Detailed analysis of left ventricular deformation in athletes doing high dynamic sports – a three-dimensional speckle-tracking echocardiographic study

Background

Physiologic remodeling due to repetitive overload induced by exercise training is a known feature in the athletes' heart including significant changes in left ventricular (LV) deformation mechanics. The aim of the present study was to investigate three-dimensional speckle-tracking echocardiography- (3DSTE-)derived LV strains in elite athletes doing high dynamic sports with different grades of static components of their training.

Methods

The athlete group comprised 67 subjects (mean age: 23.6±6.4 years, 50 men). The following groups were created regarding their physical activity: Group C. I. (high dynamic/low static) (n=12, mean age: 23.1±4.0 years, Group C. II. (high dynamic/moderate static) (n=22, mean age: 24.8±7.8 years) and Group C. III. (high dynamic/high static) (n=33, mean age: 23.0±6.1 years). Their results were compared to 83 age- and gender-matched non-athletic healthy controls (mean age: 23.6±3.2 years, 50 men). All athletes and non-athletes underwent a complete two-dimensional Doppler echocardiography examination with 3DSTE.

Results

None of the healthy subjects or athletes had any known cardiovascular risk factors or received drugs and ECG showed no significant alterations. Athletes spent 10.8±3.3 years, 10.1±5.9 years and 6.9±4.2 years in elite sport in Groups C. I., C. II. and C. III., respectively. No significant differences could be seen in the ratio of athletes being in an actual race period between Groups C. I., C. II. and C. III. [n=3 (25%), n=11 (50%) and n=11 (32%), respectively]. Enlarged LV dimensions and thickened posterior wall and interventricular septum were found in all athletes compared to the non-athlete healthy control group by 2-dimensional echocardiography. Increased 3DSTE-derived LV end-diastolic and end-systolic volumes could be seen in all athletes, the largest values were seen in the C. III. group. Global LV-LS (−18.5±3.0% vs. −16.3±2.3%, p<0.05), LV-CS (−29.9±5.2% vs. −28.1±4.8%, p<0.05) and LV-AS (−43.7±5.4% vs. −40.9±4.8%, p<0.05) were increased as compared to those of non-athlete controls. All apical regional LV strains proved to be increased in all athletes with enhanced basal LS and midventricular LS, AS and 3DS. Global LV strains did not differ between the athlete groups based on static component of their training. No significant regional differences in LV strains could be detected between C. I., C. II. and C. III. groups (except in midventricular LV-LS).

Conclusions

Enhanced LV contractility represented by LV strains in longitudinal and circumferential directions could be demonstrated in elite athletes doing high dynamic sports, which does not depend on the grade of the static component of their training.

Funding Acknowledgement

Type of funding sources: None.

Left atrial volumes changes are associated with changes in mitral annular dimensions and functional properties in healthy adults – a three-dimensional speckle-tracking echocardiographic study

Introduction

Three-dimensional (3D) speckle-tracking echocardiography (3DSTE) is a novel echocardiographic method with capability of 3D assessment of heart chambers and valvular annuli making an opportunity to compare cyclic changes of left atrial (LA) volumes and mitral annular (MA) dimensions in physiological healthy circumstances. The present study was designed to examine correlations between LA volume changes and MA dimensions and functional properties in healthy adult subjects by 3DSTE.

Methods

The study population consisted of 199 healthy adults (mean age: 33.5±12.7 years, 104 males), who had no symptoms, conditions or diseases, which could affect results. None of subjects received any medication. The group of subjects was divided according to their maximum LA volume (Vmax) into three groups using 30 ml and 50 ml as cut-off values. All subjects underwent complete two-dimensional Doppler echocardiography extended with 3DSTE.

Results

All LA volumes and stroke volumes increased with end-systolic Vmax. Early diastolic passive atrial emptying fraction (PAEF) was significantly reduced in patients with Vmax>50 ml. End-systolic total atrial emptying fraction (TAEF) and late diastolic active atrial emptying fraction (AAEF) was not accompanied with increased end-systolic Vmax. Both end-diastolic and end-systolic MA dimensions were dilated in subjects with increased Vmax, which was accompanied with reduction of MA function. Only end-systolic MA dimensions showed further increase, when end-systolic Vmax was larger than 50 ml compared to cases with Vmax between 30 ml and 50 ml. When prognostic value of MA dimensions and functional properties were analyzed, several MA dimensions and MA fractional area change (MAFAC) were found to have prognostic value to predict Vmax>50 ml. The cut-off values for end-diastolic MA diameter (MAD-D), end-systolic MA diameter (MAD-S) and area, end-diastolic and end-systolic MA perimeter and MAFAC to predict Vmax>50 ml proved to be 2.3 cm, 1.5 cm, 3.4 cm2, 10.2 cm, 7.4 cm and 50.93%, respectively. While increased LA volumes were associated with both dilated MAD-D and MAD-S, only increased diastolic LA volumes were associated with reduced MAFAC. While dilated MAD-D was associated with increased total and active atrial stroke volumes, similar relationship with MAD-S could not be detected. Increased passive atrial stroke volume was associated with augmented MAFAC. While dilated MAD-D was associated with increased AAEF, dilated MAD-S was found to be related to reduced TAEF and PAEF. Increased MAFAC was associated with increased values regarding all emptying fractions. End-diastolic MA dimensions increased with dilation of end-systolic MA dimensions and vice versa. Increased MAFAC was associated with dilated MAD-D and reduced MAD-S.

Conclusions

Strong relationship exists between LA volumes and MA dimensions and functional properties in healthy subjects.

Funding Acknowledgement

Type of funding sources: None.

Correlations between left atrial volumes and strains in healthy adults - a three-dimensional speckle-tracking echocardiographic study

Funding Acknowledgements

Type of funding sources: None.

