Hair Evaluation in Orthodontic Patients with Oligodontia

Oligodontia can be isolated or syndromic, associated with other ectodermal abnormalities. The aim of the study was to perform hair examination in orthodontic patients diagnosed with oligodontia with a low clinical expression of symptoms of ectodermal origin. All available orthodontic patients diagnosed with oligodontia in the permanent dentition were enrolled. Hair examination included clinical evaluation of the patients' hair, trichoscopy, trichogram and evaluation of the hair shafts under a polarized light microscope. In total, 25 patients, 18 males and 7 females, aged 6 to 24 years were evaluated for the presence of dental and hair abnormalities. The number of congenitally absent teeth ranged from 6 to 24 teeth and diastemas, microdontia, taurodontism and altered tooth shape were found in 23 patients. Hair disorders were found in 68% of the subjects. Hypotrichosis, the heterogeneity of shaft color and loss of pigment, androgenetic alopecia, telogen effluvium, trichoschisis, pili canaliculi, trichorrhexis nodosa and pseudomoniletrix were observed. Trichoscopy and trichogram are valid non-invasive diagnostic tests which could be used to differentiate between isolated and syndromic oligodontia in patients with a low clinical expression of ectodermal symptoms.

The Heart's Function as a Pump Assessed via Impedance Cardiography and the Autonomic System Balance in Patients with Early-Stage Acromegaly

BACKGROUND

Acromegaly is a rare, chronic disease that involves structural and functional abnormalities of the cardiovascular system. Acromegaly likely affects interactions between the cardiovascular system and the autonomic nervous system (ANS). Therefore, assessing the relationship between sympathetic-parasympathetic balance by analyzing heart rate variability (HRV) and the hemodynamic profile via impedance cardiography (ICG) may be useful in learning the exact nature of interactions between the ANS and the cardiovascular system. The purpose of this study was to assess a possible association between HRV and ICG-based parameters of cardiac function in patients newly diagnosed with acromegaly.

METHODS

This observational cohort study was conducted on 33 patients (18 men, mean age of 47 years) newly diagnosed with acromegaly and no significant comorbidities. A correlation analysis (Spearman's rank coefficient R) of the parameters assessed via ICG and the HRV assessed via 24 h ambulatory electrocardiography was performed. ICG assessments included the following parameters: stroke volume index (SI), cardiac index (CI), acceleration index (ACI), velocity index (VI), and Heather index (HI). The analysis of HRV included both time-domain parameters (pNN50, SDNN, SDSD, rMSSD) and frequency-domain parameters (total power (TP) and its individual frequency bands: low-frequency (LF day/night), high-frequency (HF day/night), and the LF/HF ratio (day/night)).

RESULTS

Frequency-domain HRV analysis showed the following correlations: (1) lower nighttime LF values with higher ACI (R = -0.38; p = 0.027) and HI (R = -0.46; p = 0.007) values; (2) higher nighttime HF values with higher ACI (R = 0.39; p = 0.027) and HI (R = 0.43; p = 0.014) values; (3) lower nighttime LF/HF values with higher ACI (R = -0.36; p = 0.037) and HI (R = -0.42; p = 0.014) values; (4) higher nighttime TP values with higher SI values (R = 0.35; p = 0.049). Time-domain parameters of HRV showed a significant correlation only between the nighttime values of SDSD and SI (R = 0.35; p = 0.049) and between the daytime and nighttime values of SDNN and HR (R = -0.50; p = 0.003 and R = -0.35; p = 0.046). In multivariate regression, only ACI was revealed to be independently related to HRV.

CONCLUSIONS

In patients newly diagnosed with acromegaly, the relationship between the sympathetic-parasympathetic balance assessed via HRV and the hemodynamic profile assessed via ICG was revealed. Better function of the left ventricle was associated with a parasympathetic shift in the autonomic balance.

Artificial intelligence in detecting left atrial appendage thrombus by transthoracic echocardiography and clinical features: the Left Atrial Thrombus on Transoesophageal Echocardiography (LATTEE) registry

AIMS

Transoesophageal echocardiography (TOE) is often performed before catheter ablation or cardioversion to rule out the presence of left atrial appendage thrombus (LAT) in patients on chronic oral anticoagulation (OAC), despite associated discomfort. A machine learning model [LAT-artificial intelligence (AI)] was developed to predict the presence of LAT based on clinical and transthoracic echocardiography (TTE) features.

METHODS AND RESULTS

Data from a 13-site prospective registry of patients who underwent TOE before cardioversion or catheter ablation were used. LAT-AI was trained to predict LAT using data from 12 sites (n = 2827) and tested externally in patients on chronic OAC from two sites (n = 1284). Areas under the receiver operating characteristic curve (AUC) of LAT-AI were compared with that of left ventricular ejection fraction (LVEF) and CHA2DS2-VASc score. A decision threshold allowing for a 99% negative predictive value was defined in the development cohort. A protocol where TOE in patients on chronic OAC is performed depending on the LAT-AI score was validated in the external cohort. In the external testing cohort, LAT was found in 5.5% of patients. LAT-AI achieved an AUC of 0.85 [95% confidence interval (CI): 0.82-0.89], outperforming LVEF (0.81, 95% CI 0.76-0.86, P < .0001) and CHA2DS2-VASc score (0.69, 95% CI: 0.63-0.7, P < .0001) in the entire external cohort. Based on the proposed protocol, 40% of patients on chronic OAC from the external cohort would safely avoid TOE.

CONCLUSION

LAT-AI allows accurate prediction of LAT. A LAT-AI-based protocol could be used to guide the decision to perform TOE despite chronic OAC.

The patient's sex determines the hemodynamic profile in patients with Cushing disease

Background

Cushing disease (CD) may lead to accelerated cardiovascular remodeling and increased mortality. There are suspected differences in the mechanism of cardiovascular dysfunction between males and females with CD. The purpose of this study was to assess the effect of patient sex on the hemodynamic profile assessed via impedance cardiography and echocardiography in patients newly diagnosed with CD.

Material and methods

The 54 patients newly diagnosed with CD (mean age 41 years; 77.8% of females) who were included in this prospective clinical study underwent impedance cardiography to assess specific parameters (including systemic vascular resistance index [SVRI], total arterial compliance index [TACI], Heather index [HI], stroke index [SI], cardiac index [CI], velocity index [VI], and acceleration index [ACI]) and transthoracic echocardiography to assess heart chamber diameters and left ventricular systolic and diastolic function.

