Prevalence and prognosis of genetically proven familial hypercholesterolemia in subjects with coronary artery disease and reduced ejection fraction

Few studies have genetically screened variants related to familial hypercholesterolemia (FH) and investigated their survival impact in patients with coronary artery disease (CAD) and reduced left ventricular ejection fraction (EF). Patients with CAD and reduced EF (< 40%) were enrolled. Their genomic DNAs were sequenced for FH-related genes. All-cause and cardiovascular mortality data served as the major outcome. A total of 256 subjects were analyzed and 12 subjects (4.7%) carried FH-related genetic variants. After a median follow-up period of 44 months, 119 of the study subjects died. Cox survival analysis showed that carrying the FH genetic variant did not have a significant impact on the survival of CAD with reduced EF. However, higher estimated glomerular filtration rate (eGFR), better EF and beta blocker use were protective for a lower all-cause mortality. Further larger studies are needed to evaluate the impact of carrying the FH-related genetic variant on survival of CAD with reduced EF.

A Higher Estimated Glomerular Filtration Rate Is Associated with Better Survival in Subjects with Coronary Artery Disease and Heart Failure with a Mildly Reduced Ejection Fraction

Subjects with coronary artery disease (CAD) have myocardial ischemia and associated abnormal left ventricular ejection fraction (EF). Heart failure with mildly reduced EF (41-49%) (HFmrEF) is a new subgroup of EF for heart failure. Although prognostic factors for CAD and HF with reduced EF are well known, fewer studies have been conducted on factors related to the survival of CAD and HFmrEF. We recruited study subjects with significant CAD and HFmrEF from our cardiac catheterization data bank. Data were recorded from traceable chart records from our hospital. All-cause and cardiovascular mortality were recorded until December 2019 and served as a follow-up outcome. A total of 348 subjects with CAD and HFmrEF were analyzed. The median duration of follow-up was 37 months. Seventy-eight subjects died during the follow-up period and 30 of them were due to cardiovascular causes. In univariate analyses, those who died were of older ages, and with a lower estimated glomerular filtration rate (eGFR) (47 ± 30 versus 71 ± 30 mL/minute/1.73 m2, P < 0.001), and lower usage of percutaneous coronary intervention (PCI) and beta blockers. In the Cox survival regression analysis, a higher eGFR (hazard ratio 0.980, P < 0.001) was protective, while older age and a higher serum total cholesterol (hazard ratio 1.006, P = 0.048) were related to all-cause mortality for CAD with HFmrEF. Furthermore, a higher eGFR was also associated with less cardiovascular mortality. In conclusion, for subjects with CAD and HFmrEF, a higher eGFR was protective and associated with a lower all-cause and cardiovascular mortality.

Plasma aryl hydrocarbon receptor associated with epicardial adipose tissue in men: a cross-sectional study

BACKGROUND

Epicardial adipose tissue (EAT) is a type of ectopic fat with endocrine and paracrine functions. Aryl hydrocarbon receptor (AhR) is a ligand-activated transcription factor that responds to environmental stimuli. AhR expression is associated with obesity. In this cross-sectional study, we aimed to determine the relationship between circulating AhR concentrations and EAT.

METHODS

A total of 30 men with obesity and 23 age-matched men as healthy controls were enrolled. Plasma AhR concentrations were determined at fasting. The EAT thickness was measured on the free wall of the right ventricle from the basal short-axis plane by magnetic resonance imaging.

RESULTS

The participants with obesity had a higher plasma AhR level than the controls (81.0 ± 24.5 vs. 65.1 ± 16.4 pg/mL, P = 0.010). The plasma AhR level was positively correlated with EAT thickness (correlation coefficient = 0.380, P = 0.005). After adjusting for fasting glucose levels, plasma AhR levels were still significantly associated with EAT thickness (95% CI 0.458‒5.357, P = 0.021) but not with body mass index (P = 0.168).

CONCLUSION

Plasma AhR concentrations were positively correlated with EAT thickness on the free wall of the right ventricle in men. Further investigations are needed to evaluate the causal effects and underlying mechanisms between AhR and EAT.

Rotablation for Octogenarians in a Modern Cathlab: Short- and Intermediate-Term Results

Background

There are limited reports on the treatment of complex calcified lesions using rotational atherectomy (RA) in octogenarians, particularly in high-risk patients.

Objective

To evaluate procedural and clinical outcomes of RA in octogenarians.

Methods

Consecutive RA patients from 2010 to 2018 were selected from our catheterization laboratory database, stratified into two groups (≥ or < 80 years old), and analyzed.

Results

A total of 411 patients (269 males and 142 females) with a mean age of 73.8 ± 11.3 years were enrolled, of whom 153 were ≥ 80 years old and 258 were < 80 years old. Most of the patients displayed high-risk features. The baseline Syntax scores were high in both groups, and most lesions were heavily calcified (96.1% vs. 97.3%, p = 0.969, respectively). The use of hemodynamic support intra-aortic balloon pump was more frequent in the octogenarians (21.6% vs. 11.6%, p = 0.007), but the RA completion rate was similarly high (95.9% vs. 99.1%, p = 0.842). There was no difference in acute complications. The total/cardiovascular (CV) death rate within one year was higher in the octogenarians, along with higher major adverse cardiovascular event (MACE)/CV MACE rates in the first month. Cox regression analysis showed that age ≥ 80 years, acute coronary syndrome, ischemic cardiomyopathy/shock, multi-vessel disease and serum creatinine were all predictors of MACE, and that these factors plus peripheral artery disease were predictors of all-cause mortality in these patients.

Conclusions

RA is feasible with a very high success rate in high-risk octogenarians with complex anatomies, and with equal safety and no increase in complications. The higher rates of all-cause death and MACE were attributed to an older age and other traditional risk factors.

Rotational atherectomy for chronically and totally occluded coronary lesions: A propensity score-matched outcomes study

Background

Despite advances being made in techniques and devices, certain chronic total occlusion (CTO) lesions remain uncrossable or undilatable. Rotational atherectomy (RA) is usually necessary for such lesions to achieve successful revascularization.

Methods

Information regarding consecutive patients who underwent coronary RA was retrieved from the catheterization laboratory database. Patients who underwent RA for CTO lesion refractory using other conventional devices were recruited, with propensity score-matched cases serving as controls.

Results

A total of 411 patients underwent coronary RA in the study period. Most patients had high-risk features (65.7% had acute coronary syndrome (ACS), 14.1% ischemic cardiomyopathy, and 5.1% cardiogenic shock), while only 20.2% of the patients had stable angina. Among them, 44 patients underwent RA for CTO lesions (CTO group), whereas the propensity score matched controls consist of 37 patients (non-CTO group). The baseline characteristics, high-risk features, coronary artery disease (CAD) vessel numbers, left ventricular function and biochemistry profiles of both groups were the same except for more patients with diabetes (67.6% vs. 45.5%, p = 0.046) in the non-CTO group and more 1.25 mm burr uses in the CTO group. There were no significant differences in acute procedural outcomes or incidence of acute contrast-induced nephropathy (CIN), and no patient demanded emergent CABG or died during the procedure. There was no significant difference in major adverse cardiovascular events (MACE), CV MACE or individual components between the two groups in the hospital, at 30, 90, and 180 days or at 1 year.

Conclusion

In comparison with the propensity risk factor scores-matched controls, there was no difference in procedural complications, acute CIN or clinical outcomes during various stages of RA for CTO lesions. RA for CTO patients was highly efficient and showed safety and outcome profiles similar to those for non-CTO lesions.

