Failed shocks in hypertrophic cardiomyopathy patients: prevalence, predictors and outcome

Funding Acknowledgements

Type of funding sources: None.

Introduction

An implantable cardioverter-defibrillator (ICD) is used in selected high-risk hypertrophic cardiomyopathy (HCM) patients in order to prevent sudden arrhythmic death. The unique features of this population raise concerns regarding the reliability of successful defibrillation.

Purpose

To describe the rate and discover potential predictors of failed shocks in HCM patients.

Methods

We retrospectively evaluated all HCM patients with an ICD from a single tertiary medical center. Clinical, electrocardiographic and echocardiographic data were collected and compared among patients with and without failed shocks.

Results

A total of 99 patients (77% male, 45±17 years old) were analyzed. Over a median follow up of 6.3 years (IQR 2.6-10.7), 20 patients developed sustained ventricular arrhythmia (VTA). Of those, 18 patients received appropriate shocks from their ICD. VTA was associated with younger age at diagnosis, history of syncope and thicker maximal LV width. Six patients experienced at least one failed shock. The likelihood of failed shocks was similar when single or dual coil electrodes were used (dual coils in 67% of patients with failed shocks and 50% in those without), and the only predictor was increased wall thickness [OR 1.2 (1.07-1.38) per 1 mm]. All-cause mortality was low and similar in patients with an without failed shocks (0% vs 8%, P=0.5)

Conclusions

Failed shocks are a rare entity in HCM patients. Increased maximal LV width was the only predictor of those events. Our findings support avoiding defibrillation threshold testing routinely, but may indicate its need in patients with extreme LV wall thickening (≥23 mm).

Quantitative SPECT/CT parameters of myocardial 99mTechnetium-3,3-diphosphono-1,2-propanodicarboxylic acid (DPD) uptake in suspected cardiac transthyretin amyloidosis

Background

^99mTc-labelled bisphosphonates are used for imaging assessment of patients with transthyretin cardiac amyloidosis (ATTR). Present study evaluates whether quantitative SPECT/CT measurement of absolute myocardial ^99mTc-labelled 3,3-diphosphono-1,2-propanodicarboxylic acid (Tc-DPD) uptake can diagnose patients with suspected ATTR.

Methods

Twenty-eight patients (25 male, age 80.03 ± 6.99 years) with suspected ATTR referred for Tc-DPD imaging had planar and SPECT/CT imaging of the chest. Three operators independently obtained Tc-DPD myocardial SUVmax and SUVmean above threshold (SMaT) (20, 40 and 60% of SUVmax), using a semi-automated threshold segmentation method. Results were compared to visual grading (0–3) of cardiac uptake.

Results

Twenty-two patients (78%) had cardiac uptake (2 grade 1, 15 grade 2, 5 grade 3). SUVmax and SMaT segmentation thresholds enabled separating grades 2/3 from 0/1 with excellent inter- and intra-reader correlation. Cut-off values 6.0, 2.5, 3 and 4 for SUVmax, SMaT_20,40,60, respectively, separated between grades 2/3 and 0 /1 with PPV and NPV of 100%. SMaT_20,40,60(cardiac)/SUVmean (liver) and SMaT_20,40,60(cardiac)/SUV_mean(liver/lung) separated grades 2 and 3.

Conclusion

Quantitative SPECT/CT parameters of cardiac Tc-DPD uptake are robust, enabling separation of patients with grades 2 and 3 cardiac uptake from grades 0 and 1. Larger patient cohorts will determine the incremental value of SPECT/CT quantification for ATTR management.

Gender variability in the clinical phenotype of hypertrophic cardiomyopathy

Introduction

Hypertrophic cardiomyopathy (HCM) is a structural heart disease defined by an increase in left-ventricular (LV) wall thickness, that may be complicated with a clinical syndrome of heart failure, arrhythmia and death.

Purpose

To characterize the clinically significant factors for female HCM patients and bring forward the awareness to gender-based differences in HCM.

Methods

We reviewed the patient records of 1297 patients age ≥18 years, diagnosed with HCM, from two tertiary medical centers in Spain and Israel, and analyzed 748 male and female patients matched for age ≥60 years at admission, BMI, hypertension, diabetes and obstructive HCM.

Results

Female patients were older at original diagnosis [median 54 years (38–66) vs. 50 years (35–60), p=0.007], and had higher rates of family history of both HCM (46% vs. 37%, p=0.01) and sudden cardiac death (23% vs. 15%, p=0.02). Female patients had lower rates of active smoking (11% vs. 25%, p<0.001) and coronary disease (3% vs. 8%, p=0.007). In echocardiographic studies, females had a smaller LV cavity both during diastole [median 42mm (39–46) vs. 46 (42–50), p<0.001] and during systole [median 24 (21–29) vs. 27 (23–31), p<0.001]. Female patients had higher rates of significant mitral insufficiency (37% vs. 19%, p<0.001), and despite no significant differences in the rates of obstructive HCM, diastolic dysfunction, left-atrial enlargement, atrial fibrillation, ventricular tachyarrhythmia or pulmonary disease, they also had more significant pulmonary hypertension (≥45mmHg, 29% vs. 14%, p<0.001). Women had a lower functional capacity (p<0.001 for differences in NYHA, see fig.), and lower exercise capacity [median 7.0 METs (5–10) vs. 10.0 (7–12), p<0.001) and more abnormal blood pressure response to exercise (35% vs. 26%, p=0.03). Electrocardiographic features were similar across genders, except for a non-clinically significant shorter QRS duration in females. No significant differences were seen in 5-year mortality follow-up, which was ∼3% in the entire cohort.

