Christodoulos E. Papadopoulos

Aortic elastic properties are related to left ventricular diastolic function in patients with type 1 diabetes mellitus.

Objective: The aim of the study was to evaluate left ventricular diastolic function and its relation to aortic wall stiffness in patients with type 1 diabetes mellitus without coronary artery disease or hypertension. Patients: Sixty-six patients with type 1 diabetes mellitus were examined by echocardiography and divided into two groups according to the diastolic filling pattern determined by mitral annulus tissue Doppler velocities. Group A patients (n = 21) presented diastolic dysfunction with a peak early diastolic mitral annular velocity (Em)/peak late diastolic mitral annular velocity (Am) ratio <1 whereas in group B patients (n = 45) the Em/Am ratio was >1. Coronary artery disease was excluded based on normal thallium scintigraphy. Aortic stiffness index was calculated from aortic diameters measured by echocardiography, using accepted criteria. Results: Aortic stiffness index differed significantly among the two groups. Significant correlations were found between parameters of left ventricular diastolic function (Em/Am, isovolumic relaxation time, deceleration time) and aortic stiffness index. Multiple stepwise linear regression analysis revealed aortic stiffness index (β = –0.39, p = 0.001) and isovolumic relaxation time (β = –0.46, p < 0.001) as the main predictors of Em/Am ratio. Conclusions: Aortic stiffness is increased in type 1 diabetic patients with left ventricular diastolic dysfunction. This impairment in aortic elastic properties seems to be related to parameters of diastolic function.

Evidence of Left Ventricular Dysfunction in Asymptomatic Elderly Patients with Non-insulin-dependent Diabetes Mellitus

Diabetic cardiomyopathy is a distinct entity in diabetic patients with congestive heart failure, who have no angiographic evidence of significant coronary artery stenosis. The aim of this study was to evaluate left ventricular (LV) function in 24 elderly patients (mean age 67 ±2 years) with type 2 diabetes, who were asymptomatic and had no history of hypertension, or coronary or valvular heart disease. LV systolic indices (ejection fraction [EF] and fractional shortening [FS]), diastolic indices (E wave, A wave, E/A ratio, isovolumic relaxation time [IVRT] and deceleration time [DT]) and the myocardial performance index (MPI) were evaluated with echocardiography. Compared to controls (24 age- and gender-matched normal subjects), the E wave was reduced (0.60 ±0.10 m/sec vs 0.72 ±0.08 m/sec, p<0.05), the A wave was increased (0.77 ±0.07 m/sec vs 0.68 ±0.06 m/sec, p<0.05), the E/A ratio was decreased (0.78 ±0.20 vs 1.06 ±0.18, p<0.001) and both IVRT and DT were prolonged (0.115 ±0.01 sec vs 0.09 ±0.01 sec, p<0.001 and 0.240 ±0.04 sec vs 0.180 ±0.03 sec, p<0.001, respectively). The MPI was significantly increased (0.640 ±0.170 vs 0.368 ±0.098, p<0.001). LV diastolic function and the MPI are markedly impaired in asymptomatic elderly patients with type 2 diabetes.

Usefulness of colour tissue Doppler imaging in assessing aortic elastic properties in Type 1 diabetic patients

Aims  Diabetes mellitus (DM) is associated with macrovascular disease and impaired aortic function. We hypothesized that the change in aortic elastic properties could be investigated with colour tissue Doppler imaging (CTDI) in Type 1 diabetic patients and that these findings could be related to the aortic stiffness index.

Evidence of ischemic preconditioning in patients experiencing first non-ST-segment elevation myocardial infarction (NSTEMI)

