Peak systolic velocity using color-coded tissue Doppler imaging, a strong and independent predictor of outcome in acute coronary syndrome patients

The Long-Term Effect of Maternal Obesity on the Cardiovascular Health of the Offspring-Systematic Review

Maternal obesity may affect offspring's cardiovascular health. Our literature search using PubMed, Web of Sciences included original English research and Google Scholar articles published over the past ten years, culminating in 96 articles in this topic. A mother's obesity during pregnancy has a negative impact on the cardiovascular risk for their offspring. Dependence was observed in relation to hypertension, coronary artery disease, stroke, and heart failure. The adverse impact of an abnormal diet in pregnant mice on heart hypertrophy was observed, and was also confirmed in human research. Pregnant women with obesity were at greater risk of having a child with innate heart disease than pregnant women with normal mass. To conclude: mother's obesity has a negative impact on the long-term cardiovascular consequences for their offspring, increasing their risk of high blood pressure, coronary heart disease, stroke and heart failure. It also increases the probability of heart hypertrophy and innate heart defects.

Reduced Left Ventricular Twist Early after Acute ST-Segment Elevation Myocardial Infarction as a Predictor of Left Ventricular Adverse Remodelling

BACKGROUND

The left ventricular (LV) remodelling process represents the main cause of heart failure after a ST-segment elevation myocardial infarction (STEMI). Speckle-tracking echocardiography (STE) can detect early deformation impairment, while also predicting LV remodelling during follow-up. The aim of this study was to investigate the STE parameters in predicting cardiac remodelling following a percutaneous coronary intervention (PCI) in STEMI patients.

METHODS

The study population consisted of 60 patients with acute STEMI and no history of prior myocardial infarction treated with PCI. The patients were assessed both by conventional transthoracic and ST echocardiography in the first 12 h after admission and 6 months after the acute phase. Adverse remodelling was defined as an increase in LVEDV and/or LVESV by 15%.

RESULTS

Adverse remodelling occurred in 26 patients (43.33%). By multivariate regression equation, the risk of adverse remodelling increases with age (by 1.1-fold), triglyceride level (by 1.009-fold), and midmyocardial radial strain (mid-RS) (1.06-fold). Increased initial twist decreases the chances of adverse remodelling (0.847-fold). The LV twist presented the largest area under the receiver operating characteristic (ROC) curve to predict adverse remodelling (AUROC = 0.648; 95% CI [0.506;0.789], p = 0.04). A twist value higher than 11° has a 76.9% specificity and a 72.7% positive predictive value for reverse remodelling at 6 months.

The association between tissue doppler-derived E/(e's') ratio and coronary atherosclerosis severity measured by the SYNTAX score in patients with non-ST elevation-acute coronary syndrome

BACKGROUND

The prognosis of patients hospitalized with non-ST elevation-acute coronary syndrome (NSTE-ACS) is typically determined by the existence and severity of myocardial necrosis and left ventricular (LV) remodeling.

AIM

The present study was to assess the association between the E/(e's') ratio and the coronary atherosclerosis severity, measured by the SYNTAX score, in patients with NSTE-ACS.

METHODS

Utilizing a descriptive correlational research design, this study was prospectively conducted on 252 patients with NSTE-ACS, undergoing an echocardiography to determine the left ventricular ejection fraction (LVEF), the left atrial (LA) volume, the pulsed-wave (PW) Doppler-derived transmitral early (E) and late (A) diastolic velocities, and the tissue Doppler (TD)-derived mitral annular early diastolic (e') and peak systolic (s') velocities. After that, a coronary angiography (CAG) was performed, and the SYNTAX score was calculated.

RESULTS

The patients were divided into two groups, viz., those with the E/(e's') ratio < 1.63 and the cases with the ratio ≥ 1.63. The results revealed that the patients with a high ratio were older, had a higher prevalence of females, a SYNTAX score ≥ 22, and a lower glomerular filtration rate than those with a low ratio (p-value < 0.001). Besides, these patients had larger indexed LA volume and lower LVEF than others (p-value: 0.028 and 0.023, respectively). Furthermore, the multiple linear regression outcomes established a positive independent association between the E/(e's') ratio ≥ 1.63 (B = 5.609, 95% CI 2.324-8.894, p-value = 0.001) and the SYNTAX score.