Introduction. Left atrium (LA) is a dynamic structure, which can be characterized by several volumetric and functional properties. Not only volumetric changes could be detected during cardiac cycle, but contractility of its walls have also special quantitative properties. Three-dimensional (3D) speckle-tracking echocardiography (3DSTE) is a new imaging technique with capability of featuring changes in both LA volume and function by several parameters based on a virtual 3D LA model respecting cardiac cycle at the same time. This ability of 3DSTE makes an opportunity to examine correlations between LA volumes and contractility features. Due to the limited number of studies assessing these physiologic relationships, the present study aimed to test correlations between LA volumes, volume-based functional properties and strains respecting cardiac cycle in healthy adults by 3DSTE. 

Methods. The present study comprised 217 healthy adult volunteers (mean age: 33.4 ± 12.7 years, 112 males) without any symptoms, known diseases or other states, which could affect results. None of them received any medication at the time of examination. Complete two-dimensional (2D) Doppler echocardiography and 3DSTE have been performed in all cases. 

Results. LA stroke volumes increased with maximum LA volume (Vmax) in reservoir, conduit and booster pump phases of LA function. LA emptying fraction (EF) remained unchanged in LA reservoir phase (total atrial EF, TAEF) with the increase in Vmax (TAEF at Vmax < 30 ml = 51.9 ± 13.7% vs. TAEF at Vmax > 50 ml = 50.9 ± 10.9%, p = ns). Significant reduction in LA-EF could be detected in LA conduit phase (passive atrial EF, PAEF), if Vmax proved to be larger than 50 ml (PAEF at Vmax < 30 ml = 34.0 ± 13.2% vs. PAEF at Vmax > 50 ml = 27.5 ± 12.6%, p < 0.05). In booster pump function LA-EF (active atrial EF, AAEF)  did not show significant alterations with the increase of Vmax (AAEF at Vmax < 30 ml = 26.9 ± 14.7% vs. PAEF at Vmax > 50 ml = 31.7 ± 11.7%, p = ns). Global peak LA radial strain (RS) (at Vmax < 30 ml = -11.7 ± 8.9% vs. at 30 ml ≤ Vmax ≤ 50 ml = -15.4 ± 7.7% and at Vmax > 50 ml = -14.7 ± 6.8%, p <0.05 and p < 0.05, respectively) and 3D strain (3DS) (at Vmax < 30 ml = -5.5 ± 5.7% vs. at 30 ml ≤ Vmax ≤ 50 ml = -7.5 ± 5.6% and at Vmax > 50 ml = -8.0 ± 5.0%, p < 0.05 and p < 0.05, respectively) increased with Vmax only until a point. LA-RS and LA-3DS at atrial contraction similarly increased with Vmax. The other strain parameters did not show any changes.

Conclusions. LA-RS and LA-3DS, objective features of LA contractility do not increase beyond a point in parallel with an increase in maximum LA volume in healthy subjects.

Left ventricular rotational mechanics in elite athletes with high dynamic component of their training - a three-dimensional speckle-tracking echocardiographic study

Funding Acknowledgements

Type of funding sources: None.

Introduction. In normal circumstances left ventricular (LV) apex and base rotate different directions during cardiac cycle, while LV apex rotates counterclocwise, LV base has a clockwise movement at the same time. This sort of towel-wringing-like movement is called LV twist. Three-dimensional speckle-tracking echocardiography (3DSTE) is a new, promising, easy-to-perform and reproducible modality for the evaluation of LV apical and basal rotations. Although cardiac adaptation is a known feature seen in highly trained athletes, there are conflicting results according to sport activity-related changes in LV rotational mechanics. The present study was designed to test whether differences in LV rotational mechanics could be detected in elite athletes with high dynamic, but different grade of static components of their training by 3DSTE.

Methods. The subjects group comprised 80 elite sportmen, which group of athletes was further divided according to the task force classification of the American College of Cardiology considering dynamic and static components of their training. The following groups were created regarding to their physical activity: Group C1 (high dynamic/low static)(n = 13, mean age: 24.0 ± 5.1 years, Group C2 (high dynamic/moderate static)(n = 23, mean age: 24.6 ± 7.7 years) and Group C3 (high dynamic/high static)(n = 34, mean age: 22.8 ± 6.0 years). Their results were compared to 67 age- and gender-matched non-athletic healthy controls (mean age: 24.0 ± 5.1 years, 33 men). 3DSTE was used for the evaluation of LV rotational abnormalities.

Results. Increased LV end-diastolic and end-systolic volumes could be detected in Groups C2 and C3 subjects as compared to controls. No changes in LV volumes and rotational mechanics could be detected in Group C1 cases. Reduced LV basal rotation was seen in Group C2 and C3 subjects compared to that of controls (-3.17 ± 2.81 degree and -2.88 ± 1.88 degree vs. -4.31 ± 1.82 degree, p < 0.05 and p < 0.05, respectively). It was accompanied with LV twist reduction in Groups C2 and C3 subjects compared to that of controls (11.3 ± 4.3 degree and 11.5 ± 4.1 degree vs. 14.0 ± 3.4 degree, p < 0.05 and p < 0.05, respectively). None of elite athletes showed absence of LV twist called as LV ‘rigid body rotation’ (LV-RBR).

Conclusions. Significant LV basal rotation and twist reduction could be detected in elite athletes with high dynamic and moderate/high static components of their training.

Normal reference values of three-dimensional speckle-tracking echocardiography-derived left ventricular strain parameters in healthy adults

Introduction

At this moment, limited number of studies is defining normal reference value of three-dimensional (3D) speckle-tracking echocardiography (3DSTE)-derived left ventricular (LV) strains. The present study aimed to quantify normal reference values of LV strains in healthy adult population in real clinical world settings in different age groups and to determine age- and gender-dependence of these parameters in a high volume single centre.