Conclusions

Female patients suffering from HCM have a clinical phenotype defined by slightly later presentation (and shorter time until admission to a tertiary-center cardiomyopathy clinic), smaller LV cavity size, higher severity of mitral insufficiency and pulmonary hypertension and worse functional and exercise capacities. Genders did not differ in 5-year mortality, which was relatively low.

Functional and exercise capacity

Funding Acknowledgement

Type of funding source: None

Bioenergetic and metabolic aberrations in induced pluripotent stem cell-derived cardiomyocytes generated from PRKAG2-mutated, WPW patient

Introduction

Familial hypertrophic cardiomyopathy (HCM) is caused by over 400 mutations affecting mostly key sarcomere components, such as titin and myosin. However, HCM also results from mutations in non-structural genes such as PRKAG2 which is involved directly in a variety of bioenergetic and metabolic pathways. When the metabolic processes fail to work properly or effectively, structural and functional aberrations resulting in cardiac dysfunction can occur. Thus, mutations in the human PRKAG2 gene lead to HCM, autosomal dominant ventricular pre-excitation - Wolff-Parkinson-White syndrome (WPW), a progressive conduction system disease and vacuolar glycogen accumulation in cardiomyocytes.

Purpose

To investigate the hypothesis that intervening with the bioenergetic and metabolic consequences of the R302Q mutation in the PRKAG2 gene causing inherited cardiomyopathy, will attenuate the cardiac impairments.

Methods

We generated mutated and isogenic induced Pluripotent Stem Cell-derived cardiomyocytes (iPSC-CMs) from a WPW patient carrying the R302Q mutation. As additional control, we used healthy volunteers' iPSC-CMs. Bioenergetic (Oxygen Consumption Rate, OCR) and metabolic status were measured using the Seahorse Flux Analyzer and LC-MS, respectively. To decipher the molecular basis underlying the bioenergetic and metabolic deficits, RNA-seq analysis was performed.

Results

The OCR results demonstrated in PRKAG2-mutated compared to isogenic and healthy iPSC-CMs, a 2-fold increase in maximal respiration rate and a 3.75-fold increase in spare respiratory capacity, while basal OCR parameters were similar in all groups. Importantly, when treated with the AMPK activator metformin (2.5 [mM]), all the abovementioned OCR parameters were similar in the three groups. RNA-seq analysis demonstrated that of the 553 differently expressed genes (DEGs), and of the 99 DEGs mutually differentially expressed, compared to isogenic and healthy cells, the most relevant altered pathways were glycolysis, carbon metabolism, biosynthesis of amino acids, HIF-1 signaling and fructose and mannose metabolism. These findings are consistent with the LC-MS results demonstrating in PRKAG2-mutated versus isogenic and healthy iPSC-CMs, at least a 3-fold decrease in metabolites linked to the abovementioned pathways: butyryl-carnitine, creatine, docosahexaenoic acid, GMP, IMP, myristoyl-carnitine, palmitoyl-carnitine, succinyl-Cys, UMP, UTP, UDP-GlcNAc.

Conclusion

PRKAG2-mutated iPSC-CMs exhibit bioenergetic and metabolic aberrations, which contribute to the cardiac pathological aspects of WPW syndrome. Importantly, treatment with the AMPK activator metformin eliminated the bioenergetic abnormalities in the mutated cells, while isogenic and healthy control cells remained unaffected. Based on these novel findings, a new therapeutic modality in WPW patients may be considered.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Israel Science Foundation (ISF)

Clinical characteristics and natural history of PRKAG2 syndrome

Purpose

Mutations in the PRKAG2 gene cause a syndrome characterized by hypertrophic cardiomyopathy, conduction disease and ventricular preexcitation. Only a small number of cases have been reported, and the natural history of the disease is poorly understood. The aim of this study is to describe phenotype and natural history of PRKAG2 mutation in a large multicenter international cohort.

Methods

We retrospectively studied clinical, electrocardiographic and echocardiographic data from 90 individuals with PRKAG2 mutations (53% males, 33±21 years) from 27 centers.

Results

At baseline evaluation, 93% of patients were in NYHA functional class I-II. Maximum left ventricular (LV) wall thickness was 18±8 mm and LV hypertrophy (LVH) was present in 60 (67%) subjects at baseline. LV ejection fraction was 61±12%. Seventeen pactients (19%) had a pacemaker (mean age at implantation 37±15and 16 (18%) had atrial fibrillation (AF) (mean age 41±23 years) and 33% had ventricular preexcitation or had undergone an accessory pathway ablation. After a median follow-up of 6 years (IQR:2.3–13.9), 71% of individuals had LVH, 29% had AF, 21% a de novo pacemaker (mean age at implantation 38±18 years), 14% required admission for heart failure (HF), 8% experienced sudden cardiac death or equivalent, 4% required a heart transplant and 13% died.

Conclusions

PRKAG2 syndrome is a severe, progressive cardiomyopathy characterized by high rates of AF, conduction disease, advanced HF and life-threatening arrhythmias. Outcome is not clearly related to the classical features of preexcitation and severe LVH, which are not always present.

