Value of conventional and tissue Doppler echocardiography in the estimation of left ventricular filling pressure

BackgroundVarious conventional and tissue Doppler parameters have been proposed for the estimation of left ventricular filling pressure.AimTo assess the utility of several conventional and tissue Doppler parameters in the estimation of left ventricular end diastolic pressure (LVEDP).MethodAmong 40 consecutive patients LVEDP was correlated with pulsed Doppler of mitral inflow and pulsed tissue Doppler of lateral mitral annulus.ResultsAmong all studied Doppler variables, E′/A′ ratio showed the most significant correlation with LVEDP (r = 0.612, p < 0.001). Among patients with grade II and III diastolic dysfunction, E′/A′ ratio showed the best correlation with LVEDP (r = 0.81, p < 0.001) with the following regression equation: LVEDP = 1.77 + (20.4 × E′/A′) while in patients with grade I diastolic dysfunction no correlation exists (r = 0.11, p = 0.63). Weak significant correlation was detected between E/E′ ratio and LVEDP (r = 0.382, p = 0.016). An E/E′ ratio > 12 had 25% sensitivity and 100% specificity to identify patients with elevated LVEDP (>15 mm Hg) with a positive predictive value of 100%. On the other hand, an E/E′ ratio of <8 had 77% sensitivity and 57% specificity to identify patients with normal LVEDP with a negative predictive value of 31%.ConclusionOf all echocardiographic variables investigated, E′/A′ ratio was identified as the best index to estimate LVEDP especially in patients with advanced LV diastolic dysfunction; a relation that was not found for other conventional or tissue Doppler variables including the E/E′ ratio.     

Role of the left atrial function on the pseudonormalization of the transmitral flow velocity pattern evaluated by two-dimensional tissue tracking technique

BackgroundMechanisms of the pseudonormalization (PN) of the transmitral flow (TMF) velocity pattern have been mainly attributed to left ventricular diastolic function.PurposeTo assess the influence of left atrial (LA) function on the PN with two-dimensional tissue tracking technique.MethodsThe subjects consisted of 21 healthy volunteers and 70 patients with various cardiac diseases. Images of one cardiac cycle in the apical four-chamber view were stored by the HIVISION 900 (Hitachi Medico, Chiba, Japan). The LA volume (LAV) loop was created using two-dimensional tissue tracking technique and LAV index (LAVI) at a given cardiac phase was calculated. A preload of 90 mmHg was applied using a customized lower body positive pressure (LBPP) system. Patients were divided into the PN group (n = 18) with their early diastolic TMF velocity (E) increased and late diastolic TMF velocity (A) decreased, and the non-(N)-PN group (n = 52) with both E and A wave velocities increased by LBPP.Results(1) During LBPP, the LAVI_max in both the groups increased significantly. (2) In the N-PN group, the LAVI_pass (p < 0.001), LAVI_act (p < 0.01), and LAVI_total (p < 0.0001) increased significantly. The dV/dt_s (p < 0.0001) and dV/dt_E (p < 0.0001) increased significantly with an increase in the dV/dt_A. On the other hand, there was no change in those parameters except LAVI_pass (p < 0.05) and dV/dt_E (p < 0.05) significantly increased in the PN group. (3) As a result, the LAVI_min was significantly greater in the PN group than in the N-PN group (p < 0.0001) during LBPP. The ratio of E velocity to early diastolic mitral annular velocity (E/E′) during LBPP was significantly greater in the PN group than in the N-PN group (p < 0.0001).ConclusionsThe lack of an increase in active LA emptying volume in response to an increase of preload leads to elevated LA pressure and the pseudonormalization of the TMF velocity pattern in patients with various cardiac diseases.     

Prognostic Significance of Diastolic Dysfunction by Tissue Doppler Imaging in Patients With Chronic Heart Failure

BackgroundThis study assesses the prognostic values of left ventricular (LV) filling patterns, as determined by tissue Doppler imaging (TDI), on cardiac events in patients with LV systolic dysfunction. Normally observed in patients with an advanced form of cardiac disease, an abnormal diastolic pattern by Doppler echocardiography reflects a poor prognosis. Recent studies using TDI have significantly contributed to efforts to evaluate diastolic function and demonstrate the prognostic importance of TDI-derived indices of the LV function.Methods and ResultsOne hundred seventy-three consecutive adult patients, mean (standard deviation) age of 62.4 (14.3), with a diagnosis of dilated cardiomyopathy and LV ejection fraction < 45% were enrolled. During a follow-up period of 321 ± 100 days, 9 patients expired from cardiac complications and 29 underwent readmission for decompensated heart failure. in multivariate analysis, only the mean value of early (E_m) and late (A_m) diastolic velocities ratio assessed by TDI, and LV end-diastolic pressure were found to be independent predictors of a cardiac event. The optimal cutoff value for forecasting cardiac event was E_m/A_m ≥ 0.74 with an area under the receiver operating characteristic curve of 0.82; sensitivity and specificity were 84% and 76%, respectively (P < 0.001; standard error = 0.046).ConclusionsE_m/A_m ratio is the important predictor of cardiac event, which allows normalization for other risk factors in patients with a clinical diagnosis of chronic heart failure with LV dysfunction comparing with conventional Doppler echocardiography.     

