Echocardiographic predictors of exercise capacity in patients with heart failure and systolic dysfunction: role of mitral regurgitation

Introduction and objectives

Patients with heart failure and similar left ventricular systolic dysfunction have differing exercise capacity. The aim of this study was to identify echocardiographic predictors of exercise capacity in patients with heart failure and systolic dysfunction.

Methods

We included 150 patients with class II (70%) or III (30%) heart failure with left ventricular ejection fraction below 40%. Six-minute walking test and cardiac color Doppler-echo, including tissue Doppler of mitral and tricuspid rings, were performed. Moderate and severe mitral regurgitation were considered as significant. Two groups were divided according to the median walking distance (290 m): Group 1, <290 m and Group 2, ≥290 m.

Results

Mitral regurgitation was detected in 112 patients (75%), which was significant in 40 (27%). Group 1 showed more significant mitral regurgitation (35 vs 18%), increased left atrium area (27±1 vs 24±1 cm²), mitral E amplitude (88±5 vs 72±3 cm/s) and systolic pulmonary pressure (37±1 vs 32±1 mmHg, all P<.05). By logistic regression analysis, only the presence of significant mitral regurgitation was independently associated with less walked distance (odds ratio: 3.44 95% confidence interval 1.02-11.66, P<.05). By multiple linear regression, the only independent predictor of walked distance was left atrium area (r=0.25, beta coefficient: −6.52 ± 2, P<.01).

Conclusions

In patients with class II-III heart failure and left ventricular systolic dysfunction, the main echocardiographic predictors of exercise capacity are related to the presence of significant mitral regurgitation.Full English text available from:www.revespcardiol.org     

Pulmonary hypertension and long-term mortality in aortic and mitral regurgitation

Background

Outcomes data in patients with aortic regurgitation or mitral regurgitation have been limited to small series with generally <10 years of follow-up. The quantitative impact of pulmonary artery hypertension has not been well described. The purpose of this study was to describe the 15-year mortality of aortic regurgitation and mitral regurgitation.

Methods

Our institution's electronic echocardiography database was queried to identify those patients examined in 1992 and reported to have at least mild aortic regurgitation or mitral regurgitation. Patients were classified by semi-quantitative degree of regurgitation. Pulmonary artery systolic pressure was categorized as normal, borderline, mild, or moderate or greater hypertension (pulmonary artery systolic pressure >40 mm Hg). Age-stratified Cox proportional hazards models compared survival among groups and adjusted for sex, depressed left ventricular ejection fraction, and pulmonary artery systolic pressure. Mortality data were obtained from the 2008 Social Security Death Index.

Results

Of 4984 echocardiograms performed in 4050 patients, 1156 patients (28%; aged 72 ± 14 years) had at least mild aortic regurgitation and 1971 patients (49%; aged 69 ± 16 years) had at least mild mitral regurgitation. Overall 15-year mortality in patients with aortic regurgitation was 74% and similar for all grades of aortic regurgitation. Overall 15-year mortality in patients with mitral regurgitation was 71% and got progressively worse with increasing severity grade of mitral regurgitation (63% for mild to 81% for at least moderate-to-severe). For both aortic and mitral regurgitation, moderate or greater pulmonary artery systolic hypertension was associated with increased mortality (in patients with aortic regurgitation, hazard ratio [HR], 1.94; 95% confidence interval [CI], 1.58-2.41, and in mitral regurgitation patients, HR, 1.48; 95% CI, 1.26-1.75).

Conclusion

Long-term (15-year) survival of patients with aortic regurgitation is poor and is independent of regurgitation severity. In contrast, long-term survival of patients with mitral regurgitation correlates with regurgitation severity. For both groups, moderate or greater pulmonary artery systolic hypertension identified those at highest risk.     

Exploration ultrasonographique des pontages mammaires internes gauches : intérêt et limites en réadaptation cardiaque

Objective

The aim of the study is to demonstrate the feasibility, interest and limits of ultrasound exploration of left internal mammary artery grafts in cardiac rehabilitation.

Methods

From January 2000 to December 2008, 1434 patients entered in cardiac rehabilitation underlying coronary artery bypass graft, were studied by transthoracic doppler echocardiography in left internal mammary artery graft, from supraclavicular fossa.

