Advances in Research on the Cardiovascular Complications of Acromegaly

Echocardiographic and Impedance Cardiography Analysis of Left Ventricular Diastolic Function in Acromegaly Patients

BACKGROUND Due to the chronic effects of excess growth hormone (GH) and insulin-like growth factor-1 (IGF-1), patients with acromegaly (AC) may develop acromegalic cardiomyopathy with biventricular hypertrophy, systolic and diastolic dysfunction, resulting in congestive heart failure. This study aimed to evaluate the echocardiographic parameters of left ventricular (LV) diastolic function and impedance cardiography (ICG) parameters of cardiovascular hemodynamics in patients with AC. MATERIAL AND METHODS A total of 33 patients (male to female ratio: 1.2; mean age 47 years) newly diagnosed with AC based on the blood hormone levels and imaging study findings were included into this observational cohort study. The echocardiographic parameters of LV diastolic function included early diastolic velocity of the average mitral annulus (e'avg), ratio of early diastolic mitral inflow velocity to early diastolic mitral annular tissue velocity (E/e'ratio), mitral flow early (E) and late (A) phase ratio (E/A). The ICG parameters included stroke volume index (SI), cardiac index (CI), acceleration index (ACI), systemic vascular resistance index (SVRI), total arterial compliance index (TACI) and thoracic fluid content (TFC). RESULTS Poorer parameters of LV diastolic function corresponded to the parameters assessed via ICG: 1) lower ratio E/A was associated with lower SI (P<0.001), CI (P=0.007), VI (P=0.04), ACI (P=0.02), TACI (P=0.005) and higher SVRI (P<0.001), 2) lower E/e' ratio was associated with higher TFC (P=0.03); 3) lower e'avg was associated with lower SI (P=0.01) and CI (P=0.048) and higher SVRI (P=0.03), despite normal LV ejection fraction. CONCLUSIONS Impaired LV diastolic function in AC is associated with impaired pumping function of the heart and higher afterload as assessed on ICG.

Electrocardiographic ventricular arrhythmia parameters during diagnosis and after the treatment of acromegaly: A case-control study

Background

The risk of death is increased in acromegaly patients compared to the general population, and cardiovascular system-related complications are among the risk factors decreasing life expectancy. The Tp-e interval, which is the distance between the point where the T-wave peaks and ends on electrocardiography (ECG), shows ventricular rapolarization and, together with the Tp-e/QT and Tp-e/QTc ratios, these are relatively new tools that predict ventricular arrhythmia. We aimed to evaluate the ECG of acromegaly patients at the time of diagnosis and compare the results with current ECG findings.

Material and methods

The study included 103 acromegaly patients and 81 control subjects. Of the 103 patients, 41 patients had only baseline ECG, 23 patients had only current ECG and 39 patients had both baseline and current ECGs. Heart rate, QT interval and corrected QT (QTc) interval, Tp-e, Tp-e/QT, Tp-e/QTc values on the ECGs were measured by a cardiologist.

Results

In the acromegaly patients with both baseline and current ECGs, heart rate, QRS duration, Tp-e, and Tp-e/QTc ratio were decreased. The decrease in these arrhythmia parameters was similar in active and remission patients. Compared to the control group, in acromegaly patients with only baseline ECG, heart rate, QTc interval, Tp-e, Tp-e/QT, and Tp-e/QTc were decreased.

Conclusion

Ventricular arrhythmia parameters improve with treatment in patients with acromegaly. The decrease in ventricular arrhythmia parameters was similar in active and remission patients, which can be explained by the significant decrease in IGF-1 levels compared to the time of diagnosis, even in patients with active disease.

