Alberto García-Lledó

Endothelial dysfunction, intima-media thickness and coronary reserve in relation to risk factors and Framingham score in patients without clinical atherosclerosis.

Background Endothelial dysfunction, decreased coronary flow reserve (CFR) and increased intima–media thickness (IMT) are related to atherosclerosis and can be assessed non-invasively by echography. Objectives In order to describe the relationship between these parameters and with cardiovascular risk, this study investigated them simultaneously in patients without clinical atherosclerosis. Methods A total of 106 subjects were studied, 91 with and 15 without cardiovascular risk factors. Cardiovascular disease was excluded in all cases. Doppler ultrasound was used to analyse endothelium-dependent vascular dilation in the brachial artery, IMT in the common carotid artery and CFR in the left anterior artery. Results Patients with cardiovascular risk factors had impaired flow-mediated dilation (FMD; 3.7 ± 3.2 versus 11.6 ± 4.4%, P = 0.000); greater IMT (0.89 ± 0.3 versus 0.56 ± 0.14 mm, P = 0.000) and lower CFR (2.7 ± 0.9 versus 4 ± 1.2, P = 0.000). Correlation was found between IMT and FMD r = −0.240, (P = 0.013), IMT and CFR, r = −0.384 (P = 0.000), and between FMD and CFR of r = 0.289 (P = 0.007). All patients with IMT greater than 1 mm showed depressed FMD, most of them with low values of CFR, but patients with reduced FMD or CFR did not necessarily show increased IMT. There was a significant correlation between the three parameters and the Framingham risk score. Multiple linear regression analysis showed that IMT was the only factor related to the Framingham score. Conclusion In patients without clinical atherosclerotic disease, cardiovascular risk factors are associated with impaired FMD, CFR and increased IMT. Even though a correlation between these changes was found, they showed different dependence on cardiovascular risk factors and with global risk, IMT being the best correlated with the Framingham score.

Asociación de la disfunción endotelial y el grosor mediointimal carotídeo con los factores de riesgo coronario en pacientes sin evidencia clínica de aterosclerosis

Introduccion y objetivos La disfuncion endotelial y el aumento del grosor mediointimal carotideo son fenomenos tempranos en el desarrollo de la aterosclerosis, que pueden estudiarse de forma incruenta por ecocardiografia. Se pretende analizar la funcion endotelial, el grosor mediointimal carotideo y la correlacion entre ambos parametros con los factores de riesgo coronario en pacientes sin evidencia clinica de aterosclerosis. Pacientes y metodo Se incluyeron 52 sujetos, 13 sin ningun factor de riesgo coronario y 39 con al menos un factor de riesgo coronario. Se les realizo una medicion ecocardiografica de la vasodilatacion dependiente del endotelio en la arteria braquial y del grosor mediointimal en la carotida comun. Resultados En comparacion con los sujetos sin factores de riesgo coronario, los pacientes con factores de riesgo presentaron una disminucion de la vasodilatacion dependiente del endotelio: 11,98 ± 4,61% frente a 2,77 ± 2,57%, (p Conclusiones En pacientes sin evidencia clinica o complicaciones ateroscleroticas pero con factores de riesgo coronario, la funcion endotelial es peor y el grosor mediointimal carotideo es mayor que en pacientes sin ellos. Ademas, existe una asociacion lineal negativa entre la vasodilatacion dependiente del endotelio y el grosor mediointimal.

Diagnosis and grading of intrapulmonary vascular dilatation in cirrhotic patients with contrast transesophageal echocardiography

