Epicardial adipose tissue in patients with heart failure

Purpose

The aim of this study was to evaluate the extent of epicardial adipose tissue (EAT) and its relationship with left ventricular (LV) parameters assessed by cardiovascular magnetic resonance (CMR) in patients with congestive heart failure (CHF) and healthy controls.

Background

EAT is the true visceral fat deposited around the heart which generates various bioactive molecules. Previous studies found that EAT is related to left ventricular mass (LVM) in healthy subjects. Further studies showed a constant EAT to myocardial mass ratio in normal, ischemic and hypertrophied hearts.

Methods

CMR was performed in 66 patients with CHF due to ischemic cardiomyopathy (ICM), or dilated cardiomyopathy (DCM) and 32 healthy controls. Ventricular volumes, dimensions and LV function were assessed. The amount of EAT was determined volumetrically and expressed as mass indexed to body surface area. Additionally, the EAT/LVM and the EAT/left ventricular remodelling index (LVRI) ratios were calculated.

Results

Patients with CHF had less indexed EAT mass than controls (22 ± 5 g/m² versus 34 ± 4 g/m², p < 0.0001). In the subgroup analysis there were no significant differences in indexed EAT mass between patients with ICM and DCM (21 ± 4 g/m² versus 23 ± 6 g/m², p = 0.14). Linear regression analysis showed that with increasing LV end-diastolic diameter (LV-EDD) (r = 0.42, p = 0.0004) and LV end-diastolic mass (LV-EDM) (r = 0.59, p < 0.0001), there was a significantly increased amount of EAT in patients with CHF. However, the ratio of EAT mass/LV-EDM was significantly reduced in patients with CHF compared to healthy controls (0.54 ± 0.1 versus 0.21 ± 0.1, p < 0.0001). In CHF patients higher indexed EAT/LVRI-ratios in CHF patients correlated best with a reduced LV-EF (r = 0.49, p < 0.0001).

Conclusion

Patients with CHF revealed significantly reduced amounts of EAT. An increase in LVM is significantly related to an increase in EAT in both patients with CHF and controls. However, different from previous reports the EAT/LVEDM-ratio in patients with CHF was significantly reduced compared to healthy controls. Furthermore, the LV function correlated best with the indexed EAT/LVRI ratio in CHF patients. Metabolic abnormalities and/or anatomic alterations due to disturbed cardiac function and geometry seem to play a key role and are a possible explanation for these findings.     

Mean Platelet Volume Is Increased in Infective Endocarditis and Decreases after Treatment

Objectives

The aim of this study was to assess the mean platelet volume (MPV), an indicator of platelet activation in patients with infective endocarditis.

Subjects and Methods

Twenty-nine patients with infective endocarditis and 29 healthy subjects were studied. Plasma MPV values in patients and control subjects were measured on admission and after 2 weeks of specific treatment of infective endocarditis.

Results

The MPV was significantly higher among patients with infective endocarditis when compared with the control group (9.86 ± 1.1 vs. 8.0 ± 1.0 fl, respectively; p < 0.01). The MPV values of patients with infective endocarditis decreased significantly after treatment from 9.86 ± 1.1 to 7.86 ± 1.0 fl (p < 0.01). Total platelet counts increased significantly after treatment from 193.4 ± 96.5 × 10⁹ to 243.7 ± 92.4 × 10⁹ (p = 0.04).

Conclusion

MPV values were higher in patients with infective endocarditis and decreased significantly after treatment. Elevated MPV values indicate that patients with infective endocarditis have increased platelet activation and infective endocarditis treatment decreases this platelet activation by decreasing MPV.Key Words: Mean platelet volume, Infective endocarditis, Thrombus, Vegetation     

Real-Time Continuous Glucose Monitoring Significantly Reduces Severe Hypoglycemia in Hypoglycemia-Unaware Patients With Type 1 Diabetes

OBJECTIVE

To evaluate the effect of continuous glucose monitoring (CGM) on the frequency of severe hypoglycemia (SH) in patients with established hypoglycemia unawareness.