Injection of composite with bone marrow-derived mesenchymal stem cells and a novel synthetic hydrogel after myocardial infarction: A protective role in left ventricle function

A number of studies have shown that the transplantation of bone marrow-derived mesenchymal stem cells (BMSCs) into the thinned infarct wall improves regional wall motion. In this study, we hypothesized that the injection of biomaterials and MSCs into the infarcted myocardium can preserve left ventricular (LV) function. To test this hypothesis, anterior acute myocardial infarction (AMI) was induced in 34 rabbits and BMSCs with hydrogel composite were prepared. One week after inducing AMI, 28 of the 34 rabbits were divided into four groups (Groups A–D; three rabbits were used for bone marrow aspiration, and three rabbits died) and all received an epicardial injection. Group A received BMSCs with hydrogel composite marked by 5-bromodeoxyuridine (BrdU); Group B received BMSCs only marked by BrdU; Group C received hydrogel only marked by BrdU; and Group D was the control group, which received fetal bovine serum. Echocardiography was performed before AMI was induced, 1 week after AMI, and 4 weeks after the epicardial injection. The results were compared with those before AMI, and the rabbits of all the four groups had significantly larger LV end-diastolic diameter (LVDd), thinner anterior wall (AW), lower LV ejection fraction (LVEF), lower V_S and V_E (p < 0.05) 1 week after AMI, which were more significant in Group A (p < 0.05). Compared with 1 week after AMI, Group A and Group B had significantly smaller LVDd, thicker AW, larger LVEF, larger V_S and V_E (p < 0.05) 4 weeks after the epicardial injection, which were more significant in Group A (p < 0.05); however, there was no significant difference in Group C and Group D. These results suggested that BMSCs with hydrogel composite could serve as an injectable biomaterial that prevents LV remodeling and dilation, and improves local systolic and diastolic function after AMI.     

Effect of cardiovascular autonomic neuropathy (CAN) on left ventricular function in normotensive type 1 diabetic patients: A study by pulsed wave tissue Doppler echocardiography

Background and aimPatients with diabetes mellitus are at increased risk for cardiovascular diseases. Cardiovascular autonomic neuropathy (CAN) is a serious complication of diabetes, as it can contribute in the pathogenesis of diabetic cardiomyopathy (DCM) and has been weakly linked with left ventricular diastolic dysfunction. Our aim was to investigate the effect of presence or absence of cardiovascular autonomic neuropathy (CAN) on systolic and diastolic LV function in normotensive type 1 diabetic patients by using both conventional and tissue Doppler echocardiography.Subjects and methodsFifty two type 1 diabetic patients entered this study. They were divided into two groups. The first group included 24 patients with evidence of cardiovascular autonomic neuropathy. The second group included 28 patients without evidence of cardiovascular autonomic neuropathy. In addition to 18 healthy normal weights non diabetic subjects as a control group. Complete clinical examination, routine laboratory investigations, lipid profile, urinary albumin excretion, HbA1c and 12 leads ECG were done to all participants. Conventional and tissue Doppler indices of systolic and diastolic left ventricular function were recorded.ResultsHeart rate was significantly higher in diabetic patients with CAN compared to both diabetic patients without CAN and normal control subjects (P < 0.001, <0.001, respectively). Glycemic control as assessed by HbA1c was more worse in diabetic patients with CAN compare to diabetic patients without CAN (P < 0.001). As regard conventional echo-Doppler, there were a significant difference in A wave velocity and E/A ratio in diabetic patients with or without CAN compared to control (P < 0.001, <0.001, <0.001, <0.001, respectively). Tissue Doppler indices show a significant difference at the lateral annular side in Em and Am velocity and Em/Am ratio in diabetic patients with or without CAN vs. control (P < 0.001, <0.001, <0.001, <0.05, <0.05, <0.01, respectively) and also, between diabetic patients with CAN vs. diabetic patients without CAN (P < 0.001, <0.05, <0.01, respectively). Also, tissue Doppler indices show a significant difference at the septal annular side in Em and Am velocity and Em/Am ratio in diabetic patients with or without CAN vs. control (P < 0.001, <0.001, <0.001, <0.01, <0.05, <0.05, respectively) and also, between diabetic patients with CAN vs. diabetic patients without CAN (P < 0.001, <0.05, <0.01, respectively). Contrary to that, no significant differences were found in LV systolic function parameters measured by either conventional or tissue Doppler imaging among the three groups.ConclusionOur results demonstrated that, LV diastolic function was impaired in normotensive type 1 diabetic patients and, the presence of CAN is associated with more deterioration in diastolic function. Systolic function is seems to be unaffected. TDI should be the preferred modality in evaluation of LV function as it can detect minimal changes in diastolic function much earlier than conventional echo-Doppler.     

