Agreement between three-dimensional planimetry and mitral navigation method in the assessment of mitral valve area in rheumatic severe mitral stenosis.

INTRODUCTION: Rheumatic heart disease predisposes to structural changes in the mitral valve including commissural fusion and calcification with subsequent narrowing of the mitral valve orifice resulting in rheumatic mitral stenosis (RMS). To define the best therapeutic strategy, an accurate measurement of mitral valve area (MVA) for RMS is of paramount importance. The propose of the present study was to assess the agreement between the mitral navigation method (MVN) and three-dimensional (3D) planimetry in the assessment of MVA in patients with RMS. METHODS: Patients who were diagnosed with a different degree of mitral stenosis with the standard transthoracic echocardiography methods such as the pressure half time and planimetry underwent 3D transesophageal echocardiography (TEE) examination. 3D TEE zoom mitral valve planimetry was measured in the diastolic frame during the mitral valve's largest opening. By using MVN software of the Philips Q-Lab, MVA was measured at its maximum diastolic opening. Both 3D planimetry (3DPL) and MVN were measured at the mid diastole during the mitral valve's largest opening. RESULTS: In this retrospective analysis, we examined consecutive 37 RMS patients (mean age 51.1 ± 11.6 years, 31 patients were female). MVA measured by the MVN method was found to be highly correlated with the 3D MVA measured by 3DPL (r = 0.937, p<.001). CONCLUSIONS: Based on our results, we showed that the MVN method may be additionally used in detecting the severity of RMS.

In-hospital and short-term predictors of mortality in patients with intermediate-high risk pulmonary embolism.

Introduction: The aim of this study was to evaluate the in-hospital and short-term predictive factors of mortality in intermediate-high risk acute pulmonary embolism (PE) patients with right ventricle (RV)dysfunction and myocardial injury. Methods: In this retrospective study, the medical records of 187 patients with a diagnosis of intermediate high risk acute PE were evaluated. A contrast-enhanced multi-detector pulmonary angiography was used to confirm diagnosis in all cases. All-cause mortality was determined by obtaining both in hospital and 30 days follow-up data of patients from medical records. Results: During the in-hospital stay (9.5±4.72 days), 7 patients died, resulting in an acute PE related in-hospital mortality of 3.2%. Admission heart rate (HR), (Odds ratio (OR), 1.028 95% Confidence interval (CI), 0.002-1.121; P = 0.048) and blood urea nitrogen (BUN) (OR, 1.028 95% CI, 0.002-1.016; P = 0.044) were found to be independent predictors for in-hospital mortality in a multi variate logistic regression analysis. In total, 32 patients (20.9%) died during 30 days follow-up.The presence of congestive heart failure (OR, 0.015, 95%CI, 0.001-0.211; P = 0.002) and dementia (OR, 0.029, 95%CI,0.002-0.516; P = 0.016) as well as low albumin level (OR, 0.049 95%CI, 0.006-0.383; P = 0.049) were associated with 30 days mortality. Conclusion: HR and BUN were independent predictors of in-hospital mortality and the presence of congestive heart failure, dementia, and low albumin levels were associated with higher 30 days mortality.

Comparison of fluoro and cine coronary angiography: balancing acceptable outcomes with a reduction in radiation dose.

UNLABELLED: Use of last fluoro hold (LFH) mode in fluoroscopy, which enables the last live image to be saved and displayed, could reduce radiation during percutaneous coronary intervention when compared with cine mode. No previous study compared coronary angiography radiation doses and image quality between LFH and conventional cine mode techniques. METHODS: We compared cumulative dose-area product (DAP), cumulative air kerma, fluoroscopy time, contrast use, interobserver variability of visual assessment between LFH angiography, and conventional cine angiography techniques. Forty-six patients were prospectively enrolled into the LFH group and 82 patients into the cine angiography group according to operator decision. RESULTS: Mean cumulative DAP was higher in the cine group vs the LFH group (50058.98 ± 53542.71 mGy•cm² vs 11349.2 ± 8796.46 mGy•cm²; P<.001). Mean fluoroscopy times were higher in the cine group vs the LFH group (3.87 ± 5.08 minutes vs 1.66 ± 1.51 minutes; P<.01). Mean contrast use was higher in the cine group vs the LFH group (112.07 ± 43.79 cc vs 88.15 ± 23.84 cc; P<.001). Mean value of Crombach's alpha was not statistically different between visual estimates of three operators between cine and LFH angiography groups (0.66680 ± 0.19309 vs 0.54193 ± 0.31046; P=.20). CONCLUSION: Radiation doses, contrast use, and fluoroscopy times are lower in fluoroscopic LFH angiography vs cine angiography. Interclass variability of visual stenosis estimation between three operators was not different between cine and LFH groups. Fluoroscopic LFH images conventionally have inferior diagnostic quality when compared with cine coronary angiography, but with new angiographic systems with improved LFH image quality, these images may be adequate for diagnostic coronary angiography.