Results

Males with CD exhibited higher afterload, with higher SVRI (3,169.3 ± 731.8 vs. 2,339.3 ± 640.8 dyn*s*cm-5*m² in males and females, respectively; p=0.002), lower TACI (0.80 ± 0.30 vs. 1.09 ± 0.30 mL/mmHg*m2; p=0.008), and lower hemodynamic parameters of left ventricular function, with lower HI (9.46 ± 2.86 vs. 14.1 ± 5.06 Ohm/s2; p=0.0007), lower VI (35.1 ± 11.9 vs. 44.9 ± 13.1 1*1000-1*s-1; p=0.009), lower SI (36.5 ± 11.7 vs. 43.6 ± 9.57 mL/m2; p=0.04), lower CI (2.36 ± 0.46 vs. 3.17 ± 0.76 mL*m-2*min-1; p=0.0009), and lower ACI (50.4 ± 19.8 vs. 73.6 ± 25.0 1/100/s2; p=0.006). There were no significant differences between the sexes in left ventricular systolic or diastolic function assessed by echocardiography.

Conclusion

In comparison with females with CD, males with CD have a less favorable hemodynamic profile, with higher afterload and worse left ventricular function. Sex differences in cardiovascular system function should be taken into consideration in designing personalized diagnostic and therapeutic management of patients with CD.

Value of Left Atrial Strain in Predicting Recurrence after Atrial Fibrillation Ablation

This study tested the relationship between left atrial (LA) function parameters and the results of pulmonary vein isolation (PVI) in patients with atrial fibrillation (AF). Consecutive patients undergoing PVI for the first time between 2019 and 2021 were included. Patients underwent radiofrequency ablation using contact force catheters and an electroanatomical system. Follow-up consisted of ambulatory visits/televisits and 7-day Holter monitoring (at 6 and 12 months after ablation). On the day of ablation, all patients underwent transesophageal and transthoracic echocardiography with LA strain analysis. The primary endpoint was atrial tachyarrhythmia recurrence during the follow-up period. Of 221 patients, 22 did not meet the echocardiographic quality criteria, leaving 199 patients. The median follow-up period was 12 months, and 12 patients were lost to follow-up. Recurrences were observed in 67 patients (35.8%) after a mean of 1.06 procedures per patient. The patients were divided into a sinus rhythm (SR, n = 109) group and an AF (n = 90) group based on their cardiac rhythm at the time of echocardiography. In the SR group, univariable analysis showed that LA reservoir strain, LA appendage emptying velocity (LAAV), and LA volume index predicted AF recurrence, with only LAAV being significant in the multivariable analysis. In AF patients, univariable analysis revealed no LA strain parameters predicting AF recurrence.

Increased Thoracic Fluid as the Most Distinctive Cardiovascular Hemodynamic Alteration in Men with Prolactinoma

Hyperprolactinemia in males with prolactin-secreting adenomas, or prolactinomas, may be associated with endothelial dysfunction and co-existing cardiovascular risk factors. As a noninvasive technique of assessing cardiac function, impedance cardiography (ICG) may be useful in the early detection of hemodynamic dysfunction. The aim of the present study was to analyze and compare the hemodynamic profiles of patients with prolactinoma versus controls. A total of 20 men with prolactinoma (PR group) (mean age 43 years) and 20 men from the control group (CG) were evaluated in this prospective, observational comparative clinical study. The study subjects were propensity score-matched in terms of clinical characteristics—age, mean blood pressure [MBP], arterial hypertension [AH] rates, and body mass index [BMI]. ICG assessments of hemodynamic profiles were conducted with the use of a Niccomo™ device and included stroke volume index (SI), cardiac index (CI), systemic vascular resistance index (SVRI), velocity index (VI), acceleration index (ACI), Heather index (HI), and thoracic fluid content (TFC). AH was well-controlled in both study groups (116/76 mmHg PR vs. 119/76 mmHg CG). In comparison with CG patients, ICG revealed PR group patients to have higher rates of high thoracic fluid content (TFC) (>35 1/kOhm; p = 0.035) and lower SI values (<35 mL/m2, p = 0.072). There was a convergent tendency towards lower values of other cardiac function parameters (SI, CI, VI, ACI, and HI). Prolactinoma-associated endocrine abnormalities are related to hemodynamic profile alterations, including higher rates of increased TFC and the risk of worsened cardiac function.

Left atrial function parameters as predictors of atrial fibrillation recurrence after pulmonary vein isolation

Background

The aim of the study was to test the relationship between left atrial (LA) function parameters and the results of the pulmonary vein isolation (PVI) in patients with atrial fibrillation (AF).

Patients and methods

Consecutive patients undergoing first time PVI in years 2019–2021 were qualified to the study. The patients underwent radiofrequency ablation using contact-force catheters and electroanatomical system. LA pressure was measured directly just after transseptal puncture. Follow-up was based on ambulatory visits/televisits and 7-day holter monitoring (6 and 12 month after ablation). On the day of ablation all the patients underwent transesophageal and transthoracic echocardiography. The primary endpoint was any atrial tachyarrhythmia recurrence during follow-up period.

Results

A total of 210 patients were included in the study. Median of follow-up was 12 months, AF recurrence was observed in 71 patients (33.8%) after mean of 1.03 procedures per patient. In univariate Cox regression analysis several echocardiographic parameters were significant predictors of AF recurrence after catheter ablation: left and right atrial area, LA volume, average e' and average E/e' values, LA reservoir strain, LA conduit strain, LA appendage emptying velocity. AF recurrence was also predicted by mean LA pressure, age, body mass index and calculated eGFR. Interestingly, LA contraction strain and LA emptying fraction were not predictors of results of AF ablation. In multivariate Cox regression analysis (that included all parameters significant in univariate analysis) LA reservoir strain (hazard ratio (HR) 1.076, 95% confidence interval (CI) 1.014–1.141; p=0.014) and LA appendage emptying velocity (HR 0.968, 95% CI 0.947–0.988; p=0.002) were significant predictors of AF ablation results.

Conclusions

LA reservoir strain and LA appendage emptying velocity are predicting factors of AF ablation results. LA contraction strain and LA emptying function were not predictors of effective AF ablation.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Statutory Grant of Military Institute of Medicine

Differences in the predictors of left atrial appendage thrombus between men and women treated with dabigatran or rivaroxaban

INTRODUCTION

Some patients with atrial fibrillation (AF) develop left atrial appendage thrombus (LAAT) despite receiving anticoagulant treatment. Different scores were proposed to evaluate thromboembolic risk in patients with AF. Risk stratification according to sex is common in clinical practice.

