[Assessment of left atrial remodeling in atrial fibrillation]

Left atrial size, most frequently assessed for practical reasons by echocardiography, is important in clinical decision-making. Left atrium volume measurements allow an accurate assessment of asymmetric remodeling and reverse remodeling in atrial fibrillation (AF) patients.

AIM

To assess a new method (CTEL2) derived from CT scan by ellipsoid formula (CTEL1) to measure LA volume, we compared the conventional echocardiography-ellipsoid method (EEL), as a reference, with CTEL1 and with the new method-CTEL2.

MATERIAL AND METHOD

Left atrium volume was measured by EEL and CTEL2 in 40 consecutive pts (group 1, 56 +/- 12 years, 80% men) and by EEL and CTEL1, in another 46 consecutive patients (group 2, 58 +/- 11 years, 80% men) with AF. For measurements by CTEL2 we used the same formula as the ellipsoid method but as optimal view for the orthogonal dimensions were taken every time the last axial section just under the superior veins (atrialized in dilated left atrium). Usual, the dimensions are taken on the largest axial left atrium area. The correlation coefficients were compared by Z test with Fisher inverse tank transformation.

RESULTS

Mean left atrium volume irrespective of methods was > 50 mL. We found a good and significant correlation between CTEL1 and EEL (r1 = 0.769; p < 0.001) but a much better between CTEL2 and EEL (r1 = 0.915; p < 0.001). Both r1 and r2 coefficients were significantly stronger for the correlation with CTEL2 and with CTEL1 (p = 0.016).

CONCLUSIONS

This new technique evaluation for left atrium volume is adequacy and could avoid an overestimation or underestimation of LA remodelation assessment, as standard ellipsoid method, in specific situations as cardioversion or AF ablation.

[Some aspects of degenerative mitral valve lesions encountered in medical practice]

In recent years, degenerative valvular heart diseases have the tendency to be equal in frequency with rheumatic valvular diseases. The maximum attention has been paid on the degenerative aortic stenosis as being a lesion with maximum frequency and a severe evolution. This study, given on the 18,391 admissions in the period 1997-2001, is a retrospective analysis and it is concerned with the degenerative mitral valvular lesions. Of the 223 patients with degenerative valvular heart lesions, 139 patients (62.3%) had degenerative aortic stenosis and 96 patients (38.5%) were diagnosed with degenerative mitral valvular lesions from which 30 patients have had no association with aortic valvular lesions while 66 patients have had such an association. The pointed out types of mitral lesions were: the mitral insufficiency in 59 patients, the mitral annular calcification without hemodynamic disease in 19 patients, the mitral stenosis in 9 patients and the mitral disease in 9 patients, too. The women were affected nearly 1.7 times more frequent than the men, with a maximum average age greater with four years for women but with a low minimal average age at 60 years for women and 52 years for men. The detailed analysis of this 96 cases had shown the presence of a cholesterol value over 200 mg/dl in 50 patients (52%), the diabetes mellitus of type II in 12 patients (12.5%), an association with HTA in 42 patients (43.7%), the cardiac insufficiency in 68 patients (70.8%), a permanent atrial fibrillation in 24 patients (25%), chronic myocardial infarct in 19 patients (19.7%) and disorders in the transmission of stimuli in 8 patients (8.3%). The degenerative mitral valvular lesions had occurred more and more frequently realizing more complex features under the mitral insufficiency predominance. Its frequent association with the degenerative valvular lesions determines the evolutive and therapeutic particulars that are dominated by the high gravity prognostic.

[Correlation between increase of oxidative stress and microalbuminuria in type-1 diabetic patients]

Oxidative stress has an important role in genesis of diabetic complications, especially diabetic nephropathy. The aim of the study was to assess correlations between increase of oxidative stress (OS) and the development of microalbuminuria (MA) in type 1 diabetic patients. We determined the oxidative status by measuring the level of superoxide dismutase (SOD-Minanui method), catalase (CAT-Aebi method), glutathione peroxidase (GPx-Fukuzawa method) and glutathione (GSH-Ellman method) in 87 type 1 diabetic patients (44 with normal urinary protein excretion-group A and 43 with MA-group B) and 38 nondiabetic matched controls, before and 24 hours after a test effort. The results of the study point out that a decreased in activity of SOD or in levels of GSH is associated with an increased MA in type 1 diabetic patients.