Lower All-Cause Mortality for Coronary Heart or Stroke Patients Who Adhere Better to Mediterranean Diet-An NHANES Analysis

Consuming a Mediterranean-style diet (MED) is helpful for primary prevention of atherosclerotic cardiovascular disease (ASCVD). However, few studies have compared mortality in ASCVD subjects with different degrees of adherence to the MED diet or have evaluated the contributions of individual diet components. We analyzed National Health and Nutrition Examination Survey (NHANES) participants with a history of coronary heart disease (CHD) or stroke (N = 2052) in a period from 1999 to 2010. Their individual vital status was linked to the National Death Index till the end of 2011. The level of adherence to the MED diet was quantified using a 9-point evaluation score (aMED score). Cox regression models were used to compare the different levels of adherence to the MED diet, and contributions of individual components of the MED diet on cardiovascular, cancer, and all-cause mortality. Among the 2052 subjects with CHD or stroke, 29.0% (596 of 2052) died after a median follow-up of 5.6 years. In Cox regression analysis, higher absolute aMED score (HR 0.798, p = 0.0079) or above median aMED score (score 4–9) (HR 0.646, p = 0.0013) was negatively associated with all-cause mortality. Among various components of the MED diet, intake of more whole grains or nuts was significantly associated with a lower all-cause mortality. In contrast, a higher aMED score was not associated with less cardiovascular mortality. In a secondary analysis that excluded deaths within 2 years of the NHANES study entry, the above median aMED score (score 4–9) was negatively associated with both all-cause and cardiovascular mortality. In conclusion, subjects with a history of CHD or stroke adhering better to the MED diet in the NHANES study had a lower all-cause mortality during follow-ups. Consuming more whole grains or nuts had a lower all-cause mortality. The protective effect of adherence to the MED diet on decreasing cardiovascular mortality was seen only after excluding those who died within first two years of the NHANES study entry.

Newly diagnosed diabetes based on an oral glucose tolerance test predicts cardiovascular outcomes in patients with coronary artery disease: An observational study

Diabetes is prevalent in patients with coronary artery disease (CAD). Using the oral glucose tolerance test (OGTT), abnormal glucose regulation can be detected early in CAD patients without known diabetes. In the present study, we assessed the impact of abnormal glucose regulation on the long-term cardiovascular outcomes of patients with established CAD. Patients hospitalized for a scheduled angiography due to angina were enrolled in Taichung Veterans General Hospital. Fasting plasma glucose (FPG) and 2-hour postload glucose (2hPG) were assessed using the OGTT. Hemoglobin A1c (HbA1c) and other biochemical analyses were assessed using fasting blood samples. During a median follow-up period of 4.6 years, a composite of all-cause mortality, nonfatal myocardial infarction, and nonfatal stroke was recorded as the primary endpoint. In 682 enrolled patients who completed the follow-up, there were 16 myocardial infarction events, 12 stroke events, and 58 deaths as composite endpoints. According to FPG and 2hPG, patients with newly diagnosed diabetes had a 2-fold higher risk for the composite endpoint than those in the normal glucose group (hazard ratio [HR], 2.011; 95% confidence interval (CI), 1.101-3.673; P = .023); however, prediabetes was not significantly associated with the composite endpoint (HR, 1.452; 95% CI, 0.788-2.675; P = .232). On the other hand, patients with diabetes diagnosed by FPG and HbA1c did not have a significantly higher risk for the composite endpoint than those in the normal glucose group (HR, 1.321; 95% CI, 0.686-2.545; P = .405). A 2hPG ≥7.8 mmol/L was a significant predictor for the composite endpoint (odds ratio, 1.743; 95% CI, 1.060-2.863; P = .028) after adjusting for age, sex, and estimated glomerular filtration rate. Diabetes, but not prediabetes, detected via OGTT is associated with a significantly increased risk for the composite endpoint in patients with established CAD. The 2hPG provided a greater predictive power for the composite endpoint than fasting glucose and HbA1c.

Whole Exome Sequencing of Patients With Heritable and Idiopathic Pulmonary Arterial Hypertension in Central Taiwan

Background

Genetic variants could be identified in subjects with idiopathic and heritable pulmonary arterial hypertension (PAH). The 6th World Symposium on Pulmonary Hypertension (WSPH) provided a list of genes with evidence of association with PAH. However, reports using whole exome sequencing (WES) from southeastern Asian PAH cohorts were scarce.

Methods

Subjects with idiopathic and heritable PAH (N = 45) from two medical centers in central Taiwan were screened for PAH related gene variants. The genomic DNA was prepared from peripheral blood lymphocytes. We performed WES for all patients enrolled in this study. All identified gene variants were validated by polymerase-chain reaction and Sanger sequencing. The clinical and hemodynamic data were compared between bone morphogenetic protein receptor type-2 (BMPR2) gene variants carriers vs. non-carriers.

Results

Eight patients (8/45 = 17.8%) was identified carrying BMPR2 gene variants and 8 patients (8/45 = 17.8%) had other WSPH-listed PAH-related gene variants (1 with ACVRL1, 1 with ENG, 1 with SMAD9, 1 with SMAD1, 1 with ATP13A3 and 3 with AQP1). In addition, a total of 14 non-WSPH-listed PAH-related genetic variant sites (ABCC8, NOTCH1, NOTCH2, NOTCH3, JAG1, BMP10, GGCX, FBLN2, ABCA3 and PTGIS) were found in this PAH cohort. Subjects carrying BMPR2 gene variant (N = 8) were younger at diagnosis of PAH (30 ± 11 vs 49 ± 13 years, p = 0.001) than the non-carrier group (N = 37). BMPR2 variant carriers had a trend toward having higher mean pulmonary arterial pressure (PAP) (61 ± 19 vs. 51 ± 13 mmHg, p = 0.076) than the non-carriers upon initial diagnosis. Pulmonary vascular resistance, right atrial pressure, cardiac output, as well as functional class were similar between BMPR2 variant carriers and non-carriers at initial diagnosis.

Conclusions

We identified 17.8% of patients with BMPR2 gene variants and 17.8% subjects with other 6th WSPH-listed PAH-related gene variants in a Taiwanese idiopathic and heritable PAH cohort. PAH patients carrying BMPR2 variants presented at a younger age with a trend toward having higher mean PAP at initial diagnosis.

Sustained Hemodynamic and Clinical Improvements for a Patient With Idiopathic Pulmonary Arterial Hypertension Over 1.5 Years After Balloon Atrial Septostomy: A Case Report

Balloon atrial septostomy (BAS) is an indicated treatment for subjects with idiopathic pulmonary arterial hypertension (IPAH), particularly for those with advanced right heart failure before bridging to lung transplantation. The mid-term clinical and hemodynamic benefits of BAS are not well studied. Here, we present a young female patient with IPAH who received maximal target medication and was admitted to our hospital due to advanced right heart failure. She had transition of subcutaneous to intravenous (IV) prostacyclin analogs (PA) injection and was registered for lung transplantation. The baseline mean right atrium (RA) pressure was 14 mmHg. BAS was performed with a balloon of 6 mm under intracardiac echocardiography (ICE) guidance. Systemic cardiac output (CO) (2.9–3.5 L/min) and oxygen delivery (OD) (291–318 ml/min) both increased after the BAS. Right heart failure was alleviated to function class II. One and a half years later, she received cardiac catheterization again. The second baseline mean RA pressure was 5 mmHg, left atrium (LA) pressure was 2 mmHg, and systemic CO was 3.3 L/min. These data indicated sustained hemodynamic improvements. The second course of BAS was performed under ICE guidance with a balloon of 8 mm. After the second BAS, her RA pressure was 3 mmHg, LA pressure was 3 mmHg, and CO was 3.4 L/min. In conclusion, BAS and IV PA infusion were effective in maintaining mid-term hemodynamic benefits and in stabilizing the critical right heart failure in a patient with IPAH over a 1.5-year period.

The Procedural and Clinical Outcomes of Rotational Atherectomy in Patients Presenting With Acute Myocardial Infarction

Background

Rotational atherectomy (RA) is an indispensable tool used for calcified lesion preparation in percutaneous coronary intervention (PCI). However, use of RA in the setting of acute myocardial infarction (AMI) is challenged with limited clinical data.

Objectives

This study aims to retrospectively investigate the procedural results, periprocedural complications, and clinical outcomes of RA in patients with AMI.

Methods

All possible consecutive patients who received RA in AMI from January 2009 to March 2018 in a single tertiary center were analyzed retrospectively. Patients without AMI during the study period were also enrolled for comparison.

