pressure and velocity waveforms. Common carotid pressure and flow velocity were measured using applanation tonometry and doppler ultrasound, respectively, in 1037 healthy humans collected randomly from the Asklepios population, aged 35 to 55 years old. Different fitting techniques to the diastolic decay of the measured arterial pressure were used to determine the asymptotic pressure decay, which in turn was used to determine the reservoir pressure waveform. The corresponding wave speed was determined using the PU-loop method, and wave intensity parameters were calculated and compared. Different fitting methods resulted in significant changes in the shape of the reservoir pressure waveform; however, its peak and time integral remained constant in this study. Although peak and integral of excess pressure, velocity components and wave intensity changed significantly with changing the diastolic decay fitting method, wave speed was not substantially modified. We conclude that wave speed, peak reservoir pressure and its time integral are independent of the diastolic pressure decay fitting techniques examined in this study. Therefore, these parameters are considered more reliable diagnostic indicators than excess pressure and velocity which are more sensitive to fitting techniques.

Feasibility and agreement of a novel combined echocardiographic method to measure global longitudinal strain and strain rate compared to speckle tracking and tissue Doppler imaging

Background: Currently, two echocardiographic techniques are used to measure deformation: tissue Doppler imaging (TDI) and speckle tracking echocardiography (STE). Recently, a technique combining STE and TDI (on TDI overlay images) has become available, allowing derivation of STE/TDI results from a single acquisition/reading (combined-STE/combined-TDI). We tested the feasibility and agreement of this novel technique to measure left ventricular deformation in the general population compared to STE and TDI.Methods: We examined a subsample of 106 consecutive subjects of the Asklepios Study, a population-based random sample of male/female volunteers without overt clinical disease (mean age: 55.9 years). Left ventricular deformation measurements were assessed with transthoracic echocardiography using the combined method, STE and TDI.Results: Almost all deformation parameters significantly differed between all methods. Global systolic longitudinal strain (GS) and strain rate (GSRs) values measured by combined-TDI were significantly higher (GS -17.2% ± 3.0, GSRs -0.9 s^-1 ± 0.2) compared to TDI (GS -21.1% ± 2.2, GSRs -1.3 s^-1 ± 0.2). Measurements by combined-STE were significantly lower (GS -19.1% ± 2.9, GSRs -1.0 s^-1 ± 0.2) compared to STE (GS -18.2% ± 3.0, GSRs -0.9 s^-1 ± 0.1). Overall, the smallest differences and highest agreement were observed between STE and combined-STE (GS r = 0.84, p < .001; GSRs r = 0.70, p < .001).Conclusions: The comparison of methods showed different values and poor agreement between the echocardiographic modalities. Regrettably, the combined method does not make it possible to obtain in a single image/measurement results that are comparable to STE and TDI data in the general population.

Estimation of Wave Condition Number From Pressure Waveform Alone and Its Changes With Advancing Age in Healthy Women and Men

Introduction

The wave condition number (WCN) is a non-dimensional number that determines the state of arterial wave reflections. WCN is equal to HR × L_eff/PWV where HR, L_eff, and PWV are the heart rate, effective length, and pulse wave velocity, respectively. It has been shown that a value of WCN = 0.1 indicates the optimum state of arterial wave reflection in which left ventricle workload is minimized. The pressure wave, flow wave, and PWV are all required to compute WCN, which may limit the potential clinical utility of WCN. The aims of this study are as follows: (1) to assess the feasibility of approximating WCN from the pressure waveform alone (WCN_Pinf), and (2) to provide the proof-of-concept that WCN_Pinf can capture age related differences in arterial wave reflection among healthy women and men.

Methods

Previously published retrospective data composed of seventeen patients (age 19–54 years; 34.3 ± 9.6) were used to assess the accuracy of WCN_Pinf. The exact value of WCN was computed from PWV (measured by foot-to-foot method), HR, and L_eff. A quarter wavelength relationship with minimum impedance modulus were used to compute L_eff. WCN_Pinf was calculated using HR and the reflected wave arrival time. Previously published analyses from a healthy subset of the Anglo-Cardiff Collaborative Trial (ACCT) study population were used to investigate if non-invasive WCN_Pinf captures age related differences in arterial wave reflection among healthy women and men.

Results

A strong correlation (r = 0.83, p-value <0.0001) between WCN_Pinf and WCN was observed. The accuracy of WCN_Pinf was independent from relevant physiological parameters such as PWV, pulse pressure (PP), and HR. Similar changes in WCN_Pinf with advancing age were observed in both healthy men and healthy women. In young, healthy individuals (women and men) the WCN_Pinf was around 0.1 (the optimum value), and reduced with aging.