Preprocedural red blood cell distribution width predicts bare metal stent restenosis.

BACKGROUND: It has been shown that increased red blood cell distribution width (RDW) predicts adverse outcomes in cardiovascular disease and in patients undergoing a percutaneous coronary intervention. The aim of the present study was to assess the predictive value of preinterventional RDW on the development of in-stent restenosis (ISR) in patients undergoing stent implantation. MATERIALS AND METHODS: In this retrospective study, we compared 131 patients with ISR and 138 patients without ISR who had undergone bare metal stent implantation. RESULTS: Preprocedural RDW was significantly higher in patients with ISR than those without restenosis (14.6±3.2 vs. 13.4±1.6%, P<0.001). Stent length was significantly longer in patients with than those without restenosis (17.9±5.6 vs. 16.2±5.2 mm, respectively, P=0.03). Compared with patients with restenosis, patients without restenosis had a lower rate of diabetes (28 vs. 61 patients, P=0.001), a significantly short period between two coronary angiographies (9.8±9.3 vs. 12.9±11.6 months, respectively, P=0.02), and lower triglyceride levels (133±53 vs. 198±121 mg/dl, respectively, P=0.05). In multivariate logistic regression analysis, diabetes mellitus, stent length, preprocedural RDW, and current smoking independently predicted ISR. CONCLUSION: Increased preinterventional RDW significantly predicts bare metal stent restenosis and might represent a useful screening tool to stratify patients according to a higher or a lower risk of ISR after stent implantation in patients with stable and unstable angina pectoris.

Peripartum cardiomyopathy: current state of knowledge, new developments and future directions.

Peripartum cardiomyopathy (PPCM) is a form of idiopathic dilated cardiomyopathy affecting women in late pregnancy or early puerperium. Although initially described in the late 1800s, it has only recently been recognized as a distinct cardiac condition. The reported incidence and prognosis varies according to geography. The clinical course varies between complete recovery to rapid progression to chronic heart failure, heart transplantation or death. In spite of significant improvements in understanding the pathophysiology and management of the PPCM many features of this unique disease are poorly understood, including incidence, etiology, epidemiology, pathophysiology, predictors of prognosis and optimal therapy. The present article revisits these concepts and recent advances in PPCM.

Is left ventricular diastolic dysfunction independent from presence of hypertension in metabolic syndrome? An echocardiographic study.

BACKGROUND: It has been shown that left ventricular diastolic dysfunction (LVDD) develops in patients with metabolic syndrome (MetS). However, there is not sufficient evidence in the literature to determine whether this condition is due to increase in blood pressure, which is frequently encountered in MetS. The purpose of this study was to test the hypothesis whether LVDD in MetS is independent from the presence of hypertension. METHODS: A total of 60 patients diagnosed with MetS and 30 healthy people, who were age- and gender-matched with the patient group, were included in the study as the control group. In the study group, 30 of the patients were normotensive whereas the other 30 had hypertension. Conventional echocardiographic examinations and tissue Doppler imaging were performed besides measurements of demographic and biochemical parameters. RESULTS: In the hypertensive MetS group, early diastolic filling flow (E), early diastolic mitral annular velocity (E'), and E/A ratio were significantly lower compared to the control group. Late diastolic filling flow (A), deceleration time (DT), late diastolic mitral annular velocity (A'), and E/E' ratio were higher in the hypertensive MetS group than the control group. In the normotensive MetS group, E, E', and E/A ratio were also lower compared to the control group whereas DT, A', and E/E' ratio were higher. CONCLUSION: These findings support the idea that LVDD may develop in patients with MetS even in the absence of hypertension. In addition, co-existence of hypertension with MetS contributes to further worsening of diastolic functions.

