The predictive value of retinal vascular findings for carotid artery atherosclerosis: are further recommendations with regard to carotid atherosclerosis screening needed?

Vascular retinopathy is the consequence of vascular disease, and the retina is the only place where the arteries can be visualized directly. The purpose of this study was to evaluate the predictive value of retinal vascular findings for carotid artery atherosclerosis. From December 2009 to January 2011, the carotid intima-media thickness (IMT) and total plaque area (TPA) were measured in 179 consecutive patients, who received a fundoscopic examination. The patients were divided into groups as follows: normal retinal artery (normal; n = 44), diabetic retinopathy (DR; n = 25), retinal artery occlusion (RAO; n = 17), retinal vein occlusion (RVO; n = 67), and hypertensive retinopathy (HTN-R; n = 26). The subjects were classified according to the presence of an increased (≥ 1 mm) IMT and plaque. The values of the mean carotid IMT in the patients with vascular retinopathy (DR, 0.87 ± 0.14 mm; RAO, 1.18 ± 0.47 mm; RVO, 0.84 ± 0.14 mm; HTN-R, 0.90 ± 0.20 mm) were significantly increased compared with those in the normal subjects (0.77 ± 0.13 mm). A total 77 of 135 vascular retinopathy patients demonstrated an increased IMT (57 %), and 97 vascular retinopathy patients had carotid artery plaque (72 %). The relative risk of vascular retinopathy in the prediction of an increased IMT and the presence of plaque was 2.79 and 3.95, respectively. Although The TPA was significantly increased in the patients with RAO (1.87 ± 2.67 cm(2)) and RVO (0.27 ± 0.23 cm(2)) compared with the normal subjects (0.18 ± 0.23 cm(2), all Ps < 0.05), there was no significant difference in the ipsilateral carotid IMT and TPA of the affected eye compared with that of the contralateral eye. In conclusion, vascular retinopathy demonstrated a good predictive value in identifying asymptomatic carotid artery atherosclerosis, and this was not confined to the ipsilateral carotid artery of the affected eye. Further recommendations with regard to carotid atherosclerosis screening in patients with vascular retinopathy should be considered.

Relationship between Nonalcoholic Fatty Liver Disease and Carotid Artery Atherosclerosis Beyond Metabolic Disorders in Non-Diabetic Patients.

BACKGROUND: The objective of this study was to investigate the association between nonalcoholic fatty liver disease (NAFLD) and carotid artery atherosclerosis beyond metabolic disorders. METHODS: We studied 320 non-diabetic patients with ultrasonographically diagnosed NAFLD and 313 non-diabetic patients without NAFLD who have less than 40 g alcohol/week drinking history. Carotid atherosclerotic burden was assessed by carotid intima-media thickness (IMT) and plaque. All subjects were divided to the metabolic syndrome (MetS) according to International Diabetes Federation criteria. RESULTS: NAFLD patients had a significantly increased mean carotid IMT (0.79 ± 0.18 vs. 0.73 ± 0.13 mm; p < 0.001) than those without the condition. The prevalence of increased IMT, defined as IMT ≥ 1 mm, and carotid plaque were 52.5% and 34.1% in the patients with NAFLD vs. 35.8% and 18.8% in the patients without this condition (p < 0.001). The difference in IMT and prevalence of plaque was also significant even in patients without MetS as well as those with MetS (all p < 0.05). NAFLD-associated adjusted odds ratio for increased IMT was 1.236 [95% confidence interval (CI), 1.023-1.467, p = 0.016] without MetS and 1.178 (95% CI, 1.059-1.311, p = 0.003) with MetS. NAFLD-associated adjusted odds ratio of carotid plaque was 1.583 (95% CI, 1.309-1.857, p = 0.024) without MetS and 1.536 (95% CI, 0.512-4.604, p = 0.444) with MetS. CONCLUSION: NAFLD is significantly associated with carotid atherosclerosis in non-diabetic outpatients even without MetS. Carotid screening for NAFLD might be beneficial for assessment of future atherosclerotic complications.

Impact of obstructive sleep apnea on left atrial functional and structural remodeling beyond obesity.

