Electrocardiography and conventional radiology accuracy compared to echocardiography in evaluating left ventricular remodelling patterns in hypertensive patients

AIM: The value of conventional radiology, electrocardiography and echocardiography in estimating the prevalence of left ventricular (LV) remodeling patterns in patients with newly discovered hypertension was less studied. The aim of the present study was to assess the accuracy of conventional radiology and electrocardiography compared to echocardiography in the diagnosis of left ventricular hypertrophy (LVH) and different remodeling types in male patients with recent primary arterial hypertension (PAH). METHODS: This cross-sectional study, enrolled 420 male patients with recent stage 2 PAH, diagnosed less than a year before, and 420 normotensive male subjects, using conventional radiological methods, ECG and also echocardiography. The ultrasound examination documented four types of LV remodeling, based on the measurement of LV parameters: concentric hypertrophy (CH), eccentric hypertrophy (EH), concentric remodeling (CR) and the normal variant (NV). RESULTS: In the recent PAH group, echocardiography diagnosed LV patterns in different proportions (34.285% CR; 24.285% NV; 21.43% EH; 20% CH), whereas the standard radiological examination and ECG documented LVH positive criteria in a much lower proportion of cases, for these patterns. CONCLUSION: The ECG and radiological examinations detected LVH in patients with EH, and CH, but both examinations were inconclusive in those with CR and NV. This study comparatively reflects the effectiveness of echocardiography, electrocardiography and conventional radiology, in the diagnosis of LV patterns in newly discovered hypertension and also illustrates the arguments for and against the usage of these three imagery techniques.     

Gastric bypass in chronic renal failure and renal transplant.

BACKGROUND: Morbid obesity has reached epidemic proportions in developed nations worldwide, causing considerable mortality and increased healthcare expenditures. The use of gastric bypass surgery to achieve weight loss in morbidly obese patients with chronic renal failure (CRF) and postrenal transplant patients has not been studied adequately. METHODS: Forty-one patients with different stages of CRF (25 already receiving dialysis) underwent a gastric bypass (GBP), and an additional 10 patients underwent a GBP after becoming morbidly obese after transplantation. RESULTS: Of the 41 patients with CRF, 5 stabilized or resolved their kidney disease and 9 underwent successful transplantation. These patients had a loss of 68% excess body mass index (BMI) by 12 months after GBP. Of the 10 patients with GBP after transplant, the mean loss of excess BMI was 70.5%. There were no in-hospital or 30-day mortalities, but 8 of the 51 patients died from 112 to 2869 days postoperatively, 7 from cardiac or vascular events and 1 from an automobile accident. This compares with an approximate 10% mortality per year for patients receiving dialysis. Comorbid conditions associated with morbid obesity improved in all patients and permitted eligibility for transplantation. CONCLUSIONS: GBP for massive weight reduction in morbidly obese renal failure and transplant patients leads to a reduction in comorbid conditions that are associated with an increased risk for cardiovascular deaths. There was no operative mortality in this series, and all but 1 death were related to previously existing disease of the cardiovascular system.     

A Depressed Nurse with Hypoglycemia

Abstract

The use of stress echocardiography has undergone considerable evolution in the past 3 decades. Although stress echocardiography was first introduced as a noninvasive diagnostic tool for determining the presence or absence of coronary artery disease (CAD), it later served a prognostic role as well. The importance of stress echocardiography in risk stratification and prognosis is substantially undervalued by clinicians. The identification of patients at risk for future cardiac events has become a primary objective in noninvasive evaluation of patients with suspected or known CAD. In particular, the ability of stress echocardiography to identify patients at low (< 1%), intermediate (1%–5%), or high (> 5%) risk for future cardiac events is essential to decision making in patient management. Moreover, previous studies have conclusively demonstrated the incremental prognostic value of stress echocardiography over clinical and treadmill exercise data in predicting future cardiac events. This article presents a primarily single-center experience of retrospective and observational studies that address the current role of stress echocardiography and summarize its use for risk stratification, prognosis, and determining clinical outcomes, as well as cost-effective integration of such information in patient management decision making.     

