Giovanni Maria Di Marco

Visceral adiposity and arterial stiffness: echocardiographic epicardial fat thickness reflects, better than waist circumference, carotid arterial stiffness in a large population of hypertensives

AIMS Relationship between obesity and cardiovascular (CV) disease depends not only on the amount of body fat, but also on its distribution. For example, individuals with increased fat accumulation in the abdominal region have atherogenic lipid profiles and are at increased CV risk. The loss of elasticity in medium and large arteries is an early manifestation of atherosclerosis. The aim of this study was to evaluate whether echocardiographic epicardial adipose tissue, an index of cardiac adiposity, is related to carotid stiffness and carotid intima-media thickness (IMT), indexes of subclinical atherosclerosis, better than waist circumference in hypertensive patients. METHODS AND RESULTS We studied 459 patients with Grade I and II essential hypertension who were referred to our outpatient clinic over a period from May 2007 to March 2008. The population was first sorted by waist circumference and then by epicardial fat < or = 7 or >7 mm. We measured epicardial fat thickness, waist circumference, carotid artery stiffness, and carotid IMT in all patients. Patients divided according to waist circumference showed no statistical differences in carotid artery stiffness between the two groups. Subjects with epicardial fat >7 mm were older, had higher systolic, diastolic, and pulse pressure, increased left ventricular mass index, carotid IMT, diastolic parameters, and stiffness parameters compared with those with epicardial fat < or = 7 mm (P < 0.001). A positive correlation was found between epicardial fat and age, pulse pressure, stiffness parameters, carotid IMT, systolic blood pressure, and duration of hypertension, and a negative correlation was found with diastolic parameters. Age, carotid IMT, and stiffness parameters were independently related to epicardial fat. CONCLUSION Our findings indicate that epicardial fat reflects carotid artery stiffness in hypertension-induced organ damage.

Clinical Relevance of Fluid Challenge in Patients Evaluated for Pulmonary Hypertension

Background Fluid challenge may help in the differential diagnosis between pre‐ and postcapillary pulmonary hypertension (PH). However, the test is still in need of standardization and better defined clinical relevance. Methods Two hundred twelve patients referred for PH underwent a right‐sided heart catheterization with measurements before and after rapid infusion of 7 mL/kg of saline. PH was defined as mean pulmonary artery pressure ≥ 25 mm Hg, and postcapillary PH was defined as pulmonary artery wedge pressure (PAWP) > 15 mm Hg. An increase in PAWP ≥ 18 mm Hg was considered diagnostic for postcapillary PH. At baseline, 66 patients received a diagnosis of no PH; 22, of postcapillary PH; and 124, of precapillary PH (mostly pulmonary arterial hypertension). Results After fluid challenge, five of 66 patients with no PH (8%) and eight of 124 with precapillary PH (6%) had the diagnosis reclassified as postcapillary PH. Fluid challenge was associated with an increase in PAWP by 7 ± 2 mm Hg in postcapillary PH and 3 ± 1 mm Hg in both precapillary PH and no‐PH groups. Between‐group differences were significant, but there was overlap. There were no adverse events related to fluid challenge. Prediction bands calculated from quadratic fits of the PAWP responses in pooled control subjects with no PH and patients with precapillary PH helped confirm 18 mm Hg as the cutoff for diagnosing postcapillary PH. Conclusions Fluid challenge with 7 mL/kg saline increases PAWP, more in postcapillary than in precapillary PH or in control subjects with no PH. A cutoff value of 18 mm Hg allows reclassification of 6% to 8% of patients with precapillary PH or normal hemodynamic characteristics at baseline.