Natural history of PRKAG2 syndrome

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Instituto de Salud Carlos III (ISCIII)

Bioenergetic and metabolic impairments in Duchenne Muscular Dystrophy (DMD) patients' iPSC-derived cardiomyocytes

Introduction

DMD, an X-linked muscle degenerative fatal disease, is caused by mutations in the dystrophin gene. Dilated cardiomyopathy (DCM) is a major cause of morbidity and mortality in DMD patients. Treatments for DCM in DMD are limited to steroids and standard heart failure medications such as β-blockers and ACE-inhibitors, and therefore novel therapeutic modalities are urgently needed.

Purpose

We hypothesized that dystrophin mutations in DMD lead to cardiomyopathy-causing bioenergetic/metabolic impairments, which can be therapeutically targeted for improving cardiac function.

Methods

Induced Pluripotent Stem Cell-derived cardiomyocytes (iPSC-CMs) were generated from healthy volunteer and 3 DMD patients: young male (YM), adult male (AM) and adult female (AF). We investigated the bioenergetics, electrophysiology, mitochondrial and metabolic features of healthy and DMD iPSC-CMs using the Seahorse Flux analyzer, patch clamp, confocal fluorescence microscopy and Liquid chromatography mass spectrometry (LC-MS) technologies, respectively.

Results

To test the hypothesis, we measured respiration and glycolytic rates of healthy and DMD iPSC-CMs. Compared to healthy iPSC-CMs, in both AM and AF DMD, but not in YM DMD cardiomyocytes, there was a 75% decrease in ATP production, and 80% and 45% decrease in basal respiration, respectively. In agreement with the healthy-like bioenergetic status of YM, the iPSC-CMs showed no arrhythmias, in contrast to the prominent arrhythmias in AM and AF cardiomyocytes. To determine whether the impairment in the phosphorylation pathway (OXPHOS) affects glycolysis, we measured the cardiomyocytes' response to glycolytic stress test. These experiments showed that the glycolytic rates were similar in healthy and DMD iPSC-CMs. In agreement with impaired OXPHOS, mitochondrial activity measured by 3D life confocal microscopy was attenuated in the DMD male by 35%, compared to healthy cardiomyocytes. Furthermore, the metabolomic LC-MS analyses demonstrated significant differences in metabolite levels in YM, AM and AF DMD iPSC-CMs relative to healthy iPSC-CMs. For example, compared to healthy iPSC-CMs, there was a dramatic fall to undetected levels in phosphocreatine in both AM and AF, but not in YM DMD, indicating a dysfunctional phosphocreatine energy system.

Conclusions

DMD iPSC-CMs exhibit bioenergetic/metabolic impairments, which constitute novel targets for alleviating the cardiomyopathy in DMD patients.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): ISF - Israel Science Foundation

Management and outcome of acute and recurrent pericarditis during pregnancy

Background

Pericarditis in pregnancy is uncommon. Treatment options, including NSAIDs and long term gluco-corticosteroids (CS) have extensive side-effects, while data on the use of Colchicine in pregnant women who suffer from pericarditis is limited.

Objective

To evaluate the management and outcome of active pericarditis during pregnancy in both acute (AP) and recurrent pericarditis (RP) patients.

Methods and results

Twelve pregnant women (14 pregnancies) with active pericarditis were followed prospectively in our cardiology-pregnancy clinic; 6 with AP and 8 with RP. Etiology: 11 idiopathic, 2 post-pericardiotomy syndrome and 1 Q fever. Maternal age on presentation was 27±4y vs. 33±3y in RP vs AP respectively. Average gestational age upon diagnosis was lower in RP than in AP (18 weeks, range 6–30 vs 26 weeks, range 5–35). In the RP group, 7/8 women (87%) were treated with CS compared with 2/6 women (33%) in the AP group; 3 women in RP group (37%) failed to respond to subsequent treatment with azathioprine and 1 patient was treated successfully with Anakinra. Colchicine was prescribed in 13/14 (93%) of pregnancies, average colchicine exposure during pregnancy was 25±15 weeks. Recurrence during pregnancy: 6/8 (75%) of RP; 2/6 (33%) of the AP, all of them on CS. All pregnancies culminated in a live birth with a mean gestational age on delivery of 37±1.4 weeks. Average birthweight was 3267±507 grams. There were no fetal anomalies or developmental delays after a mean follow-up of 2.7 years. All newborns and maternal outcomes were normal. On long term follow-up after delivery RP patients treated with colchicine developed less recurrences.

Conclusion

Active pericarditis is associated with a high recurrence rate during pregnancy despite treatment with CS. Colchicine use in pregnant women with active pericarditis appears to be safe.

Funding Acknowledgement

Type of funding source: None

Phenotype and clinical outcomes of dystrophin associated dilated cardiomyopathy

Background

Mutations in dystrophin gene (DMD) can cause skeletal myopathy and dilated cardiomyopathy (DCM) independently or in combination. Natural history of DMD mutation carriers and dystrophin-associated DCM is poorly understood.

Objectives

This study sought to describe phenotype and prognosis of DMD mutations in a large multicenter cohort of Non-Duchenne DMD mutations carriers.

Methods

The study cohort comprised 223 individuals with a DMD mutation (83% males, 33±15 years at first evaluation) followed at 26 European centers. Major adverse cardiac events (MACE) were defined as a composite of cardiac death, heart transplant, LVAD implantation, aborted SCD or appropriate ICD shock.