Uncontrolled Acromegaly Resulting in the Need for Left Ventricular Assist Device as Bridge to Heart Transplant

Acromegaly is a rare pituitary condition stemming from hypersecretion of growth hormone (GH). Classic presentation involves enlarged hands, feet, and coarse facial features. However, late-onset cardiac manifestations develop in the absence of disease control. Of the various cardiac complications, heart failure is the rarest (3%-4% of cases). Here we present a case of acromegaly diagnosed after the patient exhibited symptoms of heart failure, with eventual placement of a left ventricular assist device (LVAD) as a bridge to orthotopic heart transplant. The 37-year-old patient originally presented with exercise intolerance and "heavy heartbeats" but was found to be in acute decompensated heart failure, with an ejection fraction (EF) of 15%. The acromegaly diagnosis was confirmed with labs, and he began treatment with lanreotide 120 mg weekly along with 0.5 mg cabergoline twice weekly. EF improved up to 30%. Soon after, he was lost to follow-up during the COVID-19 pandemic and returned with worsening EF. An LVAD was placed to support recovery while the patient awaited heart transplant. While LVADs are a common measure of cardiac support for ischemic cardiomyopathy, they can also be successful options in the setting of GH-driven cardiomegaly.

Aneurysmal dilation of sinus of Valsalva in a patient with undiagnosed acromegaly

Key Clinical Message

In patients presenting with aortic ectasia and myxomatous valve diseases at young ages, possible underlying acromegaly should be in mind.

Abstract

Acromegaly is a chronic systemic disease mainly caused by the benign pituitary adenoma secreting growth hormone (GH) in excess. Acromegaly is associated with various complications such as cardiovascular diseases. In this regard, timely diagnosis, and management of these patients could be life-saving. Herein, a case of aneurysmal dilation of the sinus of Valsalva with severe aortic and mitral regurgitation in a patient with undiagnosed acromegaly is presented.

Use of speckle tracking echocardiography in evaluating cardiac dysfunction in patients with acromegaly: an update

In recent years, cardiovascular disease has garnered increasing attention as the second leading cause of death in individuals with acromegaly, following malignancy. Identifying cardiac dysfunction early in acromegaly patients for timely intervention has become a focal point of clinical research. Speckle tracking echocardiography, a well-established ultrasound technique, surpasses conventional Doppler ultrasound in its sensitivity to assess both local and global cardiac mechanics. It can accurately detect subclinical and clinical myocardial dysfunction, including myocardial ischemia, ventricular hypertrophy, and valvular changes. Over the past five years, the use of speckle tracking echocardiography in acromegaly patients has emerged as a novel approach. Throughout the cardiac cycle, speckle tracking echocardiography offers a sensitive evaluation of the global and regional myocardial condition by quantifying the motion of myocardial fibres in distinct segments. It achieves this independently of variations in ultrasound angle and distance, effectively simulating the deformation of individual ventricles across different spatial planes. This approach provides a more accurate description of changes in cardiac strain parameters. Importantly, even in the subclinical stage when ejection fraction remains normal, the strain parameters assessed by speckle tracking echocardiography hold a good predictive value for the risk of cardiovascular death and hospitalization in acromegaly patients with concomitant cardiovascular disease. This information aids in determining the optimal timing for interventional therapy, offering important insights for cardiac risk stratification and prognosis. In the present study, we comprehensively reviewed the research progress of speckle tracking echocardiography in evaluating of cardiac dysfunction in acromegaly patients, to pave the way for early diagnosis of acromegaly cardiomyopathy.

Insulin-Like Growth Factor 1 and Risk of Cardiovascular Disease: Results From the UK Biobank Cohort Study

CONTEXT

Relationships between insulin-like growth factor 1 (IGF-1) levels and cardiovascular disease (CVD) in the general population remain unclear.

OBJECTIVE

This study aims to investigate the association of circulating IGF-1 concentrations with CVD from a population-based cohort study.

METHODS

A total of 394 082 participants without CVD and cancer at baseline from UK Biobank were included with measurements of serum IGF-1 at baseline. Main outcomes were incidence of CVD, including CVD mortality, coronary heart disease (CHD), myocardial infarction (MI), heart failure (HF), and stroke.