A simple echocardiographic score for the diagnosis of pulmonary vascular disease in heart failure

Aims A simple echocardiographic score was designed for diagnosing precapillary vs postcapillary pulmonary hypertension and for discriminating between isolated postcapillary pulmonary hypertension (Ipc-PH) and combined precapillary and postcapillary pulmonary hypertension (Cpc-PH). Methods The score comprised 7 points (2 for E/e′ ratio ⩽10, 2 for a dilated non-collapsible inferior vena cava, 1 for a left ventricular eccentricity index ≥1.2, 1 for a right-to-left heart chamber dimension ratio >1 and 1 for the right ventricle forming the heart apex) and was applied to 230 consecutive patients referred for evaluation of pulmonary hypertension. Results Precapillary pulmonary hypertension and postcapillary pulmonary hypertension were diagnosed in 160 and 70 patients, respectively. In the latter, Ipc-PH was found in 51 and Cpc-PH in 19. The echo score was higher in precapillary vs postcapillary pulmonary hypertension patients (4.2 ± 1.7 vs 1.6 ± 1.7, P < 0.001) and in patients with Cpc-PH vs Ipc-PH (2.7 ± 2.1 vs 1.2 ± 1.3, P = 0.001). The sensitivity and specificity of the echo score at least 2 for precapillary pulmonary hypertension were 99 and 54%, respectively (area under the curve 0.85). In patients with postcapillary pulmonary hypertension, the sensitivity and specificity of the echo score at least 2 for Cpc-PH were 63 and 82% (area under the curve 0.73). Conclusion A simple echocardiographic score helps in the differential diagnosis between precapillary and postcapillary pulmonary hypertension, and between Ipc-PH and Cpc-PH.

Right atrial function and prognosis in idiopathic pulmonary arterial hypertension

AIM To determine whether right atrial (RA) function has prognostic value in patients with idiopathic pulmonary arterial hypertension (PAH). METHODS AND RESULTS Overall, 104 patients (70 female, mean age 58±13years) with idiopathic PAH underwent standard Doppler echocardiography and strain and strain rate (SR) analysis before right heart catheterization. At a mean follow-up of 22±7months, 30 patients (29%) had clinical worsening. On Cox multivariable proportional-hazards regression analysis, RA reservoir function measured as peak longitudinal SR (hazard ratio [HR] 0.5; P<0.0001), RA area (HR 1.2; P<0.01), right ventricular (RV) SR (HR 0.6; P<0.0001), cardiac index (HR 0.79; P<0.01), and mixed venous oxygen saturation (HR 0.82; P<0.01) were found to be independent correlates of cardiac events. A RA SR reservoir cut-off value of <1.2s-1 and a RV SR cut-off value of <1s-1 well identified patients at higher risk of clinical worsening (sensitivity 85.5%; specificity 90.4%; test accuracy 88.8%). In particular, event rates and mean survival time free of clinical worsening were: 6.1% and 23.5±2.2months in patients with normal RA and RV SR; 45% and 20.9±5.5months in patients with impaired RA and normal RV SR; 56.2% and 17.7±6.6months in patients with normal RA and impaired RV SR; and 87.5% and 12.9±7.6months in patients with impairment of both RA and RV SR. CONCLUSION Our data suggest that RA function has prognostic value in idiopathic PAH, where a poorer RA function, as explored by strain and SR analysis, is associated with a worse outcome.

Fluid challenge predicts clinical worsening in pulmonary arterial hypertension

AIM A fluid challenge with rapid saline infusion during right heart catheterization has been shown to be useful for the differential diagnosis between pre- and post-capillary pulmonary hypertension. The aim of this study was to evaluate the prognostic relevance of fluid challenge-induced changes in pulmonary hemodynamics in patients with pulmonary arterial hypertension (PAH). METHODS Overall, 118 PAH patients (mean age 57 ± 15 years, 80 female) underwent hemodynamic measurements before and after rapid saline infusion (7 mL/kg in 10 min) and were followed up for 19 ± 4 months. RESULTS Thirty-two patients (27%) had a clinical worsening event defined as the occurrence of one of the following: death, lung transplantation, initiation of parenteral prostanoids, or worsening of PAH (defined as the presence of all of the three following components: a decrease in the 6-minute walk distance of at least 15% from baseline, worsening of PAH symptoms, and need for new PAH treatment). Cardiac index (CI), stroke volume and pulmonary artery compliance were lower whereas right atrial pressure (RAP), the ratio of RAP to pulmonary artery wedge pressure (PAWP) and pulmonary vascular resistance were higher in patients with a clinical worsening event versus patients without events, both at baseline and after fluid challenge (all p < 0.01). At multivariable Cox proportional hazards regression analysis, a post-fluid challenge CI <2.8 L/min/m2 (hazard ratio 0.0143; 95% confidence interval 0.006-0.3383; p = 0.009) was the only independent predictor of outcome. CONCLUSIONS CI measured after a fluid challenge is an independent predictor of outcome in PAH.

