Aortic Stenosis, Aortic Regurgitation and Arterial Hypertension.

BACKGROUND: Hypertension (HT) is an important risk factor for cardiovascular disease and might precipitate pathology of the aortic valve. OBJECTIVE: To investigate the association of HT with aortic dysfunction (including both aortic regurgitation and stenosis) and the impact of antihypertensive treatment on the natural course of underlying aortic disease. METHODS: We performed a systematic review of the literature for all relevant articles assessing the correlation between HT and phenotype of aortic disease. RESULTS: Co-existence of HT with aortic stenosis and aortic regurgitation is highly prevalent in hypertensive patients and predicts a worse prognosis. Certain antihypertensive agents may improve haemodynamic parameters (aortic jet velocity, aortic regurgitation volume) and remodeling of the left ventricle, but there is no strong evidence of benefit regarding clinical outcomes. Renin-angiotensin system inhibitors, among other vasodilators, are well-tolerated in aortic stenosis. CONCLUSION: Several lines of evidence support a detrimental association between HT and aortic valve disease. Therefore, HT should be promptly treated in aortic valvulopathy. Despite conventional wisdom, specific vasodilators can be used with caution in aortic stenosis.

Left ventricular ejection fraction as therapeutic target: is it the ideal marker?

Heart failure (HF) consists the fastest growing clinical cardiac disease. HF patients are categorized on the basis of underlying left ventricular ejection fraction (LVEF) into HF with preserved EF (HFpEF), reduced LVEF (HFrEF), and mid-range LVEF (HFmrEF). While LVEF is the most commonly used surrogate marker of left ventricular (LV) systolic function, the implementation of two-dimensional echocardiography in estimating this parameter imposes certain caveats on current HF classification. Most importantly, LVEF could fluctuate in repeated measurements or even recover after treatment, thus blunting the borders between proposed categories of HF and enabling upward classification of patients. Under this prism, we sought to summarize possible procedures to improve systolic function in patients with HFrEF either naturally or by the means of pharmacologic and non-pharmacologic treatment and devices. Therefore, we reviewed established pharmacotherapy, including beta-blockers, inhibitors of renin-angiotensin-aldosterone axis, statins, and digoxin as well as novel treatments like sacubitril-valsartan, ranolazine, and ivabradine. In addition, we assessed evidence in favor of cardiac resynchronization therapy and exercise training programs. Finally, innovative therapeutic strategies, including stem cells, xanthine oxidase inhibitors, antibiotic regimens, and omega-3 polyunsaturated fatty acids, were also taken into consideration. We concluded that LVEF is subject to changes in HF after intervention and besides the aforementioned HFrEF, HFpEF, and HFmrEF categories, a new entity of HF patients with recovered LVEF should be acknowledged. An improved global and refined LV function assessment by sophisticated imaging modalities and circulating biomarkers is expected to render HF classification more accurate and indicate patients with viable-yet dysfunctional-myocardium and favorable characteristics as the ideal candidates for LVEF recovery by individualized HF therapy.

Pocket-sized point-of-care cardiac ultrasound devices : Role in the emergency department.

BACKGROUND: Acute breathlessness accounts for 8% of accident and emergency attendances. Point-of-care cardiac ultrasound (US) effectively reduces time to diagnosis. Fast and practical information via pocket-sized cardiac US devices may better the diagnosis in this complex patient group. METHODS: We prospectively enrolled 40 consecutive patients presenting with shortness of breath at the emergency department (ED). Divided into two groups were all adult patients over 18 with acute breathing difficulties (triage category 1-3): 21 patients received a short focused cardiac US scan using a pocket-sized Vscan and 19 patients received no scan. Data were obtained regarding the time taken for diagnosis and treatment, patient length of stay, inpatient mortality and 30-day mortality. RESULTS: In the scanned group 33% of patients had significantly abnormal Vscan results that had the potential to aid diagnosis and guide management. The difference of 20 min between the means of the time to diagnosis between the groups was not significant. DISCUSSION: The individual knowledge of UK emergency physicians regarding basic echocardiography varies greatly. An intuitive approach following a brief tutorial on pocket-size echocardiography was shown to improve diagnostic accuracy in addition to history taking and physical examination by medical students and junior doctors with no previous exposure to echocardiography. Increasing evidence shows the feasibility and benefit of FOCUS echo in the ED and the pocket-sized devices could play a large role. CONCLUSION: The Vscan is a practical, portable device that provides rapid diagnostic information. One third of patients had significant findings on the scans to possibly aid diagnosis and prevent misdiagnosis. This has the potential to reduce time to diagnosis in the ED.