RESULTS

Over a median 11.6 years of follow-up, UK Biobank documented 35 803 incident CVD cases, including 4231 from CVD-related death, 27 051 from CHD, 10 014 from MI, 7661 from HF, and 6802 from stroke. Dose-response analysis showed a U-shaped relationship between IGF-1 levels and cardiovascular events. Compared with the third quintile of IGF-1, the lowest category of IGF-1 was associated with increased risk of CVD (hazard ratio 1.128; 95% CI, 1.093 to 1.164), CVD mortality (1.294; 1.181 to 1.418), CHD (1.118; 1.078 to 1.159), MI (1.071; 1.008 to 1.139), HF (1.185; 1.107 to 1.268), and stroke (1.149, 1.070 to 1.235); also, the highest category was associated with increased risk of CVD (1.056; 1.020 to 1.094), CVD mortality (1.111; 1.000 to 1.236), CHD (1.070; 1.028 to 1.114), MI (1.111; 1.041 to 1.187) and HF (1.098; 1.015 to 1.188) after multivariable adjustment.

CONCLUSION

This study indicates that both low and high levels of circulating IGF-1 are associated with increased risk of CVD in general population. These results highlight the importance of monitoring IGF-1 status on cardiovascular health.

Effects of acromegaly treatment on left ventricular systolic function assessed by speckle tracking echocardiography in relation to sex differences: results from a prospective single center study

Background

Despite the preserved LVEF, patients with acromegaly are characterized by subclinical systolic dysfunction i.e., abnormal global longitudinal strain (GLS) assessed by speckle tracking echocardiography (STE). The effect of acromegaly treatment on LV systolic function assessed by STE, has not been evaluated so far.

Patients and methods

Thirty-two naïve acromegalic patients without detectable heart disease were enrolled in a prospective, single-center study. 2D-Echocardiography and STE were performed at diagnosis, 3&6 months on preoperative somatostatin receptor ligand (SRL) treatment and 3 months after transsphenoidal surgery (TSS).

Results

Treatment with SRL resulted in reduction in median (IQR) GH&IGF-1 levels after 3 months, from 9.1(3.2-21.9) to 1.8(0.9-5.2) ng/mL (p<0.001) and from 3.2(2.3-4.3) to 1.5(1.1-2.5) xULN (p<0.001), respectively. Biochemical control on SRL was achieved in 25.8% of patients after 6 months and complete surgical remission was achieved in 41.7% of patients. TSS resulted in decrease in median (IQR) IGF-1 compared to IGF-1 levels on SRL treatment: from 1.5(1.2-2.5) to 1.3(1.0-1.6) xULN (p=0.003). Females had lower IGF-1 levels at baseline, on SRL and after TSS compared to males. The median end diastolic and end systolic left ventricle volumes were normal. Almost half of the patients (46.9%) had increased LVMi, however the median value of LVMi was normal in both sex groups: 99g/m² in males and 94g/m² in females. Most patients (78.1%) had increased LAVi and the median value was 41.8mL/m². At baseline 50% of patients, mostly men (62.5% vs. 37.5%) had GLS values higher than -20%. There was a positive correlation between baseline GLS and BMI r=0.446 (p=0.011) and BSA r=0.411 (p=0.019). The median GLS significantly improved after 3 months of SRL treatment compared to baseline: -20.4% vs. -20.0% (p=0.045). The median GLS was lower in patients with surgical remission compared to patients with elevated GH&IGF-1 levels: -22.5% vs. -19.8% (p=0.029). There was a positive correlation between GLS and IGF-1 levels after TSS r=0.570 (p=0.007).

Conclusion

The greatest beneficial effect of acromegaly treatment on LV systolic function is visible already after 3 months of preoperative SRL treatment, especially in women. Patients with surgical remission have better GLS compared to patients with persistent acromegaly.

Cardiovascular Effects of Excess Growth Hormone: How Real is the Threat?