Results

One thousand two hundred and fifty-nine grafts were recorded (87.8 %); the diameter was 2.6 ± 0.3 mm, the peak systolic velocity 46.3 ± 17.7 cm/s, the peak diastolic velocity 34.0 ± 13.4 cm/s, the diastolic/systolic (D/S) peak velocity ratio 0.77 ± 0.26 and the mean blood flow 64.3 ± 34.5 ml/min. The D/S peak ratio is lower in the presence of high blood pressure or diabetes, is higher in men, with sequential graft or when left ventricle ejection fraction is low. It tends to increase by sportsmen.

Conclusion

Transthoracic echo-doppler assessment of internal mammary artery grafts is easily useful and allows to establish a “functional identity card” of the graft in postoperative period, which will be used like a reference for the follow-up.     

Pathophysiology of coronary blood flow in congenital heart disease

Objectives

The aim was to investigate the effects of volume and pressure overload and increased coronary perfusion pressure on coronary flow (CF) in congenital heart disease (CHD) patients.

Background

The effects of CHD on CF are poorly mapped.

Methods

A total of 65 patients with acyanotic CHD and 49 age-matched healthy controls were examined by transthoracic Doppler echocardiography. Posterior descending artery flow was measured in patients with pulmonary valve stenosis (PS) and atrial septal defects (ASDs) i.e. in lesions with right ventricular pressure or volume overload, and left anterior descending artery flow in patients with coarctation of the aorta (CoA) and ventricular septal defect (VSD), in lesions with left ventricular pressure or volume overload. The CF data in each patient group were expressed as the percent of the median for healthy controls from the same age group.

Results

The CF values were in VSD 172%, ASD 185%, PS 233%, and CoA 773% patients. In CoA patients body surface area (r = 0.90, p < 0.0001), systolic blood pressure (r = 0.72, p < 0.0001), diastolic blood pressure (r = 0.77, p < 0.0001), systolic wall tension (r = −0.77, p = 0.004), and signs of inflammation (log CRP, r = −0.75, p = 0.007) correlated with CF.

Conclusions

The increase in CF and velocity was most significant in patients with CoA. In newborns, increased coronary perfusion pressure seems to be the most important factor for increased CF, even if the pressure is not assumed to cause a significant increase in flow over the auto-regulatory range of 70-130 mm Hg. We also showed that inflammation decreases CF.     

Melatonin reduces night blood pressure in patients with nocturnal hypertension

Purpose

Nocturnal hypertension is associated with a high risk of morbidity and mortality. A blunted nocturnal surge in melatonin excretion has been described in nondipping hypertensive patients. We therefore studied the potency of melatonin to reduce nighttime blood pressure (BP) in treated hypertensive patients with nocturnal hypertension.

Patients and Methods

Thirty-eight treated hypertensive patients (22 males, mean age 64 ± 11 years) with confirmed nocturnal hypertension (mean nighttime systolic BP >125 mm Hg), according to repeated 24-hour ambulatory blood pressure monitoring (ABPM), were randomized in a double-blind fashion to receive either controlled release (CR)-melatonin 2 mg or placebo 2 hours before bedtime for 4 weeks. A 24-hour ABPM was then performed.

Results

Melatonin treatment reduced nocturnal systolic BP significantly from 136 ± 9 to 130 ± 10 mm Hg (P = .011), and diastolic BP from 72 ± 11 to 69 ± 9 mm Hg (P = .002), whereas placebo had no effect on nocturnal BP. The reduction in nocturnal systolic BP was significantly greater with melatonin than with placebo (P = .01), and was most prominent between 2:00 am and 5:00 am (P = .002).

Conclusions

Evening CR-melatonin 2 mg treatment for 4 weeks significantly reduced nocturnal systolic BP in patients with nocturnal hypertension. Thus, an addition of melatonin 2 mg at night to stable antihypertensive treatment may improve nocturnal BP control in treated patients with nocturnal hypertension.     

Oestradiol supplement minimises coronary occlusion-induced myocardial infarction and ventricular dysfunction in oophorectomised female rats

Background

Endogenous oestrogen deficiency after menopause is associated with high risk of acute cardiac events and the protection of exogenous oestrogen supplements remains uncertain. This study investigates whether oestrogen therapy protects the heart from ischemic injury in oophorectomised rats.