RESEARCH DESIGN AND METHODS

We conducted a retrospective audit of 35 patients with type 1 diabetes and problematic hypoglycemia unawareness, despite optimized medical therapy (continuous subcutaneous insulin infusion/multiple daily insulin injections), who used CGM for >1 year.

RESULTS

Over a 1-year follow-up period, the median rates of SH were reduced from 4.0 (interquartile range [IQR] 0.75–7.25) episodes/patient-year to 0.0 (0.0–1.25) episodes/patient-year (P < 0.001), and the mean (±SD) rates were reduced from 8.1 ± 13 to 0.6 ± 1.2 episodes/year (P = 0.005). HbA_1c was reduced from 8.1 ± 1.2% to 7.6 ± 1.0% over the year (P = 0.005). The mean Gold score, measured in 19 patients, did not change: 5.1 ± 1.5 vs. 5.2 ± 1.9 (P = 0.67).

CONCLUSIONS

In a specialist experienced insulin pump center, in carefully selected patients, CGM reduced SH while improving HbA_1c but failed to restore hypoglycemia awareness.Although real-time continuous glucose monitoring (CGM) has been shown in randomized controlled trials to improve glycemic control and mild-to-moderate hypoglycemia, studies to date have not shown convincing reductions in severe hypoglycemia (SH) (1,2). Clinically, CGM may benefit patients with impaired awareness of hypoglycemia (IAH), who have an increased risk of SH (3), by alerting them to impending hypoglycemia, and thus providing them with “technological” awareness to replace the loss of their “physiological” awareness. In our clinical service, across two associated tertiary hospitals, we have obtained case-specific funding for CGM for 35 patients with type 1 diabetes, IAH, and problematic hypoglycemia limiting daily activities during intensified insulin therapy. This audit evaluates outcomes at 1 year to see whether the use of CGM can reduce SH or improve awareness.     

Association between Diagonal Earlobe Crease and Cardio-Ankle Vascular Index in Asymptomatic Hypertensive Patients

Objective

The aim of this study was to investigate the association between earlobe crease (ELC) and cardio-ankle vascular index (CAVI) in asymptomatic hypertensive subjects.

Materials and Methods

A total of 75 subjects with ELC and 75 age- and gender-matched patients without ELC were prospectively selected from subjects admitted to the Outpatient Cardiology Clinic. ELC was assigned to a person with a crease stretching obliquely from the outer ear canal towards the border of the earlobe of at least one ear. CAVI was assessed by a VaSera VS-1000 instrument.

Results

There were statistically significant higher CAVI values in ELC subjects (9.8 ± 2.1 vs. 8.6 ± 1.6, p < 0.001). There was a significant and positive association between CAVI and age (r = 0.42, p < 0.001), ELC (r = 0.31, p < 0.001), BMI (0.20, p < 0.001) and male gender (r = 0.21, p = 0.04). Linear regression analysis demonstrated ELC (95% confidence interval, CI, 0.61–1.74, p = 0.009), age (95% CI 0.03–0.09, p < 0.001) and male gender (95% CI 0.48–1.55, p = 0.03) as independent determinants of CAVI. Also, there was a higher prevalence of ELC in subjects with subclinical atherosclerosis (CAVI ≥9) than in normal subjects (CAVI <9).

Conclusion

Patients with ELC had higher CAVI than normal subjects. This observation of ELC is simple, adds no cost and can be easily made by most physicians, and it may provide important predictive information of arterial stiffness and subclinical atherosclerosis in asymptomatic hypertensive subjects.Key Words: Cardio-ankle vascular index, Earlobe crease, Hypertension     

Anti-Carbonic Anhydrase II Antibodies in End-Stage Renal Disease Patients

Objective

The aim of this study was to investigate the presence of anti-carbonic anhydrase (CA II) autoantibodies in patients with end-stage renal disease (ESRD) and relationships between the autoantibody titers and ghrelin, glucose, blood urea nitrogen (BUN) and creatinine.

Subjects and Methods

Serum CA II autoantibody titers, malondialdehyde (MDA), BUN, creatinine and ghrelin levels were measured in 45 ESRD patients and 45 healthy subjects.

