Aortic stiffness and systemic inflammation changes predict clinical response to intravitreal anti-vascular endothelial growth factor therapy in patients with age-related macular degeneration

Aortic stiffness and systemic inflammation are predictors of cardiovascular risk. Anti-vascular endothelial growth factor agents (anti-VEGF), injected intravitreally, can reverse the course of exudate age-related macular degeneration (AMD). We sought to investigate the association of changes in aortic stiffness and systemic inflammation with response to anti-VEGF therapy. 54 patients (mean age: 76 ± 10 years) with AMD received two consecutive monthly intravitreal injections of ranibizumab (0.5 mg). The primary outcome measure was change in carotid-femoral pulse wave velocity (PWV) from baseline to 1 month after the second injection. Secondary endpoint was the change in serum high sensitivity interleukin-6 (hsIL-6) levels. Ranibizumab caused a decrease of PWV after the first (by 0.36 ± 1.4 m/s) and the second injection (by 0.31 ± 1.4 m/s) and remained decreased 1 month after the second injection (overall P < 0.05). PWV decreased significantly in good responders (according to clinical criteria and fundus findings, P = 0.004), whereas it increased numerically in poor responders (P = 0.21) over the study period. In responders, hsIL-6 decreased after the first injection and remained decreased 1 month after the second injection (by 0.63 ± 0.35 pg/ml, overall P = 0.02). PWV (P = 0.005) and hsIL-6 (P = 0.042) were independent predictors of improvement after adjusting for age and presence of hypertension and diabetes. The decrease in PWV through the whole study period was positively correlated with the reduction in hsIL-6 (r = 0.36, P < 0.01). Intravitreal ranibizumab injections lead to a decrease in PWV and hsIL-6. Both parameters predict clinical improvement and may aid to improving treatment targeting and hence therapeutic outcome in patients with AMD.

Sarcopenia in Rheumatoid arthritis. A narrative review

Sarcopenia was recently identified as an entity in the ICD-10 classification of October 2016. According to the recommendation of the European Working Group on Sarcopenia in Older People (EWGSOP2), sarcopenia is defined as low muscle strength and low muscle mass, while physical performance is used to categorize the severity of sarcopenia. In recent years, sarcopenia has become increasingly common in younger patients with autoimmune diseases such as Rheumatoid arthritis (RA). Due to the chronic inflammation caused by RA, patients have reduced physical activity, immobility, stiffness, and joint destruction and all of that lead to the loss of muscle mass, muscle strength, disability and significantly lowering the patients' quality of life. This article is a narrative review about sarcopenia in RA, with a special focus in its pathogenesis and management.

Red blood cell derived extracellular vesicles during the process of autologous blood doping

The purpose of this pilot study was to investigate the effects of the transfusion of one erythrocyte concentrate on the number of circulating red blood cell extracellular vesicles (RBC-EVs) and their clearance time. Six, healthy volunteers donated their blood and were transfused with their RBC concentrate after 35-36 days of storage. One K₂ EDTA and one serum sample were collected before donation, at four timepoints after donation and at another six timepoints after transfusion. RBC-EVs were analyzed on a Cytek Aurora flow cytometer. A highly significant increase (p < 0.001) of RBC-EVs from an average of 60.1 ± 19.8 (10³ /μL) at baseline to 179.3 ± 84.7 (10³ /μL) in the first 1-3 h after transfusion could be observed. Individual differences in the response to transfusion became apparent with one volunteer showing no increase and another an increased concentration at one timepoint after donation due to an influenza infection. We concluded that in an individualized passport approach, increased RBC-EVs might be considered as additional evidence when interpreting suspicious Athletes Biological Passport (ABPs) but for this additional research related to sample collection and transport processes as well as method development and harmonization would be necessary.

Statins benefit in androgen levels and target organ damage in hypertensive males with erectile dysfunction

Background

Statins may benefit cardiovascular physiology by cholesterol independent or pleiotropic actions. Target organ damage (TOD) amplifies cardiovascular risk in essential hypertension and endogenous testosterone (TT) exhibit vasoprotective effects. Erectile dysfunction (ED) is frequent in hypertensive middle aged men when androgen levels typically fall, impairing thus quality of life.

Purpose

To investigate the effect of statins in TT and TOD in hypertensive middle aged men with ED, independently of cholesterol levels.

Methods

248 hypertensive ED males (mean age: 57 yo) with no history of diabetes mellitus or overt cardiovascular disease enrolled the study. Of those 95 (38%) were on statin therapy for treatment of dyslipidemia. There were all screened for the presence of microalbuminuria, defined as urinary albumin loss 30–300 mg in a 24 h urine volume collection. TT, total cholesterol (Tchol) and low density lipoprotein (LDL) levels were measured on blood samples taken before 09:00 am. All individuals underwent a non invasive evaluation of the carotid-femoral pulse wave velocity (PWV), estimation of central pressures and augmentation index (AIx) a parameter of wave reflection amplification (Sphygmocor device). ED severity was assessed by the SHIM-5 score (range: 0–25) and higher values indicate a better erectile ability.

Results

In bivariate analysis statin use was positively related to TT (p&lt;0.05 – Figure 1) and negatively to microalbuminuria, Tchol and LDL (p&lt;0.005). Moreover TT was negatively related to PWV, AIx, microalbuminuria (all p&lt;0.005) and positively to the SHIM-5 score (p: 0.003). By linear regression analysis association of TT to statins remained significant after correction for age, BMI, PWV, AIx, Tchol and LDL levels.

Conclusions

Statin therapy benefits endogenous testosterone in hypertensive middle aged men with ED and so lessens TOD and enhances erectile ability independently of cholesterol levels. In such population group pleiotropic effects of statins may help restoring androgen levels, decrease cardiovascular risk and ameliorate quality of life.

Funding Acknowledgement

Type of funding sources: None.

Acute effects of COVID-19 vaccination on inflammatory, macrovasular and microvascular biomarkers

Purpose

To fight the COVID-19 pandemic, messenger RNA (mRNA) vaccines were the first to be adopted by vaccination programs worldwide. We sought to investigate the short-term effect of mRNA vaccine administration on endothelial function and arterial stiffness.

Methods

Thirty-two participants (mean age 37±8 years, 20 men) that received the BNT162b2 mRNA COVID-19 vaccine were studied in 3 sessions in a sequence-randomized, sham-controlled, assessor-blinded, cross-over design. Primary outcome was endothelial function assessed by brachial artery flow-mediated dilatation (FMD), and secondary outcomes were aortic stiffness, evaluated with carotid-femoral pulse wave velocity (PWV), microvascular function that was estimated with hyperemic mean blood flow velocity (HMBFV) of the brachial artery, and inflammation measured by high-sensitivity C-reactive protein (hsCRP) and interleukins (hsIL-6 and hsIL-1b) in blood samples. The outcomes were assessed prior to, and at 8h, 24h post the 1st dose of vaccination, and 8h, 24h and 48h post the 2nd.

Results

There was an increase in hsCRP that was apparent at 24h after both the 1st dose (−0.60 [95% Confidence intervals [CI]: −1.60 to −0.20], p=0.013) and the 2nd dose (max median difference at 48h −6.60 [95% CI: −9.80 to −3.40], p&lt;0.001) compared to sham. Similarly, interleukins also increased. The vaccine did not change PWV. FMD remained unchanged during the 1st dose but decreased significantly by 1.5% (95% CI: 0.1% to 2.9%, p=0.037) at 24h post the 2nd dose (Figure). FMD values returned towards baseline at 48h. HMBFV remained unchanged during the 1st dose but at 48h post the 2nd dose was numerically lower than the sham procedure but the difference between the 2 sessions was not statistically significant (max mean difference at 48h 8.6 [95% CI: −0.6 to 17.8], p=0.067).

Conclusions

Our study shows that the mRNA vaccine causes a prominent increase in inflammatory markers, especially after the 2nd dose and a transient deterioration of endothelial function at 24h that returns towards baseline at 48h. These results confirm the short-term cardiovascular safety of the vaccine.

Funding Acknowledgement

Type of funding sources: None.

The effect of an mRNA vaccine against COVID-19 on endothelial function and arterial stiffness

To fight the COVID-19 pandemic, messenger RNA (mRNA) vaccines were the first to be adopted by vaccination programs worldwide. We sought to investigate the short-term effect of mRNA vaccine administration on endothelial function and arterial stiffness. Thirty-two participants (mean age 37 ± 8 years, 20 men) who received the BNT162b2 mRNA COVID-19 vaccine were studied in three sessions in a sequence-randomized, sham-controlled, assessor-blinded, crossover design. The primary outcome was endothelial function (assessed by brachial artery flow-mediated dilatation (FMD)), and the secondary outcomes were aortic stiffness (evaluated with carotid-femoral pulse wave velocity (PWV)) and inflammation (measured by high-sensitivity C-reactive protein (hsCRP) in blood samples). The outcomes were assessed prior to and at 8 h and 24 h after the 1st dose of vaccine and at 8 h, 24 h, and 48 h after the 2nd dose. There was an increase in hsCRP that was apparent at 24 h after both the 1st dose (-0.60 [95% confidence intervals [CI]: -1.60 to -0.20], p = 0.013) and the 2nd dose (maximum median difference at 48 h -6.60 [95% CI: -9.80 to -3.40], p < 0.001) compared to placebo. The vaccine did not change PWV. FMD remained unchanged during the 1st dose but decreased significantly by 1.5% (95% CI: 0.1% to 2.9%, p = 0.037) at 24 h after the 2nd dose. FMD values returned to baseline at 48 h. Our study shows that the mRNA vaccine causes a prominent increase in inflammatory markers, especially after the 2nd dose, and a transient deterioration of endothelial function at 24 h that returns to baseline at 48 h. These results confirm the short-term cardiovascular safety of the vaccine.

