Left and right ventricular function is impaired in Behçet's disease

Objectives: Subclinical cardiac involvement may occur in patients with Behçet's disease (BD). The purpose of our study was to assess the noninvasive parameters of biventricular function derived from Doppler tissue imaging (DTI) of the tricuspid and mitral annular motion in BD. Methods: Twenty‐one patients with BD and 20 control subjects were enrolled in this study. All subjects were selected to exclude those with cardiovascular risk factors. Standard echocardiography and pulsed DTI were obtained in every patient. Results: Peak systolic (13.71 ± 2.09 vs 20.01 ± 1.57, P < 0.001), peak early diastolic (11.26 ± 2.52 vs 15.35 ± 2.06, P < 0.001) tricuspid annular velocities were significantly lower in patients than controls. Peak systolic (8.68 ± 1.4 vs 12.25 ± 1.7, P < 0.001), peak early diastolic (7.89 ± 1.07 vs 9.94 ± 1.12, P < 0.001), and peak end diastolic (8.30 ± 1.32 vs 9.23 ± 0.91, P = 0.013) lateral mitral annular velocities were significantly lower in patients than controls. Conclusions: We demonstrated that myocardial velocities, were affected in patients with BD. Therefore, we conclude that right and left ventricular function is impaired in patients with BD.     

Left ventricular systolic and diastolic function assessed with two-dimensional and Doppler echocardiography in “white coat” hypertension

Objectives. The aim of this study was to investigate left ventricular function in subjects with “white coat” hypertension, defined as office arterial diastolic pressure ≥90 and ambulatory daytime pressure < 140/90mm Hg.Background. The white coat arterial pressure response may, by influencing left ventricular function, have a confounding effect in studies of heart disease.Methods. Two-dimensional and Doppler echocardiography, combined with the calibrated subclavian arterial pulse tracing, were used to assess variables of left ventricular function in 26 subjects with white coat hypertension, as well as 22 subjects with previously untreated ambulatory hypertension (office arterial diastolic pressure ≥90 and <115 mm Hg and ambulatory daytime diastolic pressure ≥90 mm Hg) and 32 normotensive subjects.Results. In subjects with white coat hypertension, systolic arterial pressure during the echocardiographic examination was significantly higher than ambulatory daytime systolic pressure. This pressure response was positively related to the ratio of the systolic to diastolic pulmonary venous flow peak velocities and to the peak velocity of flow reversion during atrial systole; it was inversely related to the ratio of early to late mitral flow peak velocities. Left ventricular stroke volume, ejection fraction and velocity of circumferential fiber shortening did not differ in the study groups, but left ventricular external work and end-systolic wall stress were increased in the white coat group.Conclusions. The arterial pressure response in subjects with white coat hypertension is associated with increased left ventricular external work, increased end-systolic wall stress and alterations of left ventricular filling but normal ejection fraction and velocity of circumferential fiber shortening.     

Left ventricular regional and global diastolic function assessed using Quantitative Tissue velocity Imaging in patients with hypertrophic cardiomyopathy

Objectives The study was performed to assess the left ventricular (LV) regional and global diastolic function,left ventricular wall motion features in patients with Hypertrophic cardiomyopathy by Quantitative Tissue Velocity Imaging (QTVI) . Methods 42 patients with hypertrophic cardiomyopathy and 36 age-matched normal subjects underwent QTVI study. Off-line LV regional muscular tissue velocity Imaging along LV apical long-axis view were obtained. Regional diastolic function was assessed in using peak tissue velocities of LV regional muscular tissue during early diastole (Ve)and LA contraction (Va) , Ve/Va ratio, derived from Tissue Velocity Imaging. Global diastolic function was reflected by isovolumic relaxation time(IRT) and mitral valve peak flow velocity ( E/A ) calculated with pulsed wave doppler.The end-diastolic interventricular septal thickness(IVSt) was measured by conventional 2 -dimension echocardiography. Results ① Ve, Va, Ve/Va inthe segments of hypertrophic interventricular septum(IVS) reduced wlhile E/A ratio significantly reduced and IRT markedly prolonged in HCM patients than in normal subjects.② Ve, Ve/Va were significant reduced in the segments of hypertrophic interventricular septum compared with other LV segments in HCM patients . ③There was a correlation between Ve/Va and E/A in HCM patients with abnormal E/A ratio (r = 0.70). ④ There was a negative correlation between Ve/Va and IVSt in non- obstruction HCM patients (Bgroup ,r= -0.61) Conclusions QTVI offers a newer method in clinical practice which has a higher sensibility and accuracy in evaluating the LV regional and global diastolic function in HCM patients .     