Results

The CA II autoantibody titers in the ESRD group (0.170 ± 0.237) were significantly higher than those in the control group (0.079 ± 0.032; p = 0.035). MDA and ghrelin levels were also significantly higher in the ESRD group (p < 0.001). A weak positive correlation was determined between anti-CA II antibody titers and MDA, and a negative correlation was observed between ghrelin levels and anti-CA II antibody titers (r = 0.287, p = 0.028 and r =b −0.278, p = 0.032, respectively).

Conclusions

In ESRD patients, the results showed the development of an autoimmune response against CA II. This suggests that anti-CA II antibodies could be involved in the pathogenesis of ESRD.Key Words: End-stage renal disease, Carbonic anhydrase II, Malondialdehyde, Autoimmunity, Ghrelin     

Assessment of Cardiac Autonomic Nervous System Involvement in Systemic Sclerosis via Exercise Heart Rate Recovery

Objective

To assess exercise heart rate recovery (HRR) indices in patients with systemic sclerosis (SSc) for an assessment of their cardiac autonomic function.

Subjects and Methods

Thirty-five patients with diffuse or limited SSc and 35 healthy controls were enrolled. All subjects underwent exercise testing and transthoracic echocardiography. The HRR indices were calculated by subtracting the first- (HRR1), second- (HRR2) and third-minute (HRR3) heart rates from the maximal heart rate.

Results

The SSc and control groups were similar in age (45.2 ± 11.6 vs. 43.9 ± 10.0 years), had identical gender ratios (31 female/4 male in both groups) and similar left ventricular ejection fraction (66.5 ± 5.1 vs. 67.7 ± 5.9%). The mean HRR1 (21.8 ± 4.4 vs. 27.7 ± 4.3 bpm, p = 0.001), HRR2 (43.8 ± 6.3 vs. 47.6 ± 4.4 bpm, p = 0.004) and HRR3 (58.8 ± 10.3 vs. 63.6 ± 7.3 bpm, p = 0.031) values were significantly lower in the SSc group than in the healthy controls. HRR indices were similar in the limited and diffuse SSc subgroups.

Conclusions

The patients with SSc had lower HRR indices than normal subjects. Cardiac autonomic functions might be involved in SSc, even in patients without cardiac symptoms.Key Words: Cardiac autonomic dysfunction, Heart rate recovery, Scleroderma     

Sleep Status and Low-Density Lipoprotein Particle Size in a General Japanese Female Population: The Mima Study

Objective

This study investigated the relationship between sleep adequacy and small dense low-density lipoprotein (sdLDL) in a Japanese population.

Subjects and Methods

Clinical data, including atherosclerotic risk factors, in addition to the mean LDL particle size (LDL-PS) measured by gel electrophoresis, were evaluated in 136 community-dwelling female subjects (40-80 years old). The sleep status was self-reported and the subjects were divided into those who had inadequate sleep (≤6 or ≥9 h of sleep) and had adequate sleep (7-8 h).

Results

The mean LDL-PS was significantly smaller in subjects with inadequate sleep [n = 68, 26.4 ± 0.4 (SD) nm] than in those with adequate sleep (n = 68, 26.6 ± 0.4 nm, p < 0.05). This difference remained significant and independent after adjusting for confounders (β = 0.15-0.19, p < 0.05).

Conclusion

Sleep adequacy was associated with the presence of sdLDL, while the influence of the sleep status on LDL-PS was minor in this population. Further research on the associations among sleep, sdLDL and cardiovascular disease prevention is warranted.Key Words: Atherosclerosis, Small dense low-density lipoprotein, Sleep hygiene     

Increased Total Renin Levels but Not Angiotensin-Converting Enzyme Activity in Obese Patients with Polycystic Ovary Syndrome

Objective

To investigate the renin-angiotensin-aldosterone system and angiotensin-converting enzyme (ACE) activity in patients with polycystic ovarian syndrome (PCOS).

Subjects and Methods

In this case-control study, 41 obese (PCOS) women and 29 healthy controls, matched for age and body mass index, were enrolled. Anthropometric, metabolic, and hormonal patterns, including plasma aldosterone, plasma renin, and ACE activity, were measured in each subject.

