Abdul-Majeed Salmasi

Age-associated changes in left ventricular diastolic function are related to increasing left ventricular mass

Isometric exercise (IME) produces significant hemodynamic changes in the cardiovascular system. We have used IME to study the effect of age on diastolic left ventricular (LV) function in 100 normal volunteers. The E/A ratio (peak velocity of early/atrial filling phases), deceleration time (DT), and isovolumic relaxation time (IVRT) of the transmitral flow were assessed during echocardiography with pulsed-Doppler ultrasound at rest and at peak IME using handgrip. LV mass index (LVMI) and LV ejection fraction (LVEF) were also calculated. Both E/A and IVRT reduced significantly with increasing age. The LVEF decreased (P <.0001), whereas LVMI increased (P <.05) with advancing age. The LVEF was inversely related to LVMI (P <.05). An inverse relationship was noted between E/A and LVMI (P <.01) during IME. The contribution of the atrial contraction to the total diastolic flow increased significantly with advancing age (P <.02) and increased from 0.29 +/- 0.04 at rest to 0.34 +/- 0.08 during IME (P <.0001). It is concluded that with progressing age, the left ventricle becomes stiffer resulting in a reduction in early filling and a compensatory increase in flow due to atrial contraction. A progressive increase in LVMI, which accompanies aging may contribute to stiffening of the left ventricle and deterioration in diastolic function of the left ventricle. This is exaggerated by IME.

Impaired venoarteriolar reflex as a possible cause for nifedipine-induced ankle oedema

Ankle oedema is not an uncommon side effect of treatment with nifedipine. To evaluate the possible effect of nifedipine on the microcirculation of the skin, 18 patients with systemic hypertension who were known to develop ankle oedema after nifedipine and 19 patients with systemic hypertension who did not develop ankle oedema after nifedipine were studied. Following four weeks of nifedipine therapy (10 mg, three times daily), the microcirculation on the dorsum of the foot was measured using laser-Doppler flowmetry. Estimation of the microcapillary flow was made both after supine resting and on standing upright. The venoarteriolar reflex was expressed as the standing flow in percentage of the resting flow. There was no significant difference between the two groups of patients in the resting flow, supine flow, or the venoarteriolar reflex before nifedipine therapy (P greater than 0.4). Before nifedipine, the blood blow in the skin of both groups of patients was reduced from the supine level upon standing, thus indicating a normal response to dependency. After nifedipine administration, no significant difference was observed between the two groups of patients in the resting flow (P greater than 0.5). The flow on standing, however, was 96.2% of that measured during resting supine in patients who developed ankle oedema and 79.8% of the resting flow in the patients who did not develop ankle oedema, suggesting a weaker venoarteriolar reflex in patients who developed ankle oedema following administration of nifedipine (P less than 0.0001). Thus, the microcapillary flow did not decrease upon standing in patients who developed ankle oedema following nifedipine therapy, indicating an abnormal venoarteriolar reflex. This may explain why ankle oedema develops in such patients following nifedipine.

Variation of aortic blood velocity with age at rest and during exercise in normal subjects

The effect of age on aortic blood velocity signal and its derived indices of left ventricular function namely peak velocity, stroke distance (the velocity—time integral) and minute distance (stroke distance × heart rate) was studied at rest and at maximal-tolerated supine exercise using a 2-mHz continuous-wave Doppler ultrasound applied via the suprasternal notch in 66 normal healthy volunteers. The peak velocity, stroke distance and the minute distance, both at rest and at maximal exercise decreased with advancing age by 1–1.1% per annum between the ages of 20 and 70 years. Accordingly a method for age-adjustment of the peak velocity, stroke and minute distances was introduced for clinical use in assessing individual subjects. These results indicate that age is an important variable affecting aortic blood velocity and its derived variables as non-invasive measures of left ventricular function both at rest and with exercise. The relationship with age is an important consideration when assessing individual subjects.

The Glucose Tolerance Test, But Not HbA 1c, Remains the Gold Standard in Identifying Unrecognized Diabetes Mellitus and Impaired Glucose Tolerance in Hypertensive Subjects

The objective of this study was to compare the value of the oral glucose tolerance test (GTT), glycated hemoglobin concentration (HbA1c), and fasting plasma glucose (FPG) for identifying unrecognized diabetes mellitus (DM) and impaired glucose tolerance (IGT) in hypertensive subjects. One hundred forty-four consecutive subjects who were not known to have DM and who were attending the Hypertension Clinic underwent 24-hour ambulatory blood pressure (BP) monitoring. A GTT and an HbA1c measurement were also carried out. Abnormal results from GTT were found in 94 patients (65%). Results from FPG were not different between those with DM and IGT but were significantly higher than in the euglycemic subjects. The FPG was between 110-125 mg/dL (6.1-6.9 mmol/L) in 31% (n=20) of patients with IGT and in 53% (n=16) of those with DM. With use of the previously published criteria to diagnose DM of FPG ≥103 mg/dL (5.7 mmol/L) and HbA1c ≥5.9%, 33% of our diabetic subjects and 75% of those with IGT would have been misclassified as euglycemic. The previously reported cut-off point for HbA1c of >6.1% to diagnose DM was present in 77% of our patients with DM and in 14% (n=9) of the patients with IGT. Multiple regression analysis showed that an abnormal result from GTT was independent of the level of clinical or ambulatory BP, nocturnal BP dip, cholesterol level, smoking history, race, or class of antihypertensive medication taken. FPG levels or HbA1c, or their combination, are not accurate enough to identify DM or IGT in patients attending a hospital Hypertension Clinic. A GTT may be required in these patients to reliably identify those with DM or IGT.