When does the E/e’ index not work? The pitfalls of oversimplifying diastolic function

Since the E/e’ ratio was first described in 1997 as a noninvasive surrogate marker of mean pulmonary capillary wedge pressure, it has gained a central role in diagnostic recommendations and a supremacy in clinical use that require critical reappraisal. We review technical factors, physiological influences, and pathophysiological processes that can complicate the interpretation of E/e’. The index has been validated in certain circumstances, but its use cannot be extrapolated to other situations—such as critically ill patients or children—in which it has either been shown not to work or it has not been well validated. Meta-analyses demonstrated that E/e’ is not useful for the diagnosis of HFpEF and that changes in E/e’ are uninformative during diastolic stress echocardiography. A similar ratio has been applied to estimate right heart filling pressure despite insufficient evidence. As a composite index, changes in E/e’ should only be interpreted with knowledge of changes in its components. Sometimes, e’ alone may be as informative. Using a scoring system for diastolic function that relies on E/e’, as recommended in consensus documents, leaves some patients unclassified and others in an intermediate category. Alternative methods for estimating left heart filling pressures may be more accurate, including the duration of retrograde pulmonary venous flow, or contractile deformation during atrial pump function. Using all measurements as continuous variables may demonstrate abnormal diastolic function that is missed by using the reductive index E/e’ alone. With developments in diagnostic methods and clinical decision support tools, this may become easier to implement.     

Platelet glycoprotein Ibα polymorphisms and function evaluated by the platelet function analyzer PFA-100 in patients with lupus anticoagulant: the association with thromboembolic disease

Lupus anticoagulants (LA) are a surrogate marker for the risk of thromboembolic disease (TE). However, not all individuals with LA acquire TE, and it is desirable to distinguish those at risk for TE from those without. Platelets polymorphisms may contribute to the risk of TE, mainly those of glycoprotein (GP)Ibα: these are the variable number of tandem repeats (VNTR) and a dimorphism in the Kozak region, which affect platelet plug formation in healthy individuals under high shear stress rates. We determined polymorphisms within the GPIbα in individuals with persistent LA and a history of TE (LA/TE+) and in those without TE (LA/TE-). Further, we measured platelet function, as estimated by the collagen-epinephrine closure time (CEPI-CT) of the platelet function analyzer PFA-100 and compared all data with healthy controls. There was no difference of the VNTR alleles compared to healthy controls. The (−5)C allele of the Kozak dimorphism was significantly more frequent in LA patients compared to controls (p = 0.04), as a result of its increased frequency in LA/TE+ (vs controls p = 0.04), but there was no difference between LA/TE+ and LA/TE−. The increased frequency of the (−5)C allele resulted in an overrepresentation of (−5)TC genotype in the LA/TE+ group (p = 0.02) but not in a subgroup of 18 patients with arterial disease. The CEPI-CT of the PFA-100 was shorter in LA/TE+ than in LA/TE− (p = 0.044), but this difference did not persist after exclusion of patients with low platelet counts or low ristocetin cofactor activity. Unlike in healthy individuals, the CEPI-CT was not related to any Kozak dimorphism, neither in LA/TE−, nor in LA/TE+. Thus, the Kozak dimorphism may just contribute to stronger factors disposing individuals with LA towards TE without any discernible effect on their in vitro platelet function estimated by the PFA-100.     

Intraventricular dispersion of E wave velocity: an alternative measure of left ventricular diastolic function in hypertensive patients?

The E/A ratio (of peak mitral blood flow velocity during early diastole to that during atrial contraction) has limitations in the assessment of diastolic function. Previous studies have suggested that peak blood flow velocity is normally maintained or increased towards the cardiac apex but that it decreases in diastolic dysfunction. We evaluated the proposal that intraventricular dispersion of E wave velocity is an effective means of assessing diastolic function in hypertensives. Fifty-five untreated hypertensive patients underwent echocardiographic examination. Pulsed-wave Doppler recordings were made from the apical four-chamber view. Peak flow velocities were measured during early diastole at the level of the mitral valve (E0), and 3 cm distally (E3), and during atrial contraction at the level of the mitral valve (A). Mean peak flow velocities were 64.4 +/- 16.1 m/s for E0, 50.6 +/- 17.9 m/s for E3 and 61.1 +/- 12.1 m/s for A. Peak flow velocity during early diastole slowed towards the cardiac apex in most patients (E3/E0 range: 0.42-1.86, mean 0.81 +/- 0.29). There was no significant difference in E3/E0 between those with and without left ventricular hypertrophy (LVH) (0.76 +/- 0.25 vs 0.82 +/- 0.29, P = 0. 39). E3/E0 did not correlate with age (r = -0.02, P = 0.89), systolic blood pressure (BP) (r = 0.17, P = 0.20), diastolic BP (r = 0.21, P = 0.12) or LVMI (r = -0.11, P = 0.40). In contrast the E/A ratio correlated strongly with age (r = -0.66, P < 0.0001) and negatively, though not significantly, with systolic BP (r = -0.24, P = 0.07), diastolic BP (r = -0.23, P = 0.09) and LVMI (r = -0.23, P = 0.08). Although there is some intraventricular dispersion of E wave velocity in this group of hypertensive patients, the ratio of E3/E0 correlates poorly with parameters which are known to influence diastolic function. In spite of its limitations, the E/A ratio appears to be a more reliable measure of diastolic function in hypertensive heart disease than intraventricular dispersion of early diastolic filling.     