Results

Plasma renin levels were significantly higher in PCOS patients (19.7 ± 14.5 µg/ml) compared with controls (12.9 ± 9.0 µg/ml, p < 0.05). ACE activity and aldosterone levels did not significantly differ between both groups (p = 0.15 and p = 0.18, respectively). Analysis of PCOS patients showed a significant correlation of fasting insulin levels with levels of renin (r = 0.305, p < 0.01) and free testosterone (r = 0.384, p = 0.001). Similarly, homeostasis model assessment index was positively correlated with total renin concentrations (r = 0.366, p < 0.01) and free testosterone (r = 0.352, p < 0.01).

Conclusion

Obese PCOS women had higher total renin levels, but not ACE activity and aldosterone levels, related to insulin resistance compared with controls.Key Words: Polycystic ovary syndrome, Angiotensin-converting enzyme, Renin     

Serum Myeloperoxidase Level Is Associated with Heart-Type Fatty Acid-Binding Protein but Not Troponin T in Patients with Chronic Heart Failure

Objective

Our aim was to investigate the possible relationship between myeloperoxidase (MPO) and myocardial damage markers such as heart-type fatty acid-binding protein (H-FABP) and troponin T (TnT) in patients with chronic heart failure (HF).

Materials and Methods

Forty-two consecutive patients (age range: 27-80 years) with chronic HF were enrolled in the study. Serum H-FABP, TnT and MPO levels were measured. Routine biochemical and clinical parameters were recorded. Echocardiographic examinations were performed on all patients. A linear regression analysis was performed to determine the correlates of serum H-FABP.

Results

The MPO, H-FABP and TnT levels were 255 ± 227, 60.6 ± 48.5 and 0.07 ± 0.15 ng/ml, respectively. In multiple linear regression analysis, age (β = −0.36, p = 0.006), creatinine level (β = 0.3, p = 0.024) and serum MPO level (β = 0.41, p = 0.009) were significant determinants of H-FABP levels. Bivariate predictors were not significantly associated with TnT levels in linear regression analyses.

Conclusions

The MPO was significantly associated with serum H-FABP levels but not with TnT.Key Words: Myeloperoxidase, Myocardial damage, Heart failure     

Respiratory muscle endurance is limited by lower ventilatory efficiency in post-myocardial infarction patients

Background

Reduced respiratory muscle endurance (RME) contributes to increased dyspnea upon exertion in patients with cardiovascular disease.

Objective

The objective was to characterize ventilatory and metabolic responses during RME tests in post-myocardial infarction patients without respiratory muscle weakness.

Method

Twenty-nine subjects were allocated into three groups: recent myocardial infarction group (RG, n=9), less-recent myocardial infarction group (LRG, n=10), and control group (CG, n=10). They underwent two RME tests (incremental and constant pressure) with ventilatory and metabolic analyses. One-way ANOVA and repeated measures one-way ANOVA, both with Tukey post-hoc, were used between groups and within subjects, respectively.

Results

Patients from the RG and LRG presented lower metabolic equivalent and ventilatory efficiency than the CG on the second (50± 06, 50± 5 vs. 42± 4) and third part (50± 11, 51± 10 vs. 43± 3) of the constant pressure RME test and lower metabolic equivalent during the incremental pressure RME test. Additionally, at the peak of the incremental RME test, RG patients had lower oxygen uptake than the CG.

Conclusions

Post-myocardial infarction patients present lower ventilatory efficiency during respiratory muscle endurance tests, which appears to explain their inferior performance in these tests even in the presence of lower pressure overload and lower metabolic equivalent.     

An Investigation of Tenascin-C Levels in Rheumatic Mitral Stenosis and Their Response to Percutaneous Mitral Balloon Valvuloplasty

Objective

The purpose of this study was to evaluate the tenascin-C levels in severe rheumatic mitral stenosis before and after percutaneous mitral balloon valvuloplasty (PMBV).

Subjects and Methods

Forty patients with severe mitral stenosis requiring PMBV and 20 age-matched healthy subjects were included in the study. The mitral valve areas, mitral gradients and systolic pulmonary artery pressure (sPAP) were measured by echocardiography. The sPAP values and mitral gradients were also measured by catheterization before and after PMBV. The blood tenascin-C levels were measured before PMBV and 1 month after the procedure.

