Cardiovascular System Changes and Related Risk Factors in Acromegaly Patients: A Case-Control Study

Prevalence of clinical signs, symptoms and comorbidities at diagnosis of acromegaly: a systematic review in accordance with PRISMA guidelines

OBJECTIVE

Diagnostic delay is high in acromegaly and leads to increased morbidity and mortality. The aim of this study is to systematically assess the most prevalent clinical signs, symptoms and comorbidities of acromegaly at time of diagnosis.

DESIGN

A literature search (in PubMed, Embase and Web of Science) was performed on November 18, 2021, in collaboration with a medical information specialist.

METHODS

Prevalence data on (presenting) clinical signs, symptoms and comorbidities at time of diagnosis were extracted and synthesized as weighted mean prevalence. The risk of bias was assessed for each included study using the Joanna Briggs Institute Critical Appraisal Checklist for Studies Reporting Prevalence Data.

RESULTS

Risk of bias and heterogeneity was high in the 124 included articles. Clinical signs and symptoms with the highest weighted mean prevalence were: acral enlargement (90%), facial features (65%), oral changes (62%), headache (59%), fatigue/tiredness (53%; including daytime sleepiness: 48%), hyperhidrosis (47%), snoring (46%), skin changes (including oily skin: 37% and thicker skin: 35%), weight gain (36%) and arthralgia (34%). Concerning comorbidities, acromegaly patients more frequently had hypertension, left ventricle hypertrophy, dia/systolic dysfunction, cardiac arrhythmias, (pre)diabetes, dyslipidemia and intestinal polyps- and malignancy than age- and sex matched controls. Noteworthy, cardiovascular comorbidity was lower in more recent studies. Features that most often led to diagnosis of acromegaly were typical physical changes (acral enlargement, facial changes and prognatism), local tumor effects (headache and visual defect), diabetes, thyroid cancer and menstrual disorders.

CONCLUSION

Acromegaly manifests itself with typical physical changes but also leads to a wide variety of common comorbidities, emphasizing that recognition of a combination of these features is key to establishing the diagnosis.

Skin manifestations and submacroscopical features of acromegaly: A case-control study using dermoscopy and high-frequency ultrasound

BACKGROUND

Although the cutaneous involvement of acromegaly has been recognized, the submacroscopical skin changes and the extent of skin thickening of patients remain unclear.

OBJECTIVES

This study aimed at investigating the clinical cutaneous manifestations, dermoscopic features, and skin thickness revealed by high-frequency ultrasound (HFUS) of acromegalic patients.

METHODS

A case-control observational study was conducted. Patients with acromegaly and controls were prospectively included and received thorough cutaneous examinations to compare the macroscopical and dermoscopic features. The skin thickness measured by HFUS and its correlation with clinical data were also assessed.

RESULTS

Thirty-seven and 26 patients from acromegalic and control group were included, respectively. Clinical skin manifestations were recorded in detail. Under dermoscopy, red structureless area (91.9% vs. 65.4%, p = 0.021), perifollicular orange halo (78.4% vs. 26.9%, p = 0.005), and follicular plug (70.3% vs. 3.9%, p = 0.001) in the facial area, and perifollicular pigmentation (91.9% vs. 23.1%), broom-head hairs (83.8% vs. 3.9%), honeycomb-like pigmentation (97.3% vs. 38.46%), widened dermatoglyphics (81.1% vs. 3.9%) at the extremities (p < 0.001) were more prevalent in acromegaly. The mean skin thickness was 4.10 ± 0.48 mm for acromegaly, and 3.55 ± 0.52 mm for controls (p < 0.001) but no correlation with disease duration, adenoma size, and hormone level was found in acromegaly.

CONCLUSIONS

Submacroscopical skin changes under dermoscopy and skin thickness increase assessed by HFUS can provide clinicians with subtle evidences for early detection of acromegaly and objective parameters for accurate assessment of its skin involvement.

Filling the gap between the heart and the body in acromegaly: a case-control study

OBJECTIVE

Cardiovascul diseases are the most common comorbidities in acromegaly. Potential parameters in pathology of cardiovascular comorbidities are changes in levels of growth hormone (GH) and insulin-like growth factor 1 (IGF-1) as well as body composition parameters.

PURPOSE

The aim of this study was to examine morphological and functional parameters of the cardiovascular system by echocardiography and to assess its relationship with disease activity and body composition parameters.

