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Leung M, van Rosendael PJ, van der Bijl P, Regeer MV, van Wijngaarden SE, Leung DY, Delgado V, Marsan NA, Ng ACT, Bax JJ. The value of serial echocardiography in risk assessment of patients with paroxysmal atrial fibrillation. Int J Cardiovasc Imaging 2024; 40:499-508. [PMID: 38148375 DOI: 10.1007/s10554-023-03014-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 11/17/2023] [Indexed: 12/28/2023]
Abstract
Progression from paroxysmal to persistent atrial fibrillation (AF) is associated with increased morbidity and mortality. We examined the association of left atrial (LA) remodeling by serial echocardiography, and AF progression over an extended follow-up period. Two-hundred ninety patients (mean age 61 ± 11 years, 73% male) who underwent transthoracic echocardiography performed at first presentation for non-valvular paroxysmal AF (PAF) and repeat echocardiogram 1-year later, were followed for progression to persistent AF. LA and left ventricular (LV) dimensions, volumes, LA reservoir, conduit and booster pump strains, LV global longitudinal systolic strain (GLS) assessed by 2D speckle tracking, and PA-TDI (time delay between electrical and mechanical LA activation- reflecting the extent of LA fibrosis) were compared on serial echocardiography. Sixty-nine (24%) patients developed persistent AF over a mean follow-up period of 6.3 years. At baseline, patients with subsequent persistent AF had larger LA dimensions (46 mm vs. 42 mm, p < 0.001), indexed LA volumes (41 ml/m2 vs. 34 ml/m2, p < 0.001), lower LA reservoir and conduit strain (17.6% vs. 27.6%, p < 0.001; 10.5% vs. 16.3%, p < 0.001; respectively) and longer PA-TDI (155 ms vs. 132 ms, p < 0.001) compared to the PAF group. Patients with subsequent persistent AF showed over time significant enlargement in LA volumes (from 37.7 ml/m2 to 42.4 ml/m2, p < 0.001), lengthening of PA-TDI (from 142.2 ms to 162.2 ms, p = 0.002), and decline in LA reservoir function (from 21.9% to 18.1%, p = 0.024) after adjusting for age, gender, diabetes and LV GLS. There were no changes in LA diameter, LA conduit or booster pump function. Conversely, the PAF group showed no decline in LA function. Patients who developed persistent AF had larger LA size and impaired LA function and atrial conduction times at baseline, compared to patients who remained PAF. Over the 1-year time course of serial echocardiographic evaluation, there was progression of LA remodeling in patients who subsequently developed persistent AF, but not in patients who remained in PAF.
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Affiliation(s)
- Melissa Leung
- Department of Cardiology, Leiden University Medical Centre, Leiden, The Netherlands.
- Department of Cardiology, Liverpool Hospital, Ingham Institute for Applied Medical Research, The University of New South Wales, Sydney, Australia.
| | | | - Pieter van der Bijl
- Department of Cardiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Madelien V Regeer
- Department of Cardiology, Leiden University Medical Centre, Leiden, The Netherlands
| | | | - Dominic Y Leung
- Department of Cardiology, Liverpool Hospital, Ingham Institute for Applied Medical Research, The University of New South Wales, Sydney, Australia
| | - Victoria Delgado
- Department of Cardiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Nina Ajmone Marsan
- Department of Cardiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Arnold C T Ng
- The University of New South Wales, Sydney, Australia
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Centre, Leiden, The Netherlands
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2
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Xu J, Lo S, Mussap CJ, French JK, Rajaratnam R, Kadappu K, Premawardhana U, Nguyen P, Juergens CP, Leung DY. Early Effects of Ticagrelor Versus Clopidogrel on Peripheral Endothelial Function After Non-ST-Elevation Acute Coronary Syndrome and Assessment of Its Relationship With Coronary Microvascular Function. Am J Cardiol 2023; 201:16-24. [PMID: 37348152 DOI: 10.1016/j.amjcard.2023.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 05/26/2023] [Accepted: 06/01/2023] [Indexed: 06/24/2023]
Abstract
Peripheral endothelial dysfunction is an independent predictor of adverse long-term prognosis after acute coronary syndrome. Data are lacking on the effects of oral P2Y12-inhibitors on peripheral endothelial function in non-ST-elevation acute coronary syndrome (NSTEACS). Furthermore, the relation between peripheral endothelial function and invasive indexes of coronary microvascular function in NSTEACS is unclear. Between March 2018 and July 2020, hospitalized patients with NSTEACS were randomized (1:1) to ticagrelor or clopidogrel. Peripheral endothelial function was assessed with brachial artery flow-mediated vasodilation (FMD). Invasive indexes of coronary microvascular function were obtained using an intracoronary pressure-temperature sensor-tipped wire. In 70 patients included, mean age was 58.6 years, 78.6% (n = 55) were male and 20% (n = 14) had diabetes mellitus. Compared with clopidogrel, ticagrelor significantly improved FMD (14.2 ± 5.4% vs 8.9 ± 5.3%, p <0.001) after a median treatment time of 41.2 hours. The FMD was significantly correlated with the index of microcirculatory resistance (IMR) measured in the infarct-related artery (r = -0.38, p = 0.001), with a stronger correlation found in those who did not have percutaneous coronary intervention (r = -0.52, p = 0.03). Using receiver operating characteristic curve analysis, an FMD of 8.2% identified an IMR of >34 as the threshold, with 77.6% sensitivity and 52.4% specificity. In patients who did not have a percutaneous coronary intervention, an FMD of 11.49% identified an IMR of >34 with 84.6% sensitivity and 80% specificity. In conclusion, ticagrelor significantly improved peripheral endothelial function compared with clopidogrel in patients with NSTEACS. There was a significant correlation between brachial artery FMD and IMR of the infarct-related artery.
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Affiliation(s)
- James Xu
- Department of Cardiology, Liverpool Hospital, Sydney, Australia; South Western Sydney Clinical School, University of New South Wales, Sydney, Australia.
| | - Sidney Lo
- Department of Cardiology, Liverpool Hospital, Sydney, Australia; South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
| | - Christian J Mussap
- Department of Cardiology, Liverpool Hospital, Sydney, Australia; South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
| | - John K French
- Department of Cardiology, Liverpool Hospital, Sydney, Australia; South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
| | - Rohan Rajaratnam
- Department of Cardiology, Liverpool Hospital, Sydney, Australia; South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
| | - Krishna Kadappu
- Department of Cardiology, Campbelltown Hospital, Sydney, Australia; Macarthur Clinical School, Western Sydney University, Sydney, Australia
| | - Upul Premawardhana
- Department of Cardiology, Campbelltown Hospital, Sydney, Australia; Macarthur Clinical School, Western Sydney University, Sydney, Australia
| | - Phong Nguyen
- Department of Cardiology, Campbelltown Hospital, Sydney, Australia; Macarthur Clinical School, Western Sydney University, Sydney, Australia
| | - Craig P Juergens
- Department of Cardiology, Liverpool Hospital, Sydney, Australia; South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
| | - Dominic Y Leung
- Department of Cardiology, Liverpool Hospital, Sydney, Australia; South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
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3
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Faour A, Cherrett C, Gibbs O, Lintern K, Mussap CJ, Rajaratnam R, Leung DY, Taylor DA, Faddy SC, Lo S, Juergens CP, French JK. Utility of prehospital electrocardiogram interpretation in ST-segment elevation myocardial infarction utilizing computer interpretation and transmission for interventional cardiologist consultation. Catheter Cardiovasc Interv 2022; 100:295-303. [PMID: 35766040 PMCID: PMC9546148 DOI: 10.1002/ccd.30300] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 02/25/2022] [Accepted: 06/04/2022] [Indexed: 12/26/2022]
Abstract
Objectives We examined the appropriateness of prehospital cardiac catheter laboratory activation (CCL‐A) in ST‐segment elevation myocardial infarction (STEMI) utilizing the University of Glasgow algorithm (UGA) and remote interventional cardiologist consultation. Background The incremental benefit of prehospital electrocardiogram (PH‐ECG) transmission on the diagnostic accuracy and appropriateness of CCL‐A has been examined in a small number of studies with conflicting results. Methods We identified consecutive PH‐ECG transmissions between June 2, 2010 and October 6, 2016. Blinded adjudication of ECGs, appropriateness of CCL‐A, and index diagnoses were performed using the fourth universal definition of MI. The primary outcome was the appropriate CCL‐A rate. Secondary outcomes included rates of false‐positive CCL‐A, inappropriate CCL‐A, and inappropriate CCL nonactivation. Results Among 1088 PH‐ECG transmissions, there were 565 (52%) CCL‐As and 523 (48%) CCL nonactivations. The appropriate CCL‐A rate was 97% (550 of 565 CCL‐As), of which 4.9% (n = 27) were false‐positive. The inappropriate CCL‐A rate was 2.7% (15 of 565 CCL‐As) and the inappropriate CCL nonactivation rate was 3.6% (19 of 523 CCL nonactivations). Reasons for appropriate CCL nonactivation (n = 504) included nondiagnostic ST‐segment elevation (n = 128, 25%), bundle branch block (n = 132, 26%), repolarization abnormality (n = 61, 12%), artefact (n = 72, 14%), no ischemic symptoms (n = 32, 6.3%), severe comorbidities (n = 26, 5.2%), transient ST‐segment elevation (n = 20, 4.0%), and others. Conclusions PH‐ECG interpretation utilizing UGA with interventional cardiologist consultation accurately identified STEMI with low rates of inappropriate and false‐positive CCL‐As, whereas using UGA alone would have almost doubled CCL‐As. The benefits of cardiologist consultation were identifying “masquerading” STEMI and avoiding unnecessary CCL‐As.
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Affiliation(s)
- Amir Faour
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia.,South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
| | - Callum Cherrett
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Oliver Gibbs
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Karen Lintern
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Christian J Mussap
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia.,South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia.,School of Medicine, Western Sydney University, Sydney, New South Wales, Australia
| | - Rohan Rajaratnam
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia.,South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia.,School of Medicine, Western Sydney University, Sydney, New South Wales, Australia
| | - Dominic Y Leung
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia.,South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia.,School of Medicine, Western Sydney University, Sydney, New South Wales, Australia
| | - David A Taylor
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Steve C Faddy
- New South Wales Ambulance, Sydney, New South Wales, Australia
| | - Sidney Lo
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia.,South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia.,School of Medicine, Western Sydney University, Sydney, New South Wales, Australia
| | - Craig P Juergens
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia.,South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
| | - John K French
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia.,South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia.,School of Medicine, Western Sydney University, Sydney, New South Wales, Australia.,Ingham Institute, Sydney, New South Wales, Australia
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4
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Faour A, Pahn R, Cherrett C, Gibbs O, Lintern K, Mussap CJ, Rajaratnam R, Leung DY, Taylor DA, Faddy SC, Lo S, Juergens CP, French JK. Late Outcomes of Patients With Prehospital ST-Segment Elevation and Appropriate Cardiac Catheterization Laboratory Nonactivation. J Am Heart Assoc 2022; 11:e025602. [PMID: 35766276 PMCID: PMC9333384 DOI: 10.1161/jaha.121.025602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Patients with suspected ST-segment-elevation myocardial infarction (STEMI) and cardiac catheterization laboratory nonactivation (CCL-NA) or cancellation have reportedly similar crude and higher adjusted risks of death compared with those with CCL activation, though reasons for these poor outcomes are not clear. We determined late clinical outcomes among patients with prehospital ECG STEMI criteria who had CCL-NA compared with those who had CCL activation. Methods and Results We identified consecutive prehospital ECG transmissions between June 2, 2010 to October 6, 2016. Diagnoses according to the Fourth Universal Definition of myocardial infarction (MI), particularly rates of myocardial injury, were adjudicated. The primary outcome was all-cause death. Secondary outcomes included cardiovascular death/MI/stroke and noncardiovascular death. To explore competing risks, cause-specific hazard ratios (HRs) were obtained. Among 1033 included ECG transmissions, there were 569 (55%) CCL activations and 464 (45%) CCL-NAs (1.8% were inappropriate CCL-NAs). In the CCL activation group, adjudicated index diagnoses included MI (n=534, 94%, of which 99.6% were STEMI and 0.4% non-STEMI), acute myocardial injury (n=15, 2.6%), and chronic myocardial injury (n=6, 1.1%). In the CCL-NA group, diagnoses included MI (n=173, 37%, of which 61% were non-STEMI and 39% STEMI), chronic myocardial injury (n=107, 23%), and acute myocardial injury (n=47, 10%). At 2 years, the risk of all-cause death was higher in patients who had CCL-NA compared with CCL activation (23% versus 7.9%, adjusted risk ratio, 1.58, 95% CI, 1.24-2.00), primarily because of an excess in noncardiovascular deaths (adjusted HR, 3.56, 95% CI, 2.07-6.13). There was no significant difference in the adjusted risk for cardiovascular death/MI/stroke between the 2 groups (HR, 1.23, 95% CI, 0.87-1.73). Conclusions CCL-NA was not primarily attributable to missed STEMI, but attributable to "masquerading" with high rates of non-STEMI and myocardial injury. These patients had worse late outcomes than patients who had CCL activation, mainly because of higher rates of noncardiovascular deaths.