OBJECTIVE

We aimed to identify predictors of LAAT separately in men and women treated with dabigatran or rivaroxaban.

PATIENTS AND METHODS

This retrospective study included 1256 patients (479 women [38.1%]) with AF who underwent transesophageal echocardiography before electrical cardioversion or catheter ablation, between January 2013 and December 2019, and received dabigatran or rivaroxaban for at least 3 weeks.

RESULTS

Multivariable logistic regression analysis revealed nonparoxysmal AF to predict LAAT in women (odds ratio [OR], 9.70; P = 0.002). In men, the predictors were heart failure (OR, 4.14; P = 0.001), diabetes (OR, 2.64; P = 0.002), nonparoxysmal AF (OR, 5.61; P = 0.02), and estimated glomerular filtration rate below 60 ml/min/1.73 m2 (OR, 2.77; P = 0.01). In the receiver operating characteristic curve analysis, the CHA2DS2‑VASc-RAF score had the highest value for predicting LAAT in women (area under the curve [AUC] = 0.786). In men, CHA2DS2‑VASc-RAF, CHA2DS2, CHA2DS2‑VASc, and R2CHADS2 had sufficient predictive value (AUC = 0.786, 0.726, 0.734, and 0.780, respectively).

CONCLUSIONS

The predictors of LAAT differ between men and women treated with dabigatran or rivaroxaban. In women, the CHA2DS2‑VASc‑RAF score had the highest predictive value, while in men all the scores had equally sufficient predictive value.

Contouring cardiac substructures on average intensity projection 4D-CT for lung cancer radiotherapy: a proposal of a heart valve contouring atlas

BACKGROUND AND PURPOSE

A detailed contouring atlas of the heart valves is lacking. Existing heart contouring atlases have not been evaluated on average intensity projection four-dimensional non-contrast computed tomography (AVE-4D-CT) scans, routinely used for organ-at-risk delineation in lung cancer radiotherapy. We aimed to develop the heart valve contouring atlas and to assess inter-observer variation in delineation of the heart, its substructures, and coronary arteries on AVE-4D-CT scans, along with its impact on radiotherapy doses.

MATERIALS AND METHODS

A heart valve contouring atlas was developed. Five radiation oncologists and four cardiologists delineated the valves according to this atlas, and the remaining heart substructures according to the existing atlases, on AVE-4D-CT scans of ten patients who underwent radio(chemo)therapy for NSCLC. The observer contours were then compared to the collectively defined "reference" contours. Spatial variation was assessed using the Sørensen-Dice similarity coefficient (DSC), directed average Hausdorff distance (DAH), directed Hausdorff distance (HD), and the mean distance to agreement (MDA). The effect of spatial variation on radiotherapy doses was assessed using the patients' treatment plans.

RESULTS

Inter-observer contour overlap (mean DSC) was 0.68, 0.49, 0.45 and 0.45, and inter-observer contour separation (mean DAH) was 2.1, 3.4, 2.6 and 2.9 mm for the pulmonic (PV), aortic (AV), mitral (MV) and tricuspid valve (TV), respectively. Mean HD was higher for TV and MV (13.3 and 11.7mm) than for AV and PV (7.8 and 7mm). The highest mean MDA of 3.1mm was found for AV, and the lowest (1.9mm) for PV. Inter-observer agreement was the lowest for the coronary arteries, but statistically significant dose variation was found mainly in the left ventricular septal and anterior segments.

CONCLUSION

Our atlas enables reproducible delineation of the heart valves. Delineation of the heart and its substructures on AVE-4D-CT scans is feasible, with inter-observer variability similar to that reported on conventional non-contrast CT scans.

Prolactinoma and cardiovascular diseases – an interdisciplinary problem

Prolactin-secreting pituitary tumour is a rare disease, in which excess prolactin causes significant functional and constitutional disorders of the whole body. Hyperprolactinaemia is associated with changes in body composition and metabolic disorders. The long-term prognosis and quality of life in patients with prolactinoma are mainly influenced by cardiovascular disorders, which, if left untreated, increase the cardiovascular risk and limit the treatment options for secondary organ complications. Cardiovascular mortality in patients with prolactinoma is several times higher than in the general population. Early diagnosis of prolactin-releasing pituitary tumour and a thorough morphological and functional cardiovascular assessment at each stage of the disease are necessary for risk stratification. Patients with prolactinoma should be put on combined treatment based on both serum prolactin control, and reduction of cardiovascular risk factors. Normalisation of prolactin levels and reduction of the tumour mass, achieved mainly through effective pharmacotherapy, reduce mortality and the risk of cardiovascular complications; therefore, the earliest possible diagnosis of prolactin pituitary tumour and implementation of appropriate treatment as well as active diagnosis and therapy of coexisting organ complications should be set as a goal in these patients. It seems that a thorough cardiological assessment of patients with prolactinoma should be obligatory, regardless of their age or the time of diagnosis. The aim of this study was to present the complexity of clinical problems in patients with prolactin secreting pituitary tumours, who require special interdisciplinary care.

Effect of Tooth Agenesis on Mandibular Morphology and Position

Congenital missing teeth (OMIM #106600) is the most common dental abnormality. The aim of the study was to evaluate the effects of tooth agenesis on the total mandibular length, length of the mandibular body and alveolar process, and the mandibular anteroposterior position. The material was obtained from the Department of Orthodontics, Medical University of Warsaw. The study group included 116 patients aged 9–18 years with a congenital absence of at least two permanent tooth buds in the maxilla and/or mandible (mean: 6.2 teeth missing/patient). All patients were Caucasians: 68 (59%) females and 48 (41%) males. The control group included 115 patients without tooth agenesis matched with the age and gender of the study group. A cephalometric analysis was performed, and it was focused on assessing anteroposterior mandibular measurements. This assessment was based on 17 measurements (12 linear and 5 angular). Statistical analysis of the cephalometric measurements between the study group and the control group showed significant changes regarding selected mandibular measurements. Tooth agenesis does not affect the total length of the mandible and the length of the mandibular body, but it might reduce the length of the mandibular arch length and result in a more retrusive mandibular position.