Open access exercise electrocardiography: does it improve the management of cardiovascular disease in the community?

In this study the use of exercise electrocardiography, by 47 general practitioners in South East Kent has been evaluated. Of 110 consecutive requests the majority (88%) were for diagnostic purposes, while only 7% were for prognostic assessment. Many of those referred were young or had non-cardiac chest pain and in 59% of cases the test result was unlikely to alter the clinical assessment of the probability of ischaemic heart disease (IHD). The test result influenced patient management in 85% of cases. Only 15% of patients were subsequently referred to the district general hospital although all had been considered for referral prior to the test. Although referral for invasive investigation of six patients was expedited by the provision of stress testing, in five patients general practitioners failed to consider any further investigation despite the patient having a strongly positive test. General practitioners use exercise electrocardiography primarily to exclude IHD in patients at low risk and provide reassurance. They rarely use the test as a means to guide management of those with known or probable IHD.     

A comparison of the 'Sheffield' Prognostic Index with forearm muscle dynamometry in patients from Sheffield undergoing major abdominal and urological surgery

An increased awareness of the nutritional status of patients undergoing major elective surgery has lead to the finding that certain measurements of nutritional status either alone (dynamometry) or in combination (Prognostic Nutritional Index or the 'Sheffield' modified index) can identify patients at high risk from developing complications. This study presents a comparison of forearm muscle dynamometry versus the 'Sheffield' index in 70 patients undergoing major elective abdominal and urological surgery. Both tests successfully identified patients at risk of major post operative complications and death, but they failed to predict those patients who developed minor post operative complications. These data suggest that only major postoperative complications relate to the pre-operative nutritional status of patients undergoing major elective surgery. Identification of a patient as being at high risk of developing major postoperative complications by dynamometry or the 'Sheffield' index should alert the surgeon to the possible requirement for perioperative nutritional support.     

Myocardial dysfunction and adrenergic innervation in patients with Type 1 diabetes mellitus

In this study we assess the mechanisms of exercise-induced left ventricular (LV) dysfunction in asymptomatic patients with Type 1 diabetes mellitus (T1DM) without coronary artery disease. Fourteen patients and 10 volunteers were enrolled. LV volume, LV ejection fraction (LVEF) and end-systolic wall stress were calculated by two-dimensional echocardiography at rest and during isometric exercise. Myocardial iodine-123 metaiodobenzylguanidine (MIBG) scintigraphy was performed to assess adrenergic cardiac innervation. Diabetic subjects were classified into group A (n=7), with an abnormal LVEF response to handgrip (42 +/- 7%), and group B (n=7), with a normal response (72 +/- 8%). Baseline LVEF was normal in both group A and B patients. In group A patients, the LV circumferential wall stress-LVEF relation showed an impairment in LVEF disproportionate to the level of LV after load. No significant changes in LVEF occurred during dobutamine, whereas post-extrasystolic potentiation (PESP) significantly increased LVEF (60 +/- 6% vs 74 +/- 6%,p < 0.001); PESP at peak handgrip normalized the abnormal LVEF (42 +/- 7% vs 72 +/- 5%, p < 0.001); and MIBG uptake normalized for body weight or for LV mass was lower than in normal subjects (1.69 +/- 0.30 vs 2.98 +/- 0.82 cpm/MBq per g,p = 0.01) and group B diabetic patients (vs 2.79 +/- 0.94 cpm/MBq per g,p = 0.01). A linear correlation between LVEF at peak handgrip and myocardial MIBG uptake normalized for LV mass was demonstrated in the study patients. A defective blunted recruitment of myocardial contractility plays an important role in determining exercise LV dysfunction in the early phase of diabetic cardiomyopathy. This abnormal response to exercise is strongly related to an impairment of cardiac sympathetic innervation.     

