Gabriela Guzmán

Prevalence, Vascular Distribution, and Multiterritorial Extent of Subclinical Atherosclerosis in a Middle-Aged Cohort The PESA (Progression of Early Subclinical Atherosclerosis) Study

Background— Data are limited on the presence, distribution, and extent of subclinical atherosclerosis in middle-aged populations. Methods and Results— The PESA (Progression of Early Subclinical Atherosclerosis) study prospectively enrolled 4184 asymptomatic participants 40 to 54 years of age (mean age, 45.8 years; 63% male) to evaluate the systemic extent of atherosclerosis in the carotid, abdominal aortic, and iliofemoral territories by 2-/3-dimensional ultrasound and coronary artery calcification by computed tomography. The extent of subclinical atherosclerosis, defined as presence of plaque or coronary artery calcification ≥1, was classified as focal (1 site affected), intermediate (2–3 sites), or generalized (4–6 sites) after exploration of each vascular site (right/left carotids, aorta, right/left iliofemorals, and coronary arteries). Subclinical atherosclerosis was present in 63% of participants (71% of men, 48% of women). Intermediate and generalized atherosclerosis was identified in 41%. Plaques were most common in the iliofemorals (44%), followed by the carotids (31%) and aorta (25%), whereas coronary artery calcification was present in 18%. Among participants with low Framingham Heart Study (FHS) 10-year risk, subclinical disease was detected in 58%, with intermediate or generalized disease in 36%. When longer-term risk was assessed (30-year FHS), 83% of participants at high risk had atherosclerosis, with 66% classified as intermediate or generalized. Conclusions— Subclinical atherosclerosis was highly prevalent in this middle-aged cohort, with nearly half of the participants classified as having intermediate or generalized disease. Most participants at high FHS risk had subclinical disease; however, extensive atherosclerosis was also present in a substantial number of low-risk individuals, suggesting added value of imaging for diagnosis and prevention. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT01410318.

Long-term benefit of early pre-reperfusion metoprolol administration in patients with acute myocardial infarction: results from the METOCARD-CNIC trial (Effect of Metoprolol in Cardioprotection During an Acute Myocardial Infarction)

OBJECTIVESnThe goal of this trial was to study the long-term effects of intravenous (IV) metoprolol administration before reperfusion on left ventricular (LV) function and clinical events.nnnBACKGROUNDnEarly IV metoprolol during ST-segment elevation myocardial infarction (STEMI) has been shown to reduce infarct size when used in conjunction with primary percutaneous coronary intervention (pPCI).nnnMETHODSnThe METOCARD-CNIC (Effect of Metoprolol in Cardioprotection During an Acute Myocardial Infarction) trial recruited 270 patients with Killip class ≤II anterior STEMI presenting early after symptom onset (<6 h) and randomized them to pre-reperfusion IV metoprolol or control group. Long-term magnetic resonance imaging (MRI) was performed on 202 patients (101 per group) 6 months after STEMI. Patients had a minimal 12-month clinical follow-up.nnnRESULTSnLeft ventricular ejection fraction (LVEF) at the 6 months MRI was higher after IV metoprolol (48.7 ± 9.9% vs. 45.0 ± 11.7% in control subjects; adjusted treatment effect 3.49%; 95% confidence interval [CI]: 0.44% to 6.55%; p = 0.025). The occurrence of severely depressed LVEF (≤35%) at 6 months was significantly lower in patients treated with IV metoprolol (11% vs. 27%, p = 0.006). The proportion of patients fulfilling Class I indications for an implantable cardioverter-defibrillator (ICD) was significantly lower in the IV metoprolol group (7% vs. 20%, p = 0.012). At a median follow-up of 2 years, occurrence of the pre-specified composite of death, heart failure admission, reinfarction, and malignant arrhythmias was 10.8% in the IV metoprolol group versus 18.3% in the control group, adjusted hazard ratio (HR): 0.55; 95% CI: 0.26 to 1.04; p = 0.065. Heart failure admission was significantly lower in the IV metoprolol group (HR: 0.32; 95% CI: 0.015 to 0.95; p = 0.046).nnnCONCLUSIONSnIn patients with anterior Killip class ≤II STEMI undergoing pPCI, early IV metoprolol before reperfusion resulted in higher long-term LVEF, reduced incidence of severe LV systolic dysfunction and ICD indications, and fewer heart failure admissions. (Effect of METOprolol in CARDioproteCtioN During an Acute Myocardial InfarCtion. The METOCARD-CNIC Trial; NCT01311700).

Long term benefit of early pre-reperfusion metoprolol administration in patients with acute myocardial infarction: results from the METOCARD-CNIC trial.