METHODS

We prospectively enroled 129 acromegalic patients (82 females, 47 males) and 80 healthy controls (53 females, 27 males) matched for age, gender, and BMI. All patients underwent two-dimensional echocardiography. Body composition parameters were assessed by dual-energy X-ray absorptiometry.

RESULTS

Acromegaly patients presented with higher left ventricle mass (LVM) compared to controls (LVMI: 123 ± 45 g/m² vs 83 ± 16 g/m², P < 0.001). Prevalence of left ventricle hypertrophy in acromegaly patients was 67% (78% concentric, 22% eccentric). IGF -1 levels, BMI, and lean mass positively correlated with LVM in all acromegaly patients (P < 0.001). Fat mass positively correlated with LVM in females (R = 0.306, P = 0.005), but this correlation was not found in males. We did not find any difference in size of the left and right ventricle between acromegaly patients and controls. Acromegaly patients presented with left atrium enlargement, diastolic dysfunction and low incidence of systolic dysfunction. Valvopathy was found in 43% of patients with predominant (31%) prevalence of mitral regurgitation.

CONCLUSION

Our study demonstrates higher prevalence of cardiovascular comorbidities in acromegaly patients and the impact of IGF-1 levels and body composition parameters in pathology in some of these comorbidities.

An Unsupervised Deep-Transfer-Learning-Based Motor Imagery EEG Classification Scheme for Brain-Computer Interface

Brain–computer interface (BCI) research has attracted worldwide attention and has been rapidly developed. As one well-known non-invasive BCI technique, electroencephalography (EEG) records the brain’s electrical signals from the scalp surface area. However, due to the non-stationary nature of the EEG signal, the distribution of the data collected at different times or from different subjects may be different. These problems affect the performance of the BCI system and limit the scope of its practical application. In this study, an unsupervised deep-transfer-learning-based method was proposed to deal with the current limitations of BCI systems by applying the idea of transfer learning to the classification of motor imagery EEG signals. The Euclidean space data alignment (EA) approach was adopted to align the covariance matrix of source and target domain EEG data in Euclidean space. Then, the common spatial pattern (CSP) was used to extract features from the aligned data matrix, and the deep convolutional neural network (CNN) was applied for EEG classification. The effectiveness of the proposed method has been verified through the experiment results based on public EEG datasets by comparing with the other four methods.

Advances in Research on the Cardiovascular Complications of Acromegaly

Cardiovascular-related complications are one of the most common complications in patients with acromegaly, and can lead to an increased risk of death. Hypertension and cardiomyopathy are the main cardiovascular complications. The characteristics of acromegalic cardiomyopathy are concentric biventricular hypertrophy and diastolic dysfunction. In addition, arrhythmia and heart valve disease are common cardiac complications in acromegaly. Although the underlying pathophysiology has not been fully elucidated, the spontaneous overproduction of GH and IGF-1, increasing age, prolonged duration of disease and the coexistence of other cardiovascular risk factors are crucial to cardiac complications in patients with acromegaly. Early diagnosis and appropriate treatment of acromegaly might be beneficial for the prevention of cardiomyopathy and premature death.

Predictors of postoperative biochemical remission in acromegaly

PURPOSE

Acromegaly is a rare neuroendocrine condition that can lead to significant morbidity. Despite China's vast population size, studies on acromegaly remain sparse. This study aimed to investigate the clinical characteristics and predictors of biochemical remission after surgery for acromegaly using the China Acromegaly Patient Association (CAPA) database.

METHODS

A retrospective nationwide study was conducted using patient-reported data from CAPA database between 1998 and 2018. The principal component analysis (PCA) and logistic regression analysis were employed to determine independent predictors of biochemical remission at 3 months in patients after surgery.

RESULTS

Of the 546 surgical cases (mean age: 36.8 years; 59.5% females), macroadenomas and invasive tumors (Knosp score 3-4) were 83.9% and 64.1%, respectively. Ninety-five percent of patients were treated with endonasal surgery and 36.8% exhibited biochemical remission at 3-months postoperatively. The following independent predictors of biochemical remission were identified: preoperative growth hormone (GH) levels between 12 and 28 μg/L [odds ratio (OR) = 0.58; 95% confidence interval (CI), 0.37-0.92; p = 0.021], preoperative GH levels > 28 μg/L (OR = 0.55; 95% CI, 0.34-0.88; p = 0.013), macroadenoma (OR = 0.56; 95% CI, 0.32-0.96; p = 0.034), giant adenomas (OR = 0.14; 95% CI, 0.05-0.38; p < 0.001), Knosp score 3-4 (OR = 0.37; 95% CI, 0.24-0.57; p < 0.001), and preoperative medication usage (OR = 2.32; 95% CI, 1.46-3.70; p < 0.001).