Target organ damage in relation to intensity of cigarette smoking, statin therapy and the endogenous testosterone in middle aged hypertensive men with erectile dysfunction

Background

Target organ damage (TOD) amplifies cardiovascular risk in essential hypertension. Erectile dysfunction (ED) refers to microvascular disease and frequently accompanies the hypertensive middle aged male population. Endogenous testosterone (TT) and statins exhibit vasoprotective effects while cigarette smoking typically relates to an adverse cardiovascular outcome.

Purpose

To investigate TOD in relation to cigarette smoking, statin therapy and TT in essential hypertension middle aged males with ED.

Methods

223 hypertensive ED males (mean age: 59 yo) with no history of diabetes mellitus or overt cardiovascular disease enrolled the study. There were all screened for the presence of microalbuminuria, defined as urinary albumin loss 30 – 300 mg in a 24 h urine volume collection. Among them 96 (43%) were current cigarette smokers. Intensity of smoking referred in terms of packs per year. The presence and severity of ED was assessed by the SHIM-5 score (range 0–25), higher values indicate better erectile ability. All underwent a non invasive evaluation of the carotid – femoral pulse wave velocity (PWV), estimation of central pressures and augmentation index (AIx) a parameter of wave reflection amplification (Sphygmocor device).Moreover left ventricular mass index (LVMI) was assessed by 2D echocardiography (Devereux formula) and intima-media thickness (cIMT) of the common carotid artery by vascular ultrasound imaging. cIMT is a marker of atheromatosis.

Results

Microalbuminuria detected in 89 (40%) patients was positively related to other parameters of TOD such as PWV, cIMT, LVMI (all p&lt;0,005) and smoking habits (p=0,02) and negatively to the SHIM-5 score, TT and statin use (all p&lt;0,01). A notably negative correlation to the intensity of smoking was the SHIM-5 score (p=0,013) and a positive the cIMT (p=0,001). Statins were positively related to TT (p=0,006).In linear regression analysis, relation of packs per year remained significant regarding microalbuminuria and the SHIM-5 after adjustment for age, body mass index, PWV, LVMI, central systolic, diastolic and pulse blood pressure. Similarly, relation of statins, TT and microalbuminuria remained significant after adjustment for age, LVMI, PWV, AIx and smoking status.

Conclusion

Intensive cigarette smoking accelerates silent kidney damage and sabotages erectile performance in hypertensive middle aged men with ED independently of the central hemodynamic load. Statins protect from microvascular kidney damage and the decline of testosterone probably by enhancing endothelial physiology. In such population group, simple and clinically oriented criteria may reveal early diagnosis of target organ damage and guide appropriate life-style modifications and further therapeutic judgments.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Low testosterone accelerates vascular damage in hypertensive smokers with more than a 20-pack-year smoking history

Purpose

Testosterone deficiency and cigarette smoking are both associated with increased cardiovascular (CV) mortality risk. Aim of the study is to investigate the impact of low testosterone level on vascular function and structure changes related to cumulative tobacco smoke exposure in patients with arterial hypertension.

Methods

Indices of vascular function and structure including carotid-femoral pulse wave velocity (PWV) and carotid intima media thickness (cIMT) were measured in 263 hypertensive males divided into 4 age-matched groups according to pack-years of smoking as never smokers (0.0 pack-years), light smokers (0.1–20.0 pack-years), moderate smokers (20.1–40.0 pack-years), and heavy smokers (&gt;40 pack-years). Plasma total testosterone (TT) levels were measured in all patients.

Results

PWV and cIMT progressively increased from never smokers and light smokers to moderate and heavy smokers (overall P&lt;0.001 and P&lt;0.01 respectively). The hypertensive males of each smoking group were further classified according to measured low or normal TT levels (low TT&lt;3.5 ng/ml). Figure shows mean PWV and cIMT of the smoking/TT groups. Systolic and diastolic BP was higher in patients with TD compared to subjects with normal TT in moderate and severe heavy smokers (all P&lt;0.05) and similar in light and never smokers. LDL-C levels were comparable between men with TD and normal TT across the four smoking groups. The difference in aortic PWV between TD and normal TT shows a progressive increase from light to moderate and heavy smokers. Similarly, the difference in cIMT between TD and normal TT is also positively correlated with cumulative tobacco exposure. All associations remained statistically significant even after adjustment for BP differences.

Conclusions

The deficiency in TT levels accelerates vascular wall damage of large arteries among hypertensive smokers with more than 20 pack-years tobacco exposure. Considering the predictive value of vascular biomarkers, the findings of this study imply the possibility that the measurement of baseline testosterone level could be an unfavourable marker of smoking-related cardiovascular risk among moderate and heavy smokers with arterial hypertension.

Funding Acknowledgement

Type of funding sources: None. TT, tobacco smoke exposure, PWV and IMT

Renal biomarkers reflect overall hypertensive organ damage: “one organ to rule them all”

Background/Introduction

Hypertension is associated with higher cardiovascular risk as well as several markers of subclinical target organ damage (TOD). Albumin to creatinine ratio (ACR) in urine has been recognized as an independent risk factor for cardiovascular events.

Purpose

We hypothesized that there is a relationship between ACR and markers of TOD in never-treated hypertensives.

Methods

We enrolled 924 consecutive essential hypertensives (mean age 53±12 years, 486 males) without known cardiovascular disease (CVD). Markers of subclinical TOD [left ventricular mass index (LVMI), pulse wave velocity (PWV), ankle-brachial index (ABI) and estimated glomerular filtration rate (eGFR)] were evaluated in all patients. LVMI was assessed echocardiographically using the Devereux formula. Carotid-femoral PWV was estimated with the Complior device. eGFR was calculated by the Cockcroft-Gault formula. ABI was calculated by dividing the highest ankle systolic blood pressure by the highest brachial systolic blood pressure.

Results

ACR exhibited significant association with LVMI (r=0.277, p&lt;0.001, Figure), PWV (r=0.277, p&lt;0.001) ABI (r=−0.078, p=0.018) and eGFR (r=−0.100, p=0.002). In further analysis, ACR was associated with TOD as suggested by the 2018 European Guidelines for Hypertension [left ventricular hypertrophy (LVMI&gt;115 g/m2 in men and &gt;95 g/m2 in women), increased PWV (PWV&gt;10m/s), decreased ABI (ABI&lt;0.9) and decreased renal function (eGFR&lt;60ml/min)]. Specifically, ACR exhibited significant association with the number of TOD and this association was independent of age and gender (p&lt;0.05).

Conclusions

Our findings support the close relationship between ACR and TOD in hypertension, as well as, the predictive ability of ACR for TOD.

Funding Acknowledgement

Type of funding sources: None. Association between LVMI and ACR

Exercise capacity benefit in relation to endogenous testosterone, coronary and central vascular physiology, and the Mediterranean regime in hypertensive males with erectile dysfunction

Background

The Mediterranean diet (Med-diet) benefits cardiovascular health, and erectile dysfunction (ED) often coexists in the hypertensive aging male population were endogenous testosterone (TT) typically declines. Coronary flow reserve (CFR) displays the ability of the coronary circulation to increase flow. Wave reflection amplification as expressed by augmentation index (AIx) exhibits a vital parameter of central vascular stiffness.

Purpose

To investigate the possible benefits of the Med-diet in exercise capacity, central physiology, CFR and erectile ability in relation to endogenous TT in the middle aged male hypertensive population with ED.

Methods

250 hypertensive males (mean age 56 yo) with ED enrolled the study. All underwent a treadmill stress test (Bruce protocol). Exercise capacity was validated as metabolic equivalents (METs). We measured separately the CFR of the left anterior descending artery by an adenosine protocol (max dose 140μg/kg/min over 6 minutes). PW Doppler measurements were achieved at the middle/distal LAD segment under the guidance of color Doppler flow mapping. CFR was validated as ratio between peak diastolic flow velocity following drug infusion and rest. Ratios ≥2 are considered as non-ischemic response, higher values indicate microvascular coronary integrity. TT was measured on blood samples taken before 09:00 am. ED severity and adherence to the Med-diet were assessed by the SHIM-5 (range: 0–25) and the Med-diet (range: 0–55) scores. Higher values indicate a better erectile ability and Med-diet compliance respectively. Finally, central pulse pressure (cPP) and AIx were noninvasively estimated as parameters of central hemodynamic load and wave reflection amplification (Sphygmocor device).