Methods

The present study comprised 296 healthy adult subjects from which 124 cases were excluded due to inferior image quality during a 6-year period. The remaining population was further divided into 4 subgroups based on age decades. The following groups of healthy subjects were examined based on their age: 18–29 years (mean age: 23.6±2.8 years, 45 males out of 94), 30–39 years (mean age: 33.7±2.8 years, 27 males out of 34), 40–49 years (mean age: 43.4±3.4 years, 11 males out of 17) and 50+ years (mean age: 56.4±5.3 years, 12 males out of 27). All subjects underwent a complete 2D echocardiographic and Doppler assessment with negative results. None of the healthy subjects showed more than grade 1 valvular regurgitation or significant stenosis on any valves.

Results

The mean LV radial (RS), circumferential (CS), longitudinal (LS), 3D (3DS) and area (AS) strains proved to be 27.7±8.8%, −28.6±4.8%, −16.9±2.4%, 30.2±8.8% and −41.4±4.9%, respectively. While global LV-RS and LV-3DS showed an increase-decrease-increase pattern, LV-CS, LV-LS and LV-AS were somewhat lower in older ages. Only global LV-LS showed gender-dependency with higher values in females. Although somewhat higher LV-RS and LV-3DS and lower LV-CS, LV-LS and LV-AS could be measured in males, clear gender-dependency could not be detected in different age decades. The measurements were performed between 2011 and 2017, when feasibility of 3DSTE analysis improved as the operators gained experience. The number of adequate measurements proved to be 172 out of 296 (58% success ratio) for the overall time-period. For the last year, the number of good quality measurements, therefore the success ratio improved significantly (47 out of 59, 80%, p=0.001).

Conclusions

Normal reference values of 3DSTE-derived global, segmental, mean segmental and regional LV strains have been determined in healthy adult subjects based on real-life clinical experience. Age-, gender- and functional non-uniformity of LV strains were also defined.

Funding Acknowledgement

Type of funding source: None

Left ventricular apical rotation is associated with mitral annular function in healthy subjects. Results from the three-dimensional speckle-tracking echocardiographic MAGYAR-Healthy Study

Introduction

Left ventricular (LV) twist is considered an essential part of LV function due to oppositely directed LV basal and apical rotations. Several factors could play a role in determining LV rotational mechanics in normal circumstances. This study aimed to investigate the relationship between LV rotational mechanics and mitral annular (MA) size and function in healthy subjects.

Methods

The study comprised 118 healthy adult volunteers (mean age: 31.5 ± 11.8 years, 50 males). All subjects had undergone complete two-dimensional (2D) Doppler echocardiography and three-dimensional speckle-tracking echocardiography (3DSTE) at the same time by the same echocardiography equipment.

Results

The normal mean LV apical and basal rotations proved to be 9.57 ± 3.33 and -3.75 ± 1.98°, respectively. LV apical rotation correlated with end-systolic MA diameter, area, perimeter, fractional area change, and fractional shortening, but did not correlate with any end-diastolic mitral annular morphologic parameters. The logistic regression model identified MA fractional area change as an independent predictor of ≤6° left ventricular apical rotation (P < 0.003).

Conclusions

Correlations could be detected between apical LV rotation and end-systolic MA size and function, suggesting relationships between MA dimensions and function and LV rotational mechanics.

Oncologist Burnout Syndrome in Eastern Europe: Results of the Multinational Survey

PURPOSE

Burnout is defined as a three-dimensional syndrome-emotional exhaustion (EE), depersonalization (DP), and reduced personal accomplishment (PA)-caused by chronic occupational stress. The aim of the current study was to investigate the prevalence of burnout among oncologists in Eastern Europe and to identify the contributing factors.

METHODS

The study was conducted as an online survey between October 2017 and March 2018. Oncologists (including medical, radiation, clinical, and surgical oncologists) from 19 countries were invited to participate. The survey consisted of 30 questions, including the standardized burnout instrument, Maslach Burnout Inventory, and eight demographic questions. Burnout risk was scored according to the scoring manual for health care workers.

RESULTS

The study included 637 oncologists. Overall, 28% were at low or intermediate risk and 72% were at high risk for burnout. Forty-four percent of participants were at high risk for EE, 28.7% for DP, and 47.3% for PA. EE risk was associated with female sex. DP risk was highest among clinical and radiation oncologists, whereas PA risk was positively correlated with years of service, percentage of cancer deaths, and availability of the number of oncologists. In multivariate logistic regression analysis, burnout was significantly associated with standardized cancer mortality and fewer years of practice.

CONCLUSION

Burnout among oncologists in Eastern Europe is high, and younger oncologists are the most vulnerable group. Preventive measures should be taken to address this issue, which negatively affects optimal care delivery and poses a threat to oncologists' health and well-being.

P1795 Active acromegaly is associated with enhanced left ventricular contractility - A three-dimensional speckle-tracking echocardiographic study

Introduction

Acromegaly is a relatively rare, chronic hormonal disease resulting in disfigurement. In 90% of the cases, acromegaly is caused by a benign pituitary monoclonal human growth hormone-secreting tumor. Hypertension and left ventricular (LV) hypertrophy are the most common cardiovascular comorbidites, but serious valvular regurgitation and heart failure could also develop at the end-stages. The aim of the present study was to determine the presence of LV deformational abnormalities using three-dimensional speckle-tracking echocardiography (3DSTE) in a group of acromegaly patients.

Methods

Thirty-eight acromegaly patients were involved in the present study. Thirteen patients were excluded due to inadequate image quality. The mean age of the remaining patients were 57.2 ± 13.6 years (7 males). The active acromegaly subgroup consisted of 14 patients (mean age: 58.6 ± 14.6 years, 5 males), while the inactive group contained 11 patients (mean age: 54.0 ± 12.9, 2 males). Their data was compared to an age- and gender matched control population, which comprised of 34 healthy volunteers (mean age: 52.7 ± 4.9 years, 15 males). All subjects have undergone complete two-dimensional Doppler echocardiography extended with 3DSTE.