Conclusion

WCN can be approximated from a single pressure waveform and can capture age related arterial wave reflection alteration. These results are clinically significant since WCN can be extracted from a single non-invasive pressure waveform. Future studies will focus on investigating if WCN is associated with risk for onset of cardiovascular disease events.

A Belgian consensus strategy to identify familial hypercholesterolaemia in the coronary care unit and its subsequent cascade screening and treatment: BEL-FaHST (The BELgium Familial Hypercholesterolaemia STrategy)

BACKGROUND AND AIMS

Familial hypercholesterolaemia (FH) is an autosomal dominant lipoprotein disorder characterized by significant elevation of low-density lipoprotein cholesterol (LDL-C) and markedly increased risk of premature cardiovascular disease (CVD). Because of the very high coronary artery disease risk associated with this condition, the prevalence of FH among patients admitted for CVD outmatches many times the prevalence in the general population. Awareness of this disease is crucial for recognizing FH in the aftermath of a hospitalization of a patient with CVD, and also represents a unique opportunity to identify relatives of the index patient, who are unaware they have FH. This article aims to describe a feasible strategy to facilitate the detection and management of FH among patients hospitalized for CVD.

METHODS

A multidisciplinary national panel of lipidologists, cardiologists, endocrinologists and cardio-geneticists developed a three-step diagnostic algorithm, each step including three key aspects of diagnosis, treatment and family care.

RESULTS

A sequence of tasks was generated, starting with the process of suspecting FH amongst affected patients admitted for CVD, treating them to LDL-C target, finally culminating in extensive cascade-screening for FH in their family. Conceptually, the pathway is broken down into 3 phases to provide the treating physicians with a time-efficient chain of priorities.

CONCLUSIONS

We emphasize the need for optimal collaboration between the various actors, starting with a "vigilant doctor" who actively develops the capability or framework to recognize potential FH patients, continuing with an "FH specialist", and finally involving the patient himself as "FH ambassador" to approach his/her family and facilitate cascade screening and subsequent treatment of relatives.

Echocardiography during submaximal isometric exercise in children with repaired coarctation of the aorta compared with controls

Objective

Patients with repaired coarctation (RCoA) remain at higher risk of cardiac dysfunction, initially often only detected during exercise. In this study, haemodynamics of isometric handgrip (HG) and bicycle ergometry (BE) were compared in patients with RCoA and matched controls (MCs).

Methods

Case–control study of 19 children with RCoA (mean age 12.9±2.3 years; mean age of repair 7 months) compared with 20 MC. HG with echocardiography followed by BE was performed in both groups.

Results

During HG (blood pressure) BP increased from 114±11/64±4 mm Hg to 132±14/79±7 mm Hg, without significant differences. During HG as well as BE, HR increased less in patients with RCoA. There were no significant differences in (left ventricle) LV dimensions or LV mass.

The RCoA group had diastolic dysfunction: both at rest and during HG they had significantly higher transmitral E and A velocities and lower tissue Doppler E′ and A′ velocities. E/E′ was higher, reaching statistical significance during HG (p<0001).

Conventional parameters of systolic function (FS and EF) were similar at rest and HG. More sensitive tissue Doppler S′ was significantly lower at rest in CoA subjects (5.1±1.5 cm/s vs 6.5±1±1 cm/s; p<0.01), decreasing further during HG by 5% in the CoA group (NS) while unchanged in controls.

Conclusions

We provide first evidence that HG with echocardiography is feasible, easy and patient-friendly. A decreased systolic (tissue Doppler) and impaired diastolic LV function was measured in the RCoA group, a difference that tended to increase during HG.

Muscle strength is a major determinant of the blood pressure response to isometric stress testing: the Asklepios population study

AIM

Maximal handgrip strength is a strong predictor of cardiovascular mortality in economically and socioculturally diverse countries, yet the main determinants of cardiovascular response to change in afterload during handgrip are not well known. We examined the blood pressure (BP) responses during submaximal handgrip (at 25% of grip strength) and the determinants of grip strength.

METHODS

We studied 2215 participants from a population-based random sample without overt clinical disease (Asklepios Study; mean age 56.2 years). Handgrip testing was performed using a modified Jamar dynamometer with direct visual feedback. Simultaneously, a validated finger plethysmographic device measured continuous BP and heart rate.