Results

The echocardiographic mean mitral gradients had a significant decrease after PMBV (11.7 ± 2.8 vs. 5.6 ± 1.7 mm Hg; p < 0.001) and also those of catheterization (13.9 ± 4.4 vs. 4.0 ± 2.4 mm Hg; p < 0.001). Mitral valve areas increased significantly after PMBV (from 1.1 ± 0.1 to 1.8 ± 0.2 cm², p < 0.001). Tenascin-C levels decreased significantly in patients after PMBV (from 15.0 ± 3.8 to 10.9 ± 3.1 ng/ml; p < 0.001). Tenascin-C levels were higher in patients with mitral stenosis before PMBV than in healthy subjects (15.0 ± 3.8 and 9.4 ± 2.9 ng/ml; p < 0.001, respectively). There were no significant differences between patients with mitral stenosis after PMBV and healthy subjects (10.9 ± 3.1 and 9.4 ± 2.9 ng/ml; p = 0.09, respectively). There was a significant positive correlation between tenascin-C levels and sPAP (r = 0.508, p < 0.001). In multivariant analysis, tenascin-C predicted mitral stenosis (p = 0.004, OR: 2.31).

Conclusions

Tenascin-C was an independent predictor for rheumatic mitral stenosis.Key Words: Tenascin-C, Mitral stenosis, Percutaneous mitral balloon valvuloplasty, Pulmonary hypertension     

Cognitive Function in Type 1 Diabetic Adults With Early Exposure to Severe Hypoglycemia: A 16-year follow-up study

OBJECTIVE

We assessed adulthood cognition in relation to early exposure to severe hypoglycemia (SH).

RESEARCH DESIGN AND METHODS

Sixteen years subsequent to a study of cognitive function in 28 diabetic children and 28 matched control subjects, we reexamined the same subjects with a 96% participation rate. Diabetic subjects were classified as with (n = 9) or without (n = 18) early (≤10 years of age) SH, which was defined as convulsions or loss of consciousness.

RESULTS

Overall, cognitive scores were 0.9 SDs lower in subjects with early SH compared with subjects without early SH (P = 0.003). The two diabetic groups particularly differed with respect to problem solving, verbal function, and psychomotor efficiency. Earlier age at first incident of SH was associated with poorer cognition (P for trend = 0.001).

CONCLUSIONS

The findings suggest that early exposure to SH may have lasting and clinically relevant effects on cognition.Early-onset diabetes is associated with reduced cognition (1), possibly due to the effects of severe hypoglycemia (SH) on the developing brain (2–5). Although moderate (1), this cognitive deficit seems to be enduring (5–7). We hypothesized that earlier age at SH occurrence would entail more pronounced effects on cognition. In this 16-year follow-up study of diabetic subjects, we investigated cognitive function in relation to early exposure to SH.     

Mitral Annular Calcification Is Associated with Pulse Wave Velocity but Not with Augmentation Index

Objective

To investigate the possible relationship between mitral annular calcification (MAC) and arterial stiffness.

Subjects and Methods

Forty-two patients (mean age 68 ± 6 years) with MAC and an age-matched control group of 41 individuals (mean age 66 ± 6 years) were studied. Arterial stiffness and wave reflections of the study population were evaluated by using applanation tonometry (SphygmoCor). Aortic pulse wave velocity (PWV) was measured as an index of aortic stiffness. The heart rate-corrected augmentation index (AIx@75) was estimated as a composite marker of wave reflections and arterial stiffness.

Results

Aortic PWV was significantly higher in patients with MAC (12.2 ± 2.3 m/s) than in controls (10.1 ± 1.3 m/s, p = 0.0001). However, AIx@75 was similar between the groups (28 ± 10 vs. 29 ± 10%, p = 0.59). Multivariate analysis involving the whole population revealed that brachial diastolic blood pressure (β = 1.87, p = 0.04) and MAC (β = 0.41, p = 0.0001) were independent determinants of aortic PWV.