Results

Significant differences in left atrial diameter and volume, LV end-diastolic diameter and volume, interventricular septum and LV posterior wall thickness could be demonstrated between the acromegaly group and healthy controls. Global and mean segmental 3DSTE-derived LV radial strain (RS)(33.2 ± 13.4% vs. 25.2 ± 10.8%, p =0.01 and 36.0 ± 12.1% vs. 28.2 ± 10.0%, p =0.009, respectively) proved to be significantly higher in acromegaly patients compared to controls. Active acromegaly patients had a significantly higher global and mean segmental RS (35.5 ± 14.4% vs. 25.2 ± 10.8%, p =0.03 and 37.9 ± 13.3% vs. 28.2 ± 10.0%, p =0.03, respectively) as compared to that of controls. Between active and inactive acromegaly groups only basal LV circumferential strain (-30.2 ± 4.8% vs. -26.7 ± 4.1%, p =0.02) was found to be significantly different.

Conclusion

With presented clinical, demographic, therapeutic and echocardiographic features, active acromegaly is associated with enhanced LV-RS as compared to the healthy population.

P1561 Three-dimensional speckle-tracking echocardiography-derived normal reference values of left atrial volumes and volume-based functional properties in healthy adults

Introduction

Three-dimensional speckle-tracking echocardiography (3DSTE) is a new promising imaging method based on block-matching algorithm. The present study was designed to define normal reference values of 3DSTE-derived LA volumes, stroke volumes and emptying fractions respecting the cardiac cycle and to determine their age- and gender-dependency in healthy adults.

Methods

The present study involved 256 healthy adult subjects in sinus rhythm, who underwent complete two-dimensional Doppler echocardiography and 3DSTE at the same time. However, due to inferior image quality 87 subjects have been excluded. The remaining population comprised 169 cases who gave informed consent to participate in the study (mean age: 33.2 ± 12.8 years, 77 males). Complete two-dimensional Doppler echocardiography and 3DSTE have been performed in all subjects.

Results

While systolic maximum LA volume (Vmax) and early diastolic LA volume before atrial contraction (VpreA) did not change over age decades, late-diastolic minimum LA volume decreased over age decades and was lowest in subjects aged 40-49 years with an increase after 50 years. Total atrial stroke volume (TASV) remained unchanged over age decades. Passive atrial stroke volume (PASV) showed a continuous increase over age decades and a significant difference could be demonstrated between subjects aged 18-29 years and &gt;50 years. Active atrial stroke volume (AASV) did not change over age decades with a non-significant reduction in subjects aged &gt;50 years. Total atrial emptying fraction (TAEF) increased over age decades with a reduction after 50 years. Passive atrial emptying fraction (PAEF) showed a significant continuous increase over age decades. Active atrial emptying fraction (AAEF) did not change in younger ages, was highest at ages 40-49 years with a significant impairment after 50 years. Females have tendentiously higher LA volumes than males. Significant difference could be demonstrated in Vmax and VpreA of females versus males at ages 30-39 years. No significant differences were found between genders in LA stroke volumes, while indexed TASV and indexed AASV were higher in females as compared to males at ages 30-39 years. Similarly, no significant differences were found between genders in LA emptying fractions, while indexed TAEF were higher in females as compared to males at ages 18-29 years and 30-39 years, indexed PAEF at ages 18-29 years and indexed AAEF at ages 30-39 years. No correlations could be demonstrated between transmitral flow E and A velocities as well as their ratio and any of LA volumes neither in younger age group (less than 50 year) nor in older age group (more than 50 years).

Conclusions

Age- and gender-dependency of normal values of 3DSTE-derived LA volumes, stroke volumes and emptying fractions respecting the cardiac cycle were defined in healthy adult subjects.

P1562 Normal reference values of three-dimensional speckle-tracking echocardiography-derived right atrial volumes and volume-based functional properties in healthy adult subjects

Introduction

The right atrium (RA) has several roles including a systolic reservoir, early diastolic conduit and late-diastolic booster pump functions. The present study aimed to assess normal reference values of three-dimensional speckle-tracking echocardiography (3DSTE)-derived RA volumetric data and volume-based functional properties (stroke volumes, SVs and emptying fractions, EFs) in healthy adult subjects.

Methods

260 healthy adult subjects in sinus rhythm with complete clinical and demographic dataset have been included in the present study. However, due to inferior image quality 110 subjects have been excluded. The remaining population comprised 150 cases (31.0 ± 11.6 years, 79 males). Complete two-dimensional Doppler echocardiography and 3DSTE have been performed in all subjects.

Results

While systolic maximum RA volume did not change over age decades, early and late-diastolic RA pre-atrial contraction volume and minimum RA volume increased over time. Significantly larger values could be detected in more than 50 year-old healthy subjects as compared to younger subjects. Total atrial SV remained almost unchanged over age decades with a significant reduction in subjects aged &gt;50 years. Passive atrial SV showed a continuous reduction over age decades and significant difference could be demonstrated between subjects aged 18-29 years and &gt;50 years. Active atrial SV increased over age decades with a significant reduction in subjects aged &gt;50 years. Total atrial EF did not show any changes over age decades, but a significant reduction could be demonstrated in cases aged &gt;50 years. Passive atrial EF showed significant continuous reduction over age decades. Active atrial EF did not change in younger ages, it was the highest at ages 40-49 years with a significant impairment after 50 years. Females proved to have tendentiously higher RA volumes respecting the cardiac cycle regardless of age. No significant differences could be demonstrated between RA stroke volumes between genders except between 40-49 years when females had tendentiously higher values. RA emptying fractions were non-significantly, but tendentiously higher in females as compared to that of males regardless of age.

Conclusions

Normal reference values of 3DSTE-derived RA volumes and volume-based functional properties and their age- and gender dependency were defined in healthy adult subjects.