Coronary calcium score, albuminuria and inflammatory markers in type 2 diabetic patients: associations and prognostic implications.

AIMS: To investigate the relationship of coronary artery calcium (CAC) scores with common carotid artery intima media thickness (CCA-IMT), albuminuria and inflammatory factors in type 2 diabetes. METHODS AND RESULTS: 128 asymptomatic type 2 diabetic patients, with at least one cardiovascular risk factor in addition to diabetes, were included in the study. CAC scores, carotid arteries plaque formation and CCA-IMT were assessed. The patients were followed for a mean period of 36.6 ± 3.3 months. Linear regression analysis identified the logarithmically transformed (Ln) albuminuria (ß=0.32, P=0.007), age (ß=0.04, P=0.001) and the uric acid (ß=0.13, P=0.04) as independent determinants of the CAC score. During follow-up period, cardiovascular events occurred in 18 out of 46 patients with CAC score ≥100 compared with 5 out of 82 patients with CAC score <100 (log rank, P<0.0001). Multivariate Cox proportional hazards analysis identified LnCAC score (P<0.0001), LnAlbuminuria (P=0.01) and uric acid (P=0.03) as independent predictors for cardiovascular events. CONCLUSIONS: There was a significant relationship between CAC score, albuminuria and inflammation in patients with type 2 diabetes. LnCAC score together with LnAlbuminuria and uric acid were identified as independent predictors of cardiovascular events in these patients.

Delayed recovery in peripartum cardiomyopathy: an indication for long-term follow-up and sustained therapy.

AIMS: Persistence of left ventricular (LV) systolic dysfunction after 6 months of diagnosis is believed to be a marker of an irreversible cardiomyopathy in peripartum cardiomyopathy (PPCM). We sought to determine the length of time required for recovery of LV systolic function (LVSF) in patients with PPCM. METHODS AND RESULTS: Forty-two consecutive women with PPCM were enrolled in this prospective study. The minimum required time of follow-up for inclusion was 30 months. Each patient underwent transthoracic echocardiography, and plasma brain natriuretic peptide (BNP) and C-reactive protein measurement at admission, and every 3 months. Early recovery was defined as normalization of LVSF at 6 months post-diagnosis. Delayed recovery was defined if the length of time required for recovery of LVSF was longer than 6 months. Persistent left ventricular dysfunction (PLVD) was defined as an ejection fraction of <50% at the end of follow-up. Twenty patients (47.6%) recovered completely, 10 died (23.8%), and 12 (28.6%) had PLVD. Average time to complete recovery was 19.3 months after initial diagnosis (3-42 months). Early recovery was observed only in six patients (30%), whereas delayed recovery was observed in 14 out of 20 patients (70%). Patients with complete recovery were more likely to have a higher LV ejection fraction and smaller LV end-systolic dimensions at baseline. CONCLUSION: Full recovery of LVSF in PPCM patients often requires longer than 6 months.

Epicardial fat thickness is associated with non-dipper blood pressure pattern in patients with essential hypertension.

OBJECTIVE: Epicardial fat tissue reflects visceral adiposity and is a suggested cardiometabolic risk factor. Patients with abdominal obesity have an increased prevalence of the non-dipper blood pressure (BP) pattern, but it is unclear whether the same is true of patients with increased epicardial fat thickness (EFT). The association between EFT and circadian BP changes in patients with recently diagnosed essential hypertension was examined. METHODS: Sixty hypertensive patients underwent echocardiography, treadmill stress testing, and 24 hours of ambulatory BP monitoring. Epicardial fat thickness and left ventricular mass (LVM) index were measured by using transthoracic echocardiography. The patients were categorized into two groups according to their BP pattern (group 1, non-dippers; group 2, dippers). RESULTS: The mean EFT and LVM of patients in group 1 (n = 24) (EFT, 7.6 ± 2.1 mm; LVM, 130 ± 31.2 g/m(2)) were significantly greater than those of group 2 (n = 36) (EFT, 5.5 ± 1.2 mm, P = .0001; LVM, 107 ± 23.7 g/m(2), P = .002). The average systolic BP over 24 hours (BP(s) 24) and average diastolic BP over 24 hours (BP(d) 24) of group 1 (BP(s) 24, 151.1 ± 17.6 mm Hg; BP(d) 24, 94.1 ± 16.5 mm Hg) were significantly higher than those of group 2 (BP(s) 24, 136.7 ± 11.9 mm Hg, P = .0001; BP(d) 24, 84.6 ± 10.6 mm Hg; P = .008). Multivariate backward logistic regression analysis demonstrated that the non-dipper BP pattern was associated with EFT (standardized ß coefficient = 0.87, P = .005) and LVM (standardized ß coefficient = 0.43, P = .016). An EFT ≥ 7 mm was associated with the non-dipper BP pattern with 44% sensitivity and 94% specificity (receiver operating characteristic area under curve of 0.72, 95% CI [0.59-0.83], P = .0007). CONCLUSIONS: Epicardial fat thickness was above average in newly diagnosed, untreated hypertensive patients with non-dipper BP pattern. The echocardiographic measurement of EFT may be used to indicate increased risk of hypertension-related adverse cardiovascular events.

