Left Juxtaposition of the Right Atrial Appendage: Pitfalls in Diagnosis

Several congenital anomalies of the right atrial appendage (RAA) have been described including aneurysm, herniation (in association with a pericardial defect), and left juxtaposition. The left juxtaposition of the RAA (LJRAA), first described by Birmingham in 1893 and subsequently introduced by Dixon in 1954, is usually associated with complex cardiac malformations such as obstruction of the left ventricular outflow tract. In this case report, we will describe an unusual variant of LJRAA in the absence of any other cardiac defects, which was initially misinterpreted as an aortic dissection. The correct diagnosis was made after careful reinterpretation and the use of multiple imaging modalities as highlighted.

Nutritional markers accompanying acquired chylothorax in infants: a systematic review

CONTEXT

Chylothorax is a well-established acquired complication of thoracic surgery in infants. Current data suggest acquired chylothorax may affect infant growth and nutrition because of a loss of essential nutrients via chylous effusion.

OBJECTIVE

The 3 objectives for this study were: (1) identify nutritional markers affected by the development of acquired chylothorax in infants; (2) highlight the variability in methods used to assess nutritional status and growth in this patient population; and (3) highlight nutritional deficits that can serve as treatment targets during postoperative feeding protocols.

DATA SOURCES

A systematic literature search was conducted between May 31, 2021, and June 21, 2022, using the PubMed, Embase, CINAHL, and Web of Science databases. Search terms included, but were not limited to, "chylothorax," "infants," and "nutrition."

DATA EXTRACTION

Inclusion criteria required studies that measured quantitative markers of nutrition in ≥10 participants aged <1 year with acquired chylothorax. A total of 575 studies were screened and all but 4 were eliminated. Nutritional markers were categorized into 4 different groups: total serum protein level, triglyceride levels, growth velocity, and weight for length.

DATA ANALYSIS

The variation in methods, time points, interventional groups, and nutritional markers did not facilitate a meta-analysis. Risk of bias was assessed using the Cochrane Risk of Bias in Nonrandomized Studies assessment tool.

CONCLUSION

This review highlights the need for reliable quantitative markers of nutrition that will enable providers to assess the nutritional needs of infants with chylothorax. Future studies must focus on measuring markers of nutrition at regular intervals in larger study populations.

Impact of prenatal opioids on cardiac and autonomic development: systematic review and meta-analysis

Prenatal opioid exposure has recently risen four-fold with limited data on the developmental effects on neonatal physiology. The objective of this systematic review is to develop an association between prenatal opioid exposure and fetal and neonatal cardiac and autonomic development and function. The review was conducted in accordance with PRISMA Guidelines, and searches were conducted using PubMed, Embase, CINAHL, and Web of Science between May 25 and October 27, 2020. Twenty studies fit inclusion criteria, in four categories: (1) fetal cardiac outcomes, (2) neonatal cardiac outcomes, (3) noninvasive autonomic outcomes, and (4) clinical and behavioral measures. For the meta-analysis, three studies (total of 210 subjects) were included. Effect sizes were measured as the mean difference in fetal heart rate between opioid-exposed and non-exposed groups. Mothers with prenatal opioid use had a significantly lower fetal heart rate as compared to mothers without prenatal opioid use, requiring further studies to determine clinical significance.

Obese and Type 2 Diabetic Youth Have Increased Forward and Backward Wave Reflections

OBJECTIVE

Pulse wave analysis estimates arterial wave reflections relating to left ventricular dysfunction and cardiovascular event risk in adults. Forward and backward waves (Pf and Pb) may improve risk stratification for cardiovascular events. Data in youth are lacking. We hypothesized that a significant difference in wave reflections would be identified in young subjects with adverse cardiovascular risk factors. Approach and Results: Vital signs and labs were obtained in 551 patients aged 10 to 24 years who were lean (L=199), obese (O=173), or had type 2 diabetes (T=179). Wave separation was performed. Differences in cardiovascular risk factors and wave reflections were assessed using ANOVA. General linear models were constructed to elucidate independent predictors of wave reflections. O and T subjects had an adverse cardiovascular risk profile versus L. O and T subjects had higher Pf and Pb versus L (P≤0.05). When adjusted for adiposity and other cardiovascular risk factors, reflection magnitude increased from L to O to T with higher T versus L values (P≤0.05) and near-significant O versus L values (P=0.06). Adiposity and blood pressure were major determinants of wave reflections. Pb influenced log left ventricular mass index, log E/e', and log composite carotid intima-media thickness.

CONCLUSIONS

Adolescents and young adults with obesity and type 2 diabetes have altered forward and backward wave reflections versus lean controls related to adiposity, BP, and insulin levels. These parameters may help risk stratify patients with adverse cardiovascular risk factors.

Markers of cholesterol synthesis are elevated in adolescents and young adults with type 2 diabetes

BACKGROUND

Changes in cholesterol absorption and cholesterol synthesis may promote dyslipidemia and cardiovascular disease in individuals with type 2 diabetes mellitus (T2DM).

OBJECTIVE

To assess cholesterol synthesis and absorption in lean individuals, obese individuals, and individuals with T2DM.

METHODS

We measured lathosterol and lanosterol (markers of cholesterol synthesis) as well as campesterol and β-sitosterol (markers of cholesterol absorption) in the serum of 15 to 26 years old individuals with T2DM (n = 95), as well as their lean (n = 98) and obese (n = 92) controls.

RESULTS

Individuals with T2DM showed a 51% increase in lathosterol and a 65% increase in lanosterol compared to lean controls. Similarly, obese individuals showed a 31% increase in lathosterol compared to lean controls. Lathosterol and lanosterol were positively correlated with body mass index, fasting insulin and glucose, serum triglycerides, and C-reactive protein, and negatively correlated with HDL-cholesterol. In contrast, campesterol and β-sitosterol were not altered in individuals with T2DM. Moreover, campesterol and β-sitosterol were negatively correlated with body mass index, fasting insulin, and C-reactive protein and were positively correlated with HDL-cholesterol.

CONCLUSIONS

Adolescents and young adults with T2DM show evidence of increased cholesterol synthesis compared to non-diabetic lean controls. These findings suggest that T2DM may promote cardiovascular disease by increasing cholesterol synthesis, and provide additional rationale for the use of cholesterol synthesis inhibitors in this group.

Accelerated Early Vascular Aging Among Adolescents With Obesity and/or Type 2 Diabetes Mellitus

Background

The normal rate of subclinical vascular aging from adolescence to young adulthood has not been well‐characterized. We conducted a 5‐year longitudinal study among adolescents with normal‐weight, obesity, and/or type 2 diabetes mellitus to examine trajectories of early vascular aging.

