EFFECTS OF BODY WEIGHT REDUCTION ON ARTERIAL STIFFNESS AND ENDOTHELIAL FUNCTION AFTER BARIATRIC SURGERY IN MORBIDLY OBESE PATIENTS: A 4-YEAR CLINICAL STUDY.

OBJECTIVE: To determine the long-term effect of weight loss on arterial stiffness, metabolic parameters in morbidly obese patients who underwent laparoscopic adjustable gastric banding (LAGB). SUBJECTS: Forty-eight morbidly obese Caucasian subjects underwent LAGB from January 2009 to January 2010 and completed 4 years follow-up. MEASUREMENTS: Patients were evaluated for body mass index (BMI), waist circumference, arterial blood pressure (BP), metabolic factors: leptin, adiponectin, glucose, glycated haemoglobin (HbA1c), insulin. Endothelial function - evaluated as reactive hyperemic index (RHI). Arterial stiffness - determined by cardio - ankle vascular index (CAVI). RESULTS: Average BMI decreased from 46.48±7.06 kg/m2 to 39.78±7.36 kg/m2 (1year, p<0.001) and 37.29±7.49 kg/m2 (4years, p=0.012). The systolic BP and heart rate reduction were observed after the 4 years. Changes in cardiovascular parameters were accompanied by waist circumference reduction and improvement of glucose metabolism,reduction of insulin, HbA1c, leptin, C-reactive protein values. However, there were statistically significant increases in CAVI 6.58±1.77m/s vs. 7.03±2.00 m/s (p=0.014) at 1 year, but not significant 7.12±2.19 (p=0.153) after 4 years. Endothelial changes were observed only in diabetic patients one year after LAGB 2.18±0.57 vs. 1.86±0.34 (p=0.021) vs. 2.05±0.42 (p=0.086). CONCLUSION: Weight reduction induced by LAGB was associated with changes in body weight and metabolic parameters, but it was no improvement on endothelial function and arterial stiffness.

Effect of nesiritide in patients with acute decompensated heart failure.

BACKGROUND: Nesiritide is approved in the United States for early relief of dyspnea in patients with acute heart failure. Previous meta-analyses have raised questions regarding renal toxicity and the mortality associated with this agent. METHODS: We randomly assigned 7141 patients who were hospitalized with acute heart failure to receive either nesiritide or placebo for 24 to 168 hours in addition to standard care. Coprimary end points were the change in dyspnea at 6 and 24 hours, as measured on a 7-point Likert scale, and the composite end point of rehospitalization for heart failure or death within 30 days. RESULTS: Patients randomly assigned to nesiritide, as compared with those assigned to placebo, more frequently reported markedly or moderately improved dyspnea at 6 hours (44.5% vs. 42.1%, P=0.03) and 24 hours (68.2% vs. 66.1%, P=0.007), but the prespecified level for significance (P≤0.005 for both assessments or P≤0.0025 for either) was not met. The rate of rehospitalization for heart failure or death from any cause within 30 days was 9.4% in the nesiritide group versus 10.1% in the placebo group (absolute difference, -0.7 percentage points; 95% confidence interval [CI], -2.1 to 0.7; P=0.31). There were no significant differences in rates of death from any cause at 30 days (3.6% with nesiritide vs. 4.0% with placebo; absolute difference, -0.4 percentage points; 95% CI, -1.3 to 0.5) or rates of worsening renal function, defined by more than a 25% decrease in the estimated glomerular filtration rate (31.4% vs. 29.5%; odds ratio, 1.09; 95% CI, 0.98 to 1.21; P=0.11). CONCLUSIONS: Nesiritide was not associated with an increase or a decrease in the rate of death and rehospitalization and had a small, nonsignificant effect on dyspnea when used in combination with other therapies. It was not associated with a worsening of renal function, but it was associated with an increase in rates of hypotension. On the basis of these results, nesiritide cannot be recommended for routine use in the broad population of patients with acute heart failure. (Funded by Scios; ClinicalTrials.gov number, NCT00475852.).

Arterial wall dysfunction in systemic lupus erythematosus.

