High prevalence of cardiac hypertophy without detectable signs of fibrosis in patients with untreated active acromegaly: an in vivo study using magnetic resonance imaging

Myocardial, Valvular, and Vascular Structural and Functional Properties in Acromegaly

Acromegaly is an uncommon systematic endocrine disease caused by the hypersecretion of human growth hormone and, consequently, of insulin-like growth factor-1 during adulthood. Acromegaly could cause a typical cardiomyopathy characterized by left ventricular hypertrophy associated with diastolic dysfunction, which later could progress to systolic dysfunction. Moreover, some valvular and vascular abnormalities are also associated with acromegaly. This present review aims to summarize available information regarding acromegaly-associated abnormalities in myocardial, valvular, and vascular structural and functional properties and their relationship to disease activity and treatment options.

Importance of 24 h ambulatory blood pressure monitoring in patients with acromegaly and correlation with cardiac magnetic resonance findings

INTRODUCTION

Arterial hypertension (AH) is prevalent in acromegaly, but few studies using 24-h ambulatory blood pressure monitoring (24 h-ABPM) suggest that its frequency may be different from office blood pressure (OBP). Left ventricular hypertrophy (LVH) is one of the most frequent cardiac abnormalities. Cardiac magnetic resonance (CMR) is considered the gold standard to evaluate the heart.

OBJECTIVES

To compare the frequency of AH when measured by 24 h-ABPM and by OBP and to correlate BP with cardiac mass.

METHODS

Patients over 18 years of age with acromegaly underwent OBP evaluation and were later referred to the 24 h-ABPM. Treatment-naïve patients were submitted to CMR.

RESULTS

We evaluated 96 patients. From 29 non hypertensive patients by OBP, 9 had AH on 24 h-ABPM. In the group of patients with a previous diagnosis of AH by OBP, 25 had controlled BP and 42 had abnormal BP on 24 h-ABPM, when analyzed by OBP there were 28 with controlled BP. We observed a positive correlation between diastolic BP measured in 24 h-ABPM and IGF-I levels, but we did not observe the same correlation with age, sex, body mass index and GH levels. The CMR was performed in 11 patients. We found a positive correlation of left ventricular mass (LVM) and BP of 24 h-ABPM. In contrast, there was no correlation of OBP with CMR parameters.

CONCLUSIONS

We observed, that 24 h-ABPM in acromegaly allows the diagnosis of AH in some patients with normal BP in OBP and also to allow a better treatment. 24 h-ABPM shows a better correlation with VM by CMR.

Filling the gap between the heart and the body in acromegaly: a case-control study

OBJECTIVE

Cardiovascul diseases are the most common comorbidities in acromegaly. Potential parameters in pathology of cardiovascular comorbidities are changes in levels of growth hormone (GH) and insulin-like growth factor 1 (IGF-1) as well as body composition parameters.

PURPOSE

The aim of this study was to examine morphological and functional parameters of the cardiovascular system by echocardiography and to assess its relationship with disease activity and body composition parameters.

METHODS

We prospectively enroled 129 acromegalic patients (82 females, 47 males) and 80 healthy controls (53 females, 27 males) matched for age, gender, and BMI. All patients underwent two-dimensional echocardiography. Body composition parameters were assessed by dual-energy X-ray absorptiometry.

RESULTS

Acromegaly patients presented with higher left ventricle mass (LVM) compared to controls (LVMI: 123 ± 45 g/m² vs 83 ± 16 g/m², P < 0.001). Prevalence of left ventricle hypertrophy in acromegaly patients was 67% (78% concentric, 22% eccentric). IGF -1 levels, BMI, and lean mass positively correlated with LVM in all acromegaly patients (P < 0.001). Fat mass positively correlated with LVM in females (R = 0.306, P = 0.005), but this correlation was not found in males. We did not find any difference in size of the left and right ventricle between acromegaly patients and controls. Acromegaly patients presented with left atrium enlargement, diastolic dysfunction and low incidence of systolic dysfunction. Valvopathy was found in 43% of patients with predominant (31%) prevalence of mitral regurgitation.

CONCLUSION

Our study demonstrates higher prevalence of cardiovascular comorbidities in acromegaly patients and the impact of IGF-1 levels and body composition parameters in pathology in some of these comorbidities.

An Overview of Deep Learning Methods for Left Ventricle Segmentation

Cardiac health diseases are one of the key causes of death around the globe. The number of heart patients has considerably increased during the pandemic. Therefore, it is crucial to assess and analyze the medical and cardiac images. Deep learning architectures, specifically convolutional neural networks have profoundly become the primary choice for the assessment of cardiac medical images. The left ventricle is a vital part of the cardiovascular system where the boundary and size perform a significant role in the evaluation of cardiac function. Due to automatic segmentation and good promising results, the left ventricle segmentation using deep learning has attracted a lot of attention. This article presents a critical review of deep learning methods used for the left ventricle segmentation from frequently used imaging modalities including magnetic resonance images, ultrasound, and computer tomography. This study also demonstrates the details of the network architecture, software, and hardware used for training along with publicly available cardiac image datasets and self-prepared dataset details incorporated. The summary of the evaluation matrices with results used by different researchers is also presented in this study. Finally, all this information is summarized and comprehended in order to assist the readers to understand the motivation and methodology of various deep learning models, as well as exploring potential solutions to future challenges in LV segmentation.

Role of cardiovascular magnetic resonance in the clinical evaluation of left ventricular hypertrophy: a 360° panorama

Left ventricular hypertrophy (LVH) is a frequent imaging finding in the general population. In order to identify the precise etiology, a comprehensive diagnostic approach should be adopted, including the prevalence of each entity that may cause LVH, family history, clinical, electrocardiographic and imaging findings. By providing a detailed evaluation of the myocardium, cardiovascular magnetic resonance (CMR) has assumed a central role in the differential diagnosis of left ventricular hypertrophy, with the technique of parametric imaging allowing more refined tissue characterization. This article aims to establish a parallel between pathophysiological features and imaging findings through the broad spectrum of LVH entities, emphasizing the role of CMR in the differential diagnosis.

Specific FSTL1 polymorphism may determine the risk of cardiomyopathy in patients with acromegaly

BACKGROUND

We have investigated the role of a cardiomyokine, follistatin-like 1 (FSTL1), and its single nucleotide polymorphism on acromegalic cardiomyopathy.