Correlations between left atrial strain and left atrial pressures values in patients undergoing atrial fibrillation ablation

BACKGROUND

We aimed to investigate the correlations between left atrial strain (LAS) assessed by speckle tracking echocardiography and directly measured left atrial pressures (LAP) values and to estimate the features of patients with lower LAS values.

METHODS

A prospective, observational study was performed on patients with atrial fibrillation (AF) undergoing ablation. Detailed transthoracic echocardiography with the speckle tracking method was used to estimate the LAS reservoir (LASr) and direct measurements of LAP during ablation in all patients.

RESULTS

A total of 172 patients were included (98 with sinus rhythm [SR] and 74 with AF). The patients with lower LASr (first tercile) compared to those with higher (third tercile), were older, more often female, presented with a larger left atrium (LA) (per the LA area and volume index), and had more impaired left ventricular (LV) diastolic function parameters (e', E/e'). The correlation analysis of the echocardiographic parameters with the LAP revealed the most significant correlations in the SR group, where the E/e' ratio, LASr, and LAS contraction (LASct) values were all associated with LAP. The cut-off value of LASr estimating high elevated mean LAP (≥15 mm Hg) was 21.88 (Area Under Curve [AUC], 0.81; 95% confidence interval [CI], 0.72-0.90; P <0.0001) for the SR group and 11.25 (AUC, 0.66; 95% CI, 0.53-0.80; P = 0.016) for the AF group.

CONCLUSIONS

AF patients with lower LASr are older, more often female, have a larger LA, and have more impaired LV diastolic function. Low LASr and LASct and high E/e' ratio values are associated with higher LAP in AF patients with SR.

Cardiovascular risk in patients with Cushing’s disease – an interdisciplinary problem

Cushing’s disease is a chronic endogenous hypercortisolaemia associated with overproduction of adrenocorticotropic hormone by a pituitary adenoma, leading to multiple systemic complications that significantly increase morbidity and mortality, as well as reduce the quality of life as a result of prolonged tissue exposure to excess cortisol. Hypercortisolaemia in Cushing’s disease is associated with significant functional and constitutional disorders of the entire body. The consequences of chronic hypercortisolaemia include haemodynamic disorders associated with excessive vascular contraction and increased blood pressure, obesity, carbohydrate metabolism disorders, dyslipidaemia, and coagulopathies, which may contribute to significant cardiovascular remodelling. Cardiovascular disorders have a particular impact on long-term prognosis and quality of life in Cushing’s disease. If left untreated, Cushing’s disease significantly increases the cardiovascular risk and limits the treatment options for secondary organ complications. Cardiovascular mortality (myocardial infarction, heart failure, stroke) is several times higher in patients with Cushing’s disease than in the general population. Early diagnosis of the corticotropic pituitary tumour, as well as a thorough morphological and functional cardiovascular assessment seem essential in risk stratification. Normalisation of cortisol levels after combined neurosurgical and/or pharmacological treatment reduces mortality and the risk of cardiovascular and respiratory complications. The aim of this study is to present the complexity of clinical problems in patients with Cushing’s disease, who are in a particular need of interdisciplinary care.

Risk of left atrial appendage thrombus in older patients with atrial fibrillation

Introduction

We aimed to compare the prevalence of left atrial appendage (LAA) thrombus and its predictors between old and young patients with atrial fibrillation (AF).

Material and methods

The study included 1970 patients aged ≥ 65 (n = 822 (41.7%)) and < 65 (n = 1148 (58.3%)) referred for AF cardioversion or ablation preceded by transoesophageal echocardiography (TEE).

Results

Oral anticoagulation (OAC) was prescribed in 799 (97.2%) patients aged ≥ 65 years and in 1054 (91.8%) of those aged < 65 years (p < 0.001). In patients treated with OAC, those aged ≥ 65 years less often received vitamin K antagonist (VKA) (267 (33.4%) vs. 416 (39.5%)) and more often non-VKA-OAC (NOAC) (532 (66.6%) vs. 638 (60.5%), p = 0.008, p = 0.008) compared to patients < 65 years. On TEE, LAA thrombus was more often observed in patients aged ≥ 65 years than those aged < 65 years (63 (7.7%) vs. 46 (4.0%), p < 0.001), with an absolute but not statistically significant difference between patients aged 65-74 and ≥ 75 years (47 (7.3%) vs. 16 (8.8%), p = 0.528). In patients aged ≥ 65 years, there was no difference in the prevalence of LAA thrombus between patients treated with VKA and NOAC, in contrast to patients aged < 65 years, in whom such a difference was observed (27 (6.5%) vs. 16 (2.5%), p = 0.002). In multivariate logistic regression, predictors of LAA thrombus in both age groups were older age, non-paroxysmal AF, and heart failure, whereas only in patients aged < 65 years - VKA use, and in those aged ≥ 65 years - lower glomerular filtration rate and platelet count.

Conclusions

Despite OAC use, older patients with AF remain at high risk of LAA thrombus formation. Older age, non-paroxysmal AF, and heart failure are predictors of LAA thrombus, irrespective of age.

Cushing's Disease: Assessment of Early Cardiovascular Hemodynamic Dysfunction With Impedance Cardiography

BACKGROUND

Cushing's disease is a rare condition associated with a high cardiovascular risk and hypercortisolemia-related hemodynamic dysfunction, the extent of which can be assessed with a noninvasive method, called impedance cardiography. The standard methods for hemodynamic assessment, such as echocardiography or ambulatory blood pressure monitoring may be insufficient to fully evaluate patients with Cushing's disease; therefore, impedance cardiography is being currently considered a new modality for assessing early hemodynamic dysfunction in this patient population. The use of impedance cardiography for diagnosis and treatment of Cushing's disease may serve as personalized noninvasive hemodynamic status assessment and provide a better insight into the pathophysiology of Cushing's disease. The purpose of this study was to assess the hemodynamic profile of Cushing's disease patients and compare it with that in the control group.

MATERIAL AND METHODS

This observational prospective clinical study aimed to compare 54 patients with Cushing's disease (mean age 41 years; with 64.8% of this population affected with arterial hypertension) and a matched 54-person control group (mean age 45 years; with 74.1% of this population affected with arterial hypertension). The hemodynamic parameters assessed with impedance cardiography included the stroke index (SI), cardiac index (CI), systemic vascular resistance index (SVRI), velocity index (VI), (ACI), Heather index (HI), and thoracic fluid content (TFC).