Left atrial volume index in patients with asymptomatic severe aortic stenosis

BackgroundThe proper timing for aortic valve surgery in the asymptomatic patient with severe aortic stenosis (AS) remains challenging. The aim of this study was to determine the left atrial volume index (LAVI) in asymptomatic patients with severe AS in comparison to symptomatic severe AS patients and its relation to the degree of left ventricular (LV) hypertrophy and tissue Doppler measures of LV diastolic function.MethodsThirty-four patients with severe AS and preserved LV function, divided into two groups were studied. Group I comprised 17 patients with symptomatic severe AS, and Group II comprised 17 patients with asymptomatic severe AS. Echocardiographic assessment of LV dimension, function, and calculation of LV mass were done. LA volume index was obtained by the biplane Simpson method. Transmitral E, A diastolic velocities, deceleration time (DT) and E/A ratio were measured. Peak S′, early (E′) and late (A′) diastolic velocities of the lateral mitral annulus were measured by tissue Doppler imaging.ResultsLAVI was significantly higher in symptomatic compared to asymptomatic patients with severe AS (p < 0.0001). LAVI with a cutoff point of 39.5 ml/m² was a predictor of symptoms in patients with severe AS yielded an area under the curve of 0.958, P < 0.0001, with a sensitivity of 94% and specificity of 89%. LAVI had a significant positive correlation with left ventricular mass (p < 0.014), right ventricular systolic pressure (RVSP) (p < 0.009), mitral peak E (p < 0.025), and E/E′ (p < 0.008). Multiple linear regression analysis revealed that LV mass (p < 0.0001) and E/E′ (p < 0.0001) were the independent predictors of increased LAVI in severe AS.ConclusionLeft atrial volume index can predict symptoms in patients with asymptomatic severe AS. Left ventricular mass and E/E′ were the independent predictors of increased LAVI.     

Comparison between left atrial features in well-controlled hypertensive patients and normal subjects assessed by three-dimensional speckle tracking echocardiography

BackgroundThree-dimensional speckle tracking echocardiography (3D-STE) has a major advantage in the improvement of accuracy in the evaluation of cardiac chamber volume without any geometrical assumption. Thus, the aim of this study was to use 3D-STE to elucidate the features of left atrial (LA) volume and function that are altered by hypertension (HTN) by comparing well-controlled HTN patients with normal subjects.MethodsConventional echocardiographic parameters and LA phasic volume and function were measured from apical view by 3D-STE in 40 patients with well-controlled HTN [systolic blood pressure (BP) <140 and diastolic BP <90 mmHg for more than one year] and 40 normotensive subjects.ResultsThe passive LA emptying function (EF) in the patients with well-controlled HTN significantly decreased (16 ± 7% vs. 22 ± 8%, p = 0.0013) and the active LAEF in patients with well-controlled HTN significantly increased (35 ± 10% vs. 30 ± 9%, p = 0.029) compared with the values in normotensive subjects. Multivariate logistic regression analysis revealed that E/e′ was an independent determinant of well-controlled HTN. The maximum LA volume index was correlated with elevated E/e′ (r = 0.30, p = 0.0064), whereas the maximum LA volume index was not correlated with LV mass index or systolic BP. This change was independent of age.ConclusionsThese results suggest that LV diastolic dysfunction occurs before structural changes of left atrium and left ventricle even in patients with well-controlled HTN.     