Results

At initial evaluation, 85 patients (38%) had DCM (52 in combination with muscular disease) and 92 (41%) had isolated muscular disease. After a median follow-up of 96 months, 112 individuals (53%) had DCM and 20% of the individuals who had normal cardiac function at baseline developed DCM. DCM penetrance by age 30 was 56%. DCM onset was associated with male sex and was independent of the type of mutation, the presence of skeletal myopathy or serum creatine kinase levels. MACE occurred in 11% and 22% individuals from the entire cohort and with DCM respectively, and were more frequent in DCM patients without muscular disease than in those with skeletal myopathy (35.5% vs 17.7%; p=0.04). Among patients with DCM, 18% developed end-stage heart failure and 9% a major arrhythmic event (SCD/aborted SCD/ICD shock/VT). There were not differences in survival between patients with isolated DCM and those with DCM and muscular phenotype. Decreased LVEF and increased left ventricular end-diastolic diameter at baseline were associated with MACE. Atrial fibrillation and neurological events were also frequent. Prognosis of individuals who did not develop DCM was good with 96% survival during follow-up.

Conclusions

DCM caused by mutations in DMD is characterized by moderate penetrance but a high risk of MACE, progression to end-stage heart failure and ventricular arrythmias. DCM onset is the major determinant of prognosis in DMD mutation carriers with similar survival irrespectively of the presence of concomitant muscular disease.

Survival free of MACE analysis

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Instituto de Salud Carlos III. Contratos i-PFIS: Doctorados IIS-empresa en Ciencias y Tecnologías de la Salud

Effect of hypokintic transformation on the clinical phenotype and functional capacity in hypertrophic cardiomyopathy

Background

Advanced hypertrophic cardiomyopathy (HCM) may be complicated by a dilated hypokinetic transformation. Reduced left ventricular ejection fraction (HFrEF) has been described in terms of specific risks of morbidity and mortality, and specifically in terms of increased risk for fatal arrhythmias. Nevertheless, recent publications have casted doubt regarding the role of arrhythmia in non-ischemic HFrEF and questioned the role of primary prevention strategies in these cases.

Methods

We've reviewed clinical characteristics of 883 patients age ≥40, diagnosed with HCM who were evaluated in the cardiomyopathy clinic in two tertiary medical centers in Israel and Spain.

Results

Forty-five patients (5%) suffered from hypokinetic transformation. They were younger at diagnosis (median 32 [IQR 24–55] vs. 49 [35–60], p<0.001), had a lower body-mass index (28.4 [±4.7] vs. 26.0 [±3.9], p<0.001), and suffered more from strokes (19% vs 6%, p<0.001). They had lower had a lower NYHA class (p=0.001) and lower exercise capacity (7.3 [4.5–10.8] vs. 9.6 [6.7–12.0] METS, p<0.001). Patients with hypokinetic HCM had higher rates of pacemaker and implanted defibrillator (ICD) implantations (41% vs 11%, p<0.001) and (43% vs 13%, p<0.001) respectively. These patients had a higher incidence of sustained ventricular tachyarrhythmias (14% vs 2%, p<0.001). Among patients who had an ICD, patients suffering from hypokinetic transformation had received more appropriate ICD therapy (27% vs 12%, p<0.001). These patients received more heart transplantations (13% vs 1%, p<0.001), and had a trend for higher incidence rate of Sudden cardiac death (6% vs 2% p=0.06) and a higher 5-year mortality rates (21% vs. 5%, p<0.001).

Conclusions

HCM patients suffering from hypokinetic transformation have lower functional and exercise capacities, are more likely to suffer from ventricular tachyarrhythmias and experience appropriate ICD therapy, and undergo heart transplantation. They also have a significantly lower 5-year survival.

Five-year survival

Funding Acknowledgement

Type of funding source: None

Sodium-glucose cotransporter 2 inhibitor Dapagliflozin attenuates diabetic cardiomyopathy

Background

Diabetes mellitus type 2 (DM2) is a risk factor for developing heart failure but there is no specific therapy for diabetic heart disease. Sodium glucose transporter 2 inhibitors (SGLT2I) are recently developed diabetic drugs that primarily work on the kidney. Clinical data describing the cardiovascular benefits of SGLT2Is highlight the potential therapeutic benefit of these drugs in the prevention of cardiovascular events and heart failure. However, the underlying mechanism of protection remains unclear. We investigated the effect of Dapagliflozin—SGLT2I, on diabetic cardiomyopathy in a mouse model of DM2.

Methods

Cardiomyopathy was induced in diabetic mice (db/db) by subcutaneous infusion of angiotensin II (ATII) for 30 days using an osmotic pump. Dapagliflozin (1.5 mg/kg/day) was administered concomitantly in drinking water. Male homozygous, 12–14 weeks old WT or db/db mice (n = 4–8/group), were used for the experiments. Isolated cardiomyocytes were exposed to glucose (17.5–33 mM) and treated with Dapagliflozin in vitro. Intracellular calcium transients were measured using a fluorescent indicator indo-1.

Results

Angiotensin II infusion induced cardiomyopathy in db/db mice, manifested by cardiac hypertrophy, myocardial fibrosis and inflammation (TNFα, TLR4). Dapagliflozin decreased blood glucose (874 ± 111 to 556 ± 57 mg/dl, p < 0.05). In addition it attenuated fibrosis and inflammation and increased the left ventricular fractional shortening in ATII treated db/db mice. In isolated cardiomyocytes Dapagliflozin decreased intracellular calcium transients, inflammation and ROS production. Finally, voltage-dependent L-type calcium channel (CACNA1C), the sodium–calcium exchanger (NCX) and the sodium–hydrogen exchanger 1 (NHE) membrane transporters expression was reduced following Dapagliflozin treatment.

