Progression of subclinical atherosclerosis in ankylosing spondylitis: a 10-year prospective study

Chronic systemic inflammation contributes to increased CVD burden in Ankylosing Spondylitis (AS). Since long-term follow-up data on subclinical atherosclerosis acceleration are lacking, we examined its progression in contemporary AS patients during 10 years. Fifty-three (89% male, aged 50.4 (36.3-55.9) years,) non-diabetic, CVD-free AS patients and 53 age-sex-matched non-diabetic, control individuals were re-evaluated after 9.2-10.2 years by ultrasonography for carotid/femoral atheromatosis, pulse wave velocity (PWV) and intima-media thickness (IMT), performed by the same operator/protocol. New atheromatic plaque formation, PWV deterioration, and IMT increase were associated only with classical CVD risk factors, as reflected by the heartSCORE (age, gender, smoking status, blood pressure and cholesterol levels) by multivariate analysis, rather than disease presence. However, among AS patients, despite remission/low disease activity at follow-up end in 79%, atheromatosis progression was associated by multivariate analysis with higher BASDAI scores (p = 0.028), independently of biologic therapies administered in 2/3 of them. Moreover, in AS patients, but not in controls, PWV values at baseline were associated with plaque progression during the 10-year follow-up after taking into account baseline heartSCORE and plaque burden status (p = 0.033). Despite comparable prevalence of both hypertension and hypercholesterolemia at baseline between patients and controls, a lower percentage of AS patients had achieved "adequate" CVD risk factor control at follow-up end (11% vs 25% respectively, p = 0.076). Classical CVD risk factors and residual disease activity account for the progression of subclinical atherosclerosis in AS, pointing to the unmet needs in the contemporary management of these patients.

Blood pressure variability: methodological aspects, clinical relevance and practical indications for management - a European Society of Hypertension position paper ∗

Blood pressure is not a static parameter, but rather undergoes continuous fluctuations over time, as a result of the interaction between environmental and behavioural factors on one side and intrinsic cardiovascular regulatory mechanisms on the other side. Increased blood pressure variability (BPV) may indicate an impaired cardiovascular regulation and may represent a cardiovascular risk factor itself, having been associated with increased all-cause and cardiovascular mortality, stroke, coronary artery disease, heart failure, end-stage renal disease, and dementia incidence. Nonetheless, BPV was considered only a research issue in previous hypertension management guidelines, because the available evidence on its clinical relevance presents several gaps and is based on heterogeneous studies with limited standardization of methods for BPV assessment. The aim of this position paper, with contributions from members of the European Society of Hypertension Working Group on Blood Pressure Monitoring and Cardiovascular Variability and from a number of international experts, is to summarize the available evidence in the field of BPV assessment methodology and clinical applications and to provide practical indications on how to measure and interpret BPV in research and clinical settings based on currently available data. Pending issues and clinical and methodological recommendations supported by available evidence are also reported. The information provided by this paper should contribute to a better standardization of future studies on BPV, but should also provide clinicians with some indications on how BPV can be managed based on currently available data.

Vascular Implications of COVID-19: Role of Radiological Imaging, Artificial Intelligence, and Tissue Characterization: A Special Report

The SARS-CoV-2 virus has caused a pandemic, infecting nearly 80 million people worldwide, with mortality exceeding six million. The average survival span is just 14 days from the time the symptoms become aggressive. The present study delineates the deep-driven vascular damage in the pulmonary, renal, coronary, and carotid vessels due to SARS-CoV-2. This special report addresses an important gap in the literature in understanding (i) the pathophysiology of vascular damage and the role of medical imaging in the visualization of the damage caused by SARS-CoV-2, and (ii) further understanding the severity of COVID-19 using artificial intelligence (AI)-based tissue characterization (TC). PRISMA was used to select 296 studies for AI-based TC. Radiological imaging techniques such as magnetic resonance imaging (MRI), computed tomography (CT), and ultrasound were selected for imaging of the vasculature infected by COVID-19. Four kinds of hypotheses are presented for showing the vascular damage in radiological images due to COVID-19. Three kinds of AI models, namely, machine learning, deep learning, and transfer learning, are used for TC. Further, the study presents recommendations for improving AI-based architectures for vascular studies. We conclude that the process of vascular damage due to COVID-19 has similarities across vessel types, even though it results in multi-organ dysfunction. Although the mortality rate is ~2% of those infected, the long-term effect of COVID-19 needs monitoring to avoid deaths. AI seems to be penetrating the health care industry at warp speed, and we expect to see an emerging role in patient care, reduce the mortality and morbidity rate.