RESULTS

The Cushing's disease group was characterized by a higher diastolic blood pressure and a younger age than the control group (82.9 vs. 79.1 mmHg, p=0.045; and 41.1 vs. 44.9 years, p=0.035, respectively). Impedance cardiography parameters in the Cushing's disease group showed: lower values of SI (42.1 vs. 52.8 ml/m²; p ≤ 0.0001), CI (2.99 vs. 3.64 l/min/m²; p ≤ 0,0001), VI (42.9 vs. 52.1 1/1000/s; p=0.001), ACI (68.7 vs. 80.5 1/100/s²; p=0,037), HI (13.1 vs. 15.2 Ohm/s²; p=0.033), and TFC (25.5 vs. 27.7 1/kOhm; p=0.006) and a higher SVRI (2,515 vs. 1,893 dyn*s*cm^-5*m²; p ≤ 0.0001) than those in the control group.

CONCLUSIONS

Cushing's disease is associated with significantly greater vasoconstriction and left ventricular systolic dysfunction. An individual assessment with impedance cardiography may be useful in Cushing's disease patients in order to identify subclinical cardiovascular complications of chronic hypercortisolemia as potential therapeutic targets.

Acromegaly: The Research and Practical Value of Noninvasive Hemodynamic Assessments via Impedance Cardiography

BACKGROUND

Arterial hypertension (AH) that accompanies acromegaly (AC) may lead to cardiovascular dysfunction. Such consequences may be detected with impedance cardiography (ICG), which is a noninvasive method of hemodynamic assessment. Early detection of subclinical hemodynamic alterations in AC patients may be crucial for optimizing treatment and preventing cardiovascular remodeling. The purpose of this study was to identify the hemodynamic parameters of the cardiovascular system that differentiate patients with AC from those in the control group (CG), with a particular emphasis on potential targets for medical therapy.

METHODS

This observational, prospective, clinical study involved a comparative analysis of 33 AC patients with no significant comorbidities and the controls selected via propensity score matching based on a set of baseline characteristics (age, sex, body mass index, mean blood pressure [MBP]), with comparable proportions of AH patients. The assessed hemodynamic parameters included the stroke volume index (SI), cardiac index, systemic vascular resistance index, velocity index (VI), acceleration index, Heather index (HI), and thoracic fluid content (TFC).

RESULTS

Both the AC group and the CG had well-controlled AH (mean blood pressure of 121/77 mmHg and 119/76 mmHg, respectively). In terms of baseline characteristics, the AC group was characterized by a higher hear rate and lower creatinine levels than the CG (76.2 bpm vs. 66.8 bpm [p = 0.001] and 0.755 mg/dL vs. 0.850 mg/dL [p = 0.035], respectively). ICG assessment of AC patients and CG patients showed the former to have higher heart rates (73.5 bpm vs. 65.2 bpm; p = 0.003), lower SI (43.8 mL/m² vs. 53.4 mL/m²; p = 0.0001), lower VI (42.1 1/1000/s vs. 49.3 1/1000/s; p = 0.037), lower HI (8.49 Ohm/s² vs. 13.4 Ohm/s², p ≤ 0.0001), and higher thoracic fluid content (TFC) (38.4 1/kOhm vs. 28.1 1/kOhm; p ≤ 0.0001), respectively.

CONCLUSIONS

Even with well-controlled hypertension, AC is associated with a high TFC, increased heart rate, and decreased indices of cardiac contractility. Hemodynamic changes in AC patients may be detected with the modern, noninvasive diagnostic tool, ICG.

Decreased left atrial appendage emptying velocity as a link between atrial fibrillation type, heart failure and older age and the risk of left atrial thrombus in atrial fibrillation

INTRODUCTION

Decreased left atrial appendage emptying velocity (LAAV) is a known predictor of LAA thrombus in atrial fibrillation (AF). The aim of our study was to identify which of the clinical risk factors for LAA thrombus are associated with decreased LAAV.

METHODS

The study included 1476 consecutive AF patients who underwent transesophageal echocardiography (TEE) before AF direct current cardioversion or ablation in two high-reference cardiology departments. Patients were divided into two groups: 71 (4.8%) patients with LAAV < 20 cm/s and 1405 patients (95%) with LAAV ≥ 20 cm/s.

RESULTS

Compared with patients with LAAV ≥ 20 cm/s, those with decreased LAAV were older, more often had non-paroxysmal AF, were burdened with more concomitant diseases (including hypertension, diabetes, vascular disease, and heart failure [HF]) with higher median CHA₂ DS₂ -VASc score (3 [2-4] vs 2 [1-3], P < .0001), and had lower glomerular filtration rate (GFR). Prevalence of LAA thrombus was higher in patients with decreased LAAV compared with those with LAAV ≥ 20cm/s (20% vs 4.6%, P < .0001). In patients with decreased LAAV, there was no difference in the frequency of LAA thrombus between those treated with VKA and those receiving NOAC, while in patients with LAAV ≥ 20 cm/s a trend was observed towards a benefit with NOAC. In multivariate logistic regression, non-paroxysmal AF, HF and age ≥ 65 years predicted both LAAV < 20 cm/s and LAA thrombus, while GFR < 60 mL/min/1.73 m² predicted only the presence of LAA thrombus.

CONCLUSION

One in five AF patients with decreased LAAV had LAA thrombus, regardless of the type of OAC. Non-paroxysmal AF, HF and age ≥ 65 years might increase LAA thrombus risk via reduced LAAV.

Prevalence and risk factors of left atrial thrombus in patients with atrial fibrillation and lower class (IIa) recommendation to anticoagulants

Background

Oral anticoagulation therapy (OAT) prevents ischaemic incidents in patients with atrial fibrillation (AF). CHA₂DS₂-VASc risk score of ≥2 points in men and ≥3 in women is a class I indication for OAT. OAT should also be considered as a prevention of thromboembolism in AF men with a CHA₂DS₂-VASc score of 1 point and women with 2 points, but the class of recommendation is lower (IIa). This study aims to assess the occurrence of left atrial appendage thrombus (LAAT) and risk factors of its formation in patients with lower class recommendation to oral antiocoagulation treatment.

Methods

The study group consisted of 1,858 patients: 555 patients with class IIa indication to OAT (IIa group) and 1,303 patients with class I indication as a control group (I group). Patients were admitted to three cardiology departments. All subjects underwent transoesophageal echocardiography.

