Haldun Muderrisoglu

Epicardial adipose tissue thickness by echocardiography is a marker for the presence and severity of coronary artery disease

BACKGROUND AND AIM Epicardial adipose tissue (EAT), which is thought to be a component of visceral adiposity, is associated with the metabolic syndrome. We aimed to test the hypothesis that echocardiographic EAT thickness can be a marker for the presence and severity of coronary artery disease (CAD). METHOD AND RESULTS In all, 150 patients (100 patients with CAD and 50 patients with normal coronary arteries by diagnostic coronary angiography; 65 women, 85 men; mean age 55.7+/-7.4 years) were enrolled. EAT thickness was measured using 2-D echocardiographic parasternal long- and short-axis views. EAT thickness measurements were compared with angiographic findings. EAT thickness was significantly higher in patients with CAD in comparison to those with normal coronary arteries (6.9+/-1.5 mm vs. 4.4+/-0.8 mm; P<0.001). Furthermore, EAT thickness increased with the severity of CAD (multivessel disease 7.4+/-1.2 mm vs. single vessel disease 5.7+/-1.7 mm; P<0.001). Gensinis score significantly correlated with EAT thickness (r=0.600, P<0.001). EAT thickness of > or = 5.2 mm had 85% sensitivity and 81% specificity (ROC area 0.914, P<0.001, 95% CI [0.86-0.96]) for predicting CAD. CONCLUSION EAT thickness, which is easily and non-invasively evaluated by transthoracic echocardiography, can be an adjunctive marker to classical risk factors for the prediction of CAD.

Relationship of serum uric acid to measures of endothelial function and atherosclerosis in healthy adults

Although uric acid (UA) is considered as an antioxidant, the relationship between serum UA levels and cardiovascular diseases is not clear yet. Higher brachial artery resting diameter (BD), impaired brachial artery flow‐mediated dilatation (FMD), increased carotid intima‐media thickness (IMT), decreased aortic distensibility (AoD), and increased aortic stiffness index (AoSI) and elastic modulus (AoEM) are predictors for development and/or progression of atherosclerosis. In this study, BD, FMD, carotid IMT, AoD, AoSI and AoEM were studied in healthy subjects with UA concentrations in physiological range.

Effects of Normal Blood Pressure, Prehypertension, and Hypertension on Coronary Microvascular Function

Background— The assessment of coronary flow reserve (CFR) by transthoracic Doppler echocardiography has recently been introduced into clinical practice, and reduced CFR has been suggested to be a sensitive indicator of hypertensive end-organ damage; however, to date, this methodology has not been used to evaluate CFR in subjects with prehypertension. Accordingly, the present study was designed to evaluate CFR in subjects with prehypertension. Methods and Results— We measured CFR of 40 subjects with prehypertension, 60 patients with hypertension, and 50 normotensive healthy volunteers using transthoracic Doppler echocardiography. None of the subjects had any systemic disease. Age, gender, body mass index, heart rate, lipid profiles, fasting glucose levels, and hemoglobin were similar among the 3 groups. CFR was significantly lower in the hypertension group than in the prehypertension and control groups; in addition, it was significantly lower in subjects with prehypertension than in control subjects (2.23±0.47, 2.54±0.48, and 2.91±0.53, respectively). Furthermore, we found that prehypertension (β=−0.31, P<0.01) and hypertension (β=−0.57, P<0.01) were significant predictors of lower CFR in a multivariable model that adjusted for other variables. CFR was significantly and inversely correlated with age (r=−0.20, P=0.01), systolic blood pressure (r=−0.51, P<0.01), diastolic blood pressure (r=−0.47, P<0.01), high-sensitivity C-reactive protein levels (r=−0.21, P=0.01), left atrium diameter (r=−0.22, P<0.01), mitral E deceleration time (r=−0.19, P=0.02), and mitral A velocity (r=−0.27, P<0.01), whereas mitral E/A ratio was significantly and positively correlated with CFR (r=0.26, P<0.01). Conclusions— CFR is impaired in subjects with prehypertension, but this impairment is not as severe as that in hypertension.