BACKGROUND: To evaluate the left atrial (LA) volume and function of obese patients with/without obstructive sleep apnea (OSA) and its association with left ventricular (LV) diastolic function independent of obesity. METHODS: LA volumetric and functional parameters were measured by 2-dimensional and strain echocardiography in 49 obese (body mass index ≥ 25 kg/m(2)) subjects (24 non-OSA and 25 OSA). RESULTS: OSA group showed larger maximal LA volume indexed for body surface area, larger volume before atrial contraction, a reduction in the LA passive emptying fraction, and an increase in the LA active emptying fraction with no significant change in LA total emptying fraction. Mitral annular early diastolic velocity (Ea) was significantly reduced, whereas the ratio of mitral valve early diastolic velocity (E) to Ea (E/Ea) and late diastolic velocity (Aa) were significantly increased in OSA group. Although the mean peak late diastolic strain rate had not shown any differences, the LA mean peak systolic strain/strain rate, and mean peak early diastolic strain rate were significantly lower in the OSA group. Apnea-hypopnea index (AHI) of the OSA patients was significantly correlated with E/Ea (r=0.67, p<0.001). There is a significant correlation between LA active emptying volume index and E/Ea (r=0.77, p<0.001), and between LA passive emptying volume index and E/Ea (r=-0.51, p=0.009). CONCLUSION: LA structural and functional remodeling was significantly correlated with the severity of OSA and LV diastolic filling pressure. OSA impaired LA wall compliance and passive contraction independent of obesity.

Impact of obstructive sleep apnea on the global myocardial performance beyond obesity.

We aimed to assess the impact of obstructive sleep apnea (OSA) on the left ventricular (LV) function independent of obesity using the myocardial performance index (Tei index) and the global longitudinal LV strain (GLS) and its reversibility after surgery. Twenty-five newly diagnosed OSA patients, normal weight (n = 15) and obese (body mass index [BMI] ≥ 25; n = 20) controls without OSA were enrolled and underwent transthoracic echocardiographic evaluation. The OSA and obese groups had a significantly comparable increased BMI and LV chamber dimension, prolonged isovolumic relaxation time, reduced early mitral filling velocity, and increased late mitral filling velocity and Tei index as compared to the normal weight group. However, GLS was significantly reduced only in the OSA group (-16.5 ± 1.9%) as compared to the normal weight group (-20.6 ± 2.0%, P < 0.001) and obese group (-19.1 ± 2.5%, P < 0.001). As a treatment, 13 of 25 patients underwent surgical modification, and the follow-up echocardiogram revealed significantly improved Tei index and GLS as compared to baseline (0.37 ± 0.06 and -18.9 ± 3.3% vs. 0.42 ± 0.04 and -16.3 ± 2.4%, P = 0.006 and 0.031, respectively), which was comparable to the obese controls. A reduction in the apnea-hypopnea index had a significant effect on the improvement in the GLS (r = 0.73, P < 0.001). LV systolic and diastolic function significantly deteriorated in the patients with OSA beyond obesity, and an improvement in the LV function was observed within 6 months after the surgical modification. GLS is considered to be one of the parameters that can be used in the early detection of LV systolic dysfunction in patients with OSA and a normal ejection fraction.

Perforated Mitral Valve Aneurysm in the Posterior Leaflet without Infective Endocarditis.

Aneurysm of the mitral valve, although uncommon, occurs most commonly in association with infective endocarditis of the aortic valve and true mitral valve aneurysm is a rare cause of mitral regurgitation. We report a case with perforated mitral valve aneurysm in the posterior leaflet without concurrent infective endocarditis initially mistaken diagnosis of cystic mass, which was confirmed at operation with successful mitral valve annuloplasty.

Impact of right ventricular apical pacing and its frequency on left atrial function.

BACKGROUND: Right ventricular apical (RVA) pacing induces left ventricular (LV) dyssynchrony, increases the risk of persistent atrial fibrillation in the long term. The aim was to investigate the effects of RVA pacing on left atrial (LA) function, which are unknown. METHODS: Echocardiographic evaluation including LV dyssynchrony based on conventional Doppler, tissue Doppler imaging and speckle tracking strain echocardiography was done before and after (12 months) single-chamber ventricular pacemaker implantation in 40 patients with sick sinus syndrome. Patients were divided to 2 groups, according to the RVA pacing frequency (group I had higher pacing rate of more than 50% and group II, less than 50%). RESULTS: There was no significant difference in LV ejection fraction, however, mean global LV strain, myocardial performance index, and parameters of LV dyssynchrony had shown significant changes after 12 months of RVA pacing. There were also significant increase in the LA volume index and the reduction of peak systolic LA strain and strain rate (SR), peak early and late diastolic SR after RVA pacing. Moreover, there was significant deterioration of LV dyssynchrony and both LA and LV longitudinal function in even group II. LA functional deterioration and LA volume was significantly correlated with the frequency of RVA pacing. CONCLUSION: LV dyssynchrony, induced by RVA pacing, significantly impaired active LA contraction and passive stretching, and these findings were shown in the patients with even less than 50% of RVA pacing. Impairment of LA strain/SR was significantly correlated with the frequency of RVA pacing.

Alteration of left ventricular function with dobutamine challenge in patients with myocardial bridge.