Results

A total of 121 patients with AMI (76.0 ± 10.8 years, 63.6% males) and 290 patients without AMI were recruited. Among the AMI group, 81% of patients had non-ST-elevation myocardial infarction (NSTEMI) and 14% presented with cardiogenic shock. RA could be completed in 98.8% of patients in the AMI group and 98.3% in the non-AMI group (p = 1.00). The periprocedural complication rates were comparable between the AMI and non-AMI groups. The risks of in-hospital, 30-day, 90-day, and 1-year cardiovascular major adverse cardiac events (CV MACE) were significantly higher in the AMI group compared with the non-AMI group (in-hospital 13.2 vs. 2.8%, p &lt; 0.001; 30-day 14.2 vs. 4.5%, p &lt; 0.001; 90-day 20.8 vs. 6.9%, p &lt; 0.001; 1-year 30.8 vs. 19.1%, p = 0.01). AMI at initial presentation and cardiogenic shock were predictors for both in-hospital CV MACE and 1-year CV MACE in multivariable binary logistic regression analysis. Other predictors for 1-year CV MACE included serum creatinine level and triple vessel disease.

Conclusion

RA in patients with AMI is feasible with a high procedural completion rate and acceptable periprocedural complications. Given unstable hemodynamics and complex coronary anatomy, the in-hospital and 1-year MACE rates remained higher in patients with AMI compared with patients without AMI.

Case Report: Leaflet Thrombosis After Transcatheter Aortic Valve Replacement With Worsening Heart Failure—A Successful Resolution Using Non-vitamin K Antagonist Oral Anti-coagulant

Background: Transcatheter aortic valve replacement (TAVR) is indicated for treating symptomatic severe aortic valve stenosis (AS) with intermediate-to-high surgical risks. Few reports are available on managing leaflet thrombosis after TAVR with worsening heart failure.

Case Summary: A 77-year-old man with severe AS and coronary artery disease (CAD) received a successful TAVR with Edwards Sapien 3 valve. A year later, the patient developed a worsening heart failure with pulmonary edema, new-onset atrial fibrillation (Af), an increase in mean trans-aortic valve pressure gradient to 48 mmHg, worsening mitral regurgitation (MR), and pulmonary hypertension (PH). The response of the patient to intravenous diuretics and inotropic treatments was poor. Multi-slice CT (MDCT) revealed hypo-attenuated thrombus and thickened transcatheter heart valve leaflets. A non-vitamin K antagonist oral anti-coagulant (NOAC) was added to treat the new-onset Af and leaflet thrombosis on top of the con-current single antiplatelet for CAD. A series of follow-up echocardiograms showed a progressive decrease in trans-aortic valve pressure gradient to 17 mmHg and reductions in MR and PH. Three months after the NOAC treatment, MDCT revealed the resolution of hypo-attenuated thrombus and thickened leaflets. Symptoms of heart failure were also improved gradually.

Discussion: Worsening heart failure or an increase in trans-aortic valve pressure gradient after TAVR warranted further MDCT studies. Leaflet thrombosis can be resolved after using NOAC as in our present case.

Transcarotid Transcatheter Aortic Valve Replacement in an Octogenarian With Complex Type B Aortic Dissection and Aneurysm: A Case Report

We report the case of an octogenarian with severe aortic valve stenosis, chronic kidney disease (CKD) and heart failure. Due to advanced CKD, we used a 3-dimensional transesophageal echocardiogram for sizing the device before transcatheter aortic valve replacement (TAVR). Noncontrast computed tomography found complex aortic dissection involving the arch, descending thoracic aorta, and abdominal aorta. TAVR was approached via the right carotid artery using a CoreValve. There was no cerebral vascular event. Renal function was well preserved. Transcarotid TAVR can be performed safely with complex type B aortic dissection. Three-dimensional transesophageal echocardiogram provides an alternative sizing solution in advanced CKD.

Shorter (GT)n repeats in the haem-oxygenase 1 gene promoter are associated with better mid-term survival in subjects with coronary artery disease and abnormal ejection fraction

BACKGROUND

Haem oxygenase (HO)-1 is a rate-limiting enzyme for degrading haem into carbon monoxide. Subjects with longer GT repeats in the HO-1 gene (HMOX1) promoter are more likely to have coronary artery disease (CAD) and cardiovascular events.

METHODS

We retrospectively enrolled CAD subjects with an abnormal ejection fraction (EF) <50% from our catheterisation data (N = 670). Polymerase chain reactions were performed for amplifying the HMOX1 promoter GT repeating segment to determine the number of repeats.

RESULTS

In a median follow-up period of 40 months, 213 patients died. The distribution of genotype for HMOX1 promoter GT repeating segments SS, SL, and LL were significantly different (p < 0.001) between the dead (44.6%, 36.2%, 19.2%, respectively) and the survived (53.8%, 37.4%, 8.8%, respectively) (S allele: ≤30 repeats, L allele: >30 repeats). In Cox regression analysis, carrier of S allele (hazard ratio 0.665, p = 0.027), a higher EF (hazard ratio 0.037, p = 0.001), and revascularization with PCI were all negatively associated with all-cause death in subjects with CAD and abnormal EF.

CONCLUSIONS

Carrier of shorter (GT)_n repeats of HMOX1 gene promoter was negatively correlated with death events in CAD patients with abnormal EF.

Postchallenge glucose increment was associated with hemoglobin glycation index in subjects with no history of diabetes

We investigated the association between postchallenge glucose increment and hemoglobin glycation index (HGI), the difference between observed and predicted glycated hemoglobin (HbA1c), in subjects with no history of diabetes. We enrolled 1381 subjects who attended our outpatient clinic for an oral glucose tolerance test (OGTT) to screen for diabetes. HGI was defined as observed HbA1c minus predicted HbA1c. The predicted HbA1c was calculated by entering fasting plasma glucose (FPG) level into an equation [HbA1c(%)=FPG(mg/dL)*0.029+2.9686] determined from an HbA1c versus FPG regression analysis using data from an independent cohort of 2734 subjects with no history of diabetes. The association between 2-hour glucose increment and HGI was analyzed using linear regression analyses with adjustment of relevant parameters. Overall, the proportions of subjects with normal glucose tolerance, pre-diabetes, and newly diagnosed diabetes were 42.3%, 41.3%, and 16.4%, respectively. Compared with subjects who had an HGI≤0, subjects with an HGI>0 had a lower FPG (95.0±13.3 vs 98.5±15.3 mg/dL, p<0.001) but a higher 2-hour plasma glucose (151.1±52.8 vs 144.6±51.4 mg/dL, p=0.027) and 2-hour glucose increment (56.1±46.1 vs 46.1±45.0 mg/dL, p<0.001). The 2-hour glucose increment after an OGTT was independently associated with HGI (β coefficient 0.003, 95% CI 0.002 to 0.003, p<0.001). Our findings suggested that postchallenge glucose increment was independently associated with HGI in subjects with no history of diabetes.

Subjects with coronary artery disease and reduced ejection fraction have longer (GT)n repeats in the heme-oxygenase 1 gene promoter

Heme oxygenase (HO)-1 is a rate-limiting enzyme for degrading heme into carbon monoxide. Longer (GT)_n repeat of the HO-1 gene (HMOX1) promoter has a lower transcription rate. Subjects with longer GT repeats in the HMOX1 promoter are more likely to have coronary artery disease (CAD) and cardiovascular events. We retrospectively enrolled CAD subjects with an abnormal ejection fraction (EF) < 50% from our catheterization data (N = 670). Polymerase chain reactions were performed for amplifying the HMOX1 promoter GT repeating segment to determine the number of repeats. Two subgroups, reduced EF < 40% (N = 256), and mid-range EF 40-49% (N = 414), were compared. The distribution of genotypes of SS, SL and LL were significantly different in reduced EF (29%, 48%, 23%) vs. mid-range EF CAD (64%, 30%, 5%) (S allele: ≤ 30 repeats, L allele: > 30 repeats) (p < 0.001). The patients with reduced EF had a significantly longer average (GT)_n (median 27.5 vs. 26.5, p = 0.004) than those with the mid-range EF. In multivariate analysis, the carrier of L allele (odds ratio 4.437, p < 0.001) was a significant predictor for the diagnosis of reduced vs. mid-range EF CAD. In conclusion, CAD patients with reduced EF had longer HMOX1 promoter (GT)_n repeats than those with mid-range EF.