METHODS

The study was performed as a cross-sectional case research in a Tertiary Referral Centre. Forty-six patients with acromegaly (29 F-17 M, mean age: 50.3 ± 12.1 years) were included. FSTL1 levels were measured and the rs1259293 region of the FSTL1 gene was subjected to polymorphism analysis. 1.5 Tesla MRI was used to obtain cardiac images.

RESULTS

There were 15 active (6 F-9M) and 31 (22 F-9M) controlled patients. Active patients had a higher left ventricular mass (LVM) and left ventricular mass index (LVMi). GH levels were positively correlated with left ventricular end-diastolic volume index (LVEDVi), stroke volume index (SVi), cardiac index (Ci), LVM and LVMi; r = 0.35, 0.38, 0.34, 0.39 and 0.39, respectively. IGF-1 index was positively correlated with LVEDVi, left ventricular end-systolic volume index (LVESVi), SVi, Ci, LVM and LVMi; r = 0.36, 0.34, 0.32, 0.31, 0.42 and 0.42, respectively. Twenty out of 46 patients with acromegaly (43.5%) had myocardial fibrosis. FSTL1 levels were neither correlated with disease activity nor with any functional and structural cardiac parameter. Multivariate linear regression analysis revealed no association between FSTL1 and any study parameters. The rs1259293 variant genotype CC was significantly associated with low left ventricular mass.

CONCLUSIONS

Serum FSTL1 levels are not associated with functional and structural measures of myocardium in patients with acromegaly. However, the risk of left ventricular hypertrophy is reduced in CC genotyped individuals of FSTL1.

Rare Metabolic and Endocrine Diseases with Cardiovascular Involvement: Insights from Cardiovascular Magnetic Resonance - A Review

The identification of rare diseases with cardiovascular involvement poses significant diagnostic challenges due to the rarity of the diseases, but also due to the lack of knowledge and expertise. Most of them remain underrecognized and undiagnosed, leading to clinical mismanagement and affecting the patients' prognosis, as these diseases are per definition life-threatening or chronic debilitating. This article reviews the cardiovascular involvement of the most well-known rare metabolic and endocrine diseases and their diagnostic approach through the lens of cardiovascular magnetic resonance (CMR) imaging and its prognostic role, highlighting its fundamental value compared to other imaging modalities.

Serum NT-pro-BNP Levels Predict Cardiovascular Events in Acromegaly Patients

Background Acromegaly is associated with an increased risk of fatal and non-fatal cardiovascular (CV) events. Controlling acromegaly decreases, but does not normalize this risk. Brain natriuretic peptide (BNP) assessment is used in the general population for the diagnosis of heart failure and to predict ischemic recurrences and mortality. This is a retrospective, longitudinal, monocenter study that evaluates the role of serum N-terminal fragment of BNP (NT-pro-BNP) for predicting CV events in acromegaly patients.

Methods Serum NT-pro-BNP levels were measured in 76 patients with acromegaly (23 males, 57.7±1.5 years), and compared with other predictors of CV events. NT-pro-BNP cut-off value discriminating the occurrence of CV events was determined by ROC analysis. CV events were recorded during a follow-up of 78.6±6.4 months.

Results CV events occurred in 9.2% of patients. Mean log(NT-pro-BNP) concentration was higher in patients who experienced CV events than in those who did not (p<0.01) and in patients who died due to CV events than in those who died due to other causes (p<0.01). Based on the ROC curve, a cut-off value of 91.55 pg/mL could predict CV events (OR 19.06). Log(NT-pro-BNP) was lower in surgically treated patients by surgery (p<0.05), and in those cured by neurosurgery (p<0.02).

Conclusions High NT-pro-BNP value is an independent middle-term predictor of fatal or non-fatal CV events in patients with acromegaly. According to this parameter, surgically treated patients show lower CV risk than those managed with medical therapy, especially if the disease is cured.

Echocardiographic findings in acromegaly: prevalence of concentric left ventricular remodeling in a large single-center cohort

PURPOSE

Acromegaly is a rare disease and is associated with increased cardiovascular (CV) morbidity and mortality, especially in patients with uncontrolled disease. We aimed to analyze the prevalence and severity of cardiomyopathy and valvular heart disease in a large cohort of patients with a confirmed acromegaly diagnosis, at baseline and after treatment.

METHODS

We retrospectively reviewed an institutional approved database; 190 patients with confirmed acromegaly and follow-up data available (years 2006-2018). Patients with at least one baseline echocardiogram, were included. Demographic, disease control and echocardiogram variables were collected for analysis.

RESULTS

Of the 190 patients 110 (58%) had a baseline echocardiogram and 43 (39.1%) had at least one follow-up echocardiogram after surgical, medical or multimodal treatment. Baseline left ventricular hypertrophy (LVH) prevalence was 17.8% (64.7% concentric; 35.3% eccentric), diastolic and systolic dysfunction, and overt cardiomyopathy with heart failure were 15.8, 7.9, and 3.0%, respectively. Concentric remodeling of the left ventricle (LV) was noted in 31.4% of patients without LVH. Valve defects were found in 87.3% of patients (14.6% with significant valvular heart disease).

CONCLUSION

Early diagnosis of acromegaly and disease control should be attempted to prevent LVH/LV dysfunction and development of valvular heart disease. Concentric LV remodeling develops prior to obvious LV hypertrophy in almost a third of patients with acromegaly, which is a novel finding. Similar to other epidemiological studies, we found a high prevalence of LVH/LV dysfunction. Although possible, reversal of systolic and diastolic dysfunction is sporadic after treatment of acromegaly.

Transcriptome profiling of insulin sensitive tissues from GH deficient mice following GH treatment

PURPOSE

Most studies that have examined the transcriptional response to GH have been performed with a single tissue. Thus, the current study performed RNASeq across three insulin-sensitive tissues of GH-treated GH deficient (GHKO) mice.

METHODS

GHKO mice were injected with recombinant human GH (hGH) or vehicle daily for 5 days and adipose, liver, and muscle tissues were collected 4 h after the final injection. RNA was isolated from the tissues and sequenced. Genes that were differentially expressed between GH and vehicle treatments were further analyzed. Enrichment analysis and topology-aware pathway analysis were performed.

RESULTS

GHKO mice treated with hGH had expected phenotypic alterations, with increased body, fat, fluid, liver, and muscle mass, and increased serum IGF-1 and insulin. 55 Genes were differentially expressed in all three tissues, including the canonical GH targets Igf1, Igfals, and Cish. Enrichment analysis confirmed the canonical GH response in select tissues, such as cell proliferation, metabolism, and fibrosis. The JAK/STAT pathway was the only pathway significantly altered in all three tissues.