COVLIAS 1.0Lesion vs. MedSeg: An Artificial Intelligence Framework for Automated Lesion Segmentation in COVID-19 Lung Computed Tomography Scans

Background: COVID-19 is a disease with multiple variants, and is quickly spreading throughout the world. It is crucial to identify patients who are suspected of having COVID-19 early, because the vaccine is not readily available in certain parts of the world. Methodology: Lung computed tomography (CT) imaging can be used to diagnose COVID-19 as an alternative to the RT-PCR test in some cases. The occurrence of ground-glass opacities in the lung region is a characteristic of COVID-19 in chest CT scans, and these are daunting to locate and segment manually. The proposed study consists of a combination of solo deep learning (DL) and hybrid DL (HDL) models to tackle the lesion location and segmentation more quickly. One DL and four HDL models—namely, PSPNet, VGG-SegNet, ResNet-SegNet, VGG-UNet, and ResNet-UNet—were trained by an expert radiologist. The training scheme adopted a fivefold cross-validation strategy on a cohort of 3000 images selected from a set of 40 COVID-19-positive individuals. Results: The proposed variability study uses tracings from two trained radiologists as part of the validation. Five artificial intelligence (AI) models were benchmarked against MedSeg. The best AI model, ResNet-UNet, was superior to MedSeg by 9% and 15% for Dice and Jaccard, respectively, when compared against MD 1, and by 4% and 8%, respectively, when compared against MD 2. Statistical tests—namely, the Mann−Whitney test, paired t-test, and Wilcoxon test—demonstrated its stability and reliability, with p < 0.0001. The online system for each slice was <1 s. Conclusions: The AI models reliably located and segmented COVID-19 lesions in CT scans. The COVLIAS 1.0Lesion lesion locator passed the intervariability test.

A Powerful Paradigm for Cardiovascular Risk Stratification Using Multiclass, Multi-Label, and Ensemble-Based Machine Learning Paradigms: A Narrative Review

Background and Motivation: Cardiovascular disease (CVD) causes the highest mortality globally. With escalating healthcare costs, early non-invasive CVD risk assessment is vital. Conventional methods have shown poor performance compared to more recent and fast-evolving Artificial Intelligence (AI) methods. The proposed study reviews the three most recent paradigms for CVD risk assessment, namely multiclass, multi-label, and ensemble-based methods in (i) office-based and (ii) stress-test laboratories. Methods: A total of 265 CVD-based studies were selected using the preferred reporting items for systematic reviews and meta-analyses (PRISMA) model. Due to its popularity and recent development, the study analyzed the above three paradigms using machine learning (ML) frameworks. We review comprehensively these three methods using attributes, such as architecture, applications, pro-and-cons, scientific validation, clinical evaluation, and AI risk-of-bias (RoB) in the CVD framework. These ML techniques were then extended under mobile and cloud-based infrastructure. Findings: Most popular biomarkers used were office-based, laboratory-based, image-based phenotypes, and medication usage. Surrogate carotid scanning for coronary artery risk prediction had shown promising results. Ground truth (GT) selection for AI-based training along with scientific and clinical validation is very important for CVD stratification to avoid RoB. It was observed that the most popular classification paradigm is multiclass followed by the ensemble, and multi-label. The use of deep learning techniques in CVD risk stratification is in a very early stage of development. Mobile and cloud-based AI technologies are more likely to be the future. Conclusions: AI-based methods for CVD risk assessment are most promising and successful. Choice of GT is most vital in AI-based models to prevent the RoB. The amalgamation of image-based strategies with conventional risk factors provides the highest stability when using the three CVD paradigms in non-cloud and cloud-based frameworks.

Blood pressure variability within a single visit and all-cause mortality

BACKGROUND

Within-visit variability of repeated sequential readings of blood pressure (BP) is an important phenomenon that may affect precision of BP measurement and thus decision making concerning BP-related risk and hypertension management. However, limited data exist concerning predictive ability of within-visit BP variability for clinical outcomes. Therefore, we aimed to investigate the association between the variability of three repeated office BP measurements and the risk of all-cause mortality, independent of BP levels.

METHODS

Data collected through the National Health and Nutrition Examination Survey (NHANES) were analysed. NHANES is a program of studies designed to assess health and nutritional status of adults and children in the United States. A complete set of three sequential BP measurements, together with survival status, were available for 24969 individuals (age 46.8±;19.3 years, 49% males). Multivariable logistic regression models were used to determine the prognostic ability of the examined demographic, clinical, and haemodynamic indices.

RESULTS

Among various examined indices of variability of systolic (SBP) and diastolic (DBP) blood pressure measurements, the standard deviation of DBP (DBPSD) was the stronger independent predictor of mortality (odds ratio 1.064, 95% Confidence Interval: 1.011-1.12) after adjustment for age, sex, body mass index, smoking, SBP, heart rate, history of hypertension, diabetes mellitus, hypercholesterolaemia, and cardiovascular events.

CONCLUSION

Within-visit variability of three sequential office DBP readings may allow for the identification of high-risk patients better than mean SBP and DBP levels. The predictive value of within-visit BP variability and methods to improve its clinical application are worthy of further research.

Atherosclerosis is not accelerated in rheumatoid arthritis of low activity or remission, regardless of antirheumatic treatment modalities

Objectives

RA associates with increased cardiovascular disease (CVD) morbidity and mortality due to accelerated atherosclerosis, attributed to both classical risk factors and chronic inflammation. The aim of this study was to test the hypothesis that effective disease control over 3 years modifies acceleration of atherosclerosis in RA.

Methods

Consecutive, non-diabetic RA patients previously examined by ultrasonography for subclinical atherosclerosis were re-evaluated after 3.2 (0.2) years, provided that they were in remission/low disease activity (DAS28 <3.2) for at least 75% of this period. Patients (n = 139) were demographically matched with 139 non-diabetic, non-RA control individuals studied in parallel.