CONCLUSIONS

In this nationwide study spanning over two decades, we highlight that higher preoperative GH levels, large tumor size, and greater extent of tumor invasiveness are associated with a lower likelihood of biochemical remission at 3-months after surgery, while preoperative medical therapy increases the chance of remission.

Evaluation of the retinal layers and microvasculature in patients with acromegaly: a case-control OCT angiography study

BACKGROUND

The aim of study was to evaluate the retinal layers and macular capillary network with OCTA in acromegaly patients, to compare with healthy population.

METHODS

In this prospective, observational, and comparative study, 40 acromegaly patients and 40 healthy control participants were included. Serum IGF-1 levels and disease duration of all patients were noted. Macular layers and angiography scanning was performed with a Zeiss Cirrus 5000 OCTA system. Macular thickness, RNFL, and GC-IPL values were obtained. For central vessel and perfusion density, central 6 mm was obtained and was evaluated by dividing into three groups (inner, outer, full). FAZ parameters were evaluated dividing into three groups (area, perimeter, circularity index). Analysis of the data was performed with the SPSS for Windows.

RESULTS

There was no significant difference between the patient group and the control group in terms of age, gender, best corrected visual acuity (BCVA), spherical equivalent (SE), intraocular pressure (IOP), and axial length (AL). The mean follow-up period after diagnosis was 11.0 ± 5.5 years. Central and mean macular thicknesses were also significantly higher in the acromegaly group (p < 0.05). Superior, inferior, and average RNFL thicknesses were also significantly thinner in the acromegaly group (p < 0.05). When OCTA parameters were compared between groups, there was a significant decrease in central vessel density (CVD) and central perfusion density (CPD) values in all regions in acromegaly group compared with controls (p < 0.05).

CONCLUSION

Our findings with OCTA show that acromegaly causes a significant capillary network decrease according to the healthy subjects.

Sleep quality in acromegaly and changes after transsphenoidal surgery: a prospective longitudinal study

OBJECTIVE

To elucidate the sleep quality characteristics and factors related to either good or poor sleep quality in acromegaly patients before surgery and to explore sleep quality changes after transsphenoidal surgery and the factors related to these changes.

METHODS

We prospectively enrolled 39 acromegaly patients and 78 patients with nonfunctioning pituitary adenomas. Scales for anxiety, depression, disease stigma and nasal condition were evaluated. The Pittsburgh Sleep Quality Index (PSQI) questionnaire was administered before surgery as well as one month and three months after surgery.

RESULTS

A higher percentage of acromegaly patients had poor sleep quality compared to controls (35.9% vs. 5.1%, p < 0.001). In addition, acromegaly patients experienced worse subjective sleep quality, extended sleep latency, increased sleep disturbance and decreased daytime functioning. Higher scores for anxiety, disease stigma and sinonasal outcomes were correlated with worse sleep quality in acromegaly patients. At one month after transsphenoidal surgery, we found worse subjective sleep quality, extended sleep latency, shortened sleep duration, impaired sleep efficiency and increased sleep disturbance in acromegaly patients. At three months postoperatively, most impaired PSQI domains in acromegaly patients recovered to preoperative levels. The use of soluble gauze was related to decreased sleep quality at one month after surgery and severe anxiety and depression were related to improved sleep quality at three months after surgery.

CONCLUSIONS

Sleep quality was reduced in acromegaly patients. Moreover, sleep quality initially worsened after surgery but later recovered. Emotional problems and the use of soluble gauze were related factors.

CLINICAL TRIAL REGISTRATION

None.

Pre- and Postoperative Health Status of Patients with Nonfunctioning and Secretory Pituitary Adenomas and an Analysis of Related Factors

PURPOSE

To identify the characteristics of the physical and mental health status of patients with pituitary adenomas, explore the postoperative reversibility of impaired health status, and assess the impact of clinical characteristics, hormone levels, anxiety, depression, and disease stigma on health status.