Angiology in practice

Part One: General Pathophysiological Considerations. Blood Flow Dynamics and Mechanics of Circulation S. Sherriff. Pathology of Atherosclerosis S. Trotter, M. Ali. Thrombosis and Thromboembolism M. Schachter. Haemorheology and Haemorheological Mechanisms M. Rampling. The Role of Vascular Endothelium in the Modulation of Coronary Vasomotor Tone J.C. Kaski. Part Two: Diseases of the Cerebrovascular System. Cerebrovascular Flow Dynamics and Pathophysiology S. Sherriff. Stroke Epidemiology and Risk Factors M.I. Aldoori, et al. The Investigation of Extracranial Carotid Disease P.A. Gaines, et al. Management of Extracranial Carotid Disease J.D. Beard, et al. Part Three: Diseases of the Coronary Arteries. Hemodynamics of Coronary Flow in Normal and Abnormal States M. Mariani, A. Balbarini. The Pathology and Pathophysiology of Coronary Artery Disease I. Cox, R. Crook. Epidemiology and Risk Factors T.J. Bowker, et al. Symptomatology and Diagnosis of Coronary Artery Diseases P. Clifford, P. Nihoyannopoulos. Angina Pectoris in Patients with Normal Coronary Arteriograms: Syndrome X J.C. Kaski. Management of Coronary Artery Disease J.G.F. Cleland. Part Four: Diseases of the Aorta and Arteries of the Upper Limb. Aortic Aneurysm and Dissection of the Aorta J. Collin. Diseases of the Arteries of the Upper Limb M. Cospite, et al. Raynauds Syndrome S.A. Wagstaff, M.J. Grigg. Part Five: Diseases of the Arteries of the Lower Limb. Flow Dynamics and Pathophysiological Mechanisms of Diseases of Lower Limb Arteries G.M. Andreozzi. Epidemiology and Risk Factors G.C. Leng, F.G.R. Fowkes. Clinical Assessment of Diseases of Lower Limb Arteries K.A. Myers, W. Chong. Management of Peripheral Obstructive Arterial Disease of the Lower Limbs S. Novo. Part Six: Diseases of the Renal, Coeliac and Mesenteric Arteries. Pathophysiology and Clinical Manifestations P. Fiorani, et al. Management of Diseases of the Renal, Coeliac and Mesenteric Arteries P. Fiorani, et al. Part Seven: Hypertension. Classification, Epidemiology, Risk Factors, and Clinical Manifestations of Hypertension L. Corea, M. Bentivoglio. Diagnosis, Complications and Management of Hypertension G. Licata, et al. Part Eight: Diseases of the Venous System. Varicose Veins and Varicose Ulcers C. Allegra, et al. Deep Vein Thrombosis S. Coccheri. Part Nine: Associated General Illnesses and Related Conditions. Cardiovascular Manifestations and Complications of Diabetes Mellitus J. Allawi. Autonomic Dysfunction and Hypotension G. Nuzzaci, I. Nuzzaci. Haemostatic Defects and Venous Thromboembolism C. Ozanne, H. Cohen. Pulmonary Embolism and Venous Thromboembolism D. Bell. Vascular Restenosis P. Chan. Vascular Emergencies M. Bartolo, A.R. Todini. Prevention of Cardiovascular Disease M. Barbir, et al.

Improvement of silent myocardial ischaemia and reduction of plasma fibrinogen during nisoldipine therapy in occult coronary arterial disease

The effect of the long-acting calcium channel blocking agent, nisoldipine, on silent myocardial ischaemia due to occult atherosclerotic coronary arterial disease has been evaluated in 12 asymptomatic patients (seven diabetics and five claudicants), none of whom had any history suggestive of ischaemic chest pain or previous myocardial infarction. All patients had normal resting electrocardiograms but positive exercise testing using 16-lead electrocardiographic mapping of the chest wall. They also had silent episodes of ST-segment depression during 24-hour ambulatory (Holter) monitoring. The study was of double-blind, cross-over design with four weeks randomised nisoldipine 10 mg twice daily versus placebo twice daily. Both the exercise test and Holter monitoring were carried out before entry to the trial and at the end of each randomised active and placebo phase. Plasma fibrinogen was also estimated at entry to the trial and at the end of each randomised phase. There were significant reductions in the magnitude (P less than 0.001) and duration (P less than 0.001) of depression of the ST segment on exercise testing and in the number of episodes (P less than 0.01), magnitude (P less than 0.001) and duration (P less than 0.02) of ST-segment depression on Holter monitoring at the end of the nisoldipine phase as compared to the randomised placebo phase. A significant reduction in plasma fibrinogen was also noted at the end of the nisoldipine phase (P less than 0.001). This study demonstrates the efficacy and usefulness of nisoldipine in treating myocardial ischaemia due to occult coronary arterial disease in asymptomatic subjects presenting with diabetes mellitus or intermittent claudication. Its use was associated with reduction in plasma fibrinogen.