Results

Patients and controls (mean age of 56 years at baseline) had a comparable burden of classical CVD risk factors. Patients' pulse wave velocity (reflecting arterial stiffness) changed by 0.07 m/s/year and left carotid intima-media thickness (reflecting wall hypertrophy) increased by 0.009 mm/year; formation of new atheromatic plaques in carotid and/or femoral arterial beds occurred in 22%. Multivariate analysis after correcting for all classical CVD risk factors and anti-hypertensive/lipid-lowering therapies demonstrated no significant differences between patients and controls in any of the subclinical atherosclerosis indices. Changes in all atherosclerosis indices from baseline to end of follow-up were comparable between those 56 patients treated with biologic DMARDs and their demographically matched patients treated with synthetic DMARDs.

Conclusion

Effective disease control may abrogate any RA-specific effect on the progression of atherosclerosis regardless of treatment. Whether early and sustained RA control translates to the CVD outcomes expected in the general population should be examined in prospective studies.

Prevalence of childhood hypertension and hypertension phenotypes by weight status and waist circumference: the Healthy Growth Study

PURPOSE

The aim of the present study was to report for the first time the prevalence of hypertension and its phenotypes in obese children and in children with central obesity in a large sample of Greek children.

METHODS

A regionally representative sample of 2263 schoolchildren (50.3% boys) (9-13 years) having full data on blood pressure assessment, physical examination, anthropometric, and physical activity participated in a cross-sectional study in Greece.

RESULTS

Prevalence of stage 1 and 2 hypertension, of isolated systolic hypertension (ISH) and of combined systolic or diastolic hypertension, was significantly higher for obese children and children on the 3rd tertile of waist circumference in the total sample, as well as in each gender separately. ISH was the most prevalent phenotype reaching 24.3% in obese children and 17.5% in children on the highest tertile of waist circumference. Obese children and children on the highest tertile of waist circumference had 6.31 times and 3.94 times, respectively, higher likelihood to have abnormal systolic or diastolic blood pressure (SBP or DBP) than their normal-weight counterparts.

CONCLUSIONS

Prevalence of hypertension and especially ISH in obese children and in children with central obesity in Greece are among the highest reported in Europe. Future public health initiatives should aim to prevent or tackle several underlying factors related to childhood hypertension, focusing primarily on children with excess body weight.

Impact of non-steroidal anti-inflammatory drugs on cardiovascular risk: Is it the same in osteoarthritis and rheumatoid arthritis?

Although large-scale population studies have shown that non-steroidal anti-inflammatory drugs (NSAIDs) increase the risk of myocardial infarction, this is not confirmed in patients with rheumatoid arthritis (RA). Herein, we review the litterature on the differential effects of NSAIDs on cardiovascular risk in osteoarthritis (OA) versus RA and discuss possible explanations for this discrepancy. To assess a potential additive effect of age in non-RA populations, we compared weighted mean age between RA patients and unselected NSAID users included in cohort and case-control studies that estimate the cardiovascular risk of NSAIDs, assuming that the main indication for NSAID usage in elderly populations is OA. Our hypothesis that advanced age in osteoarthtitis compared to RA patients confounds the effect of NSAIDs on cardiovasular risk was not confirmed. Several other hypotheses that can be proposed to explain this counterintuitive effect of NSAIDs on the cardiovascular risk of RA patients are discussed. We conclude that patients with RA have a lower cardiovascular disease risk associated with the use of NSAIDs, probably due to the nature of their disease per se, until further research indicates differently.

Clinical interaction between diabetes duration and aortic stiffness in type 2 diabetes mellitus

Diabetes complications increase with disease duration. No study was performed on the relationship between aortic stiffness and diabetes duration, taking into account the respective influence of such factors on macro- and microcirculation. In total, 618 subjects with type 2 diabetes (259 men) attending the Department of Internal Medicine of Tizi Ouzou Hospital (Algeria) were studied in collaboration with Hotel-Dieu Hospital (Paris, France). Brachial blood pressure (BP), anthropometric, clinical and biological data were evaluated. Aortic stiffness was estimated by carotid-femoral pulse wave velocity (PWV). From lower to higher tertile of diabetes duration, age, BP and PWV (10.1±2.7 to 12.3±2.8 m s^-1) increased, while diabetes control and renal function worsened (all P<0.01). Diabetes duration was independently associated with PWV (R²=0.035, P<0.0001), even after adjustment for age, BP, heart rate, cardiovascular events and metabolic syndrome. Diabetes duration was significantly correlated to the prevalence of microalbuminuria (OR (95% CL) 1.3 (1.06-1.63), P=0.01), independently of age, sex, BP and renal function. Increased aortic stiffness was independently associated with the prevalence of cardiovascular events (P<0.001), reaching its maximal value above the first 2 years of diabetes duration. In conclusion, diabetes duration is an independent determinant of aortic stiffness in subjects with type 2 diabetes, representing about 4% of PWV variability. Diabetes duration is associated with microvascular complications independently of renal function, and with macrovascular complications through the presence of increased aortic stiffness.

Arterial wave reflection is associated with severity of extracoronary atherosclerosis in patients with coronary artery disease

BACKGROUND

Arterial wave reflection is a major determinant of left ventricular function, coronary perfusion and cardiovascular risk. We investigated whether arterial wave reflection may detect atherosclerosis of peripheral arteries in patients with documented coronary artery disease (CAD).

METHODS

Radial artery applanation tonometry and pulse wave analysis was performed in 184 patients with documented CAD at coronary angiography; central blood pressures and augmentation index (AI) were measured. Ankle-brachial (ABI) index and intima-media thickness (IMT) were used as indices of atherosclerosis of the lower limbs and the carotid arteries respectively.

