Relationship between Fragmented QRS and Microvascular Dysfunction in Masked Hypertension.

Aim: The aim of this study was to investigate the presence of fQRS and its association with subclinical systolic and microvascular dysfunction in patients with masked hypertension (MH). Methods: The study population consisted of 95 (mean age 48.9 ± 11.3, 61% males) subjects with MH and 80 age- and gender-matched healthy individuals who served as a control group. Coronary flow reserve (CFR) using transthoracic echocardiography and for left ventricular global longitudinal strain (LVGLS) using speckle-tracking strain imaging were performed. Patients with MH were stratified into two groups according to the presence of fQRS on surface electrocardiogram. Results: Fragmented QRS was more common among MH patients compared with controls (38.9% vs. 6.25%, p < 0.003). CFR was significantly lower in patients with fQRS compared with those without fQRS and controls (p < 0.001). Likewise, LVGLS values were lower in MH patients with fQRS (p < 0.001) compared with subjects without fQRS and controls. Fragmented fQRS was significantly correlated with systolic blood pressure, CFR, and LVGLS. Multivariate analysis showed that the presence of fQRS, number of leads, and CFR were independent predictors of subclinical systolic dysfunction. With ROC cure analysis, number of leads with fQRS ≥4 was the optimal value for predicting the presence of subclinical systolic dysfunction in subjects with MH. Conclusions: Fragmented QRS is more frequent among subjects with MH compared with controls. The presence of fQRS is related with pronounced subclinical left ventricular systolic dysfunction. Furthermore, CFR was significantly reduced in subjects with MH, a finding supposed that microvascular dysfunction to be a mechanistic link.

Usefulness of Stress-Derived E/e' Ratio in Asymptomatic Hypertensive Patients.

PURPOSE: We sought to investigate the usefulness of stress echocardiography-derived E/e' in predicting subclinical atherosclerosis in asymptomatic hypertensive patients. MATERIALS AND METHODS: 71 newly diagnosed untreated hypertensive patients (48 ± 13 years, 65% males) and 30 age- and sex-matched healthy controls were recruited. Resting and exercise echocardiography was performed to assess resting diastolic blood pressure and the diastolic stress parameters. Coronary flow reserve (CFR) was evaluated as well. RESULTS: Based on CFR values, newly diagnosed, untreated hypertensives were stratified into hypertensives with microvascular dysfunction (MVD; 34 patients had CFR <2.0) and those without MVD (37 patients had CFR ≥2.0). Patients with MVD had a significantly higher C-reactive protein level (p < 0.05) and lower metabolic equivalent values (p < 0.05). With resting echocardiography, only the left atrial volume index (LAVI) was significantly increased in those with MVD compared with those without MVD and controls (p < 0.05). With exercise echo, the E/e' was significantly increased in MVD patients compared with those without MVD and controls (p < 0.001). Importantly, the percentage of subjects with exercise E/e' ≥15 was 76.5% (26 patients in the group with MVD), 4.1% (3 patients in the group without MVD), and 0% in controls. At univariate analysis, high-sensitivity C-reactive protein (p < 0.05), LAVI (p < 0.05), and exercise E/e' (p < 0.001) were independently associated with reduced CFR. On the other hand, at multivariate analysis, only exercise E/e' was the independent predictor of reduced CFR in newly diagnosed hypertensives. CONCLUSION: We have demonstrated significant associations between exercise-derived raised left ventricular pressure and coronary MVD in newly diagnosed untreated hypertensive patients. Herein, we supposed that exercise-derived E/e' could predict subclinical atherosclerosis and might be a risk parameter for newly diagnosed untreated hypertensive patients.

Presence of Microvascular Dysfunction and CHA2DS2-VASc Score in Patients with ST-Segment Myocardial Infarction after Primary Percutaneous Coronary Intervention.

OBJECTIVE: We aimed to investigate the relation between CHA2DS2-VASc score and microvascular dysfunction (MVD) assessed by the index of microvascular resistance (IMR) immediately after primary percutaneous intervention (PPCI) for patients with ST-segment elevation myocardial infarction (STEMI). SUBJECTS AND METHODS: The study included 115 consecutive patients with STEMI who underwent successful PPCI. Angiographic results of reperfusion were inspected to evaluate the association of high CHA2DS2-VASc score and IMR. Also, we assessed echocardiographic changes with respect to CHA2DS2-VASc score. RESULTS: Subjects were stratified into 2 groups based on IMR

Resting Left Ventricular Dyssynchrony and Mechanical Reserve in Asymptomatic Normotensive Subjects with Early Type 2 Diabetes Mellitus.