Balloon atrial septostomy and transition of subcutaneous to intravenous prostacyclin infusion for rescuing advanced right heart failure in idiopathic pulmonary arterial hypertension: a case report

Background

Intravenous (IV) prostacyclin analogues infusion and balloon atrial septostomy (BAS) are two important treatment options for managing advanced right heart failure in patients with idiopathic pulmonary arterial hypertension (IPAH). References and protocols are rare for dose titrations and transitions between subcutaneous and IV prostacyclin in functional Class IV IPAH patients. Balloon atrial septostomy is rarely done in very few expert centres.

Case summary

A young female with IPAH who had received maximal medication including subcutaneous prostacyclin analogues injection was admitted due to advanced right heart failure. She received ascites drainage twice. Later, we directly switched the administration route of prostacyclin from subcutaneous to IV at a ratio of 1:1 instantly. Such rapid conversion led her into a state of profound hypotension and drowsy consciousness, which was resolved after escalating IV inotropics and reducing prostacyclin dosage. Five days later, she received BAS under the guidance of intracardiac echocardiography. Her urine output increased and dyspnoea improved gradually. Six months later, clinical worsening happened again with increase of ascites and dyspnoea. She underwent 2nd and 3rd session of graded BAS with relief of symptoms again. She received permanent transition to IV prostacyclin analogues infusions via a peripherally inserted central catheter after three sessions of BAS.

Discussion

Balloon atrial septostomy is effective in stabilizing the critical right heart failure in IPAH patients but should be intended as a bridge to lung transplant procedure. Transition from subcutaneous to IV prostacyclin is helpful but needs to be titrated in proper aliquots and time intervals to avoid abrupt haemodynamic changes.

Transvenous Transseptal Concurrent Inoue Balloon Mitral and Aortic Valvuloplasty in an Octogenarian With Severe Aortic and Mitral Stenosis

An octogenarian was admitted because of severe aortic stenosis (AS) and mitral stenosis. He declined surgical double-valve replacement and underwent intracardiac echocardiography–guided transseptal puncture and concurrent Inoue (Toray, Tokyo, Japan) balloon aortic valvuloplasty (BAV) and balloon mitral valvuloplasty (BMV). Nine months later, he had worsening pulmonary edema and received a second session of Inoue BAV and BMV. Our case shows that concurrent transseptal Inoue BAV and BMV can treat severe AS and mitral stenosis with adequate safety and efficacy. However, the durability is limited in elderly persons with calcified AS. The procedure should be reserved for patients who refuse surgery.

Subjects with microvascular angina have longer GT repeats polymorphism in the haem oxygenase-1 gene promoter

Objective: Few studies have investigated haem oxygenase-1 gene (HMOX1) promoter polymorphism in microvascular angina (MVA).Materials and methods: HMOX1 promoter (GT)_n repeats were examined in healthy controls (N = 220) and MVA subjects (N = 181).Results: The distribution of genotype of SS, SL and LL were significantly different in MVA (17%, 51%, 33%) vs. normal controls (35%, 46%, 20%) (p < 0.001, S allele: ≤30 repeats, L allele: >30 repeats). In multivariate analysis, carrier of L allele (odds ratio 2.772, p < 0.001) was a significant predictor for the diagnosis of MVA.Conclusions: Subjects with MVA had longer HMOX1 promoter (GT)_n repeats than the healthy controls. Trial registration number: NCT01198730 at https://clinicaltrials.gov.

A multi-ancestry genome-wide study incorporating gene-smoking interactions identifies multiple new loci for pulse pressure and mean arterial pressure

Elevated blood pressure (BP), a leading cause of global morbidity and mortality, is influenced by both genetic and lifestyle factors. Cigarette smoking is one such lifestyle factor. Across five ancestries, we performed a genome-wide gene-smoking interaction study of mean arterial pressure (MAP) and pulse pressure (PP) in 129 913 individuals in stage 1 and follow-up analysis in 480 178 additional individuals in stage 2. We report here 136 loci significantly associated with MAP and/or PP. Of these, 61 were previously published through main-effect analysis of BP traits, 37 were recently reported by us for systolic BP and/or diastolic BP through gene-smoking interaction analysis and 38 were newly identified (P < 5 × 10-8, false discovery rate < 0.05). We also identified nine new signals near known loci. Of the 136 loci, 8 showed significant interaction with smoking status. They include CSMD1 previously reported for insulin resistance and BP in the spontaneously hypertensive rats. Many of the 38 new loci show biologic plausibility for a role in BP regulation. SLC26A7 encodes a chloride/bicarbonate exchanger expressed in the renal outer medullary collecting duct. AVPR1A is widely expressed, including in vascular smooth muscle cells, kidney, myocardium and brain. FHAD1 is a long non-coding RNA overexpressed in heart failure. TMEM51 was associated with contractile function in cardiomyocytes. CASP9 plays a central role in cardiomyocyte apoptosis. Identified only in African ancestry were 30 novel loci. Our findings highlight the value of multi-ancestry investigations, particularly in studies of interaction with lifestyle factors, where genomic and lifestyle differences may contribute to novel findings.

Sinus Venosus Interatrial Communication, Anomalous Pulmonary Venous Return, Pulmonary Artery Aneurysm With Left Main Compression: Complex Case With Complex Management

A young female patient was referred for pulmonary arterial hypertension (PAH). Catheterization revealed a large sinus venosus interatrial communication (SVIAC), partial anomalous pulmonary venous return (PAPVR), pulmonary vascular resistance (PVR) 15 Wood units, and bidirectional shunting. She was then put on target medication for PAH. Two years later, she had angina and underwent computed tomography examination, which showed pulmonary arterial aneurysm compressing the left main coronary. Coronary stenting was performed, which successfully relieved the compression and angina. Meanwhile, PVR lowered to 3.5 Wood units after medical therapy. Surgical correction for SVIAC and PAPVR was done successfully 5 years after diagnosis.

Association Between Serum Adipsin Levels and Insulin Resistance in Subjects With Various Degrees of Glucose Intolerance

Context

The association between adipsin and glucose metabolism in human subjects remains unclear.

Objective

We investigated the associations between adipsin and insulin resistance/β-cell function in subjects with various degrees of glucose intolerance.

Design

Fasting blood samples were collected for measurements of fasting plasma glucose (FPG), insulin, and adipsin. An oral glucose tolerance test was conducted in subjects with no history of diabetes.

Setting

This study was conducted at a medical center.

Patients

We enrolled 240 subjects with no history of diabetes and 80 patients with known type 2 diabetes (T2D) on diet control or metformin monotherapy.

Main Outcome Measure

β-cell function and insulin resistance were assessed using the homeostasis model assessment (HOMA-β and HOMA-IR, respectively).

Results

Levels of serum adipsin were higher in subjects with normal glucose tolerance (4.0 ± 1.1 µg/mL) or prediabetes (4.0 ± 1.5 µg/mL) compared with subjects with newly diagnosed diabetes (3.8 ± 1.1 µg/mL) or with known T2D on diet control (3.4 ± 1.0 µg/mL) or metformin monotherapy (3.0 ± 1.0 µg/mL, P < 0.001). There was no significant association between adipsin and HOMA-β. In contrast, there was an independent negative association between adipsin and HOMA-IR (β coefficient −0.414, 95% CI −0.720 to −0.109, P = 0.008). The association was more prominent in subjects with a body mass index (BMI) ≥25 kg/m² or an FPG ≥100 mg/dL (P interaction < 0.001 and 0.014, respectively).

Conclusions

Serum adipsin levels were negatively associated with insulin resistance, especially in subjects with a BMI ≥25 kg/m² or an FPG ≥100 mg/dL.

Negative association between serum aryl hydrocarbon receptor concentrations and β-cell function in patients with no history of diabetes undergoing coronary angiography

BACKGROUND

The aim of the present study was to investigate the association between serum aryl hydrocarbon receptor (AhR) levels and insulin resistance and β-cell function in patients undergoing coronary angiography with no history of diabetes.

METHODS

Patients with no history of diabetes who had undergone coronary angiography underwent an oral glucose tolerance test (OGTT) 2-4 weeks after discharge from hospital; blood samples were collected for measurements of glucose, insulin, and AhR. Patients' glucose regulation status was determined on the basis of the OGTT. Insulin resistance was assessed using the homeostasis model assessment of insulin resistance (HOMA-IR). β-Cell function was assessed using the insulinogenic index (IGI).