Methods and Results

Adolescents (mean [SD] age 17.6 [3.5]; 35.3% male) had either normal weight (n=141), obesity (n=156), or type 2 diabetes mellitus (n=151) at baseline. Primary metrics used for early vascular aging included measures of vascular structure (carotid intima‐media thickness [cIMT]; common, internal, and bulb) and arterial stiffness (carotid‐femoral pulse wave velocity, and augmentation index). Longitudinal (5‐year) outcomes were examined using generalized estimating equations adjusting for baseline value, sex, race, and age. Compared with participants with normal weight, those with obesity had greater positive change in common cIMT (0.05 mm [0.03, 0.06]; P<0.001), bulb cIMT (0.02 mm [0.00, 0.05]; P=0.033), internal cIMT (0.03 mm [0.01, 0.05]; P<0.001), and pulse wave velocity carotid‐femoral (0.38 m/sec [0.14, 0.61]; P=0.001), and those with type 2 diabetes mellitus had greater positive change in common cIMT (0.05 mm [0.04, 0.07]; P<0.001), bulb cIMT (0.06 mm [0.04, 0.09]; P<0.001), internal cIMT (0.04 mm [0.02, 0.07]; P<0.001), augmentation index (4.67% [2.20, 7.13]; P<0.001), and pulse wave velocity carotid‐femoral (0.74 m/sec [0.46, 1.02]; P<0.001). Higher baseline systolic blood pressure was associated with greater positive change in common cIMT (0.007 mm [0.003, 0.011]; P<0.001), bulb cIMT (0.009 mm [0.002, 0.016]; P=0.01), internal cIMT (0.008 mm [0.003, 0.013]; P=0.001), and pulse wave velocity carotid‐femoral (0.066 m/sec [0.002, 0.130]; P=0.042).

Conclusions

These longitudinal data support the hypothesis that the presence of obesity, type 2 diabetes mellitus, and elevated baseline systolic blood pressure in early life accelerates the progression of risk factors key in the development of early vascular aging.

Type 1 diabetes is associated with an increase in cholesterol absorption markers but a decrease in cholesterol synthesis markers in a young adult population

BACKGROUND

To optimize treatment and prevent cardiovascular disease in subjects with type 1 diabetes, it is important to determine how cholesterol metabolism changes with type 1 diabetes.

OBJECTIVE

The objective of the study was to compare plasma levels of campesterol and β-sitosterol, markers of cholesterol absorption, as well as lathosterol, a marker of cholesterol synthesis, in youth with and without type 1 diabetes.

METHODS

Serum samples were obtained from adolescent subjects with type 1 diabetes (n = 175, mean age 15.2 years, mean duration of diabetes 8.2 years) and without diabetes (n = 74, mean age 15.4 years). Campesterol, β-sitosterol, and lathosterol, were measured using targeted liquid chromatography tandem mass spectrometry, compared between groups, and correlated with the available cardiometabolic variables.

RESULTS

Campesterol and β-sitosterol levels were 30% higher in subjects with type 1 diabetes and positively correlated with hemoglobin A1c levels. In contrast, lathosterol levels were 20% lower in subjects with type 1 diabetes and positively correlated with triglycerides, body mass index, and systolic blood pressure.

CONCLUSION

Plasma markers suggest that cholesterol absorption is increased, whereas cholesterol synthesis is decreased in adolescent subjects with type 1 diabetes. Further studies to address the impact of these changes on the relative efficacy of cholesterol absorption and synthesis inhibitors in subjects with type 1 diabetes are urgently needed.

Comparison of Left Ventricular Mass Calculation Methods via Two-Dimensional Echocardiogram in Children, Adolescents, and Young Adults With Systemic Hypertension

Left ventricular (LV) mass is a major determining tool for myocardial injury in hypertensive patients. Issues with LV mass calculations exist given that there are multiple methods to assess mass, including from the parasternal long axis (PLA), parasternal short axis (PSA), and 2-dimensional (2D) volumetric methods. The aim of this study was to compare the agreement of LV mass calculations using the PLA, PSA, and 2D volumetric methods. This study retrospectively reviewed 200 consecutive, initial echocardiograms for the indication of hypertension. A single reader calculated the LV mass in each patient via the PLA, PSA, and 2D volumetric methods. Percent differences for each study were calculated. LV mass threshold cutoffs of 51 g/m^2.7 (cardiac organ injury) and 38.6 g/m^2.7 (elevated LV mass) were used to compare categorical differences between the different measurement methods. Paired comparisons demonstrated an absolute mean percent difference of 8.46% to 9.41% among the different methods. LV mass calculated by the 2D volumetric method was less compared with PLA and PSA methods (31.64 vs 33.90 vs 35.51 g/m^2.7; p < 0.0001). Fewer patients were classified as having cardiac target organ injury or elevated LV mass via 2D volumetric calculation, compared with PLA and PSA methods (p = 0.02 and p = 0.03, respectively). In conclusion, there is a small but important difference in LV mass calculations for patients with hypertension. These results emphasize the need for consistency within echocardiography laboratories as surveillance studies are common in this patient population.

Clinical Implications of the Revised AAP Pediatric Hypertension Guidelines

BACKGROUND AND OBJECTIVES

New pediatric hypertension definitions were recently published in a clinical practice guideline (CPG). We evaluated the impact of the CPG, compared with the previous guideline ("Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents"), on the prevalence of hypertension and associations with target organ damage (TOD) in high-risk youth.

METHODS

Participants (10-18 years old) undergoing an evaluation of the cardiovascular effects of obesity and type 2 diabetes mellitus in youth were studied. Blood pressure was categorized according to the 2 guidelines as normal, elevated, and hypertension (stages 1 and 2). Measures of TOD (carotid artery intima-media thickness, pulse wave velocity, left ventricular mass, and diastolic function) were obtained. Associations between blood pressure categories and TOD and the sensitivity of hypertension classification in identifying TOD were evaluated.

RESULTS

Data were available for 364 participants (65% female sex; 15.1 ± 2.1 years of age). Hypertension was identified in 8% and 13% as defined in the Fourth Report and CPG, respectively (P = .007). The 2 guidelines revealed similar associations with TOD; however, the CPG demonstrated improved sensitivity of TOD detection in hypertensive participants. For example, the proportion of participants with an abnormal left ventricular mass categorized as hypertensive increased from 20% to 31% as defined in the Fourth Report and CPG, respectively (P < .001).

CONCLUSIONS

Incorporation of the CPG increased the prevalence of pediatric hypertension in a population of high-risk youth and improved the sensitivity of TOD identification in hypertensive participants.

Arterial Thickness and Stiffness Are Independently Associated with Left Ventricular Strain

BACKGROUND

The aim of this study was to examine the association between myocardial strain and arterial thickness and stiffness in young adults. Increased common carotid artery intima media thickness and peripheral arterial stiffness are known to precede coronary artery disease and cardiovascular (CV) events such as myocardial infarction and congestive heart failure. However, subclinical cardiac dysfunction can be detected in high-risk adults by myocardial strain echocardiography. The authors hypothesized that increased carotid artery intima media thickness would be associated with abnormal myocardial strain in young subjects who had obesity and type 2 diabetes mellitus.

METHODS

CV risk factors were collected in 338 young adults participating in a prospective, cross-sectional study. The CV parameters collected included intima-media thickness, peripheral arterial stiffness by brachial distensibility, and myocardial strain and strain rate. General linear models were constructed to determine if vascular structure and function measures were independently associated with myocardial strain and strain rate.

RESULTS

A linear relationship was found between global longitudinal strain obtained from the four-chamber view and global strain rate in systole and carotid intima-media thickness (four-chamber global longitudinal strain: β = 3.0, CV risk factor-adjusted R2 = 0.34; global strain rate in systole: β = 0.0053, R2 = 0.21; P ≤ .0001) and between four-chamber global longitudinal strain and lower brachial distensibility (β = -0.42, R2 = 0.22; P < .001).

CONCLUSIONS

Adverse changes in vascular structure and function are simultaneously present with reduced myocardial systolic function.

