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.

Annual rate of progression of aortic-jet velocity and survival in cases of severe asymptomatic aortic stenosis

(Full text is available at http://www.manu.edu.mk/prilozi). The aim of the study was to establish the predictive role of maximal aortic-jet velocity, i.e. its annual rate of progression, in the decision in favour of aortic valve replacement (AVR), as well as in the event appearance and/or patients' survival with severe asymptomatic aortic stenosis. 49 patients were analysed who belonged to the clinical and echocardiography group with severe asymptomatic valve aortic stenosis, with an average of 22 +/- 10 months follow-up period. The echocardiography parameters were: ejection fraction, maximal aortic-jet velocity (AV_Vmax), trans-valve maximal gradient and aortic valve area, as well as calcification rate, all of which were included in the predictive model. The progression rate of the aortic-jet velocity was established, reduced to an annual level. The variable ECHO status worsening was defined as worsening when the progression rate of the AV_Vmax at the annual level was > or = 0.3 mps per year. The results show that in 20% of the patients an annual rate of progression of the aortic-jet velocity over > or = 0.3 mps per year was registered. For the follow-up period, event appearance was registeredin 20% of the patients , where the risk of event appearance is 4.3 times higher in patients with ECHO worsening status, in relation to those without ECHO worsening status. It was established the that the probability of survival of the asymptomatic patients with severe AS over a period of 3 years was 0.57 +/- 0.11. The average length of survival in patients without ECHO worsening status was 32.8 +/- 1 months, while in patients with ECHO worsening status it was 23.5 +/- 4 months. It can be conclude that the maximal trans-valve aortic-jet velocity, especially the rate of its annual progression, is a significant predictor of the rapid progression of the disease, which contributes to the risk stratification in the risk group of patients with severe asymptomatic aortic stenosis while referring for AVR. Key words: severe asymptomatic valve aortic stenosis, echocardiography, annual rate of progression of the maximal aortic-jet velocity, survival.

Risk factors for development of peripheral and carotid artery disease among type 2 diabetic patients

(Full text is available at http://www.manu.edu.mk/prilozi). The study was aimed to define the risk factors for development of peripheral arterial (PAD) and carotid artery disease (CARD) among type 2 diabetic patients (T2D). The study population consisted of 30 patients diagnosed with type 2 diabetes and absent vascular disease. the mean age of the study population was 53.3 +/- 7.3 years. 60% of patients were women and 40% of them men. Patients were followed up for three years for development of peripheral and carotid artery disease. Peripheral arterial disease (PAD) was defined by ankle-brachial index < 0.9 or > 1.3. Carotid arterial disease was defined if carotid plaque or stenosis (> 50%) presented. We built a multivariable logistic regression analysis to define the factors of development of vascular disease and a multiple linear regression analysis to identify the factors associated independently with numerous values of carotid IMT and ABI. Development of PAD and CARD were registered in 43.8% of patients. Progression of carotid IMT was found in 62.5 % of pts. Progression of PAD was predicted by HDL - cholesterol and urea, systolic blood pressure and diabetes duration. Progression of carotid IMT was determinate with: BMI, weight, diastolic blood pressure and age. Our study defined risk factors that independently influence the development of PAD and CARD in pts with T2D. This data has clinical usefulness in the improvement of prevention and in optimizing the treatment of type 2 diabetic patients. Key words: peripheral arterial disease, ankle-brachial index, carotid plaque, carotid stenosis, IMT, type 2 diabetes.

Epidemiological characteristics of the metabolic syndrome in apparently healthy persons

The risk factors that define the metabolic syndrome lead to an accelerated development of atherosclerosis, cardiovascular diseases in apparently healthy persons. The goal of the research is determining the prevalence of the metabolic syndrome as well as the participation of the risk factors that define this condition in apparently healthy persons. The metabolic syndrome is defined according to the National Cholesterol Education Program Expert Panel. The prevalence of the metabolic syndrome in the examined population, aged 53 +/- 8, is 62 (39.7%). In the group of subjects that have the metabolic syndrome,the largest number of subjects had 3 risk factors and only 5 subjects had 5 risk factors. With the increase of the number of components of the metabolic syndrome, all the observed parameters of the metabolic syndrome also increase, while the level of HDL decreases. In all the examined groups of subjects, the low level of HDL-H is the most present metabolic risk factor, while in the groups of subjects that have the metabolic syndrome the hypertension is the second most present factor, and the waist circumference is the least present factor. According to our research, the prevalence of the metabolic syndrome in apparently healthy persons that have a sedentary life style is 39.7%. In all the subjects the low level of HDL-h is the most present, and in the subjects with the metabolic syndrome compared to subjects that do not have this syndrome the frequency of all the components of the metabolic syndrome is statistically considerably higher.

