Christodoulos Pliakos

Ambulatory blood pressure reduction after rosiglitazone treatment in patients with type 2 diabetes and hypertension correlates with insulin sensitivity increase

Background Within the metabolic syndrome, insulin resistance and compensatory hyperinsulinemia are associated with blood pressure (BP) elevation through various potential mechanisms. Thiazolidinediones are antihyperglycemic agents that decrease insulin resistance. Objective To determine the effect of the thiazolidinedione rosiglitazone on BP and insulin resistance in patients with type 2 diabetes and hypertension. Methods In 20 subjects (nine men and 11 women) with type 2 diabetes but with a poor glycemic control, and with poorly controlled or newly diagnosed hypertension, rosiglitazone 4 mg daily was added-on therapy for 26 weeks. At baseline and at the end of the treatment period patients underwent ambulatory blood pressure monitoring, a hyperinsulinemic euglycemic clamp, and blood tests for glucose, insulin, HbA1c, lipids, and routine laboratory parameters. Results Insulin sensitivity estimated with the clamp significantly increased (Mbw/I index changed from 33.9 ± 2.6 to 41.9 ± 3.2 μmol/min per kg per nmol/l, P < 0.001) and the HOMA-IR index significantly decreased (6.34 ± 0.39 versus 4.40 ± 0.33, P < 0.001) during rosiglitazone treatment. Ambulatory BP presented small but significant reductions for the total 24-h period (135.3 ± 1.8 versus 129.9 ± 1.7 mmHg, P < 0.001 for systolic BP and 76.0 ± 1.6 versus 71.9 ± 1.6 mmHg, P < 0.001 for diastolic BP), daytime and night-time. The changes in systolic and diastolic BP correlated with the change in insulin sensitivity (r = −0.78, P < 0.01 and r = −0.68, P < 0.01, respectively). There were also significant reductions in fasting plasma glucose (9.39 ± 0.41 versus 7.55 ± 0.31 mmol/l, P < 0.001), insulin (94.0 ± 0.41 versus 79.5 ± 5.6 pmol/l, P < 0.01) and HbA1c (8.15 ± 0.24 versus 7.24 ± 0.19%, P < 0.001). Conclusions Treatment of type 2 diabetic hypertensive patients with rosiglitazone significantly increased insulin sensitivity and lowered ambulatory BP. These changes were strongly correlated. Thiazolidinediones may thus possess a BP-lowering effect beyond their antihyperglycemic properties.

Atypical atrial myxomas in two asymptomatic patients: a case report

BackgroundAtypical cardiac myxomas are a rare occurrence and may present with a variety of clinical manifestations depending on the morphology and location.Case presentationTwo cases of cardiac myxomas atypically located in asymptomatic patients, diagnosed by transthoracic and transoesophageal echocardiography, are presented. In the first case a myxoma is located under the anterior mitral valve leaflet and in the second case a myxoma is located in the right atrium.ConclusionWe emphasize the leading role of transthoracic and transoesophageal echocardiography in the diagnosis of intracavitary cardiac tumours.

Identification of high risk patients with hypertrophic cardiomyopathy in a northern Greek population