Obesity and type 2 diabetes are associated with elevated PCSK9 levels in young women

BACKGROUND

Proprotein convertase subtilisin/kexin type 9 (PCSK9) is a key regulator of low-density lipoprotein cholesterol and cardiovascular disease risk, and is an emerging therapeutic target.

OBJECTIVE

We compared serum PCSK9 levels in young adults, with and without type 2 diabetes.

SUBJECTS AND METHODS

Cross-sectional analysis was conducted in a cohort, aged 15 to 26 years, in Cincinnati, OH, from 2005 to 2010. Serum PCSK9 levels were measured in 94 youth with type 2 diabetes, 93 obese control subjects, and 99 lean control subjects. Correlative analyses were conducted to determine significant covariates of PCSK9 by group and sex, and multivariate linear regression models were used to study the independent determinants of PCSK9.

RESULTS

In females, PCSK9 levels were significantly increased in the obese and type 2 diabetes subjects relative to the lean controls (P < .01). Moreover, PCSK9 was positively correlated with multiple metabolic parameters in females: body mass index, systolic blood pressure, fasting glucose, fasting insulin, and C-reactive protein levels (P ≤ .02). In males, PCSK9 levels were decreased overall compared with females (P = .03), and did not differ between the lean, obese, or type 2 diabetes groups.

CONCLUSIONS

Obesity and type 2 diabetes were associated with significantly higher levels of PCSK9 in young women, but not in young men. These data suggest that sex could modify the effects of obesity and diabetes on PCSK9 in young adults.

Longitudinal Cardiovascular Outcomes of Sleep Disordered Breathing in Children: A Meta-Analysis and Systematic Review

Objectives

The presence of sleep disordered breathing (SDB) is known to impact long-term cardiovascular morbidity in adults; however, the long-term effects in children are poorly understood. We aimed to systematically review and synthesize studies published to date on the long-term effects of SDB in children.

Study Design

Meta-analysis and systematic review using PubMed, CINAHL, Embase, and Scopus (all indexed years).

Methods

We searched for English-language articles containing original human data from prospective studies, with ≥7 participants, in children ≤18 years of age. Data regarding study design, demographics, clinical characteristics, outcomes, level of evidence, and risk of bias were obtained. Articles were independently reviewed by three investigators. Retrospective and cross-sectional studies were excluded.

Results

Of 1701 identified abstracts, 25 articles (combined n = 1418) were ultimately included. All studies reported longitudinal outcomes following treatment of SDB, 21 studies exclusively reporting outcomes after adenotonsillectomy. Therefore, studies were combined to objectively assess the effect of SDB treatment on cardiovascular outcomes. Although all cardiovascular parameters were within the normal range at baseline, at follow-up there was a significant decrease in mean pulmonary artery pressure, right ventricular end diastolic diameter, heart rate, mitral Em/Am ratio, and C-reactive protein. There was no significant change in interventricular septum thickness, left ventricular parameters (shortening fraction, systolic and end diastolic diameters, ejection fraction, posterior wall thickness, isovolumetric relaxation time), left atrial diameter, and aortic and pulmonary valve peak velocities.

Conclusions

Studies assessing the long-term cardiovascular effects of SDB in children are limited. The available literature indicates effects on autonomic function, right, and left heart function following treatment for SDB. However, well-designed, large-scale, prospective cohort studies (using standardized outcomes) are needed to better understand the relationship of cardiovascular morbidity in the context of pediatric SDB.

Lipoprotein particle number and size predict vascular structure and function better than traditional lipids in adolescents and young adults

BACKGROUND

In adults, dyslipidemia is associated with higher carotid thickness and arterial stiffness, predictors of cardiovascular events. In young subjects, lipid concentrations have not been consistently associated with vascular measures.

OBJECTIVE

The objective of the study was to compare nuclear magnetic resonance (NMR) measures of lipoprotein particle number (low-density lipoprotein [LDL] particle, low-density lipoprotein [HDL] particle, very low-density lipoprotein [VLDL] particle) and size (LDL size, HDL size, and VLDL size) to determine if they were associated with vascular measures more strongly than lipid concentrations (LDL cholesterol, HDL cholesterol, and triglyceride [TG]).

METHODS

We evaluated 214 lean (L), 228 obese (O), and 214 diabetic (T2DM) subjects aged 10 to 24 years (33% male and 39% Caucasian). Cardiovascular risk factors, vascular structure, and arterial stiffness were measured. General linear models were constructed including demographics, risk factors, and traditional or NMR lipid parameters. A composite vascular function score was developed as the outcome in receiver operator characteristic scores for determining which lipid parameter was superior in predicting vascular damage.

RESULTS

Risk factors worsened from L to O to T. However, LDL cholesterol was similar in O and T, whereas LDL size differentiated the 3 groups (T > O > L, P ≤ .0001). Models demonstrated the superiority of NMR values, which entered for all but 1 vascular outcome and explained more of the variance than traditional lipid concentrations. Receiver operator characteristic curves demonstrated that NMR values were superior in predicting vascular outcomes. Models stratified by race were similar but cutpoints predicting vascular outcomes differed by race for TG, TG/HDL, and VLDL.

CONCLUSION

Lipoprotein particle number and size are more strongly related to vascular structure and function than traditional lipid values. NMR lipid measures may be a better indicator of risk for target organ damage than traditional lipid measures in adolescents and young adults.

Cardiomyopathy With Restrictive Physiology in Sickle Cell Disease

OBJECTIVES

The aim of this study was to identify a unifying cardiac pathophysiology that explains the cardiac pathological features in sickle cell disease (SCD).

BACKGROUND

Cardiopulmonary complications, the leading cause of adult death in SCD, are associated with heart chamber dilation, diastolic dysfunction, elevated tricuspid regurgitant jet velocity (TRV), and pulmonary hypertension. However, no unifying cardiac pathophysiology has been identified to explain these findings.

METHODS

In a 2-part study, we first examined patients with SCD who underwent screening echocardiography during steady state at our institution. We then conducted a meta-analysis of cardiac studies in SCD.

RESULTS

In the 134 patients with SCD studied (median age 11 years), significant enlargement of the left atrial volume was present (z-score 3.1, p = 0.002), shortening fraction was normal (37.6 ± 4.7%), and lateral and septal ratios of mitral velocity to early diastolic velocity of the mitral annulus (E/e') were severely abnormal in 8% and 14% of patients, respectively, indicating impaired diastolic function. Both TRV and lateral E/e' correlated with enlarged left atrial volume in SCD (p = 0.003 and p = 0.006, respectively). Meta-analysis of 68 studies confirmed significant left atrial diameter enlargement in patients with SCD compared with controls, evidence of diastolic dysfunction and enlarged left ventricular end-diastolic dimension with normal shortening fraction. The majority of patients with catheter-confirmed pulmonary hypertension had mild pulmonary venous hypertension consistent with restrictive cardiac physiology.

CONCLUSIONS

Patients with SCD have a unique form of cardiomyopathy with restrictive physiology that is superimposed on hyperdynamic physiology and is characterized by diastolic dysfunction, left atrial dilation, and normal systolic function. This combination results in mild, secondary, pulmonary venous hypertension and elevated TRV. Sudden death is common in other forms of restrictive cardiomyopathy. Our finding of this unique restrictive cardiomyopathy may explain the increased mortality rates and sudden death seen in patients with SCD with mildly elevated TRV.