Methods

Sexually mature female Sprague-Dawley rats (6 for each group) with bilateral oophorectomy underwent selective ligation (occlusion) of left coronary artery for 4 weeks. 17β-oestradiol (E2) supplements (10 μg, i.m., every other day) were started before (preventive-therapeutic supplement) or after coronary occlusion (therapeutic supplement).

Results

In oophorectomised rats plasma levels of E2 declined from 1301 ± 80 to 196 ± 48 pmol/L (p < 0.01) and cardiac expression of oestrogen receptors (ER) decreased by ∼ 60%. E2 supplements recovered the ER expression. Selective ligation of left coronary led myocardial infarction in the left ventricle, with an increase in plasma cardiac troponin I (cTn-I), decrease in systolic blood pressure (SBP), and reduction of left ventricular pressures. Preventive-therapeutic but not therapeutic E2 supplement reduced cTn-I levels (from 21.9 ± 2.0 to 6.0 ± 0.3 ng/mL, p < 0.01), minimised infarction (from 37.0 ± 1.2% to 18.1 ± 2.3%, p < 0.05), increased SBP (from 82 ± 4.2 to 97 ± 4.4 mm Hg, p < 0.05), and improved left ventricular end pressures in the oophorectomised rats following coronary occlusion.

Conclusion

Postmenopausal (ooporectomised) oestrogen supplement commenced before establishment of myocardial ischemia minimises myocardial infarction and ventricular dysfunction following the coronary artery occlusion. Cellular and molecular mechanisms underlying the cardiac protection of oestrogen therapy remain unclear, in which activation of cardiac ER expression and increasing in circulating CD90⁺ stem cells may be involved.     

An observational non-interventional study of people with diabetes beginning or changed to insulin analogue therapy in non-Western countries: the A1chieve study

Aim

The aim of A₁chieve was to remedy the deficit of data on the efficacy and safety of insulin analogues in routine clinical care in less well-resourced/newly developed countries.

Methods

A non-interventional, 6-month, observational study of 66,726 people with type 2 diabetes, both insulin users and non-insulin users, started on insulin detemir, insulin aspart or biphasic insulin aspart in 28 countries across four continents.

Results

Baseline HbA_1c (±SD) was poor: 9.5 ± 1.8%. At 6 months, improvement was −2.1 ± 1.7% in the entire cohort, and −2.2 ± 1.7% and −1.8 ± 1.7% for prior non-insulin users and insulin users. All three analogue therapies gave similar results, again independently of prior insulin use, but also from seven pre-specified country groupings. Overall, hypoglycaemia did not increase in those new to insulin, and fell in those switching insulins. There was no change in body weight (−0.1 ± 3.7 kg), while lipid profile and systolic blood pressure (−6.3 ± 17.1 mmHg) were improved.

Conclusions

Beginning insulin analogue therapy in people with type 2 diabetes and poor blood glucose control is associated with marked improvements in diverse aspects of vascular risk factor profile without evidence of clinically significant safety or tolerability problems.     

B-type natriuretic peptide levels are not a surrogate marker for invasive hemodynamics during management of patients with severe heart failure

Background

We sought to assess the utility of serial BNP measurements in patients with severe heart failure and attempted to correlate values with invasively derived data.

Methods

In a retrospective study, we analyzed serial BNP levels in patients receiving hemodynamically guided therapy for severe heart failure and sought correlation with invasively derived data.

Results

Thirty-nine patients with New York Heart Association Class III-IV, with an ejection fraction of 35% or less, who had a pulmonary artery catheter inserted for hemodynamically tailored heart failure therapy, were identified and serial BNP measurements reviewed. BNP was estimated on admission, at 12 and 36 hours. Normally distributed variables are expressed as mean ± SD and otherwise as median ± interquartile range. Mean ejection fraction was 16% ± 6%. Mean pulmonary artery occlusion pressures (PAOP) fell with therapy and were 25 ± 7 mmHg, 18 ± 7 mmHg and 19 ± 7 mmHg at admission, 12 hours and 36 hours respectively (P < 0.05). Median BNP levels fell from 1200 ± 641 to 771 ± 803 at 12 hours and to 805 ± 771 at 36 hours (P < .001). There was no correlation between BNP and any hemodynamically derived variable. A change in BNP was not associated with a change in PAOP in any individual patient. Only 42% remained alive on medical therapy at 30 days.