Conclusion

Dapagliflozin was cardioprotective in ATII-stressed diabetic mice. It reduced oxygen radicals, as well the activity of membrane channels related to calcium transport. The cardioprotective effect manifested by decreased fibrosis, reduced inflammation and improved systolic function. The clinical implication of our results suggest a novel pharmacologic approach for the treatment of diabetic cardiomyopathy through modulation of ion homeostasis.

P928Pseudo-discordance mimicking low-flow low-gradient AS in TAVR patients with severe symptomatic aortic stenosis

Background

The combination of a small aortic valve area valve area (AVA) and a low mean gradient (MG) severity pose a serious clinical challenge in the diagnosis of severe aortic stenosis (AS). While this discordance is frequently labeled “low-flow low-gradient AS”, there are two additional potential causes: underestimation of MG and underestimation of AVA.

Purpose

To investigate prevalence and root causes of discordant echocardiographic findings in symptomatic patients with AS and normal LV function by comparing Doppler data, invasive hemodynamic data, CT LV outflow tract size and calcium score.

Methods and results

We studied 67 severely symptomatic patients with AS and an LVEF>50%. Thirty patients (45%) had discordant echocardiographic findings (MG<40 mmHg, AVA≤1cm2). Of those, 16 had also discordant findings by invasive measurements (True Discordants), compatible with low-gradient severe AS. In 14, catheterization data were actually concordant and hence discrepant to the echocardiographic findings (False Discordants): In 7 of them, the echocardiographic MG was >35 mmHg; in 5 it was >30 mmHg and only in 2 between 25 and 29 mmHg. In 6 of the 14 patients with underestimated MG, no right parasternal Doppler examination had been performed, LVOT VTI tracings were clearly suboptimal in 3 patients and 1 case was deemed inadequate due to poor imaging quality. LVOT area by echocardiography or by CT could not differentiate between Concordants and Discordants (p=0.3 and p=0.8 respectively) or between True and False Discordants (p=0.5 and p=0.6 respectively). While calcium score was similar in Concordants (2711±1159 AU) and False Discordants (2692±1136AU, p=0.96), it tended to be higher in Concordants (2711±1159 AU), when compared to True Discordants (1906±1284 AU, p=0.07). In patients with concordant echocardiographic findings calcium score levels of >3000 AU in men and >1600 AU in female had a positive predictive value (PPV) of 90% for the correct diagnosis of severe aortic stenosis. In patients with discordant findings the PPV was 80%.

Conclusions

1) The majority of severely symptomatic AS patients with normal LV systolic function an echocardiographic AVA≤1.0 cm2 and a MG>30mmHg considered for TAVR have severe AS by calcium score. 2) In this patient population, discordant echocardiographic findings are in about half of the cases due to technical factors (“pseudo-discordance”) rather than due to true low flow low-gradient stenosis. 3) Pseudo-discordance is mainly due to mild-moderate underestimation of gradients, caused by a lack of reliable right parasternal tracings, rather than due to underestimation of valve area due to the echocardiographic circularity assumption in the presence of an elliptical LVOT. 4) The diagnosis of true low-flow AS cannot be established without a clear Doppler tracing from the right parasternal window. 5) Absent an adequate right parasternal window, patients should undergo CT assessment of calcium score.

CYP-450 Epoxygenase Derived Epoxyeicosatrienoic Acid Contribute To Reversal of Heart Failure in Obesity-Induced Diabetic Cardiomyopathy via PGC-1 α Activation

We have previously shown that an Epoxyeicosatrienoic Acid (EET) -agonist has pleiotropic effects and reverses cardiomyopathy by decreasing inflammatory molecules and increasing antioxidant signaling. We hypothesized that administration of an EET agonist would increase Peroxisome proliferator-activated receptor-gamma coactivator (PGC-1α), which controls mitochondrial function and induction of HO-1 and negatively regulates the expression of the proinflammatory adipokines CCN3/NOV in cardiac and pericardial tissues. This pathway would be expected to further improve left ventricular (LV) systolic function as well as increase insulin receptor phosphorylation. Measurement of the effect of an EET agonist on oxygen consumption, fractional shortening, blood glucose levels, thermogenic and mitochondrial signaling proteins was performed. Control obese mice developed signs of metabolic syndrome including insulin resistance, hypertension, inflammation, LV dysfunction, and increased NOV expression in pericardial adipose tissue. EET agonist intervention decreased pericardial adipose tissue expression of NOV, while normalized FS, increased PGC-1α, HO-1 levels, insulin receptor phosphorylation and improved mitochondrial function, theses beneficial effect were reversed by deletion of PGC-1α. These studies demonstrate that an EET agonist increases insulin receptor phosphorylation, mitochondrial and thermogenic gene expression, decreased cardiac and pericardial tissue NOV levels, and ameliorates cardiomyopathy in an obese mouse model of the metabolic syndrome.

