Effect of renal sympathetic denervation used in the treatment of resistant arterial hypertension on left ventricular hypertrophy and diastolic function

Background: Hypertension [HTN] results in structural and functional cardiac changes which increase cardiovascular morbidity and mortality. The effect of renal denervation [RD] on left ventricular hypertrophy [LVH] and left ventricular [LV] diastolic function is still unclear

Objective: This study investigated the effect of catheter-based renal sympathetic denervation on LVH and diastolic function in patients with resistant hypertension

Methods: We evaluated systolic and diastolic blood pressure [SBP and DBP, LV size, mass and diastolic function before and 6 months after RD in 68 patients with resistant hypertension by transthoracic echocardiography and Doppler

Results: SBP and DBP reduced 6 months after RD [-22 +/- 3 mmHg and -10 +/- 12mmHg; P<0.0001 respectively] LV mass index decreased similarly independent on BP response [-19.37 +/- 2.6 gm/m[2]: P<0.0001]. Diastolic parameters E/A ratio, E-wave deceleration time and intra-ventricular relaxation time improved similarly in all patients after 6 months [0.89 +/- 0.04; P=0.001, -24.85 +/- 8.93 ms; P=0.007 and -6.97 +/- 2.57 ms; P=0.012 respectively]

Conclusion: In patients with resistant hypertension and beside blood pressure lowering effect, renal denervation improves left ventricular hypertrophy and diastolic function. The relation of BP reduction effect and the improvement of cardiac hypertrophy and systolic function suggests a direct effect of sympathetic activity on LV remodeling and function which needs to be confirmed in larger prospective cohorts

Assessment of regional wall motion abnormalities using parametric imaging of real time 3D echocardiography compared to 2D echocardiography: validation by coronary angiography

Identification and quantification of left ventricular regional wall motion abnormalities [RWMA] on echocardiograms is of paramount clinical importance but is still performed by a subjective visual method. we tried a new tool for assessment of RWMA using parametric [PI] of real time 3D Echocardiography [RT3DE] compared to traditional visual assessment of 2D echo [2DE] and validated by coronary angiography. We studied 100 patients scheduled for coronary angiography based on previous history of myocardial infarction [MI] [STMI or NSTMI]. RWMA was assessed by both conventional 2DE and PI of RT3DE according to the 17 segment left ventricular model of the American Society of Echocardiography [ASE].Coronary angiography was performed for all patients. Coronary artery stenosis was considered significant when luminal narrowing of 70% or more was present. The angiographic data of all patients was used as the gold standard to compare the diagnostic ability of both methods for detection of RWMA. There was a good agreement between PI of RT3DE and 2DE in assessment of RWMA of most [5 of 7] segments supplied by LAD, and all 5 segments supplied by LCX and 3 of 5 segments supplied by RCA. PI of RT3DE showed higher sensitivity than 2DE [60.71% VS 47.32%, p 0.001] for detection of RWMA in significant LAD lesion, while there was no significant difference regarding sensitivity of both methods in detection of RWMA in significant LCX or RCA lesions. [66.33%vs 54.00% p=0.074] and [62.77%vs 53.88%, p=0.140] respectively. There was no significant difference between PI of RT3DE and 2DE specificity for LAD, LCX and RCA lesions. [89.68% vs 90.07% p=0.0865], [87.42% vs 89.14%p=0.063] and [79.06% vs 80.62%, p=0.568] respectively. RT3DE showed higher sensitivity, specificity, positive predictive value and negative predictive than 2DE for detection of RWMA in patients with NSTMI in prescense of significant angiographic lesions. [77.8% vs 44.4, p=0.031], [95% vs 83.% p=0.04],[95% vs 88.8%],[60% vs 33.3%] Respectively. We have shown that PI of RT3DE can be used for assessment of RWMA with good agreement to visual assessment by conventional 2DE with better sensitivity to detect RWMA in segments supplied with LAD .PI also has better sensitivity, specificity, positive predictive value [PPV] and negative predictive value[NPV] than 2DE in patients with NSTMI

Evaluation of recently validated non- invasive formula using basic lung functions as new screening tool for pulmonary hypertension in idiopathic pulmonary fibrosis patients