Results

In bivariate analysis METs were positively associated to the Med-diet, CFR, TT and the SHIM-5 score (all p&lt;0,005) and negatively to the AIx and cPP (both p&lt;0,025). There was also positive association of the Med-diet to the CFR, TT and the SHIM-5 score (p&lt;0,02) and negative to the AIx and cPP (p&lt;0,025). By linear regression analysis association of METs to TT, CFR and Med-diet remained significant after adjustment for age, BMI, diabetes mellitus, use of statins and smoking status (p&lt;0,005). We further subdivide our population according to the TT threshold of hypogonadism (≤3 ng/ml). Hypogonadism patients exhibit a lower exercise capacity comparing to the normal TT group (picture).

Conclusion

The Med-diet regime benefits exercise tolerance and erectile performance in hypertensive males with ED by enhancing endogenous testosterone and so coronary and central vascular physiology. We strongly recommend this culinary preference promoting thus vascular health and the sense of well being.

Funding Acknowledgement

Type of funding sources: None.

Conservative management of acute coronary syndromes in chronic kidney disease patients: a deadly sin

Background/Introduction

Chronic kidney disease (CKD) is associated with worse prognosis in acute coronary syndromes (ACS).

Purpose

We sought to investigate the prognostic effect of non-invasive management of ACS in CKD patients in a tertiary University Hospital.

Methods

Two hundred and one patients (mean age 66.5±13.6 years, 150 males) admitted to our Hospital with ACS from 2016–2017 were included in the study. Patients were followed for a median of 2 years post the index event. CKD was defined by an estimated glomerular filtration rate (eGFR) &lt;60 ml/min/m2, as assessed by the Modification of Diet in Renal Disease (MDRD) equation. We grouped patients into four groups according to their CKD status and whether they underwent coronary angiography or not. The primary outcome was all-cause death and secondary outcomes were cardiovascular and non-cardiovascular death.

Results

The majority of patients (n=120, 60%) presented with non-ST elevation ACS (NSTE-ACS), whereas 81 patients as ST-elevation myocardial infarction (STEMI) (40%). Fifty-four patients (27%) were identified as CKD patients (of whom 5 were on dialysis). Overall, 29 patients (14.4%) did not undergo coronary angiography. Patients at a higher age and with CKD were more likely to not undergo angiography. Thirty-seven (18.4%) died during follow-up (25 non-cardiovascular deaths and 12 cardiovascular deaths). Patients with conservative treatment and CKD had the worse prognosis (Hazard ratio [HR] =11.00, 95% Confidence intervals [CI] 4.00 to 30.24, p&lt;0.001) followed by non-CKD patients with conservative treatment (HR=4.37, 95% CI 1.20 to 15.90, p=0.025) compared to non-CKD patients treated invasively (reference group) after adjusting for age, gender, STEMI/NSTE-ACS diagnosis (Figure). Results were similar for non-cardiovascular death, whereas regarding cardiovascular death only the group with CKD and conservative treatment had a lower survival compared to the reference group (HR=26.5, 95% CI 2.9 to 241.7, p=0.004)

Conclusions

Patients with ACS and CKD are less likely to receive invasive management and have higher mortality from both cardiovascular and non-cardiovascular causes than patients without CKD. Conservative management of ACS was associated with higher long-term mortality versus invasive management in all patients, regardless of CKD status.

Funding Acknowledgement

Type of funding sources: None.

Tobacco cigarette smoking accelerates impairment of aortic elastic properties in middle-aged patients with high normal blood pressure

Background

The impact of smoking on atherosclerosis progression is greater in patients with arterial hypertension. High blood pressure (BP) is a major determinant of increased aortic stiffness which is an independent predictor of cardiovascular events. Aim of this study was to examine whether there are differences between office BP categorization and aortic stiffness on the basis of smoking status.

Methods

We measured carotid-femoral pulse wave (PWV) in 185 men (mean age: 55±10 years) who were not receiving antihypertensive medications and they had no history of diabetes and cardiovascular disease. The cohort was divided into three groups according to office systolic BP (SBP) and diastolic BP (DBP): normal (SBP &lt;130 and DBP &lt;85 mmHg, n=79), high normal (130≤SBP&lt;140 or DBP 85≤DBP&lt;90mmHg, n=42), and hypertension (SBP≥140 or DBP≥90mmHg, n=64).

Results

The three groups had similar age and metabolic parameters (body mass index, fasting blood glucose and LDL-C). PWV progressively increased from normotensive to high normal BP, and to hypertensive patients (7.8±1.4 vs 8.2±1.4 vs 8.6±1.6 m/s, respectively, overall P&lt;0.01). Then we subdivided the three office BP groups into subgroups according to smoking status. Figure shows PWV of the three groups stratified by smoking status. The three subgroups of smokers had similar tobacco exposure (40 pack-years). There were not statistically significant differences between smokers and non smokers in each office BP category with regard to age and metabolic parameters. In separate analysis, among individuals with either normal BP the association of smoking status with PWV level was not significant. However, in hypertensive patients but also in patients with high normal BP, smoking status was significantly correlated with PWV (all P&lt;0.01). Furthermore, the differences in mean PWV between smokers with high normal BP and patients with hypertension were not statistically significant reflecting a detrimental effect of smoking on aortic stiffness among males with high normal BP.

Conclusion

Smoking has an unfavorable effect on aortic elastic properties in men with high normal BP. The smokers with high normal BP have PWV comparable to that of hypertensive patients. This finding imply that smoking cessation should be a premising non pharmacological intervention in men with high-normal BP and increased aortic stiffness who are considered to be at a higher cardiovascular risk.

Funding Acknowledgement

Type of funding sources: None. Smoking, BP categories and PWV

Low testosterone is associated with increased risk of major adverse cardiovascular events in smokers with erectile dysfunction

Purpose

Tobacco cigarette smoking and decreased concentrations of testosterone are major risk factors of erectile dysfunction (ED) and independent predictors of cardiovascular disease (CVD). We investigated, whether testosterone deficiency has a complementary predictive value for CVD events in smokers with ED.

Methods

A cohort of 398 men with ED and without known atherosclerotic CVD (mean age: 55±10 years) were followed for the occurrence of major adverse cardiovascular events (MACE), (CVD death, coronary artery disease, stroke). Total testosterone (TT) levels were measured in all patients.

Results

Among the study population, 205 (52%) were smokers. During a mean follow-up of 6 years (range: 1–11 years), 30 (7.5%) patients demonstrated a MACE. Baseline TT levels were significantly lower and prevalence of smoking was higher in the CV-event group than the event-free survival group (P&lt;0.01 and P&lt;0.05, respectively). Kaplan–Meier analysis showed that patients with low TT (≤4.0 ng/mL) had a worse prognosis than patients with TT &gt;4.0 ng/mL (log rank: 6.52, P=0.011), and that smokers had a greater risk of adverse events than never smokers (log rank: 4.42, P=0.04). We then stratified all patients into four groups, on the basis of smoking status (current/never smokers) and low or high TT (≤ or &gt;4.0 ng/mL) and cardiac event-free survival curves were constructed by Kaplan–Meier analysis (figure). The event-free rate in smokers with low TT is significantly lower than that of smokers with low TT or never smokers with normal TT (log rank: 11.3, P=0.02). Smokers with low TT had an almost 4-fold higher risk of MACEs compared to never smokers with normal TT (adjusted hazard ratio: 3.91; P=0.030).

Conclusion

Cigarette smoking combined with low TT concentration is associated with a shorter event-free period compared with either smoking or testosterone deficiency alone. The measurement of testosterone concentration may be useful to further stratify the risk of ED smokers without known CVD.

Funding Acknowledgement

Type of funding sources: None. Smoking testosterone deficiency and MACE

MiRNAs as Biomarkers in Hypertrophic Cardiomyopathy: Current State of the Art

BACKGROUND

Hypertrophic Cardiomyopathy (HCM) is the most common inherited Cardiomyopathy. The hallmark of HCM is myocardial fibrosis that contributes to heart failure, arrhythmias and sudden cardiac death.

OBJECTIVE

Currently there are no reliable serum biomarkers for detection of myocardial fibrosis, while cardiac magnetic resonance (CMR) is an imaging technique to detect myocardial fibrosis. MicroRNAs (miRNAs) have been increasingly suggested as biomarkers in cardiovascular diseases. However, in HCM there is as yet no identified and verified specific circulating miRNA signature.

METHODS

We conducted a review of literature to identify the studies that indicate the possible roles of miRNAs in HCM.

RESULTS

From studies in transgenic mice with HCM, miR-1, -133 may identify HCM in the early asymptomatic phase. Human miR-29a could be used as a circulating biomarker for detection of both myocardial hypertrophy and fibrosis in HCM, while it could also have a possible additional role in discrimination of hypertrophic obstructive cardiomyopathy from non-obstructive HCM. Additionally, miR-29a-3p is associated with diffuse myocardial fibrosis in HCM while miR-1-3p could discriminate end-stage HCM from dilated cardiomyopathy and left ventricle dilation. Another role of miRNAs could also be the contribution in differential diagnosis between HCM and phenocopies. Moreover, miRNA-targeted therapy (miR-133 mimics) is promising in inhibiting cardiac hypertrophy but this is still in the early stages.

