Association between nonalcoholic fatty liver disease and the incidence of cardiovascular and renal events

Recent data suggest that the presence of non-alcoholic fatty liver disease [NAFLD] may be linked to increased cardiovascular and chronic kidney diseases. Here we assess whether NAFLD, as diagnosed by ultrasound, predicts the risk of incident cardiovascular and renal impairment events. A total of 1150 patients with normal or near normal liver and kidney functions, and without protienuria or histories of cardiovascular accident were included in this multicenter prospective observational cohort study. All patients were subjected to full clinical evaluation, laboratory investigation including estimation of the GFR and immunonephelometric evaluation for protienuria, and abdominal ultrasonography for diagnosis of NAFLD. The metabolic syndrome was defined according to the modified National Cholesterol Education Program [NCEP]-ATP criteria. All patients followed up periodically over three years for the incidence of cardiovascular [including coronary heart disease, ischemic stroke and cerebral hemorrhage] and renal impairment events. Only 747 [62.25%] patients completed the follow-up examination and were included in the final analysis. 35.8% of them fulfilled the sonographic criteria of NAFLD. The frequency of cardiovascular accident and renal impairment was significantly higher in them: 136 patients [50.7%] vs. 110 [23%]; P < 0.001 for cardiovascular events, 88 [32.8%] vs. 88 [18.4%], P < 0.001 for microalbuminuria; and 24 [8.9%] vs. 14 [2.9%], P < 0.001 for macroalbuminuria. Also, mean estimated glomerular filtration rate [eGFR] was significantly lower in patients with NAFLD [96 +/- 23.28 vs. 111 +/- 28.37; P < 0.001]. Logistic regression analysis revealed that NAFLD was the best predictor for cardiovascular and renal impairment.

Diagnostic value of NT-PRO BNP in cardiogenic and non cardiogenic pleural effusion

The finding of an exudative effusion usually requires an extensive diagnostic workup, leading to an unnecessary exposure to invasive and expensive diagnostic procedures. Thus a strategy of identifying pleural effusions due to heart failure and possibly avoiding unnecessary diagnostic thoracentesis and/or further diagnostic procedures would be an attractive and potentially beneficial approach [6]. NT-proBNP measured in serum is a sensitive marker of cardiac dysfunction and proven to be a useful tool in the diagnosis of acute and chronic systolic and diastolic left ventricular heart failure [7, 8]. The present study was conducted to assess the diagnostic value of NT-proBNP in the differentiation of cardiogenic and non cardiogenic pleural effusion. Forty patients with pleural effusion were included in this study. Twenty patients with cardiogenic pleural effusions [pleural effusion due to cardiac cause] and 20 patients with non cardiogenic pleural effusions [pleural effusion due to non cardiac cause]. All patients were subjected to full history, clinical examination, investigation to detect the etiology of the pleural effusion and measurement of serum and pleural fluid NT-proBNP. In this study we found that pleural fluid NT-proBNP levels were significantly higher in patients with cardiogenic pleural effusions than that of patients with non cardiogenic pleural effusions [Mean +/- SEM, 5231 +/- 671.1 and 628.8 +/- 120.1 respectively, P value < 0.0001]. Also NT-proBNP levels in the serum of the patients with cardiogenic pleural effusions were significantly higher than that of patients with non cardiogenic pleural effusions [Mean +/- SEM, 4792 +/- 612.7, and 604.0 +/- 120.1 respectively, P value < 0.0001]. There was also a highly significant positive correlation between NT-proBNP levels in serum and pleural fluid Spearman's Coefficient of rank correlation is 0.992 [p < 0.0001]. We found also that at a cut-off value of 1.591 pg/ml, pleural fluid NT-proBNP level had a sensitivity of 95% and a specificity of 90% in the diagnosis of cardiogenic pleural effusion. Also at a cut off value of 1570 pg/ml, serum NT-proBNP level had a sensitivity of 95% and a specificity of 90% in the diagnosis of cardiogenic pleural effusion. It is concluded that serum and pleural fluid NT-proBNP levels are very useful in establishing the diagnosis of cardiogenic pleural effusions