Carotid-radial pulse wave velocity (PWV), aortic augmentation index (AIx) and endothelium-dependent flow-mediated dilatation (FMD) have been repeatedly showed to be related to premature atherosclerosis and cardiovascular diseases in different settings of population. The increased arterial stiffness and endothelium dysfunction may add to premature aging of the arteries in systemic lupus erythematosus (SLE) patients. Still data about arterial stiffness and endothelium function in inflammatory rheumatic diseases are not well described. The aim of this study was to determine the PWV, its derivate marker AIx and FMD and factors possibly influencing them in young SLE women without significant organ damage. Thirty women between 23 and 55 years with an established SLE diagnosis and 66 healthy women were consequently included in the study and both groups were comparable according to age, body mass index (BMI), serum lipid profile and creatinine. PWV was determined by measuring carotid-radial pulse wave transit time with the help of applanation tonometry and AIx, its derivate marker, was calculated as a difference between two waveform peaks expressed as a percentage of the pulse pressure. The FMD was performed by obtaining the repeated scans of the brachial artery at rest and during reactive hyperemia. In SLE women, PWV and AIx were significantly higher and FMD was not different from controls. In linear multiple stepwise regression analysis if patients and controls were both considered, PWV was weakly related to mean blood pressure (MBP), AIx was mostly predicted by age and MBP and FMD was predicted by the diameter of blood vessel, BMI, high density lipoproteins. If the sole SLE setting was analyzed, PWV was not related to any of the pending parameters, AIx turned out to be related to organ damage measured by Systemic Lupus International collaborative Clinics (SLICC) index and age, and FMD obtained strong and significant relation with vessel diameter, and BMI, and disease duration. Regardless of the small number of study group patients, we can state that controlling for MBP and taking measures towards organ damage prevention can partially slow down the process of early atherosclerosis in SLE patients.

An open-label study investigating the efficacy and safety of 12-96 weeks of telmisartan treatment in patients with hypertension.

This open-label, multicentre, multinational trial evaluated the efficacy and safety of telmisartan used alone or as add-on therapy in 2121 adults with mild-to-moderate essential hypertension. Patients received telmisartan 40-80 mg once daily for 12 weeks and could participate in the study for up to 96 weeks, or until a marketed supply of telmisartan became available. Mean change from baseline in mean seated trough diastolic blood pressure (DBP) after 12 weeks' treatment, the primary endpoint, was -11.8 mmHg in the intent-to-treat population. The corresponding mean change in mean seated trough systolic blood pressure (SBP) was -20.2 mmHg. Both changes were statistically significant. Mean DBP and SBP reductions were apparent from week 4 and maintained throughout the treatment period. Telmisartan was well tolerated; the most common adverse events were headache (6%) and dizziness (3%), and 10% of adverse events were considered drug-related. In conclusion, telmisartan is an effective and well-tolerated drug when used as monotherapy or add-on treatment in this broad population of patients.

Ability of the no-reflow phenomenon during an acute myocardial infarction to predict left ventricular dysfunction at one-month follow-up.

Despite angiographically successful opening of an infarct-related vessel within a 6-hour time frame, some patients do not recover left ventricular regional wall function in the infarct zone after an acute myocardial infarction (AMI). Recent evidence suggests that this finding is due to the no-reflow phenomenon, or failure to recover tissue perfusion despite patient epicardial arteries. We performed myocardial contrast echocardiography to assess tissue perfusion before and after opening of an infarct-related artery. Coronary angiograms, regional wall motion scoring, and myocardial contrast enhancement were graded by 3 observers. Of 24 patients with AMI, 7 (29%) failed to recover tissue perfusion in > or = 1 region of myocardium. Of 106 regions subtended by the infarct-related artery, 16 (15%), 43 (41%), and 47 (44%) regions had no-reflow, partial, or normal flow, respectively, after arterial patency was established. There was a spectrum of reperfusion patterns ranging from no-reflow to normal perfusion. One-month follow-up angiographic and myocardial contrast echocardiographic studies were performed in 12 of the 24 patients. At 1 month, all segments of myocardium that had immediate normal perfusion had regained normal wall motion. In contrast, 17 segments that had partial or no-reflow were identified. Of these 17, 3 regained normal function, 10 segments were hypokinetic, and 4 segments were akinetic. We conclude that myocardial contrast echocardiography can be used to identify the no-reflow phenomenon in up to 29% of patients with AMI. Additionally, we found that the immediate-reflow pattern can predict degree of left ventricular dysfunction at 1-month follow-up.

Quantitative assessment of transient left ventricular asynergy in coronary artery disease.