Conclusions

In patients with severe heart failure, BNP levels do not accurately predict serial hemodynamic changes and do not obviate the need for pulmonary artery catheterization.     

Effets de la réduction de la précharge sur les paramètres échographiques de la fonction systolique et diastolique du ventricule gauche de l’enfant en insuffisance rénale terminale : étude comparative avant et après hémodialyse

Purpose

Contrasting data exist about the hemodialysis induced changes of ventricular diastolic and systolic functions in adults. Few data in children with end-stage renal disease (ESRD) are reported. The aim of the present study was to evaluate the effect of a single hemodialysis (HD) session on left ventricular (LV) systolic and diastolic function using conventional pulsed-Doppler echocardiography and pulsed tissue Doppler imaging (TDI) in hemodialysis children.

Methods

Thirty-five children with chronic renal failure (15 males, aged 12.8 ± 3.8 years) on maintenance hemodialysis underwent conventional 2D and Doppler Echo together with measurement of longitudinal mitral annular motion velocities. Echocardiographic parameters were obtained 30 minutes before and 30 minutes after HD. Paired data were compared.

Results

Hemodialysis led to reduction in LV end-diastolic volume (p = 0.001), end-systolic volume (p = 0.05), left atrium area (p < 0.0001), peak early (E wave) transmitral flow velocity (p = 0.005), peak S velocity of pulmonary vein flow (p = 0.002), aortic time velocity integral (p < 0.0001) and aortic ejection time (p < 0.0001). No significant change in Tei Index was observed after HD. Regarding TDI measures, velocities were not affected by preload reduction. Only the early diastolic velocities on the septal side of the mitral annulus decreased significantly (p = 0.001) and the systolic velocities on the lateral side of the mitral annulus increased significantly (p = 0.042) after hemodialysis.

Conclusions

Most of Doppler-derived indices of diastolic function are preload-dependant. TDI velocities and Tei Index were not or minimally affected by preload reduction in hemodialysis children.     

Replacement therapy for iron deficiency improves exercise capacity and quality of life in patients with cyanotic congenital heart disease and/or the Eisenmenger syndrome

Introduction

Iron deficiency is common in cyanotic congenital heart disease (CHD) and results in reduced exercise tolerance. Currently, iron replacement is advocated with limited evidence in cyanotic CHD. We investigated the safety and efficacy of iron replacement therapy in this population.

Methods

Twenty-five iron-deficient cyanotic CHD patients were prospectively studied between August 2008 and January 2009. Oral ferrous fumarate was titrated to a maximum dose of 200 mg thrice-daily. The CAMPHOR QoL questionnaire, 6 minute walk test (6MWT) and cardiopulmonary exercise testing were conducted at baseline and after 3 months of treatment.

Results

Mean age was 39.9 ± 10.9 years, 80% females. Fourteen had Eisenmenger syndrome, 6 complex cyanotic disease and 5 Fontan circulation. There were no adverse effects necessitating termination of treatment. After 3 months of treatment, hemoglobin (19.0 ± 2.9 g/dL to 20.4 ± 2.7 g/dL, p < 0.001), ferritin (13.3 ± 4.7 μg/L to 54.1 ± 24.2 μg/L, p < 0.001) and transferrin saturation (17.8 ± 9.6% to 34.8 ± 23.4%, p < 0.001) significantly increased. Significant improvements were also detected in the total CAMPHOR score (20.7 ± 10.9 to 16.2 ± 10.4, p = 0.001) and 6MWT distance (371.7 ± 84.7 m to 402.8.0 ± 74.9 m, p = 0.001). Peak VO₂ remained unchanged (40.7 ± 9.2% to 43.8 ± 12.4% of predicted, p = 0.15).

Conclusion

Three months of iron replacement therapy in iron-deficient cyanotic CHD patients was safe and resulted in significant improvement in exercise tolerance and quality of life. Identification of iron deficiency and appropriate replacement should be advocated in these patients.     

The association between the triglyceride to high-density lipoprotein cholesterol ratio with insulin resistance (HOMA-IR) in the general Korean population: based on the National Health and Nutrition Examination Survey in 2007-2009

Aim

To investigate circulating visfatin and vaspin levels in first-degree relatives of subjects with type 2 diabetes mellitus (FDRs) who frequently have higher value of HOMA-IR and beta cell dysfunction.