Pre-participation screening for the prevention of sudden cardiac death in athletes

Pre-partecipation screening is the systematic practice of medically evaluating large populations of athletes before participation in sport activities for the purpose of identifying abnormalities that could cause disease progression or sudden death. In order to prevent sudden cardiac death (SCD), cardiovascular screening should include a strategy for excluding high-risk subjects from athletic and vigorous exercise. There are two major screening programmes in the world. In the United States competitive athletes are screened by means of family and personal history and physical examination. In Italy there is a mandatory screening for competitive athletes, which includes a resting electrocardiogram (ECG) for the detection of cardiac abnormalities. The most important issue to be addressed is whether a screened subject is really guaranteed that she/he is not suffering from any cardiac disease or at risk for SCD. Conceivably, the introduction of echocardiogram during the pre-participation screening, could be reasonable, despite the discrete sensitivity of ECG, in raising clinical suspicions of severe cardiac alterations predisposing to SCD. It is clear that the cost-benefit ratio per saved lives of the ECG screening is a benchmark of the Public Health policy. On the contrary, the additional introduction of echocardiography in a large population screening programme seems to be too much expansive for the Public Health and for this reason not easily practicable, even if useful and not invasive. Even if we strongly believe that a saved life is more important than any cost-efficacy evaluation, the issue of the economical impact of this approach should be further assessed.     

Early detection of myocardial dysfunction in Chagas disease using novel echocardiographic indices

The first manifestation of cardiac involvement in Chagas disease could be sudden death or rapid deterioration in cardiac function. The aim of this study was to identify a non-invasive method for early detection of cardiac involvement in patients with Chagas disease. During a 6-month period in 2001, 133 people were studied using echocardiography and electrocardiography in Honduras; 88 were seropositive for Trypanosoma cruzi, of which 31 were asymptomatic, and 45 were seronegative controls. The echocardiographic assessment included geometrical and time interval derived indices. Patients with asymptomatic Chagas disease had increased left and right myocardial performance index (MPI) when compared with seronegative controls (P= 0.003 and P= 0.023, respectively) with 36% having a left MPI above the upper limit of the normal range. They also had a reduced diastolic posterior wall thickness (P= 0.005) and lower posterior wall thickness to left ventricular cavity (PWT:LVC) ratio (P= 0.002). Our results show that the MPI, a simple Doppler parameter, and the PWT:LVC ratio are useful in the early detection of myocardial involvement in asymptomatic patients with Chagas disease. These parameters could serve as useful screening tools and monitor the disease progression in these patients.     

慢性肾功能衰竭患者超声心动图改变临床分析

目的探讨慢性肾功能衰竭患者超声心动图改变的临床意义。方法根据肌酐清除率水平，将49例慢性肾功能衰竭患者分为三组（肾功能代偿期组11例；肾功能失代偿期组16例和肾功能衰竭组22例），并以20例正常人作对照，分别用彩色多普勒超声心动图进行心脏腔径及心功能参数的测定。结果CRF患者心脏彩超异常者占80%，主要为左心损害。随着肌酐清除率水平的下降，慢性肾功能衰竭各组患者左室（LV）、左房（LA）、室间隔（IVS）、左室后壁厚度（LVPWT）和左室心肌重量指数（LVMI）均显著增加（p〈0.05，p〈0.01），而E/A比值则呈下降趋势，与对照组比较差异显著（p〈0.05）。结论通过超声心动图对慢性肾功能衰竭患者心脏改变进行严密监测，控制以上因素，有助于减少心血管病变的发生。     

Predicting elderly cardiac patients at risk for readmission.

Elder patients with cardiac disease are at high risk for physical deterioration during post hospital recovery and suffer frequent early readmission. It is important to identify such patients who frequently need help with discharge planning from social workers during their first admission. This study utilized computerized data on 628 patients, 238 of whom were readmissions. Question was raised as to what factors (functional, psychological, social and environmental), differentiated patients who were readmitted from those who were not. Using logistic regression, three variables: marital status, presence of coping difficulty and age of patients were identified as predictors of readmission within three months. Those who were married were less likely to be readmitted. Those with coping difficulties and older individuals were more likely to be readmitted. The accuracy of prediction, using these three factors, was 61 percent. Of those patients predicted as not being readmitted, sixty-nine percent were correctly predicted, while 39 percent were readmitted. Of patients predicted as readmissions, 49 percent were correctly predicted, while 51 percent were not. The major limitation of this study was that key physiological determinants of readmission were not collected. It is imperative that a valid screening device for predicting who is at risk for readmission should include physiological preconditions as well as functional and psychosocial data.     