Superiority of lipoprotein particle number to detect associations with arterial thickness and stiffness in obese youth with and without prediabetes

BACKGROUND

The nuclear magnetic resonance (NMR) lipoprotein profile provides additional cardiovascular risk information beyond traditional lipids in high-risk adults. Similar studies have not been conducted in youth.

OBJECTIVE

To evaluate the relationship between the NMR profile and preclinical vascular measures in youth.

METHODS

We studied 96 obese youth with prediabetes (mean age = 18.1 ± 3.6 years, 63% female, 78% African American) and 118 obese normoglycemic controls (mean age = 18.0 ± 3.1 years, 75% female, 62% African American) cross sectionally. Traditional lipids (triglycerides, total, high-density lipoprotein [HDL], and low-density lipoprotein [LDL] cholesterol), NMR particle size (particle concentration [P] and size) and vascular thickness (carotid IMT) and stiffness (pulse wave velocity [PWV]) were measured. Independent associations between lipoproteins with carotid IMT and PWV after adjustment for group, age, race, sex, BMI z score, blood pressure, HOMA-IR, and A1c were studied.

RESULTS

NMR analysis revealed youth with prediabetes exhibited a more atherogenic profile with higher levels of small LDL-P and HDL-P and lower levels of intermediate and large HDL-P (P < .03). In addition, lower intermediate HDL-P was associated with a higher carotid IMT, whereas higher small HDL-P was associated with a higher PWV (P < .01). Traditional lipids were not significantly different between groups and were not associated with either vascular outcome.

CONCLUSIONS

NMR lipoprotein subclasses have improved sensitivity compared to traditional lipids to detect lipoprotein abnormalities in normoglycemic and prediabetic obese youth and are independently associated with preclinical vascular thickness and stiffness. NMR lipids may enhance cardiovascular risk assessment in youth.

Single-Stage Repair of an Unusual Association: Congenital Gerbode Defect, Hypoplastic Aortic Arch, and Partially Anomalous Pulmonary Venous Return in an Infant

We present the case of a two-month-old male with congenital Gerbode defect, hypoplastic aortic arch, and left-sided partially anomalous pulmonary venous return. The patient underwent single-stage surgical repair, which consisted of aortic arch advancement with resection of the coarctation segment, pulmonary vein repair, and primary closure of the Gerbode defect. The anomalous pulmonary vein posed a particular challenge due to its size and distance from the left atrium, which we approached with a posterior atrial wall trapdoor baffle technique, without mobilizing the affected vein. Postoperatively and at one year follow-up, there was no evidence of residual lesions and there was unobstructed flow pattern across the aortic arch and the affected pulmonary vein.

New Reference Centiles for Left Ventricular Mass Relative to Lean Body Mass in Children

BACKGROUND

Echocardiographic measurement of left ventricular (LV) mass is routinely performed in pediatric patients with elevated cardiovascular risk. The complex relationship between heart growth and body growth in children requires normalization of LV mass to determine its appropriateness relative to body size. LV mass is strongly determined by lean body mass (LBM). Using new LBM predictive equations, the investigators generated sex-specific LV mass-for-LBM centile curves for children 5 to 18 years of age.

METHODS

This retrospective study used M-mode echocardiographic data collected from 1995 through 2003 from 939 boys and 771 girls between 5 and 18 years of age (body mass index < 85th percentile for sex and age) to create smoothed sex-specific LV mass-for-LBM reference centile curves using the Lamda Mu Sigma method. The newly developed reference centiles were applied to children with essential hypertension and with chronic kidney disease, groups known to be at high risk for LV hypertrophy (LVH). The identification of LVH using two different normalization approaches was compared: LV mass-for-LBM and LV mass index-for-age percentiles.

RESULTS

Among 231 children at risk for LVH, on average, relative LV mass was higher using the LV mass index-for-age percentile method than the LV mass-for-LBM percentile method. LVH was more likely to be diagnosed among overweight children and less likely among thin children.

CONCLUSIONS

This study provides new LV mass reference centiles expressing LV mass relative to LBM, the strongest determinant of LV mass. These reference centiles may allow more accurate stratification of cardiovascular risk in children.

Comparison of mercury sphygmomanometry blood pressure readings with oscillometric and central blood pressure in predicting target organ damage in youth

OBJECTIVE

Hypertension (HT) is an important risk factor for target organ damage (TOD). New methods for measuring BP are replacing mercury sphygmomanometry in many clinics. We examined the utility of different BP measurement techniques in predicting subclinical TOD in adolescents and young adults.

METHODS

Participants in a study of the cardiovascular effects of obesity and type 2 diabetes were evaluated (N=677, 18±3.3 years, 35% male, 60% non-White, 30% with type 2 diabetes). We measured adiposity, laboratory data, left ventricular mass, carotid intima-media thickness, and pulse wave velocity. BP was measured three times by mercury sphygmomanometry (BPm), using an oscillometric device (BPo), and by arterial tonometry to measure central aortic BP (BPc). Participants were stratified as normotensive, prehypertensive, or hypertensive.

RESULTS

The prevalence of HT in this cohort with a mean BMI of 31 was the highest on BPo measurement (16%), followed by BPm (11%) and BPc (9%; P≤0.001) measurements. BPm was the most consistent in differentiating left ventricular mass and pulse wave velocity among participants in the prehypertensive group as compared with the normotensive and hypertensive groups. Mercury BP measurement was also more sensitive and specific at predicting greater left ventricular mass, pulse wave velocity, and carotid thickness compared with other BP measurement techniques in logistic regression.

CONCLUSION

We conclude that mercury sphygmomanometry should remain the gold standard for evaluation of HT and the risk for TOD in adolescents and young adults.

Adiposity has no direct effect on carotid intima-media thickness in adolescents and young adults: Use of structural equation modeling to elucidate indirect & direct pathways

BACKGROUND

Carotid intima-media thickness (cIMT) is associated with CV events in adults. Thicker cIMT is found in youth with CV risk factors including obesity. Which risk factors have the most effect upon cIMT in youth and whether obesity has direct or indirect effects is not known. We used structural equation modeling to elucidate direct and indirect pathways through which obesity and other risk factors were associated with cIMT.

METHODS

We collected demographics, anthropometrics and laboratory data on 784 subjects age 10-24 years (mean 18.0 ± 3.3 years). Common, bulb and internal carotid cIMT were measured by ultrasound. Multivariable regression analysis was performed to assess independent determinants of cIMT. Analyses were repeated with structural equation modeling to determine direct and indirect effects.

RESULTS

Multivariable regression models explained 11%-22% of variation of cIMT. Age, sex and systolic blood pressure (BP) z-score were significant determinants of all cIMT segments. Body mass index (BMI) z-score, race, presence of type 2 diabetes mellitus (T2DM), hemoglobin A1c (HbA1c) and non-HDL were significant for some segments (all p = 0.05). The largest direct effect on cIMT was age (0.312) followed by BP (0.228), Blood glucose control (0.108) and non-HDL (0.134). BMI only had a significant indirect effect through blood glucose control, BP & non-HDL. High sensitivity C-reactive protein (CRP) had a small indirect effect through blood glucose control (all p = 0.05).

CONCLUSIONS

Age and BP are the major factors with direct effect on cIMT. Glucose and non-HDL were also important in this cohort with a high prevalence of T2DM. BMI only has indirect effects, through other risk factors. Traditional CV risk factors have important direct effects on cIMT in the young, but adiposity exerts its influence only through other CV risk factors.