Methods

Serum visfatin and vaspin concentrations were measured in 179 Iranian subjects (90 normoglycemic FDRs and 89 age- and sex-matched healthy controls) using enzyme-linked immunosorbent assay (ELISA) methods.

Result

Serum visfatin levels were significantly lower in the FDRs when compared to the controls (1.71 ± 0.93 ng/ml versus 2.69 ± 2.02 ng/ml, p = 0.0001). However, no significant difference was found in serum vaspin concentrations between the FDRs and the controls (0.452 ± 0.254 ng/ml versus 0.409 ± 0.275 ng/ml, p > 0.05). In multiple logistic regression analysis, the FDRs showed a significant association with lower visfatin levels after adjustments for age, sex, Body Mass Index, systolic and diastolic blood pressures, lipid profile, blood glucose levels and HOMA-IR [odds ratios (OR) = 1.71, 95% confidence interval (1.30-2.25); p < 0.0001].

Conclusion

The FDRs showed a significant association with lower visfatin levels. The observed lower circulating visfatin levels in FDRs may suggest a pathophysiological role for visfatin in beta cell dysfunction in this group.     

Association between aortic calcification and stable obstructive coronary artery disease

Aims

Atrial fibrillation and flutter remain an important cause of morbidity in adults with atrial septal defect (ASD). This study aimed at investigating predictors for late (≥ 1 month after repair) atrial arrhythmia.

Methods

Patients who underwent ASD closure after the age of 18 years, were selected through the databases of three medical centres in Belgium. Preprocedural, periprocedural and follow-up data were extracted. Univariate and multivariate Cox-regression analysis was performed. Kaplan-Meier analysis was performed for any independent predictor of late atrial arrhythmia.

Results

A total of 155 patients (38 men and 117 women) was included. Twenty-four patients (median age 48.3 years, range 19.9-79.8) underwent surgical and 131 (median age 57.6 years, range 18.2-86.9) underwent transcatheter closure. Thirty-nine patients (25.2%) presented with late atrial arrhythmia. Male gender (P = 0.008), creatinine (P = 0.002), atrial arrhythmia before (P < 0.0001) and within 1 month after repair (P = 0.001) and a mean pulmonary artery pressure (mPAP) ≥ 25 mm Hg (P < 0.0001) correlated with late atrial arrhythmia in univariate Cox-regression analysis. Multivariate analysis showed that mPAP ≥ 25 mm Hg (HR 3.72; 95%CI 1.82-7.59; P < 0.0001) and the presence of atrial arrhythmia before (HR 3.22; 95%CI 1.56-6.66; P = 0.002) and within 1 month after repair (HR 2.08; 95%CI 2.08-15.92; P = 0.001) were predictive of late atrial arrhythmia. Kaplan-Meier analysis showed that patients with a mPAP ≥ 25 mm Hg had a higher risk at developing late atrial arrhythmia (P < 0.0001).

Conclusion

In patients with ASD type secundum, a mPAP ≥ 25 mm Hg is an independent predictor of late atrial arrhythmia. The presence of pulmonary hypertension before repair should raise awareness for atrial arrhythmias and may be used to guide therapy.     

Effect of iodixanol and ioxilan on QT interval and renal function in patients with systolic heart failure

Background

Contrast media (CM) exposure is associated with a substantial risk of arrhythmias and nephrotoxicity. These adverse effects may be exacerbated in high-risk conditions such as heart failure, although no studies have evaluated newer CM agents in this population. This study evaluated the electrophysiologic and renal effects of two newer CM agents, iodixanol and ioxilan, in heart failure patients undergoing angiography.

Methods

Eighty-seven consecutive systolic heart failure patients who received either iso-osmolar iodixanol (n = 44) or low-osmolar ioxilan (n = 43), stratified for concomitant amiodarone, were evaluated for QT interval and serum creatinine changes in comparison to baseline. QT values were corrected according to three formulae: Bazett's correction, Fridericia formula, and Framingham equation.

Results

Baseline patient characteristics were not significantly different in the iodixanol versus ioxilan groups, except for myocardial infarction and renal disease. No significant change in mean QTc was observed after exposure to either CM agent compared to baseline. These results were unaffected by amiodarone. A significant improvement in serum creatinine from baseline was observed in the iodixanol group compared to the ioxilan group (−0.121 ± 0.35 mg/dL vs. 0.033 ± 0.23 mg/dL, respectively; p = 0.045).