Antenatal prediction of postpartum depression with blood DNA methylation biomarkers

Postpartum depression (PPD) affects ∼10-18% of women in the general population and results in serious consequences to both the mother and offspring. We hypothesized that predisposition to PPD risk is due to an altered sensitivity to estrogen-mediated epigenetic changes that act in a cell autonomous manner detectable in the blood. We investigated estrogen-mediated epigenetic reprogramming events in the hippocampus and risk to PPD using a cross-species translational design. DNA methylation profiles were generated using methylation microarrays in a prospective sample of the blood from the antenatal period of pregnant mood disorder patients who would and would not develop depression postpartum. These profiles were cross-referenced with syntenic locations exhibiting hippocampal DNA methylation changes in the mouse responsive to long-term treatment with 17β-estradiol (E2). DNA methylation associated with PPD risk correlated significantly with E2-induced DNA methylation change, suggesting an enhanced sensitivity to estrogen-based DNA methylation reprogramming exists in those at risk for PPD. Using the combined mouse and human data, we identified two biomarker loci at the HP1BP3 and TTC9B genes that predicted PPD with an area under the receiver operator characteristic (ROC) curve (area under the curve (AUC)) of 0.87 in antenatally euthymic women and 0.12 in a replication sample of antenatally depressed women. Incorporation of blood count data into the model accounted for the discrepancy and produced an AUC of 0.96 across both prepartum depressed and euthymic women. Pathway analyses demonstrated that DNA methylation patterns related to hippocampal synaptic plasticity may be of etiological importance to PPD.

Short-term functional outcome of ischemic stroke in the elderly: a comparative study of atrial fibrillation and non-atrial fibrillation patients

The purpose of this study was to evaluate whether atrial fibrillation affects the short-term functional outcome of elderly patients with ischemic stroke, undergoing post-acute in-hospital rehabilitation. We studied 919 consecutive patients admitted for ischemic stroke rehabilitation, out of whom 19.6% were diagnosed with atrial fibrillation. The Functional outcome of atrial fibrillation (AF) and non-atrial fibrillation (Non-AF) patients were assessed by the Functional Independence Measurement scale (FIM) at admission and discharge. Data were analyzed by t-test, Chi-square test and by multiple linear regression analysis. Compared with Non-AF, patients with AF were slightly older (p<0.001), and had lower Mini-Mental State Examination (MMSE) scores (p=0.001). Discharge total FIM scores were significantly higher in Non-AF compared with AF patients (84.34 ± 29.44 vs. 79.02 ± 30.68, p=0.031). However, total and motor FIM gains at discharge were similar in the two groups. A multiple linear regression analysis showed that age (p<0.001), admission total and motor FIM (p<0.001) and MMSE score (p<0.001) emerged as the only independent predictors of total, motor and gain FIM scores at discharge. AF was not predictive, whatsoever, of adverse FIM scores (total, motor, gain) at discharge (β=-0.024, p=0.303; β=-0.019, p=-0.455 and β=-0.04, p=0.303, respectively). The finding suggests that Non-AF ischemic stroke elderly show higher total discharge FIM scores, compared with AF patients. However, both groups achieve similar FIM gains during rehabilitation period. AF should not be considered as adversely affecting the short-term rehabilitation process of such patients.

Skeletal muscle mass abnormalities are associated with survival rates of institutionalized elderly nursing home residents

BACKGROUND

Knowledge about the changes in skeletal muscle mass in nursing home residents is very limited. We hypothesized that such patients have different types of skeletal muscle mass abnormalities that may affect mortality rates. Therefore, the objective of this study was to evaluate the prevalence and extent of skeletal muscle mass decline, its different clinical phenotypes (sarcopenia, wasting/atrophy and cachexia) and the mortality rates associated with these abnormalities.

METHODS

A retrospective chart-review study comprising 109 institutionalized nursing home residents. Body mass index, body fat mass, fat free mass, skeletal muscle mass and survival rates were assessed.

RESULTS

Skeletal muscle mass abnormalities were found among 73 out of 109 (67.0%) patients and were more prevalent in males compared with females (97.8% and 43.8%, respectively, p<0.001). Most of these patients had muscle wasting/atrophy (51.4%) or sarcopenia (40.3%), and 9.7% suffered from cachexia. One third of the patients with abnorrmal skeletal muscle mass showed a moderate decline of skeletal muscle mass (34.7%) while the remainder (65.3%) had very low levels of skeletal muscle mass. Each group was characterized by typical medical conditions associated with skeletal muscle mass abnormality. A Kaplan-Meier survival plot of mortality showed only lower one-year survival rates in the group with sarcopenia (60%) and muscle atrophy or cachexia (53%), compared with elderly participants with a normal skeletal muscle mass (73%), (p<0.0001). There were no significant differences in 1-year mortality rates between patients with abnormal skeletal muscle mass (whether sarcopenia, cachexia or wasting).

CONCLUSION

About two thirds of nursing home patients show skeletal muscle mass abnormalities, most within the range of very low skeletal muscle mass rather than moderately low skeletal muscle mass, that are associated with shorter survival rates, compared with normal skeletal muscle mass patients.

Gender and the functional outcome of elderly ischemic stroke patients

The purpose of this study was to investigate the effect of gender on the functional outcome after ischemic stroke. In a retrospective chart review we studied 919 survivors of ischemic stroke admitted for rehabilitation at a geriatric rehabilitation ward of a university affiliated hospital. Functional outcome of female and male patients was assessed by Functional Independence Measurement (FIM) at admission and discharge. Data were analyzed by t test, Chi-square test and Linear Regression. A total number of 919 patients were admitted of whom 56% were males. A higher proportion of male patients reported ischemic heart disease (p<0.001), hypercholesterolemia (p=0.035), Parkinson's disease (p=0.044), and previous stroke (p<0.001). Males had also higher Mini-Mental State Examination (MMSE) scores (p<0.001). Total FIM at admission (62.54 ± 25.98 and 66.00 ± 25.49; p=0.043), and total FIM at discharge (80.39 ± 30.35 and 85.59 ± 29.08; p=0.008), motor FIM at admission (40.04 ± 18.89 and 42.51 ± 18.47; p=0.047) and motor FIM at discharge (56.41 ± 23.04 and 60.44 ± 21.84; p=0.007) were higher among male patients. However, a trend for a borderline statistical difference was observed for FIM gains upon discharge between men and women. A multiple linear regression analysis showed that total FIM at discharge was neither associated with male nor female gender (β=-0.009; p=0.69). The findings suggest that the functional outcome of male survivors presenting for rehabilitation after acute ischemic stroke is slightly better. After adjusting for possible covariates, gender did not emerge as an independent predictor for higher FIM at discharge, suggesting that gender should not be held as adversely affecting rehabilitation of such patients.

