Global longitudinal strain as a potential marker for earlier treatment referral for severe aortic stenosis

Background

Aortic stenosis (AS) is the most prevalent valvular disease in the developed countries. The disease progression is long and It is of greatest importance to choose the optimal intervention timing and to secure best long term prognosis.

Purpose

To establish left ventricular strain as independent predictor for left ventricular function improvement after AVR which could be used for treatment decision making.

Methods

In this prospective, crossectional study 76 patients were included that fulfilled the criteria for severe aortic stenosis according to the guidelines from professional associations. In all patients before the AVR detailed clinical, functional, angiographic examination was performed as well as transthoracic echocardiography using Philips Epique 7. With 2D TTE the left ventricular systolic and diastolic function was assessed and with speckle tracking echocardiography global longitudinal strain (GLS %) was evaluated. Same TTE evaluation was performed 4 months after AVR. Measurements were analyzed using QLAB 7.1. Statistical analysis was performed using SPSS 25.0.

Results

Surgical treatment of the aortic valve significantly reduced aortic stenosis severity in all patients. Age didn't have any impact on change of left ventricular function after AVR. In both genders there was significant reduction in disease severity as well as improvement in systolic and diastolic function of the left ventricle (Figure 1) with greater improvement of GLS values in the female gender.

Analysis of GLS changes after AVR in patients divided by EF showed significant improvement of GLS in patients no matter the value of preoperative EF (Figure 2). For EF improvement after AVR independent predictors were: left ventricular systolic dimension and GLS. Analysis of our cohort before AVR showed significant correlation of impaired GLS with male gender, obesity, more severe AS, larger LVD dimension and wall thickness, as well as LV systolic and diastolic volumes, higher LVMI, lower EF and lower stroke index, reduced MAPSE and s'TDI, higher wall motion score index, higher Zva and lower left atrial EF. After AVR there was significant improvement of GLS in all patient, however patients with reduced preoperative EF had significantly worse GLS after AVR. In the patients with preserved EF ≥50%, GLS before AVR was independent predictor for postoperative improvement of EF and number of segment with LS less than 13% was independent predictor for positive remodeling only in patients with low flow.

Conclusions

Impairment of LV GLS is of particular significance in the wide variety of patients with preserved EF that vary in ratio between flow and gradient were worse values of GLS imply worse prognosis. The results from our study support promotion of LV GLS as a marker for decision on AVR timing in respect of its prognostic implications. It is our expectation that GLS evaluation would find its place in future guidelines for diagnosis and treatment of patients with AS.

Funding Acknowledgement

Type of funding sources: None.

Brain natriuretic peptide between traditional and nontraditional risk factors in hemodialysis patients: analysis of cardiovascular mortality in a two-year follow-up

BACKGROUND

The ability of brain natriuretic peptide (BNP) together with other traditional and nontraditional risk factors to predict cardiovascular (CV) mortality in hemodialysis (HD) patients has not been well established. The aim of this prospective study was to determine the predictive cutoff values of baseline measurement of BNP along with the known CV disease risk factors to predict all-cause and CV mortality in HD patients.

METHODS

BNP concentration before HD was measured in 125 prevalent HD patients (age 53.0 ± 13.5 years, HD vintage 75.2 ± 61.0 months). In addition, several traditional CV risk factors (blood pressure, dyslipidemia, diabetes mellitus, body mass index, left ventricular hypertrophy) and uremia/dialysis-related CV risk factors (anemia, calcium and phosphate impairment, malnutrition, inflammation, ultrafiltration, HD duration, Kt/V) were examined.

RESULTS

During the 2-year follow-up, we lost 28 out of 125 patients (22.5%), with CV disease (65.7%) being the main cause of mortality. The cutoff point for BNP, as predictor of the clinical outcome, according to the ROC curve was 1,194 pg/ml for CV mortality with sensitivity and specificity of 63 and 65%, respectively (AUC 0.61 and confidence interval (CI) 95% 0.47-0.75). Kaplan-Meier analysis showed that all-cause (log-rank, p = 0.002) and CV mortality (log-rank, p = 0.001) were the cause of a significantly lower survival in patients with a mean BNP >1,200 pg/ml. The univariate Cox regression analysis found the following factors to be predictors of all-cause mortality: hemoglobin (<110 g/l), phosphorus (>1.78 mmol/l), albumin (<40 g/l), C-reactive protein (CRP ≥ 10 mg/l), BNP (>1,200 pg/ml) and cardiac ejection fraction (≤ 55%). The multivariate Cox regression analyses demonstrated that only CRP ≥ 10 mg/l with a hazard ratio (HR) 6.82 (CI 95% 1.86-24.9, p = 0.004) and BNP >1,200 pg/ml with HR 5.79 (CI 95% 1.58-21.3, p = 0.004) were predictors of all-cause mortality. BNP >1,200 pg/ml with HR 13.52 (CI 95% 1.68-108.9, p = 0.014) was found to be an even stronger predictor of CV mortality than CRP ≥ 10 mg/l with HR 6.53 (CI 95% 1.35-31.6, p = 0.020).