Assessment of aortic stiffness and ventricular diastolic functions in patients with Behçet’s disease

Background: Behçets disease is a systemic vasculitis in which studies have given conflicting results about ventricular diastolic functions. However, tissue Doppler echocardiography has never been used in any of these studies. Aortic stiffness, a cardiovascular risk factor, may also precede ventricular dysfunction. Objectives: The aim of this study was to assess aortic stiffness and biventricular diastolic functions in patients with Behçets disease. Methods: A total of 26 patients with Behçets disease (mean age; 33±10 years) and 20 age- and sex-matched controls (mean age; 33±7 years) were included. Aortic stiffness was evaluated by aortic strain and distensibility. Ventricular diastolic functions were evaluated with both conventional and tissue Doppler echocardiography. Mitral E and A wave, E/A ratio of E wave, deceleration time, and isovolumic relaxation time were calculated. Results: There was no significant difference in diastolic Doppler parameters between patients and controls. Similarly, there was no significant difference in mitral annular E and A velocities between these two groups. Aortic strain in patients with Behçets disease was found to be significantly less than in the controls (8.3±4.9% and 15.7±2.7% respectively, p<0.001). Aortic distensibility was also significantly low in patients with Behçets disease when compared to controls (0.45±0.28 and 0.78±0.13 respectively, p<0.001). Beta index values were significantly high in Behçets patients (7.23±5.93 and 2.69±0.55 respectively, p<0.001). Conclusion: No significant diastolic dysfunction was found in left and right ventricles in patients with Behçets disease by using both conventional and tissue Doppler echocardiography. However, an increase in aortic stiffness was found, suggesting an inflammatory involvement of proximal aorta.     

Poor concordance of commonly used echocardiographic measures of left ventricular diastolic function in patients with suspected heart failure but preserved systolic function: is there a reliable echocardiographic measure of diastolic dysfunction?

Objective: To determine the concordance of different Doppler echocardiographic criteria for “diastolic dysfunction” in patients with suspected heart failure but preserved left ventricular systolic function.     

Is the esophageal squamous epithelial barrier function impaired in patients with gastroesophageal reflux disease?

BACKGROUND: A disturbed epithelial barrier function has been promoted as one factor in the pathogenesis of gastroesophageal reflux disease (GERD). We therefore studied the effect of acid perfusion on the transmural potential difference (PD) of the distal esophagus in relation to onset of reflux symptoms. METHODS: PD was assessed during perfusion with saline and with 0.1 M HCl in healthy controls (n = 17) and in GERD patients without (n = 15) or with esophagitis (n = 6) and in remission after a fundoplication (n = 10). Heartburn and other upper GI symptoms were recorded concomitantly. Endoscopy-negative patients were studied before and after omeprazole treatment. RESULTS: HCl perfusion induced more lumennegative peak PD values in patients with active GERD, regardless of the presence or absence of esophagitis, than in healthy controls. After successful therapy, the PD response to acid perfusion equalled that of healthy subjects. Acid perfusion was associated with the onset of heartburn in most patients with active GERD but in none of the healthy subjects, and less frequently after medical and surgical therapy. CONCLUSIONS: The epithelial permeability to hydrogen ions differs between healthy subjects and patients with active GERD. Effective treatment, such as omeprazole or fundoplication, might improve the barrier function.     

Does the presence of hibernating myocardium in patients with impaired left ventricular contraction affect QT dispersion?

BACKGROUND: Hibernating myocardium is associated with increased cardiovascular events. Increased QT dispersion on the surface electrocardiogram is a marker for serious ventricular arrhythmias. In this study, we determine whether hibernating myocardium is associated with increased QT dispersion in patients with coronary artery disease and impaired left ventricular contraction. METHODS: Positron emission tomography with (13)N-ammonia and (18)F-fluorodeoxyglucose determined the presence of metabolic-perfusion mismatch defect. QT dispersion was measured by means of a digitizing tablet with validated software. QT intervals were measured on two separate occasions by two investigators blinded to the result of the positron emission tomography scans. RESULTS: Forty-two patients with impaired left ventricular contraction were studied. They were divided into two groups: group A was made up of patients with mismatch defects (n = 26) and group B was made up of patients with no mismatch defects (n = 16). The mean (SD) QT dispersion measurements were 61.7 +/- 29.8 ms and 70 +/- 24.6 ms for groups A and B, respectively (not significant). When the patients were divided according to the dominant viability status of the impaired myocardial segment, a similar result was found. The patients whose impaired myocardium was dominantly hibernating (n = 19) had a mean QT dispersion of 66.4 +/- 31.9 ms compared with 63.6 +/- 24.8 ms in the patients whose impaired myocardium was mainly scarred (not significant). CONCLUSIONS: QT dispersion is not affected by the presence of hibernating myocardium and is therefore not clinically useful in identifying patients with this phenomenon. This is in contrast with recent reports by other groups and calls for further investigation of this dichotomy.     