P1406 Normal reference values of right atrial strain parameters using three-dimensional speckle-tracking echocardiography in healthy adults

Introduction

Classic echocardiographic methodologies offer limited opportunities in assessing right atrial (RA) morphology and function. Three-dimensional (3D) speckle-tracking echocardiography (3DSTE) is a novel imaging method with objective 3D capability in assessing volumetric and functional properties of heart chambers. Normal reference values of different 3DSTE-derived RA strains are not available, therefore the aim of this prospective study was to establish these parameters in healthy subjects.

Methods

The present study comprised 295 healthy volunteers, from which 110 were excluded due to inadequate image quality. The final population consisted of 185 healthy subjects in the present study (mean age: 32.1 ± 12.2 years, 89 males). Complete two-dimensional echocardiography and 3DSTE have been performed in all cases.

Results

While radial strain (RS) does not change significantly over the years in males, RS increases with age most significantly between 40-49 years, and it starts to decline at the age of 50 years in females. While females have higher circumferential strain (CS) and area strain (AS) values, RS decreases with age in both gender. While longitudinal strain (LS) remains almost unchanged in females until 40-49 years and declines above the age of 50 years in females, it decreases over decades in males. 3D strain (3DS) increases with ages in both gender, but almost doubles in females in older ages. While RS at atrial contraction does not change over decades in males, an obvious increase could be seen in females with a higher value between 40-49 years and a decline over 50 years. A decrease could be seen in CS at atrial contraction in males over decades, it is almost tripled in value between 40-49 years in females. Although LS at atrial contraction is higher in females, it decreases over decades in both genders. AS decreases over decades in males, while females have almost doubled AS values at the ages 40-49 years. 3DS is almost unchanged in males, while doubled in older ages in females. During evaluations, 110 subjects were excluded due to inferior image quality from the total of 295 enrolled subjects, therefore the overall feasibility of 3DSTE-derived RA quantification was 185 out of 295 (63% overall feasibility).

Conclusion

3DSTE-derived RA normal reference values with age- and gender-dependency are demonstrated in a healthy population.

P946 Right atrial volumetric and functional analysis by three-dimensional speckle-tracking echocardiography in acromegaly

Introduction

Acromegaly is a chronic, rare hormonal disease associated with major cardiovascular comorbidities. The disease, in the majority of the cases, is caused by a benign human growth hormone secreting adenoma. Cardiovascular involvement is especially common in acromegaly patients from the most common hypertension to cardiomyopathy. It was set out to quantify right atrial (RA) morphology and function in a group of acromegaly patients using three-dimensional (3D) speckle-tracking echocardiography (3DSTE).

Methods

The study comprised 30 patients from which 8 patients were excluded due to inadequate image quality. Mean age of the remaining acromegaly patients were 53.7 ± 14.5 years (7 males). Ten patients were in active phase, while 12 subjects had inactive acromegaly. In the control group 40 healthy adults were enrolled (mean age: 52.3 ± 8.2 years, 15 males). In each case, complete two-dimensional Doppler echocardiography was performed followed by 3DSTE.

Results

Maximum (54.5 ± 14.4 ml vs. 47.2 ± 11.6 ml, p &lt;0.05) and minimum (35.5 ± 10.2 ml vs. 29.2 ± 9.1 ml, p &lt;0.05) RA volumes and RA volume before atrial contraction (45.1 ± 11.1 ml vs. 38.2 ± 10.3 ml, p &lt;0.05) were significantly higher in case of acromegaly compared to the healthy controls. Both global and mean segmental peak 3D strain (-11.94 ± 7.52% vs. -8.07 ± 5.03%, p &lt;0.05 and -17.16 ± 6.13% vs. -13.78 ± 5.35%, p &lt;0.05) were higher in the acromegaly group compared to the controls. At atrial contraction, mean segmental radial strain (-13.22 ± 6.45% vs. -9.74 ± 4.58%, p &lt;0.05) was significantly higher and mean segmental 3D strain (-9.78 ± 5.44% vs. -13.78 ± 5.35%, p &lt;0.05) was significantly lower in the acromegaly group compared to the controls. Between the active and inactive group of acromegaly patients, mean segmental longitudinal strain (28.17 ± 4.89% vs. 35.34 ± 9.75%, p &lt;0.05) was significantly different. Numerous independent strain parameters had significant correlations with different hormonal variables in the active acromegaly group. These correlations were not present in the inactive acromegaly subgroup.

Conclusion

Acromegaly is associated with significant RA volumetric and functional abnormalities.

Use of glucose-lowering drugs in Hungary between 2008 and 2017: the increasing use of novel glucose-lowering drug groups

AIMS

To analyse glucose-lowering drug utilization, focusing on the novel glucose-lowering drug groups dipeptidyl peptidase-4 inhibitors, glucagon-like peptide-1 receptor agonists and sodium-glucose co-transporter-2 inhibitors, and the financial burden they entail.

METHODS

Crude reimbursed national drug utilization and expenditure data for the entire population of Hungary were obtained from the National Health Insurance Fund for the study period: 2008 to 2017. Data were analysed using the WHO's Anatomical Therapeutic Chemical Classification/defined daily dose system and were expressed in defined daily dose per 1000 inhabitants per day.

RESULTS

Total glucose-lowering drug consumption in Hungary showed an 18% increase over the study period, reaching 74.7 defined daily doses per 1000 inhabitants per day, while novel glucose-lowering drug use increased to 11.7 defined daily doses per 1000 inhabitants per day (16% of total glucose-lowering drug use) by 2017. Dipeptidyl-peptidase 4 inhibitor consumption grew to 7.4 defined daily doses per 1000 inhabitants per day by 2017. The most widely used dipeptidyl-peptidase 4 inhibitor was sitagliptin. Glucagon-like peptide-1 receptor agonists were used the least, but by 2017 rose to 1.5 defined daily doses per 1000 inhabitants per day, led by liraglutide. Sodium-glucose co-transporter-2 inhibitors appeared in the utilization data in 2014 and their consumption, mainly empagliflozin, reached 2.8 defined daily doses per 1000 inhabitants per day by 2017. The total expenditure on glucose-lowering drugs increased 94% between 2008 and 2017, and the total cost of novel glucose-lowering drug utilization comprised 44% of the total glucose-lowering drug expenditure in 2017.