Results

The incidence of LAAT was comparable in both IIa and I group: LAAT was confirmed in 30 (5.4%) subjects of IIa group and in 77 (5.9%) of I group. The prevalence of LAAT in IIa group was higher on treatment with VKAs (in comparison to NOACs) (8.4% vs. 3.4%, P=0.010), and lower in case of paroxysmal AF (in comparison to non-paroxysmal AF) (2.4% vs. 9.8%, P=0.0002). Multivariate logistic regression revealed the following variables as the independent predictors of LAAT in IIa group: treatment with VKAs (OR 2.99, 95% CI: 1.33-6.69; P=0.007), paroxysmal AF (OR 0.26, 95% CI: 0.11-0.62; P=0.002) and eGFR <60 mL/min/1.73 m² (OR 3.19, 95% CI: 1.42-7.16; P=0.005).

Conclusions

The prevalence of LAAT in AF patients with lower class (IIa) recommendation to anticoagulants was comparable to higher (I). Treatment with VKAs, along with non-paroxysmal type of AF and eGFR <60 mL/min/1.72 m² were identified as the strongest predictors of LAAT in IIa group.

Does the CHA2DS2-VASc scale sufficiently predict the risk of left atrial appendage thrombus in patients with diagnosed atrial fibrillation treated with non-vitamin K oral anticoagulants?

The CHA2DS2-VASc scale does not include potential risk factors for left atrial appendage thrombus (LAAT) formation such as a form of atrial fibrillation (AF) and impaired kidney function. The real risk of thromboembolic complications in AF patients is still unclear as well as an optimal anticoagulant treatment in males with a CHA2DS2-VASc score of 1 and females with a CHA2DS2-VASc score of 2.The aim of this study was to compare the predictive value of the CHA2DS2-VASc scale and other scales to estimate the risk of LAAT formation in AF patients treated with non-vitamin K oral anticoagulants (NOACs) and to assess the prevalence of thrombi in patients at intermediate risk of stroke.The observational study included consecutive patients with a diagnosis of non-valvular AF treated with NOACs, admitted to 3 high-reference institutions between 2013 and 2018. All individuals underwent transoesophageal echocardiography before cardioversion or ablation.Out of 1163 enrolled AF patients (62.1% male, mean age 62 years) the LAAT had been detected in 50 individuals (4.3%). Among patients with LAAT, 1 patient (2.0%) was classified as a low-risk category, 9 (18.0%) were at intermediate-risk, and 40 (80.0%) were at high risk of thromboembolic complications according to CHA2DS2-VASc scale. All patients were treated with NOACs: 51.0% rivaroxaban, 47.1% dabigatran, and 1.9% apixaban.Patients at intermediate stroke-risk with detected LAAT had higher R2CHADS2 score (2.1 ± 1.2 vs 1.2 ± 0.8, P = .007), higher CHA2DS2-VASc-RAF score (6.4 ± 4.4 vs 3.7 ± 2.6, P = .027) and more often had an estimated glomerular filtration rate below 56 mL/min/1.73 m (44.4% vs 13.2%, P = .026) compared to patients without LAAT. The receiver operating characteristics revealed that the CHA2DS2-VASc-RAF scale had better predictive ability to distinguish between patients with and without LAAT in the study group than CHA2DS2-VASc (P = .0006), CHADS2 (P = .0006) and R2CHADS2 scale (P = .0140).The CHA2DS2-VASc scale should be supplemented with an assessment of renal function and form of AF to improve stroke risk estimation. The application of additional scales to estimate the risk of LAAT might be especially useful among males with a CHA2DS2-VASc score of 1 and females with a CHA2DS2-VASc score of 2.

Thrombus in the left atrial appendage in patients with atrial fibrillation treated with non-vitamin K antagonist oral anticoagulants in clinical practice-A multicenter registry

BACKGROUND

The prevalence and predictors of left atrial appendage thrombus (LAAT) in patients with non-valvular atrial fibrillation (AF) who have been treated with non-vitamin K antagonist oral anticoagulants (NOACs) are not well defined. We aimed to assess the occurrence and predictors of LAAT on transesophageal echocardiography (TOE) in patients with non-valvular AF treated with NOACs for at least 3 weeks.

METHODS

Consecutive patients with non-valvular AF who underwent TOE before catheter ablation or electrical cardioversion in three high-reference centers between 2014 and 2018 were included. Patients on apixaban were excluded from the study due to low numbers in this category. All patients received NOACs for at least 3 weeks before TOE.

RESULTS

A total of 1148 patients (female, 38.1%; mean age, 62.1 years) referred to our centers for catheter ablation of AF (52.1%) or electrical cardioversion (47.9%) were included. Patients were on rivaroxaban (51.9%) or dabigatran (48.1%). Preprocedural TOE revealed LAAT in 4.4% of all patients. Multivariable logistic regression analysis showed the CHA2DS2-VASc score ≥2 points (OR = 2.11; 95% CI, 1.15-3.88; P = .0161), non-paroxysmal AF (OR = 6.30; 95% CI, 2.22-17.91; P = .0005), and GFR <60 mL/min/1.73 m² (OR = 2.05; 95% CI, 1.14-3.67; P = .0160) were independent predictors of LAAT in patients treated with NOACs.

CONCLUSIONS

In non-valvular AF patients treated with NOACs, the prevalence of LAAT was 4.4% before electrical cardioversion or ablation. In addition to the CHA2DS2-VASc score, the type of AF and renal function should be considered in the stratification of thromboembolism risk in AF patients and qualification for a preprocedural TOE.

Risk of left atrial appendage thrombus in patients with atrial fibrillation and chronic kidney disease

Background

Atrial fibrillation (AF) and chronic kidney disease (CKD) are associated with an increased risk of ischemic stroke. The aim of this study was to compare the clinical characteristics, the incidence of left atrial appendage (LAA) thrombus and its predictors, and spontaneous echo contrast (SEC) in a population of patients with AF depending on estimated glomerular filtration rate (eGFR) values.

Methods

This study included 1962 patients who underwent transesophageal echocardiographic examination prior to cardioversion or ablation in the years 2014–2018 in three cardiac centers.