BACKGROUND Several studies have demonstrated the protective effects of preinfarction angina in Q wave myocardial infarction, implicating the role of ischemic preconditioning but this role remains uncertain in patients with a NSTEMI. Subendocardial viability in NSTEMI patients, is thought to be less dependent on collateral circulation and thus more likely to be protected by other mechanisms such as preconditioning. METHODS We have studied prospectively 40 patients with first NSTEMI and with angiographically proven poor or no collateral development and compared two groups; those with versus those without preinfarction angina. All in-hospital events, such as recurrent angina, congestive heart failure, arrhythmias and reinfarction were recorded. Serum markers of myocardial necrosis (CPK, CPK-MB, AST) and discharge QTc values were estimated. RESULTS Preconditioned patients suffered less recurrent angina (18 vs. 55% P=0.014), congestive heart failure (0 vs. 22%, P=0.02), arrhythmic events (0 vs. 27%, P=0.008) and had significant smaller values of mean peak CPK (381 +/- 152 vs. 859 +/- 496 I.U./l, P=0.0008), mean peak CPK-MB (45.5 +/- 24.6 vs. 105.2 +/- 87 I.U./l, P=0.01), mean peak AST (59.8 +/- 23.1 vs. 112.4 +/- 64.3 I.U./l, P=0.003) and QTc value at discharge (0.42 +/- 0.03 vs. 0.46 +/- 0.05 s, P=0.005) than patients without preconditioning. Multiple logistic regression analysis confirmed that the absence of preinfarction angina (relative risk 9.10, 95% CI 2.08-40.00, P=0.003) was a significant predictor of in-hospital complications. CONCLUSIONS Preinfarction angina constitutes a strong clinical correlate to ischemic preconditioning in patients with first NSTEMI, offering serious protection, by improving in-hospital outcome and reducing infarct size.

In-hospital management of acute heart failure: Practical recommendations and future perspectives.

Acute heart failure (AHF) represents the first reason for hospitalization in the elderly and despite therapeutic advances, remains a syndrome with significant morbidity and dismal prognosis. Hospitalization for AHF, on the other hand, is the single most important contributor to the huge financial burden related to HF. As a result, there is a significant unmet need for more effective in-hospital management of patients with AHF in order to improve outcomes, reduce readmission rate and alleviate the socioeconomic burden of the syndrome. The in-hospital management of AHF patients may schematically be divided into three phases, an early phase of intensive management of congestion and/or hypoperfusion, an intermediate phase of transition to oral life-saving medications and a late phase of discharge and transition to outpatient management. In the present paper, we attempt to provide a concise and practical roadmap for each of the above phases, focusing mainly on defining clinical and laboratory criteria for the evaluation of patients and on describing therapeutic algorithms that summarize the available evidence and guidelines. In addition, we highlight some key open issues that need to be addressed by future research.

Association between plasma homocysteine levels and coronary artery disease: a population-based study in northern Greece

SUMMARY Objective: Elevated plasma total homocysteine (tHcy) levels constitute a risk factor for coronary artery disease (CAD). We prospectively examined the association of fasting tHcy levels in patients in Northern Greece who had established CAD. Patients and methods: Plasma fasting tHcy levels were measured in 42 patients with angiographically documented CAD and compared to 42 age-, sex-, BMI- and smoking habit-matched control subjects. We also determined the plasma vitamin B12, folic acid and lipoprotein levels in all patients and controls. Conventional risk factors for CAD were also estimated. Results: In a univariate analysis, tHcy (jumol/l) levels were higher in patients compared to controls almost reaching statistical significance (13 (7–41) vs 11.3 (4–39); p = 0.07). Multivariate analysis of conventional risk factors showed that tHcy levels were not an independent risk factor for CAD. However, tHcy levels were significantly higher in patients with a previous history of myocardial infarction compared to patients without such a history and to controls (15 (8.8-29) vs 11.7 (7-41); p = 0.007 and 15 (8.8-29) vs 11.3 (4-39); p = 0.002, respectively). Hyperhomocysteinaemia (> 15|imol/l) was detected in 35.7% of patients and 11.9% of controls (p < 0.05). Conclusions: In Northern Greece, plasma tHcy levels may not be an independent risk factor for CAD in patients with angiographically documented CAD. However, patients with CAD have a trend towards higher tHcy levels. Additionally, plasma tHcy levels may be associated with the development of myocardial infarction.

Parathyroid hormone-related protein is reduced in severe chronic heart failure

In the cardiovascular system, parathyroid hormone-related peptide (PTHrP) is expressed in various cells such as cardiac vascular smooth muscle cells, coronary endothelial cells and cardiomyocytes and acts as an autocrine/paracrine substance. We compared PTHrP levels in 35 consecutive patients with severe CHF (33 male, mean age 66.2 +/- 8.9 years) with 26 normal controls (24 male, mean age 63.1 +/- 8.6 years). PTHrP levels were reduced in severe CHF patients (11.10 +/- 1.37 fmol/ml) compared with the controls (20.62 +/- 3.30 fmol/ml, p = 0.005). PTHrP values decreased as a function of New York Heart Association classification. These results suggest that PTHrP levels decrease in proportion to the severity of heart failure and could potentially be used to monitor progression of disease non-invasively.