CONCLUSION

The study results demonstrated that the patients hospitalized with NSTE-ACS and the E/(e's') ratio ≥ 1.63 had worse demographic, echocardiographic, and laboratory profiles and a higher prevalence of a SYNTAX score ≥ 22 than those with a lower ratio.

Considering Both GLS and MD for a Prognostic Value in Non-ST-Segment Elevated Acute Coronary Artery Syndrome

Global longitudinal strain (GLS) and mechanical dispersion (MD), as determined by 2D speckle tracking echocardiography, have been demonstrated to be reliable indicators of prognosis in a variety of cardiovascular illnesses. There are not many papers that discuss the prognostic significance of GLS and MD in a population with non-ST-segment elevated acute coronary syndrome (NSTE-ACS). Our study objective was to examine the predictive utility of the novel GLS/MD two-dimensional strain index in NSTE-ACS patients. Before discharge and four to six weeks later, echocardiography was performed on 310 consecutive hospitalized patients with NSTE-ACS and effective percutaneous coronary intervention (PCI). Cardiac mortality, malignant ventricular arrhythmia, or readmission owing to heart failure or reinfarction were the major end points. A total of 109 patients (35.16%) experienced cardiac incidents during the follow-up period (34.7 ± 8 months). The GLS/MD index at discharge was determined to be the greatest independent predictor of composite result by receiver operating characteristic analysis. The ideal cut-off value was -0.229. GLS/MD was determined to be the top independent predictor of cardiac events by multivariate Cox regression analysis. Patients with an initial GLS/MD > -0.229 that deteriorated after four to six weeks had the worst prognosis for a composite outcome, readmission, and cardiac death according to a Kaplan-Meier analysis (all p < 0.001). In conclusion, the GLS/MD ratio is a strong indicator of clinical fate in NSTE-ACS patients, especially if it is accompanied by deterioration.

The Incremental Prognostic Value of E/(e'×s') Ratio in Non-ST-Segment Elevated Acute Coronary Syndrome

It has been shown that the E/(e’×s’) index, which associates a marker of diastolic function (E/e’, early transmitral/diastolic mitral annulus velocity ratio) and a parameter that explores LV systolic performance (s’, systolic mitral annulus velocity), is a good predictor of outcome in acute anterior myocardial infarction. There are no studies that have investigated the prognostic value of E/(e’×s’) in a non-ST-segment elevated acute coronary syndrome (NSTE-ACS) population. Echocardiography was performed in 307 consecutive hospitalized patients with NSTE-ACS and succesful percutaneous coronary intervention, before discharge and six weeks after. The primary endpoint consisted of cardiac death or readmission due to re-infarction or heart failure. During the follow-up period (25.4 ± 3 months), cardiac events occurred in 106 patients (34.5%). Receiver operating characteristic (ROC) analysis identified E/(e’×s’) at discharge as the best independent predictor of composite outcome. The optimal cut-off value was 1.63 (74% sensitivity, 67% specificity). By multivariate Cox regression analysis, E/(e’×s’) was the only independent predictor of cardiac events. Kaplan–Meier analysis identified that patients with an initial E/(e’×s’) > 1.63 that worsened after six weeks presented the worst prognosis regarding composite outcome, readmission, and cardiac death (all p < 0.001). In conclusion, in NSTE-ACS, E/(e’×s’) is a powerful predictor of clinical outcome, particularly if it is accompanied by worsening after 6-weeks.

The association of peak systolic velocity in the carotid artery with coronary heart disease: A study based on portable ultrasound

Cardiovascular disease (CVD) is the highest cause of death globally with more people dying annually from it than from any other cause. CVD is associated with modifiable risk factors (dyslipidaemia, hypertension and diabetes) and treating each of these factors lowers the risk of CVD. It is impossible to estimate the benefit of risk factor modification in the individual patient and extrapolating data from multiple trials is difficult. It would be useful to have a marker of risk that accurately estimates real time risk by measuring blood flow factors associated with the pathogenesis of atheroma. The aim of this preliminary study was to validate a low-cost measurement technique for obtaining blood flow velocity profiles and assess whether any of the measured and calculated factors, based on computational fluid dynamics (CFD) simulation, known to be associated with atheroma was associated with coronary heart disease (CHD), thus establishing its feasibility and acceptability as a clinical tool and suggesting areas for future research. Our study identified (i) that mean peak systolic (PS) velocity being associated with CHD; individuals without CHD: mean (SD) = 62.8 (16.1) cm/s, with CHD: mean (SD)  = 53.6 (17.3) cm/s, p = 0.042; and (ii) that low-cost, portable ultrasound, which is routinely available in general practice, is a suitable assessment tool.