Myocardial Performance Index (Tei Index): A simple tool to identify cardiac dysfunction in patients with diabetes mellitus

BackgroundCardiac dysfunction is the major cause of morbidity and mortality in diabetes. Myocardial Performance Index (MPI/Tei Index) includes both systolic and diastolic time intervals to assess the global cardiac dysfunction. Our aim was to assess the MPI in patients with type 2 diabetes.Material and methodsThis hospital-based analytic observational study was performed in the tertiary care center. The conventional Doppler parameters, tissue Doppler-derived E/E′ and MPI, were measured in all patients.Results100 patients with type 2 diabetes were included in the study. 65 patients showed diastolic dysfunction, 33 with Grade I diastolic dysfunction, 23 with Grade II diastolic dysfunction, and 14 patients with Grade III diastolic dysfunction. The conventional Doppler showed abnormality in 44% of patients (33 patients with Grade I and 14 patient with Grade III). 23 patients were in Grade II diastolic dysfunction (12 patients showed reversal E/A on valsalva maneuver and 11 patients showed abnormality in tissue Doppler-derived E/E′, E/E′ > 15). MPI with cut-off 0.36 was found to have 94% sensitivity, 100 specificity, and 94% PPV for the detection of cardiac dysfunction. MPI negatively correlated with systolic dysfunction (rho = 0.455, p < 0.001) and positively correlated with grade of diastolic dysfunction (rho = 0.832, p < 0.001) and NYHA grading of dyspnea (rho = 0.872, p < 0.001)ConclusionsMPI as a single parameter can be used for assessment in diabetic cardiac dysfunction.     

Association between C-reactive protein level and echocardiography assessed left ventricular function in first ST-segment elevation myocardial infarction patients who underwent primary coronary intervention

BackgroundAn elevated C-reactive protein (CRP) level is associated with adverse outcomes in patients with acute myocardial infarction (AMI). Although CRP levels have been shown to be associated with left ventricular (LV) systolic function and remodeling in AMI, little is known about their relation to early LV diastolic function.MethodsWe retrospectively studied 173 consecutive patients <75 years of age with first ST-segment elevation MI (STEMI) that was treated by primary percutaneous coronary intervention (PPCI). They had presented within 24 h of chest pain onset and their CRP levels were determined within 6 h of hospital admission. They all underwent echocardiography within 3 days of admission and were stratified by CRP tertiles.ResultsThe cut-off points for the CRP tertiles were <2.6 mg/L, 2.6–7.9 mg/L, and >7.9 mg/L. Patients with higher CRP levels had a significantly higher mean mitral inflow E wave velocity (68 ± 16 cm/s vs 77 ± 19 cm/s vs 76 ± 17 cm/s; p = 0.02), a higher E/average e′ (8.9 ± 1.9 vs 9.8 ± 2.8 vs 10.4 ± 3.2; p = 0.02), and a higher systolic pulmonary artery pressure (27 ± 6 mmHg vs 30 ± 8 mmHg vs 32 ± 10 mmHg; p = 0.04). Elevated CRP levels were associated with more advanced diastolic dysfunction than normal CRP levels (p = 0.04). The admission CRP level was an independent predictor of average E/e′ ratio (multivariate analysis).ConclusionAdmission CRP levels are associated with echocardiographic parameters of elevated LV filling pressure in patients with STEMI treated with PPCI.     

The association between interleukin-6 promoter polymorphisms and rheumatoid arthritis by ethnicity: A meta-analysis of 33 studies

ObjectiveWe performed a meta-analysis to determine the effect Interleukin-6 (IL-6) promoter polymorphism (−174 G>C, −572 G>C, and −597 G>A) have on the development rheumatoid arthritis (RA) by ethnicity.Material and methodsPubMed, EBSCO, LILACS, and Scopus databases were searched for studies exploring the association between any IL6 polymorphisms and RA until November 2018. Genotype distributions were extracted and, depending on the level heterogeneity, determined by the ψ²-based Q test and the Inconsistency Index (I²), fixed-effects or random-effects models were used to calculate pooled odds ratios (ORs) with 95% confidence intervals (95%CIs) for the heterozygous, homozygous, dominant, recessive, and allelic genetic models.ResultsFrom 708 identified publications, 33 were used in this analysis. For the −174 polymorphism, Asians (OR_heterozygous = 7.57, 95%CI: 2.28–25.14, OR_homozygous = 5.84, 95%CI: 2.06–16.56, OR_dominant = 7.21, 95%CI: 2.30–22.63, OR_recessive = 5.04, 95%CI: 1.78–14.28, OR_allelic = 6.60, 95%CI: 2.26–19.28, p < .05) and Middle East countries (OR_heterozygous = 2.30, 95%CI: 1.10–4.81, OR_dominant = 2.27, 95%CI: 1.22–4.22, OR_allelic = 2.29, 95%CI: 1.24–4.23, p < .05) were associated with a significant risk of developing RA. Whereas, for Latinos, the C-allele was associated with a benefit (OR_homozygous = 0.26, 95%CI: .08–.82, OR_recessive = .25, 95%CI: .08–.80, p < .05). For the −572 polymorphism, Asians demonstrated a significant association for the homozygous and recessive genetic models (8 studies, OR_homozygous = 1.56, 95%CI: 1.16–2.09, OR_recessive = 1.63, 95%CI: 1.08–2.45, p < .05). For the −597 polymorphism, no association was observed.ConclusionsHere, the −174 G>C polymorphism increased the risk of developing RA in Asians and Middle East populations. Interestingly, for Latinos, the polymorphism was associated with a benefit. For the −572 polymorphism, only the Asian population showed an increased risk of developing RA for the CC genotype.     