Conclusion

The data showed that MAC was significantly associated with increased arterial stiffness and that it was an independent determinant of aortic PWV.Key Words: Mitral annular calcification, Pulse wave velocity, Augmentation index     

Coexistence of Perineural Invasion and Lymph Node Metastases Is a Poor Prognostic Factor in Patients with Locally Advanced Rectal Cancer after Preoperative Chemoradiotherapy Followed by Radical Resection and Adjuvant Chemotherapy

Objective

To determine the role of lymph node metastases (ypN) and perineural invasion (PNI) in patients with locally advanced rectal cancer (LARC).

Subjects and Methods

Eighty-eight LARC patients receiving preoperative chemoradiotherapy from April 2006 to November 2011 were enrolled in this study. Univariate and multivariate analyses were conducted to determine the association between clinicopathologic features and clinical outcome.

Results

The presence of ypN (p = 0.011) and PNI (p = 0.032) was a significant adverse prognostic factor for disease-free survival (DFS). High histologic grade (p = 0.015), PNIs+ (p = 0.043) and ypNs+ (p = 0.041) were adverse prognostic factors for overall survival (OS). Positive PNI was significantly associated with a higher risk of distant failure (odds ratio = 6.09; 95s% CI: 1.57–27.05; p = 0.008). Moreover, patients with a coexistence of ypNs+ and PNIs+ had the significantly worst DFS (p < 0.001) and OS rates (p < 0.001) compared with other phenotypes.

Conclusions

The presence of either PNI or ypN was a significant prognostic factor for predicting poor survival rates in LARC patients, especially those with a coexistence of both factors. Accordingly, we recommend an intensive follow-up and therapeutic programs for LARC patients with simultaneous PNIs+ and ypNs+.Key Words: Perineural invasion, Lymph node metastases, Rectal cancer, Chemoradiotherapy     

Metabolic Syndrome Is Associated with Atrial Electrical and Mechanical Dysfunction

Objective

In this study, we aimed to investigate the left atrial (LA) electrical and mechanical functions in patients with metabolic syndrome (MetS).

Subjects and Methods

The study population consisted of 87 patients with MetS and 67 controls. Intra-atrial and interatrial electromechanical delays (EDs) were measured with tissue Doppler imaging. P-wave dispersion (Pd) was calculated from the 12-lead electrocardiograms. LA volumes were measured echocardiographically by the biplane area-length method.

Results

Intra-atrial and interatrial EDs and Pd were significantly higher in patients with MetS (10.3 ± 6.3, 21.0 ± 11.5 and 41.7 ± 10.8) than in controls (7.4 ± 5.5, 12.3 ± 10.4 and 29.2 ± 7.4; p = 0.003, p < 0.001 and p < 0.001, respectively). The LA preatrial contraction volume and active emptying volumes were higher in this population, but the LA passive emptying fraction was lower. In the multivariate linear regression analysis, the presence of MetS, LA active emptying volume and left ventricular early diastolic (E) wave velocity/late diastolic (A) wave velocity (E/A) ratios were independent correlates of interatrial ED (p = 0.002, p = 0.001 and p = 0.025, respectively).

Conclusions

This study showed that intra-atrial and interatrial EDs and Pd were prolonged and LA mechanical functions were impaired in patients with MetS.Key Words: Atrial electromechanical delay, Left atrial mechanical function, Metabolic syndrome, P-wave dispersion     

Noninvasive assessment of coronary vasodilation using cardiovascular magnetic resonance in patients at high risk for coronary artery disease

Background

Impaired coronary vasodilation to both endothelial-dependent and endothelial-independent stimuli have been associated with atherosclerosis. Direct measurement of coronary vasodilation using x-ray angiography or intravascular ultrasound is invasive and, thus, not appropriate for asymptomatic patients or for serial follow-up. In this study, high-resolution coronary cardiovascular magnetic resonance (CMR) was used to investigate the vasodilatory response to nitroglycerine (NTG) of asymptomatic patients at high risk for CAD.