Conclusions

No significant change in QTc interval was observed in patients receiving either iodixanol or ioxilan during angiography. Iodixanol appeared to improve short-term renal function in patients with heart failure and should be further investigated.     

Axillary approach for transcatheter aortic valve implantation: optimization of the endovascular treatment for the aortic valve stenosis

Introduction and objectives

To validate the axillary approach as a safe and efficient option for the transcatheter aortic valve implantation in patients who have contraindication for femoral approach at three Spanish hospitals.

Methods

We included patients with severe symptomatic aortic stenosis at very high or prohibitive surgical risk, selected by a multidisciplinary team, for transcatheter aortic valve implantation, and had contraindication to the femoral approach.

Results

We included 19 of 186 (10.5%) patients, who were implanted a percutaneous aortic valve, between November 2008 and March 2010. The mean age was 78.3 (standard deviation [SD] ± 8.65) years and 73.7% were males. The mean logistic EuroSCORE was 28.7% (SD ± 16.3%). The procedural success rate was 100%. After the procedure the maximum transvalve gradient decreased from 81.7 mmHg (SD ± 21.5) to 15.8 mmHg (SD ± 5.5), and no patient presented residual aortic regurgitation >2. The all-cause mortality, with a mean follow-up time of 9.2 (SD ± 3.2) months was 10.5%, and the in-hospital and 30-day mortality rates were 0%. The global incidence of major complications due to the procedure was 15.7%. Definitive pacemaker implantation was carried out for atrioventricular block in 8 patients (44.4%).

Conclusions

The axillary approach for transcatheter aortic valve implantation using the CoreValve^® and contraindication to the femoral approach is safe and efficient for selected patients, with excellent results in terms of success implantation and in hospital and 30-day mortality.Full English text available from: www.revespcardiol.org     

Exercise blood pressure response, albuminuria, and arterial stiffness in hypertension

Background

A hypertensive response to exercise is associated with high cardiovascular risk, whereas the data about its relation to surrogates of subclinical atherosclerosis are scarce. We investigated the relationships of a hypertensive response to exercise with urinary albumin excretion and arterial stiffness in hypertensives.

Methods

There were 171 untreated males (mean age 52 years, all Caucasian) with stage I-II essential hypertension and a negative treadmill exercise test divided into those with a hypertensive response to exercise (n = 48) (peak exercise systolic blood pressure ≥210 mm Hg) and to those with normal blood pressure response (n = 123). Albumin-to-creatinine ratio values were determined as the mean of 3 nonconsecutive morning spot urine samples, and arterial stiffness was evaluated on the basis of carotid-to-femoral pulse wave velocity.

Results

Patients with a hypertensive response to exercise compared with those with normal blood pressure response exhibited greater log albumin-to-creatinine ratio (1.52 ± 0.59 vs 0.97 ± 0.33 mg/g) and higher pulse wave velocity (8.7 ± 1.6 vs 7.7 ± 1.2 m/s), independent of potentially confounding demographic and clinical factors. Resting systolic blood pressure (odds ratio [OR] 1.11, 95% confidence interval [CI], 1.06-1.16), body mass index (OR 1.12, 95% CI, 1.02-1.23), resting heart rate (OR 0.96, 95% CI, 0.93-0.99), and albumin-to-creatinine ratio (OR 7.45, 95% CI, 2.54-21.83) were independently associated with a hypertensive response to exercise.

Conclusion

A hypertensive response to exercise is related to augmented albumin-to-creatinine ratio and arterial stiffness, reflecting accelerated subclinical atherosclerosis. The association of albumin excretion with exercise blood pressure response suggests that albuminuria constitutes an important factor in the interpretation of the hypertensive response to exercise-associated risk.     

Human plasma complement C3 is independently associated with coronary heart disease, but only in heavy smokers (the CODAM study)

Background

Complement C3 is an emerging risk factor for coronary heart disease (CHD) and is particularly increased in the metabolic syndrome. A direct effect of smoking on structure and function of complement C3 has been suggested.

Hypothesis

Smoking behavior may affect the cardiovascular risk that is associated with plasma complement C3.

Methods

The association between plasma C3 and CHD was studied in the CODAM (Cohort on Diabetes and Atherosclerosis Maastricht) study population (n = 562, 61% male) with examination of effect modification by smoking.