BACKGROUND: Most diabetic patients have silent ischemia and cardiac dysfunction that is usually observed in the late phase of the disease when it becomes clinically obvious. We hypothesized that left ventricular dyssynchrony (LVdys) (or dispersion) is an early marker of myocardial involvement in asymptomatic early type 2 diabetes mellitus (T2DM) patients. Therefore, we aimed to detect early markers of myocardial dysfunction in early T2DM using LVdys and left ventricular mechanical reserve (LVMR). METHODS: We examined 91 consecutive subjects with early T2DM with speckle tracking imaging to evaluate LVdys and with dobutamine stress to evaluate LVMR (defined as left ventricular mechanical reserve global longitudinal strain [LVMRGLS] ≥2%). Our patients were divided into two groups according to LVdys: group 1 with LVdys (n = 49), and group 2 without LVdys (n = 42). RESULTS: We found that 49 (54%) subjects in our cohort had resting LVdys (standard deviation of tissue synchronization of the 12 left ventricular segments [Ts-SD-12] ≥34.2 ms). GLS and strain rate were comparable at rest between patients with and without LVdys. On the other hand, LVMR was blunted in those with LVdys (p < 0.001). We found that HbA1c, high-sensitivity C-reactive protein, and left atrial volume index were inversely correlated with LVMR. Multivariate analysis showed that LVdys was the strongest predictor (p < 0.001) of blunted LVMR. Using receiver operating characteristic curve analysis, we found that a Ts-SD-12 ≥36.5 ms was the best cutoff value to predict blunted LVMR (area under the curve = 0.89, p < 0.001). CONCLUSION: The LVdys (Ts-SD-12) cutoff ≥36.5 ms was the optimal value for prediction of impaired LVMR and might be an early marker of subclinical cardiac dysfunction and risk stratification of subjects with asymptomatic early T2DM with preserved left ventricular ejection fraction.

Blood Pressure Variability and Atrial Fibrillation in Patients with Acute ST Segment Elevation Myocardial Infarction: The Relation with Left Atrial Electromechanical Delay - A 1-Year Follow-Up Study.

PURPOSE: To investigate the association between 24-h blood pressure variability (BPV) and atrial electromechanical delay (EMD) in patients with ST segment elevation myocardial infarction (STEMI) who developed new-onset atrial fibrillation (NOAF). MATERIALS AND METHODS: A total of 175 STEMI patients (age 56.6 ± 10.5 years) who underwent primary percutaneous coronary intervention were subjected to in-hospital 24-h ambulatory BP monitoring, comprehensive echocardiography, and assessment of atrial EMD. The parameters of BPV analyzed were: (a) 24-h standard deviation (SD), (b) the coefficient of variation, and (c) the average of the daytime and nighttime SDs weighted for the duration of the daytime and nighttime interval (SDdn ). RESULTS: Based on the median of BPV index (SDdn) = 9.5 mm Hg of all participants, patients were stratified into low and high variability groups (SDdn: 7.1 ± 1.5 vs.13.5 ± 2.9; p < 0.001). Of the 175 patients with STEMI, 29 (16.7%) patients developed NOAF; 26 (28.9%) were in the high variability group and 3.5% were in the low variability group (p < 0.001). Echocardiographic data showed that the left atrial volume index (p < 0.01) and E/e' ratio (p < 0.001) were significantly higher in patients with high BPV. Inter and intra-atrial EMD were significantly increased in the high variability group compared to the low variability group (p < 0.001). With multiple linear analysis, there was significant correlation between SDdn and intra-left atrial and inter-atrial EMD (p < 0.001 and <0.01, respectively). Cox regression analysis revealed that SDdn and intra-atrial EMD were independent predictors for NOAF in patients with STEMI (OR = 3.75 and 02.72, respectively; p < 0.001). ROC analysis revealed that SDdn ≥12.8 was the optimal cut-off value for predicting NOAF during follow-up. CONCLUSIONS: Short-term BPV was associated with NOAF during the 1-year follow-up in patients with STEMI. In addition, BPV was correlated significantly with atrial EMD. Herein, BPV was predicted to be an early predictor of NOAF in patients with STEMI.