Patients with acromegaly carry a high risk of developing cardiovascular diseases (CVD). In fact, CVD is the leading cause of mortality among this group of patients. The most frequent cardiovascular complications are heart failure (HF), valvular disease, hypertension, arrhythmias, and coronary artery disease (CAD). The pathophysiology centers on the family of growth hormone (GH). These hormones are involved in normal cardiac development and function; however, excess of insulin-like growth factor-1 (IGF-1), the principally active hormone, can also cause negative effects on the cardiovascular system. HF in acromegaly usually presents with biventricular enlargement and diastolic dysfunction and is strongly associated with the duration of GH excess rather than the degree of hormone elevation. There is a high prevalence of valvular disease affecting aortic and mitral valves among patients with longer disease duration. The development of hypertension in acromegaly may be attributed to the effects of chronic GH/IGF-1 excess on different organ systems, which act via several mechanisms. The aspect of arrhythmia and CAD complicating acromegaly are currently not fully understood.

Prescription patterns of somatostatin analogs in patients with acromegaly and neuroendocrine tumors

PURPOSE

Acromegaly and neuroendocrine tumors are rare diseases that, under certain conditions, can be treated with somatostatin analogs. The aim was to determine the prescription patterns of somatostatin analogs in a group of patients with acromegaly and neuroendocrine tumors affiliated with the Colombian Health System.

METHODS

A retrospective study. A cohort of patients from a drug dispensing database that collected all prescriptions of long-acting somatostatin analogs (octreotide, lanreotide, pasireotide). Sociodemographic variables, clinical variables (diagnosis and comorbidities) and pharmacological therapy variables (dose, changes, persistence of use, comedications) were considered.

RESULTS

A total of 213 patients were identified, including 139 (65.3%) with acromegaly and 74 (34.7%) with neuroendocrine tumors. There was a predominance of women (58.7%) and a mean age of 59.7 ± 14.5 years. The most commonly used medications were lanreotide autogel (n = 107; 50.2%), octreotide LAR (n = 102; 47.9%) and pasireotide LAR (n = 4; 1.9%). During follow-up, 11.3% of patients experienced modifications of therapy, with a mean duration from the beginning of treatment to the change in medication of 25 ± 15.9 months. A total of 48.9% of the patients with acromegaly and 87.1% of individuals with neuroendocrine tumors received maximum approved doses of the drug.

CONCLUSION

Patients with acromegaly and neuroendocrine tumors in Colombia are mainly women and are most frequently treated with lanreotide autogel for acromegaly and with octreotide LAR for neuroendocrine tumors. In addition, a high proportion are managed with maximum doses of long-acting somatostatin analogs.