CONCLUSION

A more reliable and specific signature of miRNAs is expected with forthcoming studies in samples from HCM patients and correlation of miRNAs with CMR and serum markers of fibrosis may implicate novel diagnostic and therapeutic pathways.

Central pulse load and coronary flow benefit in relation to endogenous testosterone and the Mediterranean regime in hypertensive males with erectile dysfunction

Background

Central pulse pressure (cPP) is an important parameter of target organ damage (TOD) in essential hypertension. Coronary flow reserve (CFR) displays the ability of both macro and microcirculation to augment flow to the myocardium while endogenous total testosterone (TT) exhibits vasodilator effects. The Mediterranean diet (Med-diet) benefits cardiovascular health and erectile dysfunction (ED) often coexists with the decline of endogenous testosterone in the aging male population.

Purpose

To investigate the possible benefits of the Med-diet in central PP, CFR and erectile ability in relation to endogenous TT in the primary hypertensive population with ED.

Methods

247 male hypertensive patients (mean age 57 yo) with ED enrolled the study. Significant coronary artery disease was formerly excluded by a dobutamine stess echo test. We measured the CFR of the left anterior descending artery by performing an adenosine protocol (maximum dose 140 μg/kg/min over 6 minutes). Measurements by the PW Doppler were achieved at the middle/distal LAD segment under the guidance of color Doppler flow mapping. CFR was validated as ratio between peak diastolic flow velocity following drug infusion and rest. Ratios ≥2 are considered as non-ischemic response and higher values indicate microvascular coronary integrity. TT was measured in all patients on blood samples taken before 09:00 am. ED severity and adherence to the Med-diet were assessed by the SHIM-5 (range: 0–25) and the Med-diet (range: 0–55) scores. Higher values indicate a better erectile ability and Med-diet compliance respectively. Finally, cPP and augmentation index (AIx) were estimated as parameters of central hemodynamic load and wave reflection amplification respectively (sphygmocor device).

Results

In bivariate analysis Med-diet was favorably related to CFR (p=0.24, r=0.48), TT (p=0.01, r=0.57) and the SHIM-5 score (p=0.01, r=0.45). On the contrary, it was negatively related to cPP (p=0.15, r=−0.60) and AIx (p=0.31, r=−0.45). CFR was strongly related to TT (p=0.001, r=0.8) and the SHIM-5 score (p=0.01, r=0.41). By multiple linear regression analysis the relation of CFR, SHIM-5 and Med-diet score remained significant after adjustment for age, BMI, systolic arterial blood pressure and smoking habits. We further subdivide our population according to the mean Med-diet value (26) into high and low Med-diet adherence groups. Only in the group with the greater Med-diet adherence (n=153, 62%) there were still positive relation with the CFR, TT and SHIM-5 score as well as negative correlation to cPP and AIx (p=0.04).

Conclusion

In essential hypertensive males with erectile dysfunction the Med-diet regime lessens central pulse pressure while enhancing coronary flow, testosterone levels and so peripheral vascular physiology. We strongly recommend this dietary pattern as a life-style option and strategic component of holistic therapeutic approach.

Funding Acknowledgement

Type of funding source: None

Aortic stiffness and incident diabetes: the hard, bittersweet truth

Background/Introduction

Aortic stiffness increases with advancing age and is a major risk factor for age-related morbidity and mortality. Aortic stiffness and glycaemic dysregulation are related; however, temporal relationships between aortic stiffness and incidence of diabetes have not been fully delineated.

Purpose

We sought to investigate the role of arterial stiffness in the prediction of incident diabetes.

Methods

376 untreated hypertensive patients (mean age 52.6±12.5 years, 201 males) without known cardiovascular disease and without known history of diabetes, were included in the study. Markers of subclinical organ damage [carotid-femoral pulse wave velocity (PWV) and estimated glomerular filtration rate (eGFR)] were evaluated in all patients. eGFR was estimated using the Cockcroft-Gault formula. Hemoglobin A1c (HbA1c) and blood glucose were measured in venous blood samples. Patients were prospectively followed-up, for incidence of diabetes as defined by the American Diabetes Association criteria.

Results

During a median 13.5 years follow-up, forty-six patients (12.2%) patients were diagnosed with diabetes. In multivariable logistic regression analysis, only higher PWV (Odds Ratio [OR] = 1.271, 95% Confidence intervals [CI]: 1.002–1.612, P=0.048) was associated with higher risk of incident diabetes, which was independent of age, sex, pulse pressure, HbA1c, fasting blood glucose and eGFR. In further analysis, receiver operating characteristic (ROC) curves were generated to evaluate the ability of PWV to discriminate subjects with diabetes. The area under the curve (AUC) and 95% CIs of the ROC curve was AUC=0.66 (95% CI: 0.58–0.74, P=0.001) for PWV (Figure 1).

Conclusions

In our cohort, higher aortic stiffness was associated with higher risk of incident diabetes.

Figure 1. ROC curve for the prediction of diabetes

Funding Acknowledgement

Type of funding source: None

Effect of smoking cessation with varenicline on blood pressure control in hypertensive patients

Purpose

The interaction between smoking and blood pressure (BP) is complex. Despite the strong association between cigarette smoking and cardiovascular disease (CVD) risk, there is paucity about the effect of pharmacotherapies for treating tobacco dependence on BP in already established arterial hypertension. Varenicline has been shown to be an effective and well-tolerated pharmaceutical intervention for smoking cessation. Aim of the study was to investigate the improvement in BP control in smokers with a diagnosis of hypertension who quit or reduced substantially their tobacco consumption by using varenicline and the association of nicotine dependence with BP changes.

Methods

A total of 89 (mean age:48±7, 52 males) regular smokers (28±9 pack-years) with a diagnosis of hypertension and on anti-hypertensive drugs were studied. All patients received low-intensity counseling and pharmacotherapy with varenicline (1 mg twice daily) for 12 weeks. Point prevalence smoking abstinence was defined by self-report of complete abstinence in the 7 days before the 12 week clinic visit (end of therapy). Office BP was measured at baseline and each follow-up visit (4 and 12 weeks) office BP. The Fagerström Test for Nicotine Dependence (FTND) was used for assessing nicotine dependence. High nicotine dependence (ND) was defined as a FTND score ≥6.

Results

At 12 weeks, 60 (67%) patients were abstinent from smoking and 14 (16%) were non-abstainers who reduced daily consumption to 50% of baseline. The mean time interval between the initiation of treatment with varenicline and smoking abstinence was 1.8±0.6 weeks. There were not significant differences in age, baseline BP level, severity of nicotine dependence and total cigarette consumption (pack-years) between the two groups. Systolic BP (SBP) and diastolic BP (DBP) decreased significantly in abstainers (by 7.2 and 5.5 mmHg at 12 weeks, P&lt;0.01 and P&lt;0.05, respectively) while the decrease in BP level in non-abstainers was minimal. Among patients with sustained tobacco abstinence, 18 were highly ND and 42 had mild and moderate ND. The two ND groups had similar age and BP levels at baseline. Changes in SBP and DBP from baseline in smokers with arterial hypertension between the two ND groups are illustrated in Figure. The observed reductions in SBP and DBP were significant (P&lt;0.05, both for SBP and DBP) when comparing the high ND group to the mild/moderate ND group at 12 weeks. No severe adverse reactions were reported with varenicline use throughout the entire follow-up duration.

Conclusion

Varenicline may help smokers with arterial hypertension under antihypertensive therapy to remain abstinent from tobacco cigarette smoking. A novel and important message of this study is also the substantial improvements in office SBP and DBP in highly nicotine dependent sustained tobacco abstainers.

ND-BP changes after varenicline therapy

Funding Acknowledgement

Type of funding source: None

Combined effect of cigarette smoking and prediabetes on structural and functional changes of large arteries

Purpose

Smoking is a major risk factor for cardiovascular disease and prediabetes is associated with excess risks for adverse cardiovascular outcomes and death. Aim of this study was to explore whether smoking and prediabetes exert a synergistic unfavourable effect on functional and structural parameters of large arteries.

Methods

We measured carotid-femoral pulse wave velocity (cfPWV), augmentation index (AIx) and carotid intima media thickness (cIMT) in 407 individuals without known atherosclerotic disease (mean age: 52±8 years) categorized into four age-matched groups according to glucose metabolic and smoking status: Smokers with diabetes (n=68), Smokers with prediabetes (n=87), Non-smokers with prediabetes (n=98) and Non- smokers with normal fasting blood glucose (FBG) (n=154). Prediabetes was defined as impaired fasting glucose (100–125 mg/dL), impaired glucose tolerance (2-hour glucose level of 140–199 mg/dL during an oral glucose tolerance test), or glycosylated hemoglobin (HbA1c) level of 5.7% to 6.4%. High sensitivity C-reactive protein (hsCRP) was measured in all patients.

Results

Systolic pressure, pulse pressure were increased and hsCRP levels were higher in smokers with diabetes compared to the three other groups (overall P&lt;0.05, P&lt;0.01 and P&lt;0.05, respectively, ANOVA). The cumulative tobacco exposure (measured in pack-years) was similar between smokers with diabetes and smokers with prediabetes (45 pack-years). Figure 1 shows cfPWV, AIx and cIMT of the four groups. Interestingly, smokers with diabetes and smokers with prediabetes have similar mean cfPWV and cIMT and significantly higher values compared to non-smokers with prediabetes and non-smokers with normal FBG. The associations remained statistically significant even after adjusting for systolic pressure and hsCRP level. AIx was not different between the four study groups.