Methods

A total of 46 asymptomatic subjects were studied: 13 high-risk patients [8 with diabetes mellitus (DM), 5 with end stage renal disease (ESRD)] and 33 age-matched controls. Long-axis and cross-sectional coronary artery images were acquired pre- and 5 minutes post-sublingual NTG using a sub-mm-resolution multi-slice spiral coronary CMR sequence. Coronary cross sectional area (CSA) was measured on pre- and post-NTG images and % coronary vasodilation was calculated.

Results

Patients with DM and ESRD had impaired coronary vasodilation to NTG compared to age-matched controls (17.8 ± 7.3% vs. 25.6 ± 7.1%, p = 0.002). This remained significant for ESRD patients alone (14.8 ± 7.7% vs. 25.6 ± 7.1%; p = 0.003) and for DM patients alone (19.8 ± 6.3% vs. 25.6 ± 7.1%; p = 0.049), with a non-significant trend toward greater impairment in the ESRD vs. DM patients (14.8 ± 7.7% vs. 19.8 ± 6.3%; p = 0.23).

Conclusion

Noninvasive coronary CMR demonstrates impairment of coronary vasodilation to NTG in high-risk patients with DM and ESRD. This may provide a functional indicator of subclinical atherosclerosis and warrants clinical follow up to determine prognostic significance.     

A common cause of sudden and thunderclap headaches: reversible cerebral vasoconstriction syndrome

Background

Thunderclap headache (TCH) is a sudden headache (SH) with accepted criteria of severe intensity and onset to peak within one minute. It is a well-known presentation for subarachnoid hemorrhage (SAH) but most patients with TCH or SH run a benign course without identifiable causes. Reversible cerebral vasoconstriction syndrome (RCVS), a recently recognized syndrome characterized by recurrent TCH attacks, has been proposed to account for most of these patients.

Methods

We recruited consecutive patients presenting with SH at our headache clinic. Computed tomography and/or magnetic resonance imaging with angiography were performed to exclude structural causes and to identify vasoconstriction. Catheter angiography and lumbar puncture were performed with patients consent. Reversibility of vasoconstriction was confirmed by follow-up study.

Results

From July 2010 to June 2013, 31 patients with SH were recruited. Twenty-four (72.7%) of these SH patients exhibited headache fulfilling the TCH criteria. The diagnosis of RCVS was confirmed in 14 (45.2%) of patients with SH and 11 (45.8%) of patients with TCH. Other diagnoses were as follows: primary headaches (SH: 41.9%, TCH: 45.8%) and other secondary causes (SH: 12.9%, TCH: 8.3%). Compared with non-RCVS patients, patients with RCVS were older (50.8 ± 9.3 years vs. 40.8 ± 10.0 years, P = 0.006) and less likely to experience short headache duration of < 1 hour (23.1% vs. 78.6%, P = 0.007). Patients with RCVS were more likely to cite bathing (42.9% vs. 0%, P = 0.004) and less likely to cite exertion (0% vs. 29.4%, P = 0.048) as headache triggers.

Conclusions

Reversible cerebral vasoconstriction syndrome is a common cause of SH and TCH. Considering the potential mortality and morbidity of RCVS, systemic examination of cerebral vessels should be performed in these patients.     

Malondialdehyde-Modified LDL IgG Antibody Levels and Indices of Cardiac Function in Valvular Heart and Coronary Artery Disease Patients

Objective

To compare the changes in anti-malondialdehyde-modified low-density lipoprotein (MDA-LDL) IgG levels among patients undergoing off-pump and on-pump coronary artery bypass grafting (CABG) or valvuloplasty.

Subjects and Methods

A total of 38, 39 and 34 patients who underwent off-pump CABG, on-pump CABG and valvuloplasty, respectively, were enrolled in this study. Serum anti-MDA-LDL IgG values were measured 24 h before and after the operative procedures and at discharge. Echocardiography was also done before surgery and before discharge. The results were compared with values from 50 healthy controls.