Approach of Acromegaly during Pregnancy

Acromegaly-related sub/infertility, tidily related to suboptimal disease control (1/2 of cases), correlates with hyperprolactinemia (1/3 of patients), hypogonadotropic hypogonadism—mostly affecting the pituitary axis in hypopituitarism (10−80%), and negative effects of glucose profile (GP) anomalies (10−70%); thus, pregnancy is an exceptional event. Placental GH (Growth Hormone) increases from weeks 5−15 with a peak at week 37, stimulating liver IGF1 and inhibiting pituitary GH secreted by normal hypophysis, not by somatotropinoma. However, estrogens induce a GH resistance status, protecting the fetus form GH excess; thus a full-term, healthy pregnancy may be possible. This is a narrative review of acromegaly that approaches cardio-metabolic features (CMFs), somatotropinoma expansion (STE), management adjustment (MNA) and maternal-fetal outcomes (MFOs) during pregnancy. Based on our method (original, in extenso, English—published articles on PubMed, between January 2012 and September 2022), we identified 24 original papers—13 studies (3 to 141 acromegalic pregnancies per study), and 11 single cases reports (a total of 344 pregnancies and an additional prior unpublished report). With respect to maternal acromegaly, pregnancies are spontaneous or due to therapy for infertility (clomiphene, gonadotropins or GnRH) and, lately, assisted reproduction techniques (ARTs); there are no consistent data on pregnancies with paternal acromegaly. CMFs are the most important complications (7.7−50%), especially concerning worsening of HBP (including pre/eclampsia) and GP anomalies, including gestational diabetes mellitus (DM); the best predictor is the level of disease control at conception (IGF1), and, probably, family history of 2DM, and body mass index. STE occurs rarely (a rate of 0 to 9%); some of it symptoms are headache and visual field anomalies; it is treated with somatostatin analogues (SSAs) or alternatively dopamine agonists (DAs); lately, second trimester selective hypophysectomy has been used less, since pharmaco-therapy (PT) has proven safe. MNA: PT that, theoretically, needs to be stopped before conception—continued if there was STE or an inoperable tumor (no clear period of exposure, preferably, only first trimester). Most data are on octreotide > lanreotide, followed by DAs and pegvisomant, and there are none on pasireotide. Further follow-up is required: a prompt postpartum re-assessment of the mother’s disease; we only have a few data confirming the safety of SSAs during lactation and long-term normal growth and developmental of the newborn (a maximum of 15 years). MFO seem similar between PT + ve and PT − ve, regardless of PT duration; the additional risk is actually due to CMF. One study showed a 2-year median between hypophysectomy and pregnancy. Conclusion: Close surveillance of disease burden is required, particularly, concerning CMF; a personalized approach is useful; the level of statistical evidence is expected to expand due to recent progress in MNA and ART.

Insulin-like growth factor-1 levels are associated with interventricular septal thickening

BACKGROUND AND OBJECTIVE

Insulin-like growth factor-1 (IGF-1) regulates cardiomyocyte survival, hypertrophy, and ageing. We aimed to investigate the potential correlation between IGF-1 and interventricular septal (IVS) thickening.

METHODS

Medical record data were obtained from patients hospitalized between May 1, 2012 and April 30, 2022. All patients underwent echocardiography and had laboratory data on plasma IGF-1. We analyzed the relationship between IGF-1 levels and IVS thickening based on logistic regression models.

RESULTS

Propensity score matching at 1:4 ratio was performed for 180 patients with IVS thickening and 1,964 patients without IVS thickening. Finally, 180 (case group) and 623 (control group) patients were enrolled. Of the total 803 patients, the mean age was 59 years, and 59.7% were male. In multivariate-adjusted models that adjusted for propensity scores, the risk of IVS thickening increased with increasing IGF-1 levels; specifically, the risk of IVS thickening increased per 1 ng/mL [odds ratio (OR) 1.003; 95% confidence interval (CI): 1.002-1.004; P < 0.001], per 5 ng/mL (OR, 1.016; 95% CI, 1.010-1.022; P < 0.001), and per 10 ng/mL(OR, 1.032; 95% CI, 1.019-1.045; P < 0.001) increase in IGF-1 levels. When the IGF-1 levels were expressed as a categorical variable, the increased levels of IGF-1 led to an increased risk of IVS thickening; specifically, the OR of IVS thickening for T3 >152.00 ng/mL was 2.020 (95% CI: 1.310-3.115, P < 0.01) compared with T1 <102.00 ng/mL. We performed restricted cubic splines, and it showed a linear association between IGF-1 levels and the risk of IVS thickening. In splines for the age and sex subgroups, different IGF-1 levels increased the risk of IVS thickening among different age groups in male patients: 18-44 years when IGF-1 value >164.00 ng/mL, 45-60 years when IGF-1 value > 140.34 ng/mL and ≥ 60 years when IGF-1 value >108.20 ng/mL. In female patients aged 45-60 years, the risk of IVS thickening increased when the IGF-1 levels were >207.45 ng/mL. However, IGF-1 was not significantly correlated with IVS thickening in female patients aged 18-45 and ≥60 years. Sensitivity analysis by excluding those with acromegaly did not change the relationship between IGF-1 and the risk of IVS thickening.

CONCLUSION

The plasma IGF-1 levels were related to the risk of IVS thickening irrespective of blood pressure.