Factors contributing to left atrial enlargement in adults with normal left ventricular systolic function

BackgroundCauses of left atrial (LA) enlargement and its gender difference in patients with normal left ventricular (LV) systolic function have not been clarified. We investigated the factors contributing to LA enlargement in patients with normal LV systolic function, addressing its gender difference.MethodsWe enrolled 380 patients (175 males and 205 females; mean age: 63 ± 15 years) with LV ejection fraction ≥50% who underwent Doppler echocardiography and blood tests at the same time as echocardiography. Patients with arrhythmias, significant valvular heart disease, and LV asynergy were excluded. The LA volume was measured by Simpson's method from apical 2- and 4-chamber views, and LA volume index (LAVI) was calculated as LA volume/body surface area. All patients, male and female were assigned to a group with a low or a high LAVI based on the median LAVI value, respectively.ResultsAge, female gender, hypertension, diabetes, hemoglobin concentration, LV mass index, Doppler parameters of LA contraction, and the ratio of mitral early diastolic velocity to early diastolic velocity of the mitral annulus (E/E′) were significantly associated with a high LAVI in all patients. Multivariate analysis showed that LV mass index [odds ratio (OR) 1.05, 95% confidence interval (CI) 1.03–1.06, P < 0.0001], hemoglobin concentration (OR 0.76, 95% CI 0.64–0.90, P < 0.01), and female gender (OR 1.92, 95% CI 1.12–3.30, P < 0.05) independently contributed to a high LAVI in all patients. In addition, LV mass index and hemoglobin concentration independently contributed to a high LAVI in both genders despite the absence of overt LV hypertrophy or anemia.ConclusionIncreased LV wall thickness and decreased hemoglobin concentration might contribute to LA enlargement in patients with normal LV systolic function irrespective of gender.     

Assessment of left ventricular function and aortic elastic properties in patients with Behçet’s disease using conventional and tissue Doppler echocardiography

BackgroundBehçet disease (BD) is a multisystemic, chronic inflammatory disorder of unknown etiology with diffuse clinical manifestations including the cardiovascular system.Aim of the workTo assess left ventricular (LV) function and thoracic aorta elastic properties in BD patients using Doppler echocardiography and to correlate echocardiographic findings with disease activity.Patients and methodsThe LV functions and thoracic aorta elastic properties were assessed in 30 BD patients and 30 controls using conventional and Tissue Doppler Imaging (TDI) echocardiography. Disease activity was evaluated using Behçet’s disease current activity form (BDCAF). Erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), cholesterol and triglyceride levels were measured.ResultsIn BD patients, ESR and CRP were significantly elevated while cholesterol and triglycerides were comparable to the levels in the control. In conventional echocardiography, BD patients had significantly higher aortic diastolic diameter (p < 0.05), aortic stiffness index (p < 0.001), isovolumic relaxation time (p < 0.001), flow propagation velocity (FPV) and peak E-wave velocity/FPV (E/FPV) (p < 0.001) than the control group while aortic strain was significantly lower in BD patients (p < 0.05). Lateral mitral TDI echocardiography showed that myocardial performance index was statically higher in BD patients (p < 0.001) while peak myocardial velocity and myocardial acceleration during isovolumic contraction were significantly lower (p < 0.001). The BDCAF showed a significant correlation with different echocardiographic parameters of systolic and diastolic dysfunction.ConclusionsBehçet disease patients have impaired LV systolic and diastolic functions and altered aortic elastic properties that correlate with disease activity. TDI is more sensitive than conventional echocardiography for the detection of early ventricular dysfunction in patients with BD.     