RESULTS

The study included 473 patients (mean (±SD) age 61 ±12 years, 81.8% male, mean body mass index 26.1 ±3.6 kg/m² ). Overall, mean serum AhR concentrations were 25.1 ±12.2 pg/mL. Patients with normal glucose tolerance had a lower serum AhR concentrations than patients with prediabetes or newly diagnosed diabetes (23.4 ±10.8 vs 26.2 ±13.2 and 26.9 ±12.3 pg/mL, respectively; P = 0.029). Linear regression analysis revealed that serum AhR concentrations were not associated with HOMA-IR, but were negatively associated with IGI after adjustment for several confounders, including HOMA-IR (β = -0.162; 95% confidence interval - 0.302, -0.022; P = 0.023).

CONCLUSIONS

In patients with no history of diabetes, serum AhR concentrations were negatively associated with β-cell function, independent of several confounders, including insulin resistance.

Regaining body weight after weight reduction further increases pulse wave velocity in obese men with metabolic syndrome

Subjects with metabolic syndrome (MetS) or obesity have worse arterial stiffness. However, there have been no studies addressing time-sequential changes in pulse wave velocity (PWV) after weight loss and then regaining weight in obese non-diabetic men with MetS.We prospectively enrolled 40 obese, non-diabetic men with MetS undergoing a 3-month weight reduction program. Another 26 lean and healthy men were recruited for comparisons. Oral glucose tolerance test and brachial ankle (ba) PWV were assessed in study subjects. Eighteen obese non-diabetic MetS and 15 lean control subjects had follow-ups at the 60th month.The body weight of obese MetS decreased from 94.8 ± 7.6 to 86.1 ± 9.0 (N = 18, P < .001) after a 3-month weight reduction program but regained gradually thereafter to 93.6 ± 11.6 kg at the 60th month (P < .001 versus 3rd month). baPWV decreased after weight loss slightly (P = .240) while weight regain significantly increased the baPWV (from 3rd month, 1358 ± 168 to 60th month 1539 ± 264 cm/sec, P < .001). Systolic and diastolic blood pressure increments correlated with the increment of baPWV after weight regain. At the 60th month, lean controls (N = 15) had increases in body weight while their baPWV increased non-significantly. The increments of baPWV after weight regain in obese MetS were significantly higher than the increment of baPWV in lean controls after weight gain.In conclusion, regaining body weight after weight reduction worsened arterial stiffness with significant increase of baPWV in obese non-diabetic MetS.

Testing for HbA1c, in addition to the oral glucose tolerance test, in screening for abnormal glucose regulation helps to reveal patients with early β-cell function impairment

Background:

The oral glucose tolerance test (OGTT) is recommended to screen for diabetes in patients with coronary artery disease. We hypothesized that testing for glycated hemoglobin (HbA1c), in addition to the OGTT, in screening for abnormal glucose regulation may help to reveal patients with β-cell function impairment.

Methods:

Patients with no history of diabetes who were admitted for coronary angiography were recruited to undergo an OGTT and HbA1c test 2–4 weeks after hospital discharge. β-cell function and insulin resistance were assessed using the homeostasis model assessment (HOMA-β and HOMA-IR, respectively). For patients with normal glucose tolerance (NGT) based on the OGTT, we compared HOMA-β between two subgroups of patients using an HbA1c cutoff of 39 mmol/mol or 42 mmol/mol. For patients with prediabetes based on an OGTT, we compared the HOMA-β between two subgroups of patients using an HbA1c cutoff of 48 mmol/mol.

Results:

A total of 1044 patients were analyzed. In patients with NGT by OGTT (n=432), those with an HbA1c ≥42 mmol/mol had a lower HOMA-β compared to those with an HbA1c <42 mmol/mol (107±82 vs. 132±96, p=0.018). In patients with prediabetes by OGTT (n=423), those with an HbA1c ≥48 mmol/mol had a lower HOMA-β compared to those with an HbA1c <48 mmol/mol (91±52 vs. 120±88, p=0.003). No significant between-group difference in HOMA-IR was noted.

Conclusions:

The use of HbA1c in addition to the OGTT in screening for abnormal glucose regulation helped to reveal patients with early β-cell function impairment.

A Large-Scale Multi-ancestry Genome-wide Study Accounting for Smoking Behavior Identifies Multiple Significant Loci for Blood Pressure

Genome-wide association analysis advanced understanding of blood pressure (BP), a major risk factor for vascular conditions such as coronary heart disease and stroke. Accounting for smoking behavior may help identify BP loci and extend our knowledge of its genetic architecture. We performed genome-wide association meta-analyses of systolic and diastolic BP incorporating gene-smoking interactions in 610,091 individuals. Stage 1 analysis examined ∼18.8 million SNPs and small insertion/deletion variants in 129,913 individuals from four ancestries (European, African, Asian, and Hispanic) with follow-up analysis of promising variants in 480,178 additional individuals from five ancestries. We identified 15 loci that were genome-wide significant (p < 5 × 10-8) in stage 1 and formally replicated in stage 2. A combined stage 1 and 2 meta-analysis identified 66 additional genome-wide significant loci (13, 35, and 18 loci in European, African, and trans-ancestry, respectively). A total of 56 known BP loci were also identified by our results (p < 5 × 10-8). Of the newly identified loci, ten showed significant interaction with smoking status, but none of them were replicated in stage 2. Several loci were identified in African ancestry, highlighting the importance of genetic studies in diverse populations. The identified loci show strong evidence for regulatory features and support shared pathophysiology with cardiometabolic and addiction traits. They also highlight a role in BP regulation for biological candidates such as modulators of vascular structure and function (CDKN1B, BCAR1-CFDP1, PXDN, EEA1), ciliopathies (SDCCAG8, RPGRIP1L), telomere maintenance (TNKS, PINX1, AKTIP), and central dopaminergic signaling (MSRA, EBF2).

Association analyses of East Asian individuals and trans-ancestry analyses with European individuals reveal new loci associated with cholesterol and triglyceride levels

Large-scale meta-analyses of genome-wide association studies (GWAS) have identified >175 loci associated with fasting cholesterol levels, including total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), and triglycerides (TG). With differences in linkage disequilibrium (LD) structure and allele frequencies between ancestry groups, studies in additional large samples may detect new associations. We conducted staged GWAS meta-analyses in up to 69,414 East Asian individuals from 24 studies with participants from Japan, the Philippines, Korea, China, Singapore, and Taiwan. These meta-analyses identified (P < 5 × 10-8) three novel loci associated with HDL-C near CD163-APOBEC1 (P = 7.4 × 10-9), NCOA2 (P = 1.6 × 10-8), and NID2-PTGDR (P = 4.2 × 10-8), and one novel locus associated with TG near WDR11-FGFR2 (P = 2.7 × 10-10). Conditional analyses identified a second signal near CD163-APOBEC1. We then combined results from the East Asian meta-analysis with association results from up to 187,365 European individuals from the Global Lipids Genetics Consortium in a trans-ancestry meta-analysis. This analysis identified (log10Bayes Factor ≥6.1) eight additional novel lipid loci. Among the twelve total loci identified, the index variants at eight loci have demonstrated at least nominal significance with other metabolic traits in prior studies, and two loci exhibited coincident eQTLs (P < 1 × 10-5) in subcutaneous adipose tissue for BPTF and PDGFC. Taken together, these analyses identified multiple novel lipid loci, providing new potential therapeutic targets.

Genetic and Pharmacologic Inactivation of ANGPTL3 and Cardiovascular Disease

BACKGROUND

Loss-of-function variants in the angiopoietin-like 3 gene (ANGPTL3) have been associated with decreased plasma levels of triglycerides, low-density lipoprotein (LDL) cholesterol, and high-density lipoprotein (HDL) cholesterol. It is not known whether such variants or therapeutic antagonism of ANGPTL3 are associated with a reduced risk of atherosclerotic cardiovascular disease.