Low Serum Vitamin D Levels Are Associated With Increased Arterial Stiffness in Youth With Type 2 Diabetes

OBJECTIVE

Adult studies demonstrate that low vitamin D (25[OH]D) is an independent risk factor for arterial stiffness. Similar studies have not been conducted in youth with type 2 diabetes mellitus (T2DM). The objective was to elicit the association between 25[OH]D and arterial stiffness in obese youth with and without T2DM. We hypothesized that 25[OH]D would be inversely correlated with arterial stiffness indices, including pulse wave velocity (PWV), augmentation index (AIx), and brachial distensibility (BrachD).

RESEARCH DESIGN AND METHODS

Cross-sectional analysis was conducted in Cincinnati, OH, from 2004 to 2010. 25[OH]D, PWV, AIx, and BrachD were measured in 190 youth with T2DM, 190 obese control subjects without T2DM, and 190 lean control subjects without T2DM. Multivariate analyses were conducted to elicit the independent association between 25[OH]D and arterial stiffness indices by group.

RESULTS

The mean age was 17.9 ± 3.4 years, 55% were African American, and 34% were male. The mean 25[OH]D levels were 21.27, 14.29, and 14.13 ng/mL in lean individuals, obese individuals, and obese individuals with T2DM, respectively (P < 0.01). PWV, AIx, and BrachD worsened from lean to obese to T2DM (P < 0.01). General linear models found that 25[OH]D level was independently associated with PWV in lean individuals and with AIx in the group with T2DM such that a 3 ng/mL increase in 25[OH]D was associated with an AIx decrease of 1% (baseline AIx = 5.7 ± 12.0%).

CONCLUSIONS

25[OH]D is inversely associated with some measures of arterial stiffness in lean adolescents and obese adolescents with T2DM but not in obese normoglycemic adolescents. Future studies are needed to determine if supplemental 25[OH]D is important for cardiovascular health.

Severe Obesity in Adolescents and Young Adults Is Associated With Subclinical Cardiac and Vascular Changes

CONTEXT

Severe obesity is the fastest growing subgroup of obesity in youth.

OBJECTIVE

We sought to explore the association between severe obesity and subclinical measures of cardiac and vascular structure and function in adolescents and young adults.

DESIGN, SETTING, AND PARTICIPANTS

This was a cross-sectional comparison of 265 adolescents and young adults with severe obesity (defined as body mass index [BMI] ≥120% of the 95th percentile) to 182 adolescents and young adults with obesity (defined as BMI ≥100-119th of the 95th percentile) at tertiary medical center.

MAIN OUTCOMES

Noninvasive measures of cardiac and vascular structure and function were assessed.

RESULTS

Participants were a mean age of 17.9 years, 62% were non-Caucasian, and 68% were female. Systolic blood pressure, fasting insulin, C-reactive protein, IL-6, and frequency of type 2 diabetes were higher in participants with severe obesity (all P < .05). Arterial thickness and stiffness, cardiac structure, and diastolic function were also significantly worse in youth with severe obesity as measured by higher left ventricular mass index, worse diastolic function, higher carotid intima media thickness, and pulse wave velocity and lower brachial distensibility (all P < .05). Regression modeling showed that severe obesity (compared with obesity) was independently associated with each of the above outcomes after adjustment for age, race, sex, blood pressure, lipids, and inflammatory markers (P < .05).

CONCLUSIONS

Adolescents and young adults with severe obesity have a more adverse cardiovascular risk profile and worse cardiac and vascular structure and function. More importantly, severe obesity is independently associated with these subclinical cardiac and vascular changes.

Prediabetes: the effects on arterial thickness and stiffness in obese youth

OBJECTIVE

Adults with prediabetes are at increased risk to develop cardiovascular disease. Whether prediabetes in adolescents is associated with early markers of cardiovascular disease is not known. We sought to 1) compare the cardiovascular risk profiles among adolescents and young adults with prediabetes with those with normal glucose tolerance and 2) determine whether prediabetes is independently associated with noninvasive measures of arterial thickness and stiffness.

RESEARCH DESIGN AND METHODS

We studied 102 obese youth with prediabetes and 139 obese youth with normal glucose tolerance in a cross-sectional study. Prediabetes or at increased diabetes risk was diagnosed by a fasting blood glucose level of ≥100 to 125 mg/dL, 2-hour oral glucose tolerance test value of ≥140 to 199 mg/dL, or a hemoglobin A1c (HbA1c) value of ≥5.7% to 6.4%. Arterial thickness and stiffness were measured by carotid intima-media thickness (IMT), augmentation index, pulse wave velocity, and brachial distensibility (BrachD).

RESULTS

Nearly 50% of youth were diagnosed with prediabetes by HbA1c. Youth with prediabetes had worse metabolic profiles with higher BMI z score, systolic blood pressure, and fasting insulin; increased carotid IMT; and lower BrachD compared with normal glucose-tolerant youth (P < .05). Multivariate regression analysis found prediabetes was a significant determinant of internal carotid IMT and BrachD (P < .05). After excluding youth diagnosed by HbA1c, the prediabetes group was borderline significant for internal carotid IMT (.1 > P ≥ .05) only.

CONCLUSIONS

Youth with prediabetes have worse cardiometabolic risk factors and evidence of increased arterial thickness and stiffness. Interventions to prevent prediabetes are crucial to reduce the development of early arterial disease.

Echo-Doppler assessment of the biophysical properties of the aorta in children with chronic kidney disease

Chronic kidney disease (CKD) is known to cause increased arterial stiffness, which is an important independent risk factor for adverse cardiovascular events. The purpose of this study was to assess the vascular properties of the aorta (AO) in a group of children with CKD using a noninvasive echocardiography (echo)-Doppler method. We studied 24 children with stages 2 through 5 CKD and 48 age-matched controls. Detailed echocardiographic assessment and echo-Doppler pulse wave velocity (PWV) was performed. Indices of arterial stiffness, including characteristic (Zc) and input (Zi) impedances, elastic pressure-strain modulus (Ep), and arterial wall stiffness index, were calculated. CKD patients underwent full nephrology assessment, and an iohexol glomerular filtration rate was performed, which allowed for accurate assignment of the CKD stage. CKD patients had greater median systolic blood pressure (114 vs. 110 mmHg; p < 0.04) and pulse pressure (51 vs. 40 mmHg; p < 0.001) compared with controls. PWV was similar between groups (358 vs. 344 cm s(-1); p = 0.759), whereas Zi (182 vs. 131 dyne s cm(-5); p < 0.001), Zc (146 vs. 138 dyne s cm(-5); p = 0.05), and Ep (280 vs. 230 mmHg; p < 0.02) were significantly greater in CKD than in controls. Although load-dependent measures of arterial stiffness were greater in non-dialysis dependent CKD patients, PWV was not increased compared with controls. This suggests that the increased arterial stiffness may not be permanent in these pediatric patients with kidney disease.

Lipids and lipoprotein ratios: contribution to carotid intima media thickness in adolescents and young adults with type 2 diabetes mellitus

BACKGROUND

Dyslipidemia is common among adolescents with type 2 diabetes (T2D).