RESULTS

Patients with abnormal IMT (> 0.7 mm, first tertile) or ABI (< 0.94, first tertile) had higher AI than patients with lower IMT or higher ABI (24 +/- 17 versus 17 +/- 16% and 23 +/- 18 versus 18 +/- 13%, respectively, P < 0.05). In multivariate analysis, increasing AI was associated with age, female gender, heart rate, mean blood pressure, hyperlipidaemia, and use of statins (regression coefficient (beta) = 0.50, beta = 0.15, beta = -0.60, beta = 0.23, beta = 0.16 and beta = -0.14, respectively, P < 0.05). Increasing AI was associated with an adjusted-odds ratio of 1.035 [95% confidence interval (CI), 1.005-1.066], P = 0.02 for an abnormal IMT and of 1.08 (95% CI, 1.024-1.146), P = 0.005 for ABI after adjustment for age, gender, heart rate, height, blood pressure, atherosclerotic risk factors, obesity and medication. No relation was found between AI and Gensini score or for the number of diseased coronary vessels.

CONCLUSION

Augmentation index is a marker of extensive extracoronary atherosclerosis in patients with CAD.

Association of consumption of dairy products and meat with retinal vessel calibers in subjects at increased cardiovascular risk

BACKGROUND AND AIMS

Association of dairy products and meat consumption with macrocirculation is previously described, but such association with microcirculation is poorly investigated. We aimed to test the hypothesis that the consumption of high- and low-fat dairy products as well as red, white, and processed meat is associated with retinal vessel calibers in adults at an increased risk of cardiovascular disease (CVD).

METHODS AND RESULTS

In consecutive subjects (n = 181, age: 51.3 ± 12.4 years, 51.4% women) without CVD and diabetes mellitus but with increased CVD risk, we obtained digital left and right retinal images. These images were assessed with validated software to determine central retinal arteriolar and venular equivalents and the arteriolar to venular ratio (CRAE, CRVE, and AVR, respectively). The consumption of dairy products and meat was assessed through 24-h recalls in all volunteers. After adjustment for potential confounders, the following findings were obtained: (i) low-fat milk and yogurt were positively associated with CRAE (b=0.145, p=0.031 left; b=0.141, p=0.038 right) and inversely associated with CRVE (b=-0.155, p=0.026 left; b=-0.146, p=0.041 right); (ii) low-fat cheese was positively associated with CRAE (b=0.164, p=0.011 left and b=0.155, p=0.017 right); and (iii) red meat was inversely associated with CRAE (b=-0.143, p=0.032 left; b=-0.114, p=0.050 right). High-fat milk, yogurt, and cheese or white and processed meat were not found to be associated with retinal vessel calibers.

CONCLUSIONS

High consumption of low-fat milk, yogurt, and cheese and low consumption of red meat could be beneficial for retinal microvascular health. Prospective studies are needed to verify these findings.

Blood Pressure and All-Cause Mortality by Level of Cognitive Function in the Elderly: Results From a Population-Based Study in Rural Greece

This study aimed to investigate whether the effect of blood pressure (BP) on mortality differs by levels of cognitive function. The associations of brachial systolic BP, diastolic BP, mean arterial pressure (MAP), and pulse pressure with all-cause mortality were prospectively explored (follow-up 7.0±2.2 years) in 660 community-dwelling individuals (≥60 years) using adjusted Cox models, stratified by cognitive impairment (Mini-Mental State Examination [MMSE] <24). No association between brachial BP variables and mortality was shown for the total sample in quartiles analysis; however, MAP in the highest quartile, compared with the second, was associated with mortality (hazard ratio, 1.85; 95% confidence intervals, 1.09-3.12) among cognitively impaired individuals. The fractional-polynomials approach for BP confirmed this finding and further showed, solely in the MMSE <24 subcohort, U-shaped trends of MAP and systolic BP, with increased mortality risk in extremely low or high values; no such pattern was evident for patients with MMSE ≥24. Elderly individuals with cognitive impairment might be more susceptible to the detrimental effects of low and elevated MAP and systolic BP.

Comorbidity of Cognitive Impairment and Late-Life Depression Increase Mortality: Results From a Cohort of Community-Dwelling Elderly Individuals in Rural Greece

OBJECTIVE

To investigate the association of cognitive impairment (COGI) and depression with all-cause mortality and cardiovascular-specific mortality among community-dwelling elderly individuals in rural Greece.

METHODS

Cognition and depressive symptomatology of 676 Velestino town residents aged ≥60 years were assessed using Mini-Mental State Examination (MMSE) and Geriatric Depression Scale (GDS), respectively. Eight-year all-cause mortality and cardiovascular mortality were explored by multivariate Cox regression models controlling for major confounders.

RESULTS

Two hundred and one patients died during follow-up. Cognitive impairment (MMSE ≤ 23) was independently associated with all-cause mortality (hazard ratio [HR]: 1.57, 95% confidence interval [CI]: 1.13-2.18) and cardiovascular mortality (HR: 1.57, 95%CI: 1.03-2.41). Moderate to severe depression (GDS > 10) was significantly associated only with a 51% increase in all-cause mortality. A male-specific association was noted for moderate to severe depression, whereas the effect of COGI was limited to females. Noteworthy, COGI and depression comorbidity, rather than their sole presence, increased all-cause mortality and cardiovascular mortality by 66% and 72%, respectively. The mortality effect of COGI was augmented among patients with depression and of depression among patients with COGI.