CONCLUSIONS

As expected, GH caused expression changes of many known target genes, although new candidate GH targets were identified. Liver and muscle appear to be more GH sensitive than adipose tissue due to the larger number of DEG and pathways significantly altered, but adipose still has a characteristic GH response. The diversity of changes uncovered in all three tissues after 5 days of GH treatment highlights the multiplicity of GH's effects in its target tissues.

Advances in Research on the Cardiovascular Complications of Acromegaly

Cardiovascular-related complications are one of the most common complications in patients with acromegaly, and can lead to an increased risk of death. Hypertension and cardiomyopathy are the main cardiovascular complications. The characteristics of acromegalic cardiomyopathy are concentric biventricular hypertrophy and diastolic dysfunction. In addition, arrhythmia and heart valve disease are common cardiac complications in acromegaly. Although the underlying pathophysiology has not been fully elucidated, the spontaneous overproduction of GH and IGF-1, increasing age, prolonged duration of disease and the coexistence of other cardiovascular risk factors are crucial to cardiac complications in patients with acromegaly. Early diagnosis and appropriate treatment of acromegaly might be beneficial for the prevention of cardiomyopathy and premature death.

Association between fragmented QRS and left ventricular dysfunction in acromegaly patients

Background: In acromegaly patients; it has been observed that heart failure may develop even in the absence of predisposing factors such as hypertension, diabetes mellitus, so a specific acromegalic cardiomyopathy has been suggested. We aimed to evaluate the fQRS frequency in acromegaly patients and the left ventricular (LV) functions of acromegaly patients with fQRS.Methods: Our study included 60 acromegalic patients. Each patient underwent conventional echocardiography and tissue Doppler imaging. The patients included were separated into two groups: those with (n:23) and without (n:37) fQRS.Results: Significant differences were identified between fQRS(+) and fQRS (-) groups with respect to disease duration (p < .001), Left ventricular end diastolic volume (EDV) (p < .001), E velocity (p < .001), E\A ratio (p < .001), E' velocity (p < .001), E/E' ratio (p < .001), isovolumic relaxation time (IVRT) (p < .001), MPI (p < .001). Disease duration (odds ratio [OR]: 2.120 (1.023-1.703 95% confidence interval [CI]), p = .002), E' (OR:3.029 (1.013-1.703 95% CI) p = .004) and fQRS (OR:4.59 (1.94-10.87 95% CI), p = .001) were identified as the independent predictors of myocardial performance index (MPI). However, disease duration (OR:1.078 (1.030-1.128 95% CI), p = .001), E/E' (OR: 1.43 (1.22-1.97 95% CI), p = .001), IVRT (OR:1.65 (1.32-2.06 95% CI), p = .001) and MPI (OR:1.014 (1.004-1.024 95% CI), p = .002) were the independent predictors of fQRS.Conclusions: fQRS was frequent and an independent predictor of MPI that was independelty associated with LV dysfunction in patients with acromegaly. In light of these findings the presence of fQRS is thought to be an indicator of acromegalic CMP development.

Acromegaly: Update on Management and Long-Term Morbidities

Acromegaly is a systemic disease associated with great morbidity and increased mortality if not adequately treated. In the past decades much improvement has been achieved in its treatment and in the knowledge of its comorbidities. We provide an update of acromegaly management with current recommendations. We also address long-term comorbidities emphasizing the changing face of the disease in more recent series, with a decrease of cardiovascular disease severity and an increased awareness of comorbidities like bone disease, manifested mainly as vertebral fractures and the change in the main cause of death (from cardiovascular disease to cancer in more recent series).

The Role of MRI in Prognostic Stratification of Cardiomyopathies

PURPOSE OF THE REVIEW

The aim of this review was to discuss the role of cardiac magnetic resonance (CMR) for the prognostic stratification of cardiomyopathies, highlighting strengths and limitations.

RECENT FINDINGS

CMR is considered as a diagnostic pillar in the management of non-ischemic cardiomyopathies. Over the last years, attention has shifted from CMR's diagnostic capability towards prognostication in the various settings of cardiomyopathies. CMR is considered the gold standard imaging technique for the evaluation of ventricular volumes and systolic function as well as providing non-invasive virtual-histology by means of specific myocardial tissue characterization pulse sequences. CMR is an additive tool to risk stratifying patients and to identify those that require strict monitoring and more aggressive treatment.

The right atrium in acromegaly-a three-dimensional speckle-tracking echocardiographic analysis from the MAGYAR-Path Study

BACKGROUND

Acromegaly is a chronic, rare hormonal disease associated with major cardiovascular co-morbidities. The disease, in the majority of the cases, is caused by a benign human growth hormone (hGH) secreting adenoma. Cardiovascular involvement is especially common in acromegalic patients from the most common hypertension to cardiomyopathy. Left ventricular hypertrophy and myocardial fibrosis are considered common findings in acromegalic cardiomyopathy, which might result in severe heart failure at end-stages. It was set out to quantify right atrial (RA) morphology and function in a group of acromegalic patients using three-dimensional (3D) speckle-tracking echocardiography (3DSTE).

METHODS

The study comprised 30 patients from which 8 patients were excluded due to inadequate image quality. Mean age of the remaining acromegaly patients were 53.7±14.5 years (7 males). In the control group 44 healthy adults were enrolled (mean age: 50.7±12.6 years, 15 males). In each case, complete two-dimensional Doppler echocardiography was performed followed by 3DSTE.

RESULTS

All three RA volumetric parameters (Vmax, Vmin, VpreA) were significantly higher in case of acromegaly compared to the healthy controls. Strain analysis revealed that RA function may be enhanced in acromegalic patients, which is more notable in case of active acromegaly. Numerous independent strain parameters had significant correlations with different hormonal variables in the active acromegaly group. These correlations were not present in the inactive acromegaly subgroup.

CONCLUSIONS

Acromegaly has a profound effect on RA function and with proper treatment these changes partly seem to be reversible.