Results

In all patients, a reduction in antibody titers was observed post-operatively. However, the decrease was significant only in the off-pump CABG–before surgery: 42.33 (25.83–58.51), after surgery: 30.86 (16.36–51.33) and at discharge: 10.96 (6.82–23.57; p = 0.027). There was a significant positive association between anti-MDA-LDL IgG levels and ejection fraction (r = 0.248, p = 0.036) and a negative association with E/E'', a marker of pulmonary capillary wedge pressure, in the coronary patients (r = −0.345, p = 0.012), but no significant associations were found in patients with valvular heart disease.

Conclusions

Serum anti-MDA-LDL IgG levels were associated with cardiac function indices in coronary patients undergoing CABG.Key Words: Anti-malondialdehyde-modified low-density lipoprotein, Valvular heart disease, Coronary artery bypass grafting, Cardiac function     

THE MINIMUM CLINICALLY IMPORTANT DIFFERENCE ON THE VISA‐A AND LEFS FOR PATIENTS WITH INSERTIONAL ACHILLES TENDINOPATHY

Study Design

Cohort study of subjects with insertional Achilles tendinopathy (IAT).

Objectives

The purpose of this study was to establish the minimum clinically important difference (MCID) on the Victorian Institute of Sport Assessment ‐ Achilles Questionnaire (VISA‐A) and the Lower Extremity Functional Scale (LEFS) for patients with IAT.

Background

The VISA‐A and LEFS are two measures commonly utilized for patients with IAT. Previous authors have estimated the MCID for the VISA‐A, but a MCID has not been formally established. The MCID for the LEFS has been established for patients with lower extremity conditions in general, but it is not clear if this MCID is applicable to patients with IAT.

Methods

Fifteen subjects participating in a randomized controlled trial studying the effectiveness of intervention for IAT over a 12‐week period were included in this study. Subjects completed the VISA‐A and LEFS forms at baseline and 12 weeks after the initiation of treatment. All subjects also completed a 15‐point global rating of change (GROC) questionnaire at 12 weeks after the initiation of treatment. Subjects were classified as improved or stable based on their GROC scores.

Results

The area under the curve (AUC) for the VISA‐A was 0.97 and a MCID of 6.5 points was identified. The AUC for the LEFS was 0.97 and a MCID of 12 points was identified.

Conclusion

The VISA‐A and LEFS are both useful outcome measures to assess response in patients with IAT.

Level of Evidence

3     

Atrial Electromechanical Delay Is Impaired in Patients with Psoriasis

Objective

In this study, we aimed to investigate atrial electromechanical delay (EMD) in patients with psoriasis.

Subjects and Methods

A total of 43 patients with psoriasis (26 mild-moderate, 17 severe) and 17 healthy control subjects were enrolled. Patients with psoriasis were divided into two groups: the mild-moderate group and the severe group according to their psoriasis area severity index (PASI) scores. Atrial EMD was measured from the lateral mitral annulus and called ‘PA lateral’, from the septal mitral annulus, called ‘PA septal’, and from the right ventricle tricuspid annulus, called ‘PA tricuspid’. Atrial EMD was defined as the time interval from the onset of atrial electrical activity (P wave on surface ECG) to the beginning of mechanical atrial contraction (late diastolic A wave). All three groups were compared with each other, and correlation analysis was performed to investigate the relationship between the PASI score and interatrial EMD.

Results

PA lateral was significantly higher in both the mild-moderate psoriasis group and the severe psoriasis group compared to controls (69 ± 12 and 78 ± 13 vs. 60 ± 6 ms; p = 0.001). Also, PA septal (63 ± 11 vs. 53 ± 6 ms; p = 0.005, post hoc analysis) and PA tricuspid (49 ± 7 vs. 41 ± 5 ms; p = 0.009, post hoc analysis) were significantly higher in the severe psoriasis group than in the control group. Correlation analysis revealed that the PASI score was well correlated with PA lateral (r = 0.520, p < 0.001), PA septum (r = 0.460, p = 0.002), interatrial EMD (r = 0.371, p = 0.014) and intra-atrial EMD (r = 0.393, p = 0.009).

Conclusion

Atrial EMD was prolonged in patients with psoriasis. The measurement of atrial EMD might be used to determine the risk of development of AF in patients with psoriasis.Key Words: Atrial fibrillation, Psoriasis, Atrial electromechanical delay