RESULTS

During handgrip, SBP and DBP rose by, respectively, 20 ± 13 and 10 ± 6 mmHg. These changes were normally distributed and consistently higher in men. The main independent determinants of mean arterial pressure response during handgrip were: grip strength (F = 191.4; P < 0.001), baseline pulse pressure (F = 32.0; P < 0.001), height (F = 16.4; P < 0.001) and age (F = 12.8; P < 0.001). Grip strength was associated with muscle mass, better metabolic health, but also with higher baseline DBP. There was a significant graded increase in maximum pressure achieved and in the magnitude of pressure change during handgrip with increasing BP categories (P for trend <0.001).

CONCLUSION

The population BP response to handgrip is variable and its predominant determinant turned out to be grip strength itself, which should be accounted for in future analyses. Higher baseline BP, even within the normotensive range, acted as an independent and graded predictor of BP increase during handgrip.

Effect of Race on Echocardiographic Measures of Cardiac Structure and Function

The relations between race and cardiac structure and function are incompletely understood. We hypothesized that race-specific differences in echocardiography measurements exist. We compared the relation between echocardiography measurements and race among 12,429 nonobese adults without known cardiovascular disease who underwent echocardiography. We compared measurements between whites (n = 10,508), blacks (n = 792), Asians (n = 628), Hispanics (n = 315), Native Americans (n = 34), and multiracial/other (n = 152) cohorts. Multivariate analysis compared measurements indexed to body surface area (BSA) between races and adjusted for variables including age, gender, and mean blood pressure. Mean age was 46.9 ± 17.4 years and 60.5% were women. After multivariable adjustment and using whites as a baseline, there were significant differences (p <0.05) in left ventricular end-diastolic diameter/BSA for blacks (-0.5 mm/m²), Asians (0.4 mm/m²), Hispanics (0.2 mm/m²), and multiracial/others (0.1 mm/m²); septal wall thickness/BSA for blacks (0.4 mm/m²) and Asians (0.1 mm/m²); posterior wall thickness/BSA for blacks (0.4 mm/m²), Asians (0.1 mm/m²), Hispanics (0.04 mm/m²), and multiracial/others (0.03 mm/m²); left atrial diameter/BSA for Asians (0.2 mm/m²), Hispanics (0.3 mm/m²), and multiracial/others (0.1 mm/m²); septal and lateral e' for blacks (-0.7 cm/s; -0.9 cm/s); and peak tricuspid regurgitation gradient for blacks (4.3 mm Hg) and Asians (-0.9 mm Hg). Race is associated with significant differences in left ventricular size, left atrial size, mitral annular velocity, and tricuspid regurgitation gradient. Normal reference ranges for echocardiography measurements should utilize racially diverse cohorts to prevent misclassification of echocardiography findings based on race.

Phenotype and Risk Burden of Sleep Apnea: A Population-Based Cohort Study

Sleep apnea (SA) prevalence had increased. The socioeconomic burden is significant because of healthcare-related costs and adverse outcome, especially in moderate-to-severe SA. However, the population impact is unclear, particularly for mild SA. We aimed to assess the current prevalence and the cardiovascular risk associates of SA in the general population. We performed home polygraphy and extensive clinical, sociodemographic, and cardiovascular assessment in 2205 eligible subjects from a population-based cohort. Successful polygraphy was obtained in 1809 subjects (mean age, 56.0; SD, 5.9 years; 52.3% women). The prevalence was 41.0%, 11.8%, and 6.5% for mild, moderate, and severe SA in men and 26.6%, 4.4%, and 1.2% in women. Male sex, age, increasing BMI, and snoring were independently associated with SA, whereas sleepiness or tiredness were not. Compared with those without SA, mild SA was associated with (age- and sex-adjusted OR; 95% CI): diabetes mellitus (2.40; 1.52-3.80), hypertension (1.76; 1.42-2.19), left ventricular hypertrophy (1.36; 1.03-1.79), arterial plaques (1.19; 0.94-1.52), and increased IL-6 (interleukin-6) levels (1.37; 1.10-1.72). These associations were more pronounced in moderate-to-severe SA. To conclude, SA is highly prevalent in the middle-aged general population. It is largely undetected and undetectable using a symptom-based strategy. Yet, even the large group with mild SA shows a manifestly higher metabolic, inflammatory, and cardiovascular risk factor burden, with potential public health implications.