Conclusion

The combination of prediabetes and smoking is associated with higher cfPWV and cIMT values compared to prediabetes alone. The smokers with impaired glucose regulation have functional and structural alterations of large arteries similar to that of smokers with established diabetes. Considering the risk for developing prediabetes in relation to smoking status and the number of cigarettes smoked daily and the independent predictive value of assessing vascular changes in large arteries, the present findings may have important clinical and prognostic implications.

Figure 1. Smoking, prediabetes and vascular changes

Funding Acknowledgement

Type of funding source: None

Exploring functional and structural vascular changes in obesity: are metabolically healthy obese individuals really healthy?

Purpose

Aim of the study is to compare vascular function and structure parameters among middle-aged men with differences in body mass index (BMI) and metabolic status and to investigate whether obese individuals with a normal metabolic profile have a unhealthy vascular profile.

Methods

We measured carotid-femoral pulse wave velocity (cfPWV), carotid intima media thickness (cIMT) and brachial flow-mediated dilation (bFMD) in 141 obese (BMI≥30 kg/m2) and in 176 aged-matched men with normal BMI (&lt;25 kg/m2) individuals. All participants had no clinical manifestations or a history of atherosclerotic disease. High sensitivity C-reactive protein (hsCRP) and total testosterone (TT) were measured in all patients.

Results

The two BMI groups were subdivided into subgroups according to presence/absence of abnormal metabolic profile (presence of major cardiovascular risk factors): Metabolically unhealthy obese (MeUO, n=114), metabolically healthy obese (MeHO, n=27), metabolically unhealthy with normal BMI (MeUN, n=122) and metabolically healthy with normal BMI individuals (MeHN, n=54). The four subgroups had similar age. Figure 1 shows the mean cIMT (left plot), cfPWV (middle plot) and bFMD (right plot) of the four subgroups. Carotid IMT and cfPWV is higher and bFMD is lower in metabolically unhealthy compared to individuals with a normal metabolic profile in both patients with obesity and subjects with normal BMI. Interestingly, the MeNO patients had significantly lower cIMT (P&lt;0.05) and cfPWV (P&lt;0.01) and higher bFMD (P&lt;0.01) level compared to MeUN individuals. However, as figure shows all measured vascular parameters were significantly impaired in MeNO patients compared to those of MeHN individuals. MeHO patients had comparable hsCRP and TT levels to those of MeUO and MeUN individuals denoting increased inflammatory activation and endogenous androgen deficiency.

Conclusions

MeHO which is a obesity phenotype that has created lot of debate is associated with a better vascular profile compared to MeUN status, however patients with MeHO have more impaired vascular function and structure parameters than MeHN individuals. This finding implies that even in the absence of overt metabolic aberrations, the MeHO profile may be associated with endothelial dysfunction, increased aortic stiffness and thickness of the carotid arterial wall.

Figure 1. BMI, metabolic status and vascular changes

Funding Acknowledgement

Type of funding source: None

Body mass index, silent coronary artery disease and the impact of adopting healthy lifestyle and sexual performance on the risk of major adverse cardiovascular events in erectile dysfunction patients

Background

Erectile dysfunction (ED) is associated with a higher prevalence of risk factors such as hypertension and diabetes and it is an independent predictor of major adverse cardiovascular events (MACE). ED is a common problem in men with obesity.

Purpose

The aim of this study is to investigate the association of overweight and obesity with asymptomatic coronary artery disease and the impact of lifestyle interventions on MACE risk in men suffering from ED.

Methods

A total of 614 patients (55±9 y/o) with ED and without known cardiovascular disease (CVD) underwent dobutamine stress echocardiography (and coronary angiography in patients with positive stress echocardiography for myocardial ischemia) to reveal occult coronary artery disease (CAD). In all patients C-reactive protein (CRP) and total testosterone (TT) were measured at entry. After this evaluation and management of concomitant traditional risk factors they were advised to adopt the recommended strategies for healthy lifestyle and improvement of sexual activity.

Results

The whole population was divided into three groups according to body mass index (BMI) at entry (normal: 18–25.5 kg/m2, n=132; overweight:25.5–29.9 kg/m2, n=295; and obesity: &gt;29.9kg/m2, n=187). There were no statistically significant differences in age, blood pressure (BP) level and smoking prevalence between the three groups. Obese ED patients had significantly lower TT and higher CRP compared to overweight and normal BMI patients (overall P&lt;0.001 and P&lt;0.01, respectively). The prevalence of angiographically documented CAD was not different between obese and overweight patients and it was significantly higher compared to that of subjects with normal BMI (13.8% vs 14.5% vs 7.2%, respectively, overall P&lt;0.05). In the whole study population, a total of 43 (7%) MACE occurred during a mean follow-up of 6.7 years after adopting a healthy lifestyle and improvement in sexual life. Interestingly, overweight status at baseline was associated with a higher MACE prevalence and the overall difference between the three BMI groups at entry was statistically significant (Mantel log-rank test: 8.65; P=0.0014) (Figure 1). Furthermore, in a Cox proportional hazard model overweight at entry (3.14, CI: 1.49–7.87, P&lt;0.01), TT level (0.72; CI 0.56–0.97, P&lt;0.01) and the use of phosphodiesterase-5 (PDE-5) inhibitors (0.83; CI 0.67–0.97, P&lt;0.05) were independent predictors of MACE.

Conclusion

Overweight and obese ED patients have similar prevalence of asymptomatic CAD, however the overweight profile at baseline appears to have a significantly higher MACE risk compared to obesity at follow-up after adopting a healthy lifestyle and improving sexual life with PDE-5 inhibitors. The paradox finding warrants further investigation.

Figure 1. BMI categories and MACE risk

Funding Acknowledgement

Type of funding source: None

X-linked dilated cardiomyopathy: the important role of genetic tests and imaging in the early diagnosis and treatment

Familial dilated cardiomyopathy predominantly affects younger adults and may cause advanced heart failure and sudden cardiac death. Therefore, detailed family history, family members screening, appropriate genetic testing and counselling may allow correct identification of cardiac remodeling etiology, as well as earlier disease detection. Accordingly, we present a case with an early diagnosis of an X-linked dilated cardiomyopathy guided by clinical features, cardiac MRI and genetic testing. The diagnostic workup was guided by the positive family history of cardiomyopathy and sudden cardiac deaths. Clinical implications including early management, better arrythmia risk stratification and the revealing of a potential endemic entity clustering in several male subjects of a community on Crete island are further discussed.

Cardiotoxic Profile and Arterial Stiffness of Adjuvant Chemotherapy for Colorectal Cancer

Background and Purpose

Even though new cancer therapies have improved the overall survival, in some cases they have been associated with adverse effects, including increased cardiotoxicity. The purpose of the present study was to assess the cardiovascular effects of adjuvant chemotherapy for colorectal cancer and mainly the impact on arterial stiffness indices.

Material and Methods

A total of 70 patients with non-metastatic colorectal cancer who were treated either with FOLFOX (n=16) or with XELOX (n=54) adjuvant chemotherapy were included in the study. All patients were subjected to full cardiovascular evaluation at the beginning and the end of chemotherapy. Arterial stiffness was assessed by means of pulse wave velocity (PWV) and augmentation index (Aix) and full laboratory examinations were conducted prior to, and soon after, the termination of chemotherapy.

Results

Patients exhibited significantly higher levels of carotid-radial PWV, carotid femoral RWV and Aix post-chemotherapy (p<0.001); these findings remained significant when examined separately in each treatment subgroup (FOLFOX, XELOX). The observed changes were independent of treatment regimen and baseline patient characteristics. Univariate regression analyses showed that baseline PWVc-r and PWVc-f were the only factors associated with PWVc-r and PWVc-f change, while Aix change was independent of its baseline value.

Conclusion

There is a clear burden in arterial stiffness indices post-adjuvant chemotherapy for colorectal cancer in both chemotherapy groups. This is a finding of important clinical significance, however more prospective studies are required in order to encode the possible mechanisms involved.

P806High normal blood pressure and vascular parameters in patients with erectile dysfunction

Purpose

High blood pressure (BP) is a common risk factor for erectile dysfunction (ED) which is considered as an early clinical manifestation of generalized vascular disease. High–normal BP (130–139/85–89 mmHg) is associated with high rates of progression to hypertension. Aim of the study is to examine vascular and structure parameters of patients with high-normal BP complaining of ED.

Methods

We assessed macrovascular and microvascular (penile vascular damage) changes in four age-matched groups without a history of diabetes and cardiovascular disease; Normal BP (n=162), high-normal BP (n=87), stage I hypertension (n=49) and stage II and III hypertension (n=44). All hypertensive patients were not receiving antihypertensive therapy. Indices of vascular function and structure including carotid-femoral pulse wave velocity (PWV), augmentation index (AIx), carotid intima media thickness (cIMT) and microvascular damage (penile vasculature) were evaluated in all patients. Microvascular damage was examined by measuring penile peak systolic velocity (PSV) with a dynamic penile color Doppler ultrasonography after intracavernous injection of prostaglandin E1. Lower PSV values indicate severe penile vascular disease.