BackgroundThe percentage of hypertrophic cardiomyopathy (HCM) patients who are in high risk for Sudden Death (SD) constitutes only a minority of all HCM population but the incidence of SD in this subset is high (at least 5% annually). The identification of this small but important proportion of high risk HCM patients has been the clue in the clinical evaluation of these patients.MethodsOur study cohort consisted from 123 patients with HCM who are currently followed up in our Institution. Five clinical risk factors were assessed: a family history of premature SD, unexplained syncope, Non Sustained Ventricular Tachycardia (NSVT) on 24-h ECG monitoring, Abnormal Blood Pressure Response (ABPR) during upright exercise testing and Maximum left ventricular Wall Thickness (MWT) ≥30 mm. The purpose of our study was the identification of high risk HCM patients coming from Northern Greece.ResultsFifteen patients (12.2%) of the whole cohort had MWT ≥ 30 mm, 30 patients (24.4%) had an ABPR to exercise, 17 patients (13.8%) had episodes of NSVT in 24-h Holter monitoring, 17 patients (13.8%) suffered from syncope, and 8 patients (6.5%) had a positive family history of premature SD. Data analysis revealed that 74 patients (60.1%) had none risk factor. Twenty four patients (19.5%) had 1 risk factor, 17 patients (13.8%) had 2 risk factors, 4 patients (3.25%) had 3 risk factors, and 4 patients (3.25%) had 4 risk factors, while none patient had 5 risk factors. Twenty five patients (20.3%) had 2 or more risk factors.ConclusionThis study for the first time confirms that, although a 60% of patients with HCM coming from a regional Greek population are in low risk for SD, a substantial proportion (almost 20%) carries a high risk for SD justifying prophylactic therapy with amiodaron or ICD implantation.

Hypertrophic cardiomyopathy with midventricular obstruction and apical aneurysm formation in a single family: case report

BackgroundHypertrophic cardiomyopathy (HCM) is an extremely heterogeneous disease. An under recognized and very often missed subgroup within this broad spectrum concerns patients with left ventricular (LV) apical aneurysms in the absence of coronary artery disease.Case presentationWe describe a case of HCM with midventricular obstruction and apical aneurysm formation in 3 patients coming from a single family. This HCM pattern was detected by 2D-echocardiography and confirmed by cardiac magnetic resonance imaging. A cardioverter defibrillator was implanted in one of the patients because of non-sustained ventricular tachycardia detected in 24-h Holter monitoring and an abrupt drop in systolic blood pressure during maximal exercise test. The defibrillator activated 8 months after implantation by suppression of a ventricular tachycardia providing anti-tachycardia pacing. The patient died due to refractory heart failure 2 years after initial evaluation. The rest of the patients are stable after a 2.5-y follow-up period.ConclusionThe detection of apical aneurysm by echocardiography in HCM patients may be complicated. Ventricular tachycardia arising from the scarred aneurysm wall may often occur predisposing to sudden death.

Preparticipation cardiovascular screening in competitive athletes: the case in a Greek population

There has been a growing debate recently regarding preparticipation cardiovascular screening in competitive athletes. Two trends are dominating the field today: the ‘‘American,’’ which claims that a good medical history and a thorough physical examination are enough (Maron et al., 2007), and the ‘‘European,’’ which believes that the inclusion of an ECG is essential in risk stratification (Corrado et al., 2005). Our opinion is that the issue of ‘‘preparticipation cardiovascular screening in competitive athletes’’ is far more complex. We read with great interest the review by Hernelahti et al. (2008), which proposes a Nordic model of preparticipation cardiovascular screening in competitive athletes. This is in line with the European guidelines regarding the preparticipation methodology, i.e., personal and family history, clinical examination, and ECG. The main difference between the Nordic model and the European guidelines is that the former suggests preparticipation screening only for the so-called elite athletes. For the rest active in sports young persons, the Nordic model suggests improved education in the context of seeking medical advice in case of a positive family history or alarming exercise-related symptoms. The proposed Nordic model generates some concerns. Unfortunately, sudden death is not a ‘‘privilege’’ of competitive athletes, because it may also occur in other young population subgroups, such as school pupils, high school students, or college students, during ordinary physical activity at school or during a football or a basketball game. Additionally, it is not exceptional for sudden death to occur in ‘‘pure’’ amateur athletes o35 years old during physical activities. Are we justified to exclude these groups from routine cardiovascular screening? To our knowledge, there are no published data covering all the aspects of this problem. Every country has its own policy regarding cardiovascular screening of young people, competitive or not. For example, in our country, Greece, there has been an overuse of medical examinations during the last decade. Every new state employee has to undergo thorough screening including physical examination, medical history, chest x-ray, and ECG, whereas the threshold of performing a cardiac echocardiogram is very low. Full screening, which includes physical examination, medical history, chest x-ray, ECG, and also an echocardiogram, if necessary, is also compulsory for all high school graduates who are candidates for the police and physical education academies. Physical education teachers in public or private institutes do not accept children, teenagers, or even senior subjects for participation in sports, unless they provide a medical certificate of good health signed by a cardiologist. The increased public awareness is reflected in the fact that the vast majority of the parents ‘‘demand’’ an echocardiogram for their children in addition to physical examination and ECG. Such policies complicate the matter even more by exhausting public funding and diverting funds to the private medical sector, with further medical and financial consequences. We may choose to remain skeptical about the Greek model, although we cannot simply reject it. In our opinion, a full screening, including medical history, physical examination, and ECG, should be performed in all young persons who plan to participate in any exercise program of various degrees of strength, i.e., school pupils, high school students, college students, amateur, or competitive athletes. Many structural or arrhythmogenic heart diseases, such as hypertrophic cardiomyopathy, dilated cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, long QT syndrome, and Brugada syndrome, which dominate the list of sudden death causes in athletes, cannot be excluded, unless an ECG is performed. To complicate things even further, it should be noted that 10% of patients with hypertrophic cardiomyopathy may have a normal ECG. Therefore, in many cases, an echocardiogram is mandatory to exclude the presence of the disease. In accordance to this statement, Maron et al. (1996) demonstrated that only 3% of 158 athletes with structural heart diseases who died suddenly were suspected to have cardiovascular abnormalities Scand J Med Sci Sports 2009: 19: 297–298 & 2009 John Wiley & Sons A/S Printed in Singapore . All rights reserved DOI: 10.1111/j.1600-0838.2008.00876.x

