Changes of RV-PC coupling during negative for myocardial ischemia dobutamine stress echocardiography

Background

Coupling between RV contractile function and pulmonary circulation (PC) reflects the comprehensive performance of the RV by integrating afterload and contractility. RV-PC coupling is nowadays frequently expressed by the non-invasively measured ratios TAPSE/RVSP and RVFWLS/RVSP. It has been shown that it decreases slightly during exercise, whereas no known data exist on how dobutamine does affect it.

Purpose

The aim of this study was to evaluate the changes in RV-PC coupling and RV mechanics during the different stages of dobutamine stress echocardiography (DSE) in cases without known coronary artery disease (CAD) and negative for myocardial ischemia DSE.

Methods

Patients with a low-to-intermediate risk for CAD were referred for and underwent DSE. RV systolic function was evaluated with TAPSE, S' and RV Free Wall (RVFW) Strain. The non-invasively measured RV-PC coupling was evaluated by indexing TAPSE and RV free wall longitudinal strain to right ventricular systolic pressure (RVSP) during baseline echocardiogram, low dose (inotropic dobutamine effect) and peak dose (chronotropic effect) stages of DSE.

Results

Initially, a total of 53 patients underwent DSE. Eight patients had a positive for ischemia response and were excluded.

The remaining 45 patients {mean age 65±8.7, 28 (63%) male}, 24 (53%) had hypertension, 24 (53%) were smokers, 33 (74%) had dyslipidemia, 15 (34%) had family history of CAD and 7 (15%) had diabetes mellitus. TAPSE, S' and RVFW Strain increased from baseline to peak dose [23.55±2.91 vs 28.76±1.9 (p<0.001), 13.13±1.79 vs 23.83±4.87 (p<0.001) and 19.7±5.87 vs 23.46±5.42 (p=0.044) respectively].

TAPSE/RVSP showed a significant steady decrease between baseline and low dose (0.88±0.14 vs 0.79±0.19) and peak dose (0.88±0.14 vs 0.74±0.12) stages with a difference of 0.09 (p value 0.013) and 0.14 (p value 0.000) respectively. On the other hand, RVFW Strain/ RVSP exhibited a significant decrease (0.60±0.15, p value 0.000) only between baseline and peak dose.

There was no significant correlation of the change in TAPSE/RVSP with the change in E/E' or change in Systolic Blood Pressure.

Conclusions

RV-PC coupling decreases during negative for ischemia DSE independently of LV dynamic changes and therefore, future studies should be oriented to evaluate the incremental role of this novel index not only for the assessment and evaluation of myocardial ischemia and RV disease that affects RV coupling, but also as a prognostic marker for patients with no evident ischemia.

Funding Acknowledgement

Type of funding sources: None.

Dobutamine stress echocardiography during covid-19 pandemic: impact on volume and positivity rates in a tertiary hospital

Funding Acknowledgements

Type of funding sources: None.

Introduction

The emergence of coronavirus 2019 infection (covid-19) was accompanied by severe social and economic restrictions and applied significant pressure to the healthcare systems. The first pandemic wave started in March to May 2020 and was characterized by the peak of confinement measures and lockdown application. The second wave started in September and peaked in November to December 2020 and was characterized by improved healthcare organization but significant burden for the hospitals and intensive care units. Dobutamine stress echocardiography (DSE) is used for evaluation of ischemia in patients with known or suspected coronary artery disease.

Purpose

To compare DSE volume and positivity rates between 2019 and 2020 time periods in a department of a public tertiary hospital.

Methods

We retrospectively analysed DSE studies performed in our department in 2020 including the peak of covid-19 restrictions and compared the data to the 2019.

Results

Volume of DSE studies decreased from 1516 in 2019 to 996 in 2020 (-34.3%). The study volume reduction was greater in April (-93.7%) and May (-54.5%) when the covid-19 restrictions were at the peak. Great decreases were also recorded in November (-46.8%) and December (-53.5%) when the second wave of covid-19 disease emerged. Conversely, small increases were recorded in September (7.1%) and October (10.6%) (figure 1). Regarding positivity rates, a statistically non-significant increase was recorded (33.6% vs 34.2% in 2019 and 2020 respectively, p = 0.73). Interestingly a statistically significant increase in positivity levels was recorded during the period March to May 2020 compared to the same period of 2019 (44.7% vs 36.9%, p = 0.029). On the contrary, positivity rates were decreased at the period September to December (27.1% vs 34.2%, p = 0.019) (figure 2).