Routine transthoracic echocardiography in a general Intensive Care Unit: An 18 month survey in 704 patients

The authors analyzed 704 transthoracic echocardiographic (TTE) examinations, performed routinely to all admitted patients to a general 16-bed Intensive Care Unit (ICU) during an 18-month period. Data acquisition and prevalence of abnormalities of cardiac structures and function were assessed, as well as the new, previously unknown severe diagnoses.A TTE was performed within the first 24 h of admission on 704 consecutive patients, with a mean age of 61.5 ± 17.5 years, ICU stay of 10.6 ± 17.1 days, APACHE II 22.6 ± 8.9, and SAPS II 52.7 ± 20.4. In four patients, TTE could not be performed. Left ventricular (LV) dimensions were quantified in 689 (97.8%) patients, and LV function in 670 (95.2%) patients. Cardiac output (CO) was determined in 610 (86.7%), and mitral E/A in 399 (85.9% of patients in sinus rhythm). Echocardiographic abnormalities were detected in 234 (33%) patients, the most common being left atrial (LA) enlargement (n = 163), and LV dysfunction (n = 132). Patients with these alterations were older (66 ± 16.5 vs 58.1 ± 17.4, p < 0.001), presented a higher APACHE II score (24.4 ± 8.7 vs 21.1 ± 8.9, p < 0.001), and had a higher mortality rate (40.1% vs 25.4%, p < 0.001). Severe, previously unknown echocardiographic diagnoses were detected in 53 (7.5%) patients; the most frequent condition was severe LV dysfunction. Through a multivariate logistic regression analysis, it was determined that mortality was affected by tricuspid regurgitation (p = 0.016, CI 1.007–1.016) and ICU stay (p < 0.001, CI 1–1.019). We conclude that TTE can detect most cardiac structures in a general ICU. One-third of the patients studied presented cardiac structural or functional alterations and 7.5% severe previously unknown diagnoses.     

Hypocalcemia is related to left ventricular diastolic dysfunction in patients with chronic kidney disease

BackgroundLeft ventricular (LV) diastolic dysfunction in patients with chronic kidney disease (CKD) is of a complex nature and is the predominant cause of congestive heart failure in this group of patients. This work aimed to evaluate the potential effect of disturbances in calcium-phosphorus (Ca-P) metabolism in patients with CKD on LV diastolic function as assessed by echocardiography.Materials and methodsThe study group consisted of 81 ambulatory patients with CKD, stages 2–5, with preserved LV systolic function–LV ejection fraction >50% and with sinus rhythm. Standard echocardiography was performed in all patients with tissue Doppler echocardiography for the evaluation of the systolic velocity and both diastolic velocities of LV (EmLV and AmLV). The following laboratory parameters were measured: serum creatinine concentration, estimated glomerular filtration rate, and the levels of urea, P, Ca, parathormone, platelet count, hemoglobin level, and N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels. Patients were divided into two groups according to the results of EmLV: group with LV diastolic dysfunction (EmLV < 8 cm/s) DF (+) and group with normal LV diastolic function DF (−), when EmLV was ≥8 cm/s.ResultsPatients in DF (+) group, as compared to DF (−) patients, manifested a lower serum Ca level and an elevated NT-proBNP level [9.03 ± 0.76 mg/dL vs 9.44 ± 0.78 mg/dL, p = 0.02, and 257.9 (32.6–12,633) pg/ml vs 149 (11.7–966) pg/ml, p = 0.035, respectively]. The area under the receiver operating characteristics (ROC) curve of Ca for diastolic dysfunction was 0.627, 95% CI (0.511–0.734), p = 0.04, whereas ROC derived Ca value of ≤9.82 mg/dL was characterized by a sensitivity of 91.8% and specificity of 38.1% for diagnosing LV diastolic dysfunction. The only independent variable predicting LV diastolic dysfunction as measured by a multivariate logistic regression analysis was Ca level ≤ 9.82 mg/dL with odds ratio = 8.81 (95% CI 1.49–51.82), p = 0.014.ConclusionsHypocalcemia is an independent predictive factor for LV diastolic dysfunction in patients with CKD.     

Systolic and diastolic function in patients with systemic sclerosis

BackgroundClinical and epidemiological findings indicate that symptomatic heart disease in patients with systemic sclerosis (SSc) predicts poor prognosis, but cardiac involvement may occur years before clinical manifestation. The aim of this study was to evaluate the cardiac function in patients with SSc and to correlate the echocardiographic parameters with others that quantify the diseases' severity.MethodsTwenty consecutive patients with SSc were investigated with transthoracic echocardiography (TTE). Two dimensional, pulsed Doppler and pulsed tissue Doppler imaging (TDI) techniques were used, in all the patients, to assess the systolic and diastolic function for left ventricle (LV). Correlations were made between echocardiographic measurements and some clinical and serological features of the patients.ResultsNone of the patients had any clinical signs of cardiac involvement, nor ECG or TTE systolic function impairment; there are significant differences between systemic sclerosis patients and control group for peak A velocity (0.75 ± 0.22 vs 0.57 ± 0.32, P = 0.05), E/A ratio (1.14 ± 0.22 vs 1.48 ± 0.26, P = 0.01), E/Ea ratio (8.25 ± 1.57 vs 7 ± 2.2, P = 0.05), which account for filling impairment of LV. There are also significant correlations between some other parameters, like the mean duration of Raynaud's phenomenon and E/Ea ratio (r = 0.48, P < 0.05).ConclusionsThe analysis of SSc heart disease, mainly at a preclinical level, is important in all the cases as an asymptomatic patient may have diastolic dysfunction which can be treated and should be closely observed.     