METHODS

We prospectively enrolled 147 and 138 patients with nonfunctioning and secretory pituitary adenomas, respectively. Health status was evaluated in 8 domains using the 36-item Short-Form Health Survey before and 3 months after transsphenoidal surgery. The Self-Rating Anxiety Scale, the Self-Rating Depression Scale, and the Stigma Scale for Chronic Illness were used to assess the psychological status.

RESULTS

Compared with the healthy population reference values, general physical and mental health, social functioning, and role limitations due to physical and psychological health problems were all found to be significantly impaired in the adenoma patients. Health status was worse in patients with adrenocorticotropic hormone- (ACTH-) secreting and growth hormone- (GH-) secreting adenomas than in patients with nonfunctioning adenomas. Among the patients, 11.6% had anxiety and 30.9% had depression. Higher scores for anxiety, depression, and disease stigma; older age; higher body mass index; and tumor recurrence were independent risk factors for health status impairment in at least one domain. Physical function impairment and role limitations caused by physical health problems became worse after surgery, whereas the mental component of health status remained the same.

CONCLUSION

Health status was impaired in patients with pituitary adenomas, especially secretory adenomas. Physical function and role limitations were worse 3 months after surgery than before surgery. Mental problems, old age, obesity, and tumor recurrence reduced health status.

The Change in Distance Between Bilateral Internal Carotid Arteries in Acromegaly and Its Risk Factors

Background: Studies investigating the change in distance between the bilateral internal carotid arteries (ICAs) in acromegalic patients have provided ambiguous results. The influencing factors of these changes have not been well-identified. Objective: To further investigate the change in distance between bilateral ICAs in acromegaly patients and identify the influencing factors of the change. Method: Patients diagnosed as acromegaly from Jan 2016 to Sep 2019 in the Department of Neurosurgery of the First Affiliated Hospital of Fujian Medical University, were included in this study. Computed tomography angiography (CTA) or magnetic resonance angiography (MRA) data were obtained for all patients for three-dimensional reconstruction of the ICAs. Distance between bilateral ICAs was measured and recorded for assessment. Result: 172 patients including 86 cases with acromegaly in the study group and 86 cases with non-functional pituitary adenoma in the control group were enrolled in this study. The difference of adenoma sizes between two groups was not statistically significant. Patients in acromegaly group had significantly larger maximum distances between bilateral siphon carotid ectasias (25.5 ± 4.1 vs. 23.4 ± 3.5 mm, P = 0.001) and between bilateral lacerum segments (26.2 ± 3.2 vs. 24.1 ± 4.3 mm, P < 0.001) compared with those of patients with non-functional pituitary adenomas. Multivariate analysis showed that the increased bilateral ICAs distance was associated with disease duration (odds ratio = 1.01, 95% confidence interval = 1.01-1.02, P = 0.005) and refractory pituitary adenoma (odds ratio = 9.8, 95% confidence interval = 1.1-88.7, P = 0.043) but not with level of growth hormone (GH), insulin-like growth factor-1 (IGF-1) and adenoma size in acromegaly. Conclusion: Our study showed significant change in distance between the bilateral ICAs in acromegalic patients, comparing to patients with non-functional pituitary adenomas. The increased intercarotid artery distance is associated with disease duration but not with preoperative level of GH and IGF-1. Refractory pituitary adenoma and longer disease duration are the both risk factors of the increased ICAs distance in patient with acromegly.

Cardiac Abnormalities in Acromegaly Patients: A Cardiac Magnetic Resonance Study

Cardiac abnormalities are the most common and deadly comorbidities of acromegaly. Assessments using cardiac magnetic resonance (CMR) imaging in acromegaly patients are rare. We aimed to evaluate the frequencies of left ventricular hypertrophy (LVH), interventricular septum hypertrophy (IVSH), LV systolic dysfunction (LVSD), right ventricular systolic dysfunction (RVSD), and myocardial fibrosis (MCF) and detailed quantitative parameters in acromegaly patients using CMR and analyze their correlations with clinical features. Sixty-one patients were enrolled in this study. The rates of LVH, IVSH, LVSD, RVSD, and MCF were 26.2%, 27.9%, 8.2%, 9.8%, and 14.8%, respectively. The average LV mass, LV mass index, IVS thickness, LV and RV free wall thickness, and LV and RV ejection fractions were 114.4 g, 60.0 g/m², 9.6 mm, 7.2 mm, 2.9 mm, 59.9%, and 56.6%, respectively. The LV mass index was larger (68.9 ± 26.0 vs. 48.8 ± 10.6 g/m²), the IVS was thicker (10.3 ± 2.8 vs. 8.8 ± 1.8 mm), and the LV (57.6 ± 12.3% vs. 62.8 ± 4.8%) and RV ejection fractions (54.6 ± 8.7% vs. 59.2 ± 5.9%) were lower in male patients than in female patients (all p < 0.05). Age, body mass index (BMI), disease duration, and hypertension were associated with cardiac abnormalities (all p < 0.05). In conclusion, structural and functional cardiac abnormalities can be comprehensively evaluated by CMR in acromegaly patients. Gender greatly affects the presence of cardiac abnormalities. Age, BMI, disease duration, and hypertension but not GH or IGF-1 levels are associated clinical factors.