Cardiac Abnormalities in Acromegaly Patients: A Cardiac Magnetic Resonance Study

Cardiac abnormalities are the most common and deadly comorbidities of acromegaly. Assessments using cardiac magnetic resonance (CMR) imaging in acromegaly patients are rare. We aimed to evaluate the frequencies of left ventricular hypertrophy (LVH), interventricular septum hypertrophy (IVSH), LV systolic dysfunction (LVSD), right ventricular systolic dysfunction (RVSD), and myocardial fibrosis (MCF) and detailed quantitative parameters in acromegaly patients using CMR and analyze their correlations with clinical features. Sixty-one patients were enrolled in this study. The rates of LVH, IVSH, LVSD, RVSD, and MCF were 26.2%, 27.9%, 8.2%, 9.8%, and 14.8%, respectively. The average LV mass, LV mass index, IVS thickness, LV and RV free wall thickness, and LV and RV ejection fractions were 114.4 g, 60.0 g/m², 9.6 mm, 7.2 mm, 2.9 mm, 59.9%, and 56.6%, respectively. The LV mass index was larger (68.9 ± 26.0 vs. 48.8 ± 10.6 g/m²), the IVS was thicker (10.3 ± 2.8 vs. 8.8 ± 1.8 mm), and the LV (57.6 ± 12.3% vs. 62.8 ± 4.8%) and RV ejection fractions (54.6 ± 8.7% vs. 59.2 ± 5.9%) were lower in male patients than in female patients (all p < 0.05). Age, body mass index (BMI), disease duration, and hypertension were associated with cardiac abnormalities (all p < 0.05). In conclusion, structural and functional cardiac abnormalities can be comprehensively evaluated by CMR in acromegaly patients. Gender greatly affects the presence of cardiac abnormalities. Age, BMI, disease duration, and hypertension but not GH or IGF-1 levels are associated clinical factors.

Reversibility of Cardiac Involvement in Acromegaly Patients After Surgery: 12-Month Follow-up Using Cardiovascular Magnetic Resonance

PURPOSE

Cardiac comorbidity is one of the leading causes of death among acromegaly patients. We aimed to investigate the reversibility of acromegalic cardiac involvement after surgical treatment using the gold standard method, cardiovascular magnetic resonance, and to explore the effects of endocrine remission and gender on reversibility.

METHODS

In this single-center, prospective cohort study, fifty untreated acromegaly patients were enrolled. Comprehensive cardiac assessments were performed using a 3.0 T magnetic resonance scanner before and 3 and 12 months after transsphenoidal adenomectomy.

RESULTS

Preoperatively, left ventricular (LV) enlargement (13.0%), LV systolic dysfunction (6.5%), right ventricular (RV) enlargement (4.3%), RV systolic dysfunction (2.2%) and myocardial fibrosis (12.0%) were identified. On average, the LV and RV ejection fractions of acromegaly patients were higher than the healthy reference values. Male patients had thicker LV myocardia, wider ventricular diameters and more dilated pulmonary artery roots than female patients. After surgery, LV myocardial hypertrophy was reversed, the left atrium was remodeled, and ventricular systolic dysfunction recovered to normal. Cardiac alterations were detected early in the 3^rd postoperative month and persisted until the 12^th month. The interventricular septum was initially thickened in the 3^rd postoperative month and then recovered at the 12th month. Notable postoperative cardiac reversibility was observed in male patients but did not occur in all female patients. Patients achieving endocrine remission with normalized hormone levels had thinner LV myocardia than patients without normalized hormone levels.

CONCLUSION

Our findings demonstrated that some of the cardiac involvement in acromegaly patients is reversible after surgical treatment which lowers hormone levels. Endocrine remission and gender significantly impacted postoperative cardiac reversibility.

Effect of etelcalcetide on cardiac hypertrophy in hemodialysis patients: a randomized controlled trial (ETECAR-HD)

Background

Fibroblast growth factor 23 (FGF23) is associated with left ventricular hypertrophy (LVH) in patients with chronic kidney disease, and calcimimetic therapy reduces plasma concentrations of FGF23. It remains unknown whether treatment with the calcimimetic etelcalcetide (ETL) reduces LVH in patients on hemodialysis.

Methods/design

This single-blinded randomized trial of 12 months duration will test the effects of ETL compared with alfacalcidol on LVH and cardiac fibrosis in maintenance hemodialysis patients with secondary hyperparathyroidism. Both treatment regimens will be titrated to equally suppress secondary hyperparathyroidism while alfacalcidol treatment causes an increase and ETL a decrease in FGF23, respectively.

Patients treated thrice weekly with hemodialysis for ≥ 3 months and ≤ 3 years with parathyroid hormone levels ≥ 300 pg/ml and LVH will be enrolled in the study.

The primary study endpoint is change from baseline to 12 months in left ventricular mass index (LVMI; g/m²) measured by cardiac magnetic resonance imaging. Sample size calculations showed that 62 randomized patients will be necessary to detect a difference in LVMI of at least 20 g/m² between the two groups at 12 months. Due to the strong association of volume overload and LVH, randomization will be stratified by residual kidney function, and regular body composition monitoring will be performed to control the volume status of patients.

Study medication will be administered intravenously by the dialysis nurses after every hemodialysis session, thus omitting adherence issues.

Secondary study endpoints are cardiac parameters measured by echocardiography, biomarker concentrations of bone metabolism (FGF23, vitamin D, parathyroid hormone, calcium, phosphate, s-Klotho), cardiac markers (pro-brain natriuretic peptide, pre- and postdialysis troponin T) and metabolites of the renin–angiotensin–aldosterone cascade (angiotensin I (Ang I), Ang II, Ang-(1–7), Ang-(1–5), Ang-(1–9), and aldosterone).

Discussion

The causal inference and pathophysiology of LVH regression by FGF23 reduction using calcimimetic treatment has not yet been shown. This intervention study has the potential to discover a new strategy for the treatment of cardiac hypertrophy and fibrosis in patients on maintenance hemodialysis. It might be speculated that successful treatment of cardiac morphology will also reduce the risk of cardiac death in this population.

Trial registration

European Clinical Trials Database, EudraCT number 2017-000222-35; ClinicalTrials.gov, NCT03182699. Registered on

Acromegaly and Heart Failure

In patients with acromegaly, chronic GH and IGF-I excess commonly causes a specific cardiomyopathy characterized by a concentric cardiac hypertrophy associated with diastolic dysfunction and, in later stages, with systolic dysfunction ending in heart failure in untreated and uncontrolled patients. Additional relevant cardiovascular complications are represented by arterial hypertension, valvulopathies, arrhythmias, and vascular endothelial dysfunction, which, together with the respiratory and metabolic complications, contribute to the development of cardiac disease and the increase cardiovascular risk in acromegaly. Disease duration plays a pivotal role in the determination of acromegalic cardiomyopathy. The main functional disturbance in acromegalic cardiomyopathy is the diastolic dysfunction, observed in 11% to 58% of patients, it is usually mild, without clinical consequence, and the progression to systolic dysfunction is generally uncommon, not seen or observed in less than 3% of the patients. Consequently, the presence of overt CHF is rare in acromegaly, ranging between 1 and 4%, in patients with untreated and uncontrolled disease. Control of acromegaly, induced by either pituitary surgery or medical therapy improves cardiac structure and performance, limiting the progression of acromegaly cardiomyopathy to CHF. However, when CHF is associated with dilative cardiomyopathy, it is generally not reversible, despite the treatment of the acromegaly.