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Affiliation(s)
- Amir Faour
- Department of Cardiology, Liverpool Hospital Sydney New South Wales.,The University of New South Wales Sydney New South Wales
| | - Reece Pahn
- The University of New South Wales Sydney New South Wales
| | - Callum Cherrett
- Department of Cardiology, Liverpool Hospital Sydney New South Wales
| | - Oliver Gibbs
- Department of Cardiology, Liverpool Hospital Sydney New South Wales
| | - Karen Lintern
- Department of Cardiology, Liverpool Hospital Sydney New South Wales
| | - Christian J Mussap
- Department of Cardiology, Liverpool Hospital Sydney New South Wales.,The University of New South Wales Sydney New South Wales.,Western Sydney University Sydney New South Wales
| | - Rohan Rajaratnam
- Department of Cardiology, Liverpool Hospital Sydney New South Wales.,The University of New South Wales Sydney New South Wales.,Western Sydney University Sydney New South Wales
| | - Dominic Y Leung
- Department of Cardiology, Liverpool Hospital Sydney New South Wales.,The University of New South Wales Sydney New South Wales.,Western Sydney University Sydney New South Wales
| | - David A Taylor
- Department of Cardiology, Liverpool Hospital Sydney New South Wales
| | | | - Sidney Lo
- Department of Cardiology, Liverpool Hospital Sydney New South Wales.,The University of New South Wales Sydney New South Wales.,Western Sydney University Sydney New South Wales
| | - Craig P Juergens
- Department of Cardiology, Liverpool Hospital Sydney New South Wales.,The University of New South Wales Sydney New South Wales
| | - John K French
- Department of Cardiology, Liverpool Hospital Sydney New South Wales.,The University of New South Wales Sydney New South Wales.,Western Sydney University Sydney New South Wales.,Ingham Institute Sydney New South Wales
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5
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Xu J, Lo S, Mussap CJ, French JK, Rajaratnam R, Kadappu K, Premawardhana U, Nguyen P, Juergens CP, Leung DY. Impact of Ticagrelor Versus Clopidogrel on Coronary Microvascular Function After Non-ST-Segment-Elevation Acute Coronary Syndrome. Circ Cardiovasc Interv 2022; 15:e011419. [PMID: 35369712 DOI: 10.1161/circinterventions.121.011419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Coronary microvascular dysfunction after acute coronary syndrome is an important predictor of long-term prognosis. Data is lacking on the effects of oral P2Y12-inhibitors on coronary microvascular function in non-ST-segment-elevation acute coronary syndrome. The aim of this study was to compare the acute effects of ticagrelor versus clopidogrel pretreatment on coronary microvascular function in non-ST-segment-elevation acute coronary syndrome patients. METHODS Hospitalized non-ST-segment-elevation acute coronary syndrome patients were randomized (1:1) to ticagrelor or clopidogrel. The index of microcirculatory resistance, coronary flow reserve, and resistive reserve ratio were obtained using an intracoronary pressure-temperature sensor-tipped wire. RESULTS In total, 128 patients were randomized between March 2018 and July 2020. Mean age 59.2±11.8 years, 84% were male, mean Global Registry of Acute Coronary Events score was 93.7±24.5. Intracoronary physiological measurements were obtained in 118 patients (60 ticagrelor, 58 clopidogrel). In the infarct-related artery, the ticagrelor group had lower baseline index of microcirculatory resistance (22.0 [13.0-34.9] versus 27.7 [19.3-29.8]; P=0.02) and higher baseline resistive reserve ratio (3.0 [2.3-4.4] versus 2.4 [1.7-3.4]; P=0.01) compared with the clopidogrel group. A total of 88 patients underwent percutaneous coronary intervention (PCI; 45 ticagrelor, 43 clopidogrel). The ticagrelor group had lower post-PCI index of microcirculatory resistance (22.0 [15.0-29.0] versus 27.0 [18.5-47.5]; P=0.02) and higher post-PCI resistive reserve ratio (3.0 [1.8-3.8] versus 1.8 [1.5-3.4]; P=0.006) compared with the clopidogrel group. The coronary flow reserve was not significantly different between the 2 groups at baseline or post-PCI. No between-group differences were seen in any of the indices in the non-infarct-related artery. CONCLUSIONS In non-ST-segment-elevation acute coronary syndrome patients, ticagrelor significantly improved coronary microvascular function before and after PCI compared with clopidogrel. REGISTRATION URL: https://www.anzctr.org.au; Unique identifier: ACTRN12618001610224.
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Affiliation(s)
- James Xu
- Department of Cardiology, Liverpool Hospital, Sydney, Australia (J.X., S.L., C.J.M., J.K.P., R.P.).,South Western Sydney Clinical School, University of New South Wales, Sydney, Australia (J.X., S.L., C.J.M., J.K.F., R.R., K.K., U.P., P.N., C.P.J., D.Y.L.)
| | - Sidney Lo
- Department of Cardiology, Liverpool Hospital, Sydney, Australia (J.X., S.L., C.J.M., J.K.P., R.P.).,South Western Sydney Clinical School, University of New South Wales, Sydney, Australia (J.X., S.L., C.J.M., J.K.F., R.R., K.K., U.P., P.N., C.P.J., D.Y.L.)
| | - Christian J Mussap
- Department of Cardiology, Liverpool Hospital, Sydney, Australia (J.X., S.L., C.J.M., J.K.P., R.P.).,South Western Sydney Clinical School, University of New South Wales, Sydney, Australia (J.X., S.L., C.J.M., J.K.F., R.R., K.K., U.P., P.N., C.P.J., D.Y.L.)
| | - John K French
- Department of Cardiology, Liverpool Hospital, Sydney, Australia (J.X., S.L., C.J.M., J.K.P., R.P.).,South Western Sydney Clinical School, University of New South Wales, Sydney, Australia (J.X., S.L., C.J.M., J.K.F., R.R., K.K., U.P., P.N., C.P.J., D.Y.L.)
| | - Rohan Rajaratnam
- Department of Cardiology, Liverpool Hospital, Sydney, Australia (J.X., S.L., C.J.M., J.K.P., R.P.).,South Western Sydney Clinical School, University of New South Wales, Sydney, Australia (J.X., S.L., C.J.M., J.K.F., R.R., K.K., U.P., P.N., C.P.J., D.Y.L.)
| | - Krishna Kadappu
- Department of Cardiology, Campbelltown Hospital, Sydney, Australia (K.K., U.P., P.N., C.P.J., D.Y.L.).,South Western Sydney Clinical School, University of New South Wales, Sydney, Australia (J.X., S.L., C.J.M., J.K.F., R.R., K.K., U.P., P.N., C.P.J., D.Y.L.)
| | - Upul Premawardhana
- Department of Cardiology, Campbelltown Hospital, Sydney, Australia (K.K., U.P., P.N., C.P.J., D.Y.L.).,South Western Sydney Clinical School, University of New South Wales, Sydney, Australia (J.X., S.L., C.J.M., J.K.F., R.R., K.K., U.P., P.N., C.P.J., D.Y.L.)
| | - Phong Nguyen
- Department of Cardiology, Campbelltown Hospital, Sydney, Australia (K.K., U.P., P.N., C.P.J., D.Y.L.).,South Western Sydney Clinical School, University of New South Wales, Sydney, Australia (J.X., S.L., C.J.M., J.K.F., R.R., K.K., U.P., P.N., C.P.J., D.Y.L.)
| | - Craig P Juergens
- Department of Cardiology, Campbelltown Hospital, Sydney, Australia (K.K., U.P., P.N., C.P.J., D.Y.L.).,South Western Sydney Clinical School, University of New South Wales, Sydney, Australia (J.X., S.L., C.J.M., J.K.F., R.R., K.K., U.P., P.N., C.P.J., D.Y.L.)
| | - Dominic Y Leung
- Department of Cardiology, Campbelltown Hospital, Sydney, Australia (K.K., U.P., P.N., C.P.J., D.Y.L.).,South Western Sydney Clinical School, University of New South Wales, Sydney, Australia (J.X., S.L., C.J.M., J.K.F., R.R., K.K., U.P., P.N., C.P.J., D.Y.L.)
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Poon J, Leung JT, Leung DY. An Unexpected Cause of Heart Failure in a Young Woman With Treated Lymphoma. JACC Case Rep 2021; 3:938-940. [PMID: 34317660 PMCID: PMC8311257 DOI: 10.1016/j.jaccas.2021.02.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 02/22/2021] [Accepted: 02/26/2021] [Indexed: 12/02/2022]
Abstract
Arteriovenous fistula is a rare complication of lumbar surgery that may cause high-output cardiac failure. We describe the case of a patient with treated lymphoma and recent spinal surgery who presented with heart failure. Logical deduction from clinical and imaging findings helped us arrive at this unusual diagnosis. (Level of Difficulty: Intermediate.)
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Affiliation(s)
- Jessica Poon
- Department of Medicine, Ruttonjee and Tang Shiu Kin Hospitals, Hong Kong
| | - James T Leung
- Department of Cardiology, Royal North Shore Hospital, Sydney, Australia
| | - Dominic Y Leung
- Department of Cardiology, University of New South Wales, Liverpool Hospital, Liverpool, New South Wales, Australia
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7
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Xu J, Lo S, Juergens CP, Leung DY. Impact of Targeted Therapies for Coronary Microvascular Dysfunction as Assessed by the Index of Microcirculatory Resistance. J Cardiovasc Transl Res 2020; 14:327-337. [PMID: 32710373 DOI: 10.1007/s12265-020-10062-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Accepted: 07/19/2020] [Indexed: 11/25/2022]
Abstract
Coronary microvascular dysfunction (CMD) has emerged as an important therapeutic target in the contemporary management of ischemic heart disease. However, due to a lack of a reliable traditional "gold standard" test for CMD, optimal treatment remains undefined. The index of microcirculatory resistance (IMR) is an intra-coronary wire-based technique that provides a more reliable and quantitative assessment of CMD and has been increasingly used as a preferred endpoint for evaluating CMD treatment strategies in recent studies. IMR can help diagnose CMD in angina patients with non-obstructive epicardial coronary disease, predict peri-procedural myocardial infarction in stable patients undergoing coronary stenting, and predict long-term prognosis after acute myocardial infarction. Studies of IMR in the setting of non-ST-elevation acute coronary syndromes are still lacking. This review critically appraises the current published literature evaluating targeted therapies for CMD using IMR as the assessment tool and provides insights into evidence gaps in this important field. The index of microcirculatory resistance has rapidly evolved from a research tool to being the new "gold standard" test for evaluating coronary microvascular dysfunction.
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Affiliation(s)
- James Xu
- Department of Cardiology, Liverpool Hospital, Sydney, NSW, 2170, Australia.
- South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia.
| | - Sidney Lo
- Department of Cardiology, Liverpool Hospital, Sydney, NSW, 2170, Australia
- South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Craig P Juergens
- Department of Cardiology, Liverpool Hospital, Sydney, NSW, 2170, Australia
- South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Dominic Y Leung
- Department of Cardiology, Liverpool Hospital, Sydney, NSW, 2170, Australia
- South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
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8
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Lo STH, Yong AS, Sinhal A, Shetty S, McCann A, Clark D, Galligan L, El-Jack S, Sader M, Tan R, Hallani H, Barlis P, Sechi R, Dictado E, Walton A, Starmer G, Bhagwandeen R, Leung DY, Juergens CP, Bhindi R, Muller DWM, Rajaratnum R, French JK, Kritharides L. Consensus guidelines for interventional cardiology services delivery during covid-19 pandemic in Australia and new Zealand. Heart Lung Circ 2020; 29:e69-e77. [PMID: 32471696 PMCID: PMC7202321 DOI: 10.1016/j.hlc.2020.04.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The global coronavirus disease (COVID-19) pandemic poses an unprecedented stress on healthcare systems internationally. These Health system-wide demands call for efficient utilisation of resources at this time in a fair, consistent, ethical and efficient manner would improve our ability to treat patients. Excellent co-operation between hospital units (especially intensive care unit [ICU], emergency department [ED] and cardiology) is critical in ensuring optimal patient outcomes. The purpose of this document is to provide practical guidelines for the effective use of interventional cardiology services in Australia and New Zealand. The document will be updated regularly as new evidence and knowledge is gained with time. Goals Considerations.
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Affiliation(s)
- S T H Lo
- Department of Cardiology, Liverpool Hospital, NSW, Australia.
| | - A S Yong
- Department of Cardiology, Concord Repatriation General Hospital, NSW, Australia; University of Sydney, Australia
| | - A Sinhal
- Flinders Medical Centre, SA, Australia
| | - S Shetty
- Department of Cardiology, Fiona Stanley Hospital, WA, Australia
| | - A McCann
- Department of Cardiology, Princess Alexandra Hospital, QLD, Australia; University of Queensland, Australia
| | - D Clark
- Department of Cardiology, Austin Hospital, VIC, Australia
| | - L Galligan
- Department of Cardiology, Royal Hobart Hospital, TAS, Australia
| | - S El-Jack
- Department of Cardiology, North Shore Hospital, New Zealand
| | - M Sader
- University of Sydney, Australia; Department of Cardiology, St George Hospital, NSW, Australia
| | - R Tan
- Department of Cardiology, The Canberra Hospital, ACT, Australia
| | - H Hallani
- Department of Cardiology, The Canberra Hospital, ACT, Australia
| | - P Barlis
- Department of Cardiology, Nepean Hospital, NSW, Australia; Department of Cardiology, The Northern Hospital, VIC, Australia; Department of Cardiology, St Vincents' Hospital, VIC, Australia; University of Melbourne, VIC, Australia
| | - R Sechi
- Department of Nursing, Liverpool Hospital, NSW, Australia
| | - E Dictado
- Department of Nursing, Liverpool Hospital, NSW, Australia
| | - A Walton
- Department of Cardiology, Alfred Hospital, VIC, Australia; Monash University, VIC, Australia
| | - G Starmer
- Department of Cardiology, Cairns Hospital, QLD, Australia
| | - R Bhagwandeen
- Department of Cardiology, John Hunter Hospital, NSW, Australia; Lake Macquarie Private Hospital, NSW, Australia
| | - D Y Leung
- Department of Cardiology, Liverpool Hospital, NSW, Australia; University of New South Wales, NSW, Australia
| | - C P Juergens
- Department of Cardiology, Liverpool Hospital, NSW, Australia; University of New South Wales, NSW, Australia
| | - R Bhindi
- University of Sydney, Australia; Department of Cardiology, Royal North Shore Hospital, NSW, Australia
| | - D W M Muller
- University of New South Wales, NSW, Australia; St Vincent's Hospital, NSW, Australia
| | - R Rajaratnum
- Department of Cardiology, Liverpool Hospital, NSW, Australia; University of New South Wales, NSW, Australia; Western Sydney University, NSW, Australia
| | - J K French
- Department of Cardiology, Liverpool Hospital, NSW, Australia; University of New South Wales, NSW, Australia; Western Sydney University, NSW, Australia
| | - L Kritharides
- Department of Cardiology, Concord Repatriation General Hospital, NSW, Australia; University of Sydney, Australia; ANZAC Medical Research Institute, Australia
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9
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Ng ACT, Prevedello F, Dolci G, Roos CJ, Djaberi R, Bertini M, Ewe SH, Allman C, Leung DY, Marsan NA, Delgado V, Bax JJ. Impact of Diabetes and Increasing Body Mass Index Category on Left Ventricular Systolic and Diastolic Function. J Am Soc Echocardiogr 2019; 31:916-925. [PMID: 29773243 DOI: 10.1016/j.echo.2018.02.012] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Diabetes and obesity are both worldwide growing epidemics, and both are independently associated with increased risk for heart failure and death. The aim of this study was to examine the additive detrimental effect of both diabetes and increasing body mass index (BMI) category on left ventricular (LV) myocardial systolic and diastolic function. METHODS The present retrospective multicenter study included 653 patients (337 with type 2 diabetes and 316 without diabetes) of increasing BMI category. All patients had normal LV ejection fractions. LV myocardial systolic (peak systolic global longitudinal strain and peak systolic global longitudinal strain rate) and diastolic (average mitral annular e' velocity and early diastolic global longitudinal strain rate) function was quantified using echocardiography. RESULTS Increasing BMI category was associated with progressively more impaired LV myocardial function in patients with diabetes (P < .001). Patients with diabetes had significantly more impaired LV myocardial function for all BMI categories compared with those without diabetes (P < .001). On multivariate analysis, both diabetes and obesity were independently associated with an additive detrimental effect on LV myocardial systolic and diastolic function. However, obesity was associated with greater LV myocardial dysfunction than diabetes. CONCLUSION Both diabetes and increasing BMI category had an additive detrimental effect on LV myocardial systolic and diastolic function. Furthermore, increasing BMI category was associated with greater LV myocardial dysfunction than diabetes. As they frequently coexist together, future studies on patients with diabetes should also focus on obesity.