Relation between left atrial strain and exercise tolerance in patients with mild mitral stenosis: An insight from 2D speckle-tracking echocardiography.

BACKGROUND: Mild mitral stenosis (MS) is a progressive disease but unfortunately, its clinical course is still unclearly studied. We aimed to study the left atrial (LA) deformation in such patients and how it is related to exercise intolerance. METHODS: Seventy-five patients with mitral valve area of 1.81 ± 0.13 cm2 and 40 healthy control subjects were enrolled. All participants had sinus rhythm, and they underwent conventional echocardiography and LA strain analysis with speckle-tracking study. The following parameters were obtained: left atrial reservoir strain (LAS-s), LA conduit strain (LAS-e), and LA contraction strain (LAS-a). All participants underwent symptoms limited stress ECG using modified Bruce protocol. RESULTS: Comparing with control subjects, patients with mild MS had significant lower LAS-s value (P < .01) and LAS-e (<0.03). Patients with exercise intolerance (METs < 8) had lower LAS-s (P < .001), LAS-e (P < .01), and LAS-a (P < .05) values compared to those with METs ≥ 8. We found that METs was significantly related to LAS-s (P < .001), brain natriuretic peptide (P < .001), and Δ TAPSE (P < .03). Multivariate analysis showed that LAS-s was an independent predictor of reduced exercise capacity. With ROC analysis, LAS-s ≤ 26.5% was the optimal value for prediction of exercise intolerance in patients with mild MS. CONCLUSION: A significant percentage of patients with mild mitral stenosis had exercise intolerance. We found that LAS-s was significantly associated with exercise capacity in patients with mild MS. Hence, we thought that LA deformation could be of great value in the follow-up of patients with mild MS.

Relation of microvascular dysfunction and exercise tolerance in patients with heart failure with preserved ejection fraction.

PURPOSE: We aimed to investigate the association of coronary flow reserve (CFR) with exercise tolerance (ET) in subjects with heart failure with preserved ejection fraction (HFpEF). MATERIALS AND METHODS: Seventy-seven patients with HFpEF were recruited for the study and compared with 30 healthy matched age and sex controls. All subjects underwent comprehensive echocardiographic evaluation. Exercise tolerance was assessed using 6-minute walking test (6 MWT). CFR was calculated with adenosine stress transthoracic Doppler echocardiography. RESULTS: Out of 77 patients with HFpEF, 51 (66%) had CFR < 2.0. Patients with CFR < 2.0 had lower 6 MWT distance (P < .001), increased E/e' ratio (P < .001), when compared to HFpEF patients with CFR ≥ 2.0 and controls. In subjects with HFpEF, CFR was significantly correlated with 6 MWTD (P < .001) and inversely correlated with E/e" (P < .01). With univariate analysis, the results showed that left ventricular mass index, left atrial volume index, E/e', and CFR were independent predictors for reduced exercise tolerance, whereas at multivariate analysis, reduced CFR was the only independent predictor (P < .001) for both reduced exercise tolerance in patients with HFpEF. CONCLUSION: The current study demonstrated that reduced CFR was an independent predictor for reduced exercise tolerance in patients with HFpEF. We supposed that microvascular dysfunction has an important role in pathogenesis and clinical course in subjects with HFpEF.

Ventricular Dyssynchrony based on echocardiographic variables and exercise tolerance After right ventricular pacing: Impact of alternative septal lead locations.

OBJECTIVE: We investigated the impact of alternative locations of right ventricular (RV) pacing on left ventricular function and its relation to exercise capacity. METHODS: Fifty patients who received a single lead pacemaker were divided according to RV pacing site into group 1 "high septum" (n = 15), group 2 "mid-septum" (n = 25), and group 3 "low septum" (n = 10) using a documented fluoroscopic method. Dyssynchrony parameters were obtained using different echocardiographic parameters. Their exercise tolerance was evaluated after 6 months of pacemaker implantation using 6 minutes walk test (6 MWT). RESULTS: We found a lesser degree of dyssynchrony in mid-location and high location compared with low location pacing (radial dyssynchrony: P < .001; maximum temporal difference: P < .01; inter-ventricular mechanical delay: P < .05, standard deviation of time-to-peak strain by tissue Doppler: P < .05). Sm was significantly increased 6 months following pacemaker implantation in group 1 and group 2 in contrast to group 3 patients (P < .05). Importantly, E/e' increased significantly (P < .001) in patients with low septal location pacing. Furthermore, 6 MWT distance was significantly improved (P < .001) in favor of groups 1 and 2. Importantly, the intra-ventricular dyssynchrony with speckle tracking was considerably less in group 1 and 2 patients. Tps-SL ≤ 120 ms was the optimal value to predict improvement in functional capacity following high to mid-septal pacing locations. CONCLUSION: There was significant improvement of functional capacity after RV pacing in high and mid-septal locations compared with low septal location. This was associated with a lesser degree of dyssynchrony in favor with mid- to high septal location.