Results

The overall prevalence of CHD was 23.3%. Higher plasma C3 levels were associated with a higher CHD prevalence, and there was a significant interaction with heavy smoking (p = 0.01). In never & light smokers, the univariate OR for CHD per 1 s.d. (0.33 g/L) increase in C3 was 1.09 [95% confidence interval (CI) 0.85-1.41] (p = 0.505) whereas in heavy smokers it was 2.05 [1.43-2.93] (p < 0.001). The association in the group of heavy smokers remained significant (OR 2.38 [1.54-3.68], p < 0.001) after adjustment for traditional risk factors for cardiovascular disease and also after further adjustment for other cardiometabolic risk factors, i.e. the metabolic syndrome, CRP and insulin resistance (HOMA2IR) (OR C3 between 2.16 and 2.29, all p ≤ 0.001).

Conclusion

Human plasma complement C3 is associated with prevalent CHD, but only in heavy smokers, and this association is independent of important metabolic cardiovascular risk factors.     

Low Blood Pressure and Depressive Symptoms among Chinese Older Subjects: A Population-based Study

Background

The relationships between blood pressure and depression are unclear. There are inconsistent reports of an association between low blood pressure and depressive symptoms.

Methods

In a population-based sample of 2611 Chinese older adults aged 55 years and above, including participants with treated (n = 1088), untreated (n = 545), or no hypertension (n = 978), depressive symptoms were determined by the 15-item Geriatric Depression Scale (≥5), and current systolic blood pressure and diastolic blood pressure measurements were used to classify participants into high, normal, and low blood pressure groups. Estimates of association were adjusted for confounding by use of antihypertensive and depressogenic drugs and other covariables in hierarchical regression analyses.

Results

Systolic blood pressure and diastolic blood pressure were negatively associated with Geriatric Depression Scale scores, independent of other variables. Low systolic blood pressure (odds ratio [OR] 1.54; 95% confidence interval [CI], 1.07-2.22), low diastolic blood pressure (OR 1.67; 95% CI, 0.98-2.85), and low systolic blood pressure or diastolic blood pressure (or both) (OR 1.55; 95% CI, 1.10-2.19) were independently associated with depressive symptoms. The associations with depressive symptoms were particularly observed for low systolic blood pressure (OR 2.13; 95% CI, 1.13-4.03) among treated hypertensive participants, and low diastolic blood pressure (OR 2.42; 95% CI, 1.26-4.68) among untreated or nonhypertensive participants.

Conclusion

Low blood pressure was independently associated with depressive symptoms in both older subjects who were treated for hypertension and those who were not.     

Serial monitoring of reverse left-atrial remodeling after pulmonary vein isolation in patients with atrial fibrillation: A magnetic resonance imaging study

Purpose

To prospectively determine the impact of sinus rhythm restoration on left-atrial (LA) volumes and function assessed by cardiac magnetic resonance (CMR) imaging within the first year after pulmonary vein isolation (PVI).

Methods

Forty-one patients (28 men; age: 57 ± 10 years) with paroxysmal or non-paroxysmal atrial fibrillation were studied serially using CMR at baseline and at 1-, 3-, 6- and 12-month intervals following PVI. LA diastolic and systolic volumes were determined by cine imaging with full gapless LA coverage applying Simpson's rule. Successful PVI was defined by a persisting sinus rhythm during the 12-month follow-up after a 3-month blanking period; patients with a relapse of atrial fibrillation after the blanking period were censored (4 patients at 6-month follow-up and additional 6 patients at 12-month follow-up).

Results

In all patients, LA diastolic and systolic volumes decreased significantly and progressively during the 12-month follow-up (p < 0.001 and p = 0.001, respectively). At baseline patients with successful PVI demonstrated a significantly smaller LA diastolic volume compared to patients with relapsed atrial fibrillation (p = 0.009). During the 3-month blanking period, patients with successful PVI showed a significant decrease of LA diastolic and systolic volumes (p = 0.026 and p = 0.006, respectively) and a significant increase of LA ejection fraction (p = 0.028); patients with subsequent relapse of atrial fibrillation, however, exhibited no significant change of LA diastolic and systolic volumes or LA ejection fraction.

Conclusion

Restoration of sinus rhythm led to a significant and progressive decrease of left-atrial diastolic and systolic volumes during one year following pulmonary vein isolation.     