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Affiliation(s)
- Arnold C T Ng
- Department of Cardiology, Princess Alexandra Hospital, The University of Queensland, Woolloongabba, Australia; Translational Research Institute, Brisbane, Australia; Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Francesca Prevedello
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands; University of Padua, Department of Cardiac, Thoracic and Vascular Sciences, Padova, Italy
| | - Giulia Dolci
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands; Section of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Cornelis J Roos
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Roxana Djaberi
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Matteo Bertini
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - See Hooi Ewe
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Dominic Y Leung
- Department of Cardiology, Liverpool Hospital, Sydney, Australia
| | - Nina Ajmone Marsan
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Victoria Delgado
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands.
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10
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Abstract
Clinical trials traditionally aim to show a new treatment is superior to placebo or standard treatment, that is, superiority trials. There is an increasing number of trials demonstrating a new treatment is non-inferior to standard treatment. The hypotheses, design and interpretation of non-inferiority trials are different to superiority trials. Non-inferiority trials are designed with the notion that the new treatment offers advantages over standard treatment in certain important aspects. The non-inferior margin is a predetermined margin of difference between the new and standard treatment that is considered acceptable or tolerable for the new treatment to be considered ‘similar’ or ‘not worse’. Both relative difference and absolute difference methods can be used to define the non-inferior margin. Sequential testing for non-inferiority and superiority is often performed. Non-inferiority trials may be necessary in situations where it is no longer ethical to test any new treatment against placebo. There are inherent assumptions in non-inferiority trials which may not be correct and which are not being tested. Successive non-inferiority trials may introduce less and less effective treatments even though these treatments may have been shown to be non-inferior. Furthermore, poor quality trials favour non-inferior results. Intention-to-treat analysis, the preferred way to analyse randomised trials, may favour non-inferiority. Both intention-to-treat and per-protocol analyses should be recommended in non-inferiority trials. Clinicians should be aware of the pitfalls of non-inferiority trials and not accept non-inferiority on face value. The focus should not be on the p values but on the effect size and confidence limits.
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Affiliation(s)
- James T Leung
- Cardiology, Royal North Shore Hospital, Saint Leonards, New South Wales, Australia
| | - Stephanie L Barnes
- Neurology, Concord Repatriation General Hospital, Concord, New South Wales, Australia
| | - Sidney T Lo
- Cardiology, University of New South Wales, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Dominic Y Leung
- Cardiology, University of New South Wales, Liverpool Hospital, Liverpool, New South Wales, Australia
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11
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Ng ACT, Bertini M, Ewe SH, van der Velde ET, Leung DY, Delgado V, Bax JJ. Defining Subclinical Myocardial Dysfunction and Implications for Patients With Diabetes Mellitus and Preserved Ejection Fraction. Am J Cardiol 2019; 124:892-898. [PMID: 31375242 DOI: 10.1016/j.amjcard.2019.06.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 06/09/2019] [Accepted: 06/12/2019] [Indexed: 01/07/2023]
Abstract
Left ventricular (LV) global longitudinal strain (GLS) can detect subclinical myocardial systolic dysfunction in individuals with diabetes. The present study investigates the clinical usefulness and incremental net benefit of identifying subclinical myocardial systolic dysfunction in individuals with diabetes. A cohort of 397 type 2 diabetic individuals was followed up for the occurrence of all-cause mortality. Clinical and echocardiographic data of diabetic patients were assessed retrospectively. LV GLS was evaluated on transthoracic echocardiography using speckle tracking imaging. Subclinical LV systolic dysfunction was defined as LV GLS > -17.0% from 104 healthy volunteers recruited from the community. A total of 178 (44.8%) diabetic individuals had evidence of subclinical LV systolic dysfunction and 46 (11.6%) died during follow-up. The presence of subclinical LV systolic dysfunction was independently associated with all-cause mortality on follow-up (hazard ratio [HR] 2.83, 95% confidence interval [CI] 1.40 to 5.71, p = 0.004). Diabetic individuals without subclinical LV systolic dysfunction had similar survival as the general population (standardized mortality ratio 0.94, 95% CI 0.52 to 1.58). Decision curve analysis showed identification of subclinical LV systolic dysfunction and quantification of LV GLS provided an incremental net clinical benefit at risk stratifying patients for risk of death at 5 years. In conclusion, subclinical LV systolic dysfunction is independently associated with all-cause mortality in diabetic patients. Decision curve analyses suggest use of LV GLS and identification of subclinical LV systolic dysfunction is clinically useful, and provided incremental net clinical benefit for diabetic individuals.
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Affiliation(s)
- Arnold C T Ng
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands; Department of Cardiology, Princess Alexandra Hospital, Australia; The Faculty of Medicine, South Western Sydney Clinical School, The University of New South Wales, Australia
| | - Matteo Bertini
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - See Hooi Ewe
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Enno T van der Velde
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Dominic Y Leung
- The Faculty of Medicine, South Western Sydney Clinical School, The University of New South Wales, Australia
| | - Victoria Delgado
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands.
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
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12
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Xu J, Lo S, Juergens CP, Leung DY. Assessing Coronary Microvascular Dysfunction in Ischaemic Heart Disease: Little Things Can Make a Big Difference. Heart Lung Circ 2019; 29:118-127. [PMID: 31255478 DOI: 10.1016/j.hlc.2019.05.187] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Revised: 04/10/2019] [Accepted: 05/29/2019] [Indexed: 01/01/2023]
Abstract
The role of coronary microvascular dysfunction (CMD) in the pathogenesis of ischaemic heart disease and in determining long-term prognosis is increasingly recognised. In selected patients, a comprehensive coronary assessment including an assessment of microvascular function may help refine risk stratification and improve patient outcomes. Various non-invasive and invasive techniques have been developed to assess the coronary microcirculation. Many of these tests utilise the indicator-dilution principle to determine coronary or myocardial blood flow. However, these techniques are often limited by their variability and lack of specificity for the coronary microvasculature. Consequently, there is still paucity of data on targeted therapies for CMD and their implications on long-term clinical outcomes, particularly in the setting of non-ST elevation acute coronary syndromes. Recent technical advancements, such as the index of microcirculatory resistance, have largely overcome these limitations and are able to provide novel insights into the assessment and treatment of CMD. This review summarises the currently available techniques for the assessment of CMD and provides an overview of its clinical implications.
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Affiliation(s)
- James Xu
- Department of Cardiology, Liverpool Hospital, Sydney, NSW, Australia; South Western Sydney Clinical School, University of NSW, Sydney, NSW, Australia.
| | - Sidney Lo
- Department of Cardiology, Liverpool Hospital, Sydney, NSW, Australia; South Western Sydney Clinical School, University of NSW, Sydney, NSW, Australia
| | - Craig P Juergens
- Department of Cardiology, Liverpool Hospital, Sydney, NSW, Australia; South Western Sydney Clinical School, University of NSW, Sydney, NSW, Australia
| | - Dominic Y Leung
- Department of Cardiology, Liverpool Hospital, Sydney, NSW, Australia; South Western Sydney Clinical School, University of NSW, Sydney, NSW, Australia
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13
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Fung MJ, Thomas L, Leung DY. Alterations in Layer-Specific Left Ventricular Global Longitudinal and Circumferential Strain in Patients With Aortic Stenosis: A Comparison of Aortic Valve Replacement versus Conservative Management Over a 12-Month Period. J Am Soc Echocardiogr 2018; 32:92-101. [PMID: 30236621 DOI: 10.1016/j.echo.2018.07.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Impairment in left ventricular (LV) systolic strain in aortic stenosis (AS) is well documented. However, alterations in layer-specific LV global longitudinal strain (GLS) and global circumferential strain (GCS) and their recovery following surgical aortic valve replacement (AVR) have not been established. The aim of this study was to examine layer-specific changes in GLS and GCS in patients with AS undergoing AVR and compare these patients with those managed conservatively over 12 months. METHODS Eighty-six patients (mean age, 68.8 ± 12 years; 60 men) with AS (19 mild, 15 moderate, and 52 severe) were prospectively recruited. Patients with coronary disease or other significant valvular disease were excluded. Forty patients (46.5%) with severe AS underwent AVR. All patients underwent baseline echocardiography. Patients managed conservatively underwent follow-up echocardiography at 12 months. Patients undergoing AVR underwent follow-up echocardiography at 1 week and 3, 6, and 12 months after AVR. RESULTS There was worsening in subendocardial but not subepicardial or transmural GLS even in mild AS (-20.9 ± 1.0% vs -20.6 ± 0.8%, P = .012). In moderate AS, worsening in subendocardial (-19.6 ± 0.9% vs -18.2 ± 1.5%, P = .003), subepicardial (-14.9 ± 1.0% vs -13.8 ± 1.2%, P = .004), and transmural (-17.1 ± 0.9% vs -15.8 ± 1.3%, P = .03) GLS and a trend toward significant worsening in subendocardial GCS (-29.8 ± 5.16% vs -27.5 ± 5%, P = .054) were seen. Conservatively managed patients with severe AS had significant worsening in subendocardial (-16.1 ± 1.6% vs -13.9 ± 2.6%, P = .021), subepicardial (-11.6 ± 1.1% vs -10.1 ± 2.1%, P = .027), and transmural (-13.6 ± 1.3% vs -11.8 ± 2.3%, P = .02) GLS and subendocardial (-24.9 ± 3.6% vs -20.8 ± 4.5%, P = .002) and transmural (-16.9 ± 1.7% vs -14.3 ± 3.5%, P = .04) GCS on follow-up. Patients after AVR demonstrated significant improvement in GLS (from 3 months) and GCS (from 6 months) in both myocardial layers. CONCLUSIONS Patients with AS managed conservatively had worsening of GLS over 12 months despite preserved LV ejection fraction, detected earliest in the subendocardial layer. GCS became progressively impaired in moderate and severe AS. Improvement in LV strain after AVR was seen earlier with GLS (from 3 months) than with GCS (from 6 months) in both myocardial layers.
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Affiliation(s)
- Matle J Fung
- Cardiology Department, Liverpool Hospital, Liverpool, Sydney, Australia; South Western Sydney Clinical School, Faculty of Medicine, The University of New South Wales, Sydney, Australia.
| | - Liza Thomas
- Cardiology Department, Liverpool Hospital, Liverpool, Sydney, Australia; South Western Sydney Clinical School, Faculty of Medicine, The University of New South Wales, Sydney, Australia; Cardiology Department, Westmead Hospital, Westmead, Sydney, Australia; Faculty of Medicine, The University of Sydney, Sydney, Australia
| | - Dominic Y Leung
- Cardiology Department, Liverpool Hospital, Liverpool, Sydney, Australia; South Western Sydney Clinical School, Faculty of Medicine, The University of New South Wales, Sydney, Australia
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14
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Leung M, Abou R, van Rosendael PJ, van der Bijl P, van Wijngaarden SE, Regeer MV, Podlesnikar T, Ajmone Marsan N, Leung DY, Delgado V, Bax JJ. Relation of Echocardiographic Markers of Left Atrial Fibrosis to Atrial Fibrillation Burden. Am J Cardiol 2018; 122:584-591. [PMID: 30049466 DOI: 10.1016/j.amjcard.2018.04.047] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Revised: 04/22/2018] [Accepted: 04/25/2018] [Indexed: 12/12/2022]
Abstract
In patients with atrial fibrillation (AF), left atrial (LA) fibrosis is a major determinant of the progression to, and burden of AF. LA reservoir strain and total atrial conduction time (PA-TDI) reflect LA fibrotic content. We aimed to investigate the relation between LA reservoir strain and PA-TDI in AF patients and control subjects. Six-hundred two patients (mean age 56 years, 53% men) with first episode of AF and 342 controls (mean age 64 years, 71% men) without structural heart disease underwent echocardiography. LA volumes, PA-TDI, LA reservoir strain, and left ventricular global longitudinal strain (GLS) were compared. Compared with controls, patients with paroxysmal AF and patients with persistent AF had longer PA-TDI (128 ± 25 millisecond, 140 ± 31 millisecond, and 154 ± 33 millisecond, respectively; p <0.001) and a progressive decline in LA reservoir strain (36.9 ± 11.6%, 29.8 ± 13.4%, 24.2 ± 12.3%, respectively; p <0.001). LA reservoir strain was negatively correlated with PA-TDI (r = -0.43, p <0.001). On multivariate analyses, LA reservoir strain, diabetes mellitus, and burden of AF were independent correlates of PA-TDI (R2 = 0.23, p <0.001); whereas only PA-TDI was an independent correlate of LA reservoir strain (R2 = 0.43, p <0.001); controlling for age, hypertension, coronary artery disease, body mass index, severity of mitral regurgitation, left ventricular global longitudinal strain, and LA volume. In conclusion, PA-TDI and LA reservoir strain are negatively correlated in all subjects, irrespective of the presence or burden of AF. Patients with persistent AF have longer PA-TDI and impaired LA reservoir strain compared with paroxysmal AF and controls, suggesting increasing burden of fibrosis and LA structural remodeling in the progression of AF.