Cardiac memory (t-wave memory) after ablation of posteroseptal accessory pathway

BACKGROUND

Cardiac memory is a phenomenon characterized by transient T-wave abnormalities occurring during normal sinus rhythm, after a period of altered ventricular depolarization, where the T-wave vector has the same direction as the vector of the previously altered QRS complex (T-wave inversion). It is a form of electrical remodelling of the ventricular, where the T-wave follows ("remembers") a previously altered QRS vector.

METHODS AND RESULTS

Over a 5-year period (2002-2006), 525 consecutive patients underwent electrophysiological study. One hundred and one patients underwent ablation of the atrioventricular reentry tachycardia (AVRT) with an accessory pathway (AP). Forty-two of them were without delta wave on the electrocardiogram (concealed accessory pathway), and 58 patients had an open form of accessory pathways, with delta wave on EKG (Wolff-Parkinson-White syndrome) and only one patient had an accessory pathway between the right atrium and right bundle branch (Mahaim form). According to the location of the accessory pathway, 17 patients (29.3 %) had an accessory pathway in the right posteroseptal region. There was the highest percentage of the appearance of inversion of the T-wave in patients with this position of accessory pathway. T-wave changes were followed in the frontal plane (leads II, III, and aVF). Electrocardiogram (ECG) signs of cardiac memory were present in 16 of 17 (94.1 %) patients within one day after the ablation. The post-ablation T-wave vector had the same direction as the vector of the pre-excited QRS complex (and delta wave) creating inferior T-wave inversions. There was no correlation between the number or duration of energy applications and the extent of cardiac memory post ablation. A majority (90% of cases) of ECGs recorded 3 months after the procedure showed complete or almost complete normalization. None of the patients with T-wave inversion after ablation had a recurrence of preexcitation or tachycardia during the follow-up period of 12 +/- 4 months.

CONCLUSIONS

T-wave inversion in leads II, III and aVF with the disappearance of the delta wave after ablation of the accessory pathway in patients with Wolff-Parkinson-White syndrome (accessory pathway in the right posteroseptal region of the heart), is the most powerful marker of successful ablation.

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.

Effect of nephrology referral on the initiation of haemodyalisis and mortality in ESRD patients

Late nephrology referral of patients with chronic kidney disease (CKD) has been suggested as increasing mortality after the initiation of dialysis. The aim of this study was to assess the impact of nephrology referral on the initiation of haemodyalisis (HD) and mortality during HD treatment in end-stage renal disease (ESRD) patients who have died in our institution over a five-year period. We studied data from all 117 patients on HD treatment in our institution who died (after 90 days of HD treatment) in the period between 01.01. 2002 and 31.12. 2006. Early (ER) and late referral (LR) were defined by the time of follow-up by a nephrologist greater than or less than 6 months, respectively, before the initiation of haemodialysis. Out of a total of 117 patients, 37.6% (44 patients) started HD in the ER group and 62.4% (73 patients) in the LR group. At the start of HD, LR patients were older, had a higher proportion of temporary catheters and had a significantly lower levels of haemoglobin and diuresis. Creatinine clearance was less in the LR (7.67 +/- 3.86 ml/min/1.73 m2) vs. the ER group (8.70 +/- 3.62 ml/min/1.73 m2), but not significantly different. Cardiovascular disease (CVD), defined by a history of myocardial infarction, cerebral vascular disease, peripheral arteriopathy, and/or heart failure, was also significantly more common among LR patients compared to ER (56%; 27%, p = 0.002). During the haemodyalisis treatment, the LR group had significantly lower levels of haemoglobin and haematocrit. CVD accounted for about 64% of deaths observed in the LR group. According to echocardiography data, there were no significant differences in the left ventricular mass index (LVMI) between the LR and ER groups at the time of dialysis initiation, but during haemodialysis treatment the LR group had significantly greater LVMI than the ER group (232,96 +/- 92,48 g/m2 vs.184,09 +/- 51,74 g/m2; p = 0,031). The time until death in months during dialysis treatment was significantly different between the LR and ER group, (69.51 +/- 64.03 vs.113.27 +/- 89.03, p = 0.0025). LR patients experienced a greater degree of anaemia and a high prevalence of CVD at the time of dialysis initiation. Our data suggest that the anaemia, CV damage and progression of left ventricular hypertrophy (LVH) in the LR patients during haemodialysis treatment are associated with poor survival on haemodialysis.