Subaortic and midventricular obstructive hypertrophic cardiomyopathy with extreme segmental hypertrophy

BackgroundSubaortic and midventricular hypertrophic cardiomyopathy in a patient with extreme segmental hypertrophy exceeding the usual maximum wall thickness reported in the literature is a rare phenomenon.Case PresentationA 19-year-old man with recently diagnosed hypertrophic cardiomyopathy (HCM) was referred for sudden death risk assessment. The patient had mild exertional dyspnea (New York Heart Association functional class II), but without syncope or chest pain. There was no family history of HCM or sudden death. A two dimensional echocardiogram revealed an asymmetric type of LV hypertrophy; anterior ventricular septum = 49 mm; posterior ventricular septum = 20 mm; anterolateral free wall = 12 mm; and posterior free wall = 6 mm. The patient had 2 types of obstruction; a LV outflow obstruction due to systolic anterior motion of both mitral leaflets (Doppler-estimated 38 mm Hg gradient at rest); and a midventricular obstruction (Doppler-estimated 43 mm Hg gradient), but without apical aneurysm or dyskinesia. The patient had a normal blood pressure response on exercise test and no episodes of non-sustained ventricular tachycardia in 24-h ECG recording. Cardiac MRI showed a gross late enhancement at the hypertrophied septum. Based on the extreme degree of LV hypertrophy and the myocardial hyperenhancement, an implantation of a cardioverter-defibrillator was recommended prophylactically for primary prevention of sudden death.ConclusionMidventricular HCM is an infrequent phenotype, but may be associated with an apical aneurysm and progression to systolic dysfunction (end-stage HCM).

Aortic redissection after glue repair: a rare echocardiographic finding

A 66-year-old male patient underwent supracoronary ascending aortic grafting and resuspension of the incompetent aortic valve because of a type A aortic dissection. Three months later, he presented with ongoing low-grade fever and sternal wound discharge. Wound and blood cultures were positive for methicillinresistant Staphylococcus aureus. Sinography was consistent with mediastinitis and infection of the vascular prosthesis. Magnetic resonance angiography and computed tomography angiography showed redissection at the distal anastomotic site extending down to the abdominal aorta and both of the common iliac arteries. Transesophageal echocardiography (TEE) findings were equivocal (Fig. 1). We considered the possibility of vegetation on the vascular graft. After a 6-week-long unsuccessful treatment with intravenous antibiotics, the patient was referred for redo surgery. Surgical findings included: (1) dehiscence of the distal anastomotic site and (2) a piece of surgical adhesive (BioGlue , CryoLife, Inc., Kennesaw, GA), which was used during the first operation, found protruding into the false aortic lumen (Fig. 2). This piece of surgical glue produced the rare echocardiographic picture seen on TEE.