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15
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Fung MJ, Thomas L, Leung DY. Left atrial function: Correlation with left ventricular function and contractile reserve in patients with hypertension. Echocardiography 2018; 35:1596-1605. [DOI: 10.1111/echo.14051] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Affiliation(s)
- Matle J. Fung
- Cardiology Department; Liverpool Hospital; Liverpool, Sydney NSW Australia
- South Western Sydney Clinical School; Faculty of Medicine; The University of New South Wales; Sydney NSW Australia
| | - Liza Thomas
- Cardiology Department; Liverpool Hospital; Liverpool, Sydney NSW Australia
- South Western Sydney Clinical School; Faculty of Medicine; The University of New South Wales; Sydney NSW Australia
- Cardiology Department; Westmead Hospital; Westmead, Sydney NSW Australia
- Faculty of Medicine; The University of Sydney; Sydney NSW Australia
| | - Dominic Y. Leung
- Cardiology Department; Liverpool Hospital; Liverpool, Sydney NSW Australia
- South Western Sydney Clinical School; Faculty of Medicine; The University of New South Wales; Sydney NSW Australia
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16
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Leung M, van Rosendael PJ, Abou R, Ajmone Marsan N, Leung DY, Delgado V, Bax JJ. The Impact of Atrial Fibrillation Clinical Subtype on Mortality. JACC Clin Electrophysiol 2018; 4:221-227. [DOI: 10.1016/j.jacep.2017.09.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Revised: 08/24/2017] [Accepted: 09/07/2017] [Indexed: 10/18/2022]
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17
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Fung MJ, Thomas L, Leung DY. Left ventricular function and contractile reserve in patients with hypertension. Eur Heart J Cardiovasc Imaging 2018; 19:1253-1259. [DOI: 10.1093/ehjci/jex338] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 12/16/2017] [Indexed: 11/12/2022] Open
Affiliation(s)
- Matle J Fung
- Department of Cardiology, Liverpool Hospital, Elizabeth Street, Liverpool, Sydney, New South Wales, Australia
- Faculty of Medicine, South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
| | - Liza Thomas
- Department of Cardiology, Liverpool Hospital, Elizabeth Street, Liverpool, Sydney, New South Wales, Australia
- Faculty of Medicine, South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
- Westmead Hospital, Hawkesbury Road and Darcy Road, Westmead, Sydney, New South Wales, Australia
| | - Dominic Y Leung
- Department of Cardiology, Liverpool Hospital, Elizabeth Street, Liverpool, Sydney, New South Wales, Australia
- Faculty of Medicine, South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
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18
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Leung M, van Rosendael PJ, Abou R, Ajmone Marsan N, Leung DY, Delgado V, Bax JJ. Left atrial function to identify patients with atrial fibrillation at high risk of stroke: new insights from a large registry. Eur Heart J 2017; 39:1416-1425. [DOI: 10.1093/eurheartj/ehx736] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 12/11/2017] [Indexed: 12/19/2022] Open
Affiliation(s)
- Melissa Leung
- Department of Cardiology, Leiden University Medical Centre, Albinusdreef 2, Leiden 2300RC, The Netherlands
- Department of Cardiology, Ingham Institute at Liverpool Hospital, University of New South Wales, Corner of Elizabeth and Goulburn Streets, Liverpool NSW 2170, Sydney, Australia
| | - Philippe J van Rosendael
- Department of Cardiology, Leiden University Medical Centre, Albinusdreef 2, Leiden 2300RC, The Netherlands
| | - Rachid Abou
- Department of Cardiology, Leiden University Medical Centre, Albinusdreef 2, Leiden 2300RC, The Netherlands
| | - Nina Ajmone Marsan
- Department of Cardiology, Leiden University Medical Centre, Albinusdreef 2, Leiden 2300RC, The Netherlands
| | - Dominic Y Leung
- Department of Cardiology, Ingham Institute at Liverpool Hospital, University of New South Wales, Corner of Elizabeth and Goulburn Streets, Liverpool NSW 2170, Sydney, Australia
| | - Victoria Delgado
- Department of Cardiology, Leiden University Medical Centre, Albinusdreef 2, Leiden 2300RC, The Netherlands
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Centre, Albinusdreef 2, Leiden 2300RC, The Netherlands
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19
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Li S, Villarreal M, Stewart S, Choi J, Ganguli-Indra G, Babineau DC, Philpot C, David G, Yoshida T, Boguniewicz M, Hanifin JM, Beck LA, Leung DY, Simpson EL, Indra AK. Altered composition of epidermal lipids correlates with Staphylococcus aureus colonization status in atopic dermatitis. Br J Dermatol 2017; 177:e125-e127. [PMID: 28244066 DOI: 10.1111/bjd.15409] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- S Li
- Department of Pharmaceutical Sciences, College of Pharmacy, Oregon State University and Oregon Health and Science University, Corvallis, OR, U.S.A
| | | | - S Stewart
- Department of Pharmaceutical Sciences, College of Pharmacy, Oregon State University and Oregon Health and Science University, Corvallis, OR, U.S.A
| | - J Choi
- Linus Pauling Institute, Oregon State University, Corvallis, OR, U.S.A
| | - G Ganguli-Indra
- Department of Pharmaceutical Sciences, College of Pharmacy, Oregon State University and Oregon Health and Science University, Corvallis, OR, U.S.A
| | | | | | - G David
- Rho, Inc., Chapel Hill, NC, U.S.A
| | - T Yoshida
- University of Rochester Medical Center, Rochester, NY, U.S.A
| | | | - J M Hanifin
- Department of Dermatology, Oregon Health and Science University, Portland, OR, U.S.A
| | - L A Beck
- University of Rochester Medical Center, Rochester, NY, U.S.A
| | - D Y Leung
- National Jewish Health, Denver, CO, U.S.A
| | - E L Simpson
- Department of Dermatology, Oregon Health and Science University, Portland, OR, U.S.A
| | - A K Indra
- Department of Pharmaceutical Sciences, College of Pharmacy, Oregon State University and Oregon Health and Science University, Corvallis, OR, U.S.A.,Linus Pauling Institute, Oregon State University, Corvallis, OR, U.S.A.,Department of Dermatology, Oregon Health and Science University, Portland, OR, U.S.A.,Molecular Cell Biology Program, Oregon State University, Corvallis, OR, U.S.A.,Knight Cancer Institute, Oregon Health and Science University, Portland, OR, U.S.A
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20
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Ng ACT, Prihadi EA, Antoni ML, Bertini M, Ewe SH, Ajmone Marsan N, Leung DY, Delgado V, Bax JJ. Left ventricular global longitudinal strain is predictive of all-cause mortality independent of aortic stenosis severity and ejection fraction. Eur Heart J Cardiovasc Imaging 2017; 19:859-867. [DOI: 10.1093/ehjci/jex189] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Accepted: 07/05/2017] [Indexed: 12/19/2022] Open
Affiliation(s)
- Arnold C T Ng
- Department of Cardiology, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
- Department of Cardiology, Princess Alexandra Hospital, Centre for Advanced Imaging, The University of Queensland, Australia
| | - Edgard A Prihadi
- Department of Cardiology, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - M Louisa Antoni
- Department of Cardiology, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Matteo Bertini
- Department of Cardiology, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - See Hooi Ewe
- Department of Cardiology, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Nina Ajmone Marsan
- Department of Cardiology, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Dominic Y Leung
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Victoria Delgado
- Department of Cardiology, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
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21
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Abstract
AIMS Weight loss in obese patients leads to improved left ventricular (LV) function. It is unclear whether improving glycaemic control has additional benefits to weight loss alone in patients with type 2 diabetes, or if benefits of weight loss are mediated through improving glycaemic control. This case-control study examined the incremental impact of these approaches on LV function. METHODS Three groups of age, gender, and baseline HbA1c-matched patients with type 2 diabetes and suboptimal glycaemic control were followed-up for 12 months. Group 1 patients did not improve HbA1c ≥ 1 % (10.9 mmol/mol) or lose weight. Group 2 improved HbA1c ≥ 1 % but did not lose weight. Group 3 improved HbA1c ≥ 1 % (10.9 mmol/mol) and lost weight. All patients underwent transthoracic echocardiogram at baseline and at follow-up. RESULTS At baseline, three groups were comparable in all clinical and metabolic parameters except Group 3 had highest body mass index. The three groups had similar echocardiographic parameters except Group 3 had the worst LV systolic function [global longitudinal strain (GLS)]. At follow-up, LV ejection fraction and diastolic function improved with a reduction in filling pressures in Group 2 and more so in Group 3. LV filling pressures in Group 1 increased. There was a significant improvement in GLS in Group 2 and more so in Group 3. Despite GLS being the worst in Group 3 at baseline, this was comparable between Groups 2 and 3 at follow-up. CONCLUSIONS In overweight patients with type 2 diabetes, weight loss and improved glycaemic control had additive beneficial effects on improving LV systolic and diastolic function.
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Affiliation(s)
- Melissa Leung
- Department of Cardiology, Liverpool Hospital, South Western Sydney Clinical School, University of New South Wales, Locked Bag 7103, Liverpool BC, NSW, 1871, Australia.
- Ingham Institute for Applied Medical Research, Sydney, NSW, Australia.
- Leiden University Medical Centre, Leiden, The Netherlands.
| | - Vincent W Wong
- Ingham Institute for Applied Medical Research, Sydney, NSW, Australia
- Liverpool Diabetes Collaborative Research Unit, South Western Sydney Clinical School, University of New South Wales, Locked Bag 7103, Liverpool BC, NSW, 1871, Australia
| | | | - Victoria Phan
- Department of Cardiology, Liverpool Hospital, South Western Sydney Clinical School, University of New South Wales, Locked Bag 7103, Liverpool BC, NSW, 1871, Australia
- Ingham Institute for Applied Medical Research, Sydney, NSW, Australia
| | - Mikey Xie
- Department of Cardiology, Liverpool Hospital, South Western Sydney Clinical School, University of New South Wales, Locked Bag 7103, Liverpool BC, NSW, 1871, Australia
- Ingham Institute for Applied Medical Research, Sydney, NSW, Australia
| | - Dominic Y Leung
- Department of Cardiology, Liverpool Hospital, South Western Sydney Clinical School, University of New South Wales, Locked Bag 7103, Liverpool BC, NSW, 1871, Australia
- Ingham Institute for Applied Medical Research, Sydney, NSW, Australia
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22
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Abstract
AIMS The aims of this study were to compare the index of microcirculatory resistance (IMR) and its determinants in diabetes mellitus (DM) and non-DM patients with vascular risk factors, and to evaluate the potential differential involvement of coronary microvascular beds. METHODS AND RESULTS Fifty-six patients (32 with DM), without significant epicardial coronary disease, had IMR measured in the anterior and posterior circulations. There was no significant difference in the anterior compared to posterior circulation IMR in the whole group (27 vs. 26, p=0.92) or in the DM subgroup (35 vs. 28, p=0.31). DM patients had higher anterior circulation IMR compared to non-DM patients (27 vs. 15, p=0.009). Posterior circulation IMR was higher than anterior circulation IMR in non-DM patients (25 vs. 16, p=0.01). Multivariate determinants of higher anterior circulation IMR in DM were dyslipidaemia, hypertension, worsening glycaemic control, and higher body mass index; metformin had a protective effect. CONCLUSIONS There is differential involvement of the coronary microvascular beds. In the presence of risk factors, microvascular function of the posterior circulation was affected before the anterior; DM patients had worse microvascular function in the anterior but not posterior circulation compared to patients without DM. Vascular risk factors, including DM, adversely affect coronary microvascular function, and their treatment was associated with improvement.
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Affiliation(s)
- Melissa Leung
- Department of Cardiology, Liverpool Hospital, University of New South Wales, Sydney, Australia
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23
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Abstract
Background Diabetic cardiomyopathy is an increasingly prevalent health issue, with no specific management options. We examined the impact of weight loss with sleeve gastrectomy on diabetic cardiomyopathy. Methods Eight obese patients with type 2 diabetes undergoing sleeve gastrectomy had left ventricular (LV) systolic and diastolic function assessed by global longitudinal strain (GLS) and septal early diastolic velocity (e’) using echocardiography, before and 9 months after surgery. Results Following surgery, mean weight loss was 28.0 ± 16 kg; body mass index (BMI) decreased from 44 ± 9 to 35 ± 6 kg/m2 (p < 0.001). Glycaemic control improved with glycated haemoglobin (HbA1c) improving from 9.2 % at baseline to 6.7 % at follow-up (p = 0.002), with a corresponding improvement in LV GLS from −13.2 ± 3.7 to −19.7 ± 2.2 % (p < 0.001), and LV ejection fraction from 60 ± 5 to 70 ± 4 % (p < 0.001). Improvement in GLS was associated with the amount of weight lost (ρ = 0.81, p = 0.015). LV septal e’ velocities increased, and LV filling pressures decreased after surgery. Conclusions Weight loss with sleeve gastrectomy in obese patients with type 2 diabetes is effective in improving glycaemic control in subjects with type 2 diabetes and results in significant improvement in both systolic and diastolic myocardial function.
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Affiliation(s)
- Melissa Leung
- Department of Cardiology, Liverpool Hospital, Locked Bag 7103, Liverpool BC, Sydney, 1871, Australia.
- University of New South Wales, Sydney, NSW, Australia.
| | - Mikey Xie
- Department of Cardiology, Liverpool Hospital, Locked Bag 7103, Liverpool BC, Sydney, 1871, Australia.