BACKGROUND/AIMS: The aim of this study was to identify changes in left ventricular (LV) performance in patients with a myocardial bridge (MB) in the left anterior descending coronary artery during resting and in an inotropic state. METHODS: Myocardial strain measurement by speckle-tracking echocardiography and conventional LV wall-motion scoring was performed in 18 patients with MB (mean age, 48.1 ± 1.7 years, eight female) during resting and intravenous dobutamine challenge (10 and 20 µg/kg/min). RESULTS: Conventional LV wall-motion scoring was normal in all patients during resting and in an inotropic state. Peak regional circumferential strain increased dose dependently upon dobutamine challenge. Longitudinal strains of the anterior and anteroseptal segments were, however, reduced at 20 µg/kg/min and showed a dyssynchronous pattern at 20 µg/kg/min. Although there were no significant differences in radial strain and displacement of all segments at rest compared with under 10 µg/kg/min challenge, radial strain and displacement of anterior segments at 20 µg/kg/min were significantly reduced compared with posterior segments at the papillary muscle level (44.8 ± 14.9% vs. 78.4 ± 20.1% and 5.3 ± 2.3 mm vs. 8.5 ± 1.8 mm, respectively; all p < 0.001), and showed plateau (40%) or biphasic (62%) patterns. CONCLUSIONS: Reduced LV strain of patients with MB after inotropic stimulation was identified. Speckle-tracking strain echocardiography identified a LV myocardial dyssynchrony that was not demonstrated by conventional echocardiography in patients with MB.

Arterial stiffness in female patients with fibromyalgia and its relationship to chronic emotional and physical stress.

BACKGROUND AND OBJECTIVES: In patients with fibromyalgia (FM) syndrome, stress and pain may chronically enhance sympathetic activity, altering cardiovascular responses and inducing the arterial wall-stiffening process. We investigated arterial stiffness in FM patients using pulse wave velocity (PWV) and analyzed whether arterial stiffness was affected by the clinical parameters of FM. SUBJECTS AND METHODS: This study included 108 female FM patients (51.5±8.9 years) without any known cardiovascular diseases and 76 healthy female controls (50.1±8.9 years). FM patients underwent a manual tender point survey for tender point counts, and completed the visual analogue scale (VAS) of pain and fibromyalgia impact questionnaire (FIQ), which were composed of a physical and feel score. Brachial-ankle pulse-wave velocity (baPWV) was measured with an automated device. The study participants were subdivided into 2 groups based on the sum of the FIQ score (group A: FIQ ≥50, group B: <50). RESULTS: Patients with FM had significantly higher baPWV than the controls, and significant increase were noted in baPWV values of group A compared with those of group B. BaPWV showed a significant positive correlation (correlation coefficient=6.83, p=0.022) with severity of disease assessed by FIQ. CONCLUSION: The patients with FM showed significantly increased arterial stiffness, suggesting a pathophysiologic link between FM and endothelial dysfunction. This study provides a basis for clarifying the mechanism by which chronic pain syndrome is associated with an increased risk of vascular stiffness.

Dual fistulas of ascending aorta and coronary artery to pulmonary artery.

Coronary artery fistula to pulmonary artery is common. However, to the best of our knowledge, a case of coronary artery fistula to pulmonary artery associated with aortopulmonary fistula remains unreported. We herein report a 64-year-old female with a left anterior descending coronary artery and ascending aorta to pulmonary artery fistulas, and conduct a brief review of the literature.

Assessment of endothelial function in patients with fibromyalgia--cardiac ultrasound study.

In patients with fibromyalgia (FM) syndrome, stress and pain may chronically enhance sympathetic activity, altering cardiovascular response and inducing endothelial dysfunction. We investigated endothelial function in FM patients using echocardiography and analyzed whether endothelial function was affected by the clinical parameters of FM. Fifty-five postmenopausal women with FM and 35 healthy controls were included. Endothelial function was examined by brachial artery flow-mediated dilatation (FMD, endothelium dependent) and response to 40 µg of sublingual nitroglycerine (NTG-induced dilatation, endothelium independent). FM patients underwent manual tender point survey and completed visual analogue scale (VAS) of pain and fibromyalgia impact questionnaire (FIQ). The study participants were subdivided into two groups based on the sum of the FIQ score (group A, FIQ ≥ 50, group B, <50). The FMD value (5.7 ± 3.9% vs. 7.0 ± 1.4%, P = 0.008) and NTG-induced dilatation (12.5 ± 5.1% vs. 14.7 ± 2.5%, P = 0.006) were significantly lower in FM group than healthy control. There were no significant differences in FMD between groups A and B (5.4 ± 3.3% vs. 6.6 ± 3.5%, P = 0.19). However, significant decreases were noted in NTG-induced dilatation values of group A compared with those of group B (11.0 ± 4.4% vs. 14.3 ± 3.8%, P = 0.004). FMD and NTG-induced dilatation showed a significant inverse association with pain VAS and FIQ. Pain exerts a negative effect on endothelial function in FM patients, and that effect was significantly different according to the FIQ score.