CONCLUSION

COGI and depression, 2 entities often coexisting among elderly individuals, appear to increase all-cause mortality and cardiovascular mortality. Gender-specific modes may prevail but their comorbidity should be carefully assessed, as it seems to represent an independent index of increased frailty, which eventually shortens life expectancy.

Subclinical Atherosclerosis Is Not Accelerated in Patients with Ankylosing Spondylitis with Low Disease Activity: New Data and Metaanalysis of Published Studies

OBJECTIVE

Chronic inflammatory rheumatic diseases are associated with accelerated atherosclerosis, but data in ankylosing spondylitis (AS) are limited and the relative contribution of inflammation versus classical cardiovascular (CV) risk factors remains a matter of controversy. We addressed this in an original study and a metaanalysis of previous studies.

METHODS

Atheromatic plaques in carotid and femoral arteries, carotid hypertrophy [intima-media thickness (IMT), cross-sectional area], and carotid stiffness by ultrasound, as well as aortic stiffness by pulse wave velocity, were examined in consecutive nondiabetic, CV disease (CVD)-free patients with AS. Healthy individuals carefully matched 1:1 with patients for age, sex, smoking habits, hyperlipidemia, and hypertension served as controls. A metaanalysis of original studies that examined subclinical atherosclerosis in patients with AS versus controls with comparable CVD risk factors was also performed.

RESULTS

Carotid and femoral atheromatic plaques were slightly less prevalent compared with controls in a contemporary cohort consisting of 67 patients with AS (82% men), aged 47.5 ± 12.5 years (mean ± SD), with a median disease duration of 12 years and a Bath AS Disease Activity Index (BASDAI) of 1.8 (interquartile range 0.4-3.6), of whom 66% were receiving anti-tumor necrosis factor (TNF) treatment. Carotid hypertrophy and stiffness, as well as aortic stiffness, were similar between patients and their matched controls. Metaanalysis of all published studies revealed a significantly increased carotid IMT, but not plaque burden, in AS versus controls. Notably, however, increased IMT was not evident in studies involving patients with low disease activity (mean BASDAI < 4) or in those studies that included > 50% of patients treated with anti-TNF.

CONCLUSION

Low AS disease activity is not associated with accelerated atherosclerosis.

The Additive Value of Femoral Ultrasound for Subclinical Atherosclerosis Assessment in a Single Center Cohort of 962 Adults, Including High Risk Patients with Rheumatoid Arthritis, Human Immunodeficiency Virus Infection and Type 2 Diabetes Mellitus

BACKGROUND

Presence of femoral atheromatic plaques, an emerging cardiovascular disease (CVD) biomarker additional to carotid plaques, is poorly investigated in conditions associating with accelerated atherosclerosis such as Rheumatoid Arthritis (RA), Human Immunodeficiency Virus (HIV) infection and Type 2 Diabetes Mellitus (T2DM).

OBJECTIVE/METHODS

To assess the frequency of femoral/carotid subclinical atheromatosis phenotypes in RA, HIV and T2DM and search for each disease-specific probability of either femoral and/or carotid subclinical atheromatosis, we examined by ultrasound a single-center cohort of CVD-free individuals comprised of consecutive non-diabetic patients with RA (n=226) and HIV (n=133), T2DM patients (n=109) and non-diabetic individuals with suspected/known hypertension (n=494) who served as reference group.

RESULTS

Subclinical atheromatosis--defined as local plaque presence in at least on arterial bed--was diagnosed in 50% of the overall population. Among them, femoral plaques only were found in 25% of either RA or HIV patients, as well as in 16% of T2DM patients and 35% of reference subjects. After adjusting for all classical CVD risk factors, RA and HIV patients had comparable probability to reference group of having femoral plaques, but higher probability (1.75; 1.17-2.63 (odds ratio; 95% confidence intervals), 2.04; 1.14-3.64, respectively) of having carotid plaques, whereas T2DM patients had higher probability to have femoral and carotid plaques, albeit, due to their pronounced dyslipidemic profile.

CONCLUSION

RA and HIV accelerate predominantly carotid than femoral. A "two windows" carotid/femoral, rather than carotid alone ultrasound, screening improves substantially subclinical atheromatosis detection in patients at high CVD risk.

Rheumatoid arthritis is sufficient to cause atheromatosis but not arterial stiffness or hypertrophy in the absence of classical cardiovascular risk factors

Rheumatoid arthritis (RA) associates with increased cardiovascular disease (CVD) mortality thought to be due to accelerated arterial disease. Different components of arterial disease, namely, atheromatosis, arteriosclerosis, and arterial wall hypertrophy, are differentially affected by classical CVD risk factors, which are highly prevalent in these patients. We hypothesized that RA disease per se may also differentially affect these components. Of 267 consecutive RA patients, we selected specifically those who were free of established CVD and CVD risk factors (18 %); of them, 41 patients (36 women, 49 ± 13 years) could be matched effectively 1:1 for age and gender to healthy controls. Atheromatosis was assessed by the presence of carotid and/or femoral artery plaques, arteriosclerosis by pulse wave velocity and local wall elasticity, and arterial hypertrophy by intima-media thickness and cross-sectional area. More patients had atheromatic plaques than controls (29 vs. 12 %, p = 0.039), and multiarterial atheromatosis was more prevalent in RA (22 vs. 2 %, p = 0.026). Accelerated atheromatosis was not associated with rheumatoid factor, or anti-cyclic citrullinated peptide (CCP) autoantibody status. Plaque burden in patients with less than 5 years disease duration (aged 41 ± 13 years) was comparable to their matched controls. In contrast, all indices of arterial stiffness and hypertrophy were similar between controls and RA patients, even in those with long-standing disease. RA per se is sufficient to cause atheromatosis in the absence of classical CVD risk factors, but has minimal, if any, effect on arteriosclerosis and arterial wall hypertrophy.