Reversibility of Cardiac Involvement in Acromegaly Patients After Surgery: 12-Month Follow-up Using Cardiovascular Magnetic Resonance

PURPOSE

Cardiac comorbidity is one of the leading causes of death among acromegaly patients. We aimed to investigate the reversibility of acromegalic cardiac involvement after surgical treatment using the gold standard method, cardiovascular magnetic resonance, and to explore the effects of endocrine remission and gender on reversibility.

METHODS

In this single-center, prospective cohort study, fifty untreated acromegaly patients were enrolled. Comprehensive cardiac assessments were performed using a 3.0 T magnetic resonance scanner before and 3 and 12 months after transsphenoidal adenomectomy.

RESULTS

Preoperatively, left ventricular (LV) enlargement (13.0%), LV systolic dysfunction (6.5%), right ventricular (RV) enlargement (4.3%), RV systolic dysfunction (2.2%) and myocardial fibrosis (12.0%) were identified. On average, the LV and RV ejection fractions of acromegaly patients were higher than the healthy reference values. Male patients had thicker LV myocardia, wider ventricular diameters and more dilated pulmonary artery roots than female patients. After surgery, LV myocardial hypertrophy was reversed, the left atrium was remodeled, and ventricular systolic dysfunction recovered to normal. Cardiac alterations were detected early in the 3^rd postoperative month and persisted until the 12^th month. The interventricular septum was initially thickened in the 3^rd postoperative month and then recovered at the 12th month. Notable postoperative cardiac reversibility was observed in male patients but did not occur in all female patients. Patients achieving endocrine remission with normalized hormone levels had thinner LV myocardia than patients without normalized hormone levels.

CONCLUSION

Our findings demonstrated that some of the cardiac involvement in acromegaly patients is reversible after surgical treatment which lowers hormone levels. Endocrine remission and gender significantly impacted postoperative cardiac reversibility.

ECHOCARDIOGRAPHIC MYOCARDIAL CHANGES IN ACROMEGALY: A CROSS-SECTIONAL ANALYSIS IN A TERTIARY CENTER IN BULGARIA

Context

Cardiomyopathy is the most frequent cardiovascular complication in acromegaly.

Objective

We aimed to compare some echocardiographic markers in acromegaly patients with controls and find a correlation with disease duration, disease activity, levels of growth hormone (GH) and insulin-like growth factor 1 (IGF-1).

Design

We conducted a cross-sectional case-control study for the period of 2008-2012.

Subjects and methods

Acromegaly patients altogether 146 (56 men and 90 women), were divided into four groups according to disease activity and the presence of arterial hypertension (AH). The control group included 83 subjects, matching the patient groups by age, gender and presence of AH. GH was measured by an immunofluorometric method, while IGF-1 by IRMA method. All patients and controls were subjected to one- and two-dimensional transthoracic echocardiography, color and pulse Doppler.

Results

We found a thickening of the left ventricular walls and an increase in the left ventricular mass. However, these changes were not statistically significant in all groups and no correlation with disease duration could be demonstrated. As markers of diastolic dysfunction, increased deceleration time and isovolumetric relaxation were registered, which were dependent mainly on age in a binary logistic regression analysis, but not GH or IGF-1. Using absolute values, ejection and shortening fractions were increased in some groups. Using cut-off values, a higher percentage of systolic dysfunction was demonstrated in patients compared to their corresponding controls. Engagement of the right heart ventricle was also found - increased deceleration time and decreased e/a tric ratio.

Conclusions

In conclusion, functional impairments of both ventricles were present, with a predominance of left ventricular diastolic dysfunction.