CONCLUSIONS

Our study pointed out that BNP >1,200 pg/ml as a marker of cardiac dysfunction and CRP ≥ 10 mg/l as a marker of inflammation identify HD patients at increased risk of CV mortality.

Endothelial dysfunction correlates with plasma fibrinogen and HDL cholesterol in type 2 diabetic patients with coronary artery disease

OBJECTIVE

Assessment of endothelial dysfunction (ED) in type 2 diabetic patients with coronary artery disease (CAD) and estimation of correlation of ED with metabolic parameters: low HDL, hypertriglyceridemia, obesity, systolic blood pressure and with inflammatory-hemostatic parameters: CRP and fibrinogen.

PATIENTS AND METHODS

42 patients (age 60.0 +/- 8.5 years) with diagnosed type 2 diabetes and CAD were randomly included in a cross sectional study. B-mode ultrasound system with a linear transducer 7.5 MHz was used for evaluation of flow mediated vasodilation in brachial artery (FMV). FMV was presented as the percentage increase in brachial artery diameter, within 30 s after limb ischemia, previously provoked by cuff inflation. Percentage value up to 10% was defined as ED.

RESULTS

Bivariate linear correlation model presented significant correlation between plasma fibrinogen and FMV percentage, with r -0.47, p < 0.01. Presence of ED correlates linearly with plasma level of HDL < 1.03 mmol/L (r -0.35, p < 0.03). Multivariate analysis using Backward Wald model presented fibrinogen (OR 3.14, 95% CI 0.87-11.28) and low HDL (OR 5.16, 95% CI 0.53-60.39) as factors correlated with the presence of endothelial dysfunction.

CONCLUSION

These results presented plasma fibrinogen level and low HDL < 1.03 mmol/L as factors, independently correlated to the presence of endothelial dysfunction in type 2 diabetic patients with coronary artery disease (Tab. 8, Fig. 1, Ref. 25). Full Text (Free, PDF) www.bmj.sk.

Arterial hypertension in patients with coronary artery disease treated with surgical myocardial revascularization

OBJECTIVES

To evaluate the incidence and prognostic power of arterial hypertension in patients with coronary artery disease treated with surgical myocardial revascularisation, before and after the operation.

BACKGROUND

Arterial hypertension is one of the leading modifiable risk factors in CAD patients who underwent CABG surgery with the major impact on clinical outcome in these patients.

METHODS

749 patients with mean age of 55 +/- 8 years, (639 male/119 female) were analyzed for their preoperative: demographic, clinical, left ventricular morphologic and functional and angiographic, perioperative: type of operation, type and number of applied conduits, in-hospital morbidity and mortality, and post-operative: demographic, clinical, left ventricular morphologic and functional and angiographic characteristics. Mean postoperative follow-up period was 5.97 +/- 4.27 years.

RESULTS

Hypertension was found in 52.7% of patients before the operation, and it was the most frequent risk factor, without any differences between different age groups, but significantly more often in females (p = 0.0001), diabetics (p = 0.0001), and patients with preserved LV function (p = 0.011). Although significantly correlated with in-hospital morbidity (r = 0.085 and p = 0.023), HTA was not identified as independent predictor. The most predictable was the occurrence of early neurological complications. HTA was also found to be a predictor of long life prognosis in CABG patients, but not as independent prognostic factor. Significant reduction in incidence was found in post-CABG patients (30.1%), which is most likely a result of applied pharmacologic treatment. ACE-inhibitors, Ca-antagonists and B-blockers were applied in 39.44%, 30.1% and 33.6% of patients respectively, with significant positive correlations found for all of them as follows: r = 0.221, p = 0.0001, r = 0.316, p = 000.1 and r = 0.093, p = 0.031.

CONCLUSION

Hypertension is the most powerful risk factor in CAD patients who undergo CABG surgery in our country, and a powerful prognostic factor of early and late clinical outcome. There is a trend toward decreasing the incidence of HTA in post-CABG patients, as a result of improved pharmacologic treatment after the operation (Tab. 5, Fig. 1, Ref. 13). Full Text (Free, PDF) www.bmj.sk.

Factors influencing graft potency in patients who underwent CABG for treatment of CAD

OBJECTIVES

To identify factors that influence graft disease and native coronary arteries progression disease and prognostic implication of this process.

BACKGROUND

Unsolved problem in CABG patients is progression of the disease in bypass grafts and native coronary arteries.

METHODS

Data from 102 patients with CABG, who underwent re-coronarography, were analyzed: - Pre and post-operative variables: risk factors, clinical status, functional capacity, left ventricular parameters and angiographic status (before and after CABG). Proportional hazard regression model, was used, p<0.05 was considered statistically significant.

RESULTS

Cardiac death, myocardial infarction and heart failure were more frequent in patients with graft occlusion, non-stable angina pectoris in non-occlusive graft disease, which together with acute myocardial infarction was more often in patients with native coronary arteries progression disease. PCI was significantly more often performed on native coronary arteries.

CONCLUSION

Graft disease and native coronary artery progression disease is a continuous process which can be slowed by aggressive risk factors reduction, medications, and PCI procedures. In contrary, it leads to unfavorable clinical outcome (Tab. 8, Fig. 6, Ref 19).