Predictive value of preoperative electrocardiography for perioperative cardiovascular outcomes in patients undergoing noncardiac, nonvascular surgery.

BACKGROUND: The utility of routine preoperative electrocardiography (ECG) for assessing perioperative cardiovascular risk in patients undergoing noncardiac, nonvascular surgery (NCNVS) is unclear. HYPOTHESIS: There would be an association between preoperative ECG and perioperative cardiovascular outcomes in patients undergoing NCNVS. METHODS: A total of 660 patients undergoing NCNVS were prospectively evaluated. Patients age >18 years who underwent an elective, nonday case, open surgical procedure were enrolled. Troponin I concentrations and 12-lead ECG were evaluated the day before surgery, immediately after surgery, and on the first 5 postoperative days. Preoperative ECG showing atrial fibrillation, left or right bundle branch block, left ventricular hypertrophy, frequent premature ventricular complexes, pacemaker rhythm, Q-wave, ST-segment changes, or sinus tachycardia or bradycardia were classified as abnormal. The patients were followed up during hospitalization and were evaluated for the presence of perioperative cardiovascular events (PCE). RESULTS: Eighty patients (12.1%) experienced PCE. Patients with abnormal ECG findings had a greater incidence of PCE than those with normal ECG results (16% vs 6.4%; P < 0.001). Mean QTc interval was significantly longer in the patients who had PCE (436.6 ± 31.4 vs 413.3 ± 16.7 ms; P < 0.001). Univariate analysis showed a significant association between preoperative atrial fibrillation, pacemaker rhythm, ST-segment changes, QTc prolongation, and in-hospital PCE. However, only QTc prolongation (odds ratio: 1.15, 95% confidence interval: 1.06-1.2, P < 0.001) was an independent predictor of PCE according to the multivariate analysis. Every 10-ms increase in QTc interval was related to a 13% increase for PCE. CONCLUSIONS: Prolongation of the QTc interval on the preoperative ECG was related with PCE in patients undergoing NCNVS.

The effects of obstructive sleep apnea syndrome due to adenotonsillar hypertrophy on the cardiovascular system in children.

Obstructive sleep apnea syndrome (OSAS) due to adenotonsillar hypertrophy (ATH) is a common and important problem in children. OSAS can lead to significant cardiopulmonary complications, poor growth and problems with learning and behavior. Many studies in the literature show that OSAS due to ATH causes pulmonary hypertension, ventricular hypertrophy and systemic hypertension in the pediatric population. In this review, we discuss the effects of ATH on cardiac function. It is well known that as a child grows, the nasopharyngeal passage becomes enlarged, helping to improve OSAS. Based on this, we discuss the possible positive effect of this age-related improvement on the obstruction of cardiovascular disturbances. Finally, the possible relationship between the duration of OSAS and the timing of surgery with the permanency of cardiovascular disturbances is discussed.

Increased aortic stiffness can predict perioperative cardiovascular outcomes in patients undergoing noncardiac, nonvascular surgery.