Systemic Complications of Acromegaly and the Impact of the Current Treatment Landscape: An Update

Acromegaly is a chronic systemic disease with many complications and is associated with increased mortality when not adequately treated. Substantial advances in acromegaly treatment, as well as in the treatment of many of its complications, mainly diabetes mellitus, heart failure, and arterial hypertension, were achieved in the last decades. These developments allowed change in both prevalence and severity of some acromegaly complications and furthermore resulted in a reduction of mortality. Currently, mortality seems to be similar to the general population in adequately treated patients with acromegaly. In this review, we update the knowledge in complications of acromegaly and detail the effects of different acromegaly treatment options on these complications. Incidence of mortality, its correlation with GH (cumulative exposure vs last value), and IGF-I levels and the shift in the main cause of mortality in patients with acromegaly are also addressed.

ECHOCARDIOGRAPHIC MYOCARDIAL CHANGES IN ACROMEGALY: A CROSS-SECTIONAL ANALYSIS IN A TERTIARY CENTER IN BULGARIA

Context

Cardiomyopathy is the most frequent cardiovascular complication in acromegaly.

Objective

We aimed to compare some echocardiographic markers in acromegaly patients with controls and find a correlation with disease duration, disease activity, levels of growth hormone (GH) and insulin-like growth factor 1 (IGF-1).

Design

We conducted a cross-sectional case-control study for the period of 2008-2012.

Subjects and methods

Acromegaly patients altogether 146 (56 men and 90 women), were divided into four groups according to disease activity and the presence of arterial hypertension (AH). The control group included 83 subjects, matching the patient groups by age, gender and presence of AH. GH was measured by an immunofluorometric method, while IGF-1 by IRMA method. All patients and controls were subjected to one- and two-dimensional transthoracic echocardiography, color and pulse Doppler.

Results

We found a thickening of the left ventricular walls and an increase in the left ventricular mass. However, these changes were not statistically significant in all groups and no correlation with disease duration could be demonstrated. As markers of diastolic dysfunction, increased deceleration time and isovolumetric relaxation were registered, which were dependent mainly on age in a binary logistic regression analysis, but not GH or IGF-1. Using absolute values, ejection and shortening fractions were increased in some groups. Using cut-off values, a higher percentage of systolic dysfunction was demonstrated in patients compared to their corresponding controls. Engagement of the right heart ventricle was also found - increased deceleration time and decreased e/a tric ratio.

Conclusions

In conclusion, functional impairments of both ventricles were present, with a predominance of left ventricular diastolic dysfunction.

Bringing Cardiovascular Comorbidities in Acromegaly to an Update. How Should We Diagnose and Manage Them?

Patients with acromegaly frequently develop cardiovascular comorbidities, which significantly affect their morbidity and contribute to an increased all-cause mortality. In this regard, the most frequent complications that these patients may encounter include hypertension, cardiomyopathy, heart valve disease, arrhythmias, atherosclerosis, and coronary artery disease. The specific underlying mechanisms involved in the pathophysiology of these comorbidities are not always fully understood, but uncontrolled GH/IGF-I excess, age, prolonged disease duration, and coexistence of other cardio-vascular risk factors have been identified as significant influencing predisposing factors. It is important that clinicians bear in mind the potential development of cardiovascular comorbidities in acromegalic patients, in order to promptly tackle them, and avoid the progression of cardiac abnormalities. In many cases, this approach may be performed using straightforward screening tools, which will guide us for further diagnosis and management of cardiovascular complications. This article focuses on those cardiovascular comorbidities that are most frequently encountered in acromegalic patients, describes their pathophysiology, and suggests some recommendations for an early and optimal diagnosis, management and treatment.

Increased fibrosis: A novel means by which GH influences white adipose tissue function

OBJECTIVE

White adipose tissue (WAT) fibrosis - the buildup of extracellular matrix (ECM) proteins, primarily collagen - is now a recognized hallmark of tissue dysfunction and is increased with obesity and lipodystrophy. While growth hormone (GH) is known to increase collagen in several tissues, no previous research has addressed its effect on ECM in WAT. Thus, the purpose of this study is to determine if GH influences WAT fibrosis.

DESIGN

This study examined WAT from four distinct strains of GH-altered mice (bGH and GHA transgenic mice as well as two tissue specific GH receptor gene disrupted lines, fat growth hormone receptor knockout or FaGHRKO and liver growth hormone receptor knockout or LiGHRKO mice). Collagen content and adipocyte size were studied in all cohorts and compared to littermate controls. In addition, mRNA expression of fibrosis-associated genes was assessed in one cohort (6month old male bovine GH transgenic and WT mice) and cultured 3T3-L1 adipocytes treated with GH.

RESULTS

Collagen stained area was increased in WAT from bGH mice, was depot-dependent, and increased with age. Furthermore, increased collagen content was associated with decreased adipocyte size in all depots but more dramatic changes in the subcutaneous fat pad. Notably, the increase in collagen was not associated with an increase in collagen gene expression or other genes known to promote fibrosis in WAT, but collagen gene expression was increased with acute GH administration in 3T3-LI cells. In contrast, evaluation of 6month old GH antagonist (GHA) male mice showed significantly decreased collagen in the subcutaneous depot. Lastly, to assess if GH induced collagen deposition directly or indirectly (via IGF-1), fat (Fa) and liver (Li) specific GHRKO mice were evaluated. Decreased fibrosis in FaGHRKO and increased fibrosis in LiGHRKO mice suggest GH is primarily responsible for the alterations in collagen.

CONCLUSIONS

Our results show that GH action is positively associated with an increase in WAT collagen content as well as a decrease in adipocyte size, particularly in the subcutaneous depot. This effect appears to be due to GH and not IGF-1 and reveals a novel means by which GH regulates WAT accumulation.