BACKGROUND/AIMS The use of transesophageal contrast echocardiography (TOCE) in the diagnosis of intrapulmonary vascular dilatation (IVD) and hepatopulmonary syndrome (HPS) needs to be studied. We tested the specificity of TOCE using traditional criteria and the value of a new method based on TOCE, a grading scale and a selected contrast. METHODS 1) Several solutions were tested and two were selected: 20% mannitol and 0.9% saline. 2) 71 cirrhotic patients and 20 controls were studied. Left atrium opacification with contrast was classified into 6 degrees by TOCE. Mild and significant IVD were considered in relation to results in controls. Patients were studied with saline and mannitol-TOCE. Results were compared to transthoracic contrast echocardiography (TTCE), to gas exchange abnormalities and to Child class. RESULTS The reproducibility of TOCE grading was excellent, (Kappa >0.9). IVD detection using TTCE, mannitol-TOCE and saline-TOCE was 29.5%, 55% (25% mild and 30% significant), and 45% (38% mild and 7% significant), respectively. The best agreement with TTCE (reference method) was obtained with mannitol-TOCE, using significant IVD as the cut point. By this criterion, 18% reached the criteria of HPS using TTCE and 22% using mannitol-TOCE. Patients with IVD by TTCE had non-significant changes in gas exchange determinations. Patients with significant IVD by saline TOCE had lower mean PaO2 levels (67.3+/-14 vs. 79.5+/-11 mm Hg, p<0.05) than patients without IVD. Patients with significant IVD by mannitol TOCE had higher mean AaPO2 (29.3+/-14 vs. 19.7+/-9 mm Hg; p<0.005) and lower mean PaCO2 levels (30.1+/-4.4 vs. 33.4+/-4.8 mm Hg; p<0.05) than patients without IVD. Severity of IVD by TOCE correlated to Child class (r = 0.43; p<0.001). CONCLUSIONS The presence of contrast in the left atrium cannot be a criterion of IVD when TOCE is used. Our semi-quantitative scale has proved to be feasible and reproducible, presenting a good agreement with TTCE, and has shown better correlation with gas exchange abnormalities and Child class. Saline TOCE appears to be more specific in the detection of hypoxemic patients with IVD, but mannitol TOCE adds sensitivity.

Effect of candesartan on coronary flow reserve in patients with systemic hypertension.

Background Patients with hypertension have structural and functional changes in conductance and resistance vessels. In the absence of coronary stenosis the coronary microvascular function can be analysed by studying the coronary reserve. The aim of this study was to evaluate, non-invasively, the effect of candesartan on coronary microvascular function in hypertensive patients. Methods Twenty-two hypertensive patients (> 40 years) without clinical coronary disease (age 63.86 ± 10.3 years; women, 59.1%) were studied. In addition to blood pressure (BP), measurement of carotid intima–medial thickness (IMT), left ventricle mass index (LVMI) and the coronary flow reserve (CFR) were evaluated with echography at the beginning, and after 3 months of treatment with 16 mg/day of candesartan. Twelve hypertensive controls (64.50 ± 10.8 years; women, 58.4%) completed the same study without any change in treatment. Results A 15% improvement in CFR (3.10 ± 1.02 to 3.56 ± 1.06; P = 0.001) was observed simultaneously with the BP reduction. There was no change in CFR in the control group (2.9 ± 1.1 to 3.01 ± 0.9; P = 0.23). The IMT was not modified significantly at the end of the follow-up (0.86 ± 0.1 to 0.83 ± 0.1 mm; P = 0.103). Conclusion Candesartan improves the CFR in hypertensive patients. The improvement was not related to BP control or LVMI regression. Patients with a lower CFR show a better response to candesartan. This fact can be demonstrated non-invasively with echography after 3 months of therapy.

Indexed left atrial volume is a more sensitive indicator of filling pressures and left heart function than is anteroposterior left atrial diameter.

Introduction: Left atrial (LA) size is an indicator of the pressure to which it is chronically subjected. Although guidelines recommend measuring it using volume indexed to body surface, the anteroposterior diameter is still normally used. Aim: To evaluate which of these measurements correlates better with atrial pressure‐related echocardiographic parameters. Methods: Atrial diameter and volume, together with parameters of systolic function, diastolic function, pressure, and degree of mitral regurgitation, were measured in 121 consecutive outpatients. Results: Atrial diameter correlated with its indexed volume (r: 0.69) with a low degree of agreement for detecting dilation (Kappa: 0.51). Atrial diameter was related to the parameters associated with atrial pressure: E/E′ (r: 0.44), pulmonary vein systolic/diastolic rates quotient (r: 0.25) and degree of mitral regurgitation (r: 0.19). The correlations improved when volume indexed to body surface was measured (r: 0.52; 0.38 and 0.44, respectively). In a multiple regression analysis that included E/E′, pulmonary vein flow and degree of mitral regurgitation, LA diameter depended entirely on E/E′ (r: 0.44; B: 0.04; P: 0.000). The relationship improved when the diameter was corrected for body surface or the volume was measured (r: 0.54 and 0.54, respectively), and in particular when volume indexed to body surface was measured (r: 0.66). In this case, pulmonary vein flow (B: 6.8; P: 0.03), degree of mitral regurgitation (B: 5.2; P: 0.000) and E/E′ ratio (B: 0.8; P : 0.000) were included in the equation. Conclusions: Indexed atrial volume correlates better with LA pressure surrogates than the anteroposterior diameter, even when this is corrected for body surface. (Echocardiography 2010;27:1049‐1055)