OBJECTIVESnThe goal of this trial was to study the long-term effects of intravenous (IV) metoprolol administration before reperfusion on left ventricular (LV) function and clinical events.nnnBACKGROUNDnEarly IV metoprolol during ST-segment elevation myocardial infarction (STEMI) has been shown to reduce infarct size when used in conjunction with primary percutaneous coronary intervention (pPCI).nnnMETHODSnThe METOCARD-CNIC (Effect of Metoprolol in Cardioprotection During an Acute Myocardial Infarction) trial recruited 270 patients with Killip class ≤II anterior STEMI presenting early after symptom onset (<6 h) and randomized them to pre-reperfusion IV metoprolol or control group. Long-term magnetic resonance imaging (MRI) was performed on 202 patients (101 per group) 6 months after STEMI. Patients had a minimal 12-month clinical follow-up.nnnRESULTSnLeft ventricular ejection fraction (LVEF) at the 6 months MRI was higher after IV metoprolol (48.7 ± 9.9% vs. 45.0 ± 11.7% in control subjects; adjusted treatment effect 3.49%; 95% confidence interval [CI]: 0.44% to 6.55%; p = 0.025). The occurrence of severely depressed LVEF (≤35%) at 6 months was significantly lower in patients treated with IV metoprolol (11% vs. 27%, p = 0.006). The proportion of patients fulfilling Class I indications for an implantable cardioverter-defibrillator (ICD) was significantly lower in the IV metoprolol group (7% vs. 20%, p = 0.012). At a median follow-up of 2 years, occurrence of the pre-specified composite of death, heart failure admission, reinfarction, and malignant arrhythmias was 10.8% in the IV metoprolol group versus 18.3% in the control group, adjusted hazard ratio (HR): 0.55; 95% CI: 0.26 to 1.04; p = 0.065. Heart failure admission was significantly lower in the IV metoprolol group (HR: 0.32; 95% CI: 0.015 to 0.95; p = 0.046).nnnCONCLUSIONSnIn patients with anterior Killip class ≤II STEMI undergoing pPCI, early IV metoprolol before reperfusion resulted in higher long-term LVEF, reduced incidence of severe LV systolic dysfunction and ICD indications, and fewer heart failure admissions. (Effect of METOprolol in CARDioproteCtioN During an Acute Myocardial InfarCtion. The METOCARD-CNIC Trial; NCT01311700).

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.

Noninvasive monitoring of serial changes in pulmonary vascular resistance and acute vasodilator testing using cardiac magnetic resonance.

OBJECTIVESnThe study sought to evaluate the ability of cardiac magnetic resonance (CMR) to monitor acute and long-term changes in pulmonary vascular resistance (PVR) noninvasively.nnnBACKGROUNDnPVR monitoring during the follow-up of patients with pulmonary hypertension (PH) and the response to vasodilator testing require invasive right heart catheterization.nnnMETHODSnAn experimental study in pigs was designed to evaluate the ability of CMR to monitor: 1) an acute increase in PVR generated by acute pulmonary embolization (n = 10); 2) serial changes in PVR in chronic PH (n = 22); and 3) changes in PVR during vasodilator testing in chronic PH (n = 10). CMR studies were performed with simultaneous hemodynamic assessment using a CMR-compatible Swan-Ganz catheter. Average flow velocity in the main pulmonary artery (PA) was quantified with phase contrast imaging. Pearson correlation and mixed model analysis were used to correlate changes in PVR with changes in CMR-quantified PA velocity. Additionally, PVR was estimated from CMR data (PA velocity and right ventricular ejection fraction) using a formula previously validated.nnnRESULTSnChanges in PA velocity strongly and inversely correlated with acute increases in PVR induced by pulmonary embolization (r = -0.92), serial PVR fluctuations in chronic PH (r = -0.89), and acute reductions during vasodilator testing (r = -0.89, p ≤ 0.01 for all). CMR-estimated PVR showed adequate agreement with invasive PVR (mean bias -1.1 Wood units,; 95% confidence interval: -5.9 to 3.7) and changes in both indices correlated strongly (r = 0.86, p < 0.01).nnnCONCLUSIONSnCMR allows for noninvasive monitoring of acute and chronic changes in PVR in PH. This capability may be valuable in the evaluation and follow-up of patients with PH.