Conclusions

Volume of DSE studies was significantly reduced in 2020 when compared to 2019 during respective peaks of the pandemic and the accompanying restriction measures. Positivity rates were higher during the first pandemic wave, possibly due to decreased hospital attendance of mildly symptomatic patients in combination with stricter admission criteria at the emergency department. Lower positivity rates during the second pandemic wave possibly reflect an adjustment of both healthcare systems and patients to the new conditions imposed by the covid-19 pandemic. Abstract Figure 1  Abstract Figure 2

P1556Cardiovascular risk in white-coat hypertension individuals stratified by their nocturnal blood pressure dipping status

Background/Introduction

Nocturnal blood pressure (BP) dipping status, defined by the night-to-day BP ratio, has been correlated with the cardiovascular (CV) risk in patients with arterial hypertension. The risk is higher in those with less than normal or no drop in nocturnal BP while data in extreme dippers are inconsistent. On the other hand, white-coat hypertension (WCHT), defined as an elevated office BP despite a normal out-of-office BP, is characterized by a lower CV risk than that of sustained hypertension and rather comparable with that of true normotension.

Purpose

The present study assessed the possible relation between the nocturnal BP dipping status and the underlying CV risk in WCHT individuals.

Methods

Among all individuals examined in our outpatient anti-hypertensive units over the past 15 years, 2310 (42% men, 52.2±13.1 years of age) were diagnosed with WCHT (increased office BP: 156.4±10.0/99.6±6.2 mmHg and normal 24-hour ambulatory BP: 122.4±6.3/75.3±5.4 mmHg) and were enrolled in the study. A night-to-day BP ratio (from the 24-hour ambulatory BP monitoring) 0.8–0.9 defined Normal nocturnal BP Dipping, <0.8 Extreme Dipping, 0.9–1 Mild Dipping and >1 Absence of Dipping. The underlying 10-year CV risk of death in the studied population was calculated with the Hellenic version of the HeartScore (Hellenic Score), as proposed by the current 2018 European Society of Hypertension guidelines, based on age, gender, smoking status, systolic BP and total cholesterol levels.

Results

From 2310 individuals studied, 1208 (52.3%) were found with Normal Dipping, 386 (16.7%) with Extreme Dipping, 622 (26.9%) with Mild Dipping and 94 (4.1%) with Absence of Dipping. Hellenic Score was 3.21±4.67% in subjects with Normal Dipping, 3.49±4.97% in those with Extreme Dipping, 3.66±5.04% in those with Mild Dipping, 6.21±7.29%, in those with Absence of Dipping (p for trend<0.05) and 3.50±4.99% in the whole cohort of the studied population.

Conclusions

Nocturnal BP dipping status is closely associated with the underlying CV risk of WCHT individuals. Extreme Dipping, Mild Dipping and especially Absence of Dipping increase CV risk thus necessitating closer follow-up of these individuals and possibly faster initiation of BP-lowering drug treatment.

Neutrophil Gelatinase-Associated Lipocalin as an Early Marker of Contrast-Induced Nephropathy After Elective Invasive Cardiac Procedures

BACKGROUND

Contrast-induced nephropathy (CIN) is an acute kidney injury (AKI) defined as serum creatinine (sCr) increase 48 to 72 hours after contrast administration. Because most subjects undergoing invasive cardiac procedures are discharged within 24 hours, sCr is unsuitable for CIN detection.

HYPOTHESIS

In the present study we tested the hypothesis that neutrophil gelatinase-associated lipocalin (NGAL) is superior compared with sCr and other established nephropathy markers in early CIN diagnosis after elective invasive cardiac procedures.

METHODS

Serum creatinine, urine creatinine, serum cystatin C, urine albumin, urine NGAL (uNGAL), and plasma NGAL were measured at 0, 6, 24, and 48 hours after contrast administration in 100 elective invasive cardiac procedures. Estimated glomerular filtration rate and albumin-to-creatinine ratio were calculated. Changes from baseline were considered statistically significant at P < 0.05 and clinically significant when > the biomarker's reference change value. Participants were divided into those with and without clinically significant uNGAL changes (uNGAL positive and negative for AKI, respectively).

RESULTS

Thirty-three individuals were uNGAL positive for AKI. Serum cystatin C changes were statistically and clinically nonsignificant in both groups. Serum creatinine and plasma NGAL were statistically but not clinically elevated 48 hours postcatheterization in the AKI group. Except for contrast volume (higher in AKI group), groups were comparable at baseline (P not significant) regarding cardiovascular risk factors, coronary heart disease, coronary interventions performed, and renal biomarkers. Baseline uNGAL was significantly correlated to estimated glomerular filtration rate and albumin-to-creatinine ratio.