Estimación de la severidad de la insuficiencia mitral según un método simplificado basado en el flujo de convergencia proximal

Introduction and objectives. Calculation of the effective regurgitant orifice (ERO) is regarded as the most accurate way of assessing the severity of mitral regurgitation (MR), but the technique’s complexity limits its use. Our objective was to modify and validate a previously published semiquantitative method of assessment based on measurement of the proximal isovelocity surface area (PISA) in order to adapt it to recent recommendations from American and European cardiology societies. Methods. In the PISA method, maximum regurgitant flow (MRF) is a function of the radius and aliasing velocity (AV). Using this relationship, it is possible to construct a nomogram formed by lines of different MRF value, which can be easily derived by looking for radius values on the graph and observing where they cross with AV values. The MR severity limits on the nomogram were set to reflect the different severity grades and limits recommended for use with ERO measurements by American and European cardiology societies. Results. We studied 76 patients with MR using Doppler echocardiography. There was an excellent correlation between MRF and ERO (r=0.98, P<.001). Estimates of MR severity made using the new nomogram were in good agreement with those derived from the ERO: for a scale with three severity grades, kappa was 0.951 and the standard error was 0.11; for four grades, kappa was 0.969 and the standard error, 0.11. Conclusions. Estimates of MR severity derived semiquantitatively from MRF using the nomogram proposed here were in excellent agreement with quantitative estimates obtained using the ERO, and the method was faster and easier to use.

Four chamber right ventricular longitudinal strain versus right free wall longitudinal strain. Prognostic value in patients with left heart disease

BACKGROUND There is no consensus on which right ventricle (RV) strain parameter should be used in the clinical practice: four chamber RV longitudinal strain (4CH RV-LS) or free wall longitudinal strain (FWLS). The aim of this study was to analyze which RV strain parameter better predicts prognosis in patients with left heart disease. METHODS One hundred and three outpatients with several degrees of functional tricuspid regurgitation severity secondary to left heart disease were prospectively included. 4CH RV-LS and FWLS were assessed using speckle tracking. Left ventricular (LV) systolic function was determined using LV ejection fraction and RV systolic function using tricuspid annular plane systolic excursion (TAPSE). Patients were followed up for 23.1 ± 12.4 months for an endpoint of cardiac hospitalization due to heart failure. RESULTS The cutoff value related to RV dysfunction (TAPSE < 17 mm) was lower, in absolute value, for 4CH RV-LS (4CH RV-LS = -17.3%; FWLS = -19.5%). There were 33 adverse events during the follow-up. Patients with 4CH RV-LS > -17.3% (log rank [LR] = 22.033; p < 0.001); FWLS > -19.5% (LR = 12.2; p < 0.001), TAPSE < 17 mm (LR = 17.4; p < 0.001) and LV systolic dysfunction (LR = 13.3; p < 0.001) had lower event-free survival (Kaplan Meier). In Cox multivariate analysis, 4CH RV-LS > -17.3% (hazard ratio [HR] = 3.593; p < 0.002), TAPSE < 17 (HR = 2.093; p < 0.055) and LV systolic dysfunction (HR = 2.087; p < 0,054) had prognostic value, whereas FWLS did not reach significance. CONCLUSIONS Although both 4CH RV-LS and FWLS have prognostic value, 4CH RV-LS is a better predictor of episodes of heart failure in patients with left heart disease, providing additional information to that obtained by TAPSE.