When chewing gum is more than just a bad habit.

In November, 2008 a 13-year-old boy (weight 45 kg, height 160 cm) was taken by his parents to the emergency department. His parents reported that after school the boy had been agitated and aggressive, in contrast with his normal mood. He denied feeling stressed or having used drugs or stimulants. He complained of abdominal discomfort, increased diuresis, dysuria, and prickling sensations in his legs. On examination, he was restless, with sinus tachycardia (147 beats per min [bpm] on electrocardiogram [ECG]), tachypnoea (25 breaths per min), and raised blood pressure (145/90 mm Hg). Chest radiography and laboratory blood test results were normal. Toxicological screen was negative for cocaine, heroin, and amphetamine. Psychiatric consultation was unremarkable. Our patient’s condition improved overnight without any treatment and he was discharged the following morning. At discharge he was noted to have sinus bradycardia (40 bpm).Later that day, his mother returned to the emergency unit with two empty packets of stimulant (“energy”) chewing gum that she had found in her son’s bag; he had admitted consuming the confectionery at school. The chewing gum contained 160 mg caff eine per packet (0·57% caff eine per gum pellet) and non-specifi ed amounts of guarana,

Which is the correct management of patients with asymptomatic severe calcific aortic stenosis after symptomatic spontaneous calcium cerebral embolism

Elective surgery cannot be recommended in every patient with asymptomatic severe aortic stenosis, and predictors identifying high-risk patients need to be identified. In guidelines we read that elective surgery, at the asymptomatic stage, can only be recommended in selected patients, at low operative risk (see guidelines of European Society of Cardiology and American Heart Association), but we have not read any reference to patients with severe calcific aortic stenosis after symptomatic spontaneous calcium cerebral embolism. Because cardioembolic stroke is associated with poor prognosis compared to other stroke subtypes, in patients with asymptomatic severe aortic stenosis and spontaneous calcific embolic stroke valve replacement appears to offer the best hope of avoiding a recidivation of stroke and should be considered in most cases. On the contrary, is it still correct to consider as asymptomatic patients with severe aortic stenosis and cerebral thromboembolism from a calcified aortic valve?

Invasive and Noninvasive Evaluation for the Diagnosis of Pulmonary Hypertension

The etiologic diagnosis of pulmonary hypertension (PH) may be very challenging. Right-heart catheterization (RHC) in isolation cannot classify a precapillary PH patient into group 1, 3, 4, or 5. Moreover, RHC may be not sufficient for reaching a definitive differential diagnosis of precapillary or postcapillary PH if hemodynamic data are not integrated in clinical context and combined with information gleaned from noninvasive imaging. Therefore, only the integration of risk factors, clinical evaluation, invasive and noninvasive tests allows the physician to distinguish between different forms of PH.

Eisenmenger Syndrome in Patients with Down Syndrome

Down syndrome (DS) is the most common autosomal chromosome abnormality with an estimated incidence of approximately 1.1 per 1000 live births, without significant differences across different races. Pulmonary hypertension (PH) can significantly affect the prognosis and quality of life of DS patients. While the most common cause of PH is congenital heart disease (CHD), DS is often associated with comorbidities that may cause or worsen PH.

FLUID CHALLENGE TEST IN NORMAL SUBJECTS AND IN A HETEROGENEOUS POPULATION WITH PULMONARY HYPERTENSION

Aim of the study was to explore the response to a fluid challenge test (FCT) in normal subjects and in patients with pulmonary hypertension (PH). 168 subjects underwent right heart catheterization in basal conditions and after FCT. At baseline, 50 subjects showed normal pressures (healthy controls