[HDL-cholesterol--active or passive participant in the pathogenesis of atherosclerosis? (II)]

It is known that high sanguin levels of cholesterol and LDL-cholesterol (LDLc) have an important role in the pathogenesis of atherosclerosis. The treatment of hypercholesterolemia with statins and/or with fibrates have had beneficial effects on coronary heart disease and on other localization of atherosclerosis. The decreased of cholesterol and LDL-cholesterol is the most important effect of this treatment. The epidemiological studies have revealed that the treatment with statins and/or with fibrates produce an increase of HDL-cholesterol (HDLc), which is also very important in the regression of atherosclerosis. We tried in this review to explain the mechanisms of the increase of HDL-cholesterol, in concordance with the data from literature.

[Implications of some risk factors in degenerative valvular heart diseases]

A retrospective study on 223 patients diagnosed with degenerative heart valvular lesions: 124 women with an average of 74.9 years old and 99 men with an average of 70.1 years old with the lower limit under 50 years old (one woman and one man) and upper limit over 80 years old (22 women and 11 men) revealed that 109 patients (48.8%) had arterial hypertension, 30 patients (13.4%) had diabetes mellitus, and 16 patients (7%) had obesity. Chronic alcoholism was present at 89 patients (39.9%), chronic tobacco consumption at 54 patients (24.2%), cholesterol value over 200mg/dl in 99 patients (44%) and triglycerides value over 150 mg/dl in 15 patients (6.6%). In the 15 patients with a sever form of aortic stenosis was discovered cholesterol value over 200 mg/dl as well as chronic tobacco use and alcoholism.

CONCLUSION

Degenerative heart valvular disease represents a different process from arteriosclerosis, therefore the conventional risk factors of arteriosclerosis, can not be considered as having the same significance for degenerative heart diseases.

[Implication of methylglyoxal in diabetes mellitus]

Methylglyoxal (MG) is an early glycation product which is implicated in genesis of diabetic complications either as a direct toxin or as a precursor for advanced glycation end products. It is metabolized via S-D-lactoylglutathione to D-lactate by means of the enzymes glyoxalase I and II, which depend on glutattione as cofactor. MG is highly reactive and can bind to and modify proteins by chemical interaction with cellular proteins, action on energy production, induce free radical generation and cell killing. That way MG play a role in the events of the development of diabetic complications.

[Effect of antilipemic therapy on patients with diabetes mellitus and obesity]

Fibrates are hypolipemic agents used in noninsulin dependent diabetes mellitus (NIDDM) because these drugs have no influence on glycemia control. The efficiency of fenofibrate (Lipanthyl) was studied in a group of 22 subjects, 30-70 years, obese (body mass index-BMI over 30 kg/m2) or overweight (BMI = 28-30 kg/m2) with hypertension or/and diabetes. All the patients received 200 mg fenofibrate daily, for 6 month, and they had a hypocaloric diet. We measured seric lipids. The results were compared with a control group (20 normal subjects). Under treatment, atherogenic lipids (total cholesterol, LDL-cholesterol and triglycerides) had significantly decreased (p < 0.05) and antiatherogenic fraction (HDL-cholesterol) significantly increased (p < 0.05) compared to initial values. In the mean time, the BMI has significantly decreased under fenofibrate treatment, this body mass loss having a positive influence on lipid metabolism. We observed a better therapeutically response in obese patients vs. the overweight ones, probably due to a higher prevalence of the hypertension in the second subgroup. In conclusion fenofibrate is the drug which can be choose in diabetic dyslipidemia without cardiac disease.

[Some aspects regarding degenerative mitral valvular lesions encountered in medical practice]

In the last years, the degenerative valvular heart diseases have the tendency to equalize in frequency the rheumatismal valvular diseases. The maximum attention has been paid on the degenerative aortic stenosis as being a lesion with maximum frequency and a severe evolution. This study, given on the 18391 admissions in the period 1997-2001, is a retrospective analyse and it is concerned with the degenerative mitral valvular lesions. Of the 223 patients with degenerative valvular heart lesions, 139 patients (62.3%) had degenerative aortic stenosis and 96 patients (38.5%) were diagnosed with degenerative mitral valvular lesions from which 30 patients have had no association with aortic valvular lesions while 66 patients have had such an association. The pointed out types of mitral lesions were: the mitral insufficiency in 59 patients, the mitral annular calcification without hemodynamic disease in 19 patients, the mitral stenosis in 9 patients and the mitral disease in 9 patients, too. The women was affected nearly 1.7 times more frequent than the men, with a maximum average age greater with four years for women but with a low minimal average age at 60 years for women and 52 years for men. The detailed analyse of this 96 cases had shown the presence of a cholesterol value over 200 mg/dl in 50 patients (52%), the diabetic mellitus of type II in 12 patients (12.5%), an association with HTA in 42 patients (43.7%), the cardiac insufficiency in 68 patients (70.8%), a permanent atrial fibrillation in 24 patients (25%), the chronical myocardiac infarct in 19 patients (19.7%) and disorders in the transmission of stimuli in 8 patients (8.3%). The degenerative mitral valvular lesions had occurred more and more frequently realizing more complex features under the mitral insufficiency predominance. Its frequent association with the degenerative valvular lesions determines the evolutive and therapeutic particularities that are dominated by the high gravity prognostic.