Mechanical Alternans Detected by Doppler-Derived dP/dt

Mechanical alternans refers to the succession of strong and weak heartbeats. It is classically associated with advanced-stage heart failure although it can also be seen in aortic stenosis, hypertrophic cardiomyopathy, a sharp increase in cardio post load, a drop in preload, acute ischaemia and the onset of tachycardia. Mechanical alternans have been explained by mechanisms related to the FrankStarling law, incomplete ventricular relaxation, partial asystole or variations in post load1 and, more recently, by disorders of the coupling between the release and re-uptake of calcium, supported by studies that found disorders in the genes of proteins related to calcium handling.2 Its negative impact on the prognosis of heart failure has been shown using

Valor pronóstico del electrocardiograma en pacientes con diabetes tipo 2 sin enfermedad cardiovascular conocida

Introduction and objectives. The predictive value of ECG abnormalities in patients with type-2 diabetes mellitus (DM2) has not been fully studied. Our objective was to assess the prognostic value of ECG abnormalities in patients with DM2 but without known cardiovascular disease. Methods. Overall, 412 patients with DM2 were identified at 2 primary care centers in the same city. Two hundred and twenty one patients < 80 years of age without known cardiovascular disease were included in the study. An ECG was recorded at baseline and annually during follow-up. The ECGs were evaluated using a system based on the Minnesota code. The main study end-point during follow-up was the occurrence of a cardiovascular event, as defined in the Framingham study. Results. The mean follow-up duration was 5.9 years (1.1-8.5 years). At the beginning of the study, 24.9% of patients had ECG abnormalities; at the end, 44.3% had abnormalities. Cardiovascular events occurred in 65 patients (29.4%). The relative risk (RR) of a cardiovascular event in a patient with an ECG abnormality was 8.28 (95% confidence interval [CI], 3.36-20.42). Only hypertension (RR=2.29; 95% CI, 1.24-4.22) and age were significantly related to the occurrence of a cardiovascular event. Multiple regression analysis that included classical risk factors and ECG findings showed that an ECG abnormality was a significant independent predictor, with adjusted RR=5.95 (95% CI, 2.29-15.47). Conclusions. The presence of an ECG abnormality can predict the occurrence of a future cardiovascular event in patients with DM2 more accurately than risk factors alone. This finding could be helpful in selecting subgroups of high-risk diabetic patients.

Prognostic Value of Valsalva Maneuver-Induced Change in Doppler-Detected Ventricular Filling in Patients With Systolic Dysfunction

INTRODUCTION AND OBJECTIVES In patients with systolic dysfunction, different ventricular filling patterns are associated with different prognoses. The load changes resulting from nitroprusside infusion or long-term therapy for heart failure induce alterations in filling pattern that have been shown to serve as outcome markers. Our aim was to investigate the prognostic value of the Doppler-detected change in pseudonormal or restrictive left ventricular filling pattern induced by the Valsalva maneuver in patients with systolic dysfunction. MATERIAL AND METHOD The study included 36 patients in sinus rhythm with a depressed ejection fraction and an E/A ratio greater than 1. Filling velocities were recorded before and after 3 Valsalva maneuvers. RESULTS The E/A ratio remained greater than 1 in 12 patients (group A); in 24 patients (group B), it fell below 1, indicating an abnormal relaxation pattern (i.e., a reversible pattern). During a mean follow-up period of 18 months, 8 patients died: 6 in group A (50%) and 2 in group B (8.3%; P=.005). Moreover, 12 patients either died or suffered severe heart failure: 8 in group A (67%) and 4 in group B (17%; P=.003). A reversible filling pattern was associated with lower risks of death (hazard ratio [HR]=0.06; 95% confidence interval [CI], 0.01-0.48) and of hospitalization or death (HR=0.11; 95% CI, 0.03-0.43). CONCLUSIONS Change of a pseudonormal or restrictive left ventricular filling pattern into an abnormal relaxation pattern after the Valsalva maneuver in patients with systolic dysfunction predicts a lower risk of death or severe heart failure.