CONCLUSIONS

Both the use of and the financial burden posed by novel glucose-lowering drugs in Hungary increased steadily between 2008 and 2017. This increase is expected to continue.

Is there a relationship between increased aortic stiffness and segmental left ventricular deformation in elite athletes? (Insights from the MAGYAR-Sport Study)

Introduction Myocardial contractility of the left ventricle (LV) is related to arterial distensibility. Sport activity is frequently associated with changes in both LV and arterial functions. This study aimed to find correlations between three-dimensional speckle-tracking echocardiography-derived segmental LV deformation parameters and echocardiographically assessed aortic stiffness index (ASI) in athletes. This study comprised 26 young elite athletes (mean age: 26.7 ± 8.4 years, nine men). Results Among segmental circumferential strains (CSs), only that of apical anterior (r = 0.40, p = 0.05), septal (r = 0.47, p = 0.01), inferior (r = 0.59, p = 0.001), lateral (r = 0.44, p < 0.05), and midventricular anteroseptal (r = 0.44, p < 0.05) segments correlated with ASI, whereas LV-CS of the midventricular anterior segment showed a correlation tendency. Only longitudinal strain of basal anteroseptal (r = -0.46, p < 0.05) and inferoseptal (r = -0.57, p < 0.01) segments showed correlations with ASI, whereas that of the basal anterior segment had only a tendency to correlate. Some segmental multidirectional strains also correlated with ASI. Conclusions Correlations could be demonstrated between increased aortic stiffness and circular function of the apical and midventricular LV fibers and longitudinal motion of the basal septum and LV anterior wall (part of LV outflow tract) in maintaining circulation in the elite athletes.

Early histopathological changes in new-onset diabetes after kidney transplantation

BACKGROUND

New-onset diabetes after transplantation (NODAT) is one of the most common complications after kidney transplantation.

METHODS

Patients were randomly assigned to receive cyclosporine A-based or tacrolimus-based immunosuppression. Fasting and oral glucose tolerance tests were performed, and the patients were assigned to one of the following 3 groups, on the basis of the results: normal, impaired fasting glucose/impaired glucose tolerance, or NODAT. NODAT developed in 14% of patients receiving cyclosporine A-based immunosuppression and in 26% of patients taking tacrolimus (P = .0002).

RESULTS

Albumin levels were similar, but uric acid level (P = .002) and the age of the recipient (P = .003) were significantly different between the diabetic and the normal groups. Evaluation of tissue samples revealed that acute cellular rejection and interstitial fibrosis/tubular atrophy were significantly different in the NODAT group. Changes in the Banff score provided significant difference regarding tubulitis and interstitial inflammation (P = .05).

CONCLUSIONS

The pathological effect of new-onset diabetes after kidney transplantation can be detected in the morphology of the renal allograft earlier, before the development of any sign of functional impairment.

Changes in food group consumption and associations with self-rated diet, health, life satisfaction, and mental and physical functioning over 5 years in very old Canadian men: the Manitoba Follow-Up Study

OBJECTIVE

To identify longitudinal food group consumption trends and the relationship to perceived changes in diet, health, and functioning.

DESIGN

A prospective longitudinal study.

SETTING

Canada.

PARTICIPANTS

Seven hundred and thirty-six community-dwelling Canadian men (mean age: 2000=79.4 yrs; 2005=84.5 yrs) participating in the Manitoba Follow-up Study.

MEASUREMENTS

Self-reported food consumption, self-rated diet and health, life satisfaction, physical and mental functioning from questionnaires completed in 2000 and 2005.

RESULTS

The majority of participants did not consume from all four food groups daily, based on Canada's Food Guide recommendations, with only 8% in 2000 and up to 15% in 2005. However, over a five year period, more men improved their consumption in each food group than declined. An association was found between change in the self-rating of the healthiness of their diet and change in consumption of vegetables and fruit, or grain products. Men whose self-rating of the healthiness of their diet remained high or improved between 2000 and 2005, were 2.15 times more likely (95% CI=1.45, 3.17) to also have increased consumption of vegetables and fruit, and 1.71 times more likely (95% CI=1.51, 2.54) to have increased consumption of grain products, relative to men whose self-rating of the healthiness of their diet declined between 2000 and 2005. Men who consumed more food groups daily had better mental and physical component scores.

CONCLUSION

Dietary improvements are possible in very old men. Greater daily food group consumption is associated with better mental and physical functioning. Given these positive findings, there is still a need to identify older men who require support to improve their dietary habits as nearly half of the participants consumed two or fewer groups daily.

[Applicable methods of reconstruction for the replacement of soft tissue after the radical resection of oral tumors]

In Hungary the number of oral and pharyngeal cancers is alarmingly high. While the mortality rate in 1955 was 282, by 2005 it rose to 1567. However, in the last 1-2 years stagnation can be observed. Nevertheless, even now significant proportions of men and women are involved. Alcohol consumption and smoking are invariably the leading causes, but one cannot disregard the shortcomings of oral cancer screenings, either. Unfortunately, drastic changes in this field are not likely to occur in the near future. Numerous solutions have been developed for the replacement of soft tissue. In our article, we describe and evaluate four of them. When using these techniques, we were often successful in replacing soft tissue deficiencies.

Combined pharmacological block of I(Kr) and I(Ks) increases short-term QT interval variability and provokes torsades de pointes

BACKGROUND AND PURPOSE

Assessing the proarrhythmic potential of compounds during drug development is essential. However, reliable prediction of drug-induced torsades de pointes arrhythmia (TdP) remains elusive. Along with QT interval prolongation, assessment of the short-term variability of the QT interval (STV(QT)) may be a good predictor of TdP. We investigated the relative importance of I(Ks) and I(Kr) block in development of TdP together with correlations between QTc interval, QT interval variability and incidence of TdP.