The purpose of this study was to determine the diagnostic value of quantitative two-dimensional echocardiography during transesophageal atrial pacing in assessing the presence and severity of coronary artery disease. Apical four- and two-chamber views were registered at rest and at different pacing rates. Computerized quantitative evaluation of left ventricle wall motion was performed. On the basis of left ventricle wall motion analysis data of 22 individuals with no coronary pathology, as assessed by angiography and with negative exercise ECG and transesophageal atrial pacing ECG test, nomograms for assessment of wall motion abnormalities and for calculation of asynergy area as a measure of wall motion abnormality extent were obtained. The method revealed new transient wall motion abnormalities during pacing or exacerbation of old ones present at rest in 83 of the 89 patients with angiographically proven coronary artery stenosis greater than or equal to 70% and in 3 of the 32 controls with no changes in their coronary angiograms. Thus, it showed high sensitivity (93%), specificity (91%), predictive value of positive result (96%), predictive value of negative result (83%), and efficiency of the test (93%). These values appeared to be higher than those calculated for transesophageal atrial pacing ECG, recorded simultaneously with echocardiographic images (81, 87, 95, 62, and 83%, respectively) and for exercise ECG test which was performed in 66 coronary patients and in 29 controls (68, 86, 92, 54, and 74%, respectively). The extent of pacing-induced left ventricular regional wall motion abnormalities appeared to be directly correlated to the extent of coronary artery disease.(ABSTRACT TRUNCATED AT 250 WORDS)

Computer-assisted two-dimensional echocardiography in preoperative evaluation of left ventricular function in patients with aortic valve disease.

Seventy-six healthy adults and 228 patients with aortic valve disease were studied by means of two-dimensional echocardiography (2D-EchoCG). Functional properties of the left ventricle in patients with aortic valve disease were studied by means of computer analysis of echocardiograms and patients requiring cardiac surgery were identified. It was found that an increased left ventricular (LV) end-systolic volume (110 ml and more), assessed by 2D-EchoCG, is an unfavourable prognostic sign, and elevated risk factor of cardiac surgery. It invariably proved to be related to LV dysfunction after the surgery. A decreased diastolic LV mass/volume ratio (1.255 and less), found in 16% of patients with pressure overload, means nonadequate development of hypertrophy and an elevated risk of cardiac surgery.

[Therapy of refractory ventricular tachycardia by transvenous electrical ablation]. / Therapie refraktärer ventrikulärer Tachykardien durch transvenöse, elektrische Ablation.

In 6 patients (mean age 49 +/- 11 years) with chronic recurrent ventricular tachycardia which were relatively slow during antiarrhythmic therapy and had been proven to be resistant to various antiarrhythmic drugs, catheter ablation of the site of origin of ventricular tachycardia was performed after endocardial activation and/or pace-mapping. According to the results of catheter mapping, the sites of origin of ventricular tachycardia were in the region of the infero-lateral wall (n = 3), in the anterolateral wall (n = 1) and in the right ventricle (n = 2). In 3 cases, two ablative procedures were performed as the first was only transiently successful. A total of 51 shocks was delivered (200 J 45 times, 100 J 5 times and 400 J once). The following complications were observed: multiple episodes of spontaneous, partly polymorphous ventricular tachycardia which degenerated into ventricular flutter on several episodes (n = 1); transient third degree AV-block and intermittent complete right bundle branch block (n = 1); transient ST-elevation (n = 3); and self-terminating atrial tachycardia lasting for several minutes (n = 1). Immediately after the first ablative procedure, either no ventricular tachycardia could be induced any longer (n = 2) or non-clinical ventricular tachycardia was induced (n = 2). In the remaining 2 patients, programmed ventricular stimulation was not repeated immediately at the end of the ablative procedure. During a follow-up study at the end of the first week, the clinical ventricular tachycardia could be induced again in 3 of 4 cases. In 3 cases, a second ablative procedure was performed because of recurrences of ventricular tachycardia (n = 2) or syncope (n = 1). During final follow-up (mean 4.3 +/- 3.4 months), no recurrences of ventricular tachycardia were observed in 5 cases. In one case, recurrences occurred. Therefore, an automatic cardioverter was implanted. In conclusion, these preliminary results show that catheter ablation of drug-resistant ventricular tachycardia is feasible and may be an alternative to surgical procedures.