[HDL-cholesterol-- active or passive participant in the pathogenesis of atherosclerosis]

It is known that high sanguin levels of cholesterol and LDL-cholesterol (LDLc) have an important role in the pathogenesis of atherosclerosis. The treatment of hypercholesterolemia with statins and/or with fibrates have had beneficial effects on coronary heart disease and on other localization of atherosclerosis. The decreased of cholesterol and LDL-cholesterol is the most important effect of this treatment. The epidemiological studies have revealed that the treatment with statins and/or with fibrates produce an increase of HDL-cholesterol (HDLc), which is also very important in the regression of atherosclerosis. We tried in this review to explain the mechanisms of the increase of HDL-cholesterol, in concordance with the data from literature.

[Evaluation of the systolic and diastolic function of the left ventricle in patients with diabetes mellitus and microalbuminuria]

The objective of this study is to reveal the deterioration of the systolic and diastolic function of the left ventricle (LV) in patients with diabetes mellitus (DM), in correlation with type of DM, the edge and the complications of DM and the associated diagnosis.

METHODS

The study included 43 patients with DM (29 patients with DM type 1 or 2 insulinodependent--DMID and 14 patients with DM type 2 nonisulinodependent--DMNID). The age of patients was between 21 years and 57 years, with a duration of DM between 1 year and 22 years. The ecocardiographic evaluation have determined 38 parameters (B mod, M mod, CWD, PWD, colour Doppler). From these parameters, 12 was used for the measurement of the systolic function of the LV and 18 was used for the determination of the diastolic function of the left ventricle. The clinical and biological exam have performed: glycaemia, proteinuria, dyslipidemic syndrome, complications of DM and ischaemic heart disease (ECG).

RESULTS

The ejection fraction (EF) of the LV was ?60% in 23 patients, between 50% and 60% in 17 patients and between 40% and 50% in 3 patients. The values of MSER (mean systolic ejection rate) was between 221 ml/s şi 515 ml/s and the values of MVCF (mean velocity of circumferential shortening) was between 0.9 circ/s şi 1, 8 circ/s. The ratio of the E and A waves at the mitral valve was > 1 in 22 patients and < 1 in 21 patients. The LV isovolumic relaxation time (IVRT) was < 70 ms in 13 patients, > 100 ms in 14 patients and had normal values in 16 patients. The E wave deceleration time (EDT) was < 150 ms in 24 patients and had normal values in 19 patients. There is no connection between the systolic/diastolic function and the other determined parameters.

CONCLUSIONS

The alteration of the LV systolic function was present in 20 patients from 43 patients. The LV diastolic dysfunction through relaxation troubles was present in 14 patients and the LV diastolic dysfunction through compliance trouble was present in 13 patients. A number of 16 patients had preserved (for the moment) a normal LV diastolic function. The number of patients with these two types of LV diastolic dysfunction was equal in our study. Other studies had found a predominance of LV diastolic dysfunction through compliance troubles in DM.

[Myocardial remodeling]

Chamber remodeling and myocardial systolic dysfunction play an important role in the development of cardiac failure after myocardial infarction. The process is accompanied by qualitative and quantitative changes in the expression and reexpression of genes regulating cell growth and contractile function. The article tries to explain some of the mechanisms of the myocardial remodeling that permit the modifications and adaptation of the heart to normal and pathological conditions from a clinical point of view and, in the same time, from a molecular point of view.

Evaluation of simvastatin antioxidant effects

3-Hydroxy-3-methyl-coenzyme A reductase (HMG-CoA reductase) which transforms 3-hydroxy-3-methylglutaril-coenzyme A (HMG-CoA) in mevalonate, is the rate limiting enzyme in cholesterol biosynthesis. In our study, from HMG-CoA reductase's known inhibitors, we used simvastatin (ZOCOR), which is a semi synthetic derivative of the second generation. The study was performed on 25 subjects (12 men and 12 women) aged 33-67 yo, with hypercholesterolemia, which have received simvastatin, 10 mg daily for 8 months. Under treatment with simvastatin we obtained a significant decrease of total cholesterol (p < 0.0001) and an improvement of enzymatic antioxidant parameters: superoxide dismutase (SOD), glutathione peroxidase (GPx), and catalase (CAT). In conclusion, simvastatin therapy determines a significant decrease in SOD, GPx, CAT, and an increase in CAT/SOD and GPx/SOD ratios.