Role of real-time three-dimensional transoesophageal echocardiography for guiding transcatheter patent foramen ovale closure

Patent foramen ovale (PFO) is a relatively common congenital condition which has been implicated in cryptogenic stroke as a result of paradoxical thromboembolism by right-to-left shunting. Many studies have demonstrated that transcatheter PFO closure significantly reduced the incidence of recurrent strokes in a small group of high-risk patients with PFO and atrial septal aneurysm compared with antithrombotic drugs. Two-dimensional transoesophageal echocardiography (2D TEE) has become the election technique for guiding patent foramen ovale closure. Real-time Three-dimensional transoesophageal echocardiography (3D TEE) may be potentially superior to 2D TEE in the accurate assessment of the morphology and efficacy of transcatheter closure devices because of a better spacial orientation.

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.

Apical right ventricular dysfunction in patients with pulmonary hypertension demonstrated with magnetic resonance

Objective To evaluate segmental right ventricular (RV) dysfunction in pulmonary hypertension (PH) using cardiac magnetic resonance (CMR). Design Cross-sectional analysis in a retrospective cohort of consecutive adult patients. Setting Mount Sinai Hospital in New York. Patients 192 patients with known or suspected PH undergoing right heart catheterisation and CMR. PH was defined as mean pulmonary artery pressure ≥25u2005mmu2002Hg. Abnormal RV ejection fraction (RVEF) was defined as <50%. Patients were classified into: group 1 (no PH, normal RVEF; n=40), group 2 (PH, normal RVEF; n=41) or group 3 (PH, abnormal RVEF; n=111). Interventions CMR and right heart catheterisation within a 2-week interval. Main outcome measures On cine CMR images, the stack of RV short-axis views was divided into two equal halves. Basal and apical RVEF were calculated using Simpsons method, and a ratio of basal-to-apical RVEF (RVEFratio) was derived. Results Basal RVEF did not differ between groups 1 and 2 (63±8% vs 64±8%; p=1); however, patients in group 2 had significantly lower apical RVEF (46±13% vs 58±10%; p<0.01) and higher RVEFratio (median 1.4 vs 1.1; p<0.01). Both apical and basal RVEF were reduced in group 3 compared with groups 1 and 2 (p<0.01), and the RVEFratio increased with increasing PH severity (p<0.01 for trend). An apical RVEF <50% was more sensitive than global RV dysfunction for the detection of PH. Conclusions Apical dysfunction appears to occur before global RVEF decreases in chronic PH, potentially constituting an early and sensitive marker of RV dysfunction in this setting.

New index alpha improves detection of pulmonary hypertension in comparison with other cardiac magnetic resonance indices

BACKGROUNDnCardiovascular magnetic resonance (CMR) has been proposed for the evaluation of patients with pulmonary hypertension (PH). However, there is no consensus on the optimal method for PH diagnosis using CMR.nnnOBJECTIVEnTo compare the diagnostic ability of multiple CMR-derived indices for the detection of PH as determined by right heart catheterization (RHC).nnnMETHODSnA total of 185 patients with known or suspected chronic PH who underwent cardiac CMR and RHC in ≤15 days were included. PH was defined as a mean pulmonary artery (PA) pressure ≥25 mmHg. Right ventricular (RV) volumes, RV ejection fraction (RVEF), PA areas, and PA average blood flow velocity were quantified with CMR. A novel index α was defined as the ratio between minimal PA area and RVEF.nnnRESULTSnAccording to the RHC, PH was present in 152 patients. All CMR-derived parameters correlated with the degree of mean PA pressure, with α having the highest correlation coefficient (r=0.61, p<0.001). Correlations were also highest for α in the patients with pulmonary arterial hypertension (PAH; r=0.55, p<0.001) and non-PAH subgroup (r=0.61, p<0.001). Diagnostic accuracy for the detection of PH, based on receiver operating curve analysis, was best for α (area under the curve=0.95). A cutoff value of 7.2 demonstrated a sensitivity of 90% and a specificity of 88%.nnnCONCLUSIONSnAn easily-obtainable and novel CMR index α that combines geometrical and functional information of the PA and the RV allows for the noninvasive diagnosis of PH with high accuracy, above other common CMR-derived parameters.

Coronary CT and the coronary calcium score, the future of ED risk stratification?

Accurate and efficient evaluation of acute chest pain remains clinically challenging because traditional diagnostic modalities have many limitations. Recent improvement in non-invasive imaging technologies could potentially improve both diagnostic efficiency and clinical outcomes of patients with acute chest pain while reducing unnecessary hospitalizations. However, there is still controversy regarding much of the evidence for these technologies. This article reviews the role of coronary artery calcium score and the coronary computed tomography in the assessment of individual coronary risk and their usefulness in the emergency department in facilitating appropriate disposition decisions. The evidence base and clinical applications for both techniques are also described, together with cost- effectiveness and radiation exposure considerations.