The degree of albuminuria is related to left ventricular hypertrophy in hypertensive diabetics and is associated with abnormal left ventricular filling: A pilot study

The association of albuminuria and left ventricular (LV) hypertrophy (LVH) in diabetics aggra vates the prognosis. The authors studied the relation between LVH and the degree of albu minuria in diabetics and investigated the relationship of albuminuria to LV filling. A comparison was made between 30 hypertensive diabetics, 10 of whom had microalbuminuria (MIC) and 20 had macroalbuminuria (MAC), and 18 diabetics who were normotensive and normalbuminuric (NOR). LV mass index (LVMI) and LV ejection fraction (LVEF) were measured during echocar diography. LV filling pattern at rest and at peak standardized isometric exercise (IME) using handgrip was assessed by measuring E/A (peak velocity of the early/atrial filling waves) of the transmitral flow during Doppler and echocardiography. Each patient underwent a stress ECG test. LVMI was higher in MAC (132.3 ±55.4) than in MIC (115.6 ±32.5) or NOR (90.0 ±31.8) (p<0.01). There were more patients in MAC with LVH (n = 13) and abnormal filling (n = 9 at rest and 16 with IME) than in MIC (LVH = 5, abnormal filling = 1 at rest and 10 during IME) or NOR (LVH = 3, abnormal filling = 1 at rest and 9 during IME) (p < 0.02). LVMI was not related to LVEF. Although blood pressure was not different between MAC and MIC groups, it was signif icantly higher than in the NOR group. This study suggests that a high degree of albuminuria in hypertensive diabetics is associated with greater value for LVMI and an increased incidence of LVH independent of blood pressure level or systolic LV function. LVH is associated with abnormal LV filling. The degree of albuminuria may predict LVMI and LVH, which are associated with abnormal LV filling. This association of abnormal LV filling with albuminuria in hypertensive diabetic patients may account for their high risk of cardiovascular events.

Atrial Septal Aneurysm and Patent Foramen Ovale Are Less Prevalent in the Indo-Asian Than in the Caucasian or Afro-Caribbean Population

Atrial septal aneurysm (ASA) and patent foramen ovale (PFO) are not uncommon during routine echocardiographic scanning and were reported to be associated with stroke, transient ischemic attacks, and migrainous headache. To assess the prevalence of ASA and PFO according to ethnicity, we retrospectively studied 887 consecutive referrals to a General Cardiology and Hypertension clinics. All participants underwent trans-thoracic echocardiography (TTE). In some patients, the TTE was repeated using bubble contrast. Results: Atrial septal aneurysm was detected in 70 participants (7.9%) and PFO in 18 (2%). Atrial septal aneurysm, PFO, or their combination was detected in 12% of the Caucasian patients, 15% of the Afro-Caribbean, and 3.7% of the Indo-Asian patients. Conclusions: There was a lower prevalence of ASA and PFO and their combination in Indo-Asians and a higher rate in Afro-Caribbeans than in Caucasians. The higher prevalence in the Afro-Caribbean participants may contribute to the high incidence of stroke in black participants.

Cardiac output and regional flow in health and disease

Part One: Technical Considerations. Part Two: Cardiac Output: Physiological Considerations. Cardiac output in Normal Subjects at Rest and During Exercise. Part Three: Cardiac Output in Cardiac Disease. Part Four: Cardiac Output in the Critically Ill Patient. Part Five: Cardiac Output: Effect of Intervention. Part Six: Fetal Circulation and Cardiac Output during pregnancy and in Neonates. Part Seven: Cardiac Output in Non-Cardiac Diseases. Part Eight: Regional Circulation. Index.

Hydatid Cyst of the Heart

Cystic hydatid disease is responsible for the loss of 1 to 3 million disability-adjusted life years every year. Infestation of the heart, though rare, can result in serious complications if left untreated. We retrospectively collected information on 19 patients with cardiac hydatid cyst admitted at the Center for Cardiac Surgery of Ibn Al-Bitar Hospital in Baghdad from July 2007 to July 2011 who were either in need of a cardiac surgery for treating hydatid cysts or presented with emergency conditions. Nine (47%) patients presented with left-sided heart failure and mitral valve dysfunction, 5 (26%) patients had hydatid cysts in the pericardium, 3 (16%) patients had hydatid cyst in the right ventricle and presented with right-sided heart failure, and 2 (11%) patients who presented with cardiac arrhythmias had infestation in the interventricular septum. Removal of cysts following open-heart surgery was successful and was followed by the use of mebendazole or albendazole for 5 years. We conclude that cardiac hydatid cyst that leads to various cardiac symptoms can be successfully managed and should be considered as a diagnostic possibility in patients with cardiac symptoms in endemic areas.