Testosterone Therapy: An Assessment of the Clinical Consequences of Changes in Hematocrit and Blood Flow Characteristics

INTRODUCTION

Clinical guidelines indicate that hematocrit should be monitored during testosterone replacement therapy (TTh), with action taken if a level of 0.54 is exceeded.

AIM

To consider the extent of changes in hematocrit and putative effects on viscosity, blood flow, and mortality rates after TTh.

METHODS

We focused on literature describing benefits and possible pitfalls of TTh, including increased hematocrit. We used data from the BLAST RCT to determine change in hematocrit after 30 weeks of TTh and describe a clinical case showing the need for monitoring. We consider the validity of the current hematocrit cutoff value at which TTh may be modified. Ways in which hematocrit alters blood flow in the micro- and macro-vasculature are also considered.

MAIN OUTCOME MEASURES

The following measures were assessed: (i) change in hematocrit, (ii) corresponding actions taken in clinical practice, and (iii) possible blood flow changes following change in hematocrit.

RESULTS

Analysis of data from the BLAST RCT showed a significant increase in mean hematocrit of 0.01, the increase greater in men with lower baseline values. Although 0 of 61 men given TTh breached the suggested cutoff of 0.54 after 30 weeks, a clinical case demonstrates the need to monitor hematocrit. An association between hematocrit and morbidity and mortality appears likely but not proven and may be evident only in patient subgroups. The consequences of an increased hematocrit may be mediated by alterations in blood viscosity, oxygen delivery, and flow. Their relative impact may vary in different vascular beds.

CONCLUSIONS

TTh can effect an increased hematocrit via poorly understood mechanisms and may have harmful effects on blood flow that differ in patient subgroups. At present, there appears no scientific basis for using a hematocrit of 0.54 to modify TTh; other values may be more appropriate in particular patient groups. König CS, Balabani S, Hackett GI, et al. Testosterone Therapy: An Assessment of the Clinical Consequences of Changes in Hematocrit and Blood Flow Characteristics. Sex Med Rev 2019;7:650-660.

Embryonic programming of heart disease in response to obesity during pregnancy

Obesity during pregnancy programs adult-onset heart disease in the offspring. Clinical studies indicate that exposure to an adverse environment in utero during early, as compared to late, gestation leads to a higher prevalence of adult-onset heart disease. This suggests that the early developing heart is particularly sensitive to an adverse environment. Accordingly, growing evidence from clinical studies and animal models demonstrates that obesity during pregnancy alters the function of the fetal heart, programming a higher risk of cardiovascular disease later in life. Moreover, gene expression patterns and signaling pathways that promote initiation and progression of cardiovascular disease are altered in the hearts in offspring born to obese mothers. However, the mechanisms mediating the long-term effects of an adverse environment in utero on the developing heart leading to adult-onset disease are not clear. Here, we review clinical and experimental evidence documenting the effects of maternal obesity during pregnancy on the fetal and post-natal heart and emphasize on the potential mechanisms of disease programming.

Effects of exercise intensity and nutrition advice on myocardial function in obese children and adolescents: a multicentre randomised controlled trial study protocol

INTRODUCTION

The prevalence of paediatric obesity is increasing, and with it, lifestyle-related diseases in children and adolescents. High-intensity interval training (HIIT) has recently been explored as an alternate to traditional moderate-intensity continuous training (MICT) in adults with chronic disease and has been shown to induce a rapid reversal of subclinical disease markers in obese children and adolescents. The primary aim of this study is to compare the effects of HIIT with MICT on myocardial function in obese children and adolescents.