Right ventricular mechanics and exercise capacity in patients with microvascular angina: The impact of microvascular function.

OBJECTIVES: We planned to assess the right ventricular mechanics in subjects with typical chest pain and angiographically normal coronary arteries (microvascular angina [MVA]) and to search for an association between right ventricular mechanics, coronary flow reserve, and exercise tolerance. METHODS: Seventy-one patients with MVA (mean age of 48.5 ± 7.9 years, 63% female) and 30 healthy control subjects were recruited. Right ventricular mechanics were calculated utilizing speckle tracking imaging. The exercise capacity was assessed by metabolic equivalents (METs). Coronary flow reserve (CFR) was calculated as the ratio between hyperemic (in response to intravenous adenosine) diastolic peak flow velocity and the basal diastolic peak velocity. RESULTS: Coronary flow reserve (a surrogate marker of microvascular dysfunction) was diminished in MVA patients compared with the control group (2.41 ± 0.35 vs 3.35 ± 0.5; P < .03). Patients with lower right ventricular global longitudinal strain (RVGLS) and right ventricular global longitudinal strain rate (RVGLSr) had a considerably lower CFR (P < .001) and a significantly lower MET (P < .001) than patients with normal RV mechanics. Right ventricular global longitudinal strain and RVGLSr were significantly correlated with both CFR and METs in subjects with MVA. Receiver operating characteristic (ROC) curve analysis demonstrated that RVGLS ≤ -14.5 was the best cutoff value for the prediction of impaired exercise tolerance in patients with MVA. CONCLUSION: We suggested that impaired right ventricular mechanics in subjects with microvascular angina was associated with reduced exercise capacity. Moreover, right ventricular mechanics is significantly correlated with coronary flow reserve. Henceforth, right ventricular mechanics might be of value for both risk stratification and follow-up in cases with microvascular dysfunction.

Association between fragmented QRS and exercise intolerance in hypertensive patients: the relation with coronary flow.

OBJECTIVE: We aimed to investigate the relation between the presence of fragmented QRS (FQRS) and exercise intolerance as assessed by 6 minute walking test (6MWT) and its association with coronary flow reserve (CFR). METHODS: One hundred and twenty patients with hypertension (age: 47.3 + 6.9) who were never treated and without left ventricular hypertrophy underwent 6MWT. Echocardiographic examination was obtained for all patients. CFR was calculated as the hyperemic to baseline mean velocity ratio (hyperemia was induced by intravenous adenosine 0.14 mg/kg/min). Patients were stratified into one group with FQRS and another group without FQRS. Forty-eight normotensive subjects with a mean age of 45.7 + 5.3 were recruited and served as a control group. RESULTS: The frequency of FQRS was 49% in hypertensive patients versus 2% in control subjects. Patients with FQRS had higher systolic blood pressure (p < .05; <.01), a significant lower 6MWTD (p < .001), increased LAVI (p <.05), increased E/e' ratio (p < .01) and lower CFR (p < .001) compared with those without FQRS and controls. FQRS was inversely correlated with CFR (-0.531; p < .001) and 6 MWTD (-0.415; p < .001) and positively correlated with E/e' (0.352, p < .02) and LAVI (0.296; p < .05). By a multivariate regression analysis, FQRS (OR = 6.13; p < .001) and CFR (OR = 3.28; p < .001) were the only two independent predictors for decreased 6 MWTD in hypertensive patients. Importantly the ≥3 cutoff number of leads was found to be the best predictor of CFR < 2.0 in hypertensive patients. CONCLUSION: FQRS is frequent and an independent predictor of reduced exercise tolerance in hypertensive patients. More so, it is significantly associated with decreased CFR and left ventricular diastolic dysfunction. In light of these findings, fragmented QRS might be considered a simple marker for risk stratification of hypertensive patients.