Differences in Clinical Presentation and Findings between Idiopathic Dilated and Ischaemic Cardiomyopathy in an Unselected Population of Heart Failure Patients

We explored the differences in epidemiologic, clinical, laboratory and echocardiographic characteristics between idiopathic dilated (IDCM) and ischaemic cardiomyopathy (ICM). Consecutive patients with stable chronic heart failure evaluated at a tertiary cardiac centre were enrolled. Clinical examination, blood tests and echocardiographic study were performed. A total of 76 patients (43 IDCM, 33 ICM) were studied. IDCM patients were younger (p<0.001) and female gender was more prevalent (p=0.022). NYHA class and left ventricular ejection fraction were similar. IDCM patients had lower rates of dyslipidaemia (p<0.001) but smoked more than ICM patients (p=0.023) and had higher rates of family history of sudden cardiac death (p=0.048). Blood pressure was similar but resting heart rate was higher in IDCM patients (p=0.022). IDCM patients presented less frequently with peripheral oedema or ascites (p=0.046 and 0.020, respectively) and showed better right ventricular function on echocardiogram. QRS duration was similar between groups but only in IDCM patients there was a positive correlation between QRS duration and age (r=0.619, p<0.001). Cardiac output was similar but functional capacity assessed by the Duke Activity Status Index was better in IDCM (p=0.036). Despite these differences, IDCM and ICM patients received similar treatments. Patients with IDCM were younger, presented lower rates of right ventricular dysfunction and clinical right ventricular failure and had better functional capacity. Additional differences in clinical and laboratory findings exist pointing to a different patient population with diverse prognosis and potential need for individualized management.

Triple type of obstruction in hypertrophic cardiomyopathy.

Case description A 19-year-old man with recently diagnosed hypertrophic cardiomyopathy (HCM) was referred to our department for sudden death risk assessment. The diagnosis was made by a private cardiologist to whom the patient was presented due to a history of cardiac murmur. The patient had mild exertional dyspnea (New York Heart Association functional class II), but without syncope or chest pain. There was no family history of HCM or sudden death. The patient’s blood pressure (BP) was 130/70 mmHg and a grade 3–4/6 systolic ejection murmur was present between the left parasternal border and the apex. The ECG showed a left ventricular (LV) hypertrophy with strain pattern. A two-dimensional echocardiogram revealed an asymmetrical type LV hypertrophy; anterior ventricular septum equal to 35 mm; posterior ventricular septum equal to 20 mm; anterolateral free wall equal to 12 mm; and posterior free wall equal to 6 mm (Fig. 1). The patient had three types of obstruction; LV outflow obstruction due to systolic anterior motion of both mitral leaflets with a Doppler-estimated 34 mmHg gradient at rest (Fig. 2a and b); a midventricular obstruction with a Doppler-estimated 55 mmHg gradient at rest but without apical aneurysm or dyskinesia (Fig. 2a and c); and right ventricular (RV) outflow tract obstruction with a Doppler-estimated 40 mmHg gradient at rest (Fig. 3). The LV end-diastolic dimension was 45 mm and the left atrium was 45 mm. The RV dimension was 30 mm and the RV free-wall thickness was 8 mm. No mitral or tricuspid regurgitation was detected. The patient had a normal BP response on exercise test with a VO2max of 20 ml/kg per minute and no episodes of nonsustained ventricular tachycardia in 24-h ECG recording. Cardiac magnetic resonance imaging (MRI) showed a gross late enhancement at the septum. On the basis of the extreme