METHODS

We sequenced the exons of ANGPTL3 in 58,335 participants in the DiscovEHR human genetics study. We performed tests of association for loss-of-function variants in ANGPTL3 with lipid levels and with coronary artery disease in 13,102 case patients and 40,430 controls from the DiscovEHR study, with follow-up studies involving 23,317 case patients and 107,166 controls from four population studies. We also tested the effects of a human monoclonal antibody, evinacumab, against Angptl3 in dyslipidemic mice and against ANGPTL3 in healthy human volunteers with elevated levels of triglycerides or LDL cholesterol.

RESULTS

In the DiscovEHR study, participants with heterozygous loss-of-function variants in ANGPTL3 had significantly lower serum levels of triglycerides, HDL cholesterol, and LDL cholesterol than participants without these variants. Loss-of-function variants were found in 0.33% of case patients with coronary artery disease and in 0.45% of controls (adjusted odds ratio, 0.59; 95% confidence interval, 0.41 to 0.85; P=0.004). These results were confirmed in the follow-up studies. In dyslipidemic mice, inhibition of Angptl3 with evinacumab resulted in a greater decrease in atherosclerotic lesion area and necrotic content than a control antibody. In humans, evinacumab caused a dose-dependent placebo-adjusted reduction in fasting triglyceride levels of up to 76% and LDL cholesterol levels of up to 23%.

CONCLUSIONS

Genetic and therapeutic antagonism of ANGPTL3 in humans and of Angptl3 in mice was associated with decreased levels of all three major lipid fractions and decreased odds of atherosclerotic cardiovascular disease. (Funded by Regeneron Pharmaceuticals and others; ClinicalTrials.gov number, NCT01749878 .).

Differential expression of circulating vascular cell adhesion molecule-1 in subjects with coronary artery disease and cardiac syndrome X without known diabetes mellitus

CONTEXT

Inflammation is one of the mechanisms underlying cardiac syndrome X (CSX).

OBJECTIVES

Few studies have compared the expression of inflammatory or adhesion molecules between coronary artery disease (CAD) versus CSX.

MATERIALS AND METHODS

Ninety-two CSX and 145 CAD subjects without known diabetes mellitus underwent coronary angiogram for angina.

RESULTS

Vascular cell adhesion molecule (VCAM)-1 (median, 507 versus 431 ng/ml, p = 0.001) was significantly higher in the CAD group. In the binary regression, VCAM-1 was a significant differential factor for CAD versus CSX.

DISCUSSION AND CONCLUSION

Adhesion molecules might be implicated in the differential expression of macro versus microvascular coronary disease.

TRIAL REGISTRATION NUMBER

NCT01198730 at https://clinicaltrials.gov.

Familial clustering of congenital deafness, patent ductus arteriosus, Eisenmenger complex, and differential cyanosis: A case report

RATIONALE

Few studies had reported syndromes that include patent ductus arteriosus (PDA) with Eisenmenger syndrome and congenital deafness clustered in male siblings without facial, skeletal, or mental abnormalities.

PATIENT CONCERNS

Two brothers, who were deaf and had PDA with Eisenmenger complex, were first seen at our Cardiology clinic at the ages of 25 and 41, respectively. They presented with progressive dyspnea on exertion. Upon physical examination, both brothers had clubbing and/or cyanotic toes, normal fingers, and without facial, skeletal, ophthalmological, or mental abnormalities.

DIAGNOSES AND INTERVENTIONS

Echocardiography and multidetector computed tomography revealed large PDAs in both brothers. Cardiac catheterization showed bidirectional shunting via the PDA.

OUTCOMES AND LESSONS

Familial clustering of Eisenmenger PDA and congenital deafness is rare. Further studies are warranted to define possible genetic links.

Genome-Wide Association Study Meta-Analysis of Long-Term Average Blood Pressure in East Asians

BACKGROUND

Genome-wide single marker and gene-based meta-analyses of long-term average (LTA) blood pressure (BP) phenotypes may reveal novel findings for BP.

METHODS AND RESULTS

We conducted genome-wide analysis among 18 422 East Asian participants (stage 1) followed by replication study of ≤46 629 participants of European ancestry (stage 2). Significant single-nucleotide polymorphisms and genes were determined by a P<5.0×10-8 and 2.5×10-6, respectively, in joint analyses of stage-1 and stage-2 data. We identified 1 novel ARL3 variant, rs4919669 at 10q24.32, influencing LTA systolic BP (stage-1 P=5.03×10-8, stage-2 P=8.64×10-3, joint P=2.63×10-8) and mean arterial pressure (stage-1 P=3.59×10-9, stage-2 P=2.35×10-2, joint P=2.64×10-8). Three previously reported BP loci (WBP1L, NT5C2, and ATP2B1) were also identified for all BP phenotypes. Gene-based analysis provided the first robust evidence for association of KCNJ11 with LTA systolic BP (stage-1 P=8.55×10-6, stage-2 P=1.62×10-5, joint P=3.28×10-9) and mean arterial pressure (stage-1 P=9.19×10-7, stage-2 P=9.69×10-5, joint P=2.15×10-9) phenotypes. Fourteen genes (TMEM180, ACTR1A, SUFU, ARL3, SFXN2, WBP1L, CYP17A1, C10orf32, C10orf32-ASMT, AS3MT, CNNM2, and NT5C2 at 10q24.32; ATP2B1 at 12q21.33; and NCR3LG1 at 11p15.1) implicated by previous genome-wide association study meta-analyses were also identified. Among the loci identified by the previous genome-wide association study meta-analysis of LTA BP, we transethnically replicated associations of the KCNK3 marker rs1275988 at 2p23.3 with LTA systolic BP and mean arterial pressure phenotypes (P=1.27×10-4 and 3.30×10-4, respectively).

CONCLUSIONS

We identified 1 novel variant and 1 novel gene and present the first direct evidence of relevance of the KCNK3 locus for LTA BP among East Asians.

The synergistic effect of vascular cell adhesion molecule-1 and coronary artery disease on brain-derived neurotrophic factor

BACKGROUND

Brain-derived neurotrophic factor (BDNF) is important for neural protection and energy homeostasis. In this study, we examined the effects of vascular cell adhesion molecule-1 (VCAM-1) and coronary artery disease (CAD) on BDNF.

METHODS

Subjects who had undergone diagnostic angiography for angina were recruited, and a total of 240 subjects (144 with CAD and 96 without CAD) were enrolled. Serum BDNF was determined at 0, 30, and 120min during an oral glucose tolerance test (OGTT) to calculate the area under the curve (AUC) for BDNF. Serum VCAM-1 was determined at fasting.

RESULTS

Significantly lower AUC of BDNF (42.8±10.7 vs. 47.4±11.7ng-h/ml, P=0.002) and higher serum VCAM-1 (583±383 vs. 482±171ng/ml, P=0.017) were noted in subjects with CAD compared to those without CAD. High VCAM-1 level was an independent predictor of low AUC of BDNF in subjects with and without CAD (95%CI between -0.011 and -0.002, P=0.008; -0.033 and -0.002, P=0.029, respectively). Serum BDNF was lowest in the CAD subjects with high VCAM-1 levels at all time points during OGTT.

CONCLUSION

Our results showed that CAD was associated with low serum BDNF in response to OGTT, and VCAM-1 had a synergistic effect with CAD on the BDNF.

Post-challenge insulin concentration is useful for differentiating between coronary artery disease and cardiac syndrome X in subjects without known diabetes mellitus

BACKGROUND

Cardiac syndrome X (CSX) is characterized by angina pectoris but with patent coronary arteries. Our previous study demonstrated that subjects with CSX had a higher fasting insulin-resistance (IR) than the controls. However, few studies have investigated the degree of IR, including oral glucose tolerance test (OGTT)-derived indices and profiles of metabolic abnormalities between CSX and coronary artery disease (CAD).

METHODS

Ninety-two CSX and 145 CAD subjects without known diabetes mellitus (DM) underwent coronary angiogram (CAG) for angina pectoris and also agreed to receive OGTT and glycated hemoglobin (HbA_1C) evaluations for screening abnormal glucose regulation and IR.