High prevalence of vitamin D deficiency and its association with left ventricular dilation: An echocardiography study in elderly patients with chronic heart failure

Background and aimsVitamin D deficiency has been associated with chronic heart failure (CHF). We evaluated vitamin D levels in relationship with New York Heart Association (NYHA) classes, N-terminal pro-brain natriuretic peptide (NT-proBNP) values and left ventricular (LV) measures in ≥60 year old patients with stable CHF. Differently from previous investigations, LV function was assessed by transthoracic echocardiography, to provide easily reproducible results.Methods and resultsThe study was performed at geographic latitude 44° N, from March to May and from September to November 2008. Acute HF and diseases or drugs altering vitamin D status were exclusion criteria. NYHA scores and 25-hydroxyvitamin D [25(OH)D], 1,25-dihydroxyvitamin D and NT-proBNP concentrations were assessed in 90 (45 F, 45 M) Caucasian patients with CHF secondary to hypertension and/or coronary artery disease. Vitamin D levels were also measured in 31 subjects without heart disease (controls). LV echocardiography was performed in 52 (26 F, 26 M) representative patients. Vitamin D concentrations were significantly lower in CHF cases than in controls. Among subject with CHF, 97.8% presented vitamin D deficiency (25(OH)D < 75 nmol/L), being severe (<25 nmol/L) in 66.7%. LV end-diastolic and end-systolic diameters were significantly longer, LV end-diastolic and end-systolic volumes bigger and fractional shortening lower in CHF patients with 25(OH)D < 25 nmol/L than with 25(OH)D ≥ 25 nmol/L (p < 0.05). Log-values of 25(OH)D were negatively correlated with LV end-systolic diameter and volume (r = ?0.28; p < 0.05). On subgroup analysis, these results persisted only in male patients.ConclusionsIn elderly CHF patients, vitamin D deficiency was highly prevalent and often severe. This first addressed echocardiography study showed a sex-specific association between vitamin D deficiency and LV dilation. Since further echocardiography data are easily obtainable, larger investigations are demanded.     

Aortic stiffness is increased in patients with premature coronary artery disease: A tissue Doppler imaging study

BackgroundAtherosclerosis and arterial stiffening may coexist and the correlation of these parameters in patients with premature coronary artery disease (CAD) has not been well elucidated. Tissue Doppler imaging of the ascending aorta may be used in the assessment of elastic properties of the great arteries.ObjectiveTo investigate the correlation between aortic stiffness and premature CAD using parameters derived from two-dimensional and tissue Doppler imaging (TDI) echocardiography of the ascending aorta.MethodsFifty consecutive subjects younger than 40 years old who were hospitalized with diagnosis of acute coronary syndrome and had undergone coronary angiography were recruited. The control group included 70 age–sex matched individuals without a diagnosis of CAD. Aortic stiffness index (SI), aortic distensibility (D), and pressure-strain elastic modulus (E_p) were calculated from the aortic diameters measured by two-dimensional M-mode echocardiography and blood pressure obtained by sphygmomanometry. Aortic systolic velocity (S_Ao), and early (E_Ao) and late (A_Ao) diastolic velocities were determined by pulse-wave TDI from the anterior wall of ascending aorta 3 cm above the aortic cusps in parasternal long-axis view.ResultsStiffness index was higher [median 5.40, interquartile range (IQR) 5.98 vs. median 4.14 IQR 2.43; p = 0.03] and distensibility was lower (median 2.86 × 10⁻⁶ cm²/dyn, IQR 2.51 × 10⁻⁶ cm²/dyn vs. median 3.46 × 10⁻⁶ cm²/dyn, IQR 2.38 × 10⁻⁶ cm²/dyn; p = 0.04) in patients with CAD compared to the control group. E_Ao was significantly lower in the CAD group (7.2 ± 1.8 cm/s vs. 9.2 ± 2.4 cm/s, p < 0.01). The difference in E_Ao remained significant when CAD patients with a left ventricular ejection fraction >55% was compared to the control group. S_Ao and A_Ao velocities of ascending aorta were similar in control and CAD groups. There was a significant correlation between E_Ao velocity and aortic stiffness index (r = −0.28, p = 0.01), distensibility (r = 0.19, p = 0.04) and elastic modulus (r = −0.24, p = 0.01). In multivariate regression analysis, decreased levels of high-density lipoprotein cholesterol [odds ratio (OR): 1.12 95% CI 1.06–1.19; p = 0.01] and E_Ao (OR: 1.41 95% CI 1.12–1.79; p = 0.01) measurements remained as the variables independently correlated with premature CAD in the study group.ConclusionArterial stiffness is increased in patients with premature CAD. E_Ao of the anterior wall of ascending aorta measured with pulse-wave TDI echocardiography is correlated with arterial stiffening and is decreased in patients with premature CAD.     