[Analysis of some clinical aspects of degenerative valvular heart diseases in medical practice]

In a period of 5 years there were 18,391 admissions; out of them 1129 cases were diagnosed with valvular lesions: 223 (19.7%) were degenerative valvular heart disease, 608 (53.8%) had rheumatismal valvular lesions, 7 (0.6%) had congenital valvular lesions and 291 cases (25.7%) had valvular lesions of other etiologies. Out of the 223 cases with degenerative valvular lesions, 99 cases (44.4%) were men with an average age of 70.1 years old and 129 were women (55%) with an average age of 74.9 years old. The calcific aortic valve stenosis was encountered in 139 patients (62.3%), the aortic insufficiency was diagnosed in 19 patients (8.5%), the mitral insufficiency 49 patients (21.9%) and the mitral stenosis in 10 patients (4.4%) the other patients having either aortic or mitral valvular disease. The combination of an aortic stenosis with a mitral insufficiency was diagnosed in 46 cases (20.6%) from the 223. Only 14 patients were asymptomatic, most of them having heart failure (namely, 178 patients i.e. 78%) with or without angine pectoris or effort vertigo, or they had only effort angina, vertigo or effort sincope. Rhythm disorders happened in 59 patients (26.4%) while disorders in the transmission of the stimuli were diagnosed in 14 patients (5.2%). Two patients died due to cardiac causes.

CONCLUSION

Rheumatismal valve disease are nearly 2.5 times more frequent than degenerative valve disease and they became a practical reality, which is claimed by its continuously increasing frequency, by a variety of lesional aspects and by implications on the heart, and by it, presence in an age group were arteriosclerosis cumulates its risk factors.

[The implications of thromboembolism in chronic heart failure]

The goal of investigation was to determine whether long-term anticoagulant therapy influences the mortality rate in CHF. The method consisted in the calculation of the annual death rate of the patients with CHF class III-IV NYHA: group A (controls)--who did not receive anticoagulant or antiplatelet therapy; group B--treated with Acenocumarol or Aspirin. The results show in group A, which included 150 patients, during the 5-year interval under study 30 deaths, representing an annual death rate of 4%. In group B, which included 325 patients of which 75 treated with Acenocumarol and 250 patients with aspirin, 20 deaths were recorded during the same 5-year interval, representing an annual death rate of 1.2%. Thus, the mortality risk proved to be 70% lower in group B than in the control group. It came out that the main mechanism of death in CHF is thrombembolism and in this circumstance anticoagulant or antiplatelet therapy would be essential.

[Clinical and biochemical aspects of diabetic nephropathy]

Diabetic nephropathy (DN) is the most important cause of increased morbidity and mortality in patients with diabetes mellitus. Moreover DN is associated with a high risk for cardiovascular complications and progression of renal failure. It is known that there is a cumulative risk of development of DN represented by genetic factors, glycaemic factors, hypertension, alterations in the lipid metabolism, smoking. Functionally, it is represented by increased glomerular filtration rate (silent phase) and renal hypertrophy, increased the urinary albumin excretion rate, increased blood pressure and decline in glomerular filtration rate (end phase). Biochemical DN induced the alterations in lipid metabolism (increased the serum concentrations of triglicerides, VLDL, LDL), alterations in glycaemic metabolism (blood glucose, glycated hemoglobin, glycated albumin). The correlations between clinical and biochemical aspects are developed in this reference.

[The cardiovascular significance of nitric oxide]

Nitric oxide (NO) synthesized from L-arginine is a ubiquitous intercellular chemical messenger involved in signal transduction in diverse mammalian cells. The isolation of molecular clones for NO synthases has permitted the characterization of several distinct enzyme isoforms. NO synthesized in vascular endothelial cells plays an important role in the control of vascular tonus and platelet aggregation, through the activation of guanylate-cyclase activity in target tissues mediated by NO. Nitric oxide which is produced by cytokine activated mononuclear cells plays an important role in inflammation and immunity as a cytotoxic effector molecule and as a transducer molecule in immune cells and in oxidative stress as a potential source of intracellular free radicals. An increase in reactive oxygen species can produce damage to lipids, proteins and DNA and induce necrosis or apoptosis. The implication of NO in different pathological processes, such as atherosclerosis, diabetes, ischaemia and reperfusion, or during inflammatory processes and the generation of free radicals contributing to the endothelial injury associated to these processes.