Preeclampsia: What Does the Father Have to Do with It?

Preeclampsia (PE) is one of the leading causes of maternal and fetal morbidity and mortality, with incidence rates ranging between 2 and 5 % in the Western World. The exact causes of the disease remain largely unknown, because of the complex pathophysiologic mechanisms involved in the process. Genetic, environmental, and epigenetic parameters have been implicated by various authors as culprits for the pathogenesis of PE. Recent reports in the literature highlight the paternal role. Still, the exact extent and mechanism remain elusive. In this systematic review, we attempt to present data regarding the paternal role in a concise and comprehensive manner.

Effects of cardiac resynchronisation therapy in patients with heart failure having a narrow QRS Complex enrolled in PROSPECT.

INTRODUCTION: Current guidelines recommend cardiac resynchronisation therapy (CRT) in patients with severe symptomatic heart failure, depressed left ventricular (LV) systolic function and a wide QRS complex (>or=120 ms). However, patients with heart failure having a narrow QRS complex might also benefit from CRT. DESIGN SETTING PATIENTS INTERVENTIONS: During the Predictors of Response to Cardiac Resynchronisation Therapy (PROSPECT) trial, 41 patients were enrolled in a 'narrow' QRS sub-study. These patients had a QRS complex <130 ms, but documented evidence of mechanical dyssynchrony by any of seven pre-defined echocardiographic measures. RESULTS: After 6 months of CRT, 26 (63.4%) patients showed improvement according to the Clinical Composite Score, 4 (9.8%) remained unchanged and 11 (26.8%) worsened. In patients with paired data, the 6-min walking distance increased from 334+/-118 m to 382+/-128 m, (p=0.003) and quality-of-life score improved from 44.2+/-19.7 to 26.8+/-20.2 (p<0.0001). Furthermore, there was a significant decrease in LV end-systolic diameter (from 59+/-9 to 55+/-12 mm, p=0.002) and in LV end-diastolic diameter (from 67+/-9 to 63+/-11 mm, p=0.007). CONCLUSION: The results suggest that CRT may have a beneficial effect in heart failure patients with a narrow QRS complex and mechanical dyssynchrony as assessed by echocardiography. The majority of patients improved on clinical symptoms, and there was an evident reduction in LV diameters. Larger studies are needed to clearly define selection criteria for CRT in patients with a narrow QRS complex.

The use of real-time three-dimensional echocardiography for assessing mechanical synchronicity.

BACKGROUND: Biventricular pacing (BIV) has been established as a credible adjuvant treatment for patients with moderate-to-severe systolic heart failure (class III-IV of the New York Heart Association (NYHA) classification) and left bundle branch block (LBBB), which results in acute haemodynamic, neurohormonal and functional improvements, ventricular remodelling and has significant impact on survival and symptomatic improvement. Based on the current guidelines (ESC/AHA/ACC), several studies have demonstrated a failure to respond to cardiac resynchronisation therapy (CRT) both with clinical criteria and using reverse remodelling (20-30% and 30-40%, respectively, of the implanted patients). Consequently, imaging-based measures of dyssynchronous myocardial contraction have been intensively investigated with the aim of improving the prediction of response to therapy. In this study, we hypothesised that real-time three-dimensional echocardiography (RT3DE) may be a robust technique in assessing mechanical synchronicity in heart failure patients and may be effective in identifying patients who might benefit from BIV. METHODS: 48 consecutive heart failure patients were screened with routine echocardiography, 35 (72%) of whom were eventually included in the study. An additional 35 age-matched and sex-matched healthy subjects were recruited as a control group. 20 patients from the heart failure group received biventricular pacemakers and were followed up to six months. The response to CRT was defined as either improvement in the NYHA class or reduction of the end-systolic volume >15%. Tissue Doppler imaging and real-time 3D data were obtained for all subjects and evaluation of volumes, ejection fraction and systolic dyssynchrony index was performed. RESULTS: Of 35 heart failure patients, five (14%) had mild, seven (20%) moderate and 23 (66%) severe systolic dysfunction based on the EF calculation (45-50%, 45-35% and <35% respectively). The systolic dyssynchrony index (SDI) was 11.2% (2.2%), 13.7% (3.2%) and 17.3% (4%), respectively, while in the control group it was 9.8% (2.1%). The QRS length was <120 ms in 29%, 120-140 ms in 26% and >140 ms in 45% of the patients. CONCLUSIONS: Real-time three-dimensional echocardiography is a robust technique, which can be used to accurately and effectively assess global and regional mechanical dyssynchrony in heart failure patients.