CONCLUSIONS

Urine NGAL is potentially superior compared with conventional nephropathy markers in early CIN diagnosis after elective invasive cardiac procedures. Definition of clinically significant uNGAL changes with reference change value is probably a valuable supplement to statistically defined significant variations.

Laparoscopic versus open cholecystectomy. An analysis of clinical and financial aspects

BACKGROUND

The aim of this study is to assess the clinical and financial aspects of laparoscopic cholecystectomy (LC) compared to open cholecystectomy (OC).

METHODS

Thirty-six patients treated with LC were prospectively, not randomized, compared with 35 patients that underwent OC. The data used were taken from local registers, patient-statistics and hospital accounting systems. We evaluated the costs, morbidity and mortality for both surgical procedures.

RESULTS

Significant differences were observed concerning the number of days that pain was suffered (mean 7.6 days in LC versus 18.5 days in OC), the duration of postoperative hospitalization (LC mean 2-3 days; OC 7-9 days), the extent of postoperative monitoring performed, and the number of days in order to return to normal activity (mean 4.4 days in LC; mean 7.6 days in OC). Calculation of the costs was based on the Diagnosis Related Groups (DRG). The profit for a DRG is the result of the difference between the reimbursement obtained from the execution of the operation and the cost in order to carry it out. The total cost for the execution of LC is Italian 3,332,632 pound sterling with a profit of Italian 1,208,807 pound sterling while for OC the cost is 4,007,359 pound sterling and the profit is 347,041 pound sterling.

CONCLUSIONS

The results of our study is that, clinically and financially, LC has obvious advantages over OC.

[Inflammatory markers after laparoscopy versus laparotomy cholecystectomy]

OBJECTIVE

The study is carried out to determine whether the level of IL-6 is altered and in what way after surgery as well as if such a change could be an indicator of increased morbidity after surgical treatment. MATERIALS OF THE STUDY: Chemiluminesence immunoeassay system was used in order to establish IL-6 level in blood samples of 71 patients that underwent abdominal surgery, 36 Laparoscopic Cholecystectomy (LC) and 35 Open Cholecystectomy (OC) at time 0 (before the operation), 1 h, 2 h, 3 h, 6 h, 24 h and 48 h after the operation.

RESULTS

Plasma IL-6 levels are significantly increased after OC; we observed 3 cases of post-operative infections, in which IL-6 returned to normal levels 6 days after surgery. Analogous variation to the IL-6 levels was noted for the C-reactive protein levels.

DISCUSSION

Laparoscopic cholecystectomy, a so called mini-invasive surgical procedure, is associated to a small increase of IL-6 serum levels and provides better post-operative conditions to the patients by reducing surgical stress and the infectious complications correlated to the surgical procedure.

CONCLUSIONS

During OC there is a significant higher elevation of IL-6 serum levels than after laparoscopic cholecystectomy. Variation of C-reactive protein serum levels after surgery is analogous to variation of IL-6 levels.

[Structure, function, and levels of neutrophil elastase after laparoscopic cholecystectomy]

Neutrophil elastase is a neutral proteinase present mainly in the azurophilic granules of segmented granulocytes, the main cells involved in the inflammatory response reaction. In our study we attempted to determine whether an enzyme such as neutrophil elastase produced by polymorpho-nuclear leukocytes could be an indicator capable of determining the degree of surgical trauma, comparing two surgical approaches, namely, laparoscopic cholecystectomy and open cholecystectomy. Plasma neutrophil elastase was determined photometrically, using an immune-activation immunoassay, in 66 patients (32 patients underwent open cholecystectomy and 34 laparoscopic cholecystectomy) 1 day before surgery and 1, 3, 6 and 12 days after surgery. We established a reference range for elastase by measuring the serum elastase concentration in 48 healthy control patients. A significant increase (p < 0.05) in plasma neutrophil elastase levels was observed on days 1, 3 and 6 after surgery in patients undergoing open cholecystectomy, whereas the levels of the enzyme were almost stable in patients undergoing laparoscopic cholecystectomy. We recorded two cases (6.2%) of respiratory tract infections in the "open" group. Neutrophil elastase is a good indicator for discriminating the severity of the surgical trauma, which is certainly more severe in laparotomy than in laparascopic cholecystectomy. Peripheral leukocyte function seems to be better preserved after laparoscopic surgery than after laparotomy.

Prevalence of autoantibodies against contractile proteins in coronary artery disease and their clinical implications

In this initial study, we found that autoantibodies against actin and myosin were present during and after an acute coronary syndrome. Moreover, they correlated with persistent troponin-I elevation at follow-up, and with late myocardial infarction.