- University of New South Wales, Sydney, NSW, Australia.
- Liverpool Diabetes Collaborative Research Unit, Ingham Institute, Liverpool, Sydney, Australia.
| | | | - Dominic Y Leung
- Department of Cardiology, Liverpool Hospital, Locked Bag 7103, Liverpool BC, Sydney, 1871, Australia.
- University of New South Wales, Sydney, NSW, Australia.
| | - Vincent W Wong
- University of New South Wales, Sydney, NSW, Australia.
- Liverpool Diabetes Collaborative Research Unit, Ingham Institute, Liverpool, Sydney, Australia.
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Abstract
BACKGROUND Patients with type 2 diabetes mellitus are at risk of heart failure. Specific therapeutic interventions for diabetic heart disease are still elusive. We aimed to examine the impact of improved glycemic control on left ventricular (LV) function in these patients. METHODS AND RESULTS A total of 105 subjects with type 2 diabetes mellitus (aged 54±10 years) and poor glycemic control received optimization of treatment for blood glucose, blood pressure, and cholesterol to recommended targets for 12 months. LV systolic and diastolic function, measured by LV global longitudinal strain (GLS) and septal e' velocities, were compared before and after optimization. At baseline, patients had impaired LV systolic (GLS -14.9±3.2%) and diastolic function (e' 6.2±1.7 cm/s). After 12 months, glycated hemoglobin (HbA1c) decreased from 10.3±2.4% to 8.3±2.0%, which was associated with significant relative improvement in GLS of 21% and septal e' of 24%. There was a progressively greater improvement in GLS as patients achieved a lower final HbA1c. Patients achieving an HbA1c of <7.0% had the largest improvement. The 15 patients whose HbA1c worsened experienced a decline in GLS. Patients who improved their HbA1c by ≥1.0% had a significantly higher relative improvement in e' than those who did not (32% versus 8%; P=0.003). Baseline GLS, decrease in body mass index, and treatment with metformin were additional independent predictors of GLS improvement. CONCLUSIONS Improvements in glycemic control over a 12-month period led to improvements in LV systolic and diastolic function. This may have long-term prognostic implications.
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Affiliation(s)
- Melissa Leung
- From the Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia (M.L., D.Y.L.); University of New South Wales, Sydney, New South Wales, Australia (M.L., V.W.W., D.Y.L.); Liverpool Diabetes Collaborative Research Unit, Ingham Institute, Liverpool, Sydney, New South Wales, Australia (V.W.W.); Department of Statistics, Macquarie University, Sydney, New South Wales, Australia (M.H.); and NHMRC CTC, University of Sydney, Sydney, New South Wales, Australia (M.H.).
| | - Vincent W Wong
- From the Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia (M.L., D.Y.L.); University of New South Wales, Sydney, New South Wales, Australia (M.L., V.W.W., D.Y.L.); Liverpool Diabetes Collaborative Research Unit, Ingham Institute, Liverpool, Sydney, New South Wales, Australia (V.W.W.); Department of Statistics, Macquarie University, Sydney, New South Wales, Australia (M.H.); and NHMRC CTC, University of Sydney, Sydney, New South Wales, Australia (M.H.)
| | - Malcolm Hudson
- From the Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia (M.L., D.Y.L.); University of New South Wales, Sydney, New South Wales, Australia (M.L., V.W.W., D.Y.L.); Liverpool Diabetes Collaborative Research Unit, Ingham Institute, Liverpool, Sydney, New South Wales, Australia (V.W.W.); Department of Statistics, Macquarie University, Sydney, New South Wales, Australia (M.H.); and NHMRC CTC, University of Sydney, Sydney, New South Wales, Australia (M.H.)
| | - Dominic Y Leung
- From the Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia (M.L., D.Y.L.); University of New South Wales, Sydney, New South Wales, Australia (M.L., V.W.W., D.Y.L.); Liverpool Diabetes Collaborative Research Unit, Ingham Institute, Liverpool, Sydney, New South Wales, Australia (V.W.W.); Department of Statistics, Macquarie University, Sydney, New South Wales, Australia (M.H.); and NHMRC CTC, University of Sydney, Sydney, New South Wales, Australia (M.H.)
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25
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Abstract
AIMS Recent studies have raised concerns regarding increased heart failure in patients on dipeptidyl peptidase-4 inhibitors. We examined whether dipeptidyl peptidase-4 inhibitors, compared to non-incretin-based therapies, have differential effects on left ventricular and endothelial function in patients with type 2 diabetes mellitus. METHODS A total of 25 type 2 diabetes mellitus patients commenced on a dipeptidyl peptidase-4 inhibitor were compared with 50 matched controls. Left ventricular systolic and diastolic function and flow-mediated dilatation were compared before and 12 months after treatment. RESULTS At baseline, both dipeptidyl peptidase-4 inhibitor and control groups had elevated HbA1c and comparable subclinical left ventricular dysfunction (left ventricular global longitudinal strain: -15.4% vs -15.9%, p = 0.538; e' velocities: 6 vs 6 cm/s, p = 0.151, where e' is the peak mitral annular early diastolic tissue velocity). After 12 months, both groups had similar improvement in HbA1c. However, patients on dipeptidyl peptidase-4 inhibitors had greater improvement in systolic (ΔGLS: 3.6% vs 1.3%, p < 0.001), despite no significant differences in weight, blood pressure or lipid parameters in both groups. Diastolic (Δe': 38% vs 17%, p = 0.001) and endothelial function improved in the dipeptidyl peptidase-4 inhibitor group but not the control group (ΔFMD: 5% vs -1%, p = 0.029). CONCLUSION We demonstrated significant improvements in LV systolic, diastolic and endothelial function in patients treated with a dipeptidyl peptidase-4 inhibitor over 12 months. These beneficial effects may provide some reassurance regarding the cardiovascular safety of dipeptidyl peptidase-4 inhibitors.
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Affiliation(s)
- Melissa Leung
- Department of Cardiology, Liverpool Hospital, Sydney, NSW, Australia University of New South Wales, Sydney, Australia
| | - Dominic Y Leung
- Department of Cardiology, Liverpool Hospital, Sydney, NSW, Australia University of New South Wales, Sydney, Australia
| | - Vincent W Wong
- University of New South Wales, Sydney, Australia Liverpool Diabetes Collaborative Research Unit, Ingham Institute, Liverpool, NSW, Australia
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Ng AC, Kong WKF, Kamperidis V, Bertini M, Antoni ML, Leung DY, Marsan NA, Delgado V, Bax JJ. Anaemia in patients with aortic stenosis: influence on long-term prognosis. Eur J Heart Fail 2015; 17:1042-9. [DOI: 10.1002/ejhf.297] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2015] [Revised: 04/25/2015] [Accepted: 05/04/2015] [Indexed: 12/21/2022] Open
Affiliation(s)
- Arnold C.T. Ng
- Department of Cardiology; Leiden University Medical Centre; Leiden the Netherlands
- Department of Cardiology; Princess Alexandra Hospital, The University of Queensland; 199 Ipswich Road, Woolloongabba Brisbane Australia 4102
| | - William K. F. Kong
- Department of Cardiology; Leiden University Medical Centre; Leiden the Netherlands
| | - Vasileios Kamperidis
- Department of Cardiology; Leiden University Medical Centre; Leiden the Netherlands
| | - Matteo Bertini
- Department of Cardiology; Leiden University Medical Centre; Leiden the Netherlands
| | - M. Louisa Antoni
- Department of Cardiology; Leiden University Medical Centre; Leiden the Netherlands
| | - Dominic Y. Leung
- Department of Cardiology; Liverpool Hospital, The University of New South Wales; Australia
| | - Nina Ajmone Marsan
- Department of Cardiology; Leiden University Medical Centre; Leiden the Netherlands
| | - Victoria Delgado
- Department of Cardiology; Leiden University Medical Centre; Leiden the Netherlands
| | - Jeroen J. Bax
- Department of Cardiology; Leiden University Medical Centre; Leiden the Netherlands
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Leung M, Phan V, Whatmough M, Heritier S, Wong VW, Leung DY. Left ventricular diastolic reserve in patients with type 2 diabetes mellitus. Open Heart 2015; 2:e000214. [PMID: 25893102 PMCID: PMC4395831 DOI: 10.1136/openhrt-2014-000214] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2014] [Revised: 01/28/2015] [Accepted: 03/04/2015] [Indexed: 12/26/2022] Open
Abstract
AIMS Diastolic reserve is the ability of left ventricular filling pressures to remain normal with exercise. Impaired diastolic reserve may be an early sign of diabetic cardiomyopathy. We aimed to determine whether diastolic reserve differs in type 2 diabetes (DM) compared with non-DM, and to identify clinical, anthropological, metabolic and resting echocardiographic correlates of impaired diastolic reserve in patients with DM. METHODS AND RESULTS 237 patients (aged 53±11 years, 133 DM, ejection fraction 68±9%) underwent rest and exercise echocardiography. Mitral E and septal e' were measured at rest, immediately post, and 10 min into recovery. Analysis of covariance (ANCOVA) and binary regression with continuous outcomes were used to model e' and E/e' changes with exercise to identify impaired diastolic reserve defined as post-exercise E/e' ≥15. After adjusting for baseline differences, patients with DM immediately post-exercise had a lower septal e', a lower Δe' (1.2 vs 2.3 cm/s, p=0.006) and a higher Δ septal E/e' (1.7 vs 0.08, p<0.001) than patients without DM. In patients with normal resting E/e' of ≤8 (n=130), DM had a significantly higher post-exercise septal E/e' and a higher Δseptal E/e' (2.63 vs 0.50, p<0.001). E/e' in patients with DM remained significantly elevated up to 10 min post-exercise. Hypertension, longer duration of insulin therapy, poorer glycaemic control, worse renal function, larger left atrial volume and lower septal e' were independent correlates of impaired diastolic reserve in patients with DM. CONCLUSIONS Patients with DM have impaired diastolic reserve manifest as a blunted e' response with exercise, persisting into recovery. Clinical, anthropometric, metabolic and echocardiographic correlates of impaired diastolic reserve in patients with DM were identified. An impaired LV diastolic reserve may be the underlying pathophysiological mechanism in patients with DM with unexplained exertional dyspnoea and may allow earlier detection of DM cardiomyopathy.
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Affiliation(s)
- Melissa Leung
- Department of Cardiology , Liverpool Hospital, University of New South Wales , Sydney, New South Wales , Australia
| | - Victoria Phan
- Department of Cardiology , Liverpool Hospital, University of New South Wales , Sydney, New South Wales , Australia
| | - Melinda Whatmough
- Department of Cardiology , Liverpool Hospital, University of New South Wales , Sydney, New South Wales , Australia
| | - Stephane Heritier
- The George Institute, University of Sydney , Camperdown, New South Wales , Australia
| | - Vincent W Wong
- Liverpool Diabetes Collaborative Research Unit, Ingham Institute, Liverpool, Sydney, New South Wales , Australia ; University of New South Wales, Sydney, New South Wales , Australia
| | - Dominic Y Leung
- Department of Cardiology , Liverpool Hospital, University of New South Wales , Sydney, New South Wales , Australia
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28
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Leung M, Phan V, Leung DY. Endothelial function and left ventricular diastolic functional reserve in type 2 diabetes mellitus. Open Heart 2014; 1:e000113. [PMID: 25332819 PMCID: PMC4189301 DOI: 10.1136/openhrt-2014-000113] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Revised: 05/30/2014] [Accepted: 07/15/2014] [Indexed: 01/22/2023] Open
Abstract
Background Endothelial dysfunction is an early feature of vascular disease. Left ventricular (LV) diastolic reserve is the ability of the left ventricle to augment diastolic function with exercise and may be impaired in patients with diabetes mellitus (DM). It is unclear if endothelial dysfunction is related to impaired LV diastolic reserve and diminished exercise capacity. Methods 96 patients with type 2 DM and 10 controls had brachial artery reactivity testing, followed by exercise echocardiography. The brachial artery diameter was measured at rest and during reactive hyperaemia. LV diastolic reserve was measured as Δe′ with exercise and diastolic reserve index (Δe′/rest e′). Exercise capacity was calculated by metabolic equivalents (METs). Results Compared with controls, patients with DM had lower rest e′ (7 vs 9 cm/s, p=0.002), lower Δe′(1 vs 4 cm/s, p=0.023), lower Δe′/rest e′ (0.20 vs 0.47, p=0.003) and reduced flow mediated dilation (FMD, 5 vs 15%, p<0.001). FMD was correlated with Δe′ (r=0.65, p<0.001), diastolic reserve index (r=0.61, p<0.001) and post-exercise septal E/e′ (r=−0.50, p<0.001), but not with rest e′ (r=0.13, p=0.177). FMD was an independent predictor of Δe′ (β=0.002, p<0.001, R2=0.47) and diastolic reserve index (β=0.030, p<0.001, R2=0.41). Younger age (p<0.001), male gender (p=0.014), lower body mass index (p<0.001), lower rest E/e′ (p=0.042) and higher FMD (p=0.025) were independent predictors of higher METs (R2=0.52, p<0.001). Conclusions Patients with DM had impaired endothelial function and LV diastolic dysfunction. LV diastolic reserve and exercise capacity are linked to endothelial function. Targeting vascular risk factors to improve endothelial function may improve LV diastolic reserve and exercise capacity.