Results

Body-mass index (BMI) was significantly higher in patients with hypertension and patients with high- normal BP compared to subjects with normal BP. Smoking prevalence and LDL-C level were not different between the four subgroups. Figure shows a progressive increase in PWV and cIMT from normal BP group, to patients with high- normal BP and to untreated patients with hypertension. Compared to patients with normal BP, patients with high- normal BP had significantly higher PWV (p<0.01), cIMT (p<0.05), AIx (p<0.05) and lower penile PSV (p<0.01). Interestingly, figure shows that the individuals with high- normal BP level and patients with stage I hypertension had similar AIx and penile PSV denoting no difference in central haemodynamics and penile vasculature between the two groups.

High-normal BP and vascular parameters

Conclusions

Middle-aged men with high-normal BP have significant microvascular and macrovascular damage compared to subjects with normal BP. The ultrasonographically documented functional changes in the vascular wall of the smaller in size penile vasculature are similar to that of men with stage I arterial hypertension. These findings bring new insights into the clinical significance of high- normal BP, which might be a premising therapeutic target for men with ED who are considered to be at a higher cardiovascular risk.

P4534The Mediterranean diet benefit in chronic heart failure by decoding central and peripheral vessel rheology, atheroma formation and serum prolactin levels

Background

Central hemodynamics and especially wave reflection amplification exhibit a vital parameter of chronic heart failure (CHF) physiology. Erectile dysfunction (ED) displays a poor peripheral vessel rheology and serum prolactin role is still debated in CHF mechanisms. The Mediterranean diet (Med-diet) is famous for its vasoprotective and wellbeing properties.

Purpose

To investigate the effect of the Med-diet in central hemodynamics, erectile status, atheroma formation and serum prolactin levels in male patients with chronic heart failure.

Methods

123 CHF male patients under optimal medical therapy enrolled the study (mean age: 65±8 yo, NYHA class II, ejection fraction <40%). All underwent evaluation of the carotid – femoral pulse wave velocity (PWV), estimation of central pressures and augmentation index (AIx) as parameter of wave reflection amplification (sphygmocor device). Ejection fraction (EF) of the left ventricle was estimated by using 2D echocardiography (Simpson method). ED severity and adherence to the Med-diet were assessed by the SHIM-5 (range: 0–25) and the Med-diet (range: 0–55) scores. Higher values point to better erectile function and a great Med-diet compliance respectively. Detection of atheroma was based on the intima- media thickness (IMT) of the common carotid artery. Prolactin levels were assessed in morning blood samples taken before 09:00 am.

Results

The SHIM −5 score (mean: 12±4) was associated to the AIx (p=0,03, r=0,75) and both positively and strongly related to the Med-diet score (p=0,01, r=0,8 and p=0,01, r=0,75 respectively). Med-diet compliance was negatively associated to IMT (p=0,02, r=−0,8) and serum prolactin levels (p=0,03, r=−0,6).Moreover, we notice a positive association between prolactin and the IMT (p=0,04, r=0,7). By multiple linear regression analysis the relation of SHIM-5 and Med-diet score remained significant (p=0,04) after adjustment for BMI, central pulse and mean arterial pressures. We further subdivide our population according to the mean Med-diet value (28) into high and low Med-diet adherence groups. Only in the group with the greater Med-diet adherence (n=73, 60%) AIx was strongly associated to the SHIM-5 score (p=0,02) even after adjustment for PWV, age and BMI. Prolactin levels there were still related to IMT (p=0,04) after adjustment for PWV, AIx, BMI and central pulse pressure. All statistics remained significant when adjusting for ejection fraction of the left ventricle.

Conclusion

High adherence to the Med-diet benefits CHF hemodynamics by enforcing wave reflection amplification, thus generating a stronger pulse signal to peripheral vasculature. Moreover suppresses serum prolactin levels that relates to atheroma formation. Both actions enhance erectile performance independently of the EF of the left ventricle. It is important to advise CHF patients to adopt this dietary pattern in order to improve hemodynamic status and the sense of wellbeing.

P4394Two-year therapeutic effectiveness of pharmacotherapy versus electronic cigarettes for smoking cessation: A single-center experience

Purpose

Aim of this study is to compare the long-term (2-year) effectiveness of e-cigarettes (EC) vs pharmacotherapy for smoking cessation.

Methods

We analyzed data from 173 smokers visiting our unit from January 2012 to December 2016 followed for two years. Of them, 128 were treated with varenicline for 3 months and 45 used EC for 3 months to quit smoking.

Results

There were not significant differences in severity of nicotine dependence and cigarette consumption (pack-years) between the two groups. Compared to smokers under varenicline therapy, EC users were younger (38±7 vs 49±12 years, P<0.01). The two groups had no gender difference and similar prevalence of traditional risk factors and coronary artery disease. Figure shows the smoking abstinence rates at the end of treatment period (3 months) and the continuous abstinence rates at 2 years. At the end of treatment period, 79 (62%) of subjects under therapy with varenicline were abstinent from smoking while 31 (69%) of individuals using EC did not smoke combustile cigarettes 3 months after the initiation of vaping. The continuous abstinence rates at 2 years was significantly higher among individuals treated with varenicline compared to EC (41% vs 24%, P<0.05). Interestingly, at 2 years, 12 EC users (27%) continued vaping alone and 21 (47%) were dual (EC and tobacco cigarette) users.

EC vs varenicline and smoking abstinence

Conclusions

Our preliminary data indicate that smokers who received varenicline had significantly higher continuous abstinence rates compared to individuals who used EC at a 2-year follow-up. Furthermore, almost half of the later group maintained dual use.

P6262Coronary microphysiology in relation to low endogenous testosterone and dietary habits in andropause men with erectile dysfunction

Background

Coronary flow reserve (CFR) in the presence of non-obstructive coronary artery disease displays the ability of microcirculation to augment flow to the myocardium. Endogenous total testosterone (TT) exhibits vasodilator effects and the Mediterranean diet (Med-diet) promotes cardiovascular health. Erectile dysfunction (ED) in a milieu of subclinical microvascular damage often coexists with the decline of endogenous testosterone of the aging male population.

Purpose

To investigate the effects of male hypogonadism in CFR and the relation between the Med-diet and the TT of the andropause middle aged men with ED.

Methods

190 non-diabetic male patients with ED (mean age: 56yo) enrolled the study. Significant epicardial coronary artery disease was excluded after a negative for ischemia dobutamine stress echo test. We measured the CFR of the left anterior descending artery by performing an adenosine protocol (maximum dose 140μg/kg/min over 6 minutes). Measurements by the pulse wave Doppler were achieved at the middle/distal LAD segment under the guidance of color Doppler flow mapping. CFR was estimated as ratio between peak diastolic flow velocity following drug infusion and rest. CFR ratio ≥2 is considered as non-ischemic response and higher values indicate microvascular coronary integrity. TT was measured in all patients on blood samples taken before 09:00 am and hypogonadism was considered when TT <3,5 ng/ml. ED severity and adherence to the Med-diet were assessed by the SHIM-5 (range: 0–25) and the Med-diet (range: 0–55) scores. Higher values point to better erectile function and a great Med-diet compliance respectively. Finally, carotid – femoral pulse wave velocity (PWV) was assessed as index of central vascular stiffness (sphygmocor device).

Results

In bivariate analysis CFR ratio (mean value: 2,35) was positively related to TT (p<0,001, r=0,9), the SHIM-5 and the Med-diet score (p<0,05 for both r=0,45 and r=0,5 respectively).On the contrary, it was negatively related to the PWV (p<0,05, r=−0,35). Med-diet was related to the SHIM-5 score (p=0,01, r=0,363) and to TT (p=0,02, r=0,46). In multiple linear regression analysis relation of CFR to TT remain significant (p<0,01) after adjustment for age, body mass index (BMI), LDL, PWV, smoking habits and systolic blood pressure. We further stratified our population in to hypogonadics (HYPO, n=38, 20%) and patients with normal TT levels. Poor adherence to the Med-diet was the only factor related to hypogonadism (independent sample t-test p=0,005) as compared with age, BMI and smoking.

Conclusion

In middle aged men with ED endogenous testosterone enhances coronary microcirculation. Moreover the Med-diet regime may blunt the fall of androgens during andropause independently of other life-style parameters. We emphasize on this culinary preference to assist coronary microvascular physiology and maintain hormonal balance.

P3833Low heart rate variability is associated with future arrhythmic events in hypertension

Background/Introduction

Cardiac autonomic dysfunction and target organ damage are associated with increased cardiovascular mortality and arrhythmias.

Purpose

The aim of the study was to investigate the effect of heart rate variability (HRV) and markers of target organ damage in the prognosis of future arrhythmic events.