Evaluation of aggressive heart rate reduction in patients with stable angina

There is a strong correlation between heart rate and myocardial ischemia, cardiovascular diseases, and life expectancy in general; however, heart rate has been neglected as an important risk factor as well as a therapeutic opportunity. To investigate the effect of aggressive heart rate reduction [50 HR 60 bpm] on anti-ischemic and anti-anginal efficacy, left ventricular function, exercise tolerance and quality of life in patients with stable coronary artery disease with or without left ventricular dysfunction during 4 months. A total of 159 patients presented with stable CAD without clinical heart failure symptoms were included in a open-label, non-comparative, prospective clinical study between June 2009 to February 2010 in King Abdul Aziz Specialist Hospital, Taif, KSA, Al Hayah National Hospital, Khamis Mushyt, KSA and Critical care department, Cairo University, Egypt. All included patients were, in addition to the ant ischemic treatment, subjected to aggressive heart rate control starting by beta blocker titrated to the maximum dose as tolerated, then Ivabradine added if the target heart rate is not achieved or rate control started by Ivabradine if beta blockers are contraindicated. Exercise treadmill test [ETT] to assess exercise capacity using time to 1 mm ST-segment depression in milliseconds, ejection fraction [EF] assessed by transthoracic echocardiography and frequency of angina attacks and the use of sublingual nitroglycerin per week during the last week were evaluated during a follow-up for 4 months. The patients were divided into two groups, group-I [patients achieved a resting heart rate between 50 and 60 bpm with heart rate reduction treatment] and group-II [patients with resting HR >60 bpm in spite of maximum treatment for heart rate reduction]. The resting heart rate was significantly reduced from 77.98 +/- 8.7 at baseline to 60.68 +/- 4.34 bpm after 4 months of treatment, P < 0.001. The frequency of angina pectoris attacks had been significantly reduced from 2.14 +/- 1.27 to 0.48 +/- 0.58 attacks per week, P < 0.001 and the highest significant reduction was observed with group-I. Also, the frequency of use sublingual nitrate therapy was significantly reduced from 1.38 +/- 1.1 tablet per week at the last week before the study to 0.12 +/- 0.33 tablet per week during the last week after 4 months of treatment, P < 0.001 and the reduction was more significantly with group-I. Exercise treadmill test demonstrated statistically significant increase in the time to 1 mm ST-segment depression from 357.36 +/- 66.73 at baseline to 387.96 +/- 65.19 ms. after 4 months with P < 0.001. The degree of improvement was significantly higher for group-I [from 358.06 +/- 68.81 at baseline to 391.71 +/- 69.01 after 4 months with P < 0.001] than that of group-II [from 356.11 +/- 64.8 at baseline to 381.27 +/- 59.08 after 4 months with P < 0.001]. Ejection fraction showed a statistically significant increase from 59.76 +/- 6.86 at baseline to 61.04 +/- 5.35 after 4 months with P < 0.001. This study indicates that heart rate reduction has been associated with an improvement in quality of life in patients with stable coronary artery disease, presenting new opportunities for treatment

Transvaginal sonography and color doppler imaging in the follow-up of patients with gestational trophoblastic disease

Uterine morphology assessed by transvaginal sonography [TVS] and the hemodynamics of intra-tumoral vessels assessed by color Doppler ultrasound [CDU] were prospectively correlated with the clinical outcome of 9 patients with gestational trophoblastic disease [GTD]. Six patients were managed and followed without treatment and 4 of them achieved complete local resolution. Three patients were referred for sonographic evaluation of persistent trophoblastic disease. Our four patients with one referred subject did not need any further treatment [Observation group, n = 5]. Two of our patients plus two of the three referred patients were found to have persistent disease and they received chemotherapy [Treatment group, n = 4]. In the observation group both techniques; TVS and CDU, had 100% accuracy in predicting local resolution or local persistence. Persistence was predicted 1-2 weeks before the increase of B human chorionic gonadotropin [B-hCG] levels, whereas resolution was observed up to 6 weeks before the disappearance of beta-hCG. In one patient normal uterine morphology and vascularization in the presence of elevated hCG levels was associated with extrauterine spread. In the treatment group, normal uterine ultrasound morphology and negative color Doppler results had 75% negative predictive value, A false-positive result was observed in one case. We conclude that ultrasound evidence of abnormal uterine morphology or persistent vascularization on color Doppler examination with persistent hCG levels is indicative of local persistence. Normal uterine morphology with negative color Doppler results may be associated with extrauterine spread