Left ventricular twist is impaired in acromegaly: Insights from the three-dimensional speckle tracking echocardiographic MAGYAR-Path Study

INTRODUCTION

Acromegaly is a rare, chronic, disfiguring, and debilitating disease caused, in 90% of cases, by a benign monoclonal growth hormone-secreting pituitary adenoma. The present study aimed to assess left ventricular (LV) rotational and twist mechanics in acromegalic patients and to compare their results to age- and gender-matched healthy controls.

METHODS

The present study comprised 24 acromegalic patients, from which 4 were excluded due to insufficient image quality (mean age: 57.8 ± 13.7 years, 7 men). The control group consisted of 18 age- and gender-matched healthy individuals (mean age: 54.8 ± 6.9 years, 8 men).

RESULTS

In 4 out of 20 acromegalic patients, LV showed near absence of twist, as the so-called LV "rigid body rotation" (RBR). Between all acromegalic patients without LV-RBR and controls, both LV basal (-3.76 ± 1.73 vs. -6.17 ± 2.66°, P = .004) and apical rotation (6.12 ± 4.03 vs. 10.81 ± 3.65°, P = .001) and LV twist (9.88 ± 4.74 vs. 16.98 ± 3.88°, P < .001) differed significantly. Between active and nonactive acromegaly subgroups, only the time-to-peak LV twist (377 ± 78 vs. 229 ± 97 ms, P = .005) showed significant difference.

CONCLUSIONS

Acromegaly is associated with impaired LV rotation and twist as assessed by 3-dimensional speckle tracking echocardiography. LV-RBR is a frequent phenomenon in acromegaly.

Cardiovascular Disease in Acromegaly

In patients with acromegaly, chronic excess of growth hormone (GH) and insulin-like growth factor-1 (IGF-1) leads to the development of acromegalic cardiomyopathy. Its main features are biventricular hypertrophy, diastolic dysfunction, and in later stages, systolic dysfunction and congestive heart failure. Surgical and/or pharmacological treatment of acromegaly and control of cardiovascular risk factors help reverse some of these pathophysiologic changes and decrease the high risk of cardiovascular complications.

Two-dimensional speckle tracking echocardiography demonstrates no effect of active acromegaly on left ventricular strain

BACKGROUND

Speckle tracking echocardiography (STE) allows for the study of myocardial strain (ε), a marker of early and subclinical ventricular systolic dysfunction. Cardiac disease may be present in patients with acromegaly; however, STE has never been used to evaluate these patients.

OBJECTIVE

To evaluate left ventricular (LV) global longitudinal strain in patients with active acromegaly with normal LV systolic function.

DESIGN

Cross-sectional clinical study.

METHODS

Patients with active acromegaly with no detectable heart disease and a control group were matched for age, gender, arterial hypertension and diabetes mellitus underwent STE. Global LV longitudinal ε (GLS), left ventricular mass index (LVMi), left ventricular ejection fraction (LVEF) and relative wall thickness (RWT) were obtained via two-dimensional (2D) echocardiography using STE.

RESULTS

Thirty-seven patients with active acromegaly (mean age 45.6 ± 13.8; 48.6% were males) and 48 controls were included. The mean GLS was not significantly different between the acromegaly group and the control group (in %, -20.1 ± 3.1 vs. -19.4 ± 2.2, p = 0.256). Mean LVMi was increased in the acromegaly group (in g/m², 101.6 ± 27.1 vs. 73.2 ± 18.6, p < 0.01). There was a negative correlation between LVMi and GLS (r = -0.39, p = 0.01).

CONCLUSIONS

Acromegaly patients, despite presenting with a higher LVMi when analyzed by 2D echocardiography, did not present with impairment in the strain when compared to a control group; this finding indicates a low chance of evolution to systolic dysfunction and agrees with recent studies that show a lower frequency of cardiac disease in these patients.

Complications of acromegaly: cardiovascular, respiratory and metabolic comorbidities

Acromegaly is associated with an enhanced mortality, with cardiovascular and respiratory complications representing not only the most frequent comorbidities but also two of the main causes of deaths, whereas a minor role is played by metabolic complications, and particularly diabetes mellitus. The most prevalent cardiovascular complications of acromegaly include a cardiomyopathy, characterized by cardiac hypertrophy and diastolic and systolic dysfunction together with arterial hypertension, cardiac rhythm disorders and valve diseases, as well as vascular endothelial dysfunction. Biochemical control of acromegaly significantly improves cardiovascular disease, albeit completely recovering to normal mainly in young patients with short disease duration. Respiratory complications, represented mainly by sleep-breathing disorders, particularly sleep apnea, and respiratory insufficiency, frequently occur at the early stage of the disease and, although their severity decreases with disease control, this improvement does not often change the indication for a specific therapy directed to improve respiratory function. Metabolic complications, including glucose and lipid disorders, are variably reported in acromegaly. Treatments of acromegaly may influence glucose metabolism, and the presence of diabetes mellitus in acromegaly may affect the choice of treatments, so that glucose homeostasis is worth being monitored during the entire course of the disease. Early diagnosis and prompt treatment of acromegaly, aimed at obtaining a strict control of hormone excess, are the best strategy to limit the development or reverse the complications and prevent the premature mortality.

Cardiovascular comorbidities in acromegaly: an update on their diagnosis and management

Comorbidities related to the cardiovascular system are one of the most prevalent in patients with acromegaly, and contribute to an increased risk of morbidity and all-cause mortality. Specifically, hypertension, cardiomyopathy, heart valve disease, arrhythmias, atherosclerosis, coronary artery disease, and cardiac dysfunction may be frequent findings. Although the underlying physiopathology for each comorbidity may not be fully elucidated, uncontrolled growth hormone/insulin-like growth factor 1 excess, age, prolonged disease duration, and coexistence of other cardio-vascular risk factors are significant influencing variables. A simple diagnostic approach to screen for the presence of these comorbidities may allow prompt treatment and arrest the progression of cardiac abnormalities. In this article, we revise the most prevalent cardiovascular comorbidities and their pathophysiology in acromegalic patients, and we address some recommendations for their prompt diagnosis, management and treatment. Strengths and pitfalls of different diagnostic techniques that are currently being used and how different treatments can affect these complications will be further discussed.

Low frequency of cardniac arrhythmias and lack of structural heart disease in medically-naïve acromegaly patients: a prospective study at baseline and after 1 year of somatostatin analogs treatment

BACKGROUND

The incidence of arrhythmias may be increased in acromegaly, but the pathophysiologic mechanisms involved are still unclear, and it has never been correlated with structural heart changes analyzed by the gold-standard method cardiac magnetic resonance (CMR).