Methods

We studied 292 untreated at baseline hypertensives (mean age 53±13, 153 males). Cardiac autonomic function was evaluated by analysis of short-term HRV measures over 24-h using 24-h ambulatory blood pressure monitoring and the standard deviation of the measurements. Echocardiography was also performed and left ventricular mass index (LVMI) was estimated with the Demereux formula. Aortic stiffness was assessed with carotid-femoral pulse wave velocity (cfPWV) and wave reflections with aortic augmentation index corrected for heart rate (Alx@75). Patients were followed up for a median period of 13 years. The primary endpoint was a composite of atrial/ventricular tachycardias, symptomatic multiple premature ventricular contractions, second and third-degree heart blocks and pacemaker/defibrillator placement.

Results

In comparison without events, patients with the primary endpoint (n=37, 13%) had lower 24-h daytime HRV (9.6 beats per minute vs. 11.1 beats per minute, p=0.005), higher systolic blood pressure (168 mmHg vs. 163 mmHg, p=0.003), higher cfPWV (8.4 m/s vs. 7.7 m/s, p=0.005), higher LVMI (133 g/m2 vs. 122 g/m2, p=0.002) and higher AIx@75 (29.0% vs. 26.3%, p=0.043). In further analysis, receiver operating characteristic (ROC) curves were generated to evaluate the ability of HRV, cfPWV, LVMI and AIx@75 to discriminate subjects with arrhythmic events. The area under the curve (AUC) and 95% CIs of the ROC curves were AUC=0.35 (95% CI: 0.26–0.44, p=0.003) for HRV, AUC=0.64 (95% CI: 0.54–0.73, P<0.006) for cfPWV, AUC=0.67 (95% CI: 0.58–0.75, P=0.001) for LVMI and AUC=0.55 (95% CI: 0.47–0.64, P=0.298) for AIx@75 (Figure). In Cox regression analysis, only HRV was associated with increased risk of arrhythmic events (Hazard ratio per 1 unit =0.87, 95% Confidence intervals 0.76 to 0.995, p=0.043) when adjusted for age, gender, cfPWV, LVMI and AIx@75.

ROC curves of HRV & target organ damage

Conclusions

Low heart rate variability is associated with increased risk of future arrhythmic events suggesting an early sympathovagal imbalance that could lead to future events in hypertension.

P6259Unfavourable vascular risk profile of smokers with testosterone deficiency

Purpose

Testosterone deficiency and cigarette smoking are both associated with increased cardiovascular (CV) mortality risk. We examined whether vascular function and structure parameters are significantly impaired in smokers with low testosterone levels.

Methods

Carotid intima media thickness (cIMT) and aortic pulse wave velocity (aPWV) were measured in a total of 690 patients (mean 58±7 yrs) without manifest CV/atherosclerotic disease. All patients underwent exercise stress test (and coronary angiography) to reveal coronary artery disease (CAD). Plasma total testosterone (TT) levels were measured in all patients.

Results

Participants were divided into four subgroups according to smoking (yes/no) and measured low or normal TT levels (low TT<3.5 ng/ml). The subgroups had similar prevalence of hypertension and smoking and comparable LDL-C levels. The mean age of patients with low TT was greater than that of subjects with normal TT (P<0.05). Aortic PWV was significantly higher in smokers with low TT compared to smokers with normal TT (P=0.01) and non-smokers with either low TT (P=0.005) or normal TT (P<0.001) (left plot). Similarly, cIMT was significantly higher in smokers with low TT compared to smokers with normal TT (P=0.01) and non-smokers with either low TT (P=0.005) or normal TT (P<0.001) (right plot). All associations remained statistically significant after adjustment for age. Among smokers with low TT both aPWV and cIMT significantly increased with increasing cigarette smoking intensity (all P<0.05), whereas the associations between smoking intensity and either aPWV or cIMT were not significant among smokers with normal TT concentration (all P=NS). Interestingly, the prevalence of angiographically documented CAD was significantly higher among smokers with low TT (18%) compared to the CAD prevalence of the three other subgroups (overall P<0.001).

TT level, smoking and vascular profile

Conclusions

Carotid IMT and aortic PWV are significantly increased and the prevalence of angiographically documented CAD is greater in smokers with testosterone deficiency. Further studies should be conducted to evaluate how much of the unfavorable effect of both cigarette smoking and testosterone deficiency on coronary atherosclerotic burden is mediated by their associations with function and structure changes in the vascular wall.

P2644Coronary atherosclerotic burden and risk of major adverse cardiac events in hypertensive patients with erectile dysfunction

Purpose

Aim of the study is to assess the prevalence of angiographically coronary artery disease (CAD) and the incidence of future cardiovascular (CV) events among hypertensive males with erectile dysfunction (ED) on the basis of calculated total CV risk at first presentation.

Methods

A total of 392 hypertensive ED patients without diabetes or known cardiovascular disease underwent a comprehensive evaluation for presence of target organ damage (TOD) and stratified into three total CV risk categories based on blood pressure (BP) category, CV risk factors, TOD and presence of chronic kidney disease. Total testosterone (TT) and peak systolic velocity (PSV) at penile arteries were measured as markers of ED severity and predictors of CV risk. All patients underwent exercise treadmill test and stress echocardiography to reveal myocardial ischemia. Men with positive one or both of the two tests were referred for coronary angiography in order to document CAD. Our primary outcome was a composite measure which included acute myocardial infarction (AMI), stroke, congestive heart failure, revascularization with either percutaneous coronary intervention or coronary artery bypass graft surgery. All patients were followed from cohort entry until major CV event, or end of study period (December 2018), whichever occurred first.

Results

The whole population was divided into high (n=176), intermediate (n=120) and low (n=96) total CV risk groups. The three groups had similar mean age (57 yrs). The prevalence of angiographically documented CAD was significantly higher among patients in the high risk group (n=32, 18%), compared to intermediate (n=15, 12.5%) and low risk (n=4, 4.1%) (overall P<0.05). Furthermore, there was a progressive decrease in penile PSV and TT levels from low to moderate and high total CV risk (35 vs 31 vs 28 cm/s and 5.1 vs 4.3 vs 3.8 ng/ml, respectively, overall P<0.001), indicating significant microvascular damage and androgen deficiency in men with a higher CV risk category. Interestingly, Kaplan-Meier analysis revealed a comparable incidence of major CV events in patients who were at high and intermediate total CV risk at entry (12.5% vs. 11%, respectively, log-rank =0.57) and a greater incidence of major CV events compared to that of low CV risk patients (3.2%), (log-rank P=0.004, for all comparisons) during a 9-year follow-up period (figure).

CV events during a 9-year follow-up

Conclusion

The incidence of future CV events is considerably high among hypertensive ED patients with a intermediate total CV risk at first evaluation. Such patients may require a comprehensive evaluation to reveal occult CAD and they need an aggressive management of BP and concomitant risk factors to reduce their CV risk and improve their sexual life.

P6219Can too much exercise “burn” your endothelium?

Background/Introduction

Regular aerobic exercise has beneficial effects on the cardiovascular system. Marathon running is an aerobic and extremely vigorous exercise. Endothelial function and carotid subclinical atherosclerosis are independent predictors of cardiovascular risk.

Purpose

We investigated the chronic alterations of these indices in marathon runners.

Methods

We studied 30 marathon runners and 20 age- and sex-matched recreationally active control subjects. Endothelial function was evaluated with flow-mediated dilatation of the brachial artery (FMD) and early atherosclerosis with carotid intima-media thickness (cIMT). All subjects completed analytical questionnaires about their medical history and training.

Results

Marathon runners had significantly higher systolic and pulse pressure compared to controls. They also had reduced body-mass index, waist to hip ratio and heart rate compared to controls (p<0.05, for all). Common cIMT was significantly lower in athletes than controls (0.56±0.11 vs. 0.63±0.07, p=0.029), while there was no difference in carotid bulb IMT between groups. FMD was higher in marathon runners compared to controls and nitrate-mediated dilatation (NMD) was similar in the two groups (9.0±3.7 vs. 6.4±1.7 and 12.6±5.7 vs. 12.3±3.4; p=0.002 and p=0.821, respectively). We also observed a reverse U-shaped curve between endothelial function and amount of exercise. (Figure)

Effect of amount of exercise on FMD

Conclusions

Our study shows, that marathon runners have higher FMD compared to controls, indicating better vascular endothelial function, and also have lower cIMT compared to controls. Increased amount of exercise training seems to abolish the beneficial effect of exercise on endothelial function. These findings provide further insights in the effects of marathon running on endothelial function and carotid atherosclerosis.

P6136Intense daily cigarette smoking accelerates vascular damage of smokers with a moderate cumulative tobacco smoke exposure

Purpose

Coronary artery disease death has been associated with increased cigarette smoking intensity. Aim of the study is to investigate the impact of cigarette smoking intensity on vascular function and structure changes among male smokers with similar age at starting smoking and moderate cumulative tobacco smoke exposure.

Methods

Indices of vascular function and structure including carotid-femoral pulse wave velocity (PWV), brachial flow-mediated dilation (bFMD), carotid intima media thickness (cIMT) and microvascular damage (penile vasculature) were measured in 118 smokers consuming up to 1 pack (20 cigarettes)/day and 58 patients smoking >1 pack (20 cigarettes)/day. The two groups had a similar mean cigarette smoking exposure (32 pack/years). Microvascular damage was examined by measuring penile peak systolic velocity (PSV) with a dynamic penile color Doppler ultrasonography after intracavernous injection of prostanglandin E1. Lower PSV values indicate severe penile vascular disease.