Association of left ventricular diastolic dysfunction with 24-h aortic ambulatory blood pressure: the SAFAR study

Aortic blood pressure (BP) and 24-h ambulatory BP are both better associated with target organ damage than office brachial BP. However, it remains unclear whether a combination of these two techniques would be the optimal methodology to evaluate patients' BP in terms of left ventricular diastolic dysfunction (LVDD) prevention. In 230 participants, office brachial and aortic BPs were measured by a validated BP monitor and a tonometry-based device, respectively. 24-h ambulatory brachial and aortic BPs were measured by a validated ambulatory BP monitor (Mobil-O-Graph, Germany). Systematic assessment of patients' LVDD was performed. After adjustment for age, gender, hypertension and antihypertensive treatment, septum and lateral E/Ea were significantly associated with office aortic systolic BP (SBP) and pulse pressure (PP) and 24-h brachial and aortic SBP and PP (P ⩽ 0.04), but not with office brachial BP (P ⩾ 0.09). Similarly, 1 standard deviation in SBP was significantly associated with 97.8 ± 20.9, 86.4 ± 22.9, 74.1 ± 23.3 and 51.3 ± 22.6 in septum E/Ea and 68.6 ± 2 0.1, 54.2 ± 21.9, 37.9 ± 22.4 and 23.1 ± 21.4 in lateral E/Ea, for office and 24-h aortic and brachial SBP, respectively. In qualitative analysis, except for office brachial BP, office aortic and 24-h brachial and aortic BPs were all significantly associated with LVDD (P ⩽ 0.03), with the highest odds ratio in 24-h aortic SBP. Furthermore, aortic BP, no matter in the office or 24-h ambulatory setting, showed the largest area under receiver operating characteristic curves (P ⩽ 0.02). In conclusion, 24-h aortic BP is superior to other BPs in the association with LVDD.

A pilot study of endothelial dysfunction and aortic stiffness after interleukin-6 receptor inhibition in rheumatoid arthritis

Interleukin (IL)-6 is a pleiotropic proinflammatory cytokine involved in the pathogenesis of both atherosclerosis and rheumatoid arthritis. The role of the IL-6/IL-6 receptor pathway in the documented acceleration of atherosclerosis in rheumatoid arthritis has not been examined. In a non-randomized prospective pilot study we asked whether endothelial dysfunction, defined as impaired flow mediated dilatation (FMD), and aortic stiffness, assessed by pulse wave velocity (PWV) improve after 3 and 6 monthly therapeutic infusions of the anti-IL-6 receptor antibody tocilizumab for active rheumatoid arthritis. We found that FMD increased from 3.3 ± 0.8 to 4.4 ± 1.2 to 5.2 ± 1.9% (p = 0.003), whereas PWV decreased from 8.2 ± 1.2 to 7.7 ± 1.3 to 7.0 ± 1.0m/s (p < 0.001). Whether these beneficial arterial changes are direct effects of the IL-6/IL-6 receptor pathway inhibition, maintained over time and translate into better clinical outcome warrants further studies.

Cardiovascular risk factors in adult patients with multisystem Langerhans-cell histiocytosis: evidence of glucose metabolism abnormalities

BACKGROUND

Langerhans-cell histiocytosis (LCH) is a rare disease with features of chronic inflammation and it may also induce hypopituitarism, conditions associated with an increased risk of cardiovascular diseases.

AIM

Cardiovascular and metabolic risk profile investigation in multisystem LCH patients with and without anterior pituitary deficiency.

DESIGN

Prospective, observational study.

METHODS

Fourteen adult patients with LCH, 7 with and 7 without anterior pituitary deficiency, and 42 controls matched for age, body mass index (BMI) and smoking. Cardiovascular risk factors were estimated in all subjects: glucose and lipid profile, mathematical indices of insulin resistance (IR), blood pressure, structural arterial and functional endothelial properties (intima-media thickness, brachial artery flow-mediated dilatation). Cardiovascular risk factors were estimated in the three groups studied; the effect of disease activity and/or treatment was also determined in patients with LCH.

RESULTS

Ten patients had diabetes insipidus, and 7 anterior pituitary hormone deficiencies: 8 patients had active disease and 11 had received systemic treatment. No difference was observed between the study groups in vascular parameters, in lipid profile or in blood pressure. However, the insulin resistance index GIR was decreased in patients with LCH without anterior pituitary deficiency compared to controls (P = 0.033). Three patients had impaired glucose tolerance and one diabetes mellitus type 2. These patients were older and had active disease; there was no association with hypopituitarism and/or previous treatment.

CONCLUSION

Adults patients with LCH have abnormalities of glucose metabolism that tend to occur in patients with active disease, and may be a consequence of the pro-inflammatory state.