Projecting the Effect of Nesiritide on Dialysis and Hospital Mortality in Cardiac Surgery Patients

ObjectiveTo predict the effect of nesiritide on clinical outcomes based on the renal function change demonstrated in the Nesiritide Administered Peri-Anesthesia (NAPA) in patients undergoing cardiac surgery trial.MethodsWe built a decision analytical model to replicate the NAPA trial with 1000 hypothetical patients in both nesiritide and placebo arms. The incident rates of dialysis, hospital death, and their composite were predicted based on the renal function data obtained from the NAPA trial. All analyses were further repeated for two subgroups stratified by the presence of preoperative renal dysfunction (RD).ResultsThe base-case analyses significantly favored nesiritide for the three clinical end points. In the total NAPA sample, the absolute risk reductions (ARRs) for dialysis, hospital death, and their composite across 100 simulated trials were 1.3%, 3.3%, and 4.1%, respectively. The improvement was more pronounced in the preoperative RD subgroup with the three ARRs of 4.1%, 7.1%, and 9.4%, respectively. The beneficial effect diminished in the normal preoperative renal function (NRF) subgroup with the three ARRs of 0.6%, 3.0%, and 3.4%, respectively. The best case analyses confirmed the robustness of the base-case results in the total NAPA sample and RD subgroup, but not in the NRF subgroup.ConclusionIf the demonstrated renal preservation can be extrapolated, nesiritide may reduce dialysis and hospital death in cardiac surgery patient with preoperative RD, but to a much lesser extent or not in patients with normal preoperative renal function.     

Risk factors for unfavorable outcome of pulmonary tuberculosis in adults in Taipei, Taiwan

This study was undertaken to identify factors associated with unfavorable outcomes in patients with pulmonary tuberculosis (PTB) in Taipei, Taiwan in 2007-2008. Taiwanese adults with culture-positive PTB diagnosed in Taipei during the study period were included in this retrospective cohort study. Unfavorable outcomes were classified as treatment default, death, treatment failure, or transfer. Of 1616 eligible patients, 22.6% (365) had unfavorable outcomes, mainly death. After controlling for patient sociodemographic factors, clinical findings, and underlying disease, independent risk factors for unfavorable outcomes included advanced age, unemployment, end-stage renal disease requiring dialysis, malignancy, acid-fast bacilius smear-positivity, multidrug-resistant TB, and notification from ordinary ward or intensive care unit. In contrast, patients receiving directly observed treatment, and with a high school or higher education were significantly less likely to have unfavorable outcomes. This study advanced our understanding by revealing that a high school or higher education might lower the risk of an unfavorable outcome. Our results also confirmed the risk factors for unfavorable outcomes shown in previous research. Future TB control programmes in Taiwan should target particularly high-risk patients including those who had lower educational levels.     