A prediction formula for mean pulmonary artery pressure [MPAP] using standard lung function measurement has been recently validated to screen for pulmonary hypertension [PH] in idiopathic pulmonary fibrosis [IPF] patients. To test the usefulness of this formula as a new non invasive screening tool for PH in IPF patients. Also, to study its correlation with patients' clinical data, pulmonary function tests, arterial blood gases [ABGs] and other commonly used screening methods for PH including electrocardiogram [EGG], chest X ray [CXR], trans-thoracic echocardiography [TTE] and computerized tomography pulmonary angiography [CTPA]. Cross-sectional study of 37 IPF patients from tertiary hospital. The accuracy of MPAP estimation was assessed by examining the correlation between the predicted MPAP using the formula and PH diagnosed by other screening tools and patients' clinical signs of PH. There was no statistically significant difference in the prediction of PH using cut off point of 21 or 25 mm Hg [P= 0.24]. The formula-predicted MPAP greater than 25mm Hg strongly correlated in the expected direction with O[2] saturation [r = -0.95, P < 0.000], partial arterial O[2] tension [r = -0.71, P < 0.000], right ventricular systolic pressure measured by TTE [r = 0.6, P < 0.000] and hilar width on CXR [r = 0.31, P = 0.03]. Chest symptoms, EGG and CTPA signs of PH poorly correlated with the same formula [P > 0.05]. The prediction formula for MPAP using standard lung function measurements is a simple non invasive tool that can be used as TTE to screen for PH in IPF patients and select those who need right heart catheterization

Corrected QT dispersion [QTDC] improves the diagnostic performance of treadmill exercise test in diagnosing coronary artery disease [CAD]

To find out the best combination of parameters; clinical and exercise induced hemodynamic and electrocardiographs, that could improve the diagnostic performance of exercise test. Exercise test and coronary angiography were performed for 112 patients with angina pectoris and normal electrocardiogram. The univariate predictors of the presence of CAD were aged >/= 40 years, male gender, hypertension, smoking, typicality of chest pain, development exertional chest pain, shorter exercise duration, decrease systolic blood pressure [BP] >/= 10 mmHg or systolic BP 3 min post-exercise >90% peak, heart rate drop <12 b/m one minute post exercise, exercise induced ST-segment depression >/= 1 mm, ST/HR slope >/= 2.4 microV/beat/minute, increased T amplitude >/= 2.5 mm, lengthening or no change of P wave duration, decrease or no change in Q wave depth, either R wave increase >/= 2mm or decrease >/= 1mm, QTD >60 ms, QTDc >70 ms, Q-X/QT ratio in V5 >0.5 and delta QTD rest to peak exercise >/= 16 mm and. Using multivariate logistic regression analysis we proved that using either ST depression >/= 1 mm or QTDc >70 ms as a positive exercise test significantly improved the sensitivity and the negative predictive value of the test without a significant decrease in the specificity. Using either ST depression >/= 1 mm or QTDc >70 ms as a positive exercise test improves the diagnostic performance of the test

Pacing for symptomatic AV block safety and efficacy of VDD compared to DDD pacing

