Left atrial size may predict exercise capacity and cardiovascular events in patients with heart failure

Our aim was to investigate, in patients with heart failure, the relationship between left atrial size and exercise capacity and cardiovascular events. Seventy-five patients (67 men and 8 women; mean age, 53.4 +/- 8.8 yr) with left ventricular ejection fractions of < or =0.45 (New York Heart Association functional classes I-III) were matched by age and sex with 20 healthy control subjects. Echocardiographic examinations were performed, as was exercise testing by the modified Bruce protocol. Patients were monitored for a period of 330 to 480 days for cardiac death or for heart failure that required hospitalization. The indexed left atrial diastolic size (beta level = -0.534, P <0.001) and left ventricular late diastolic filling velocity (beta level = 0.247, P <0.017) were the most important values in predicting low exercise capacity. The only independent predictor of low exercise capacity (<5 METS) was the indexed left atrial diastolic size (odds ratio, 1.428; 95% confidence interval, 1.09-1.702; P <0.001). Every 1 mm/m2 increase in indexed left atrial diastolic dimension caused a 42.8% increase in the risk of severe heart failure (exercise capacity, <5 METS). Independent predictors for cardiovascular events were indexed as left atrial systolic size (odds ratio, 1.383; 95% confidence interval, 1.145-1.671; P <0.001) and left ventricular early diastolic/late diastolic filling velocity (odds ratio, 1.096; 95% confidence interval, 1.010-1.189; P <0.027). Indexed left atrial diastolic and left atrial systolic size predict exercise capacity and cardiovascular events, respectively, in New York Heart Association functional class I through III heart failure patients.     

Low Pulse Pressure as a Predictor of Death in Patients with Mild to Advanced Heart Failure

The prognostic value of pulse pressure has been investigated in heart-failure patients. Low pulse pressure in advanced heart failure and high pulse pressure in mild heart failure have been separately linked to increased mortality rates. We prospectively investigated an association between pulse pressure and 2-year cardiovascular death in an entire heart-failure population.We prospectively enrolled 225 heart-failure patients (New York Heart Association [NYHA] functional class, I–IV; mean age, 56.5 ± 12.3 yr; 188 men). The patients'' blood pressures were measured in accordance with recommended guidelines. Pulse pressures were calculated as the difference between systolic and diastolic blood pressure values. The patients were monitored for a mean period of 670 ± 42 days for the occurrence of cardiovascular death.All patients were divided into quartiles according to their pulse pressures (<35, 35–45, 46–55, and >55 mmHg). Pulse pressure decreased as NYHA class worsened (P <0.001). Patients in the <35-mmHg quartile had the lowest plasma sodium concentrations, left ventricular ejection fractions, and systolic myocardial velocities upon echocardiography; and the highest left ventricular dimensions, early diastolic/late diastolic filling velocity ratios, and peak early/peak late diastolic myocardial velocity ratios. Pulse pressure independently predicted death in the patients with advanced heart failure and in the entire population. Upon receiver operating characteristic analysis, a 30-mmHg cutoff value for pulse pressure predicted death with 83.7% sensitivity and 79.7% specificity.Pulse pressure is easily calculated and enables the prediction of cardiovascular death in patients with mild to advanced heart failure. Pulse pressure can be used reliably as a prognostic marker in clinical practice.Key words: Blood pressure/physiology, cardiovascular diseases/mortality/physiopathology, epidemiologic methods, heart failure/epidemiology/etiology/physiopathology, multivariate analysis, predictive value of tests, prospective studies, pulse/physiology, reference values, risk factorsPulse pressure (PP) is the difference between systolic and diastolic blood pressure (BP) values. Pulse pressure markedly rises after the 5th decade of life, due to arterial stiffening with increasing age.^1,2 Several studies have shown a close relationship between high PP and the occurrence of cardiovascular (CV) death.^3-5 Furthermore, high PP is a risk factor for the development of coronary heart disease, myocardial infarction, and heart failure in normotensive and hypertensive persons.^6-10Data regarding the prognostic value of PP in patients with heart failure are limited and controversial. The importance of PP was investigated in 2 large studies. The SAVE¹¹ (Survival and Ventricular Enlargement) trial revealed a worse prognosis in patients with high PP and symptomatic or asymptomatic left ventricular (LV) systolic dysfunction. The SOLVD¹² (Studies of Left Ventricular Dysfunction) trial found that high PP independently predicted total and CV death in mild heart failure. However, in both studies, patients in New York Heart Association (NYHA) functional classes I and II constituted most of the population, and few patients had advanced heart failure (NYHA classes III and IV). In other studies involving patients with advanced heart failure, low PP was associated with high CV mortality rates.^13-16 We believed that further study was warranted in order to elucidate the prognostic value of PP in an entire heart-failure population. Accordingly, we investigated the association between PP and 2-year CV death in patients in whom the severity of heart failure ranged from mild to advanced.     