The significance of E/E′ to detect coronary artery disease during dobutamine stress echocardiography

AimTo determine how the left ventricular diastolic filling pressure determined by E/E′ during dobutamine stress echocardiographic (DSE) by tissue Doppler Imaging (TDI) is affected by the presence and the severity of coronary artery disease (CAD) among patients with stable angina pectoris and also its relation to inducible ischemia.Patients and methodsThis study comprises 60 patients with suspected angina pectoris. All subjects were examined with DSE and TDI to assess resting mean E/E′ at peak stress, E/E′ change and E/E′ index. Coronary angiography was performed within 1 month.ResultsCoronary angiography revealed CAD in 38 patients (CAD group) while the remaining 22 patients formed the non-CAD group. There is a significant decrease of peak E′, S′ and increase peak E/E′ in CAD group during stress compared to non-CAD group (P < 0.01, P < 0.05 and P < 0.001, respectively). Thirty-two patients with inducible ischemia during stress had higher peak E/E′, E/E′ index compared to 28 patients with non-inducible ischemia. Receiver operating curve analysis showed an optimal cut-off value of peak E/E′, E/E′ change, E/E′ index (>4.11, >0.9 and >0.8, respectively) for the presence of CAD (area under curve 0.91, 0.93 and 0.88, respectively P < 0.001 for all). Sensitivities for detection of CAD were 94.7%, 84.2% and 89.5% and specificity was 90.9%, 72.7% and 74.7%, respectively. Peak E/E′, E/E′ index increased proportionally with the number of stenotic vessels (r = 0.89 and 0.76, respectively, P < 0.001).ConclusionDuring DSE the changes of mean E/E′ ratio are associated with inducible ischemia, the presence of CAD and the extent of CAD. So, E/E′ can be used as objective evidence during DSE.     

The addition of pioglitazone in type 2 diabetics poorly controlled on insulin therapy: A meta-analysis

AimTo quantify the effect of a pioglitazone on glycemic control and lipid parameters, as well as the risk of adverse events when incorporated into the treatment regimen of patients with type 2 diabetes inadequately controlled on insulin.MethodsThe electronic databases PubMed, Embase and The Cochrance Library were searched systematically to identify randomized controlled trials (RCTs) of pioglitazone therapy in patients with type 2 diabetes mellitus (DM) inadequately controlled after treatment with insulin. Data on change of haemoglobin A1C (HbA1c), fasting plasma glucose (FPG), lipid parameters and risk of hypoglycemic, edema events were extracted from each study and pooled according to fixed effect model or random effect model in meta-analyses.ResultsFour RCTs including 1767 patients were included. The pooled estimate of change in HbA1c from baseline was 1.22% (95% CI 1.01–1.44, p < 0.001 vs. baseline) and of change in FPG from baseline was 1.63 mmol/l (95% CI 0.75–2.50, p < 0.001 vs. baseline). Pioglitazone significantly increased high-density lipoprotein cholesterol (HDL-c) level (0.2 mmol/L, 95%CI: 0.13–0.28) and low-density lipoprotein cholesterol (LDL-c) level (0.10 mol/L, 95%CI: 0.09–0.17), and lowered triglyceride (TG) level (0.05 mmol/L, 95%CI: 0.01–0.09). The odds of experiencing a hypoglycemic event in pioglitazone-treated arms was significantly higher than comparator treatments (RR = 1.57, 95% CI 1.12–2.20, p < 0.001). The case was the same with edema (RR = 2.42, 95% CI 1.67–3.50, p < 0.001).ConclusionsOur study implied that in patients with type 2 DM whose control is inadequate on insulin therapy, the additional pioglitazone could significantly improve glucose metabolism and might have a positive effect on important components of the lipid profile, which may have important implications in reducing the risk of cardiovascular disease, a major long-term complication in type 2 diabetes mellitus. Besides, the adverse events (AEs) were well tolerated.