Prevalence of Asthma and COPD and Blood Eosinophil Count in a Middle-Aged Belgian Population

Various phenotypes exist in asthma and Chronic Obstructive Pulmonary Disease (COPD). These are important to identify in order to guide treatment decisions. We aim to investigate the prevalence and clinical characteristics of obstructive airway diseases in the middle-aged population. We estimated the prevalence of COPD and/or asthma in the Asklepios cohort study (Belgium), using information from the third European Community Respiratory Health Survey (ECRHS3), medical records, and spirometry. Respiratory symptoms, respiratory medication, and current disease status distinguished clinical from sub-clinical cases. In addition, we compared the blood eosinophil count/µL (median [IQR]) between cases and controls. Of the 2221 participants (mean age 56.1 ± 5.9 years; 48.7% males), 138 (6.2%) participants had clinical current asthma, 22 (1.0%) participants had sub-clinical ever asthma, 102 (4.6%) had sub-clinical spirometry-defined COPD, 104 (4.6%) participants had clinical spirometry-confirmed COPD, and 11 (0.5%) had asthma and COPD overlap (ACO). Clinical current asthma (160.0 [110.0–250.0]), sub-clinical ever asthma (170.0 [110.0–230.0]), and clinical COPD (160.0 [110.0–220.0])—but less sub-clinical COPD (140.0 [90.0–210.0])—had higher eosinophil counts, compared to controls (130.0 [80.0–200.0]). We conclude that obstructive airway diseases are prevalent in the middle-aged Asklepios cohort. Moreover, the systemic eosinophil count is increased in clinical COPD cases, and in asthma cases regardless of clinical remission.

Effect of Obesity on Left Atrial Strain in Persons Aged 35-55 Years (The Asklepios Study)

Obesity increases the risk of heart failure and atrial fibrillation. Left atrial (LA) dysfunction is increasingly recognized as a mediator of cardiovascular disease. Early effects of obesity on LA function have not been examined in large population samples. We quantified LA strain and strain rate (SR) through speckle tracking echocardiography in 1,531 middle-aged community-based participants enrolled in the Asklepios study. We compared LA function between individuals with body mass index (BMI) < 25 kg/m² (n = 779), 25 to 29.9 kg/m² (n = 618) and ≥ 30 kg/m² (n = 134). Significant differences in reservoir longitudinal LA strain (BMI < 25 kg/m² = 35.3%, BMI 25-29.9 kg/m² = 33.1%, and BMI ≥ 30 kg/m² = 30.9%; p < 0.00001) strain rate ([SR] BMI < 25 kg/m² = 151; BMI 25 to 29.9 kg/m² = 141; and BMI ≥ 30 kg/m² = 135 %/s; p <0.00001) and expansion index (BMI < 25 kg/m² = 1.6, BMI 25 to 29.9 kg/m² = 1.4, and BMI ≥ 30 kg/m² = 1.4; p <0.00001) were seen, indicating reduced reservoir function with increasing BMI. Obesity was also associated with impaired LA conduit function, including conduit longitudinal LA strain (BMI < 25 kg/m² = 21.6%, BMI 25 to 29.9 kg/m² = 18.9%, and BMI ≥ 30 kg/m² = 16.7%; p <0.00001), SR (BMI < 25 kg/m² = -189, BMI 25 to 29.9 kg/m² = 166, and BMI ≥ 30 kg/m² = 150 %/s; p <0.0001) and passive LA emptying fraction (BMI < 25 kg/m² = 40.5, BMI 25 to 29.9 kg/m² = 36.5, and BMI ≥ 30 kg/m² = 36%, p <0.00001). These differences persisted after adjustment for age, gender and other potential confounders. In contrast to reservoir and conduit function, obesity was associated with increased booster pump function (active LA emptying fraction: BMI < 25 kg/m² = 19.4%, BMI 25 to 29.9 kg/m² = 20.5%, and BMI ≥ 30 kg/m² = 21.5%; p <0.00001). In middle-aged adults, obesity is associated with impaired reservoir and conduit LA function and higher booster function, which may be compensatory. Loss of booster LA function, either because of more advanced LA dysfunction or atrial fibrillation, may play an important role in precipitating heart failure in obese individuals.

Arterial properties in adults with long-lasting active juvenile idiopathic arthritis compared to healthy controls

BACKGROUND

The data on cardiovascular risk and systemic arterial properties in patients with long-lasting juvenile idiopathic arthritis (JIA) is limited. The objective of this study was to describe systemic arterial properties including characteristic impedance (Z₀), total arterial compliance (C), and peripheral vascular resistance (R) in patients with long-lasting active JIA compared with matched controls, and to assess the relation to JIA disease variables and traditional cardiovascular risk factors.