Right and left ventricular adaptation to training determined by conventional echocardiography and tissue Doppler imaging in young endurance athletes

OBJECTIVE: Some findings of left ventricular (LV) functions in athletes are controversial. On the other hand, studies concerning the right ventricle (RV) are limited. The aim of the study was to assess the effects of endurance training on LV and RV systolic and diastolic function. METHODS: A total of 60 (54 male, 6 female) athletes (mean age 20.7 +/- 2.5 years) and 60 (51 male, 9 female) healthy subjects (mean age 21.3 +/- 2.6 years) were included in the study. Standard echocardiographic examination and pulsed wave Doppler and tissue Doppler imaging (TDI) were performed. RESULTS: Except LV and RV ejection fraction, all M-mode echocardiographic parameters of the athletes were found to be significantly greater compared to untrained subjects. LV cavity dimension enlarged (> 55 mm) in 23 (38.4%) athletes but none of the controls. Of 54 male and 6 female athletes 33 (61.1%) and 5 (83.3%) had left vantricular hypertrophy. Athletes also had a greater RV free-wall thickness and mass index. None of the control subjects had either LV or RV hypertrophy. The mean LVMI/RVMI ratio was 3.77 +/- 1.59 and 3.40 +/- 1.32 in athletes and controls, respectively (p = 0.5). The mean E/A and Em/Am ratios and Sm velocities of both ventricles were significantly higher in athletes compared to untrained subjects (p < 0.001). CONCLUSION: Our study shows that despite an increase in left and right ventricular mass indexes, the LVMI/RVMI ratio stays stable. Training results in a better systolic and diastolic function.     

Frequency of Brugada-type ECG pattern (Brugada sign) in Southern Turkey

The frequency of Brugada sign was found to differ among ethnic groups. Yet, there is no data regarding the prevalence of Brugada syndrome and sign in our country. The aim of this study was to determine the frequency of a Brugada-type electrocardiogram (ECG) pattern in southern Turkey. A total of 1,238 subjects (males, 671, females, 567) were included in the study. The previously archived ECGs of 807 subjects without any evidence of structural heart disease were chosen randomly and evaluated. In addition, prospective analysis of the ECGs of 431 subjects (males, 293, females, 138) randomly chosen from healthy university students were also included. The mean age was 38.9 +/- 17.6 years. Six subjects (0.48%) had a Brugada-type ECG pattern. One (0.08%) of them had the coved-type and 5 (0.40%) had the saddleback-type. All subjects were asymptomatic. A Brugada-type ECG pattern was obtained in 1 (0.17%) female and in 5 (0.74%) males (OR: 4.2 CI: 0.5-36.4, P = 0.2). The Brugada-type ECG pattern frequency was 0.12% in subjects >or= 25 years old and 1.16% in subjects between 17-24 years old (OR: 9.4 CI: 1.1-81.2, P = 0.02). Young males between 17-24 years had the highest (1.70%) frequency. The results indicate that the frequency of the Brugada-type ECG pattern was 0.48% in the general population, being more prevalent in young males in our region. These results are similar to the findings of studies performed in other countries.     

Multimodal imaging of dendritic cells using a novel hybrid magneto-optical nanoprobe

A transfecting agent-coated hybrid imaging nanoprobe (HINP) composed of visible and near-infrared (NIR) light emitting quantum dots (QDs) tethered to superparamagnetic iron oxide (SPIO) nanoparticles was developed. The surface modification of QDs and SPIO particles and incorporation of dual QDs within the SPIO were characterized by dynamic light scattering (DLS), quartz crystal microbalance (QCM) analysis and atomic force microscopy (AFM). The optical contrasting properties of HINP were characterized by absorption and photoluminescence spectroscopy and fluorescence imaging. Multicolor HINP was used in imaging the migration of dendritic cells (DCs) by optical, two-photon and magnetic resonance imaging techniques. FROM THE CLINICAL EDITOR: The development of a transfecting agent-coated hybrid imaging nanoprobe (HINP) composed of visible and near-infrared light emitting quantum dots (QDs) tethered to superparamagnetic iron oxide nanoparticles is reported in this paper. Multicolor HINP was used in imaging the migration of dendritic cells by optical, two-photon and magnetic resonance imaging techniques.     

The relation between aortic atherosclerosis and risk factors.