Fragmented QRS complex is an independent predictor of plaque burden in patients at intermediate risk of coronary artery disease.

OBJECTIVE: We aimed to evaluate the relationship between fragmented QRS complex and plaque burden in patients presented with typical chest pain and deemed to have intermediate pretest probability of CAD using coronary computed tomography angiography (CCTA). METHODS: We studied electrocardiograms (ECGs) obtained from 172 subjects (47.5 ± 9.5 years, 125 were men) presented with chest pain and had intermediate pretest probability for CAD. The presence was found and evaluation of CAD was performed with CCTA. RESULTS: Seventy four (43%) of the study cohort had CCTA-documented CAD. Meanwhile the frequency of fQRS in our cohort was (57%). 70 (71.4%) patients with fQRS had CAD compared with only 4 (5.4%) patients without fQRS (p < 0.001). The number of leads with fQRs was correlated with the calcium score (p < 0.005), segment stenosis score, segment involvement score, total plaque score (TPS), and E/e ratio (p < 0.001, for all). Multivariate analysis demonstrated that fQRS was a strong independent predictor for CAD (or = 2.15, p < 0.001). ROC analysis showed that the number of leads ≥3 was the optimal number for predicting CAD (AUC = 0.89, sensitivity 88%, and specificity 83%, p < 0.001). CONCLUSION: Fragmented QRS was seen more often in patients with high plaque burden. We suggest that fQRS might provide a useful noninvasive prognosticator for subjects with intermediate pretest probability of CAD for further investigation.

Interatrial septal fat thickness and left atrial stiffness are mechanistic links between nonalcoholic fatty liver disease and incident atrial fibrillation.

BACKGROUND AND AIM: Recently, a clear evidence suggests that nonalcoholic fatty liver disease (NAFLD) is associated with an increased risk of incident atrial fibrillation (AF). Yet, the underlying pathogenesis is speculative. Thereby, we aimed to investigate the hypothesis that, interatrial thickness (IAST) and left atrial stiffness (LASt) might have mechanistic links between NAFLD and AF. METHODS: Echocardiography and speckle-tracking assessment of left atrial function, transient elastography (TE) of the liver, basal ECG, and Holter monitoring were performed in 180 patients with (NAFLD) and 80 subjects without NAFLD. RESULTS: Patients with NAFLD had higher values of IAST (P < 0.001), LASt (<0.001), and E/e' ratio (<0.003) compared with controls. IAST was correlated with LASt (r = 0.413; P < 0.001). 15.6% of patients with NAFLD had AF. More so, patients with increased IAST/LASt had a higher incidence of AF (25%) vs 3.8% in those with normal IAST/LASt. The LASt and IAST increased significantly in those with AF compared with those without (P < 0.001). Patients who experienced AF had higher values (P < 0.01) of TE (kPa). The degree of liver stiffness TE (kPa) was correlated with both IAST and LASt (r = 461, r = 0.535; P < 0.001). Furthermore, multivariate regression analysis showed that LASt and IAST were independent predictors of incident AF in subjects with NAFLD. CONCLUSIONS: Our data suggest that increased IAST and LASt index are independently associated with incident atrial fibrillation in patients with NAFLD. Increased IAST and LASt index might provide mechanistic links between NAFLD and incident atrial fibrillation.

Determinants and impact of masked hypertension in offspring of patients with diabetes: relation with coronary flow and cardiac function.