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Affiliation(s)
- Melissa Leung
- Department of Cardiology , Liverpool Hospital, University of New South Wales , Sydney , Australia
| | - Victoria Phan
- Department of Cardiology , Liverpool Hospital, University of New South Wales , Sydney , Australia
| | - Dominic Y Leung
- Department of Cardiology , Liverpool Hospital, University of New South Wales , Sydney , Australia
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Leung M, Juergens CP, Lo ST, Leung DY. Evaluation of coronary microvascular function by left ventricular contractile reserve with low-dose dobutamine echocardiography. EUROINTERVENTION 2014; 9:1202-9. [PMID: 24561737 DOI: 10.4244/eijv9i10a202] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS Coronary microvascular function has important diagnostic and prognostic implications but routine assessment is difficult. The index of microcirculatory resistance (IMR) is a reliable but invasive measure. We evaluated whether left ventricular contractile reserve (CR), measured with strain imaging on dobutamine echocardiography (DSE), is a reliable non-invasive measure of coronary microvascular function. METHODS AND RESULTS Forty-five patients underwent low-dose DSE and invasive coronary angiography with IMR measurement in the left anterior descending artery. Global mean peak systolic longitudinal strain was measured in three apical views at rest, and with low-dose DSE. CR was the difference between the resting and low-dose values. Mean IMR was 19.8 (range 6-104): mean peak global systolic strain at rest was -17.90% and at low-dose was -21.46%, giving a mean CR of +3.6% (20% relative increase). IMR and CR were significantly correlated, IMR(-1)=(0.0014×CR+0.05), r=0.64, p<0.001. CR of ≥10% relative increase identified IMR <25 (100% sensitivity and specificity) and <16 (93% sensitivity, 50% specificity [AUC=0.84]). CR ≥20% identified IMR of <16 (78% sensitivity, 82% specificity) with CR ≥ 41% having 100% specificity. CONCLUSIONS LV CR with low-dose DSE may be used to estimate IMR non-invasively. An impaired CR indicates coronary microvascular dysfunction.
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Affiliation(s)
- Melissa Leung
- Department of Cardiology, University of New South Wales, Liverpool Hospital, Liverpool, NSW, Australia
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30
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Leung DY. Implantable defibrillators in ischaemic cardiomyopathy: should women be treated differently to men? Heart 2014; 100:190-1. [DOI: 10.1136/heartjnl-2013-305072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Leung M, Wong VW, Heritier S, Mihailidou AS, Leung DY. Rationale and design of a randomized trial on the impact of aldosterone antagonism on cardiac structure and function in diabetic cardiomyopathy. Cardiovasc Diabetol 2013; 12:139. [PMID: 24083804 PMCID: PMC3850740 DOI: 10.1186/1475-2840-12-139] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Accepted: 09/21/2013] [Indexed: 01/19/2023] Open
Abstract
Development of a cardiomyopathy in diabetes mellitus is independent of traditional risk factors, with no clinical trials targeting specific therapeutic interventions. Myocardial fibrosis is one of the key mechanisms and aldosterone is a key mediator of myocardial fibrosis. We propose that aldosterone antagonism will improve cardiac function. We aim to evaluate the efficacy of selective aldosterone receptor antagonism with eplerenone added to optimal medical treatment in improving cardiac structure and function in diabetic cardiomyopathy. We will randomize 130 patients with type 2 diabetes mellitus, stable metabolic control and impaired left ventricular (LV) systolic or diastolic function, to either eplerenone (target dose 50mg) or matching placebo, in addition to optimal medical therapy for 12 months. The primary endpoints are changes in LV systolic and diastolic function, measured by echocardiographic 2-dimensional speckle tracking strain and strain rate and tissue Doppler imaging. The secondary endpoints include changes in echocardiographic markers and plasma biomarkers of collagen turnover; left atrial dimensions and function, incidence of atrial fibrillation and changes in exercise capacity and dyspnea score. The present study will assess whether specific aldosterone antagonism with eplerenone in addition to standard therapy will prevent progression or reverse cardiac dysfunction in diabetic cardiomyopathy using sensitive, robust and quantifiable echocardiographic measures that allow early detection of change. The study may offer a new direction in the management of this condition.
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Affiliation(s)
- Melissa Leung
- Department of Cardiology, Liverpool Hospital, Locked Bag 7103, Liverpool BC, NSW 1871, Australia.
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Gattellari M, Worthington JM, Leung DY, Zwar N. Supporting Treatment decision making to Optimise the Prevention of STROKE in Atrial Fibrillation: the STOP STROKE in AF study. Protocol for a cluster randomised controlled trial. Implement Sci 2012; 7:63. [PMID: 22770423 PMCID: PMC3443055 DOI: 10.1186/1748-5908-7-63] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2012] [Accepted: 07/06/2012] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Suboptimal uptake of anticoagulation for stroke prevention in atrial fibrillation has persisted for over 20 years, despite high-level evidence demonstrating its effectiveness in reducing the risk of fatal and disabling stroke. METHODS The STOP STROKE in AF study is a national, cluster randomised controlled trial designed to improve the uptake of anticoagulation in primary care. General practitioners from around Australia enrolling in this 'distance education' program are mailed written educational materials, followed by an academic detailing session delivered via telephone by a medical peer, during which participants discuss patient de-identified cases. General practitioners are then randomised to receive written specialist feedback about the patient de-identified cases either before or after completing a three-month posttest audit. Specialist feedback is designed to provide participants with support and confidence to prescribe anticoagulation. The primary outcome is the proportion of patients with atrial fibrillation receiving oral anticoagulation at the time of the posttest audit. DISCUSSION The STOP STROKE in AF study aims to evaluate a feasible intervention via distance education to prevent avoidable stroke due to atrial fibrillation. It provides a systematic test of augmenting academic detailing with expert feedback about patient management.
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Ng AC, Auger D, Delgado V, van Elderen SG, Bertini M, Siebelink HM, van der Geest RJ, Bonetti C, van der Velde ET, de Roos A, Smit JW, Leung DY, Bax JJ, Lamb HJ. Association Between Diffuse Myocardial Fibrosis by Cardiac Magnetic Resonance Contrast-Enhanced T
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Mapping and Subclinical Myocardial Dysfunction in Diabetic Patients. Circ Cardiovasc Imaging 2012; 5:51-9. [DOI: 10.1161/circimaging.111.965608] [Citation(s) in RCA: 101] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Affiliation(s)
- Arnold C.T. Ng
- From the Departments of Cardiology (A.C.T.N., D.A., V.D., M.B., H.-M.S., C.B., E.T.v.d.V., J.J.B.), Radiology (S.G.C.E., R.J.v.d.G., A.d.R., H.J.L.), and Endocrinology (J.W.A.S.), Leiden University Medical Center, Leiden, The Netherlands; Department of Cardiology (A.C.T.N.), Princess Alexandra Hospital, University of Queensland, Brisbane, Australia; and Department of Cardiology (D.Y.L.), Liverpool Hospital, Sydney, New South Wales, Australia
| | - Dominique Auger
- From the Departments of Cardiology (A.C.T.N., D.A., V.D., M.B., H.-M.S., C.B., E.T.v.d.V., J.J.B.), Radiology (S.G.C.E., R.J.v.d.G., A.d.R., H.J.L.), and Endocrinology (J.W.A.S.), Leiden University Medical Center, Leiden, The Netherlands; Department of Cardiology (A.C.T.N.), Princess Alexandra Hospital, University of Queensland, Brisbane, Australia; and Department of Cardiology (D.Y.L.), Liverpool Hospital, Sydney, New South Wales, Australia
| | - Victoria Delgado
- From the Departments of Cardiology (A.C.T.N., D.A., V.D., M.B., H.-M.S., C.B., E.T.v.d.V., J.J.B.), Radiology (S.G.C.E., R.J.v.d.G., A.d.R., H.J.L.), and Endocrinology (J.W.A.S.), Leiden University Medical Center, Leiden, The Netherlands; Department of Cardiology (A.C.T.N.), Princess Alexandra Hospital, University of Queensland, Brisbane, Australia; and Department of Cardiology (D.Y.L.), Liverpool Hospital, Sydney, New South Wales, Australia
| | - Saskia G.C. van Elderen
- From the Departments of Cardiology (A.C.T.N., D.A., V.D., M.B., H.-M.S., C.B., E.T.v.d.V., J.J.B.), Radiology (S.G.C.E., R.J.v.d.G., A.d.R., H.J.L.), and Endocrinology (J.W.A.S.), Leiden University Medical Center, Leiden, The Netherlands; Department of Cardiology (A.C.T.N.), Princess Alexandra Hospital, University of Queensland, Brisbane, Australia; and Department of Cardiology (D.Y.L.), Liverpool Hospital, Sydney, New South Wales, Australia
| | - Matteo Bertini
- From the Departments of Cardiology (A.C.T.N., D.A., V.D., M.B., H.-M.S., C.B., E.T.v.d.V., J.J.B.), Radiology (S.G.C.E., R.J.v.d.G., A.d.R., H.J.L.), and Endocrinology (J.W.A.S.), Leiden University Medical Center, Leiden, The Netherlands; Department of Cardiology (A.C.T.N.), Princess Alexandra Hospital, University of Queensland, Brisbane, Australia; and Department of Cardiology (D.Y.L.), Liverpool Hospital, Sydney, New South Wales, Australia
| | - Hans-Marc Siebelink
- From the Departments of Cardiology (A.C.T.N., D.A., V.D., M.B., H.-M.S., C.B., E.T.v.d.V., J.J.B.), Radiology (S.G.C.E., R.J.v.d.G., A.d.R., H.J.L.), and Endocrinology (J.W.A.S.), Leiden University Medical Center, Leiden, The Netherlands; Department of Cardiology (A.C.T.N.), Princess Alexandra Hospital, University of Queensland, Brisbane, Australia; and Department of Cardiology (D.Y.L.), Liverpool Hospital, Sydney, New South Wales, Australia
| | - Rob J. van der Geest
- From the Departments of Cardiology (A.C.T.N., D.A., V.D., M.B., H.-M.S., C.B., E.T.v.d.V., J.J.B.), Radiology (S.G.C.E., R.J.v.d.G., A.d.R., H.J.L.), and Endocrinology (J.W.A.S.), Leiden University Medical Center, Leiden, The Netherlands; Department of Cardiology (A.C.T.N.), Princess Alexandra Hospital, University of Queensland, Brisbane, Australia; and Department of Cardiology (D.Y.L.), Liverpool Hospital, Sydney, New South Wales, Australia
| | - Cosimo Bonetti
- From the Departments of Cardiology (A.C.T.N., D.A., V.D., M.B., H.-M.S., C.B., E.T.v.d.V., J.J.B.), Radiology (S.G.C.E., R.J.v.d.G., A.d.R., H.J.L.), and Endocrinology (J.W.A.S.), Leiden University Medical Center, Leiden, The Netherlands; Department of Cardiology (A.C.T.N.), Princess Alexandra Hospital, University of Queensland, Brisbane, Australia; and Department of Cardiology (D.Y.L.), Liverpool Hospital, Sydney, New South Wales, Australia
| | - Enno T. van der Velde
- From the Departments of Cardiology (A.C.T.N., D.A., V.D., M.B., H.-M.S., C.B., E.T.v.d.V., J.J.B.), Radiology (S.G.C.E., R.J.v.d.G., A.d.R., H.J.L.), and Endocrinology (J.W.A.S.), Leiden University Medical Center, Leiden, The Netherlands; Department of Cardiology (A.C.T.N.), Princess Alexandra Hospital, University of Queensland, Brisbane, Australia; and Department of Cardiology (D.Y.L.), Liverpool Hospital, Sydney, New South Wales, Australia
| | - Albert de Roos
- From the Departments of Cardiology (A.C.T.N., D.A., V.D., M.B., H.-M.S., C.B., E.T.v.d.V., J.J.B.), Radiology (S.G.C.E., R.J.v.d.G., A.d.R., H.J.L.), and Endocrinology (J.W.A.S.), Leiden University Medical Center, Leiden, The Netherlands; Department of Cardiology (A.C.T.N.), Princess Alexandra Hospital, University of Queensland, Brisbane, Australia; and Department of Cardiology (D.Y.L.), Liverpool Hospital, Sydney, New South Wales, Australia
| | - Johannes W.A. Smit
- From the Departments of Cardiology (A.C.T.N., D.A., V.D., M.B., H.-M.S., C.B., E.T.v.d.V., J.J.B.), Radiology (S.G.C.E., R.J.v.d.G., A.d.R., H.J.L.), and Endocrinology (J.W.A.S.), Leiden University Medical Center, Leiden, The Netherlands; Department of Cardiology (A.C.T.N.), Princess Alexandra Hospital, University of Queensland, Brisbane, Australia; and Department of Cardiology (D.Y.L.), Liverpool Hospital, Sydney, New South Wales, Australia
| | - Dominic Y. Leung
- From the Departments of Cardiology (A.C.T.N., D.A., V.D., M.B., H.-M.S., C.B., E.T.v.d.V., J.J.B.), Radiology (S.G.C.E., R.J.v.d.G., A.d.R., H.J.L.), and Endocrinology (J.W.A.S.), Leiden University Medical Center, Leiden, The Netherlands; Department of Cardiology (A.C.T.N.), Princess Alexandra Hospital, University of Queensland, Brisbane, Australia; and Department of Cardiology (D.Y.L.), Liverpool Hospital, Sydney, New South Wales, Australia
| | - Jeroen J. Bax
- From the Departments of Cardiology (A.C.T.N., D.A., V.D., M.B., H.-M.S., C.B., E.T.v.d.V., J.J.B.), Radiology (S.G.C.E., R.J.v.d.G., A.d.R., H.J.L.), and Endocrinology (J.W.A.S.), Leiden University Medical Center, Leiden, The Netherlands; Department of Cardiology (A.C.T.N.), Princess Alexandra Hospital, University of Queensland, Brisbane, Australia; and Department of Cardiology (D.Y.L.), Liverpool Hospital, Sydney, New South Wales, Australia
| | - Hildo J. Lamb
- From the Departments of Cardiology (A.C.T.N., D.A., V.D., M.B., H.-M.S., C.B., E.T.v.d.V., J.J.B.), Radiology (S.G.C.E., R.J.v.d.G., A.d.R., H.J.L.), and Endocrinology (J.W.A.S.), Leiden University Medical Center, Leiden, The Netherlands; Department of Cardiology (A.C.T.N.), Princess Alexandra Hospital, University of Queensland, Brisbane, Australia; and Department of Cardiology (D.Y.L.), Liverpool Hospital, Sydney, New South Wales, Australia
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Leung DY. Aldosterone Blockade in Metabolic Syndrome. JACC Cardiovasc Imaging 2011; 4:1250-2. [DOI: 10.1016/j.jcmg.2011.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2011] [Accepted: 10/24/2011] [Indexed: 10/14/2022]
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Yiu KH, de Graaf FR, Schuijf JD, van Werkhoven JM, Marsan NA, Veltman CE, de Roos A, Pazhenkottil A, Kroft LJ, Boersma E, Herzog B, Leung M, Maffei E, Leung DY, Kaufmann PA, Cademartiri F, Bax JJ, Jukema JW. Age- and gender-specific differences in the prognostic value of CT coronary angiography. Heart 2011; 98:232-7. [PMID: 21917657 DOI: 10.1136/heartjnl-2011-300038] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To evaluate the potential age- and gender-specific differences in the incidence and prognostic value of coronary artery disease (CAD) in patients undergoing CT coronary angiography (CTA). DESIGN AND PATIENTS In this multicentre prospective registry study, 2432 patients (mean age 57 ± 12, 56% male) underwent CTA for suspected CAD. Patients were stratified into four groups according to age <60 or ≥60 years and, male or female gender. MAIN OUTCOME MEASURES A composite end point of cardiac death and non-fatal myocardial infarction. RESULTS CTA results were normal in 991 (41%) patients, showed non-significant CAD in 761 (31%) patients and significant CAD in the remaining 680 (28%) patients. During follow-up (median 819 days, 25-75th centile 482-1142) a cardiovascular event occurred in 59 (2.4%) patients. The annualised event rate was 1.1% in the total population (men=1.3% and women=0.9%). In patients aged <60 years, the annualised event rate of male and female patients was 0.6% and 0.5%, respectively. Among patients aged ≥60 years the annualised event rate was 1.9% in male and 1.1% in female patients. Observations on CTA predicted events in male patients, both age <60 and ≥60 years and in female patients age ≥60 years (log-rank test in all groups, p<0.01). However, CTA provided limited prognostic value in female patients aged <60 years (log-rank test, p=0.45). CONCLUSIONS After age and gender stratification, CTA findings were shown to be of limited predictive value in female patients aged <60 years as compared with male patients at any age and female patients aged ≥60 years.