The prevalence and risk factors for cholelithiasis and asymptomatic gallstones in adults with congenital heart disease

Purpose

Cyanosis is considered to be a risk factor for cholelithiasis which is an important complication of cyanotic congenital heart disease (CCHD) in adults. In this study, the prevalence of cholelithiasis and asymptomatic calcium bilirubinate gallstones was evaluated in adults with congenital heart disease (CHD). Furthermore, risk factors for this potentially high risk complication were assessed.

Materials and methods

Subjects were derived from 114 consecutive congenital patients who visited our center from May 2008 to January 2009. For analyses of risk factors, we divided them into 4 groups: group A, 15 CCHD patients without reparative surgery (7 men, 31.8 ± 7.0 years old); group B, 41 CCHD patients rendered acyanotic by reparative surgery (21 men, 32.5 ± 11.8 years old); group C, 23 unoperated acyanotic CHD patients (11 men, 42.4 ± 16.4 years old); and group D, 35 patients who were acyanotic before and after operation (18 men, 36.3 ± 14.8 years old). Gallstones were identified by abdominal ultrasound and risk factors were analyzed by a multivariate logistic regression model.

Results

Cholecystectomy was performed in 5/114 (4.3%), asymptomatic gallstones were seen in 16/114 (14%), and symptomatic gallstones except for patients after cholecystectomy were seen in 7/114 (6.1%). In group A, 4 (27%) with gallstones underwent cholecystectomy (p < 0.01). Non-cholesterol gallstones were observed in 5 patients (33%) in group A, 12 patients (29%) in group B, nobody in group C, and 3 patients (8.6%) in group D. By a multivariate logistic regression model, CCHD by nature regardless of repair, prolonged cyanosis periods, higher frequency of cardiopulmonary bypass (CPB), and lower platelet counts were significant factors predicting gallstones (odds ratio 4.48, 1.08, 3.96, and 0.87, 95% CI, 1.14-17.5, 1.00-1.18, 1.65-9.54, and 0.75-0.99, respectively).

Conclusions

The prevalence of cholelithiasis and asymptomatic gallstones is significantly high in CCHD patients regardless of cardiac repairs. CCHD by nature, prolonged cyanosis durations, high frequency of CPB and low platelet counts have influences on gallstone formation in adults with CHD.     

Sex differences in ambulatory blood pressure monitoring

Purpose

Referral to ambulatory blood pressure monitoring may have bearing upon blood pressure control and prognosis. We describe sex-related differences in referral for ambulatory monitoring and their prognostic impact.

Methods

Between 1991 and 2005, 3957 patients were monitored in our ambulatory monitoring service, of whom 2114 (53%) were women. Demographic and clinical data were analyzed according to sex.

Results

Age (58 ± 15 vs 52 ± 17 years, respectively) and body mass index (27.5 ± 4.9 vs 26.9 ± 4.0 kg/m², respectively) were higher in women than men. Treatment for hypertension was more prevalent in women (62% vs 53%, respectively). Clinic systolic blood pressure (148 ± 24 vs 146 ± 20 mm Hg, respectively) and clinic pulse pressure (65 ± 22 vs 59 ± 18 mm Hg, respectively) were higher in women compared with men. In women, the white-coat effect was increased, compared with men; 5.2 ± 12.4% vs 1.5 ± 10.7% systolic, and 5.4 ± 11.2% vs 3.6 ± 10.3% diastolic. Consequently, women had lower ambulatory blood pressure than men. In women, 24-hour blood pressure was 136 ± 17/76 ± 10 vs 140 ± 15/81 ± 10 mm Hg in men, awake blood pressure 141 ± 17/80 ± 11 vs 144 ± 15/84 ± 10 mm Hg, and sleep blood pressure was 125 ± 19/67 ± 10 vs 127 ± 18/71 ± 11 mm Hg. Age-adjusted ambulatory blood pressure also was lower in women. Ambulatory heart rate was higher in women (P <.0001). Kaplan-Meier survival did not differ by sex (P = .66), despite older age and higher clinic blood pressure.

Conclusions

The results might imply that referral was driven by the physicians' overall patient risk perception. The greater magnitude of white-coat effect in women, and correspondingly lower ambulatory blood pressure, might in part account for similar mortality in the face of older age and higher clinic blood pressure.