OBJECTIVE

To assess whether the lipoprotein ratios of low-density lipoprotein (LDL) cholesterol/high-density lipoprotein (HDL) cholesterol or triglycerides/HDL or non-HDL cholesterol are more useful than the traditional lipid panel to predict increased arterial thickness in adolescents and young adults with T2D.

METHODS

We evaluated 244 adolescents and young adults with T2D in a cross-sectional study (mean age 18 years; 56% African American; 65% female). Demographics, anthropometrics, and laboratory data were collected. Arterial thickness was assessed with carotid intima media thickness (IMT). Bivariate correlations and general linear models were used to determine the independent contributions of the various lipid parameters to carotid IMT.

RESULTS

Bivariate correlations showed LDL/HDL ratio was the strongest predictor of carotid IMT (P < .02). After adjustment for potential covariates LDL/HDL was no longer significant. HDL cholesterol was the only lipid to independently (negatively) contribute to carotid IMT. Other risk factors that were independently associated with carotid IMT included age, race, sex, body mass index z score, and hemoglobin A1c. Together these cardiovascular risk factors explained <20% of the variance in carotid IMT.

CONCLUSIONS

HDL cholesterol is the only lipid to independently associate with carotid IMT. Lipoprotein ratios and non-HDL did not provide additional information. The low variance in carotid IMT explained by traditional risk factors suggests nontraditional risk factors may be important to assess to better understand the contributors to early-stage atherosclerosis in adolescents and young adults with T2D.

Abstract 333: Design and Implementation of a Pediatric Outpatient Cardiology Clinic Renovation Utilizing Quality Improvement Methodology

Background: With increasing pressure to manage medical resources prudently, quality improvement methodology can be utilized to increase efficiency and decrease cost in current outpatient cardiology clinic operations. However, there are few examples of quality improvement methodology applied to the design, implementation and management of a renovation project aimed at meeting a five year projected volume increase of 155% and multidisciplinary clinic expansion. We hypothesized that by using quality improvement methodology, the increasing volume demands could be met by improving clinic flow and thus maintain patient access while reducing medical resource expansion.

Methods: Outpatient cardiology clinics and testing functions were assessed for clinic visit volumes and duration, testing volumes and durations, patient no show rates, the number of provider clinic hours, room utilization, scheduling template design and accuracy, and the scheduling process. Baseline assessments were made prior to process improvement efforts. A series of interventions were made as follows: modification of the patient follow up scheduling process, reduction in the number of scheduling templates, modification of templates to include pre visit nursing and electrocardiographic acquisition time, change from half day to all day clinic templates, pre visit registration, limiting of exam room assignment to a maximum of 3 per provider and spread of the clinic across 5 days per week.

Results: Baseline data revealed a 43% no show rate, room utilization was 34%, patient access defined by lag days between first contact and appointment was 22 days. These metrics indicated that the number of exam rooms needed to meet our projected volume increase would result in an increase from 10 to 30 rooms. Two years into our interventions and our no show rate is 6%, room utilization is 68%, patient access has improved with lag days at 10. These improvements have occurred in the presence of an 18% annual volume increase, an increase of 5% in patient provider hours and an exam room increase from 10 to 23.

Conclusions: Process improvement methodology applied to room utilization, patient scheduling, provider staffing patterns and clinic visit templates can be successfully utilized to design and implement an outpatient cardiology clinic renovation. If properly applied, process improvement can be a method to maximize the use of current and future medical resources while insuring patient access to services.

Triglyceride to HDL-C ratio and increased arterial stiffness in children, adolescents, and young adults

BACKGROUND AND OBJECTIVE

Lipid levels are linked to early atherosclerosis. Risk stratification may be improved by using triglyceride to high-density lipoprotein cholesterol ratio (TG/HDL-C), which relates to arterial stiffness in adults. We tested whether TG/HDL-C was an independent predictor of arterial stiffness in youth.

METHODS

Subjects 10 to 26 years old (mean 18.9 years, 39% male, 56% non-Caucasian, n = 893) had laboratory, anthropometric, blood pressure, and arterial stiffness data collected (brachial distensibility, augmentation index, carotid-femoral pulse-wave velocity). Subjects were stratified into tertiles of TG/HDL-C (low, n = 227; mid, n = 288; high, n = 379).

RESULTS

There was a progressive rise in cardiovascular (CV) risk factors and arterial stiffness across TG/HDL-C ratio. The high TG/HDL-C ratio group had the stiffest vessels (all P < .03 by analysis of variance). TG/HDL-C as a continuous variable was an independent determinant of brachial distensibility in CV risk factor adjusted model and for carotid-femoral pulse-wave velocity in obese subjects, with trend for higher augmentation index.

CONCLUSIONS

TG/HDL-C, an estimate of small, dense low-density lipoprotein cholesterol, is an independent determinant of arterial stiffness in adolescents and young adults, especially in obese youth. These data suggest that use of TG/HDL-C may be helpful in identifying young adults requiring aggressive intervention to prevent atherosclerotic CV diseases.

Physical activity is independently associated with multiple measures of arterial stiffness in adolescents and young adults

Physical activity (PA) is associated with decreased levels of arterial stiffness in adults, but the relationship between PA and multiple measures of arterial stiffness in adolescents and young adults is not clear. The objective of this study was to test the hypothesis that PA is an independent predictor of multiple measures of arterial stiffness in adolescents and young adults. A total of 548 participants were enrolled in a study of the cardiovascular effects of obesity and type 2 diabetes mellitus (T2DM) (lean, 201; obese, 191; T2DM, 156). Anthropometrics, blood pressure, central and peripheral measures of arterial stiffness (pulse wave velocity, brachial distensibility, and augmentation index), blood (lipids and metabolic tests), and accelerometry data were collected. General linear modeling was performed to test for the independent relationship of PA on arterial stiffness. The mean age of the participants was 17.9 years (standard deviation, 3.5 years). After adjusting for other cardiovascular disease risk factors such as age, sex, body size, mean arterial pressure, and the presence of obesity or T2DM, PA was an independent predictor of augmentation index and brachial distensibility (P < .001). A greater effect of PA on pulse wave velocity was found in participants with T2DM (P = .009) compared with participants in the lean or obese groups. Physical activity is significantly and independently associated with multiple measures of arterial stiffness in adolescents and young adults. The role of PA in the prevention of cardiovascular disease target organ damage in youth, independent of energy balance, merits further exploration.

Racial differences in arterial stiffness among adolescents and young adults with type 2 diabetes

BACKGROUND

African-American adults demonstrate a higher prevalence of cardiovascular complications including myocardial infarction and stroke. Whether similar racial disparities are present to suggest African-Americans adolescents are at higher risk to develop cardiovascular disease is not known. Thus, we compared arterial stiffness, an early marker of cardiovascular disease, in African-American and Caucasian adolescents and young adults with type 2 diabetes.

METHODS

Demographic, anthropometric, laboratory data, and arterial stiffness measures including pulse wave velocity (PWV) and augmentation index (AIx) were collected in a cross-sectional study of 215 adolescents (average age 18 yr) with type 2 diabetes (55% African-American and 65% female).

RESULTS

Compared to Caucasians, African-Americans had increased PWV (6.21 ± 0.87 vs. 6.96 ± 1.30, p < .01) and AIx (4.44 ± 11.17 vs. 7.64 ± 12.02, p = 0.05). Regression modeling demonstrated age, lipids, blood pressure, and duration of diabetes were differently associated with arterial stiffness in each race group (p < 0.05).