Preoperative and Postoperative Bone Mineral Density Change and Risk Factor Analysis in Patients with a GH-Secreting Pituitary Adenoma

PURPOSE

This study analysed changes in bone mineral density (BMD) at different sites in patients with acromegaly and postoperative BMD changes and explored risk factors associated with BMD.

METHODS

Clinical data of 39 patients with growth hormone- (GH-) secreting pituitary adenomas and 29 patients with nonfunctioning pituitary adenomas who were newly diagnosed in neurosurgery from January 2016 to December 2018 were retrospectively analysed, including measurements of preoperative and postoperative BMD, serum GH glucose inhibition, random GH and IGF-1, and other anterior pituitary hormones.

RESULTS

The average patient age and disease duration were 43.74 (33.41-54.07) years and 72.15 (22.82-121.48) months, respectively. Compared with patients with nonfunctioning adenomas, patients with GH-secreting pituitary adenomas had significantly higher BMDs at L1, L2, femoral neck, Ward triangle, trochanter, femoral shaft, and total hip sites (p < 0.05). The BMD Z score at L1 and femoral neck sites significantly increased (p < 0.05). Thirteen patients underwent re-examination of BMD 1 year postsurgery, and the BMD Z score was reduced to normal levels at L1, L2, L3, L4, L1-L4, and L2-L4 compared with preoperative levels (p < 0.05). Postoperative BMD Z scores in the femoral neck and total hip were significantly increased (p < 0.05). Disease duration was negatively correlated with the lumbar-spine BMD Z score. IGF-1 burden was negatively correlated with the BMD Z score at L1 and L1-L4. Multiple regression analysis showed that IGF-1 burden was a risk factor for a BMD Z score decrease at L1 and L1-L4.

CONCLUSION

BMD in patients with GH-secreting pituitary adenomas (compared with nonfunctional adenomas) increased at L1, L2, femoral neck, Ward triangle, trochanter, femoral shaft, and total hip sites. Lumbar-spine BMD Z score recovered to normal levels postsurgically when GH and IGF-1 levels were controlled. BMD Z score was negatively correlated with disease duration and IGF-1 burden in patients with GH-secreting pituitary adenomas, and IGF-1 burden was an independent risk factor for reduced lumbar-spine BMD Z score.

3D Facial Analysis in Acromegaly: Gender-Specific Features and Clinical Correlations

Objective: Quantitative investigations of facial changes in acromegaly are rare. A new imaging technique, three-dimensional (3D) stereophotography, can accurately quantify whole facial changes. We aimed to measure facial characteristics in acromegaly patients using 3D stereophotography, analyze gender-specific features, and explore clinical influencing factors. Design: Single-center case-control study. Methods: Thirty-nine acromegaly patients and 39 age- and gender-matched healthy subjects were prospectively enrolled. 3D stereophotography was performed, and facial lines and angles were quantified for each subject. Clinical information for each acromegaly patient was acquired. Results: The nose width, length, height and depth were longer; the upper and lower lips were thicker; the face length, face width and gonion-gnathion distances were longer; and the nasofrontal and columella-labial angles were smaller in the acromegaly patients, especially in males, than in the healthy controls, with statistical significance (p < 0.05). No differences were found in the face breadth, columella-labial angle, or nose length, height or depth between the female patient and healthy control groups. The insulin-like growth factor 1 (IGF-1) levels in the acromegaly patients were linearly and positively correlated with the nose width (p = 0.006) and gonion-gnathion distance (p = 0.029) and linearly and negatively correlated with the nasofrontal angle (p = 0.026). Conclusions: The acromegaly patients' facial changes exhibit a unique trend, and the characteristics are not identical between genders. 3D stereophotography is an accurate and reliable tool for investigating facial characteristics. Recognizing the above facial features might be potential to assist in the early diagnosis and timely treatment of acromegaly and aid in predicting the severity of systemic complications.

Screening for comorbid conditions in patients enrolled in the SODA registry: a 2-year observational analysis

PURPOSE

This 2-year analysis assessed frequency of comorbidities and comorbidity screening in the Somatuline^® (lanreotide, LAN) Depot for Acromegaly (SODA) registry.

METHODS

Patient data collected included pituitary hormone deficiencies, sleep studies, echocardiograms, gallbladder sonographies, colonoscopies, and glycated hemoglobin (HbA1c) levels. Insulin-like growth factor-1 (IGF-1) and growth hormone levels in patients with (DM) and without (non-DM) diabetes mellitus were analyzed.