A rare case with primary undifferentiated carcinoma of pericardium.

A primary pericardial tumor is very rare. A 77-year-old woman was admitted to our hospital with chief complaint of exertional dyspnea due to large amount of pericardial effusion. She was finally diagnosed as pericardial undifferentiated carcinoma without definite histopathologial, immunochemistry feature. Despite palliative radiation therapy, the patient died of multiple organ failure. The prognosis of primary pericardial undifferentiated carcinoma is known to be very poor, especially in old people.

Assessment of myocardial function in patients with fibromyalgia and the relationship to chronic emotional and physical stress.

BACKGROUND AND OBJECTIVES: An association between emotional or physical stressful triggers and adverse cardiovascular events, such as death and myocardial infarction, has been recognized for many years. The clinical features of transient left apical ballooning syndrome have been clearly described, but the effect of chronic stress on the myocardium is unknown. Our objective was to assess left ventricular (LV) function in patients with fibromyalgia (FM) with chronic emotional and physical stress. SUBJECTS AND METHODS: We investigated 30 consecutive postmenopausal women (mean age, 48+/-8 years) satisfying the criteria for FM with atypical chest pain and 20 age-matched healthy controls by means of standard and 2-dimensional strain (2DS) echocardiography. Patients with hypertension, coronary heart disease, or diabetes were excluded. Global and segmental longitudinal deformation parameters of LV function from 3 apical views were analyzed, and patients underwent a manual tender point survey for the number of tender points and tender point counts, and completed the Fibromyalgia Impact Questionnaire (FIQ), which was comprised of physical and feel scores, the Brief Fatigue Inventory (BFI), and the Beck Depression Inventory (BDI). RESULTS: Both global and segmental longitudinal LV strains were significantly reduced in FM patients with high FIQ scores (>50) compared to FM patients with low FIQ scores (-18.98% vs. -22.72%). Various emotional and physical stress indexes were significantly correlated with global LV strain. CONCLUSION: Global and segmental LV strains were negatively associated with fatigue, tender point count, and FIQ score. However, there was no significant association between depression and LV strain. This study demonstrated that chronic emotional or physical stress in FM patients might reduce myocardial longitudinal deformation.

N-terminal pro-B-type natriuretic Peptide in overweight and obese patients with and without diabetes: an analysis based on body mass index and left ventricular geometry.

BACKGROUND AND OBJECTIVES: Several recent studies have shown that there is an inverse relationship between plasma B-type natriuretic peptide (BNP) and body mass index (BMI) in subjects with and without heart failure. Obesity frequently coexists with diabetes, so it is important to consider the relationship between diabetes and natriuretic peptide levels. We evaluated the influence of diabetes on the correlation of BNP and BMI. SUBJECTS AND METHODS: We examined 933 patients with chest pain and/or dyspnea undergoing cardiac catheterization between Feb. 2006 and Nov. 2007 in the Maryknoll cardiac center who had creatinine levels <2.0 mg/dL and normal systolic heart function. BMI was checked, transthoracic echocardiography was performed, and aminoterminal pro-brain natriuretic peptide (NT-proBNP) was sampled at the start of each case. RESULTS: In 733 non-diabetic patients, mean plasma NT-proBNP levels of non obese individuals (BMI <23 kg/m(2)), overweight individuals (23/=25 kg/m(2)) showed a significant negative correlation with increasing BMI (856.39+/-237.3 pg/mL, 601.69+/-159.6 pg/mL, 289.62+/-164.9 pg/mL, respectively, p<0.0001). However, in 200 diabetic patients, the correlation between BMI and NT-proBNP was not significant (r=-0.21, p=0.19), and NT-proBNP did not correlate with mitral E/Ea in obese diabetic patients (r=0.14, p=0.56). NT-proBNP was significantly correlated with mitral E/Ea in the non-obese (r=0.24, p=0.008) and non diabetic (r=0.32, p=0.003) groups. Left ventricular (LV) mass index was significantly correlated with NT-proBNP in all BMI groups (r=0.61, p<0.001), and patients with concentric cardiac hypertrophy showed the highest NT-proBNP levels. CONCLUSION: The present study demonstrates that obese patients have reduced concentrations of NT-proBNP compared to non obese patients despite having higher LV filling pressures. However, NT-proBNP is not suppressed in obese patients with diabetes. This suggests that factors other than cardiac status affect NT-proBNP concentrations.