OBJECTIVE: To evaluate the impact of risk factors on atherosclerotic changes of aortic wall and valve in patients with and without non-familial hypercholesterolemia by transthoracic echocardiography. METHODS: One hundred and eleven patients with non-familial hypercholesterolemia and 112 control subjects were included in the study. Aortic wall and valve were evaluated by visual assessment of wall hyperechogenicity and measuring the valve thickness. Aortic diameters were obtained at the levels of annulus, sinus of Valsalva and at the supravalvular level in the parasternal long-axis view by M-Mode echocardiographic examination. The relationship between parameters of aortic atherosclerosis and risk factors was studied by multivariate logistic regression analysis, Pearson and Spearman correlation analyses. RESULTS: The prevalence of aortic wall hyperechogenicity was found to be higher in patients with hypercholesterolemia (84.7% vs 70.5%, p=0.01). The mean aortic root diameters at all levels of patients with hypercholesterolemia were found to be significantly smaller than in patients of the control group (3.1+/-0.3 mm vs 3.2+/-0.5 mm, p=0.02 for annulus level, 3.4+/-0.4 mm vs 3.5+/-0.4, p=0.004 mm for the level of sinus of Valsalva and 3.2+/-0.3 mm vs 3.4+/-0.5 mm, p<0.001 - supravalvular level), but no difference was noted regarding the aortic velocity and pressure gradient across the aortic valve. Multivariate stepwise logistic regression analysis showed that age (OR=1.1, CI - 1.02-1.09, p=0.002) and smoking (OR=2.2, CI - 1.06-4.58, p=0.04) were independent predictors of aortic valve thickness. Hypercholesterolemia was an independent predictor for aortic wall hyperechogenicity (OR=2.5, CI - 1.3-4.9, p=0.009) but not for valve thickness. CONCLUSIONS: Age, smoking and hypercholesterolemia are related to atherosclerotic involvement of aortic wall and valve.     

Apical hypertrophic cardiomyopathy: diagnosis with contrast-enhanced echocardiography--a case report

Apical hypertrophic cardiomyopathy is a rare form of hypertrophic cardiomyopathy (HCM) recognized by a unique spadelike configuration on the left ventriculogram. Two-dimensional echocardiography is another useful tool in the diagnosis of this condition. The diagnosis may be difficult and may mimic akinesia or apical thrombus in some patients with poor acoustic windows. A 50-year-old woman with typical angina and left ventricular hypertrophy with T wave inversion in leads V3-V6, II, III and aVF is presented. Apical HCM was diagnosed with contrast-enhanced echocardiography and confirmed by finding a spadelike configuration on the left ventriculogram. Apical HCM should be considered in patients in whom symptoms and ECG findings mimic ischemic heart disease. Contrast-enhanced echocardiography is a reliable and simple method in the diagnosis of apical HCM.     

Daily blood pressure control is not sufficient to regress cardiac hypertrophy and dysfunction: a bi-ventricular tissue Doppler echocardiographic study

BACKGROUND: Hypertension is one of the main causes of cardiovascular complications leading to death and allograft dysfunction. The aim of this study was to determine the relationship between the levels of 24 h blood pressure and left ventricular mass index (LVMI) and bi-ventricular tissue Doppler echocardiographic measurements in renal transplant recipients (RTxr) and dialysis patients. METHODS: In this cross-sectional study, we evaluated 32 non-diabetic renal transplant recipients (GI) and 18 patients with end-stage renal insufficiency who underwent haemodialysis (GII). RESULTS: The mean follow-up periods were 49.16 +/- 38.02 and 56.83 +/- 34.14 months in GI and GII, respectively. There were no differences for age, gender, daytime systolic-diastolic blood pressures and loads among the groups. The mean night-time systolic-diastolic blood pressures in GI and GII were 119.77 +/- 17.41-77.34 +/- 14.46 and 120.23 +/- 25.53-76.17 +/- 18.77 mmHg, respectively (P I-II = 0.453-0.72). The mean night-time systolic blood pressure loads in GI and GII were 4.92 +/- 7.77 and 6.10 +/- 8.16%, respectively (P I-II = 0.68). The mean night-time diastolic blood pressure loads were 7.79 +/- 7.83 and 8.02 +/- 8.28% in GI and GII, respectively (P I-II = 0.55). The mean levels of LVMI in GI and GII were 115.81 +/- 28.07 and 128.06 +/- 65.72 g/m(2), respectively (P I-II = 0.85). The mean levels of left ventricular Em/Am by tissue Doppler echocardiography were 1.13 +/- 0.40 and 0.90 +/- 0.29, respectively (P I-II = 0.127), while the mean levels of right ventricular Em/Am were 0.89 +/- 0.37 and 0.88 +/- 0.26, respectively (P I-II = 0.50). CONCLUSION: After renal transplantation, LVMI and bi-ventricular diastolic dysfunction were not regressed. Daytime and night-time blood pressures and loads were similar in the two groups. We can say that well-controlled daytime blood pressure and load is not sufficient to decrease cardiovascular risk in RTxr. Also, it is important to control of night-time blood pressure and load to reduce cardiovascular risk in RTxr. RTxr should be monitored with ambulatory blood pressure monitoring and tissue Doppler echocardiography.