FINDINGS

Methods: Eighty-one JIA patients (median age 38.6) with at least 15 years of active disease were reexamined after median 29 years of disease duration and compared to 41 healthy controls. With use of echocardiography and calibrated right common carotid artery tonometric pulse traces, noninvasive estimates of pressure and blood flow from the aortic root were obtained and used to estimate the systemic arterial parameters Z₀, C and R.

RESULTS

The patients had higher Z₀ as assessed by Windkessel model (mean ± SD 65.0 ± 30.1 versus 53.4 ± 18.8 10^- 3 mmHg/ml/s, p = 0.027), lower C as assessed by either Windkessel model or ratio of stroke volume and pulse pressure (1.57 ± 0.46 versus 1.80 ± 0.65 ml/mmHg, p = 0.030, 1.29 ± 0.37 versus 1.43 ± 0.34 ml/mmHg, p = 0.038), and similar R compared to the controls. Years on daily prednisolone and insulin resistance were the most important correlates of Z_0. Metotrexat use, polyarticular disease course and erythrocyte sedimentation rate were also associated with a higher Z_0. CONCLUSION: Our results indicate that JIA patients had altered arterial properties as compared to controls. Years on daily prednisolone and insulin resistance were the most important correlates of altered arterial properties.

Body mass index is negatively associated with telomere length: a collaborative cross-sectional meta-analysis of 87 observational studies

Background

Even before the onset of age-related diseases, obesity might be a contributing factor to the cumulative burden of oxidative stress and chronic inflammation throughout the life course. Obesity may therefore contribute to accelerated shortening of telomeres. Consequently, obese persons are more likely to have shorter telomeres, but the association between body mass index (BMI) and leukocyte telomere length (TL) might differ across the life span and between ethnicities and sexes.

Objective

A collaborative cross-sectional meta-analysis of observational studies was conducted to investigate the associations between BMI and TL across the life span.

Design

Eighty-seven distinct study samples were included in the meta-analysis capturing data from 146,114 individuals. Study-specific age- and sex-adjusted regression coefficients were combined by using a random-effects model in which absolute [base pairs (bp)] and relative telomere to single-copy gene ratio (T/S ratio) TLs were regressed against BMI. Stratified analysis was performed by 3 age categories ("young": 18-60 y; "middle": 61-75 y; and "old": >75 y), sex, and ethnicity.

Results

Each unit increase in BMI corresponded to a -3.99 bp (95% CI: -5.17, -2.81 bp) difference in TL in the total pooled sample; among young adults, each unit increase in BMI corresponded to a -7.67 bp (95% CI: -10.03, -5.31 bp) difference. Each unit increase in BMI corresponded to a -1.58 × 10(-3) unit T/S ratio (0.16% decrease; 95% CI: -2.14 × 10(-3), -1.01 × 10(-3)) difference in age- and sex-adjusted relative TL in the total pooled sample; among young adults, each unit increase in BMI corresponded to a -2.58 × 10(-3) unit T/S ratio (0.26% decrease; 95% CI: -3.92 × 10(-3), -1.25 × 10(-3)). The associations were predominantly for the white pooled population. No sex differences were observed.

Conclusions

A higher BMI is associated with shorter telomeres, especially in younger individuals. The presently observed difference is not negligible. Meta-analyses of longitudinal studies evaluating change in body weight alongside change in TL are warranted.

Leukocyte telomere length and diet in the apparently healthy, middle-aged Asklepios population

Telomere length is a prognostic biomarker for aging diseases. As it is unknown whether diet plays a role in these associations, we aimed to assess the impact of diet on telomere length. Moreover, given that telomere length is modulated by oxidative stress and inflammation, an additional goal was to evaluate whether the latter may mediate possible telomere - diet associations. Southern blot measured leukocyte telomere length and food frequency questionnaire data were compared for 2509 apparently healthy men and women (~35 to 55 years) from the Asklepios population. No significant associations were found between telomere length and overall dietary characteristics, such as dietary diversity, quality, equilibrium, and the dietary inflammatory index. Exploratory analysis of individual dietary variables revealed that a higher daily intake of deep fried potato products was associated with shorter telomeres (P = 0.002, 151 bp per 100 g/day), also in both sexes separately. Deep fried potato product consumption was also significantly associated with C-reactive protein (P = 0.032) and uric acid (P = 0.042), but not other inflammation and oxidative stress markers. These results suggest an at most limited association between overall dietary patterns and telomere length in the general population. Nevertheless, the association between telomere length and deep fried potato product intake warrants additional research.