RESULTS

CAD group had more subjects with metabolically unhealthy obesity (52.4 vs. 31.5%, p < 0.001) than the CSX group. The CAD group had higher OGTT 2 h glucose and insulin (both p < 0.005) while fasting glucose, insulin and HOMA-IR were similar to those of CSX subjects. In the binary regression analysis, OGTT 2 h insulin and being metabolic unhealthy were significantly different between the CAD and CSX groups, but there were no significant differences in Matsuda index, fasting glucose, insulin, HOMA-IR, or HbA_1C.

CONCLUSIONS

Post challenge OGTT 2 h insulin and being metabolic unhealthy were useful parameters in differentiating between CAD and CSX in subjects without known DM but suffered from angina pectoris and underwent CAG. Different degrees of IR and metabolic abnormalities might be implicated in the pathogenesis of micro vs. macro vascular coronary diseases. Trial registration NCT01198730 at https://clinicaltrials.gov, Registered Sep. 8, 2010.

The genetics of blood pressure regulation and its target organs from association studies in 342,415 individuals

To dissect the genetic architecture of blood pressure and assess effects on target organ damage, we analyzed 128,272 SNPs from targeted and genome-wide arrays in 201,529 individuals of European ancestry, and genotypes from an additional 140,886 individuals were used for validation. We identified 66 blood pressure-associated loci, of which 17 were new; 15 harbored multiple distinct association signals. The 66 index SNPs were enriched for cis-regulatory elements, particularly in vascular endothelial cells, consistent with a primary role in blood pressure control through modulation of vascular tone across multiple tissues. The 66 index SNPs combined in a risk score showed comparable effects in 64,421 individuals of non-European descent. The 66-SNP blood pressure risk score was significantly associated with target organ damage in multiple tissues but with minor effects in the kidney. Our findings expand current knowledge of blood pressure-related pathways and highlight tissues beyond the classical renal system in blood pressure regulation.

Comparing HbA1c, fasting and 2-h plasma glucose for screening for abnormal glucose regulation in patients undergoing coronary angiography

BACKGROUND

We aimed to investigate the prevalence of undiagnosed abnormal glucose regulation (AGR, including diabetes and prediabetes) in patients undergoing coronary angiography (CAG) by using both glycated hemoglobin (HbA1c) and oral glucose tolerance test (OGTT) to screen, and to compare the performance of fasting plasma glucose (FPG), 2-h plasma glucose (2hPG), and HbA1c for screening for AGR.

METHODS

Eligible patients were adults without known diabetes who were admitted for CAG. Patients' glucose regulation status was defined by conducting HbA1c and OGTT 2-4 weeks after hospital discharge. The performance of FPG, 2hPG, and HbA1c for detecting AGR was evaluated using receiver operating characteristic (ROC) analysis.

RESULTS

A total of 689 subjects were included. According to OGTT, the prevalence rates of diabetes and prediabetes were 19.9% and 41.7%, respectively. The corresponding values were 28.0% and 60.4%, respectively, when HbA1c was adopted as a diagnostic criterion in addition to OGTT. For detecting diabetes, the area under the ROC curve (AUC) was higher for HbA1c than for FPG (0.87 vs. 0.80, p=0.005), but was not significantly different from that for 2hPG (0.87 vs. 0.88, p=0.58). For detecting AGR, the AUC was higher for HbA1c than for either FPG (0.94 vs. 0.74, p<0.001) or 2hPG (0.94 vs. 0.83, p<0.001).

CONCLUSIONS

Using HbA1c and OGTT to screen, we reported an extremely high prevalence of previously undiagnosed AGR (28.0% diabetes and 60.4% prediabetes) in patients admitted for CAG. HbA1c may be adopted as an alternative to OGTT for screening for AGR in patients undergoing CAG.

Consecutive Sessions of Rescue Balloon Aortic Valvuloplasty for Critical Aortic Valve Stenosis Followed by Successful Bridging to Trans-Catheter Aortic Valve Implantation

Percutaneous balloon aortic valvuloplasty (BAV) was a rare procedure in catheterization laboratories because of its limited prognostic impact. The recent advent of transcatheter aortic valve implantation (TAVI) has led to a resurgence of BAV, opening the way to a new indication as a bridge to TAVI. Herein, we reported an 83-year-old man with critical aortic valve stenosis and pulmonary edema, who strongly declined surgical aortic valve replacement. He also lacked financial support or insurance reimbursement for TAVI. He received BAV for relief of syncope, pulmonary edema and impending respiratory failure 4 times within 4 years and was successfully bridged to TAVI after receiving charity aid funding from the hospital.

KEY WORDS

Aortic valve stenosis; Balloon aortic valvuloplasty (BAV); Transcatheter aortic valve implantation (TAVI).

Left Main Coronary Artery Stenting to Relieve Extrinsic Compression by a Giant Pulmonary Artery Aneurysm in a Patient with Idiopathic Pulmonary Artery Hypertension

Pulmonary artery aneurysm (PAA) is a rare but lethal disease. We present a female patient with idiopathic pulmonary artery hypertension (IPAH)-related PAA, who suffered from unstable angina pectoris. Multi-detector computed tomography and coronary angiogram revealed extrinsic compression of the left main coronary artery (LMCA) caused by a giant PAA with severe ostial stenosis. Intravascular ultrasound showed an oval-shaped ostium of the LMCA, indicating extrinsic compression. After successful LMCA stent implantation, chest pain was greatly relieved. This case illustrates that beyond right ventricle ischaemia and coronary atherosclerotic disease, LMCA compression by PAA should be considered in the differential diagnosis of angina in patients with IPAH related PAA. In addition, intravascular ultrasound can be used to confirm the diagnosis and guide the stent implantation safely.

Aryl Hydrocarbon Receptor Deficiency Attenuates Oxidative Stress-Related Mesangial Cell Activation and Macrophage Infiltration and Extracellular Matrix Accumulation in Diabetic Nephropathy

AIMS

Activation of glomerular mesangial cells (MCs) and functional changes of renal tubular cells are due to metabolic abnormalities, oxidative stress, and matrix accumulation in the diabetic nephropathy (DN). Aryl hydrocarbon receptor (AhR) activation has been implicated in DN. In this study, we investigated the role of AhR in the pathophysiological processes of DN using AhR knockout (AhRKO) and pharmacological inhibitor α-naphthoflavone mouse models.

RESULTS

The increased blood glucose, glucose intolerance, MC activation, macrophage infiltration, and extracellular matrix (ECM) accumulation were significantly attenuated in AhRKO mice with diabetic inducer streptozotocin (STZ) treatment. AhR deficiency by genetic knockout or pharmacological inhibition also decreased the induction of cyclooxygenase-2 (COX-2)/prostaglandin E₂ (PGE₂), lipid peroxidation, oxidative stress, NADPH oxidase activity, and N-ɛ-carboxymethyllysine (CML, a major advanced glycation end product) in STZ-induced diabetic mice. CML showed remarkably increased AhR/COX-2 DNA-binding activity, protein-DNA interactions, gene regulation, and ECM formation in MCs and renal proximal tubular cells, which could be reversed by siRNA-AhR transfection. CML-increased AhR nuclear translocation and biological activity in MCs and renal proximal tubular cells could also be effectively attenuated by antioxidants.

INNOVATION

We elucidate for the first time that AhR plays an important role in MC activation, macrophage infiltration, and ECM accumulation in DN conferred by oxidative stress.

CONCLUSIONS

AhR-regulated COX-2/PGE₂ expression and ECM deposition through oxidative stress cascade is involved in the CML-triggered MC activation and macrophage infiltration. These findings suggest new insights into the development of therapeutic approaches to reduce diabetic microvascular complications. Antioxid. Redox Signal. 24, 217-231.

Weight loss reduces serum monocyte chemoattractant protein-1 concentrations in association with improvements in renal injury in obese men with metabolic syndrome

BACKGROUND

Monocyte chemoattractant protein-1 (MCP-1) is involved in obesity-related renal injury. The aim of the present study was to examine the effects of weight loss on changes in MCP-1 and markers of renal injury, specifically serum cystatin C (S-CysC) and urinary N-acetyl glucosaminidase (UNAG), in obese people.

METHODS

In this prospective study, 40 obese men with metabolic syndrome (MetS) participated in a 3-month dietary and exercise intervention. Twenty-eight subjects completed the study with a ≥5% weight loss. Circulating MCP-1, S-CysC and UNAG to creatinine ratio (UNCR) were determined before and after the weight loss program.