CONCLUSIONS

African-American adolescents and young adults with type 2 diabetes have increased vascular stiffness than age-matched Caucasians. This process is mediated by different cardiovascular risk factors. These results suggest race-specific risk factor modification may be helpful to prevent early cardiovascular disease in this high risk population.

Cardiovascular impact of the pediatric obesity epidemic: higher left ventricular mass is related to higher body mass index

OBJECTIVE

To compare secular changes in body mass index (BMI) and left ventricular mass (LVM) in today's children versus children of a generation earlier.

STUDY DESIGN

All healthy patients aged 2 to 19 years who underwent echocardiography at a single US academic medical center in 1986 to 1989 (prior era) and 2008 (current era) were included in this retrospective cross-sectional study. BMI, BMI z score, LVM indexed to height (LVMI), LVM z score, and relative wall thickness were calculated. Cardiac geometries were assigned based on LVM z score and relative wall thickness and classified as normal, concentric hypertrophy, eccentric hypertrophy, or concentric remodeling. Stepwise regression analysis was performed to identify determinants of LVMI.

RESULTS

There were 350 subjects in the prior era and 350 age- and sex-matched subjects in the current era. Mean BMI and LVMI were both significantly higher in the current era than in the prior era (BMI, 19.9 ± 5.6 kg/m(2) vs 18.1 ± 3.8 kg/m(2), P = .0004; LVMI, 32.7 ± 7.8 g/m(2.7) vs 31.5 ± 8.1 g/m(2.7); P = .02). Determinants of LVMI in both eras were BMI z score, younger age, male sex, and African-American race.

CONCLUSIONS

Today's children have higher BMI, LVMI, and predicted cardiovascular risk than their counterparts a generation earlier. Reversal of these trends is needed, and intervention is required.

Cardiac and vascular consequences of pre-hypertension in youth

Hypertension is associated with increased left ventricular mass (LVM) and carotid intima-media thickness (cIMT), which predict cardiovascular (CV) events in adults. Whether target organ damage is found in pre-hypertensive youth is not known. The authors measured body mass index, blood pressure, fasting glucose, insulin, lipids and C-reactive protein, LVM/height(2.7) (LVM index), diastolic function, cIMT, carotid stiffness, augmentation index, brachial artery distensibility, and pulse wave velocity (PWV) in 723 patients aged 10 to 23 years (29% with type 2 diabetes mellitus). Patients were stratified by blood pressure level (normotensive: 531, pre-hypertensive: 65, hypertensive: 127). Adiposity and CV risk factors worsened across blood pressure group. There was a graded increase in cIMT, arterial stiffness, and LVM index and decrease in diastolic function from normotension to pre-hypertension to hypertension. In multivariable models adjusted for CV risk factors, status as pre-hypertension or hypertension remained an independent determinant of target organ damage for LVM, diastolic function, internal cIMT, and carotid and arterial stiffness. Pre-hypertension is associated with cardiovascular target organ damage in adolescents and young adults.

The effects of obesity and type 2 diabetes mellitus on cardiac structure and function in adolescents and young adults

AIMS/HYPOTHESIS

We sought to evaluate the effects of obesity and obesity-related type 2 diabetes mellitus on cardiac geometry (remodelling) and systolic and diastolic function in adolescents and young adults.

METHODS

Cardiac structure and function were compared by echocardiography in participants who were lean, obese or obese with type 2 diabetes (obese diabetic), in a cross sectional study. Group differences were assessed using ANOVA. Independent determinants of cardiac outcome measures were evaluated with general linear models.

RESULTS

Adolescents with obesity and obesity-related type 2 diabetes were found to have abnormal cardiac geometry compared with lean controls (16% and 20% vs <1%, p < 0.05). These two groups also had increased systolic function. Diastolic function decreased from the lean to obese to obese diabetic groups with the lowest diastolic function observed in the obese diabetic group (p < 0.05). Regression analysis showed that group, BMI z score (BMIz), group × BMIz interaction and systolic BP z score (BPz) were significant determinants of cardiac structure, while group, BMIz, systolic BPz, age and fasting glucose were significant determinants of the diastolic function (all p < 0.05).

CONCLUSIONS/INTERPRETATION

Adolescents with obesity and obesity-related type 2 diabetes demonstrate changes in cardiac geometry consistent with cardiac remodelling. These two groups also demonstrate decreased diastolic function compared with lean controls, with the greatest decrease observed in those with type 2 diabetes. Adults with diastolic dysfunction are known to be at increased risk of progressing to heart failure. Therefore, our findings suggest that adolescents with obesity-related type 2 diabetes may be at increased risk of progressing to early heart failure compared with their obese and lean counterparts.

Clustering of risk factors: a simple method of detecting cardiovascular disease in youth

OBJECTIVE

Cardiovascular risk assessment is an accepted practice in adults and correlates with early changes in carotid structure and function. Its clinical use in pediatrics is less common. We sought to determine whether a simple method of clustering cardiovascular risks could detect early atherosclerotic changes in youth. In addition, we compared risk clustering with the accepted Patholobiological Determinants of Atherosclerosis in Youth score to assess its utility for predicting early vascular disease.

PATIENTS AND METHODS

We collected demographic, anthropometric, laboratory, and vascular measures in a cross-sectional study. The study population (n = 474; mean age: 18 years) was divided into low-risk (0-1) or high-risk (≥ 2) groups on the basis of the number of cardiovascular risk factors present at evaluation. Group differences and vascular outcomes were compared. General linear models were used to compare clustering cardiovascular risks with the Patholobiological Determinants of Atherosclerosis in Youth score.

RESULTS

The high-risk group had higher vascular thickness and stiffness compared with the low-risk group (P < .05). Regression models found that clustering cardiovascular risks is associated with abnormal vascular structure and function after adjustment for age, race, and gender. The Patholobiological Determinants of Atherosclerosis in Youth score also is associated with abnormal vascular structure and function but with lower R(2) values (P < .05).

CONCLUSIONS

Cardiovascular risk clustering is a reliable tool for assessing abnormal vascular function. Its simplicity, compared with the Patholobiological Determinants of Atherosclerosis in Youth score, provides an advantageous tool for the practicing clinician to identify those youth who are at higher risk for early cardiovascular disease.

Disparities exist in the emergency department evaluation of pediatric chest pain

OBJECTIVES

To identify and describe disparities in the provision of Emergency Department (ED) care in pediatric patients presenting with chest pain (CP).

PATIENTS AND METHODS

Nationally representative data were drawn from the National Hospital Ambulatory Medical Care Survey (NHAMCS). All ED visits with a chief complaint of CP and age <19 years from 2002 to 2006 were analyzed. The primary outcome variable was "Anytest" performed (defined as any combination of complete blood count, electrocardiogram, and/or chest x-ray). Univariable analyses were performed with "Anytest" as the dependent variable and patient characteristics as independent variables. Multivariable analysis was performed using logistic regression with the same independent patient characteristics.

RESULTS

Eight hundred eighteen pediatric CP visits representing 2 552 193 such visits nationwide were analyzed. Gender and metro/non-metro location were not associated with "Anytest." However, Caucasian patients (p = 0.01) and those with private insurance (p < 0.01) were significantly more likely to receive testing despite otherwise similar demographics and severity of illness. Multivariate analysis revealed race (p = 0.03), expected payer (p = 0.003), and triage level (p = 0.009) were significantly and independently associated with the frequency of testing performed.