Left Ventricular Dilation: When Pediatric Meet Adult Guidelines

Measuring and grading left ventricular (LV) size is essential for diagnostic, treatment, and prognostic purposes. Guidelines for quantifying LV size exist for pediatric and adult patients via M-mode measurements, but no data exist determining how well they agree with one another. The goal of this study was to determine the agreement between pediatric echocardiographic readers (PER), pediatric guidelines, and adult guidelines in assessing LV dilation. A retrospective review of all noncongenital echocardiograms from 9/2002 to 11/2015 that had a left ventricular end-diastolic diameter (LVEDD) >5.8 cm for males and >5.2 cm for females was performed. LV size was graded as normal (Z-score ≤ 2), mild (2 < Z-score ≤ 3), moderate (3 < Z-score ≤ 4), or severe (4 < Z-score) based on pediatric and adult guidelines. PER interpretation was also recorded. Agreement between LV size assessments was determined for these three interpretations. A total of 1489 echocardiograms met the inclusion criteria (654 males:835 females). Males were 19.0 ± 6.9 years old and had a BSA of 1.9 ± 0.3 m², and LVEDD was 6.3 ± 0.5 cm. Females were 18.7 ± 8.3 years old and had a BSA of 1.8 ± 0.3 m², and LVEDD was 5.7 ± 0.5 cm. There was a 63.91% agreement for males and an 81.8% agreement for females between PER and pediatric guidelines in assessing LV size. There was a 39.14% agreement for males and a 14.13% agreement for females between PER and adult guidelines in assessing LV size. There was a 41.44% agreement for males and a 14.49% agreement for females between adult and pediatric guidelines in assessing LV size. These agreement percentages did not change significantly when separating the population into greater than or less than 18 years of age cohorts. Pediatric echocardiographic readers were more consistent in following pediatric guidelines than adult guidelines in assessing LV size. The agreement for PER and pediatric guidelines was poor, especially for females, in relation to adult guidelines when assessing LV size. Further standardization and guidelines are needed for pediatric patients that are adult size.

Speckle tracking echocardiography predicts early subclinical anthracycline cardiotoxicity in patients with breast cancer

PURPOSE

This study aimed to assess the early changes of left ventricular (LV) and right ventricular (RV) mechanics associated with anthracycline treatment for breast cancer and to determine whether two-dimensional speckle tracking echocardiography (2D-STE) analysis could predict chemotherapy-induced cardiotoxicity.

BACKGROUND

Anthracycline generates progressive LV dysfunction associated with a poor prognosis. Early detection of minor change of myocardial mechanics is thus important.

METHODS

Pretreatment (T0), first (T1), and second (T2) on-treatment echocardiograms were available for analysis with 2D-STE. All patients had normal pretreatment left ventricular ejection fraction (LVEF). Cardiotoxicity was defined as a drop in LVEF to ≤53% or an absolute decrease of 10% on a follow-up echocardiogram. Analysis of variance receiver operating curve and area under the curve (AUC) analysis was performed.

RESULTS

Eighty-six patients with breast cancer who received anthracycline treatment were included. Compared with T0, LV and RV global longitudinal strain (GLS), and LV global circumferential strain (GCS) at T1 and T2 were reduced significantly (p < 0.005 for all). There was a significant decrease in the LV GLS with increasing age at both T1 and T2 (p < 0.05 for all). GLS at T1 (AUC 0.83; cutoff -14.06; sensitivity 83%; specificity 84%; p = 0.0033) and at T2 (AUC 0.90; cutoff -13.84; sensitivity 93%; specificity 84%; p < 0.0001) was the strongest indicator of subsequent cardiotoxicity.

CONCLUSIONS

Anthracycline treatment induces early deterioration of LV global longitudinal and circumferential strain, involving also the RV. Early change in the GLS seems to be a good predictor of the development of chemotherapy-induced cardiotoxicity. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:222-230, 2017.

Left Ventricular Contraction Pattern in Chronic Aortic Regurgitation and Preserved Ejection Fraction: Simultaneous Stress-Strain Analysis by Three-Dimensional Echocardiography

BACKGROUND

The role of speckle-tracking echocardiography in the assessment of chronic aortic regurgitation (AR) is not established. Load dependency may encumber the interpretation of strain measurements in the chronically overloaded left ventricle. The aim of this study was to investigate the mechanisms of left ventricular (LV) contraction patterns in asymptomatic patients with moderate to severe AR and preserved ejection fractions.