Discharge hemoglobin and functional outcome of elderly hip fractured patients undergoing rehabilitation

AIM

Low hemoglobin level is considered a marker of poor functional outcome. The objective of this study was to explore possible relationship of discharge hemoglobin levels and functional outcome of elderly hip fracture patients, undergoing in-hospital rehabilitation.

METHODS

A retrospective chart review study, comprising consecutive elderly patients suffering traumatic hip fractures. Main outcome measurement was the functional outcome of patients, as assessed by motor and total Functional Independence Measurement (FIM) scores upon admission and discharge.

RESULTS

Mean discharge hemoglobin levels were significantly associated with prefracture function and Mini Mental State Examination (MMSE) score (P=0.002 and P=0.01, respectively). The authors observed a significant positive correlation between serum hemoglobin and total FIM at discharge (Pearson's coefficient =0.13; P=0.005) as well as with motor FIM at discharge (Pearson's coefficient =0.13; P=0.005). Regression analyses showed that high MMSE scores (beta=0.55; P<0.001), female gender (beta=0.07; P=0.01), younger age (beta=-0.10, P=0.001) and a better pre-fracture function (beta=-0.27 P<0.001) are associated with higher total FIM scores upon discharge. Neither discharge hemoglobin levels nor the number of transfused blood packs were significantly associated with better total FIM, motor FIM, FIM gain or FIM= or >80.scores.

CONCLUSION

Higher hemoglobin at discharge was not associated with a better postfracture function, as reflected by FIM scores. The authors suggest that clinically reasonable low hemoglobin levels are not associated with adverse functional outcome of elderly hip fracture patients, thus, actively correcting hemoglobin levels, per se, may not result in better functional outcomes in this population.

Monitoring lung fluid content in CHF patients under intravenous diuretics treatment using bio-impedance measurements

A pulmonary edema monitoring system (PulmoTrace, CardioInspect, Tel-Aviv University, Israel) was evaluated for tracking lung resistivity during diuretics treatment in congestive heart failure (CHF) patients. The system incorporates a bio-impedance measurement algorithm and enables, by employing an eight-electrode thoracic belt, the assessment of both the left- and right-lung resistivity values. A clinical study was conducted on a group of 13 CHF patients under intravenous diuretics treatment. The group was measured twice-before the beginning of treatment and following a period of a couple of hours. An increase of 8% of the mean lung resistivity (median value) was found between the two measuring sessions, which indicates a dehydration of the lungs, and a significant correlation (R=0.73, p=0.004) was found between the lung resistivity change and the urine output. In conjunction with previously reported results, which demonstrated the system's reproducibility and long-term monitoring capabilities, this study further supports the diagnostics value of the system.

Parametric EIT for monitoring cardiac stroke volume

The bio-impedance technique appears appropriate for non-invasive cardiac stroke volume (SV) measurement, as the thoracic conductivity distribution is altered during the cardiac cycle due to the heart contraction and blood perfusion. In the present work, the feasibility of a parametric electrical impedance tomography (EIT) for assessing the cardiac SV was studied. An impedance model of the thorax was constructed from segmented axial MRI images along 19 phases of the cardiac cycle. The heart was simulated as an ellipsoid, with its axes' lengths set as the reconstruction parameters, while all other tissues' geometry and conductivity values were kept fixed. A Newton-Raphson parametric optimization scheme was utilized, yielding a correlation between the reconstructed and anatomical left ventricular volumes of 0.97 (p = 2 x 10(-11)). An analysis of noise sensitivity showed that the proposed algorithm requires an SNR greater than 65 dB. The simulation results were compared to physical data, collected with a portable EIT system (PulmoTrace, CardioInspect). The validation study was employed for a group of N = 28 healthy patients, and a comparison with impedance cardiography measurements (BioZ, Cardiodynamics) was made, showing a correlation of r = 0.86 (p = 4 x10(-9)). The preliminary results demonstrate that parametric EIT has the potential to measure SV, and may be applicable for both clinical and home environment usage.

A portable bio-impedance system for monitoring lung resistivity

The principles of a hybrid bio-impedance technique are implemented in a novel, lung resistivity monitoring system ("CardioInspect" Tel-Aviv University, Israel). The system is to be utilized in the clinic or at home, for daily monitoring of patients suffering from pulmonary edema. The developed system consists of an eight-electrode belt worn around the thorax, an electronic unit containing analog and digital boards, and a stand-alone DSP based system with a designated software to analyze the data. A Newton-Raphson algorithm based on the finite-volume method is employed for the optimization of the left and right lung resistivity values, making use of the voltage measurements retrieved from opposite current injections. In this preliminary study, 33 healthy volunteers were measured with the system during tidal respiration, yielding symmetric mean left and right lung resistivity values of (1205+/-163, 1200+/-165) (Omega cm). The system reproducibility was better than 2% for both within and between tests measurements, and no dependency between the reconstructed values and various anthropometric parameters was found.