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Affiliation(s)
- Kai Hang Yiu
- Department of Cardiology, Leiden University Medical Center, The Netherlands
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Ng ACT, Yiu KH, Ewe SH, van der Kley F, Bertini M, de Weger A, de Roos A, Leung DY, Schuijf JD, Schalij MJ, Bax JJ, Delgado V. Influence of left ventricular geometry and function on aortic annular dimensions as assessed with multi-detector row computed tomography: implications for transcatheter aortic valve implantation. Eur Heart J 2011; 32:2806-13. [PMID: 21785108 DOI: 10.1093/eurheartj/ehr237] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
AIMS Evaluate changes in aortic annular dimensions in relation to severe aortic stenosis (AS) and left ventricular (LV) dysfunction. METHODS AND RESULTS Mean aortic annular diameters and geometries were compared between 90 severe AS patients and 111 controls by multi-detector row computed tomography (MDCT). All severe AS patients were also dichotomized into two groups based on the presence of preserved (≥ 50%) or impaired (<50%) LV ejection fraction (EF). The influence of LV geometry and function on changes in aortic annular dimensions was examined. Patients with severe AS had similar aortic annular dimensions and geometries compared with controls even after correcting for baseline differences in age and body surface area (BSA). However, severe AS patients with LV dysfunction (LVEF <50%) had significantly larger mean aortic annular diameter (26.4 ± 1.9 vs. 24.5 ± 2.1 mm, P < 0.001) compared with patients with preserved LVEF. The presence of LV dysfunction, male gender, and larger BSA were independent determinants of a larger aortic annulus on MDCT. CONCLUSION In severe AS patients, the presence of LV dysfunction, not the presence of severe AS, was an independent determinant of a larger aortic annular diameter.
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Affiliation(s)
- Arnold C T Ng
- Department of Cardiology, Princess Alexandra Hospital, University of Queensland, Australia
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Gattellari M, Leung DY, Ukoumunne OC, Zwar N, Grimshaw J, Worthington JM. Study protocol: the DESPATCH study: delivering stroke prevention for patients with atrial fibrillation - a cluster randomised controlled trial in primary healthcare. Implement Sci 2011; 6:48. [PMID: 21599901 PMCID: PMC3121604 DOI: 10.1186/1748-5908-6-48] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2011] [Accepted: 05/20/2011] [Indexed: 12/21/2022] Open
Abstract
Background Compelling evidence shows that appropriate use of anticoagulation in patients with nonvalvular atrial fibrillation reduces the risk of ischaemic stroke by 67% and all-cause mortality by 26%. Despite this evidence, anticoagulation is substantially underused, resulting in avoidable fatal and disabling strokes. Methods DESPATCH is a cluster randomised controlled trial with concealed allocation and blinded outcome assessment designed to evaluate a multifaceted and tailored implementation strategy for improving the uptake of anticoagulation in primary care. We have recruited general practices in South Western Sydney, Australia, and randomly allocated practices to receive the DESPATCH intervention or evidence-based guidelines (control). The intervention comprises specialist decisional support via written feedback about patient-specific cases, three academic detailing sessions (delivered via telephone), practice resources, and evidence-based information. Data for outcome assessment will be obtained from a blinded, independent medical record audit. Our primary endpoint is the proportion of nonvalvular atrial fibrillation patients, over 65 years of age, receiving oral anticoagulation at any time during the 12-month posttest period. Discussion Successful translation of evidence into clinical practice can reduce avoidable stroke, death, and disability due to nonvalvular atrial fibrillation. If successful, DESPATCH will inform public policy, providing quality evidence for an effective implementation strategy to improve management of nonvalvular atrial fibrillation, to close an important evidence-practice gap. Trial registration Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12608000074392
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Affiliation(s)
- Melina Gattellari
- School of Public Health and Community Medicine, The University of New South Wales, Sydney, Australia.
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Affiliation(s)
- Dominic Y Leung
- Department of Cardiology, University of New South Wales, Liverpool Hospital, Liverpool BC NSW 1871, Australia.
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Ng AC, Delgado V, Bertini M, Antoni ML, van Bommel RJ, van Rijnsoever EP, van der Kley F, Ewe SH, Witkowski T, Auger D, Nucifora G, Schuijf JD, Poldermans D, Leung DY, Schalij MJ, Bax JJ. Alterations in multidirectional myocardial functions in patients with aortic stenosis and preserved ejection fraction: a two-dimensional speckle tracking analysis. Eur Heart J 2011; 32:1542-50. [DOI: 10.1093/eurheartj/ehr084] [Citation(s) in RCA: 150] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Shugman IM, Diu P, Gohil J, Kadappu KK, Leung M, Lo S, Leung DY, Hopkins AP, Juergens CP, French JK. Evaluation of troponin T criteria for periprocedural myocardial infarction in patients with acute coronary syndromes. Am J Cardiol 2011; 107:863-70. [PMID: 21376928 DOI: 10.1016/j.amjcard.2010.11.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2010] [Revised: 11/04/2010] [Accepted: 11/05/2010] [Indexed: 11/28/2022]
Abstract
In patients with acute coronary syndromes undergoing percutaneous coronary intervention (PCI), the diagnosis of periprocedural myocardial infarction is often problematic when the pre-PCI levels of cardiac troponin T (TnT) are elevated. Thus, we examined different TnT criteria for periprocedural myocardial infarction when the pre-PCI TnT levels were elevated and also the associations between the post-PCI cardiac marker levels and outcomes. We established the relation between the post-PCI creatine kinase-MB (CKMB) and TnT levels in 582 patients (315 with acute coronary syndromes and 272 with stable coronary heart disease). A post-PCI increase in the CKMB levels to 14.7 μg/L (3 × the upper reference limit [URL] in men) corresponded to a TnT of 0.23 μg/L. In the 85 patients with acute coronary syndromes and normal CKMB, but elevated post peak TnT levels before PCI (performed at a median of 5 days, interquartile range 3 to 7), the post-PCI cardiac marker increases were as follows: 21 (24.7%) with a ≥ 20% increase in TnT, 10 (11.8%) with an CKMB level >3 × URL, and 12 (14%) with an absolute TnT increase of >0.09 μg/L (p <0.005 for both). In the patients with stable coronary heart disease and post-PCI cardiac markers > 3× URL compared to those without markers elevations, the rate of freedom from death or nonfatal myocardial infarction was 88% for those with TnT elevations versus 99% (p <0.001, log-rank) and 84% for those with CKMB elevations versus 98% (p <0.001, log-rank). Of the patients with acute coronary syndromes, the post-PCI marker levels did not influence the outcomes. In conclusion, in patients with acute coronary syndromes and elevated TnT levels undergoing PCI several days later, ≥20% increases in TnT were more common than absolute increments in the TnT or CKMB levels of >3× URL. Also, periprocedural cardiac marker elevations in patients with acute coronary syndromes did not have prognostic significance.
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Affiliation(s)
- Ibrahim Meloud Shugman
- Department of Cardiology, University of New South Wales, Sydney, New South Wales, Australia
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Boyd AC, Ng AC, Tran DT, Chia EM, French JK, Leung DY, Thomas L. Left Atrial Enlargement and Phasic Function in Patients Following Non–ST Elevation Myocardial Infarction. J Am Soc Echocardiogr 2010; 23:1251-8. [DOI: 10.1016/j.echo.2010.09.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2010] [Indexed: 01/16/2023]
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Ng ACT, Bertini M, Borleffs CJW, Delgado V, Boersma E, Piers SRD, Thijssen J, Nucifora G, Shanks M, Ewe SH, Biffi M, van de Veire NRL, Leung DY, Schalij MJ, Bax JJ. Predictors of death and occurrence of appropriate implantable defibrillator therapies in patients with ischemic cardiomyopathy. Am J Cardiol 2010; 106:1566-73. [PMID: 21094356 DOI: 10.1016/j.amjcard.2010.07.029] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2010] [Revised: 07/21/2010] [Accepted: 07/21/2010] [Indexed: 01/08/2023]
Abstract
Most patients with chronic ischemia and an implantable cardiac defibrillator (ICD) for primary prevention do not experience therapies for ventricular arrhythmias on follow-up. The present study aimed to identify independent clinical, electrocardiographic, and echocardiographic predictors of death and occurrence of ICD therapy in patients with chronic ischemic cardiomyopathy and ICD for primary prevention. A total of 424 patients with chronic ischemic cardiomyopathy, ejection fraction ≤ 35%, and New York Heart Association (NYHA) class ≥ II were recruited. All patients underwent echocardiography before ICD insertion. Primary outcome was all-cause mortality; secondary outcome was occurrence of appropriate ICD therapy on follow-up. Primary and secondary outcomes occurred in 84 and 95 patients, respectively. Patients who died were more likely to have diabetes (hazard ratio [HR] 1.67, 95% confidence interval [CI] 1.00 to 2.79, p = 0.049), higher NYHA class (HR 1.96, 95% CI 1.15 to 3.33, p = 0.013), lower peri-infarct strain on echocardiogram (HR 1.25, 95% CI 1.07 to 1.46, p = 0.005), and lower glomerular filtration rate (HR 1.01, 95% CI 1.00 to 1.03, p = 0.022). Only peri-infarct strain (HR 1.22, 95% CI 1.09 to 1.36, p < 0.001) predicted the occurrence of ICD therapy on follow-up. In conclusion, in chronic ischemic patients with an ICD for primary prevention, the presence of diabetes, renal dysfunction, higher NYHA class, and impaired peri-infarct zone function were predictors of all-cause mortality. In contrast, only impaired peri-infarct zone function determined the occurrence of appropriate ICD therapy on follow-up.
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Affiliation(s)
- Arnold C T Ng
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
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Ng ACT, Delgado V, Bertini M, van der Meer RW, Rijzewijk LJ, Hooi Ewe S, Siebelink HM, Smit JWA, Diamant M, Romijn JA, de Roos A, Leung DY, Lamb HJ, Bax JJ. Myocardial steatosis and biventricular strain and strain rate imaging in patients with type 2 diabetes mellitus. Circulation 2010; 122:2538-44. [PMID: 21126971 DOI: 10.1161/circulationaha.110.955542] [Citation(s) in RCA: 161] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Magnetic resonance spectroscopy can quantify myocardial triglyceride content in type 2 diabetic patients. Its relation to alterations in left (LV) and right (RV) ventricular myocardial functions is unknown. METHODS AND RESULTS A total of 42 men with type 2 diabetes mellitus were recruited. Exclusion criteria included hemoglobin A(1c) >8.5, known cardiovascular disease, diabetes-related complications, or blood pressure >150/85 mm Hg. Myocardial ischemia was excluded by a negative dobutamine stress test. LV and RV volumes and ejection fraction were quantified by magnetic resonance imaging. LV global longitudinal and RV free wall longitudinal strain, systolic strain rate, and diastolic strain rate were quantified by echocardiographic speckle tracking analyses. Myocardial triglyceride content was quantified by magnetic resonance spectroscopy and dichotomized on the basis of the median value of 0.76. The median age was 59 years (25th and 75th percentiles, 54 and 62 years). Median diabetes diagnosis duration was 4 years, and median glycohemoglobin level was 6.2 (25th and 75th percentiles, 5.9 and 6.8). There were no differences in LV and RV end-diastolic and end-systolic volume indexes and ejection fraction between patients with high (≥0.76) and those with low (<0.76) myocardial triglyceride content. However, patients with high myocardial triglyceride content had greater impairment of LV and RV myocardial strain and strain rate. The myocardial triglyceride content was an independent correlate of LV and RV longitudinal strain, systolic strain rate, and diastolic strain rate. CONCLUSIONS High myocardial triglyceride content is associated with more pronounced impairment of LV and RV functions in men with uncomplicated type 2 diabetes mellitus.