Report on the European Association of Echocardiography accreditations in echocardiography: December 2003-September 2006.

AIMS: The European Association of Echocardiography (EAE) launched its Accreditation scheme in echocardiography in December 2003. Currently there are accreditations in Adult Transthoracic Echocardiography and Transesophageal Echocardiography and an Accreditation in Echocardiography for Congenital Disease will be launched in December 2006. METHODS AND RESULTS: Over the past 3years 350 applicants have undertaken the written exams and 157 applicants have completed the process and achieved accreditation. This report summarises the accreditation process, the details of the numbers of applicants and their progress through the Accreditation scheme. This report also provides data about the performance of the written exam, its reliability and the effectiveness of the questions and data about the reproducibility of the log book marking system. CONCLUSION: Taken together this report provides evidence that the EAE Accreditation schemes have been effective in establishing a standard for echocardiographic practice and an accreditation that is effectively organised, reliable, robust and successful.

EAE laboratory standards and accreditation.

Laboratory standards have been set by the European Association of Echocardiography of the European Society of Cardiology, in order to homogenize the practice of echocardiography in Europe and therefore ultimately, to protect patients. These standards have been developed for transthoracic, transesophageal and stress Echocardiography into two levels; the basic level, set to provide basic laboratory standards for an optimal clinical service and the advanced level, which is set to establish a fewer number of advanced laboratories in each country, where by in addition to basic standards, they may be providing extensive teaching and research.

Aspirin reduces anticardiolipin antibodies in patients with coronary artery disease.

BACKGROUND: Anticardiolipin antibodies (aCL) have been found to be elevated in patients with coronary artery disease (CAD) and have been associated with an adverse outcome owing to their prothrombotic activity. The aim of this study was to investigate the effect of aspirin treatment on aCL levels in patients with chronic CAD. MATERIALS AND METHODS: Forty patients with chronic CAD scheduled for elective coronary artery bypass graft surgery (CABG) and 40 healthy controls participated in the study. Patients were treated with 300 mg of aspirin once daily (o.d.) for the first 12 days and placebo for the following 12 days before CABG in a double-blind, cross-over trial. Immunoglobulin (Ig) G-, IgM-, IgA-aCL and C-reactive protein (CRP) levels were measured in the controls and at the end of each treatment period in the patients with CAD. RESULTS: The IgA- and IgG-aCL levels were greater in patients with CAD than in the controls. Compared with the placebo, IgA, IgG subtypes and CRP levels were reduced after aspirin treatment (P = 0.001, P = 0.02, P = 0.04, respectively). The percentage reduction of IgA- and IgG-aCL was related to the percentage reduction of CRP after aspirin (P < 0.05). CONCLUSION: Aspirin treatment with 300 mg o.d. reduced the serum levels of IgA and IgG subtypes in patients with chronic CAD in parallel to a reduction in CRP. These findings offer an additional pathophysiological mechanism of the beneficial effects of aspirin in patients with chronic CAD.

The future of cardiovascular imaging and non-invasive diagnosis: a joint statement from the European Association of Echocardiography, the Working Groups on Cardiovascular Magnetic Resonance, Computers in Cardiology, and Nuclear Cardiology, of the European Society of Cardiology, the European Association of Nuclear Medicine, and the Association for European Paediatric Cardiology.

Advances in medical imaging now make it possible to investigate any patient with cardiovascular disease using multiple methods which vary widely in their technical requirements, benefits, limitations, and costs. The appropriate use of alternative tests requires their integration into joint clinical diagnostic services where experts in all methods collaborate. This statement summarises the principles that should guide developments in cardiovascular diagnostic services.

Differences in the association between type 2 diabetes and impaired microvascular function among Europeans and African Caribbeans.

AIMS/HYPOTHESIS: Diabetes is associated with microvascular damage in all populations, but diabetic patients of Black African descent (African Caribbeans) have a greater risk of vascular target organ damage than would be anticipated for any given blood pressure level. We investigated whether this may be due to differences in the microvasculature. MATERIALS AND METHODS: To assess the maximum hyperaemic response to heating and the post-ischaemic response, Laser Doppler fluximetry was performed on 51 and 100 Europeans, and on 66 and 88 African Caribbeans with and without diabetes, respectively. Subjects were aged between 40 and 65 years and recruited from the general population. Echocardiographic interventricular septal thickness (IVST) was measured as a proxy for vascular target organ damage. RESULTS: In diabetic subjects of both ethnic groups, the maximum hyperaemic response and peak response to ischaemia were attenuated as compared to the corresponding non-diabetic subjects (p=0.08 for diabetic and 0.03 for non-diabetic Europeans; p=0.03 and 0.1 for African Caribbeans). Adjustment for cardiovascular risk factors, in particular insulin and blood pressure, abolished these differences in Europeans (p=0.8 for diabetic and 0.2 for non-diabetic Europeans), but not in African Caribbeans (p=0.03 and 0.05). CONCLUSIONS/INTERPRETATION: Persisting microvascular dysfunction in African Caribbeans may contribute to the increased risk of target organ damage observed in diabetes in this population. The weak contribution of conventional cardiovascular risk factors to these disturbances indicates that conventional therapeutic interventions may be less beneficial in these patients. There was a risk-factor-independent, inverse association between IVST and maximal hyperaemia. These ethnic differences in microvascular responses to temperature and arterial occlusion could account for increased target organ damage in African Caribbeans.