OBJECTIVE: We aimed to evaluate the prevalence, determinants and clinical impact of masked hypertension in offspring of patients with diabetes. Masked hypertension was defined according to guidelines as daytime ambulatory blood pressure monitoring "ABPM" ≥135/85 mmHg and clinic BP <140/90 mmHg. METHODS: 100 nondiabetic offspring of patients with diabetes and 60 offspring of healthy people were enrolled; 24-h ABPM was applied to evaluate mean 24-h systolic/diastolic blood pressure "BP", daytime, nighttime and night dipping readings. Left ventricular parameters and coronary flow reserve of the left anterior descending artery (induced by adenosine 0.14 mg/kg/min) was calculated in all offspring. RESULTS: 29% of offspring of patients with diabetes had masked hypertension compared to only 3.3% offspring in healthy people (p < 0.001). Compared with those without masked hypertension, offspring with masked hypertension had a significantly reduced coronary flow reserve (p < 0.001), significantly higher E/e' (p < 0.01), [a surrogate marker of left ventricular filling pressure], more microalbuminuria (p < 0.01), and higher values of high-sensitive C-reactive protein "CRP" (p < 0.001). Multivariate regression analysis showed that, fasting blood glucose, and high-sensitive CRP, were independently associated with masked hypertension, whilst daytime systolic BP and non-dipping systolic BP were the strongest predictors for masked hypertension. Logistic regression analysis revealed that masked hypertension was independently associated with reduced coronary flow reserve (p < 0.0001) and diastolic dysfunction (p < 0.001). CONCLUSION: Masked hypertension is prevalent in offspring of patients with diabetes and significantly associated with reduced coronary flow reserve and left ventricular diastolic dysfunction. These findings suggest that offspring of patients with diabetes constitute a high risk group and deserve close follow up, mainly with the use of ABPM.

Right ventricular dyssynchrony and functional capacity before and after percutaneous balloon mitral valvuloplasty in patients with mitral stenosis: Determinants and clinical impact.

OBJECTIVE: We aimed to investigate the utility of right ventricular (RV) dyssynchrony to assess functional capacity utilizing 6-minute walking test distance (6MWTD) and to measure brain natriuretic peptide levels (BNP) in patients with mitral stenosis (MS) and to study its value to predict adverse outcome following percutaneous balloon mitral valvuloplasty (PBMV). METHODS: A total of 108 patients with moderate to severe MS (26.5 ± 7.5 years) were included in this study. All were candidates for PBMV. RV strain curves were obtained using two-dimensional speckle-tracking echocardiography, and standard deviation (SD) of 4 segments without RV apex (-SD4) was also assessed. 6MWT and BNP were before and after 12 months following PBMV. RESULTS: RV-SD4 was significantly prolonged in patients with MS compared with controls (P < 0.001). Patients with 6MWTD ≤300 m had a significantly increased RV-SD4 (P < 0.001) and had higher BNP values (P < 0.03) compared with those with 6MWTD >300 m. RV-SD4 showed a strong correlation with 6MWT and BNP level. RV-SD4 was the strongest independent predictor of adverse outcome following PBMV (P < 0.0001). Receiver operating characteristic analysis showed that RV-SD4 ≥24 ms was the cutoff value which predicts the adverse outcome following PBMV. A considerable improvement of mean 6MWT with significant reduction of BNP levels after 12 months of follow-up (P < 0.001) in subjects with RV dyssynchrony <24 ms. CONCLUSION: Right ventricular dyssynchrony is a useful predictor of functional status, as assessed with 6MWTD and BNP level in patients with MS. Furthermore, it might be considered as an independent predictor of adverse outcome following PMBV.

Association of morning blood pressure surge with carotid intima-media thickness and cardiac dysfunction in patients with cardiac syndrome-X.

Background & hypothesis: We hypothesized that exaggerated morning blood pressure surge, may contribute in cardiac dysfunction and arterial stiffness in patients with cardiac syndrome X. Thus we investigated the impact of morning blood pressure surge on cardiac function and carotid intima-media thickness in subjects with cardiac syndrome X. METHODS: We studied patients with cardiac syndrome X using ambulatory blood pressure monitoring and investigated the association of morning blood pressure surge with carotid intima thickness, left atrial volume index and left ventricular filling (E/e'). Seventy patients with cardiac syndrome X were enrolled for the study and compared with 70 age and sex matched controls. RESULTS: Patients with cardiac syndrome X were stratified based on the systolic morning blood pressure surge value of control subjects to patients with exaggerated blood pressure surge (n = 42) and those with normal morning blood pressure surge (n = 28). Basal heart rate (p < .05), high sensitive C-reactive protein (p < .01), left atrial volume index (p < .01), E/e' (p < .01); carotid intima-media thickness (p < .001) and percentage of detected plaque (p < .005) were significantly higher in patients with exaggerated morning blood pressure surge group than those with morning blood pressure surge group. Morning blood pressure surge was significantly correlated with carotid intima-media thickness, high sensitive C-reactive protein, left atrial volume index and E/e' ratio in patients with cardiac syndrome X. In multivariate analysis, exaggerated morning blood pressure surge was the only independent predictor of increased carotid intima-media thickness (OR = 2.379; p < .001), and diastolic dysfunction (OR = 2.464; p < .001) in patients with cardiac syndrome X. CONCLUSION: Our data suggest that excessive morning blood pressure surge is an independent predictor for arterial stiffness and diastolic dysfunction in patients with cardiac syndrome X.