METHODS

In this prospective, cross-sectional study, 31 patients with moderate to severe AR, 15 elite endurance athletes, and 17 healthy control subjects were examined using three-dimensional speckle-tracking echocardiography. Global circumferential strain (GCS), global longitudinal strain (GLS), end-systolic circumferential wall stress (ESSc), end-systolic meridional wall stress (ESSm), and the wall stress ratio (ESSc/ESSm) were measured.

RESULTS

LV end-diastolic volumes were similar in athletes and patients with AR and significantly larger than in healthy control subjects. Values of GLS in control subjects, athletes, and patients with AR were -18.8 ± 1.9%, -17.3 ± 2.0%, and -16.4± 2.0%, respectively (control subjects vs athletes and patients, P < .05), whereas values of GCS were -16.9 ± 2.0%, -15.5 ± 1.9%, and -17.9 ± 2.6%, respectively (athletes vs control subjects and patients, P < .01). The ESSc/ESSm ratio was lower in patients with AR (P < .01). When adjusted for ESSm, GLS remained impaired in patients compared with control subjects and athletes (P = .015). On the other hand, GCS was better in patients with AR when adjusted for ESSc (P = .003).

CONCLUSIONS

In compensated AR, relatively high GCS compensates for reduced GLS in a manner consistent with the preserved ejection fractions observed in these patients.

Arterial Path Length for Arterial Stiffness: Methodological Consideration

BACKGROUND

Carotid-femoral pulse wave velocity (cfPWV) is the most established measure of central arterial stiffness and is calculated by dividing the distance travelled by the pulse wave by the pulse transit time. However, there is no universally accepted standardized measurement of pulse travel distance for cfPWV. This study sought to assess validity and convertibility of 2 most frequently used travel distance estimations, and create the simple and useful conversion equation to unify cfPWV values obtained with different methodologies for pulse travel distance.

METHODS

In a total of 227 adults, cfPWV was calculated using 2 different pulse travel distances: suprasternum-femoral distance minus suprasternum-carotid distance (the subtraction method) and carotid-femoral straight distance × 0.8 (the 80% method). They were compared against 3D arterial tracing via magnetic resonance imaging (MRI).

RESULTS

The subtraction method underestimated travel distance and cfPWV by 8.7% although correlations with the MRI reference values were significant. The 80% method provided more reliable cfPWV, showing a stronger linearity (r = 0.96, P < 0.0001) and a better agreement with the MRI-based reference value (+0.02±0.54 m/s). Values of cfPWV were influenced primarily by pulse transit time, explaining ~80% of the variation in cfPWV, and the contribution of pulse travel distance was relatively small irrespective of how the travel distance was measured. After the application of the conversion factor (the 80% method = the subtraction method × 1.1), cfPWV values obtained with both methods were strongly correlated and estimation errors were comparable (+0.03±0.75 m/s).

CONCLUSION

Our findings indicate that the subtraction method and the 80% method can provide equivalent cfPWV values by the application of a simple conversion factor.

The Link Between Obstructive Sleep Apnea and Cardiovascular Disease

Obstructive sleep apnea (OSA) is common in the general population and highly prevalent in patients with cardiovascular disease. In this paper, we review (1) the pathophysiological mechanisms of OSA that may causally contribute to cardiovascular disease; (2) current evidence regarding the association between OSA and hypertension, stroke, ischemic heart disease, heart failure, atrial fibrillation, and cardiovascular mortality; and (3) the impact of continuous positive airway pressure (CPAP) treatment on cardiovascular risk factors and outcomes. We emphasize the importance of obesity as a comorbidity of OSA and a confounder in the association between OSA and cardiovascular disease. We also discuss the importance of addressing obesity in patients with OSA, as a strategy to reduce the burden of cardiovascular risk factors in this population. Implications for the approach of patients' OSA in clinical practice and future research directions are discussed.

Cardiorespiratory interactions: Noncontact assessment using laser Doppler vibrometry

The application of a noncontact physiological recording technique, based on the method of laser Doppler vibrometry (LDV), is described. The effectiveness of the LDV method as a physiological recording modality lies in the ability to detect very small movements of the skin, associated with internal mechanophysiological activities. The method is validated for a range of cardiovascular variables, extracted from the contour of the carotid pulse waveform as a function of phase of the respiration cycle. Data were obtained from 32 young healthy participants, while resting and breathing spontaneously. Individual beats were assigned to four segments, corresponding with inspiration and expiration peaks and transitional periods. Measures relating to cardiac and vascular dynamics are shown to agree with the pattern of effects seen in the substantial body of literature based on human and animal experiments, and with selected signals recorded simultaneously with conventional sensors. These effects include changes in heart rate, systolic time intervals, and stroke volume. There was also some evidence for vascular adjustments over the respiration cycle. The effectiveness of custom algorithmic approaches for extracting the key signal features was confirmed. The advantages of the LDV method are discussed in terms of the metrological properties and utility in psychophysiological research. Although used here within a suite of conventional sensors and electrodes, the LDV method can be used on a stand-alone, noncontact basis, with no requirement for skin preparation, and can be used in harsh environments including the MR scanner.