Structural and functional arterial properties in patients with obstructive sleep apnoea syndrome and cardiovascular comorbidities

The increased severity of obstructive sleep apnoea syndrome (OSAS) is associated with a parallel increase in the incidence of cardiovascular events. Whether the increased severity of OSAS is in fact associated with impaired arterial properties has never been thoroughly studied. In patients with OSAS who carry a high burden of cardiovascular risk factors, we investigated whether the severity of OSAS is associated with deterioration in the arterial properties, independent of classical cardiovascular risk factors. In 74 consecutive patients with OSAS, we non-invasively assessed, by means of tonometry and high-resolution ultrasound: carotid intima-media thickness (IMT), carotid diameter and plaques, carotid-femoral pulse wave velocity (PWV), central augmentation index (AI) and central blood pressures. The respiratory disturbance index was an independent predictor of IMT and PWV but not of carotid plaques, carotid diameter, AI or central blood pressures. Several parameters of nocturnal hypoxaemia were independently correlated with carotid IMT and PWV. In conclusion, arterial stiffening and thickening are modulated by the severity of OSAS, independently from age and cardiovascular risk factors.

Acute effects of renin-angiotensin system blockade on arterial function in hypertensive patients

The acute effects of the renin-angiotensin system (RAS) blockers may be important in some clinical settings. To assess the acute impact of such drugs on arterial function, we studied the effects of captopril 25 mg, quinapril 20 mg and telmisartan 80 mg on 100 hypertensive patients, according to a randomized, double-blind, placebo-controlled study. Central (aortic) blood pressure (BP) and augmentation index (AIx, a measure of wave reflections), as well as flow-mediated dilatation (FMD) of the brachial artery and forearm blood flow (FBF) (measures of conduit and resistance artery endothelial function, respectively), were evaluated before and 2 h after oral drug administration. Compared to placebo, captopril and quinapril decreased central systolic (by 7.5 mm Hg, P<0.05 and by 12.3 mm Hg, P<0.001) and diastolic BP (by 4.9 mm Hg, P<0.01 and by 8.4 mm Hg, P<0.001), whereas telmisartan had no significant effect (P=NS). Additionally, AIx was reduced after quinapril (absolute decrease of 7.2%, P<0.01) and marginally after captopril (decrease of 4.7%, P=0.07). Only quinapril led to a beneficial change of FMD (absolute increase of 2.7%, P<0.001). No treatment was related to significant changes of peak hyperaemic or 3-min hyperaemic FBF. In adjusted analyses, all the favourable alterations induced by quinapril were independent of potential confounding haemodynamic factors. Our data show that acute RAS inhibition with quinapril (20 mg) may be more beneficial in terms of arterial function and central haemodynamics compared to captopril (25 mg) or telmisartan (80 mg). Further studies are needed to investigate whether these acute arterial effects of quinapril are clinically significant.

Early microvascular and macrovascular dysfunction is not accompanied by structural arterial injury in polycystic ovary syndrome

OBJECTIVE

During the last decade cardiovascular risk factors and endothelial dysfunction have been shown to be present early in life in women with Polycystic Ovary Syndrome (PCOS). The aim of the present study was a global assessment of abnormalities in the arterial bed of young women with PCOS by non-invasive, reproducible methods.

DESIGN

27 women with PCOS and 27 control women of comparable age, body mass index and waist-to-hip ratio were studied. Macrovascular function was assessed by flow-mediated dilatation (FMD) on the brachial artery. Nitrate-induced dilatation (NID) was performed to exclude a vascular smooth muscle cells injury. Microvascular function was assessed by venous occlusion plethysmography studying forearm blood flow. Arterial structure was evaluated by ultrasonographic assessment of intima-media thickness (IMT) of the carotid artery.

RESULTS

FMD values were lower in women with PCOS compared to controls (PCOS: 3.84+/-0.74% vs. controls: 9.83+/-0.97%, P<0.001), but no difference was observed in NID (PCOS: 16.59+/-1.84% vs. controls: 16.64+/-2.05%, P=0.98) values. The time required for reactive hyperemia to reach peak value, a plethysmography parameter, was longer in PCOS women (PCOS: 20.63+/-4.67 sec vs. controls: 10.38+/-5.11 sec, P=0.02). No difference was observed in the combined IMT among the studied groups (PCOS: 0.49+/-0.01 mm v.s. controls: 0.51+/-0.02 mm, P=0.19).

CONCLUSIONS

Using non invasive methodologies endothelial dysfunction in the macrocirculation and early impairment in the microcirculation were demonstrated in young women with PCOS who had normal profile of glycemia, lipidemia and blood pressure, and no evidence of structural arterial impairment.