Association between left atrial stiffness and aortic plaque thickness in hypertensive patients with stroke.

OBJECTIVE: Our aim was to investigate the relation between left atrial stiffness (LASt) and thoracic aortic plaque thickness in hypertensive patients with stroke. METHOD: A total of 97 hypertensive patients were recruited (age: 59.2 ± 7.5 years), including 56 consecutive patients with undefined stroke and 41 age-matched hypertensive patients without stroke. Left atrial strain and stiffness were measured using speckle tracking echo. Thoracic aortic plaque detection and evaluation was performed using transesophageal echocardiography. RESULTS: Hypertensive patients with stroke, when compared with those without stroke, had a significantly higher LASt value (P < .001). The percentage of plaque 1-4 mm thickness were comparable in both groups (23.2% vs 21.9%; P > .05). While the percentage of plaque ≥4 mm thickness was much higher in hypertensive patients with stroke (71.4% vs 4.9%; P < .001). LASt was considerably increased in hypertensive group with paroxysmal atrial fibrillation (PAF) when compared to hypertensive group without PAF (P < .01). A significant positive correlation was found between the LASt and plaque thickness (P < .001). Multivariate analysis showed that LASt was the strongest independent predictor for ≥4 mm aortic plaque thickness (Hazard ratio = 6.153; P < .001). With receiver operating characteristic (ROC) curve analysis, LASt > 0.63 was the best cutoff value in predicting aortic plaque thickness ≥ 4 mm. CONCLUSION: Left atrial stiffness was significantly associated with aortic plaque thickness ≥ 4 mm, in hypertensive patients with stroke. These finding prevailed the importance of LASt in risk stratification of hypertension.

Ventricular dyssynchrony as a marker of latent carditis in children with acute rheumatic fever: A tissue Doppler imaging.

OBJECTIVE: We aimed to investigate the hypothesis that the presence of left ventricular (LV) dyssynchrony in children with acute rheumatic fever (ARF) children may be a predictor of latent rheumatic carditis. METHODS: Eighty-nine children with ARF and 45 healthy control children were included the study. LV dyssynchrony was investigated by color-coded tissue Doppler imaging. RESULTS: LV dyssynchrony parameters including Ts-SD-12, Ts-12, Ts-SD-6, and Ts-6 were found to be prolonged in children with ARF than in controls (P < .001). We found that 45.2% in children with ARF without carditis had LV dyssynchrony (Ts-SD-12 ≥ 34.4 ms), while 63.4% in children with ARF with carditis had LV dyssynchrony. Follow-up analysis demonstrated that children with arthritis and without dyssynchrony had no adverse events (recurrent rheumatic activity, development of valvular diseases; heart failure and atrial fibrillation), while those with LV dyssynchrony had events rate of 40.9% (P < .001). Likewise, children with carditis had event rates of 63.4%. Ts-SD-12 was found to be correlated with hs-CRP (r = .63; P < .001). Receiver-operating characteristic (ROC) curve analysis showed that a Ts-SD-12 ≥ 36.5 was the optimal cutoff value in predicting unfavorable outcome in patients with ARF, with a sensitivity of 95% and specificity of 82%. CONCLUSIONS: We found that children with ARF without any evidence of carditis had a significant LV systolic dyssynchrony spite of normal EF. LV dyssynchrony in those children had a significant event rates on follow-up. These results highlighted the incremental value of LV dyssynchrony as a marker of subclinical carditis in children with ARF.

Atrial dyssynchrony and left atrial stiffness are risk markers for cryptogenic stroke in patients with patent foramen ovale.