Global myocardial perfusion and diastolic function are impaired to a similar extent in patients with type 2 diabetes mellitus and in patients with coronary artery disease—evaluation by contrast echocardiography and pulsed tissue Doppler

Aims/hypothesis Using modern echocardiography, we quantified the extent of global myocardial function and perfusion abnormalities in patients with type 2 diabetes and compared this with the hypothetically similar extent of impairments in patients with coronary artery disease (CAD).Subjects and methods This case–control study (66 patients) compared four age-matched groups: control, type 2 diabetic, CAD, and diabetic subjects with CAD (DCAD) and left ventricular ejection fraction >50%. CAD patients had 1–2 vessel disease. Diastolic and systolic myocardial velocities were assessed with pulsed tissue Doppler. Global myocardial perfusion was assessed with contrast echocardiography as indices of capillary blood volume and myocardial blood flow at maximal vasodilatation. In CAD and DCAD patients, functional and perfusion parameters were additionally assessed in the territory with a normal coronary angiogram reading, providing a model for comparison with the global data from control and diabetic patients.Results Comparing diabetic with control subjects, myocardial velocity at early diastole was impaired (8.8±1.8 vs 10.1±1.7 cm/s; p=0.02) and correlated inversely with age, HbA_1c and pulse pressure (R ²=0.761). Capillary blood volume (16.6±5.0 vs 24.4±4.9%) and blood flow (56±35 vs 114±40) were decreased (p=0.001). In CAD patients, myocardial velocity at early diastole was similarly decreased (p=0.02). CAD and DCAD patients were receiving more cardiovascular preventive therapy for the same extent of impaired global perfusion as in the less extensively treated diabetes group without CAD (p<0.002), but had superior perfusion of the ‘normal’ coronary territory than that group (p<0.05).Conclusions/interpretation In patients with diabetes, global diastolic function and myocardial capillary blood volume and blood flow are impaired to the same extent as in patients with CAD. These impairments could form the basis of new therapeutic concepts.     

Comparison of nifedipine GITS and hydrochlorothiazide in the management of elderly patients with stage I–III diastolic hypertension

A randomized, double blind, parallel study was performed to compare the effects of nifedipine gastrointestinal therapeutic system (GITS) to hydrochlorothiazide (HCTZ) in the management of the elderly hypertensive. Eighteen patients, mean age 65 ± 5 years, with Stage I–III diastolic hypertension (sitting diastolic BP between 90 and 115 mm Hg) were included in each treatment group. Following a 2 to 8 week placebo washout phase, patients received either nifedipine GITS or HCTZ and were titrated over 5 weeks to achieve a goal diastolic blood pressure less than 90 mm Hg.Patients were then continued on medication during an 8 week maintenance phase. Treatment effect on systolic and diastolic blood pressure was assessed. Serum electrolytes, lipids, blood urea nitrogen, and creatinine were measured before and after treatment. Posttreatment changes in renal and cardiovascular function, as well as left ventricular mass were evaluated.The results showed significant reductions in systolic and diastolic blood pressure with both drugs; no treatment difference was found, although goal blood pressure was achieved more rapidly with nifedipine GITS (28 v 34 days, P < .05). BUN was significantly increased only after diuretic therapy (P < .01) and serum potassium fell to a greater degree with HCTZ (0.3 mEq/L v 0.1 mEq/L) than with nifedipine GITS. No statistically significant changes in left ventricular mass, ejection fraction, glomerular filtration rate, or renal blood flow were seen after therapy with either drug. However, the time to peak LV diastolic filling rate decreased with nifedipine GITS (197 to 164 msec) and increased with HCTZ (172 to 198 msec). This treatment difference approached statistical significance (P = .07). Adverse side effects of treatment were reported by 50% of nifedipine GITS patients and 28% of patients treated with HCTZ. This treatment difference was not statistically significant.We conclude that both nifedipine GITS and HCTZ monotherapy provide significant blood pressure reduction in older hypertensives with Stage I–III diastolic hypertension. Both drugs are well tolerated with no significant adverse effect on renal or cardiovascular function after short term therapy.