AIM

Evaluate the frequency of arrhythmias in drug-naïve acromegaly patients at baseline and after 1 year of somatostatin analogs (SA) treatment and to correlate the occurrence of arrhythmias with the presence of structural heart changes.

PATIENTS AND METHODS

Consecutive drug-naïve acromegaly patients were recruited. The occurrence of arrhythmias and structural heart changes were studied through 24-h Holter and CMR, respectively, at baseline and after 1-year SA treatment.

RESULTS

Thirty-six patients were studied at baseline and 28 were re-evaluated after 1 year of SA treatment. There were 13 females and median age was 48 years (20-73 years). Nine patients (32 %) were controlled after treatment. No sustained arrhythmias were reported in the 24-h Holter. No arrhythmia-related symptoms were observed. Only two patients presented left ventricular hypertrophy and three patients presented fibrosis at baseline. There was no correlation of the left ventricular mass with the number of episodes of arrhythmias and they were not more prevalent in the patients presenting cardiac fibrosis.

CONCLUSION

We found no sustained arrhythmias and a lack of arrhythmia-related symptoms at baseline and after 1 year of SA treatment in a contemporary cohort of acromegaly patients that also present a low frequency of structural heart changes, indicating that these patients may have a lower frequency of heart disease than previously reported.

Low Frequency of Cardiomyopathy Using Cardiac Magnetic Resonance Imaging in an Acromegaly Contemporary Cohort

CONTEXT

Left ventricular hypertrophy (LVH) and myocardial fibrosis are considered common findings of the acromegaly cardiomyopathy in echocardiography studies.

OBJECTIVE

To evaluate the frequency of LVH, systolic dysfunction and myocardial fibrosis was undertaken in patients with acromegaly using cardiac magnetic resonance imaging (CMRi) before and after 12 months of octreotide long-acting repeatable treatment.

PATIENTS AND METHODS

Consecutive patients with active acromegaly submitted to biochemical analysis and CMRi before and after 12 months of treatment. Additionally, echocardiography was performed before treatment.

RESULTS

Forty consecutive patients were evaluated using CMRi at baseline and 30 patients were reevaluated after 12 months of treatment. Additionally, 29 of these patients were submitted to echocardiography. Using CMRi, the frequency of LVH was 5%. The mean left ventricular mass index (LVMi) was 61.73 ± 18.8 g/m(2). The mean left ventricular ejection fraction (LVEF) was 61.85 ± 9.2%, and all patients had normal systolic function. Late gadolinium enhancement was present in five patients (13.5%), and one patient (3.5%) had an increased extracellular volume. After treatment, 12 patients (40%) had criteria for disease control. No clinically relevant differences in cardiac variables before and after treatment were observed. Additionally, there was no difference in LVMi and LVEF among patients with and without disease control. Using echocardiography, 31% of the patients had LVH, mean LVMi was 117.8 ± 46.3 g/m(2) and mean LVEF was 67.3 ± 4.4%. All patients had normal systolic function.

CONCLUSIONS

We demonstrated by CMRi, the gold-standard method, that patients with active acromegaly might have a lower prevalence of cardiac abnormalities than previously reported.

Improvement of cardiac parameters in patients with acromegaly treated with medical therapies

In acromegaly, growth hormone (GH) and insulin-like growth factor-1 (IGF-1) excess results in a specific cardiomyopathy characterized by concentric cardiac hypertrophy primarily associated with diastolic dysfunction that can lead to impaired systolic function and eventually heart failure. This review of the literature evaluates the effect of therapeutic intervention on cardiac parameters. Clinical studies investigating the impact of treatments for acromegaly on cardiac function published between January 1980 and January 2009 were identified through electronic searches of Medline. Suppression of GH and IGF-1 following surgery or medical treatment with somatostatin analogue therapy is effective in decreasing left ventricular (LV) hypertrophy, with subsequent improvement in cardiac function. First-line treatment with somatostatin analogues resulted in improved cardiac outcome compared with first-line surgery, possibly due to somatostatin analogues acting directly through somatostatin receptors on cardiac cells. Additional cardiac improvement has been reported when somatostatin analogue treatment was combined with surgery. In patients where complete biochemical control was not achieved, an improved cardiac performance following treatment with somatostatin analogues has been reported. Treatment with pegvisomant has been demonstrated to reduce LV hypertrophy and improve diastolic and systolic performance. In contrast, reports have suggested that treatment with the dopamine agonist cabergoline increased the incidence of valvular heart disease. Although surgery and somatostatin analogues are effective in improving cardiomyopathy, a greater beneficial effect is observed with somatostatin analogue treatment. Selected patients with acromegaly should consider first-line therapy or pre-treatment with somatostatin analogues prior to surgery to achieve biochemical control and improve cardiac dysfunction.

[Acromegalic cardiomyopathy]

Acromegaly is an endocrine disease with specific somatic changes due to an excess of growth hormone. The majority of cases are caused by growth hormone producing pituitary tumors. Cardiovascular complications, which can be detected even in the early stages of the disease, are considered as major contributing factors in the increased morbidity and mortality of the patients. In this review authors briefly summarize clinical characteristics of acromegalic cardiomyopathy.

Myocardial blood flow and fibrosis in hypertrophic cardiomyopathy

BACKGROUND

We investigated the relationship between myocardial blood flow (MBF), fibrosis, risk factors for sudden death, and clinical manifestations in hypertrophic cardiomyopathy (HCM).

METHODS AND RESULTS

Sixty-two patients with HCM (45 men, overall mean age 47 ± 16 years), 15 acromegalic patients with left ventricular hypertrophy (9 man, overall mean age 47 ± 12 years), and 20 healthy subjects underwent cardiac magnetic resonance. Resting MBF was measured as the ratio between coronary sinus flow measured by phase-contrast technique and left ventricular mass. Myocardial fibrosis was evaluated by late gadolinium enhancement (LGE) technique. In HCM patients, MBF was significantly lower than in control subjects and acromegalic patients. Patients with LGE had lower MBF than those without it (0.46 ± 0.2 vs 0.66 ± 0.29 mL·min(-1)·g(-1); P < .005). Patients with ventricular tachycardia at Holter monitoring had lower MBF (0.4 ± 0.14 vs 0.6 ± 0.29 mL·min(-1)·g(-1); P < .04). Among patients with preserved systolic function, those in New York Heart Association (NYHA) functional class ≥II had lower MBF than those in NYHA functional class I (0.46 ± 0.2 vs 0.69 ± 0.3 mL·min(-1)·g(-1); P < .003). MBF was the only independent predictor of worse clinical status (NYHA ≥II; P = .01).