OBJECTIVE: The clinical and echocardiographic parameters associated with the risk predictors of cryptogenic stroke (CS) in patients with patent foramen ovale (PFO) still diverse and with a great debate. We hypothesized that left atrial stiffness (LASt) and atrial dyssynchrony may increase the risk of CS in patients with PFO. METHODS: A total of 129 consecutive patients presented without clinical reasoning of stroke were recruited. Transesophageal echocardiographic assessment was performed to investigate the presence of PFO. PFO was identified in 52% (group I) and absent in 48% (group II). Utilizing speckle-tracking imaging LASt and atrial dyssynchrony was evaluated among patients with PFO (group I) vs those without PFO (group II). RESULTS: LASt was significantly increased in group I patients compared with group II (P < .001). Likewise patients with PFO had a significant LA dyssynchrony compared with those in group II (P < .001). Interatrial dyssynchrony and left atrial dyssynchrony were correlated with LASt (r = .47 and 0.51, respectively; P < .001). Cardiac arrhythmias were significantly encountered in group I patients (at presentation and with Holter monitoring) P < .001. Besides significantly increase in atrial dyssynchrony and in LASt in patients with arrhythmias compared with those without (P < .001). ROC analysis revealed that LASt index ≥ 0.61 and LA dyssynchrony ≥ 23.5 predicts cardiac arrhythmias in CS patients with PFO with (AUC: 0.85 and 0.87, respectively, P < .001). CONCLUSION: In conclusion, we demonstrated that LASt and atrial dyssynchrony might be risk markers of cryptogenic stroke in patients with PFO.

Ventricular dyssynchrony in pregnant women: A tissue Doppler study.

OBJECTIVE: The aim of the study was to assess the left ventricular (LV) synchronicity in pregnant women and to identify the main determinants of LV dyssynchrony in asymptomatic pregnant women. METHODS: One hundred sixty-seven pregnant women consecutively and 48 age-matched nonpregnant controls were enrolled. For the assessment of LV systolic dyssynchrony, the standard deviation of the time from QRS onset to peak systolic (Tps-LV- standard deviation [SD]) velocity and the maximal difference of the time from QRS onset to peak systolic velocity (Tps-LV) from 12 segments at the apical views. For the LV diastolic dyssynchrony, the standard deviation of the time from QRS onset to peak diastolic (Tpe-LV-SD) velocity and the maximal difference of the time from QRS onset to peak diastolic velocity (Tpe-LV) were calculated. RESULTS: Both systolic and diastolic dyssynchrony indexes were significantly higher in pregnant women than in the normal controls (Tps-LV; P<.01, Tps-LV-SD; P<.03, Tpe-LV, P<.05 and Tpe-LV-SD; P<.02). A total of 28 (16.8%) of the pregnant women had a dyssynchrony index above the accepted value for LV dyssynchrony (>34.4 msec). There was a significant correlation between LV dyssynchrony indexes with, multiparty, multifetal pregnancies, systolic blood pressure in pregnant women with LV dyssynchrony. Additionally LV dyssynchrony was significantly associated with elevated E/e" and brain natriuretic peptide (BNP). CONCLUSIONS: Both systolic synchronicity and diastolic synchronicity were affected in pregnant women compared to nonpregnant women. LV dyssynchrony was significantly correlated with age, multiparity, and BNP level. Early detectable changes in systolic and diastolic synchrony may be present in pregnant women at higher risk of peripartum cardiomyopathy.

Coronary flow reserve in mitral stenosis before and after percutaneous balloon mitral valvuloplasty.

We aimed to evaluate the coronary flow reserve (CFR) before and after percutaneous balloon mitral valvuloplasty (PBMV) in patients with mitral stenosis (MS) and its association to clinical events. A prospective study included 45 patients with mitral stenosis candidate for PBMV (age 38 ± 19 years, 27 were females) and 20 with matched age and sex, healthy controls were included in the study. Noninvasive CFR was measured using transthoracic echocardiography and utilizing adenosine stress echocardiography (0.14 mg/kg/min) before PMBV, and one weak post PBMV using multi-tract balloon valvuloplasty technique. CFR was significantly lower in patients with MS compared to controls (P < 0.001). Moreover the CFR was significantly increased post-PBMV (P < 0.001) associated with significant increase in LVEF% (P < 0.05), decrease in systolic pulmonary artery pressure (P < 0.001), significant increase in TAPSE (P < 0.001). CFR was significantly correlated with the degree of change (Δ) in MVA, TAPSE, LVEF%, mean mitral PG and sPAP (r = 0.77, P < 0.001, r = 0.63; P < 0.001; r = 0.42; P < 0.05; r = -0.81; P < 0.001 and r = -0.65; P < 0.001). Mitral valve stenosis was associated with significantly impaired coronary flow reserve that significantly improved after PMBV. The improved CFR values were significantly correlated with the gain in the MVA and the improvement in the functions of both left and right ventricles.