Evaluation of a Doppler-Derived Index Combining Systolic and Diastolic Left Ventricular Function in Acute Myocardial Infarction

Assessment of left ventricular (LV) function is crucial in the immediate postinfarction period. The authors evaluated the clinical applicability of the Doppler-derived myocardial performance index (MPI, defined as the sum of isovolumic contraction and relaxation times divided by LV ejection time) in patients with acute myocardial infarction (AMI) as to whether this index reflects the severity of LV dysfunction in this subgroup of patients. Post-AMI patients (n = 33) were compared with age- and sex-matched healthy subjects (n = 35). Within 24 hours of the AMI and 1 month thereafter, patients underwent 2D and Doppler echocardiography. Patients were divided into group A (Killip Class I, n = 22) and group B (Killip Class II-III, n = 11). The authors measured the LV ejection fraction (EF), diastolic indices (transmitral E and A waves, E/A ratio, deceleration time [DT], isovolumic contraction time [IVCT], isovolumic relaxation time [IVRT], MPI, LV end-systolic and end-diastolic volume indices [ESVi and EDVi] and wall motion score index [WMSi]). One-year mortality was also assessed. There was no significant difference concerning E and A waves, E/A ratio, and IVRT between the 2 groups. There were highly statistical differences at day 1 for EF (59.3 ± 6.7% vs 36.8 ± 4.5%, p<0.0001), DT (0.160 ± 0.030 sec vs 0.127 ± 0.022, p < 0.005), MPI (0.344 ± 0.084 vs 0.686 ± 0.120, p < 0.0001), ESVi (28.4 ± 3.9 mL/m2 vs 46.2 ± 8.4, p < 0.001), and WMSi (1.58 ± 0.06 vs 1.88 ± 0.35, p = 0.05), which persisted after 1 month. One-year mortality was significantly (0 vs 27.3%, p<0.01) lower in group A patients. This study shows that the MPI, reliably indicated LV dysfunction post-AMI, significantly correlated with clinically determined functional class, and possibly has some prog nostic implication.

Preconditioning Reduces QTc Value in Patients with First Non‐ST‐Segment Elevation Myocardial Infarction (NSTEMI)

Background: Preinfarction angina (PA) consists a strong clinical correlate to ischemic preconditioning (PC) and seems to occur in a bimodal time course. The aim of the study is to evaluate the impact of both forms of PC on QTc value representing myocardial electric stability, in patients with a first NSTEMI.

Left Ventricular Myocardial Mechanics in Cirrhosis: A Speckle Tracking Echocardiographic Study

Cirrhosis is commonly associated with impaired left ventricular (LV) myocardial contractile reserve to stress and diastolic dysfunction. The aim of this study was to assess LV systolic performance at rest, using both “standard” echocardiographic indices and novel deformation–rotational parameters, in order to elucidate the pathophysiologic basis of cardiac dysfunction in cirrhosis. Seventy‐seven men with cirrhosis (mean age 54.4 ± 9.7) of variable Child–Pugh class (A, B, C) and 20 healthy control subjects were prospectively evaluated by standard as well as speckle tracking echocardiography. Left ventricular ejection fraction (LVEF) was significantly higher in patients with cirrhosis compared to controls (64.6 ± 5.7% in controls vs. 71 ± 9.5%, 71.2 ± 7.1%, and 73 ± 7% in Child–Pugh classes A, B, and C, respectively, P = 0.002). Interestingly, LV systolic function augmentation was not associated with changes in LV longitudinal deformation (LV strain −19 ± 1.9% in controls vs. −20.1 ± 5.3% in class A vs. −21.3 ± 2.6% in class B vs. −21 ± 3.4% in class C, P = NS), but a statistically significant increase in LV apical systolic rotation and accordingly in LV twist was observed (LV twist 13.0 ± 3° in controls vs. 14.9 ± 5° in class A vs. 16.5 ± 2.8° in class B vs. 18.2 ± 2.9° in class C, P < 0.0005). Despite the increase in LV rotation, time to both basal and apical peak systolic rotation was significantly delayed in patients compared to healthy controls (P = 0.015 and P = 0.017 accordingly). Increased EF in cirrhosis could be attributed to increased LV torsion. Despite the “improved” rotation values at rest, there is a significant time delay in succeeding peak systolic rotation, hampering also the consequent untwisting–diastolic period.