Risk of cardiac complications in patients undergoing major vascular surgery

In patients undergoing major vascular surgery cardiac complications are the major cause of perioperative morbidity and mortality. This is related to the frequent presence of underlying coronary artery disease. The aim of the preoperative cardiac risk assessment is to evaluate the presence and degree of coronary artery disease along with other risk factors such as cerebrovascular disease, renal insufficiency, and diabetes mellitus that may influence the perioperative risk of these patients. Based on the presence and number of cardiac risk factors the individual risk profile can be determined, which may facilitate medical decision making about the perioperative and long-term management of these patients. In the present review based on data from current literature we summarized the pathology of perioperative cardiac complications, and the role of cardiac risk assessment and risk reduction strategies in patients undergoing major vascular surgery. In this review the authors summarized data from current literature and found that a limited set of risk factors and a result of a noninvasive test used for detection of coronary artery disease may help to stratify patients into low-, intermediate- and high risk for perioperative cardiac complications. If patients with intermediate- to high-risk prescribed beta-blockers the risk of cardiac complications can be reduced. Along with beta-blockers it was also found that perioperative use of statins may also help to reduce the risk of cardiac complications. In patients identified to be at very high-risk further perioperative evaluation and management should include coronary angiography with subsequent coronary revascularization if there is a clearly defined need, independent of the need for vascular surgery.     

Predictive characteristics for early mortality in patients on the waiting list for aortocoronary bypass surgery

In 1986, 1124 patients were selected for coronary artery bypass surgery (CABG). Of patients in line for CABG 25 (2.2%) died of a cardiac cause before operation. This complies with a cardiac mortality risk of 8.3 patients per 100 patient years follow-up. To assess patient characteristics predictive for early mortality before surgery, 25 deceased patients were analysed and compared with 50 controls matched by age, gender, type of surgery and priority. Using multivariate analysis, cardiac enlargement on chest X-ray, positive exercise testing with short duration (less than 6 minutes), smoking, coumarin treatment, unstable angina just prior to angiography and left main or three-vessel disease were independent predictors for death while waiting for CABG. We conclude that patients with the above mentioned characteristics have an increased short term mortality while waiting for CABG. These indicators may contribute important information for determination of priority in patients at high risk while waiting for CABG.     

Effect of Renal Transplantation on Sexual Function

This investigation was conducted to determine whether renal transplantation can improve sexual function in male patients with chronic renal failure. The authors retrospectively studied 121 men undergoing renal transplantation who complained of any type or degree of sexual dysfunction pre-operatively. Sexual function was evaluated by questionnaire which included erectile, ejaculative, and orgasmic functions. Pre- and postoperative frequency of sexual intercourse was also recorded. Patient characteristics, laboratory data, and endocrinologic profiles were analyzed to identify factors that might influence sexual function. In patients with hormonal determinations, results essentially normalized after transplantation. However, only 43 patients (35.5%) reported improvement of overall sexual function after renal transplantation, while 34 (28.1%) reported worsening. Although frequency of sexual intercourse was unaffected by transplantation, 15 of 20 patients who had no intercourse before transplantation initiated intercourse afterward. These 15 patients all underwent transplantation before 40 years of age. Comparisons of variables by sexual function showed significant differences for type of immunosuppressive treatment, interval after renal transplantation, and serum concentration of hemoglobin A1c. It is concluded that renal transplantation cannot improve sexual function in allpatients, although hormonal profiles were largely normalized, and that renal transplantation should be encouraged at a younger age.     

肾移植术后肺部感染状况及相关因素分析

目的 观察肾移植术后患者感染的发生率并探讨原因及相关因素，加强预防及治疗措施。方法 对1998年1月至2003年5月我院手术及门诊随诊321例肾移植术后患者中124例肺部感染病例进行回顾性调查。结果 其中发生肺炎感染者124例次，感染率为38．6％。呼衰发生率29．8％，治疗平均天数22d。引起肺部感染的主要因素为免疫抑制剂组合、环孢素浓度、生物制剂的使用、白细胞数量。结论 肾移植术后肺部感染病情严重，住院周期长．死亡率较高。引起肺部感染的因素较多，主要与免疫抑制剂使用剂量与用药方案有关。     

False positive stress tests due to undetected left ventricular hypertrophy

Without large vessel coronary artery disease, clinically evident left ventricular hypertrophy (LVH) is an identified cause of ischemic ST segment changes during exercise. The contribution of subclinical LVH to false positive exercise stress test was evaluated from data of 31 patients without electrocardiographic evidence of LVH who underwent concurrent exercise stress testing, M-mode echocardiography and coronary arteriography at Temple University Hospital, Philadelphia, PA, between January, 1976, and December, 1979, and who met echocardiographic criteria for LVH. Using Bayes theorem, the authors found the probability was 0.59 that a patient with electrocardiogram-undetected LVH does not have significant coronary disease with a positive stress test. The probability of normal coronary arteries with a positive stress test in patients without LVH on echocardiogram was 0.24. Inapparent LVH detected by echocardiography increases the likelihood that a patient with a positive stress test does not have coronary disease. Thus, the positive exercise electrocardiogram should be cautiously interpreted in apparently normal patients who have LVH detectable only by echocardiography.     