Results

More than a quarter of AF patients had decreased eGFR (< 60 mL/min/1.73 m²) and were characterized as a high-risk population, with more comorbidities, higher thromboembolic and bleeding risk compared to those with normal renal function. Oral anticoagulation (OAC) was prescribed in 97% and 93% of patients with decreased and normal eGFR, respectively, with a higher prevalence of prescribed non-vitamin K antagonist oral anticoagulants (NOACs). The incidence of LAA thrombus (24%, 9% and 4%) and SEC (25%, 25% and 19%) increases simultaneously with a decrease in eGFR (< 30, 30–59 and ≥ 60 mL/min/1.73 m², respectively). Among patients prescribed reduced doses of NOAC, those with decreased eGFR were more often observed with LAA thrombus (10% vs. 2.5%). Non-paroxysmal AF, heart failure and previous bleeding were predictors of LAA thrombus, irrespective of eGFR value. CKD was the predictor of LAA thrombus in all patients including those with non-paroxysmal AF, males, without diabetes, without hypertension and with CHA₂DS₂-VASc < 2.

Conclusions

Despite OAC, patients with concomitant AF and CKD remain at high risk for LAA thrombus formation.

Left Heart Dysfunction in Acromegaly Revealed by Novel Echocardiographic Methods

Background: Acromegaly is a rare disease that requires modern treatment to decrease the risk of mortality, mainly from vascular diseases. Identifying acromegalic patients with increased cardiovascular risk is challenging. Speckle-tracking echocardiography (STE) is a modern, well-validated, and reproducible method of assessing left ventricular longitudinal deformation and providing a sensitive assessment of myocardial contractility. We hypothesized that STE may be useful in evaluating subclinical dysfunction of the left heart in acromegalic patients, especially when a left ventricle (LV) assessment is completed with STE of the left atrium (LA). Purpose: To assess the diagnostic value of speckle-tracking echocardiography in identifying the occurrence of LV and LA functional impairment in patients with acromegaly, in comparison to patients without this rare pituitary disease. Methods: Echocardiographic assessments of LV and LA function using the new STE method were performed in 60 subjects: 30 acromegalic (ACRO group) patients and a CONTROL group with 30 patients matched in terms of age, gender, systolic/diastolic pressure, and history of hypertension for at least 12 months. Results: The ACRO group, compared to the CONTROL group, presented: (1) higher left ventricular mass (left ventricular mass index: 132 vs. 108 g/m², p < 0.001) and, in consequence, more frequent LV hypertrophy (80.0 vs. 53.3%; p = 0.028); (2) impaired LV systolic function measured by both left ventricular ejection fraction (LVEF) (63.4 vs. 66.9%, p < 0.001) and global longitudinal strain (GLS) (-18.1 vs. -19.4%, p = 0.023); (3) greater LA anteroposterior diameter (40.3 vs. 36.9 mm, p = 0.003) and indexed left atrial volume (37.9 vs. 27.6 ml/m², p < 0.001); and (4) impaired echocardiographic strain parameters corresponding with LA function. Conclusions: Acromegaly, even in young patients with good blood pressure control, may be associated with left ventricular hypertrophy and subclinical impairment of the left ventricular and left atrial mechanical function, which may be identified by speckle-tracking echocardiography. Further research in this area is necessary to clarify the prognostic value of these phenomena.

Cushing's Disease: Subclinical Left Ventricular Systolic and Diastolic Dysfunction Revealed by Speckle Tracking Echocardiography and Tissue Doppler Imaging

OBJECTIVE

Novel echocardiographic techniques, such as speckle tracking echocardiography (STE) and tissue Doppler imaging, are sensitive tools for assessing left ventricular (LV) performance. LV global longitudinal strain (GLS), assessed by STE, is a sensitive marker of myocardial systolic function. Cardiovascular complications in patients with Cushing's disease (CD) determine a higher mortality than that in an age- and gender-matched population. Cardiac systolic dysfunction may be detected in early stages by STE. Thus, the aim of this study was to investigate the usefulness of STE in detecting subclinical LV dysfunction in three groups of patients: CD group, arterial hypertension group (AHG), and healthy volunteers (HV).

METHODS

Echocardiographic assessments of LV systolic and diastolic function were performed in 171 subjects (CD: 22, AHG: 114, HV: 35) with no symptoms of heart failure. A statistical comparison included separate analyses for men and women.

RESULTS

CD patients showed good blood pressure (BP) control (below 140/90 mmHg in 82% of cases). However, in comparison AHG and HV groups they exhibited: (1) significantly lower LV contractility expressed by GLS (CD group: -17.7%, AHG group: -19.2%, HV: -20.0%; p = 0.004) and (2) higher prevalence of LV diastolic dysfunction (45.0, 14.2, 0.0%, respectively; p < 0.00001). Men with CD showed significantly more pronounced LV diastolic dysfunction. Cortisol excess in women was related to impaired LV systolic function.

CONCLUSION

CD, even with well-controlled BP, is associated with LV dysfunction which depends individually on sex. These hemodynamic alterations can be detected by modern non-invasive diagnostic tools and may become potential therapeutic objectives.

The effect of hemodynamically-guided hypotensive therapy in one-year observation: Randomized, prospective and controlled trial (FINEPATH study)

BACKGROUND

The use of impedance cardiography (ICG) revealed to provide beneficial blood pressure (BP) lowering effect. However, the follow-up in previous trials was short and brachial BP was the only evaluated hemodynamic variable. Thus, we aimed to estimate the influence of ICG-guided therapy on brachial and central BP, impedance-derived hemodynamic profile and echocardiographic features after 12 months in a randomized, prospective and controlled trial (NCT01996085).

METHODS

One hundred and forty-four hypertensives were randomly assigned to groups of empiric (GE) and ICG-guided therapy (HD). Office BP, ambulatory BP monitoring, central BP and echocardiography (left ventricular hypertrophy and diastolic function assessment) were performed before and after 12 months of treatment.

RESULTS

Blood pressure reduction was higher in HD (office BP: 21.8/14.1 vs. 19.9/11.8 mm Hg; mean 24-h BP: 19.0/10.9 vs. 14.4/9.2 mm Hg). However, the only statistically significant differences were: percentage of patients achieving BP reduction of minimum 20 mm Hg for of-fice diastolic BP (27.3% vs. 12.1%; p = 0.034) and mean 24-h systolic BP (49.1% vs. 27.3%; p = 0.013). More pronounced improvement in the left ventricular diastolic dysfunction (delta E/A 0.34 vs. 0.12, p = 0.017) was the only other beneficial hemodynamic effect.