Relation between epicardial fat thickness and coronary flow reserve in women with chest pain and angiographically normal coronary arteries

OBJECTIVE A significant proportion of women with angina-like chest pain and angiographically normal coronary arteries have microvascular dysfunction as detected by reduced coronary blood flow reserve (CFR). Classical clinical risk factors of atherosclerosis poorly predict this scenario. We sought to assess whether increased epicardial fat tissue, which is a metabolically active organ, could be associated with impaired CFR in these patients. METHODS We enrolled 68 women who underwent coronary angiography and had no obstructive coronary artery disease. Data about classical risk factors, insulin resistance and serum levels of C-reactive protein (CRP) and adiponectin were obtained. Stress tests were evaluated. Coronary flow velocities at baseline and under-induced hyperemia and epicardial fat thickness (EFT) were measured by transthoracic echocardiography within 48 h of angiography. CFR >or=2.0 was considered normal. RESULTS Forty percent of women had reduced CFR suggestive of microvascular dysfunction and 60% had normal CFR. Menopause, hypertension and abnormal stress tests were significantly more prevalent, adiponectin level was significantly decreased, CRP, insulin resistance, and EFT were significantly increased in women with microvascular dysfunction as compared with those without. On multivariate regression analysis EFT emerged as the only independent predictor of microvascular dysfunction (P<0.0001). EFT of >0.45 cm had 85% sensitivity and 75% specificity to detect CFR <2 (P<0.0001). Traditional risk factors for atherosclerosis did not predict women with abnormal microvascular function. CONCLUSIONS EFT has the potential to be an additional and easy diagnostic tool for risk stratification of women with chest pain and angiographically normal coronary arteries.

Effect of Mechanical Dyssynchrony and Cardiac Resynchronization Therapy on Left Ventricular Rotational Mechanics

Alterations in rotational mechanics can bring new aspects to the understanding of left ventricular (LV) dyssynchrony. The aims of this study were to investigate LV rotational mechanics in candidates for cardiac resynchronization therapy (CRT) and to assess the effect of CRT by speckle-tracking echocardiography. Fifty-four patients with heart failure and 33 healthy controls were studied. Thirty-three underwent CRT. Speckle tracking was applied to short- and long-axis views. Radial and longitudinal dyssynchrony were assessed as previously defined. Apical and basal rotations were measured as the average angular displacement about the LV central axis. LV twist and torsion were then calculated. Peak apical and basal rotation, peak LV twist and torsion, apical and basal rotation at aortic valve closure (AVC), and LV twist and torsion at AVC were significantly lower in patients than controls. Apical-basal rotation delay and AVC-to-peak LV twist interval were longer in patients and associated with decreased peak LV twist and LV twist at AVC, respectively. In patients, rotational indexes, particularly LV twist and torsion, were correlated strongly with radial dyssynchrony. LV torsion (cutoff 0.1 degrees /cm) and twist (cutoff 1 degrees ) at AVC had the highest sensitivity (90%) and specificity (77%) to predict CRT responders among all other parameters, including radial and longitudinal dyssynchrony. In conclusion, LV dyssynchrony is associated with discoordinate rotation of the apical and basal regions, which in turn significantly decreases peak LV twist and torsion and LV twist and torsion at AVC. CRT significantly restored the altered rotational mechanics in responders. These parameters have potential for predicting responders to CRT.