CONCLUSION

Disparities exist in the ED care of pediatric patients with CP. Identification of such variations is important and provides an opportunity for targeted interventions that ensure delivery of high-quality, cost-effective health care for children.

Aortic arch recoarctation after the Norwood stage I palliation: the comparative accuracy of blood pressure cuff and echocardiographic Doppler gradients in detecting significant obstruction

OBJECTIVE

Aortic arch recoarctation is responsible for significant morbidity and mortality after the Norwood Stage I procedure. Cuff blood pressure (BP) gradients and echocardiographic Doppler gradients are routinely used as noninvasive screening tests for early detection, but accuracy has not been systematically tested. We sought to evaluate the ability of cuff BP and Doppler gradients, measured at routine outpatient clinic visits, to predict significant arch obstruction in single ventricle patients after the Norwood operation.

DESIGN

Consecutive patients who underwent Norwood operation at our institution were identified retrospectively. Cuff and echocardiographic gradients measured prior to the pre-Glenn catheterization were compared to peak-to-peak systolic neoaortic arch gradients obtained at catheterization. Statistical analyses, including Receiver Operator Characteristic (ROC) curves, were performed using different cutpoints for cuff and echocardiographic gradients, evaluating their ability to predict a clinically significant catheter gradient.

RESULTS

Data were obtained in 68 patients. Echocardiographic gradient cutpoints were more sensitive but less specific than cuff BP gradient cutpoints at detecting a catheter gradient > or = 10 mm Hg. Echo gradients > or = 20 mm Hg showed 85% sensitivity and 95% specificity in detecting a systolic catheter gradient > or = 10 mm Hg.

CONCLUSION

chocardiographic Doppler outperforms cuff BP as a sensitive noninvasive screening tool for early detection of significant arch obstruction in infants after the Norwood operation.

Anomalous origin of the right coronary artery from the left ventricle

A 22-month-old boy was referred to pediatric cardiology for evaluation of a heart murmur. He was asymptomatic except for occasional wheezing with activity. On evaluation, he was found to have both systolic and diastolic murmurs. Electrocardiography demonstrated possible left ventricular hypertrophy, with no evidence of ST-segment abnormalities. Echocardiography and cardiac catheterization showed an anomalous origin of the patient's right coronary artery from his left ventricle, just inferior to his aortic valve annulus.

Influence of duration of diabetes, glycemic control, and traditional cardiovascular risk factors on early atherosclerotic vascular changes in adolescents and young adults with type 2 diabetes mellitus

BACKGROUND

Carotid intima-media thickness (IMT) provides a mechanism for detecting early atherosclerosis. Little information is available concerning carotid IMT and the progression of atherosclerosis in adolescents and young adults with type 2 diabetes mellitus.

OBJECTIVE

We sought to determine the factors that contribute to early changes in carotid IMT in youth with type 2 diabetes mellitus and to identify any predictors of increased carotid IMT.

METHODS

Demographic, anthropometric, laboratory data and carotid imaging were obtained in 129 youth of mixed ethnicity, ages 10-23 yr. Associations of carotid IMT outcomes and risk variables were analyzed by regression analysis. Logistic regression was performed to elucidate independent determinants that predict a worse carotid IMT.

RESULTS

Carotid IMT increased with higher glycosylated hemoglobin (HbA1c) levels and longer duration of diabetes. Regression modeling showed that HbA1c and duration of diabetes in the presence of traditional cardiovascular risk factors (male sex, LDL cholesterol, and blood pressure) were independent determinants of carotid IMT. Logistic regression analysis demonstrated that each 1% increase in HbA1c or each year increase in duration of type 2 diabetes mellitus is associated with approximately 30% increased odds of a thicker carotid IMT.

CONCLUSIONS

Poorer glycemic control and longer disease duration have independent adverse effects on carotid IMT in youth with type 2 diabetes mellitus. These adverse effects appear to be more prominent in males. Developing effective strategies to improve blood glucose control in youth with type 2 diabetes mellitus is essential to prevent or limit the development and progression of atherosclerotic cardiovascular disease.

Youth with obesity and obesity-related type 2 diabetes mellitus demonstrate abnormalities in carotid structure and function

BACKGROUND

Adults with obesity or type 2 diabetes mellitus (T2DM) are at higher risk for stroke and myocardial infarction. Increased carotid intima-media thickness (cIMT) and stiffness are associated with these adverse outcomes. We compared carotid arteries in youth who were lean, were obese, or had T2DM.

METHODS AND RESULTS

Carotid ultrasound for cIMT measurement was performed, the Young elastic modulus and beta stiffness index were calculated, and anthropometric and laboratory values and blood pressure were measured in 182 lean, 136 obese, and 128 T2DM youth (aged 10 to 24 years). Mean differences were evaluated by ANOVA. Independent determinants of cIMT, Young elastic modulus, and beta stiffness index were determined with general linear models. Cardiovascular risk factors worsened from lean to obese to T2DM groups. T2DM subjects had greater cIMT than that in lean and obese subjects for the common carotid artery and bulb. For the internal carotid artery, cIMT measurements in both obese and T2DM groups were thicker than in the lean group. The carotid arteries were stiffer in obese and T2DM groups than in the lean group. Determinants of cIMT were group, group x age interaction, sex, and systolic blood pressure for the common carotid artery (r2=0.17); age, race, and systolic blood pressure for the bulb (r2=0.16); and age, race, sex, systolic blood pressure, and total cholesterol for the internal carotid artery (r2=0.21). Age, systolic blood pressure, and diastolic blood pressure were determinants of all measures of carotid stiffness, with sex adding to the Young elastic modulus (r2=0.23), and body mass index Z score, group, and group x age interaction contributing to the beta stiffness index (r2=0.31; all P<0.0001).

CONCLUSIONS

Youth with obesity and T2DM have abnormalities in carotid thickness and stiffness that are only partially explained by traditional cardiovascular risk factors. These vascular changes should alert healthcare practitioners to address cardiovascular risk factors early to prevent an increase in the incidence of stroke and myocardial infarction.

Cardiac output and associated left ventricular hypertrophy in pediatric chronic kidney disease

A significant number of children with chronic kidney disease (CKD) have eccentric left ventricular hypertrophy (LVH), suggesting the role of preload overload. Therefore, we hypothesized that increased cardiac output (CO) might be a contributing factor for increased left ventricular mass index (LVMI) in these children. Patients aged 6-20 years with CKD stages 2-4 were enrolled. Echocardiograms were performed to assess LV function and geometry at rest and during exercise. Heart rate, stroke volume, and CO were also assessed at rest and during exercise. Twenty-four-hour ambulatory blood pressure (AMBP) monitoring was performed. Of the patients enrolled in this study, 17% had LVH. Increased stroke volume and CO were observed in patients with LVH compared to patients without LVH. Univariate analysis revealed significant positive associations between LVMI and CO, stroke volume, body mass index, pulse pressure from mean 24-h AMBP, and mean 24-h systolic BP load. No association with heart rate, age, parathyroid hormone, glomerular filtration rate, or anemia was observed. Only CO (beta = 1.98, p = 0.0005) was independently associated with increased LVMI in multivariate modeling (model R (2) = 0.25). The results of this study suggest that increased CO might predispose to increased LVMI in pediatric patients with CKD. Adaptations may be required to meet increased metabolic demand in these patients.