RESULTS

Obesity-associated components of MetS demonstrated significant improvements after the weight loss program. In addition, at baseline, circulating MCP-1 concentrations were positively correlated with UNCR and S-CysC levels. After weight loss, blood MCP-1 and UNCR levels were significantly decreased, but S-CysC was not affected. Using multiple linear regression analysis, there was a significant relationship between changes in UNCR and MCP-1 after adjusting for other potential confounding factors.

CONCLUSIONS

Weight loss may improve renal tubular injury by ameliorating obesity-related inflammation in obese men with MetS.

Value of Chromosome 9p21 Polymorphism for Prediction of Cardiovascular Mortality in Han Chinese Without Coronary Lesions: An Observational Study

Variants at chromosome 9p21 are associated with coronary artery disease (CAD). However, the longitudinal effects of 9p21 variants on cardiovascular mortality remain controversial and may depend on whether the patient has CAD. We tested the hypothesis that the single-nucleotide polymorphism (SNP) rs4977574 is associated longitudinally with cardiovascular death in patients without detectable coronary lesions. We enrolled patients who underwent coronary angiography for angina pectoris but had normal angiographic findings. Laboratory analyses and rs4977574 TaqMan genotyping were performed using fasting blood samples collected during hospitalization. Cardiovascular and all-cause mortality rates were acquired from a national database. Among the 679 enrolled subjects with neither myocardial infarction nor an angiographic coronary lesion, 28 (19.0%) of the 147 homozygous GG carriers suffered a cardiovascular death, compared with 63 (11.8%) of the 532 subjects with the AG or AA genotype during the median 12.3 years (interquartile range 8.6-12.7 years) of follow-up. In a recessive model, cardiovascular mortality was significantly higher in subjects with the GG genotype than in those with the other genotypes (hazard ratio, 1.69, 95% confidence interval 1.08 to 2.64; P = 0.021). In this follow-up study, rs4977574, a tag SNP at chromosome 9p21, was shown to be associated with cardiovascular mortality in Taiwanese patients with angina pectoris but no coronary lesions.

Circulating adipokines and insulin resistance in subjects with combined cardiac and metabolic syndrome X

BACKGROUND

Cardiac syndrome X (CSX) is characterized by angina pectoris but with patent coronary arteries. Our previous study showed that CSX subjects had decreased serum adiponectin but higher leptin and insulin resistance (IR). However, few studies have investigated circulating adipokines and IR in subjects with combined metabolic syndrome X (MetX) and CSX.

METHODS

Fifty-nine subjects with CSX were retrospectively enrolled from our cardiac catheterization patient databank. Fifty-four subjects with valvular heart disease or arrhythmia and with normal coronary angiograms were recruited as the non-CSX comparison group. The study subjects were reclassified according to the presence or absence of MetX. Circulating adipokines and degree of IR were measured.

RESULTS

Subjects with combined MetX and CSX had a significantly higher HOMA-IR, a higher circulating leptin level (median 8.7 vs. 3.3 ng/mL, p < 0.001), but a lower circulating adiponectin level (median 2.8 vs. 12.3 μg/mL, p < 0.001) than those without MetX and CSX. In pairwise comparisons, combined MetX and CSX subjects had a similar circulating adipokines and IR index as those who had only either one syndrome X. In a multivariate regression analysis, serum triglycerides (odds ratio 1.011, p = 0.024) and hypertension (odds ratio 14.453, p = 0.003) were independently associated with diagnosis of combined MetX and CSX.

CONCLUSIONS

Combined MetX and CSX had a significantly higher HOMA-IR, a higher circulating leptin but a lower circulating adiponectin level than those without MetX and CSX. Combined syndrome X did not confer more changes on adipokines or IR index comparing with those with only one syndrome X.

Dynamic Compression of the Left Coronary Artery by a Left Ventricular Pseudoaneurysm after Myocarditis

A 69-year-old man with a recent diagnosis of suspected leptospirosis infection-related myocarditis presented with antecedent arthralgia, myalgia, fever, intermittent anterior chest pain, yellowish sclera, yellowish skin and shortness of breath. His symptoms improved after antibiotic treatment with penicillin for 14 days. However, recurrent chest pain and progressive dyspnea upon exertion developed 2 months later. A newly developed left ventricular outflow tract pseudoaneurysm was identified by cardiac sonography and multi-detector computed tomography of the heart. A subsequent coronary arteriogram demonstrated an left ventricular (LV) pseudoaneurysm causing compression to both the left circumflex coronary artery and the left anterior descending coronary artery with significant stenosis. To the best of our knowledge, this is the first reported case of a LV pseudoaneurysm developing after a clinical course of suspected leptospirosis-related myocardit is causing dynamic compression of the left coronary artery.

KEY WORDS

Dynamic compression of coronary artery; Left ventricular pseudoaneurysm; Leptospirosis; Myocarditis.

Nε-carboxymethyllysine-mediated endoplasmic reticulum stress promotes endothelial cell injury through Nox4/MKP-3 interaction

N(ε)-carboxymethyllysine (CML) is an important driver of diabetic vascular complications and endothelial cell dysfunction. However, how CML dictates specific cellular responses and the roles of protein tyrosine phosphatases and ERK phosphorylation remain unclear. We examined whether endoplasmic reticulum (ER) localization of MAPK phosphatase-3 (MKP-3) is critical in regulating ERK inactivation and promoting NADPH oxidase-4 (Nox4) activation in CML-induced endothelial cell injury. We demonstrated that serum CML levels were significantly increased in type 2 diabetes patients and diabetic animals. CML induced ER stress and apoptosis, reduced ERK activation, and increased MKP-3 protein activity in HUVECs and SVECs. MKP-3 siRNA transfection, but not that of MKP-1 or MKP-2, abolished the effects of CML on HUVECs. Nox4-mediated activation of MKP-3 regulated the switch to ERK dephosphorylation. CML also increased the integration of MKP-3 with ERK, which was blocked by silencing MKP-3. Exposure of antioxidants abolished CML-increased MKP-3 activity and protein expression. Furthermore, immunohistochemical staining of both MKP-3 and CML was increased, but phospho-ERK staining was decreased in the aortic endothelium of streptozotocin-induced and high-fat diet-induced diabetic mice. Our results indicate that an MKP-3 pathway might regulate ERK dephosphorylation through Nox4 during CML-triggered endothelial cell dysfunction/injury, suggesting that therapeutic strategies targeting the Nox4/MKP-3 interaction or MKP-3 activation may have clinical implications for diabetic vascular complications.

2014 Guidelines of Taiwan Society of Cardiology (TSOC) for the Management of Pulmonary Arterial Hypertension

Pulmonary hypertension (PH) is a hemodynamic and pathophysiologic condition, defined as a mean pulmonary arterial pressure exceeding 25 mmHg at rest. According to the recent classifications, it is grouped into pulmonary arterial hypertension (PAH), heart-related, lung-related, thromboembolic, and miscellaneous PH. In the past two decades, tremendous advances have occurred in the field of PH. These include (1) development of clinical diagnostic algorithm and a monitoring strategy dedicated to PAH, (2) defining strong rationales for screening at-risk populations, (3) advent of pulmonary specific drugs which makes PAH manageable, (4) recognition of needs of having proper strategy of combining existing pulmonary specific drugs, and/or potential novel drugs, (5) pursuit of clinical trials with optimal surrogate endpoints and study durations, (6) recognition of critical roles of PH/right ventricular function, as well as interdependence of ventricles in different conditions, especially those with various phenotypes of heart failure, and (7) for rare diseases, putting equal importance on carefully designed observation studies, various registries, etc., besides double blind randomized studies. In addition, ongoing basic and clinical research has led to further understanding of relevant physiology, pathophysiology, epidemiology and genetics of PH/PAH. This guidelines from the working group of Pulmonary Hypertension of the Taiwan Society of Cardiology is to provide updated guidelines based on the most recent international guidelines as well as Taiwan's domestic research on PH. The guidelines are mainly for the management of PAH (Group 1) ; however the majority of content can be helpful for managing other types of PH.

KEY WORDS

Pulmonary arterial hypertension; Taiwan guidelines.