Functional outcome of elderly hip fracture patients: does diabetes matter?

The purpose of this study was to investigate whether diabetes mellitus may affect the functional outcome of hip fractured patients. We studied 759 consecutive patients admitted for hip fracture rehabilitation, out of whom 18.2% were diabetics. The functional outcomes of diabetics and nondiabetics were assessed by the functional independence measurement scale (FIM) at admission and discharge. Data were analyzed by t-tests, Pearson correlation, and chi-square test as well as by multiple logistic regression analysis. Compared with nondiabetics, diabetic patients were slightly younger (p=0.003) and more hyperlipidemic (p=0.01), had a higher prevalence of previous stroke (p=0.03) and lower cognitive Mini-Mental State Examination (MMSE) scores (p=0.007). Absolute and relative FIM parameters, at admission and discharge, were similar in both groups. A multiple logistic regression analysis showed that diabetes was independently, and inversely, associated with male gender [odds ratio (OR), 2.11 (95% CI, 1.41-3.18)] and higher admission motor-FIM [OR, 1.05 (95% CI, 1.03-1.07)], whereas higher cognitive scores upon admission emerged as being "protective" for being in the motor-FIM gain <20 [OR, 0.94 (95% CI, 0.91-0.97)]. However, diabetes was not associated with any of the parameters indicating unsuccessful rehabilitation. The findings suggest that there is no difference in the functional outcome of diabetic and nondiabetic patients, presenting for rehabilitation after surgery of hip fractures. Diabetes should not be considered as adversely affecting rehabilitation of such patients.

Clock drawing task, mini-mental state examination and cognitive-functional independence measure: relation to functional outcome of stroke patients

The use of reliable and valid brief cognitive screening instrument for selecting the appropriate candidates for stroke rehabilitation is crucial. Clinicians often face the question which test should be preferred, that will best correlate with functional outcome. The objective of this study was to compare the clock drawing task with other cognitive tests used for the evaluation of discharge functional outcome in elderly stroke patients. We conducted a retrospective chart study including 151 consecutive patients, admitted for inpatient comprehensive rehabilitation following acute stroke. The clock drawing task (CDT), mini-mental state examination (MMSE) and the cognitive-functional independence measure (cognFIM) were used to assess the cognitive status. Functional status outcome was evaluated by the functional independence measure (FIM), using absolute and relative parameters of efficacy and efficiency. Correlation coefficients (Pearson correlation) between the three cognitive tests resulted in r-values ranging from 0.51 to 0.59 (P<0.001). All three tests correlated significantly with motor outcomes. MMSE did not confer additive value to CDT. It is concluded that CDT is similar to mini-mental and both are somewhat better than cognFIM with respect to the evaluation of functional status outcome following stroke. The correlations between the tests as well as the simplicity of administration favor the use of either CDT or MMSE in the initial assessment of elderly stroke patients.

Meperidine analgesia and delirium in aged hip fracture patients

Delirium is quite frequent in elderly patients who sustain hip fractures. The use of Meperidine by physicians, unaware of the possible emergence of delirium in elderly patients, is very popular. We have retrospectively examined the incidence of delirium in 181 consecutive patients admitted to the orthogeriatric ward with hip fractures. We used the confusion assessment method to establish the presence of delirium in all patients. A database search was conducted to identify which patients were treated by Meperidine, or Morphine, prior to delirium onset. We identified 92 cases, 44 of whom were treated by Meperidine alone, and the other 48 treated by Morphine alone. Delirium was diagnosed in 13 (27.1%) Morphine treated patients as compared with 19 (43.2%) treated by Meperidine (P<0.001). Age, cognitive status and opiate use were associated with perioperative delirium. A subset regression analysis showed that exposure to Meperidine was significantly associated with delirium (odds ratio 2.5, P<0.01), in contrast with Morphine. Our results confirm the association between exposure to Meperidine and delirium, suggesting that this drug should be withdrawn in elderly hip fractured patients undergoing surgery, and substituted by low dose Morphine analgesia. Reducing the incidence of delirium, by adopting such an approach, may result in a significant potential of savings in direct costs, related to treatment of delirium in this population.

The unfavorable nature of preoperative delirium in elderly hip fractured patients

The onset of delirium is frequent in elderly patients who sustain hip fractures. The purpose of this study was to characterize different patterns of preoperative and postoperative delirium, to study factors associated with preoperative delirium and to evaluate the possible different outcome of these patients. This retrospective study comprised 281 elderly patients with hip fractures undergoing surgical fixation. Data collection included age, sex, length of stay, type of fracture, cognitive status by mini mental state examination (MMSE), assessment of possible delirium by the confusion assessment method (CAM) and functional outcome assessed by functional independence measure (FIM). A database search was conducted to identify whether delirium onset occurred prior to or following surgery. About 31% of the total sample developed delirium. Delirious patients tended to be more disabled (P = 0.03) and cognitively impaired (P = 0.018), compared with non-delirious patients. Most delirious cases (53%) had their onset in the preoperative period. Patients with preoperative delirium were older (P = 0.03), had a lower prefracture mobility (P < 0.01), impaired cognition (P = 0.04) and showed an adverse functional outcome in terms of FIM score. Regression analysis showed that prefracture dementia, prefracture mobility and low MMSE scores were strongly associated with higher probability of having preoperative delirium, with no additional effect of other variables. It is concluded that preoperative delirium should be viewed as a separate entity with unfavorable nature and adverse outcome. Careful preventive measures and better treating strategies should be employed to avoid this clinical condition.