BACKGROUND: Aortic stiffness is an early marker of arteriosclerosis and associated with cardiovascular mortality. However, the impact of aortic stiffness on perioperative cardiovascular outcomes in patients undergoing noncardiac surgery is unknown. METHODS: The study population was composed of 660 consecutive adults aged 18 years and over (mean age = 65.3 ± 14 years) who underwent intermediate-risk (nonvascular), noncardiac surgery between January 2010 and February 2011. Nonemergency, non-day-case, open surgical procedures were enrolled. Aortic stiffness indices were calculated from the aortic diameters measured by echocardiography. Electrocardiography and cardiac biomarkers were evaluated 1 day before surgery, and on days 1, 3, and 7 after surgery. RESULTS: Eighty patients (12.1%) experienced perioperative cardiovascular events (PCE). Preoperative aortic distensibility (AD) (2 ± 1.3 vs. 2.9 ± 1.1 cm2/dyn/10(3), P < 0.001) and aortic strain (AS) (4.4 ± 2.4 vs. 6.4 ± 1.9, P < 0.001) of the patients with PCE were significantly lower than in patients without PCE. Univariate analysis showed a significant association between age, diabetes mellitus (DM), coronary artery disease, preoperative atrial fibrillation, American Society of Anesthesiologists (ASA) status, Revised Cardiac Risk Index, left ventricle ejection fraction (LVEF), AD, aortic strain, and in-hospital PCE. However, on multivariate logistic regression analysis, only AD (OR: 1.94, 95% CI: 1.1-3.4; P = 0.02), AS (OR: 0.45, 95% CI: 0.3-0.6; P < 0.001), DM (OR: 2.28, 95% CI: 1.08-4.82; P = 0.03), and LVEF (OR: 0.96, 95% CI: 0.93-0.99; P = 0.03) remained as significant variables associated with PCE. CONCLUSION: Impaired elastic properties of the aorta are associated with increased PCE rates in patients undergoing noncardiac, nonvascular surgery.

Effect of adenotonsillectomy on endothelin-1 and C-reactive protein levels in children with sleep-disordered breathing.

OBJECTIVE: This study aimed to evaluate the influence of adenotonsillectomy on the plasma concentration of endothelin-1 (ET-1) and C-reactive protein (CRP) in children with sleep-disordered breathing (SDB). The relationship between quality of life and ET-1 levels was also evaluated. SETTING: Tertiary referral center. STUDY DESIGN: Before-and-after case series. METHODS: Fasting blood samples for ET-1 and high-sensitivity CRP were drawn preoperatively in all patients and at 3 to 4 months postoperatively. The Obstructive Sleep Apnea-18 (OSA-18) survey and Brouilette symptom score were completed by each child's parents during the same time periods. RESULTS: The mean ET-1 level decreased from 3.51 ± 0.93 fmol/mL to 2.67 ± 0.69 fmol/mL postoperatively (P < .01). OSA-18 survey scores and Brouilette symptom scores also decreased in the postoperative period (P < .01). When comparing moderate and severe cases to mild cases according to Brouilette scores, ET-1 levels were significantly higher in moderate and severe cases (P < .01). There was a significant correlation between ET-1 and the OSA-18 survey scale (r = 0.442; P = .001). Although CRP levels decreased from 0.63 ± 1.19 mg/dL to 0.31 ± 0.23 mg/dL postoperatively, this was not statistically significant. CONCLUSION: Adenotonsillectomy effectively lowered plasma ET-1 levels in children with SDB and thus may have reduced their related risk for cardiovascular disease. In addition, adenotonsillectomy improved quality of life in this group.

Inappropriate use of digoxin in elderly patients presenting to an outpatient cardiology clinic of a tertiary hospital in Turkey.