Single lead atrial synchronous ventricular pacing [VDD] is used increasingly in place of conventional dual chamber pacing [DDD] for patients with atrioventricular [AV] block and preserved sinus node function. Compared to the latter, VDD pacemakers provide similar haemodynamic benefits derived from atrial synchronous pacing, with the added benefit of an easier implant procedure. To review the use, safety and efficacy of long-term VDD compared to DDD pacing in our locality. A study of all patients with atrioventricular block and normal sinus node function implanted with DDD and VDD pacemakers over a 10-year period [26 DDD, 15 VDD] at the cardiology department of Assiut University Hospital was performed. Data on complications, atrial sensing performance and maintenance of atrioventricular synchrony during implant and at subsequent follow-up visits were obtained from a prospectively maintained registry and analysed. The pacing period was 5.3 +/- 2.6 in DDD vs 2.9 +/- 1.8 years in VDD group [P=0.02]. The implant time was significantly reduced in VDD compared to DDD patients [60 +/- 26 vs 84 +/- 20 min., P< 0.05]. The implant P wave was significantly higher in DDD than VDD pacing [3.92 +/- 1.53 vs 2.71 +/- 1.30 mV, P<0.01], but was comparable at pre-discharge and last follow-up visit [1.93 +/- 1.0 vs 1.47 +/- 0.65, 1.75 +/- 1.0 vs 1.18 +/- 0.82 mV], P>0.05 for both. The total complication rate was comparable in DDD and VDD groups [24% vs 26% P>0.05]. The total AF rate was 12% in DDD patients vs 13.3% in VDD patients, P>0.05. However, it was persistent in12% of DDD vs 6.6% of VDD patients, P<0.01. Atrial under-sensing occurred in 4% of DDD vs 13.3% of VDD patients, P>0.01. At the last follow-up visit, 88% DDD vs 86.6%VDD patients were maintained on the original mode. Maintenance of AV synchrony was also comparable in the 2 groups [88% in DDD vs 80% in VDD, P>0.05]. VDD pacing systems can provide excellent long-term performance in AV block patients with normal sinus node function. They are as safe and effective in maintaining a physiological A V synchronous pacing mode as DDD systems with decreased implantation time and decreased rate of persistant AF

Cardiac troponins in children with chronic renal failure

Cardiac troponins T and I [cTnT, cTnI] are highly sensitive biomarkers for the detection of myocardial damage. Patients with chronic renal failure [CRF]on regular hcmodialysis [HD] often have increased serum concentrations of cardiac troponins and left ventricular hypertrophy [LVH] with or without evidence of acute myocardial injury. Thirty eight pediatric patients [23 males and 15 females], aged 4-18 years, suffering from CRF and on regular HD for more than one year were prospectively included in this study as well as 15 apparently healthy children matched for age and sex as controls. All patients and controls had detailed history and full clinical examination. Serum levels of Na, K, cTnT, cTnI, creatinin kinase [CK] and creatinin kinase MB [CK-MB] and hematocrit were estimated. Echocardiographic estimation of left ventricular [LV] dimensions, FS, EF, LV mass index [LVMI] and relative wall thickness [RWT] was done. Patients were classified into three subgroups according to presence or absence of LVH, congestive heart failure [CHF] and anurea. Serum levels of cTnT, cTnI and CK-MB were significantly higher in the patient group [0.086 +/- 0.054, 0.357+0.17, 5.65 +/- 3.94ng/ml] compared to controls [0.052 +/- 0.036, 0.26 +/- 0.12, 4.2 +/- 2.88ng/ml] respectively [p<0.05 for all]. In the patient group, cTnT was elevated in 58% [22/38], cTnI was elevated in 15.7% [6/38], while CK-MB was elevated in only 8% [3/38]. Significantly higher cTnT was detected in patients with LVH, CHF and anurea [0.126 +/- 0.11, 0.132 +/- 0.123, 0.134 +/- 0.13ng/ml] than those-without [0.054 +/- 0.034, 0.062 +/- 0.048, 0.071 +/- 0.049ng/ml], [p<0.01, 0.025, 0.05] respectively. Also, cTnI was significantly higher in patients with LVH, CHF and anurea [0.381 +/- 0.05, 0.391 +/- 0.12, 0.389 +/- 0.13ng/ml] than those without [0.337 +/- 0.07, 0.339 +/- 0.014, 0.323 +/- 0.019ng/ml] p<0.05 for all. LVH was found in 58% of patients who had significantly higher LVMI than controls [39.9 +/- 14.2 Vs. 24.3 +/- 6.3g/m[2.7], p<0.001]. Concentric LVH was found in 8 [36%] of them. LVMI correlated significantly, with systolic BP [r=0.72, p=0.011], diastolic BP [r=0.83, p=0.002], indexed end diastolic LV dimension [r=0.68, p=0.010]. In addition, a highly significant positive correlation was detected between LVMI and cTnT serum level [r=0.591, p<0,001]. Serum levels of cardiac troponins [cTnT and cTnI] and LVMI are increased in pediatric patients with chronic renal failure on regular hemodialysis particularly those with cardiac complications. Cardiac troponins and LVH appear to predict cardiac complications in this group of patients