Diastolic function abnormalities in rheumatoid arthritis: relation with disease duration and severity

Cardiac involvement is common in patients with rheumatoid arthritis [RA] and cardiovascular disease represent the most common cause of death in those patients. Data about left ventricular diastolic function abnormalities in patients with RA are scarce. The aim of this study was to evaluate left ventricular filling abnormalities as early predictor of asymptomatic cardiac involvement in patients with RA and 10 to study the correlation between diastolic function abnormalities with disease duration and severity. This study enrolled 31 patients affected by RA according to ACRA criteria who had no evidence of cardiac disease, and compared with 10 age and gender matched control group. All patients were subjected to clinical evaluation and Iaboratory testing which included sedimentation rate [ESR], rheumatoid factor [RF] and blood picture. All patients and I'onirol group were subjected to echo-Doppler study for assessment of the mitral flow and measurements of maximal [early diastolic flow velocity [Peak E] [m/sec], maximal late diastolic flow velocity [Peak A] [m /sec], E/A ratio, the area under the the atria I filling velocity curve [Time velocity integral of the velocity waveform representing left atrial contraction, TVI of A [m/sec]. The total area under the mitral flow velocity curve [Time velocity integral of the velocity Wave form representig diastolic filling, TVI of DF [m/sec] and ratio of A/TVI of DF. There was a statistically significant impairment in left ventricular filling pattern in patients with rheumatoid arthritis compared to the control group as evidenced by taeased E/A ratio [0.96 +/- 0.29 in RA patients versus 1.38 +/- 0.19 in ihe control group, p=0.0017]. Also, there was a statistically significant difference in the TVI of A/TVI ofDF [0.46 +/- 0.16 in the patients group versus 0.33 +/- 0.058 in the control group, p=0.017. There was a significant negative correlation between the E/A ratio and the age of the patients with RA [p=0.0181 4p-[1.4216]. Interestingly, in patients with subcutaneous nodules, we found a significant correlation between E/A ratio and the number of swollen joints [p=0.0341 and r=-3.162]. to; was a significant correlation between TVI of A/TVI of DF and disease duration in patients with RA [p=0.0028 and dl.4W5]. Also, There was a significant negative correlation between hemoglobin level and TVI of A/TVI of DF ratio [p=0.034 and r=-0.65]. The prevalence of diastolic dysfunction is high in patients with rheumatoid arthritis. This raises the importance of performing echocardiography in these patients particularly those with long disease duration, patients with seropositive sera especially when they have a combination of subcutaneous nodules and increased number of swollen joints.

Right ventricular diastolic function abormalities in patients with systemic sclerosis

Systemic sclerosis is a generalized disorder of connective tissue characterized clinically by thickening and fibrosis of the skin and by distinctive forms of involvement of internal organs, among which is the heart. Manifestations of scleroderma heart disease are quite variable, and often not seen until late in the course of the disease. This work aimed to assess the prevalence of right ventricular diastolic abnormalities in patients with systemic sclerosis and to investigate the relation to the clinical manifestations of the disease. Our study group included thirty four patients with systemic sclerosis [32 females and 2 males, their age ranged from 19 to 67yrs with a mean of 40.3 +/- 11.5yrs and a mean disease duration of 8.9 +/- 7.4yrs.] and thirty healthy subject who served as controls. All the study groups were subjected to full clinical evaluation and echo-Doppler study. Parameters of diastolic function included, E/A ratio and time velocity integrals of A wave and diastolic filling [TVI of A/TVI of DF]. Patients were diagnosed as having diastolic dysfunction when one or more of the two criteria were abnormal. Right ventricular diastolic abnormalities were found in 23 patients [67.65%] while left ventricular diastolic abnormalities were found in 11 patients [32.35%]. Seven patients had an ejection fraction below 60%, all had right ventricular diastolic dysfunction. There was a highly statistically significant difference between patients and control as regard tricuspid E/A [1.1 +/- 0.3 vs 1.3 +/- 0.2, p=0.0001] and tricuspid TVI of A/TVI of DF [0.4 +/- 0.1 vs 0.3 +/- 0, p=0.0001]. A significant correlation was found between right ventricular diastolic abnormalities and age of patients [the mean age of patients with abnormal diastolic function was 44.6 +/- 12 vs 35.4 +/- 8.8 for patients with normal diastolic function, p=0.017]. Right and left ventricular diastolic function abnormalities are common in patients with systemic sclerosis. Echocardiography should be recommended for all patients with systemic sclerosis even in asymptomatic patients especially in elderely