OBJECTIVES: We investigated the prevalence and indications of digoxin use in elderly patients presenting to a cardiology outpatient clinic of a tertiary hospital in Turkey. STUDY DESIGN: On a prospective basis, the study included 800 consecutive patients aged 70 or over (mean age 77 ± 6 years) who presented to our cardiology outpatient clinic. There were 124 patients (15.5%) receiving digoxin. All the patients underwent transthoracic echocardiography. Digoxin use was considered inappropriate if the patient had normal left ventricle systolic function or if there was no atrial fibrillation (AF). RESULTS: The reasons for use of long-term digoxin were persistent AF (n=55, 44.4%), heart failure (HF) (n=51, 41.1%), and paroxysmal AF (n=8, 6.5%). The exact reason could not be determined in 10 patients (8.1%). Digoxin use was based on appropriate indications in 76 patients (61.3%), whereas 48 patients (38.7%) were taking digoxin with inappropriate indications. Of 51 patients for whom HF was the only reason for digoxin therapy, diagnosis of HF was incorrect in 30 patients (24.2%). Other inappropriate indications were paroxysmal AF and undetermined indication for digoxin prescription. Concerning digoxin dose, 24 patients (19.4%) received one tablet (0.25 mg) and 30 patients (24.2%) received a half tablet (0.125 mg) on a daily basis, while 10 patients (8.1%) used six tablets per week with one day off (0.214 mg/day) and 60 patients (48.4%) took five tablets per week with two days off (0.179 mg/day). The median daily dose was 0.182 mg/day. Digoxin dose was higher than the recommended doses for elderly patients in 75.8% of the patients. CONCLUSION: Our findings show that nearly 40% of elderly patients receive digoxin with inappropriate indications and 75% of these patients take digoxin at higher doses than the recommended doses for this age group.

The association of epicardial fat thickness with blunted heart rate recovery in patients with metabolic syndrome.

Epicardial fat tissue has unique endocrine and paracrine functions that affect the cardiac autonomic system. Epicardial fat thickness (EFT) and blunted heart rate recovery (HRR) are newly identified cardiovascular risk factors in patients with metabolic syndrome (MS). The objective of this study is to evaluate the association between EFT and HRR in patients with MS. Forty patients with MS and 36 healthy controls were included in the study. Echocardiographic EFT and HRR at 1min after exercise termination (HRR-1) are measured and compared between the two groups. HRR-1 equal to or lower than 18 beats is considered as blunted HRR. EFT was increased (7.2 ± 2 vs. 5.6 ± 1.8 mm; p = 0.001) and HRR-1 was significantly reduced in patients with MS compared to control group (21 ± 8 vs. 26 ± 9; p = 0.006). Among the MS patients, subjects with blunted HRR had increased EFT compared to patients without blunted HRR (8.5 ± 2.0 vs. 5.9 ± 1.1 mm, p < 0.001). In multivariate analysis, EFT was the only independent predictor of blunted HRR in patients with MS (95% confidence interval = 1.42-3.87, OR = 2.34, p = 0.001). Furthermore, EFT of equal to or thicker than 5.5 mm was associated with the blunted HRR with 84% sensitivity and 52% specificity (ROC area under curve: 0.84, 95% confidence interval = 0.70-0.96, p < 0.001). In conclusion, EFT is an independent predictor of blunted HRR, a novel cardiovascular risk factor, in patients with MS.

Impaired fasting glucose is associated with increased perioperative cardiovascular event rates in patients undergoing major non-cardiothoracic surgery.

BACKGROUND: Diabetes mellitus (DM) is a well-established risk factor for perioperative cardiovascular morbidity and mortality in patients undergoing noncardiac surgery. However, the impact of preoperative glucose levels on perioperative cardiovascular outcomes in patients undergoing nonemergent, major noncardiothoracic surgery is unclear. METHODS AND RESULTS: A total of 680 patients undergoing noncardiothoracic surgery were prospectively evaluated. Patients older than 18 years who underwent an elective, nonday case, open surgical procedure were enrolled. Electrocardiography and cardiac biomarkers were obtained 1 day before surgery, and on days 1, 3 and 7 after surgery. Preoperative risk factors and laboratory test results were measured and evaluated for their association with the occurrence of in-hospital perioperative cardiovascular events. Impaired fasting glucose (IFG) defined as fasting plasma glucose values of 100 to 125 mg/dl; DM was defined as fasting plasma glucose ≥ 126 mg/dl and/or plasma glucose ≥ 200 mg/dl or the current use of blood glucose-lowering medication, and glucose values below 100 mg/dl were considered normal. Plasma glucose levels were significantly higher in patients with perioperative cardiovascular events (n=80, 11.8%) in comparison to those without cardiovascular events (131 ± 42.5 vs 106.5 ± 37.5, p < 0.0001). Multivariate analysis revealed that patients with IFG and DM were at 2.1- and 6.4-fold increased risk of perioperative cardiovascular events, respectively. Every 10 mg/dl increase in preoperative plasma glucose levels was related to a 11% increase for adverse perioperative cardiovascular events. CONCLUSIONS: Not only DM but also IFG is associated with increased perioperative cardiovascular event rates in patients undergoing noncardiothoracic surgery.