Update on cardiotoxicity of anti-cancer treatments

BACKGROUND AND AIMS

Anti-cancer treatments markedly improved the prognosis of patients, but unfortunately might be hampered by cardiotoxicity. Both symptomatic and asymptomatic clinical forms of heart failure have been reported, which may be reversible or irreversible. The aim of this review is to provide an overview of the antineoplastic agents associated with cardiac toxicity and of the available diagnostic techniques.

METHODS AND METHODS

This narrative review is based on material from MEDLINE and PUBMED up to November 2015. We looked at the terms antineoplastic drugs and cardiac toxicity in combination with echocardiography, troponins, cardiac magnetic resonance, and positron emission tomography.

RESULTS

Anthracyclines, monoclonal antibodies, fluoropyrimidines, taxanes, alkylating agents, vinka alkaloids were reported to induce different clinical manifestations of cardioxicity. Chest radiotherapy is also associated with various forms of cardiac damage, which are indistinguishable from those found in patients with heart disease of other aetiologies and that may even appear several years after administration. Among diagnostic techniques, echocardiography is a noninvasive, cost-effective, and widely available imaging tool. Nuclear imaging and cardiac magnetic resonance may be used but are not so widely available and are more difficult to perform. Finally, some biomarkers, such as troponins, may be used to evaluate cardiac damage, but establishing the optimal timing of troponin assessment remains unclear and defining the cut-off point for positivity is still an important goal.

CONCLUSIONS

Cardiotoxicity of anti-cancer treatments is associated with development of heart failure. Novel diagnostic tools might be relevant to early recognize irreversible forms cardiac diseases.

Advanced Echocardiographic Techniques in Detection of Cardiotoxicity

OPINION STATEMENT

As advancements are made in cancer treatment, there is an increasing recognition of the cardiotoxic potential of chemotherapies and the need to monitor for the development of cardiac dysfunction in survivors. Echocardiography is the cornerstone of cardiac imaging and provides a feasible and non-invasive method to assess cardiac dysfunction in patients with cancer. In recent years, there has been increasing research in echocardiographic techniques to improve diagnosis of cardiotoxicity, including a more accurate assessment of the left ventricular function and the detection of subclinical disease. These specialized techniques include stress and contrast echocardiography, three-dimensional echocardiography, diastolic dysfunction, tissue Doppler imaging, and strain parameters.

Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging

The rapid technological developments of the past decade and the changes in echocardiographic practice brought about by these developments have resulted in the need for updated recommendations to the previously published guidelines for cardiac chamber quantification, which was the goal of the joint writing group assembled by the American Society of Echocardiography and the European Association of Cardiovascular Imaging. This document provides updated normal values for all four cardiac chambers, including three-dimensional echocardiography and myocardial deformation, when possible, on the basis of considerably larger numbers of normal subjects, compiled from multiple databases. In addition, this document attempts to eliminate several minor discrepancies that existed between previously published guidelines.

The Ten-Year History of the Asklepios Study: An Interview with Professor Ernst R. Rietzschel, Primary Investigator and Leader of the Asklepios Study

The Asklepios study started 10 years ago when 2,500 subjects were screened between 2002 and 2004. And all of the 90+ publications we have for the moment are from those cross-sectional data. This is called round 1. Since 2011, in round 2, all of those patients have started to come back for a 10-year follow-up. At this moment, approximately 1,750 of those patients have been seen. The patients were followed by general practitioners (GP), and the GP again provided the information about what has happened with the medical status in the past 10 years including drug therapy: not only the drugs that they are taking at the moment were evaluated, but, because patients often use many drugs, the chronicles of drugs for major risk factors, for hypertension, lipids, contraceptives and more. Then, patients come to the study center where the same cluster of examinations are undertaken by one single doctor, Prof. Ernst R. Rietzschel and one study nurse, just like 10 years ago. Again, using a single observer at the two time frames has kept the methodology very strict.