CONCLUSIONS

Beneficial BP lowering effect of hemodynamically-guided pharmacotherapy, observed previously in short-term observation, persists over time. Hemodynamic effects of such a treatment approach, especially those of prognostic value (central BP, myocardial hypertrophy), should be evaluated in further studies including patients with resistant hypertension, heart failure, diabetes mellitus and chronic kidney disease.

Postural imbalance and vibratory sensitivity in patients with idiopathic scoliosis: implications for treatment

Sporadic research reports of decreased proprioception and balance problems have been reported in subjects with idiopathic scoliosis, yet these sensory motor deficits have not been addressed in conservative clinical management programs. The purpose of this study was to compare both balance reactions and vibratory sensitivity (as an estimate of proprioception) in patients with idiopathic scoliosis (N = 24) and age-matched controls (N = 24). Balance was measured by the ability to pass a series of simple static and complex sensory-challenged balance tasks. Vibratory thresholds were measured with the Bio-Thesiometer at the cervical spine, wrist, and foot. Compared with age-matched controls, regardless of curve severity or spinal fusion, the subjects with idiopathic scoliosis had similar simple static balance responses when the somatosensory system was stable (with or without vision or head turning), but they were significantly more likely to fail the complex, sensory-challenged balance tasks when the somatosensory system was challenged by an unstable position of the feet, particularly when the eyes were closed. The vibratory thresholds were similar in subjects with scoliosis and their age-matched controls, but individuals with moderate to severe scoliosis (> 25 degrees) had significantly higher vibratory thresholds than those with mild curves. These findings suggest there may be problems with postural righting in patients with idiopathic scoliosis, particularly when the balance task challenges the vestibular pathways. Although vibration sensitivity did not distinguish normal healthy individuals from individuals with idiopathic scoliosis, those with more severe scoliotic curves appear to have a high threshold to vibration. These balance and vibratory differences could either be interpreted as etiologic risk factors or as consequences of spinal asymmetry. In either case, given that curves can continue to progress even into the adult years, improving the ability to right the body with gravity could help maintain the balance of the spine despite structural asymmetry.

Vitamin C blocks inflammatory platelet-activating factor mimetics created by cigarette smoking

Cigarette smoking within minutes induces leukocyte adhesion to the vascular wall and formation of intravascular leukocyte-platelet aggregates. We find this is inhibited by platelet-activating factor (PAF) receptor antagonists, and correlates with the accumulation of PAF-like mediators in the blood of cigarette smoke-exposed hamsters. These mediators were PAF-like lipids, formed by nonenzymatic oxidative modification of existing phospholipids, that were distinct from biosynthetic PAF. These PAF-like lipids induced isolated human monocytes and platelets to aggregate, which greatly increased their secretion of IL-8 and macrophage inflammatory protein-1alpha. Both events were blocked by a PAF receptor antagonist. Similarly, blocking the PAF receptor in vivo blocked smoke-induced leukocyte aggregation and pavementing along the vascular wall. Dietary supplementation with the antioxidant vitamin C prevented the accumulation of PAF-like lipids, and it prevented cigarette smoke-induced leukocyte adhesion to the vascular wall and formation of leukocyte-platelet aggregates. This is the first in vivo demonstration of inflammatory phospholipid oxidation products and it suggests a molecular mechanism coupling cigarette smoke with rapid inflammatory changes. Inhibition of PAF-like lipid formation and their intravascular sequela by vitamin C suggests a simple dietary means to reduce smoking-related cardiovascular disease.

Structure-affinity relationships of retinoids with embryonic cellular retinoic acid-binding protein

Separation and quantitation of cellular retinoic acid-binding protein (CRABP) in embryonic and fetal hamster tissues was accomplished with high-performance size-exclusion chromatography. Binding affinity of 26 retinoids was established by in vitro displacement of high specific activity all-trans-[3H2]retinoic acid from fetal CRABP. The CRABP concentration in presomite-to-early somite (Day 8) hamster embryos was 1.9 pmol/mg cytosolic protein and increased to 7.5 pmol/mg protein in Day 13 fetuses; CRABP concentrations subsequently declined as gestation progressed. CRABP was located primarily in fetal brain and skin (5.8 +/- 0.3 and 2.2 +/- 0.1 pmol/mg protein, respectively), whereas only trace concentrations were found in fetal liver, placenta, and maternal uterus. Retinoids that could displace all-trans-retinoic acid from CRABP had a free acid at the polar terminus (or were carboxylate esters that were readily hydrolyzed to the corresponding free acid) and had a hydrophobic ring at the distal position. The ligand specificity of the CRABP studied here suggests that this protein was analogous to the CRABP I isoform. The in vitro binding affinities of teratogenic retinoids that competed for embryonic CRABP failed to correlate directly with relative teratogenic potency. In some instances, the latter observation can be related to extensive in vivo biotransformation of retinoids to multiple teratogenic metabolites and to retinoid persistence in the embryo. Three analogs containing a free carboxy terminus, SRI 5898-21, SRI 7323-78, and SRI 6153-40, were identified with high teratogenic potency but failed to bind fetal hamster CRABP. The structure-activity and binding data of the analogs studied here indicate that many, if not most, teratogenic retinoids (or their acidic metabolites) bind with embryonic/fetal CRABP, but the present data question the role for CRABP in their teratogenic mechanism of action.

Chronic effects of diethylstilbestrol on estrogen metabolism in the mouse

Female C3H mice were exposed to 0 (control) and 640 ppb DES (experimental) in the diet for 12 mon. Subsequently, both groups of animals were dosed orally with radiolabeled 3H-DES. Experimental animals received low (349 ng) and high (312 micrograms) doses while controls received low doses. Based on the total plasma radioactivity derived from 3H-DES, comparisons of the apparent volume of distribution (AVD), metabolic clearance rate (MCR) and the plasma half-life (T1/2) were made. The AVD's and MCR's calculated for both experimental groups were significantly less than the control group (P less than 0.05). However, the T1/2's did not differ between experimental and control groups. Metabolic studies with 14C-DES (312 micrograms) showed that control and experimental animals differed only in their urinary-conjugate patterns. Pharmacokinetic studies with intravenously administered 3H-estradiol (E2) were performed in control mice, 640 ppb DES fed mice and 5000 ppb E2 fed mice. Significant differences were observed (P less than 0.005) between the experimental and control groups with regard to plasma T1/2, but not AVD or MCR. These results indicate that chronic estrogen exposure alters some pharmacokinetic properties of both steroidal and non-steroidal estrogens.