EXPERIMENTAL APPROACH

ECGs were recorded from conscious dogs and from anaesthetized rabbits given the I(Kr) blocker dofetilide (DOF), the I(Ks) blocker HMR-1556 (HMR) and their combination, intravenously. PQ, RR and QT intervals were measured and QTc and short-term variability of RR and QT intervals calculated.

KEY RESULTS

DOF increased QTc interval by 20% in dogs and 8% in rabbits. HMR increased QTc in dogs by 12 and 1.9% in rabbits. Combination of DOF+HMR prolonged QTc by 33% in dogs, by 16% in rabbits. DOF or HMR given alone in dogs or HMR given alone in rabbits induced no TdP. Incidence of TdP increased after DOF+HMR combinations in dogs (63%) and following HMR+DOF (82%) and DOF+HMR combinations (71%) in rabbits. STV(QT) markedly increased only after administration of DOF+HMR combinations in both dogs and rabbits.

CONCLUSION AND IMPLICATIONS

STV(QT) was markedly increased by combined pharmacological block of I(Kr) and I(Ks) and may be a better predictor of subsequent TdP development than the measurement of QTc interval prolongation.

Coronary flow reserve, insulin resistance and blood pressure response to standing in patients with normoglycaemia: is there a relationship?

AIMS

To establish the relationships between coronary flow reserve, cardiovascular autonomic function, and insulin resistance characterized by the homeostasis model assessment insulin resistance score in patients with normal carbohydrate metabolism according to the World Health Organization (WHO) and American Diabetes Association (ADA) criteria, and with morphologically normal epicardial coronary arteries.

METHODS

Twenty-five patients [12 women and 13 men, mean (sd) age: 53 +/- 11 years] with normal coronary angiography were enrolled into the study. Coronary flow reserve was measured during stress transoesophageal echocardiography. Autonomic dysfunction was assessed by means of five standard cardiovascular reflex tests. The fasting serum glucose and insulin levels were determined and the homeostasis assessment model insulin resistance score was calculated.

RESULTS

In patients with normal carbohydrate metabolism, negative correlations were observed between the coronary flow reserve and both the serum insulin level (r = -0.445, P = 0.026) and the homeostasis assessment model insulin resistance score (r = -0.449, P = 0.024). The systolic blood pressure response to standing also correlated with the coronary flow reserve (r = -0.519, P = 0.011). The heart rate response to deep breathing, the Valsalva ratio, the 30/15 ratio and the sustained handgrip test results were not correlated with the coronary flow reserve.

CONCLUSIONS

Our data suggest the possible role of insulin resistance and early sympathetic nerve dysfunction in the development of decreased coronary flow reserve in patients without diabetes mellitus or impaired glucose tolerance.

Regional Differences in the Manifestation of Gastrointestinal Motor Disorders in Type 1 Diabetic Patients with Autonomic Neuropathy

OBJECTIVE

The aim of this work was to establish the prevalence and severity of different gastrointestinal symptoms and their relationships to esophageal, gastric and recto-anal motor disturbances by manometry in patients with Type 1 diabetes mellitus and autonomic neuropathy.

PATIENTS AND METHODS

Sixteen patients (mean age: 53.4 +/- 14.9 years) with long standing type 1 diabetes mellitus (mean diabetes duration: 22.1 +/- 14.7 years) and autonomic neuropathy (mean Ewing score: 5.73 +/- 2.34) were investigated. The gastrointestinal symptom scores were established by using the Talley dyspepsia questionnaire. The motor function of the digestive tract was tested in the esophagus, in the stomach, and in the ano-rectum by perfusion manometry.

RESULTS

Manometric evaluation of the esophagus did not reveal significant abnormalities in the region of the upper sphincter in patients with diabetes mellitus. In contrast, diabetic patients had decreased peristaltic wave amplitude, prolonged duration, decreased wave propagation velocity, and increased number of simultaneous contractions in the esophageal body, and decreased lower esophageal sphincter pressures with prolonged relaxation compared to the age- and sex-matched controls. Symptom analysis showed correlations between reflux symptoms and LES relaxation times, and between dysphagia scores and esophageal body peristaltic wave duration, propagation velocity and the rate of simultaneous contractions. In the gastric antrum, frequent, and often severe, fasting motility disorders were observed, which had no correlation with dyspeptic symptoms. In the ano-rectal region the diabetic patients had a lower squeezing-resting pressure difference, and impaired fecal expulsive function. Motility disorders were simultaneously present at multiple parts of the gastrointestinal tract in 13/16 cases.

CONCLUSIONS

In patients with type 1 diabetes mellitus and autonomic neuropathy gastrointestinal motility disorders were observed frequently, and in most of the cases simultaneously. While esophageal and ano-rectal symptoms correlated better with the manometric abnormalities, the lack of correlation between the impaired fasting gastric motility and dyspeptic symptoms shows that, on the basis of the clinical symptom analysis, the prevalence of such motor disorders could be underestimated. The early recognition of gastrointestinal motility disorders may be important for the better long-term management of patients with type 1 diabetes mellitus.

Gallbladder hypomotility in diabetic polyneuropathy

This study was performed to evaluate the gallbladder motility in long-standing diabetes mellitus. The gallbladder function of diabetic patients was measured by means of quantitative hepatobiliary scintigraphy, and the severity of the associated autonomic and sensory polyneuropathy was determined. The presence of a marked gallbladder hypomotility was established, and a positive correlation was observed between the severity of the autonomic disturbance and the contractile disorder. This study underlines the important role of the neuropathy in the development of gallbladder hypomotility accompanying long-term diabetes mellitus.