Correlation between enzymatic estimation of myocardial infarct size and myocardial perfusion defect using SPECT

In patients with acute MI correlation between quantitative estimation of infarct size from the marker enzymes and non enzymatic proteins with perfusion defect using thallium 201 can help in the early choice of management strategy. Concentrations of six-marker enzymes and non-enzymatic protein [CPK, CKMB, LDH, SGOT, alpha HBDH and HFABP] were assayed in serial samples from 12 patients with AMI. Quantitative assessment of infarct size was done by a model developed by Witteveen et al in 1975, a modification was done on the model for estimation of infarct size using HFABP as it overestimates the infarct size using the standard model. Myocardial perfusion defect study using SPECT was done within one week of onset of AMI. Correlation between the infarct size using these enzymes and HFABP with perfusion defect was significant for all except infarct size using peak SGOT. A nearly equal estimate in absolute terms was obtained on using all of total [CPK, LDH, alpha HBDH and HFABP applying the modified model]. Infarct size using CKMB and SGOT underestimates the infarct size, on the other hand infarct size using HFABP is overestimated on applying the standard model. Using peak value of HFABP and applying the modified model can give an early reliable estimate of infarct size within 2 hours of admission or 6 hours of onset of symptoms. Conclusions: Using a single peak value of HFABP at 2 hours from admission or 6 hours from the onset of symptoms and applying the modified model can give an early nearly reliable estimate of infarct size. This can be used for early risk stratification and for the early choice of management strategy

Pulmonary hypertension in patients with chronic renal failure: the role of parathormone and pulmonary calcification

Cardiovascular complications especially coronary artery disease are considered to be a major cause of mortality in patients with chronic renal failure [CRF] on regular hemodialysis. Abnormal technetium-m99 methylene diphosphonate [99mTc-MDP] lung uptake was reported in 61% of patients with CRF on regular hemodialysis in the presence of normal chest radiographs indicating the presence of pulmonary calcifications. Pulmonary calcification was reported to be a possible cause for the development of pulmonary hypertension [PH] in patients with CRF on regular hemodialysis. 51 patients [28 males and 23 females] who had end stage renal disease and were on regular hemodialysis. Those patients were divided according to the presence of pulmonary hypertension by echo-Doppler study into: Group 1: 15 patients [5 males and 10 females] with a mean age of 43.5 +/- 9.8 years who had pulmonary hypertension and subjected to 99m Tc-MDP. Group II: 15 patients [10 males and 5 females] with a mean age of 40.3 +/- 10.9 years without pulmonary hypertension. Also, those patients were subjected to 99m Tc-MD and were considered as a control group. Group III: 21 patients [15 males 6 females] with a mean age of 3g9 +/- 11.0 years without pulmonary hypertension but were not subjected to 99m Tc-MDP scan. All patients were subjected to full clinical evaluation, chest X ray and well standardized 12 leads ECO. Laboratory investigations included BUN, creatinine, calcium [Ca], phosphorus [Ph], alkaline phosphatase [ALK], hemoglobin [Rb] ,complete lipid profile, and intact molecule parathormone hormone [PTH]. Echo-Doppler study was performed mainly for estimation of the pulmonary artery systolic pressure [PASP]. Only patients in groups I and IT were subjected to 99m techn MDP scan. Twenty patients from 30 patients [66.6%] had positive 99m Tc-MDP lung uptake. There was no significant difference between patients with positive or negative 99m Tc-MDP lung uptake regarding the duration of dialysis, the serum level of Ca, Ph, ALK, Rb, cholesterol, triglyceride and PTH .15 patients [29.47%] had pulmonary hypertension [The mean value of PASP was 45.2 +/- 6.7 Hg]. There was no significant difference regarding the mean value of PASP in patients with positive or negative 99m Tc-MDP lung uptake .The mean value of PASP in patients with positive 99m Tc-MDP was 33.9 +/- 11.8 mmHg vs 36.5 +/- 11.8 mmHg in patients with negative 99m Tc-MDP lung uptake [p=0.3]. This study demonstrated that 66.6% of patients with CRF and on regular hemodialysis had pulmonary calcifications. There was no significant difference between patients with or without pulmonary calcifications regarding serum Ca, Ph, ALK, Hb, cholesterol, triglyceride and PTH. There was no correlation between pulmonary calcifications and pulmonary hypertension. The mechanism of pulmonary hypertension is uncertain and other factors rather than pulmonary calcifications and hyperparathyroidism should be considered