Results

The individuals smoking more than 1 pack/day were 10 years younger than smokers consuming up to 1 pack/day, however systolic, diastolic blood pressure, body-mass index, fasting blood glucose levels, lipid profile, C-reactive protein and total testosterone concentration were similar between the two groups. Figure shows mean bFMD, penile PSV, PWV and cIMT of the two groups. Interestingly, despite the similar cumulative smoking exposure between the two groups, the younger in age individuals with the intense cigarette smoking history had significantly lower mean bFMD and penile PSV (all P<0.05) and similar PWV and cIMT compared to the mean values of older subjects smoking up to 1 pack/day.

Smoking intensity and vascular changes

Conclusions

Intense daily smoking accelerates damage of large arteries and significantly impairs microvascular and systemic endothelial function. Considering the predictive value of vascular biomarkers, the findings of this study imply the possibility that baseline daily smoking intensity could be a better summary measure of smoking-related cardiovascular risk among young heavy smokers, relative to total pack-years of smoking.

P4392A systematic review and meta-analysis of the cardiovascular effects of e-cigarette

Background

Electronic cigarette (EC) is marketed as a safe alternative to tobacco smoking, but EC cardiovascular effects remains largely unknown.

Purpose

To systematically review and meta-analyse published literature to investigate the cardiovascular effects and associated risk from EC use.

Methods

We searched PubMed from January 2000 until November 2017 for published studies assessing the cardiovascular effects of EC. For each eligible study we used the mean difference (MD) with 95% confidence intervals (CIs) for SBP, DBP and HR. The pooled MDs for each outcome of interest were calculated by using a fixed effects model. The presence of heterogeneity among studies was evaluated by the I2 statistic.

Results

We report conflicting evidence on the effects of EC on heart rate and blood pressure, which is mainly based on non-randomized clinical studies of moderate quality. In a meta-analysis of 14 studies (n=441 participants), that despite the negative effects of EC on heart rate (pooled MD=2.27, 95% CI: 1.64 to 2.89, p<0.001), diastolic (DBP, pooled MD=2.01mmHg, 95% CI: 0.62 to 3.39, p=0.004) and systolic blood pressure (SBP, pooled MD=2.02mmHg, 95% CI: 0.07 to 3.97, p=0.042), benefits may be observed in terms of blood pressure regulation when switching from tobacco smoking to EC (SBP pooled MD=−7.00, 95% CI: −9.63 to −4.37, p<0.001; DBP pooled MD=−3.65, 95% CI: −5.71 to −1.59, p=0.001). Evidence suggests that EC negatively affects endothelial function, arterial stiffness and the long-term risk for coronary events, but these findings are derived from single study reports and have not been confirmed in additional studies.

Conclusions

We report adverse effects of EC use on heart rate and blood pressure. Unless supported by stronger evidence, EC should not be labelled as cardiovascular safe products. Future studies should delineate whether EC use is less hazardous to cardiovascular health than conventional cigarette smoking.

P2642Optimal blood pressure control in relation to target organ physiology in hypertensive men with erectile dysfunction

Background

Target organ damage (TOD) in essential hypertension relates to an adverse prognosis. Middle aged men are considered a population group where cardiovascular risk typically augments and erectile dysfunction (ED) that frequently accompanies both entities refers to a subclinical vascular damage process.

Purpose

To identify the optimal blood pressure (BP) levels in middle aged hypertensive males with ED in relation to TOD.

Methods

258 ED males (mean age: 56 yo) with essential hypertension under medical treatment enrolled the study. All underwent 2D echocardiography and carotid ultrasound evaluation to determine left ventricular mass index (LVMI) and intima – media thickness (IMT) respectively. Carotid – femoral pulse wave velocity (PWV) and augmentation index (AIx) were also assessed as indices of central vascular stiffness and wave reflection physiology (complior & sphygmocor devices). Office brachial blood pressure (BP) measurements where performed according to the current guidelines and an average of three consecutive values was computed. Erectile dysfunction was assessed by using the SHIM-5 score (range 0–25, lower values display a pronounced dysfunction).

Results

In bivariate analysis brachial systolic blood pressure (bSAP) was positively and strongly associated with LVMI (r=0,6), PWV (r=0,65), AIx (r=0,67, all p<0,001) and IMT (p<0,05, r=0,55). Erectile performance as assessed by the SHIM-5 score was negatively related to PWV, AIX and IMT (r=−0,58, r=−0,45 and r=−0,65 all p<0,001) pointing out the underlying vascular detriment. Interestingly, there were no such correlations regarding the diastolic blood pressure values. Multiple linear regression analysis was performed and the relation of bSAP with LVMI, PWV, AIx and IMT remained significant after adjustment for age, BMI, smoking habits and presence of diabetes mellitus (all p<0,05). We further subdivided our population into three groups according to the values of office bSAP for normal blood pressure (≤129mmHg, n=143,55%), high normal (130–139mmHg, n=59, 23%) and high (≥140mmHg, n=56,22%). In patients with high-normal bSAP, the parameters of PWV and LVMI were significantly higher than in patients with normal BP (independent sample t-test, p: 0,032 and 0,016 respectively). Patients of the high bSAP group as expected, had more extensive cardiac and vascular damage (LVMI, PWV and AIx).

Conclusion

In essential hypertensive middle aged men with erectile dysfunction, guiding therapy toward normal systolic blood pressure values as compared to the high normal benefits target organ physiology. It is clinically important to identify this vascular patients group in order to adjust regimens and further therapeutic strategies.

Effect of Ticagrelor Versus Clopidogrel on Aortic Stiffness in Patients With Coronary Artery Disease

Background

We compared the acute and midterm effect of ticagrelor versus clopidogrel on aortic stiffness.

Methods and Results

We studied 117 patients in a randomized, assessor‐blinded, parallel‐group trial. The acute effect of ticagrelor was studied in 58 patients randomized (1:1) to receive a loading dose of clopidogrel (600 mg) or ticagrelor (180 mg). Carotid‐femoral pulse wave velocity (cfPWV) was measured before, 3, and 24 hours after the loading dose. The midterm effect (30‐day treatment period) was studied in 59 subjects who underwent percutaneous coronary intervention and were randomized to either clopidogrel (75 mg, OD) or ticagrelor (90 mg BID). cfPWV was measured before and at 30 days of treatment. Circulating markers of inflammation and endothelial function were measured at all study points. Repeated‐measures analysis showed a significant main effect for treatment (P=0.03), with the ticagrelor showing a reduction in cfPWV after treatment. cfPWV at 24 hours was significantly lower in the ticagrelor group compared with the clopidogrel group (P=0.017) (maximal response reduction by 0.42±0.26 m/s). At 30 days, cfPWV decreased in the ticagrelor group, whereas there was no change with clopidogrel (−0.43±0.57 versus 0.12±0.14 m/s, P=0.004). There were no significant changes in both the acute and midterm study period in the pro‐inflammatory and endothelial function parameters.

Conclusions

URL: https://www.clinicaltrials.gov. Unique identifier: NCT02071212. Ticagrelor decreases cfPWV for 24 hours after the loading dose and at 1 month post–percutaneous coronary intervention compared with clopidogrel. Considering that aortic stiffness is an independent predictor of cardiovascular events, this finding may have clinical implications regarding the beneficial effect of ticagrelor.

Clinical Trial Registration

URL: http://www.clinicaltrials.gov. Unique identifier: NCT02071212.

Biomarkers of Atrial Fibrillation in Metabolic Syndrome

Whether the increased atrial fibrillation (AF) risk in metabolic syndrome (MetS) patients is due to the syndrome as a whole or simply the sum of the risks of its individual component parts is still obscure. These two clinical entities share many pathophysiological links and thus distinction between a casual observation and a significant association is difficult. Biomarkers associated with pathogenesis of AF in the context of MetS have the ability to refine future risk prediction. In the present review we identify circulating substances that could be regarded as potential biomarkers for prediction of incident AF, or of cardiovascular events in the setting of AF in patients with MetS. Cardiac myocyte injury and stress markers (troponin and natriuretic peptides), markers of renal function (glomeral filtration rate, cystatin-C), and inflammation markers/mediators (interleukin- 6, CRP) are promising biomarkers of patients with AF and MetS.

Diagnostic modalities in peripheral artery disease

Peripheral artery disease (PAD) affects approximately one in five persons older than 70 years of age and it is often present in patients with concomitant vascular disease in different body territories (e.g. coronary artery disease). Diagnosis at an early stage is important in order to achieve improvement in patient's symptoms and prognosis. Remarkable improvements in the field of noninvasive and invasive imaging techniques have led to an advanced level the management of patients with PAD. Throughout this review article, the clinically available diagnostic modalities in PAD are presented. Strong and weaker points are stressed out in a manner that elucidates that no perfect diagnostic method exists. Based on the patient's individual profile, as well as on certain aspects of the disease (e.g. morphology of carotid plaque lesions) the attending physician will ultimately decide which diagnostic path will lead to a prompt and correct diagnosis of PAD with the minimum amount of exams and risk for the patient.