Brainstem auditory-evoked potential examinations in diabetic patients

Brainstem auditory-evoked potential (BAEP) examinations were performed in 15 patients with long-standing type-1 diabetes mellitus (DM). Cardiovascular reflex tests were applied for assessment of autonomic neuropathy. The aim of our investigation was to compare the BAEP results of this patient group with controls and to look for a possible correlation between the alteration of the auditory brainstem function and the cardiovascular autonomic neuropathy. Analysis of the latencies (waves I, II, III and V) and the inter-peak latencies (waves I-III and I-V) of BAEPs revealed a significant difference between diabetics and healthy controls. The amplitudes of waves I, III and V were definitely lower in comparison with those of healthy controls. A positive correlation was observed between the overall autonomic score and the latencies (waves III and V) and inter-peak latencies (waves I-III and I-V). These data support the hypothesis that long-standing DM and diabetic neuropathy might be related as a cause of certain dysfunctions of the central auditory pathways.

Suppression of erythromycin-induced early afterdepolarizations and torsade de pointes ventricular tachycardia by mexiletine

Erythromycin is a selective IKr-blocking, action potential duration (APD)-prolonging drug, which may induce early afterdepolarizations (EADs) and torsade de pointes ventricular tachycardia. The successful termination of an erythromycin-induced clinical torsades de pointes by the authors with mexiletine prompted them to investigate in vitro whether erythromycin is able to induce EADs in Purkinje fibers and, if so, whether EADs are suppressible or not by mexiletine. Electrically stimulated canine Purkinje fibers (n = 9) were superfused with erythromycin (200 mg/l) and action potentials were recorded by an intracellular microelectrode technique. Erythromycin induced a pronounced prolongation of APD and the appearance of EADs in all Purkinje preparations (9/9). After the addition of mexiletine (10 mM), a marked shortening of APD and the disappearance of EADs (7/9) were observed. Mexiletine, an inhibitor of the tetrodotoxin-sensitive window Na(+)-current, may prevent IKr-blocking drug-induced torsade de pointes ventricular tachycardia by abolishing APD prolongation and EADs.

[Gallbladder hypomotility in diabetic polyneuropathy]

A study was made of the pathogenic role of gallbladder hypomotility, which is presumably responsible for the high incidence of gallstone disease in long-standing diabetes mellitus. The gallbladder motility of diabetic patients (n = 10) was measured by means of quantitative hepatobiliary scintigraphy, and the severity of concomitant autonomic and sensory polyneuropathy was determined. The presence of marked gallbladder hypomotility was proven, and a positive correlation was observed between the severity of autonomic neuropathy and the contractile disorder. In this group of diabetic patients, a hypaesthetic sensory polyneuropathy too was recognized, the degree of which exhibited a positive correlation with the autonomic neuropathy score. This study underlines the important role of the autonomic neural dysfunction in the development of gallbladder hypomotility accompanying long-term diabetes mellitus.

[Erythrocyte-induced "torsade de pointes" ventricular tachycardia]

A case of erythromycin-induced acquired long QT syndrome and "torsades de pointes" ventricular tachycardia is reported. The peculiar ventricular tachyarrhythmia was evoked by orally administered erythromycin (1.5 g/die) in the presence of diuretic (clopamide)-induced hypokalaemia. The pause-dependent "torsades de pointes" was preceded by prolonged QTU interval (560 ms), "particular bigeminy" and "short-long-short" RR interval sequence. The recurrent ventricular tachycardia causing syncopal attacks was abolished by the discontinuation of erythromycin treatment, K+/Mg(2+)-supplementation and oral mexiletine therapy. It is emphasized that the macrolide antibiotic/prokinetic erythromycin, applied in therapeutic dosages, blocks the rapidly activating delayed rectifier potassium current (IKr), and as such, prolongs ventricular repolarization and may be "torsadogenic".

[Increase of the QT interval dispersion in diabetes mellitus]

The QT dispersion, measured as the interlead variability of QT interval (QTd = QTmax-QTmin), reflects the spatial inhomogeneity of ventricular repolarization times. The authors studied QTd and heart rate-corrected QTd (QTc-d) in 81 patients with diabetes mellitus (IDDM: 39, NIDDM: 42) using Bazett's formula; 20 non-diabetic subjects acted as controls (means +/- SD). QTd (43 +/- 17 ms) and QT c-d (52 +/- 20 ms) were increased (p < 0.05) as compared to the control values (QTd = 32 +/- 17 and, QTc-d = 35 +/- 17 ms, respectively). A significant difference was also observed in QTc-d if the two diabetic groups were compared to the control separately (p < 0.05). Moreover, comparison of the diabetic groups (IDDM vs NIDDM) revealed that type I diabetes mellitus is accompanied by a more pronounced spatial dispersion of ventricular reporlarization (QTd = 49 +/- 16, and QTc-d = 59 +/- 19 ms) as compared to NIDDM (QTd = 38 +/- 16, QTc-d = 46 +/- 20 ms [p < 0.01]). The hypothesis that increased QTd/QTc-d is truly a predictive marker of sudden arrhythmic cardiac death in patients with diabetes mellitus needs further clinical investigation.

[Amiodarone-induced pulmonary fibrosis]

The most feared side-effect of long-term amiodarone therapy is progressive alveolitis/pneumonitis leading to pulmonary fibrosis. The case history of a patient is presented who received amiodarone unnecessarily in a high dose (600 mg/day) for 4 years: drug-induced dermatopathy, hypothyroidism and lung fibrosis developed. After cessation of amiodarone treatment the pulmonary complication did not disappear therefore glucocorticoid therapy was introduced. New-onset improductive cough, dyspnea, fever and/or enhanced erythrocyte sedimentation rate may suggest the presence of amiodarone pulmonary toxicity and may form the basis of indication of high-resolution computed tomography (HRCT). Amiodarone-induced pulmonary involvement can be shown by HRCT early, before the appearance of any considerable abnormality of chest radiography.