RESULTS

There were 241 patients enrolled. Pituitary hormone deficiencies were reported more frequently at enrollment in male (56.9%) vs female patients (32.0%; p < 0.001). TSH deficiency was the most common endocrine deficiency (69.8%), followed by gonadotropin deficiency (62.3%). Screening tests reported at enrollment: sleep studies in 29.9% (79.2% had sleep apnea), echocardiogram in 46.1% (46.8% abnormal), gallbladder sonography in 18.7% (17.8% had gallstones), and colonoscopy in 48.1% (35.3% had polyps). Follow-up studies were reported less frequently at 1 and 2 years. HbA1c data were reported in 30.8% and 41.2% after 1 and 2 years. HbA1c levels were similar at 1 and 2 years of LAN therapy among DM and non-DM patients with available data. Fewer DM vs non-DM patients achieved IGF-1 below upper limit of normal at Month 24 (58.3% vs 80.6%; p = 0.033).

CONCLUSIONS

Fewer than half of patients in SODA had screening results reported at enrollment for sleep apnea, cardiomyopathy, and colon polyps. Gallbladder imaging was reported in a minority of patients. Lower IGF-1 control rates were observed in DM vs non-DM patients at Month 24. These data suggest a need for better monitoring of comorbidities in US acromegaly patients.

Acromegalic cardiomyopathy: Epidemiology, diagnosis, and management

Acromegalic cardiomyopathy is the leading cause of morbidity and all-cause mortality in patients with acromegaly. Though acromegaly is a rare condition, the associated derangements are vast and severe. Stemming from an increase in circulating growth hormone (GH) and insulin-like growth factor-1 levels (IGF-1), acromegalic cardiomyopathy results in pathological changes in myocyte growth and structure, cardiac contractility, and vascular function. These molecular changes manifest commonly as biventricular hypertrophy, diastolic and systolic dysfunction, and valvular regurgitation. Early recognition of the condition is paramount, though the insidious progression of the disease commonly results in a late diagnosis. Biochemical testing, based on IGF-1 measurements, is the gold standard of diagnosis. Management should be centered on normalizing serum levels of both IGF-1 and GH. Transsphenoidal resection remains the most cost-effective and permanent treatment for acromegaly, though medical therapy possesses benefit for those who are not surgical candidates. Ultimately, achieving control of hormone levels results in a severe reduction in mortality rate, underscoring the importance of early recognition and treatment.

Elevated serum IGF-1 level enhances retinal and choroidal thickness in untreated acromegaly patients

PURPOSE

1) To compare the retinal, choroidal, Haller's layer, and Sattler's/choriocapillaris thicknesses of untreated acromegaly patients without chiasm compression or diabetes mellitus and healthy controls. 2) To evaluate the correlations of retinal and choroidal thicknesses with serum growth hormone (GH) and insulin-like growth factor 1 (IGF) burden.

METHODS

This prospective, case-control study included 27 untreated acromegaly patients and 27 sex-matched and age-matched controls. Subfoveal choroidal, Haller's layer and Sattler's/choriocapillaris thicknesses were determined by enhanced-depth imaging optical coherence tomography (EDI-OCT). Foveal and macular retinal thicknesses were determined with SD-OCT. GH and IGF-1 burdens were defined as the product of disease duration and treatment-naïve serum GH and IGF-1 levels.

RESULTS

Compared with healthy controls, patients with acromegaly exhibited significantly increased foveal retinal (p = 0.003), subfoveal choroidal (p < 0.001), and Haller's layer (p < 0.001) thicknesses, with no differences in Sattler's/choriocapillaris layer thickness. Multiple point measurements in the posterior pole area showed equally increased nasal and temporal parts of the choroid. The retinal thickness maps of the two groups did not significantly differ. Correlation analysis indicated that choroidal thickness was significantly correlated with disease duration (p = 0.01), serum IGF-1 level (p = 0.03) and IGF-1 burden (p = 0.009). No significant correlations were detected between choroidal thickness and GH burden (p = 0.44). Retinal thickness was not significantly correlated with any factor.

CONCLUSION

The choroidal thickness of acromegaly patients was greater than that of healthy controls and was significantly correlated with disease duration, IGF-1 level and IGF-1 burden, indicating that excessive serum IGF-1 and its exposure time have a combined effect on choroidal thickness.