The combined effect of augmentation index and carotid intima-media thickness on cardiovascular risk in young and middle-aged men without cardiovascular disease

Carotid artery intima-media thickness (IMT) has been used as a surrogate marker of atherosclerosis and is related to cardiovascular risk. Indices of arterial stiffness are also associated with cardiovascular risk and atherosclerosis. The aim of this study was to assess the prognostic value of the combination of surrogate markers of cardiovascular disease measured non-invasively in subjects without cardiovascular disease. In this cross-sectional study, 81 young and middle aged males (39.2+/-6.3 years) without evidence of overt cardiovascular disease or diabetes mellitus were enrolled. High-resolution B-mode ultrasonography and pulse wave analysis were used to measure carotid artery IMT and augmentation index (AI), a measure of arterial stiffness. Framingham risk score (FRS) was used as an estimate of the risk for development of cardiovascular disease. Regional differences were observed in the carotid arteries' IMT regarding their relationship with FRS: combined (average from all sites) IMT and IMT in the carotid bulb (CB), but not in the common (CC) and internal carotid artery (IC), and AI showed significant increases of FRS by their tertiles. However, subjects with both AI and IMT at any site in the highest tertile (AI>15%, CC>0.65 mm, CB>0.8 mm, IC>0.65 mm) had an increased FRS compared to subjects with one or none of these parameters in the highest tertile. In conclusion, young and middle-aged men without overt cardiovascular disease with both high IMT and AI are in high cardiovascular risk, as assessed by FRS. Epidemiological studies are needed to further validate this combination.

Arterial stiffness assessed by pulse wave analysis in essential hypertension: relation to 24-h blood pressure profile

BACKGROUND

Arterial stiffness is a risk factor for cardiovascular morbidity and mortality and appears to be increased in arterial hypertension. The purpose of the present study was to relate systemic arterial stiffness assessed by pulse wave analysis to variables of 24-h ambulatory blood pressure monitoring (ABPM) in patients with essential hypertension.

METHODS

Seventy-two subjects with untreated mild to moderate arterial hypertension underwent evaluation with 24-h ambulatory blood pressure monitoring. In the same subjects, applanation tonometry and pulse wave analysis was performed for evaluation of systemic arterial stiffness expressed as augmentation index and estimated aortic pulse wave velocity.

RESULTS

Clinic systolic blood pressure, mean heart rate during 24-h blood pressure monitoring and height were independent predictors of augmentation index and estimated aortic pulse wave velocity. The 41 patients with blunted reduction in nighttime blood pressure (nondippers) showed higher mean systolic blood pressure (p=0.02), lower systolic and diastolic blood pressure variability (p<0.001), higher pulse pressure during 24-h monitoring (p=0.05) and higher estimated aortic pulse wave velocity (p=0.03), indicating stiffer arteries in this group.

CONCLUSIONS

These results suggest that blood pressure change from day- to nighttime is an important determinant of arterial stiffness assessed by pulse wave analysis; this association could contribute to the higher cardiovascular risk in nondippers.

Tamoxifen improves endothelial function and reduces carotid intima-media thickness in postmenopausal women

BACKGROUND

Tamoxifen is a selective estrogen-receptor modulator shown to improve several cardiovascular risk factors in postmenopausal women with breast cancer. In animal studies tamoxifen inhibits the progression of atherosclerosis. Although the presence of a history with tamoxifen treatment is related to a lower intima-media thickness (IMT) of the common carotid artery, data from controlled follow-up studies are lacking to support this observation.

METHODS

We examined 14 postmenopausal women with early stage breast cancer with indication for tamoxifen treatment (20 mg/d) and 13 healthy postmenopausal women. Flow-mediated dilatation (FMD) of the brachial artery, combined carotid IMT, and aortic pulse wave were measured before and 6 months after treatment in the tamoxifen group and at the same times in the control group.

RESULTS

FMD and IMT were significantly increased and decreased, respectively, in the treatment group compared to the control group (FMD: +2.2% +/- 0.9% vs +0.085% +/- 1%, P =.012; IMT: -0.088 +/- 0.03 mm vs +0.04 +/- 0.03 mm, P =.018, mean +/- standard error of the mean, treatment vs control group). These differences remained significant even when adjusted for age, duration of menopause, and cardiovascular risk factors. Low-density lipoprotein cholesterol was also significantly reduced after tamoxifen treatment.

CONCLUSIONS

Tamoxifen treatment slows the progression of atherosclerosis in postmenopausal women with breast cancer as assessed by changes in carotid IMT. An improvement in endothelial function and blood lipid profile may be the reason for this beneficial effect.

Heart rate effect on hemodynamics during mechanical assistance by the intra-aortic balloon pump

Heart rate (HR) has been characterized as an important cardiovascular parameter that affects acute hemodynamic performance of intra-aortic balloon counterpulsation (IABC). However, the effect of HR on hemodynamics during mechanical assistance by the IABC has neither been clarified nor quantified. We sought to evaluate the relationship between IABC and HR and also to examine whether there is a range of HR with optimum hemodynamic response to IABC.

METHODS

20 patients (14 males--6 females, mean age 64.4 +/- 11.4 years) with post-infarction cardiogenic shock undergoing IABC treatment were evaluated. Hemodynamics were recorded for each patient once per day during the assistance period; 131 measurements were taken and thus a wide range of heart rates was obtained (64-141 bpm). The following changes in aortic pressures were used to evaluate acute IABC performance on: a) the maximal increase of diastolic aortic pressure induced by IABC and b) the reduction in systolic and end-diastolic aortic pressure.

RESULTS

Non-linear regression analysis and analysis of variance revealed that a significant correlation exists between IABC performance indices and heart rate. At HR<80 bpm, IABC performance tended to be reduced, whereas the increase in HR above 110 bpm resulted in a significant reduction of all IABC performance indices. In contrast, IABC operating at 80-110 bpm resulted in optimum hemodynamic performance. In conclusion, the effect of heart rate on IABC performance is non-linear indicating that IABC may be more effective when operating within 80-110 bpm.