Prevalence of metabolic syndrome components in the type 2 diabetic population who presented coronary artery disease

The scope of our study was to assess the prevalence of metabolic syndrome (MSy) and its components in the type 2 diabetic population with symptomatic coronary artery disease in a sample of the Macedonian population. 327 pts with type 2 diabetes and manifested coronary artery disease were randomly included in a survey. MSy was defined according ATP III criteria. The data presented a prevalence of MSy in 86.2%, respectively. 98% of pts had at least one more MSy component than impaired glycaemia. Study groups with four and three MSy components were most frequent in the study population. The data presented gender differences in MSy prevalence: 93.4% in women vs. 82.8% in men (p 0.009), as women tend to have a much more increased waist, arterial hypertension and low HDL. The most prevalent metabolic syndrome component was arterial hypertension (78.3%). Low HDL was detected in 67.9%, hypertriglicerydaemia in 62.7%, and an increased waist in 49.8% of the study population.

Carotid ultrasound, blood lipids and waist determination can predict a future coronary revascularisation in the type 2 diabetic cohort

The aim of the study was to identify incremental values of carotid ultrasound measurements (carotid plaques and stenosis) on the prediction of future coronary revascularization among type 2 diabetic patients. The second objective was to determine the predictive value of the assessment of blood lipids, BMI, abdominal obesity and the ankle-brachial index (ABI). Three hundred and thirty three (333) patients with type 2 diabetes and manifested coronary artery disease were randomly selected in a cohort prospective study. Univariate and multivariate logistic regression analyses were conducted to identify variables predictive of the need for future revascularization: percutaneus coronary interventions (PCI) or coronary bypass surgery (CABG) followed 24 months after the study starting point. The presence of arterial hypertension, hyperlipidemia, physical inactivity, intermittent claudication, the value of systolic pressure, BMI, waist and hip measurement, glycemia and blood lipid fraction (total cholesterol, HDL, LDL, non-HDL, triglycerides) were entered in a model. Ultrasound measurements: carotid IMT, presence of carotid plaques and stenosis, and ABI were also included in the analysis. Based on the univariate and multivariate findings, the presence of internal carotid artery (ICA) stenosis (OR 4,562, 95% CI 1,327-15,687), carotid plaque (OR 1,465, 95% CI 0,829-2,591), and increased waist measurement (OR 1,371, 95% CI 0,757-2,483) were found as significant independent predictors of future PCI. LDL and non HDL cholesterol were found to be factors independently associated with the need for future CABG by univariate analysis, which was not confirmed by multivariate analysis. In conclusion, the current study has provided an identification of predisposing factors for the future need of coronary revascularization among type 2 diabetic patients that permits risk stratification and may facilitate improved patient selection or optimization.

Is assessment of peripheral endothelial dysfunction useful tool for risk stratification of type 2 diabetic patients with manifested coronary artery disease?

Endothelial dysfunction, per se, in coronary arteries can stratify a risk in coronary artery disease patients. Selected studies evaluating endotheliopathy as predictor of events in patients with type 2 diabetes, but without coronary artery disease. We hypothesized that peripheral endothelial dysfunction could predict prognosis of type 2 diabetic patients who presented coronary artery disease. Our data presented endothelial dysfunction as prognostic marker of cardiovascular events in type 2 diabetic patients with manifested coronary artery disease, according univariate regression model.

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).