Heart in Acromegaly: The Echocardiographic Characteristics of Patients Diagnosed with Acromegaly in Various Stages of the Disease

To determine whether the echocardiographic presentation allows for diagnosis of acromegalic cardiomyopathy. 140 patients with acromegaly underwent echocardiography as part of routine diagnostics. The results were compared with the control group comprising of 52 age- and sex-matched healthy volunteers. Patients with acromegaly presented with higher BMI, prevalence of arterial hypertension, and glucose metabolism disorders (i.e., diabetes and/or prediabetes). In patients with acromegaly, the following findings were detected: increased left atrial volume index, increased interventricular septum thickness, increased posterior wall thickness, and increased left ventricular mass index, accompanied by reduced diastolic function measured by the following parameters: E'med., E/E', and E/A. Additionally, they presented with abnormal right ventricular systolic pressure. All patients had normal systolic function measured by ejection fraction. However, the values of global longitudinal strain were slightly lower in patients than in the control group; the difference was statistically significant. There were no statistically significant differences in the size of the right and left ventricle, thickness of the right ventricular free wall, and indexed diameter of the ascending aorta between patients with acromegaly and healthy volunteers. None of 140 patients presented systolic dysfunction, which is the last phase of the so-called acromegalic cardiomyopathy. Some abnormal echocardiographic parameters found in acromegalic patients may be caused by concomitant diseases and not elevated levels of GH or IGF-1 alone. The potential role of demographic parameters like age, sex, and/or BMI requires further research.

GH, IGF-1, and Age Are Important Contributors to Thyroid Abnormalities in Patients with Acromegaly

PURPOSE

To determine the prevalence, risk factors, and possible mechanisms of structural and endocrinological changes to the thyroid in acromegaly.

METHODS

We studied 93 acromegalic patients from PUMCH between January 2013 and December 2013. The demographic and clinical information were recorded. Specimens of pituitary adenomas and thyroid cancer were collected for BRAF mutation assessments.

RESULTS

Thyroid morphological abnormalities were found in 72 (77.4%) patients. Three (3.2%) were diagnosed with thyroid cancer. The thyroid gland volume was significantly increased in patients with higher random GH (p = 0.01), higher nadir GH (p = 0.008), and higher IGF-1 level (p = 0.018). Age (p = 0.002) was an independent risk factor for thyroid morphological abnormalities in acromegaly. The GH burden was significantly higher in patients with thyroid morphological abnormalities (p = 0.036). The BRAF V600E mutation was detected in the PTCs of the two patients with thyroid cancer.

CONCLUSIONS

Both benign and malignant thyroid abnormalities are increased in the acromegalic population compared to those in the general population. Age at diagnosis is an independent risk factor for thyroid abnormalities, and GH burden may be a partial contributor. Early diagnosis, early treatment, and monitoring of postoperational endocrine levels are important for acromegalic patients.

Risk of left ventricular hypertrophy and diastolic and systolic dysfunction in Acromegaly: A meta-analysis

OBJECTIVE

To perform a meta-analysis to evaluate the exact incidence of left ventricular hypertrophy, diastolic dysfunction and systolic dysfunction in patients with treatment-naïve acromegaly.

METHODS

PubMed, EMBASE, Ovid MEDLINE, the Cochrane Library, Scopus, Science Citation Index Expand and PubMed Central were searched for eligible studies. Eligible data were extracted and evaluated using a fixed- or random-effects model. The Q test, I² statistics for testing heterogeneity, the Newcastle-Ottawa Scale (NOS) for the retrospective appraisal of study quality, and Begg's test and Harbord's modified test for the evaluation of publication bias were used.

RESULTS

Seven eligible studies were selected, and a total of 458 patients and 650 controls were included. Left ventricular hypertrophy was significantly more frequent in treatment-naïve acromegaly patients than in controls [odds ratio (OR) = 28.2, 95% confidence interval (CI) = 19.17-41.49] with a prevalence of 65.1%. Diastolic dysfunction was also common (50.5%) in acromegaly patients (OR = 15.62, 95% CI = 1.98-123.34). Moreover, 19.6% of patients presented abnormal systolic function with an OR of 13.1 (95% CI = 6.64-25.84).

CONCLUSIONS

Patients with treatment-naïve acromegaly are at an increased risk of developing left ventricular hypertrophy, diastolic dysfunction and systolic dysfunction than the general population.