CONCLUSIONS

In HCM patients low resting MBF is associated with the presence of fibrosis. MBF is a predictor of worse clinical status.

Effect of rosiglitazone on serum IGF-I concentrations in uncontrolled acromegalic patients under conventional medical therapy: results from a pilot phase 2 study

OBJECTIVE

Current therapies for acromegaly are unsatisfactory for some patients. High-dose thiazolidinediones have been reported to reduce serum GH levels in animal models of acromegaly. The objective of the study was to evaluate the effect of increasing doses of rosiglitazone on serum GH and IGF-I concentrations in acromegalic patients.

DESIGN

Phase 2 clinical trial.

PATIENTS AND METHODS

Five consecutive patients with active and uncontrolled acromegaly under conventional medical therapies were treated with increasing doses of rosiglitazone [4 mg/day every month, starting from 8 up to 20 mg/day] added to previous medical therapies for acromegaly.

RESULTS

Mean serum IGF-I concentrations decreased from 547 ± 91 to 265 ± 126 μg/l (p<0,001) during rosiglitazone treatment: 4 patients had normal serum IGF-I concentrations, and a patient had lowered serum IGF-I values, although still abnormal, at the end of the study. On the contrary, serum GH concentrations did not significantly changed during rosiglitazone therapy as well as other pituitary hormones. No relevant side effects of rosiglitazone were observed during the study period. Quantitative real time PCR and Western blotting showed that rosiglitazone lowered GH-dependent hepatic generation of IGF-I in HepG2 cell line.

CONCLUSIONS

Rosiglitazone reduces serum IGF-I concentrations in patients with uncontrolled acromegaly under conventional medical therapies, likely acting on the GH-dependent hepatic synthesis of IGF-I. Large studies are necessary to confirm the role of rosiglitazone as an adjunctive therapy for uncontrolled acromegalic patients under conventional medical therapies.

Current cardiac imaging techniques for detection of left ventricular mass

Estimation of left ventricular (LV) mass has both prognostic and therapeutic value independent of traditional risk factors. Unfortunately, LV mass evaluation has been underestimated in clinical practice. Assessment of LV mass can be performed by a number of imaging modalities. Despite inherent limitations, conventional echocardiography has fundamentally been established as most widely used diagnostic tool. 3-dimensional echocardiography (3DE) is now feasible, fast and accurate for LV mass evaluation. 3DE is also superior to conventional echocardiography in terms of LV mass assessment, especially in patients with abnormal LV geometry. Cardiovascular magnetic resonance (CMR) and cardiovascular computed tomography (CCT) are currently performed for LV mass assessment and also do not depend on cardiac geometry and display 3-dimensional data, as well. Therefore, CMR is being increasingly employed and is at the present standard of reference in the clinical setting. Although each method demonstrates advantages over another, there are also disadvantages to receive attention. Diagnostic accuracy of methods will also be increased with the introduction of more advanced systems. It is also likely that in the coming years new and more accurate diagnostic tests will become available. In particular, CMR and CCT have been intersecting hot topic between cardiology and radiology clinics. Thus, good communication and collaboration between two specialties is required for selection of an appropriate test.

Effects of somatostatin analogues on acromegalic cardiomyopathy: results from a prospective study using cardiac magnetic resonance

OBJECTIVE

Left ventricular (LV) hypertrophy is the main finding of patients with active acromegaly at cardiac magnetic resonance (CMR). The aim of the study was to evaluate heart changes in acromegalic patients treated with somatostatin analogues (SMSA) using CMR.

DESIGN AND PATIENTS

This was a prospective study. Fourteen consecutive patients (8 women, mean age 46+/-10 yr) with untreated active acromegaly were submitted to CMR and 2D-color Doppler echocardiography before and after a 6-month SMSA course.

MEASUREMENTS

LV volume, mass (LVM) and wall thickness.

RESULTS

CMR: Mean LVM and LVM index (i) decreased from 151+/-17 g and 77+/-9 g/m2, to 144+/-24 g and 70+/-12 g/m2, respectively (p=0.047 and p<0.0001, respectively); LV hypertrophy reverted in 6 out of 10 patients (p=0.016). Systolic function, evaluated by measuring LV ejection fraction remained normal in all patients (67+/-11%). There was not a correlation between changes in LVMi and changes in serum IGF-I concentrations. However, patients with controlled disease had higher reduction of LVMi than those with uncontrolled acromegaly (DeltaLVMi, -8.2+/-4.2 vs 4.0+/-5.3 p<0.05). 2D-echo cardiography: Mean LVMi decreased from 110+/-24 g/m2 to 100+/-20 g/m2 (p=0.026); hypertrophy, revealed in 5 patients (36%) at baseline, reversed in 2 patients (p=0.500) after SMSA; abnormal diastolic function [evaluated by isovolumic relaxation time or early (E) to late of atrial (A) peak velocities ratio] found in 4 patients (29%) at the study entry, improved in a patient. Systolic function remained within the normal range in all patients during the study period.

CONCLUSIONS

CMR detects changes in LVMi in most patients with acromegaly treated with SMSA, which are more evident if the disease is controlled.

Identification, treatment and management of cardiovascular risks in patients with acromegaly

Acromegaly, a syndrome related to growth hormone/IGF-1 excess, is frequently complicated by cardiovascular abnormalities (acromegalic cardiomyopathy). Extremely frequent are left ventricular hypertrophy and alterations of diastolic filling, which may progress to systolic dysfunction and eventually heart failure. Cardiac abnormalities may normalize after successful medical or surgical treatment of acromegaly, particularly in young patients with short-lasting disease, but this is less likely to occur in elderly patients. Both hypertension and cardiac valve disease are frequently encountered in acromegaly, but neither seems to be favorably influenced by disease control. The prevalence of coronary heart disease (CHD) is controversial but is probably not increased in acromegaly. Arrhythmias are relatively common in untreated acromegalic patients, although their clinical relevance is unknown. A cardiac evaluation of acromegalic patients should include echocardiography, basal electrocardiogram and blood pressure measurement, and evaluation of common risk factors for CHD. Appropriate and prompt treatment allowing a rapid control of growth hormone/IGF-1 hypersecretion is warranted because many features of acromegalic cardiomyopathy may be reverted, particularly in younger patients. In view of the lack of association with acromegaly, common risk factors for CHD, hypertension, arrhythmias or valve disease should be managed independently, irrespective of control of disease activity.