Prophylactic perioperative beta-blockade reduces cardiac morbidity and mortality following non-cardiac surgery in patients at risk

Approximately 5% of all patients undergoing non-cardiac surgery suffer some form of perioperative cardiac morbidity, usually preceded by myocardial ischaemia. In the Netherlands, the cardiac mortality following non-cardiac surgery is 0.68%. The patient groups at risk for cardiac complications are: age 65 years and older, patients with coronary artery disease or risk factors for coronary artery disease, and those undergoing major surgery. The period of greatest risk is the early postoperative phase. Prophylactic beta-blockade significantly reduces perioperative cardiac morbidity and mortality: the odds ratio for myocardial ischaemia is 0.34 (95% CI: 0.23-0.52), for non-fatal myocardial infarction 0.15 (95% CI: 0.06-0.40) and for cardiac mortality 0.25 (95% CI: 0.09-0.73). Long-term continuation of the beta-blockade also reduces cardiac morbidity and mortality in the first two years following the operation.     

Morbus Diureticus in the Elderly: Epidemic Overuse of a Widely Applied Group of Drugs

Diuretics (thiazides, loop diuretics) are established as treatments of common diseases: arterial hypertension, heart failure, and renal disease. In aging societies, their prevalence sharply rises with age. Thus, diuretic efficacy and safety need to be considered in the elderly as main consumers. Diuretics expose several disadvantages with particular relevance for the elderly. The most acknowledged side effects concern electrolyte disturbances. Hypokalemia (up to 8%) may not only precipitate cardiac arrhythmias and related sudden death but also adynamia by muscular weakness. Hyponatremia (up to 17%) may contribute to confusion, delirium, and irreversible brain damage adding to age-related dementia. Thiazides are the antihypertensive drugs with the strongest diabetogenic activity. In heart failure treatment, overdosing of diuretics is common, as doses often reflect requirements for acute recompensation, which is two- to threefold the requirement of that in maintenance therapy. Trial data demonstrate a positive correlation between mortality and diuretic use/dose, which may also be related to volume contraction, related ACE-inhibitor intolerance, renal impairment, and venous thromboembolism. Combining loop and thiazide diuretics may be indicated for severe cardiac or renal failure, but it is also excessively used in less severe stages, causing an even more severe threat to patients; thiazides are often added unintentionally if overlooked in combination pills. Diuretics may be used to treat peripheral “edema” in obese patients, patients on calcium antagonists, or those with venous thrombotic disease. Here they are not indicated and may even induce edema. In statistics on adverse drug reactions leading to hospitalization, diuretics are among the 5 leading drug classes. Misleading interpretations of clinical trials and their low cost have pushed them into the front position of hypertension treatment. Here, side effects, including the urge of voiding, lead to the lowest adherence rate among first-line antihypertensives.It is proposed to term the syndrome of inappropriate diuretic application “morbus diureticus.” It should be diagnosed by history taking, force assessment (timed-up-and-go, chair-rise tests), clinical hydration assessment, and laboratory tests (electrolytes, creatinine). In heart failure, dose reductions/step-down from loop to thiazide diuretics should be tested routinely at 3- to 6-month intervals. In hypertension treatment, diuretics should be third in line if control by RAS inhibitors and long-acting dihydropyridine calcium antagonists is insufficient. If symptoms improve after diuretic step-down (including improved tolerance to RAS inhibitors or renal function), this diagnosis may also be made “ex juvantibus.”