High Serum Bilirubin Concentrations Preserve Coronary Flow Reserve and Coronary Microvascular Functions

Background—Elevated serum bilirubin concentrations protect against atherosclerotic diseases; however, it is not clear whether higher serum bilirubin concentrations in physiological ranges work in favor of the cardiovascular system in younger persons with no cardiovascular risk factors. Accordingly, we investigated the effects of high, intermediate, and low serum bilirubin concentrations on coronary flow reserve (CFR). Methods and Results—Fifty-two healthy subjects with hyperbilirubinemia (total bilirubin 1.43±0.33 mg/dL; mean age 35.9±7.3), 55 subjects with intermediate bilirubin level (total bilirubin: 0.69±0.11 mg/dL; mean age: 36.4±6.8), and 53 healthy subjects with hypobilirubinemia (total bilirubin 0.37±0.08 mg/dL; mean age, 37.6±6.6) were studied. Transthoracic second harmonic Doppler echocardiography examination was performed using an Acuson Sequoia C256 Echocardiography System. Coronary diastolic peak flow velocities were measured at baseline and after dipyridamole infusion (0.84 mg/kg over 6 minutes). CFR was calculated as the ratio of hyperemic to baseline diastolic peak velocities. Demographic features, coronary risk factors, echocardiographic measurements, and biochemical measurements were similar among the 3 groups, except high-sensitivity C-reactive protein (hsCRP). CFR values were significantly higher in subjects with high bilirubin concentrations than those were in the intermediate and the low bilirubin groups (3.19±0.73; 2.75±0.42; 2.56±0.52, respectively; P<0.0001), and hsCRP levels were significantly lower in subjects with high bilirubin concentrations than those in both intermediate and low bilirubin groups (1.4±1.0, 2.0±1.7, 3.0±1.9 mg/L, respectively; P<0.001). hsCRP levels correlated with total bilirubin concentration and with CFR. Conclusion—Elevated serum bilirubin concentrations protect from CFR impairment, coronary microvascular dysfunction, and possibly coronary atherosclerosis.

Impaired Coronary Flow Reserve in Hemodialysis Patients: A Transthoracic Doppler Echocardiographic Study

Background: Coronary flow reserve (CFR) reflects the functional capacity of microcirculation to adapt to blood demand during increased cardiac work. In this study, CFR of hemodialysis patients with angiographically normal coronary arteries was evaluated using transthoracic second harmonic Doppler echocardiography. Methods and Results: Ten hemodialysis patients, and 14 sex-, age- and left ventricular mass index-matched hypertensive controls with angiographically normal coronary arteries underwent transthoracic second harmonic Doppler echocardiographic examination. Coronary basal diastolic peak flow velocities and hyperemic peak flow velocities after dipyridamole infusion (0.56 mg/kg over 4 min) were measured. CFR was defined as the ratio of hyperemic to basal diastolic peak velocities. CFR ≧2.0 was regarded as normal. Additionally, Doppler tissue imaging pulse wave measurements were taken from the lateral and septal corners of the mitral annulus. CFR values were significantly lower in the study group than in the control group (2.03 ± 0.3 vs. 2.61 ± 0.5, p = 0.005). In 5 of 10 hemodialysis patients, CFR was <2.0 (50%), however in only 1 of 14 control patients it was <2.0 (5%). Conclusions: Impairment of coronary microvasculature occurs earlier in patients with chronic renal failure and may be the harbinger of subsequent primary uremic myocardial disease. In patients with chronic renal failure and normal coronary arteries, decreased CFR by transthoracic echocardiography might be regarded as an early finding of an affected coronary vasculature.

Impaired coronary microvascular function and increased intima-media thickness in rheumatoid arthritis