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Affiliation(s)
- Arnold C T Ng
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, the Netherlands
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Bertini M, Ng ACT, Borleffs CJW, Delgado V, Wijnmaalen AP, Nucifora G, Ewe SH, Shanks M, Thijssen J, Zeppenfeld K, Biffi M, Leung DY, Schalij MJ, Bax JJ. Longitudinal mechanics of the periinfarct zone and ventricular tachycardia inducibility in patients with chronic ischemic cardiomyopathy. Am Heart J 2010; 160:729-36. [PMID: 20934568 DOI: 10.1016/j.ahj.2010.06.041] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2010] [Accepted: 06/24/2010] [Indexed: 11/17/2022]
Abstract
BACKGROUND Quantification of segmental left ventricular (LV) strain by speckle-tracking echocardiography can identify transmural infarcts in patients with chronic ischemic cardiomyopathy. The aim of the study was to explore the relationship between the LV longitudinal peak systolic strain (LPSS) of the infarct, periinfarct, and remote zones and monomorphic ventricular tachycardia (VT) inducibility on electrophysiologic (EP) study. METHODS A total of 134 patients with chronic ischemic cardiomyopathy scheduled for EP study were included. The protocol consisted of clinical, electrocardiographic, and echocardiographic evaluation, including LV longitudinal strain analysis using speckle-tracking echocardiography, immediately before EP study. An infarct segment was defined as a longitudinal strain value of greater than -5%, and a periinfarct segment was defined as immediately adjacent to an infarct segment. RESULTS The infarct zone had the most impaired longitudinal strain (-0.5% ± 3.0%), whereas the periinfarct and remote zones had more preserved longitudinal strain (-10.8% ± 1.9% and -14.5% ± 3.0%, respectively; analysis of variance, P < .001). Seventy-two (54%) patients had inducible monomorphic VT on EP study. There was no significant difference in LV ejection fraction (31% ± 9% vs 32% ± 11%, P = .29) between inducible and noninducible patients. Longitudinal peak systolic strain of the periinfarct zone was more impaired in inducible patients (-9.8% ± 1.5% vs -11.0% ± 2.1%, P = .001), but no differences in LPSS of the infarct (-0.5% ± 3.2% vs -0.4% ± 2.7%, P = .75) and remote (-14.6% ± 2.8% vs -14.5% ± 3.4%, P = .92) zones were observed. Only LPSS of the periinfarct zone (OR 1.43, 95% CI 1.15-1.78, P = .001) was independently related to monomorphic VT inducibility on multiple logistic regression. CONCLUSIONS Longitudinal strain analysis may be a useful imaging tool to risk stratify ischemic patients for malignant ventricular arrhythmia.
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Affiliation(s)
- Matteo Bertini
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
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Vazquez-Tello A, Semlali A, Chakir J, Martin JG, Leung DY, Eidelman DH, Hamid Q. Induction of glucocorticoid receptor-beta expression in epithelial cells of asthmatic airways by T-helper type 17 cytokines. Clin Exp Allergy 2010; 40:1312-22. [PMID: 20545708 DOI: 10.1111/j.1365-2222.2010.03544.x] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Corticosteroid insensitivity in asthmatics is associated with an increased expression of glucocorticoid receptor-beta (GR-beta) in many cell types. T-helper type 17 (Th17) cytokine (IL-17A and F) expressions increase in mild and in difficult-to-treat asthma. We hypothesize that IL-17A and F cytokines alone or in combination, induce the expression of GR-beta in bronchial epithelial cells. OBJECTIVES To confirm the expression of the GR-beta and IL-17 cytokines in the airways of normal subjects and mild asthmatics and to examine the effect of cytokines IL-17A and F on the expression of GR-beta in bronchial epithelial cells obtained from normal subjects and asthmatic patients. METHODS The expression of IL-17A and F, GR-alpha and GR-beta was analysed in bronchial biopsies from mild asthmatics and normal subjects by Q-RT-PCR. Immunohistochemistry for IL-17 and GR-beta was performed in bronchial biopsies from normal and asthmatic subjects. The expression of IL-6 in response to IL-17A and F and dexamethasone was determined by Q-RT-PCR using primary airway epithelial cells from normal and asthmatic subjects. RESULTS We detected significantly higher levels of IL-17A mRNA expression in the bronchial biopsies from mild asthmatics, compared with normal. GR-alpha expression was significantly lower in the biopsies from asthmatics compared with controls. The expression of IL-17F and GR-beta in biopsies from asthmatics was not significantly different from that of controls. Using primary epithelial cells isolated from normal subjects and asthmatics, we found an increased expression of GR-beta in response to IL-17A and F in the cells from asthmatics (P< or =0.05). This effect was only partially significant in the normal cells. Dexamethasone significantly decreased the IL-17-induced IL-6 expression in cells from normal individuals but not in those from asthmatics (P< or =0.05). CONCLUSION Evidence of an increased GR-beta expression in epithelial cells following IL-17 stimulation suggests a possible role for Th17-associated cytokines in the mechanism of steroid hypo-responsiveness in asthmatic subjects.
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Affiliation(s)
- A Vazquez-Tello
- Meakins-Christie Laboratories, Department of Medicine, Respiratory Division, McGill University, 3626 St. Urbain Street, Montreal, QC, Canada
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Leung DY, Chi C, Allman C, Boyd A, Ng AC, Kadappu KK, Leung M, Thomas L. Prognostic implications of left atrial volume index in patients in sinus rhythm. Am J Cardiol 2010; 105:1635-9. [PMID: 20494675 DOI: 10.1016/j.amjcard.2010.01.027] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2009] [Revised: 01/10/2010] [Accepted: 01/10/2010] [Indexed: 11/28/2022]
Abstract
The maximum left atrial volume index (LAVI) has been shown to be of prognostic values, but previous studies have largely been limited to older patients with specific cardiovascular conditions. We examined the independent prognostic values of LAVI in a large unselected series of predominantly younger patients in sinus rhythm followed up for a long period. We evaluated 483 consecutive patients (mean age 47.3 years) using transthoracic echocardiography. The median LAVI was 24 ml/m(2). A primary combined end point of cardiovascular death, stroke, heart failure, myocardial infarction, and atrial fibrillation was sought. We had complete follow-up data for 97.3% of the 483 patients. During a median follow-up of 6.8 years, 86 patients (18.3%) reached the primary end point. Older age, male gender, diabetes, hypertension, hypercholesterolemia, chronic renal failure, a history of myocardial infarction or stroke, a mitral E deceleration time of </=150 ms, and LAVI of >/=24 ml/m(2) were univariate predictors of the primary end point. Event-free survival was significantly lower for patients with a LAVI of >/=24 ml/m(2). Age, a history of stroke, hypertension, chronic renal failure, and male gender were independent clinical predictors. A LAVI of >/=24 ml/m(2) was the only independent echocardiographic predictor (hazard ratio 1.72, 95% confidence interval 1.34 to 2.13, p = 0.018), with the chi-square of the Cox model increased significantly with the addition of the LAVI (p <0.001). The LAVI independently predicted an increased risk of cardiovascular death, heart failure, atrial fibrillation, stroke, or myocardial infarction during a median follow-up of 6.8 years. In conclusion, the prognostic values were incremental to the clinical risks and were valid in a younger, general patient population.
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Affiliation(s)
- Dominic Y Leung
- Department of Cardiology, Liverpool Hospital, University of New South Wales, Liverpool, New South Wales, Australia.
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Affiliation(s)
- John M. Worthington
- From Northern Beaches Stroke Service and Department of Neurology, Liverpool Health Service, Liverpool, Sydney, Australia (J.M.W.); Department of Cardiology, Liverpool Health Service, Liverpool, Sydney, Australia (D.Y.L.); Centre for Research, Evidence Management and Surveillance, Division of Population Health, Sydney South West Area Health Service, NSW, Australia (M.G.); The University of New South Wales, Sydney, Australia (J.M.W., M.G., D.Y.L.)
| | - Melina Gattellari
- From Northern Beaches Stroke Service and Department of Neurology, Liverpool Health Service, Liverpool, Sydney, Australia (J.M.W.); Department of Cardiology, Liverpool Health Service, Liverpool, Sydney, Australia (D.Y.L.); Centre for Research, Evidence Management and Surveillance, Division of Population Health, Sydney South West Area Health Service, NSW, Australia (M.G.); The University of New South Wales, Sydney, Australia (J.M.W., M.G., D.Y.L.)
| | - Dominic Y. Leung
- From Northern Beaches Stroke Service and Department of Neurology, Liverpool Health Service, Liverpool, Sydney, Australia (J.M.W.); Department of Cardiology, Liverpool Health Service, Liverpool, Sydney, Australia (D.Y.L.); Centre for Research, Evidence Management and Surveillance, Division of Population Health, Sydney South West Area Health Service, NSW, Australia (M.G.); The University of New South Wales, Sydney, Australia (J.M.W., M.G., D.Y.L.)
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Shanks M, Ng ACT, van de Veire NRL, Antoni ML, Bertini M, Delgado V, Nucifora G, Holman ER, Choy JB, Leung DY, Schalij MJ, Bax JJ. Incremental prognostic value of novel left ventricular diastolic indexes for prediction of clinical outcome in patients with ST-elevation myocardial infarction. Am J Cardiol 2010; 105:592-7. [PMID: 20185002 DOI: 10.1016/j.amjcard.2009.10.039] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2009] [Revised: 10/23/2009] [Accepted: 10/28/2009] [Indexed: 12/17/2022]
Abstract
This study examined the prognostic value of novel diastolic indexes in ST-elevation acute myocardial infarction (AMI), derived from strain and strain rate analysis using 2-dimensional speckle tracking imaging. Echocardiograms were obtained within 48 hours of admission in 371 consecutive patients with first ST-elevation AMI (59.7 +/- 11.6 years old). Indexes of diastolic function including mean strain rate during isovolumic relaxation (SR(IVR)), mean early diastolic strain rate (SR(E)) and mean diastolic strain at peak transmitral E wave (E) were obtained from 3 apical views. Mean early diastolic velocity from 4 basal segments by color-coded tissue Doppler imaging was measured. Indexes of diastolic filling including E/SR(IVR), E/SR(E), E/diastolic strain at E, and E/early diastolic velocity were calculated. The primary end point (composite of death, hospitalization for heart failure, repeat MI, and repeat revascularization) occurred in 84 patients (22.6%) during a mean follow-up of 17.3 +/- 12.2 months. Mean SR(IVR) (p <0.001), multivessel disease (p <0.001), Thrombolysis In Myocardial Infarction grade 0 to 1 flow after percutaneous coronary intervention (p = 0.004), and left ventricular ejection fraction (p = 0.008) were independent predictors of the combined end point on Cox regression analysis. Mean SR(IVR) showed incremental prognostic value over baseline clinical and echocardiographic variables (global chi-square increase from 41.0 to 51.6, p <0.001). After dividing patient population based on median SR(IVR), patients with SR(IVR) < or =0.24/second had significantly higher event rates than others (hazard ratio 2.74, 95% confidence interval 1.61 to 4.67, p <0.001). In conclusion, SR(IVR) was incremental to left ventricular ejection fraction, Thrombolysis In Myocardial Infarction grade 0 to 1 flow after percutaneous coronary intervention, and multivessel disease and superior to other diastolic indexes in predicting future cardiovascular events after AMI. SR(IVR) may be useful in identifying high-risk patients soon after AMI.
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Affiliation(s)
- Miriam Shanks
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
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Ng AC, Tran DT, Allman C, Vidaic J, Leung DY. Prognostic implications of left ventricular dyssynchrony early after non-ST elevation myocardial infarction without congestive heart failure. Eur Heart J 2009; 31:298-308. [DOI: 10.1093/eurheartj/ehp488] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Ng ACT, Delgado V, van der Kley F, Shanks M, van de Veire NRL, Bertini M, Nucifora G, van Bommel RJ, Tops LF, de Weger A, Tavilla G, de Roos A, Kroft LJ, Leung DY, Schuijf J, Schalij MJ, Bax JJ. Comparison of aortic root dimensions and geometries before and after transcatheter aortic valve implantation by 2- and 3-dimensional transesophageal echocardiography and multislice computed tomography. Circ Cardiovasc Imaging 2009; 3:94-102. [PMID: 19920027 DOI: 10.1161/circimaging.109.885152] [Citation(s) in RCA: 271] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND 3D transesophageal echocardiography (TEE) may provide more accurate aortic annular and left ventricular outflow tract (LVOT) dimensions and geometries compared with 2D TEE. We assessed agreements between 2D and 3D TEE measurements with multislice computed tomography (MSCT) and changes in annular/LVOT areas and geometries after transcatheter aortic valve implantations (TAVI). METHODS AND RESULTS Two-dimensional circular (pixr(2)), 3D circular, and 3D planimetered annular and LVOT areas by TEE were compared with "gold standard" MSCT planimetered areas before TAVI. Mean MSCT planimetered annular area was 4.65+/-0.82 cm(2) before TAVI. Annular areas were underestimated by 2D TEE circular (3.89+/-0.74 cm(2), P<0.001), 3D TEE circular (4.06+/-0.79 cm(2), P<0.001), and 3D TEE planimetered annular areas (4.22+/-0.77 cm(2), P<0.001). Mean MSCT planimetered LVOT area was 4.61+/-1.20 cm(2) before TAVI. LVOT areas were underestimated by 2D TEE circular (3.41+/-0.89 cm(2), P<0.001), 3D TEE circular (3.89+/-0.94 cm(2), P<0.001), and 3D TEE planimetered LVOT areas (4.31+/-1.15 cm(2), P<0.001). Three-dimensional TEE planimetered annular and LVOT areas had the best agreement with respective MSCT planimetered areas. After TAVI, MSCT planimetered (4.65+/-0.82 versus 4.20+/-0.46 cm(2), P<0.001) and 3D TEE planimetered (4.22+/-0.77 versus 3.62+/-0.43 cm(2), P<0.001) annular areas decreased, whereas MSCT planimetered (4.61+/-1.20 versus 4.84+/-1.17 cm(2), P=0.002) and 3D TEE planimetered (4.31+/-1.15 versus 4.55+/-1.21 cm(2), P<0.001) LVOT areas increased. Aortic annulus and LVOT became less elliptical after TAVI. CONCLUSIONS Before TAVI, 2D and 3D TEE aortic annular/LVOT circular geometric assumption underestimated the respective MSCT planimetered areas. After TAVI, 3D TEE and MSCT planimetered annular areas decreased as it assumes the internal dimensions of the prosthetic valve. However, planimetered LVOT areas increased due to a more circular geometry.
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Affiliation(s)
- Arnold C T Ng
- Department of Cardiology, the Department of Cardiothoracic Surgery, and the Department of Radiology, Leiden University Medical Center, Albinusdreef 2, Leiden, The Netherlands
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