Attenuated cardiovascular response to sympathetic system activation during exercise in patients with dialysis-induced hypotension.

BACKGROUND: We wished to investigate potential causes of dialysis-induced hypotension (DIH), including the attenuated cardiovascular response to sympathetic system activation during exercise and myocardial dysfunction. METHODS: This study included 26 end-stage renal disease (ESRD) patients with DIH, 30 ESRD patients without DIH (Non-DIH), and 30 control subjects. Each patient was evaluated with echocardiography and a symptom-limited treadmill stress test. The chronotropic index (CRI), heart rate recovery (HRR), systolic blood pressure response to exercise (SBP response), and tissue Doppler systolic myocardial velocities were calculated. RESULTS: The HRR and velocities were reduced in dialysis patients compared to controls; however, they were similar in patients with and without DIH. Patients with DIH had the lowest CRI compared to the Non-DIH group (0.62 ± 0.15 vs. 0.73 ± 0.17, p = 0.020) and controls (0.62 ± 0.15 vs. 0.86 ± 0.11, p < 0.001). Similarly, patients with DIH had the lowest SBP response values compared to the Non-DIH (34.88 ± 15.01 vs. 55.67 ± 25.42, p = 0.002) and controls (34.88 ± 15.01 vs. 59.70 ± 23.04, p < 0.001). CONCLUSION: Patients with DIH have inadequate sympathetic activity of the cardiovascular system during exercise and impaired left ventricular systolic function. Both factors could contribute to the development of hypotension during hemodialysis.

Echocardiographic epicardial fat thickness is related to altered blood pressure responses to exercise stress testing.

OBJECTIVE: Hypertensive response at peak exercise and blunted blood pressure (BP) recovery, altered BP responses obtained from exercise stress testing, have been suggested as risk factors for future onset of hypertension in previous studies. Epicardial fat, a new cardiometabolic risk factor, has been linked to hypertension in some recent studies. In this study, we tested the primary hypothesis suggesting that the epicardial fat thickness (EFT) is related to altered BP responses to treadmill exercise testing. We also evaluated the sensitivity and specificity of the EFT as a predictor of hypertensive response to peak exercise. METHODS: Normotensive subjects underwent to treadmill stress testing and transthoracic echocardiography. Hypertensive response to peak treadmill exercise testing was defined as ≥ 210/105 mmHg and ≥ 190/105 mmHg at peak exercise in males and females, respectively. BP recovery index (BPRI) was defined as the ratio of the BP at the 3rd minute of the recovery phase to BP at peak exercise. EFT was measured by echocardiography. Thirty-two subjects with hypertensive response to peak exercise constituted Group 1 and 48 subjects with normal response constituted Group 2. RESULTS: The mean EFT of subjects in Group 1 was significantly higher (8.2 ± 1.1 mm vs 5.1 ± 1.5 mm; p = 0.0001) than subjects in Group 2. In correlation analysis performed in Group 1, EFT was found to be significantly correlated with BPRI (r = 0.51, p < 0.003). An EFT of ≥ 6.5 mm predicted the hypertensive response to peak exercise test with 68.8% sensitivity and 87.5% specificity (receiving operator characteristic area under curve: 0.879, 95% CI 0.793-0.965, p < 0.001). Patients with EFT ≥ 6.5 mm showed a significantly increased BPRI (0.89 ± 0.07 vs 0.74 ± 0.09, p < 0.0001) and peak systolic BP (198.4 ± 15.3 mmHg vs 169.4 ± 19.8 mmHg, p < 0.0001). There were significant differences in metabolic equivalents, maximum heart rate, homeostatic model assessment of insulin resistance, high-density lipoprotein-cholesterol, waist circumference and age values between two patients groups dichotomized according to the cut-off value of EFT. BPRI was the only independent variable related to EFT in the multivariate analysis (odds ratio = 1.4, 95% CI 2.75-7.16, p = 0.001). CONCLUSIONS: EFT was found to be related to altered BP responses to exercise stress testing. The echocardiographic measurement of EFT may serve as a useful non-invasive indicator of heightened risk of future hypertension.