Stress echocardiography for the diagnosis and risk stratification of patients with suspected or known coronary artery disease: a critical appraisal. Supported by the British Society of Echocardiography.

Stress echocardiography today has matured into a robust and reliable technique not only for the diagnosis of suspected coronary artery disease (CAD) but also for the accurate risk stratification of patients with suspected and established CAD. This is mainly because of rapid advances in image acquisition, digital display, and the development of harmonic and contrast imaging. Stress echocardiography today is also utilised in patients with heart failure both for assessing the cause of heart failure and determining the extent of hibernating myocardium. With advances in myocardial perfusion imaging, stress echocardiography now allows simultaneous assessment of myocardial function and perfusion. Tissue Doppler imaging allows quantitation of wall motion. Ready availability and reliability makes stress echocardiography a cost effective technique for the assessment of CAD.

Extreme variability of skeletal and cardiac muscle involvement in patients with mutations in exon 11 of the lamin A/C gene.

Mutations of the LMNA gene, encoding the nuclear envelope proteins lamins A and C, give rise to Emery-Dreifuss muscular dystrophy and to limb-girdle muscular dystrophy 1B (EDMD and LGMD1B). With one exception, all the reported EDMD and LGMD1B mutations are confined to the first 10 exons of the gene. We report four separate cases, with mutations in the same codon of LMNA exon 11, characterized by remarkable variability of clinical findings, in addition to features not previously reported. One patient had congenital weakness and died in early childhood. In two other patients, severe cardiac problems arose early and, in one of these, cardiac signs preceded by many years the onset of skeletal muscle weakness. The fourth case had a mild and late-onset LGMD1B phenotype. Our cases further expand the clinical spectrum associated with mutations in the LMNA gene and provide new evidence of the role played by the C-terminal domain of lamin A.

Echocardiographic evaluation of cardiac dyssynchrony for predicting a favourable response to cardiac resynchronisation therapy.

Cardiac resynchronisation therapy (CRT) is an established therapy for patients with heart failure with wide QRS duration. Recent studies observed that assessment of systolic dyssynchrony is an important diagnostic tool as the treatment involves the re-coordination of regional wall contraction within the left ventricle. Therefore, the effectiveness of CRT depends heavily on whether systolic dyssynchrony is present before the treatment. Echocardiography is a useful tool for quantitative measurement of the severity of dyssynchrony in these patients before and after CRT. A number of echocardiographic tools have been developed during the past three years for such purpose, include M mode measurement of septal-to-posterior wall delay, tissue Doppler imaging for septal-to-lateral wall delay, the measurement of standard deviation of peak contraction time over 12 left ventricular segments, delayed longitudinal contraction, and potentially three dimensional echocardiography. This review discusses the potential role of various echocardiographic techniques in the assessment of systolic dyssynchrony and their clinical applications.

Lipomatous hypertrophy of the interatrial septum: a commonly misdiagnosed mass often leading to unnecessary cardiac surgery.

Lipomatous hypertrophy of the interatrial septum is a benign cardiac mass that should be considered as part of the differential diagnosis for any atrial cardiac tumour. In the reported case, this lesion was initially suspected to be malignant and the patient was thus referred directly to cardiac surgeons for surgical removal. Unnecessary surgical intervention was swiftly averted because the cardiac surgeon promptly referred the patient for an expert echocardiogram that confirmed the diagnosis of lipomatous hypertrophy. The authors discuss the characteristic features of this lesion and how the diagnosis may be made based on several non-invasive imaging modalities without the need for a tissue biopsy. This condition is more common than initially thought and remains under-recognised by most clinicians. In such cases an increased awareness of this lesion along with the opinion of a specialist echocardiologist would help to avoid a misdiagnosis and unnecessary intervention.