METHODS AND ANALYSIS

Multicentre randomised controlled trial of 100 obese children and adolescents in the cities of Trondheim (Norway) and Brisbane (Australia). The trial will examine the efficacy of HIIT to improve cardiometabolic outcomes in obese children and adolescents. Participants will be randomised to (1) HIIT and nutrition advice, (2) MICT and nutrition advice or (3) nutrition advice. Participants will partake in supervised exercise training and/or nutrition sessions for 3 months. Measurements for study end points will occur at baseline, 3 months (postintervention) and 12 months (follow-up). The primary end point is myocardial function (peak systolic tissue velocity). Secondary end points include vascular function (flow-mediated dilation assessment), quantity of visceral and subcutaneous adipose tissue, myocardial structure and function, body composition, cardiorespiratory fitness, autonomic function, blood biochemistry, physical activity and nutrition. Lean, healthy children and adolescents will complete measurements for all study end points at one time point for comparative cross-sectional analyses.

ETHICS AND DISSEMINATION

This randomised controlled trial will generate substantial information regarding the effects of exercise intensity on paediatric obesity, specifically the cardiometabolic health of this at-risk population. It is expected that communication of results will allow for the development of more effective evidence-based exercise prescription guidelines in this population while investigating the benefits of HIIT on subclinical markers of disease.

TRIAL REGISTRATION NUMBER

NCT01991106.

Automated analysis of color tissue Doppler velocity recordings of the fetal myocardium using a new algorithm

Background

Tissue Doppler imaging (TDI) can be used to assess fetal cardiac function and it has been shown to detect changes associated with hypoxia in animal models. However, the analysis is cumbersome and time consuming. The main objective of this study was to evaluate the feasibility of a new algorithm developed for the automated analysis of color TDI velocity recordings of the fetal myocardium. Furthermore, we wanted to assess the effect of different sizes of region of interests (ROI) on the measurement of cardiac cycle time intervals and myocardial velocities at different gestations.

Methods

This study included analysis of 261 TDI velocity traces obtained from 17 fetal echocardiographic examinations performed longitudinally on five pregnant women. Cine-loops of fetal cardiac four chamber view were recorded with color overlay in TDI mode and stored for off-line analysis. ROIs of different sizes were placed at the level of the atrioventricular plane in the septum and in the right and left ventricular walls of the fetal heart. An automated algorithm was then used for the analysis of velocity traces.

Results

Out of the total 261 velocity traces, it was possible to analyze 203 (78 %) traces with the automated algorithm. It was possible to analyze 93 % (81/87) of traces recorded from the right ventricular wall, 82 % (71/87) from the left ventricular wall and 59 % (51/87) from the septum. There was a trend towards decreasing myocardial velocities with increasing ROI length. However, the cardiac cycle time intervals were similar irrespective of which ROI size was used.

Conclusions

An automated analysis of color TDI fetal myocardial velocity traces seems feasible, especially for measuring cardiac cycle time intervals, and has the potential for clinical application.

Systolic and Diastolic Function by Tissue Doppler Imaging Predicts Mortality in Patients with Atrial Fibrillation

AIM

Tissue Doppler Imaging (TDI) detects early signs of left ventricular dysfunction. The prognostic potential of TDI in patients with atrial fibrillation (AF) has, however, not yet been clarified. This study evaluates the prognostic value of TDI in patients with atrial fibrillation.

METHODS AND RESULTS

In total, echocardiograms from 313 patients with AF during examination were analyzed offline. Longitudinal systolic velocity (s'), early diastolic velocity (e') and longitudinal displacement (LD) were measured by color TDI. During a median follow-up of 891 days, 64 patients (20%) died. TDI was significantly associated with all-cause mortality, and the risk of dying increased significantly per 1 cm/s decrease in s' (HR of 1.31, 95% CI 1.05-1.63; p=0.018) and e' (HR of 1.17, 95% CI 1.01-1.35; p=0.038) respectively, even after adjustment for age, gender, heart rate, aortic stenosis, DM and LVEF quartiles. LD also proved to be a significant predictor of outcome after multivariate adjustment (HR 1.23; 95% CI 1.05-1.44; p=0.012). The population was stratified according to high or low s' and e'. Patients with low s' and e' had more than three times the risk of mortality compared to the patients with high s' and e' (HR 3.64; 95% CI 1.83-7.26; p<0.001) and remained in significantly higher risk after adjustment for various risk factors.

CONCLUSIONS

Both systolic and diastolic performance, as assessed by TDI, are strong predictors of mortality in patients with atrial fibrillation, and especially the combination of systolic and diastolic dysfunction is a significant prognostic marker.