BACKGROUND Rheumatoid arthritis (RA) is associated with excessive cardiovascular mortality. Recently, some studies have shown endothelial dysfunction in RA patients with high inflammatory activity. In addition, it has been suggested that the chronic inflammatory state of RA contributes to accelerated atherosclerosis. Therefore, we aimed to evaluate whether coronary microvascular dysfunction and increased carotid artery intima-media thickness exist in patients with a long history and well controlled disease activity of RA lacking traditional cardiovascular risk factors. METHODS Thirty RA patients (22 women; mean age 43.7+/-9.0) and 52 healthy volunteers (38 women; mean age 45.3+/-5.4) were included into the study. Using transthoracic echocardiography, each subject underwent echocardiographic examination including coronary flow reserve (CFR) and carotid intima-media thickness (IMT) measurement. RESULTS CFR values were statistically reduced for RA patients as compared to controls (2.4+/-0.5 vs. 2.7+/-0.4, P=0.002) whereas IMT values were significantly increased (0.6+/-0.1 vs. 0.5+/-0.1, P=0.001). In RA patients, CFR positively correlated with lateral Em/Am ratio (r=0.399, P=0.029), and negatively correlated with lateral isovolumic relaxation time (IVRT) (r=-0.744, P=0.005), IMT (r=-0.542, P=0.002) and RA disease duration (r=-0.495, P=0.005). Reflecting LV diastolic function, mitral E-wave deceleration time and isovolumic relaxation time were borderline significant between the groups, however lateral Em/Am ratio and lateral IVRT were statistically different. CONCLUSIONS Patients with RA had impaired CFR and increased carotid IMT, and these injurious effects correlated significantly with disease duration.

Prevention of contrast-induced impairment of renal function by short-term or long-term statin therapy in patients undergoing elective coronary angiography

A decline in kidney function after contrast exposure is associated with a high risk of morbidity and mortality during hospitalization and over long-term periods. Several retrospective and recent prospective clinical trials have shown that statin therapy might prevent contrast-induced nephropathy in patients undergoing percutaneous coronary intervention. In this study, we aimed to assess the effects of statin therapies on renal function parameters in patients undergoing elective coronary angiography. One hundred and sixty patients undergoing elective coronary angiography were randomized equally into two groups: atorvastatin 40 mg/day group (statin started 3 days before coronary angiography) and an untreated control group. An additional 80 patients were included as a chronic statin therapy group. Serum creatinine, serum cystatin C, and glomerular filtration rate (GFR) were measured before and 48 h after coronary angiography. Cockcroft–Gault and Modification of Diet in Renal Disease (MDRD) equations were used to determine GFR. After coronary angiography, serum creatinine and GFR determined by MDRD were significantly better in patients using atorvastatin than those in controls (P = 0.002 and P = 0.004, respectively). Postprocedure serum creatinine, cystatin C, and GFR determined by MDRD were also significantly better in chronic statin therapy group than those in controls (P = 0.006, P = 0.003, and P = 0.004, respectively). There were no differences in renal function parameters between the short-term atorvastatin group and the chronic statin therapy group. Our data demonstrate that the use of short-term atorvastatin and chronic statin therapy may have a role in protecting renal function after elective coronary angiography.

Tissue Doppler study of the right ventricle with a multisegmental approach: comparison with cardiac magnetic resonance imaging.

OBJECTIVE We investigated whether systolic right ventricular (RV) function and myocardial performance index (MPI) studied with a multisegmental approach improve the accuracy of RV function estimation based on tricuspid lateral annulus. METHODS Systolic and isovolumic contraction velocities, isovolumic acceleration, regional MPI from the tricuspid lateral and septal annulus, and basal and apical RV free wall and blood pool MPI were obtained in 69 patients and compared with RV ejection fraction (EF) by cardiac magnetic resonance. RESULTS Average systolic velocity from 2 annular sites had the highest correlation to the RVEF (r = 0.74; P < .001) and highest accuracy to estimate RVEF > 45% (cutoff = 7.0 cm/s; area under the curve 0.908; 95% confidence interval, 0.84-0.98; sensitivity 83%; specificity 86%; P < .0001). Average annular systolic velocity correlated with the RVEF more strongly than the lateral annular systolic velocity in patients with and without dilated RVs and in patients with and without pulmonary arterial hypertension. Four-region average MPI correlated with the RVEF (r = 0.70; P < .001) more strongly than regional MPI and blood pool MPI, with a higher accuracy to estimate RVEF > 45% (cutoff = 0.66; area under the curve 0.849; 95% CI, 0.76-0.94; sensitivity 86%; specificity 75%; P < .0001). Lateral annular measurements were mostly determined by the RVEF, whereas septal annular measurements were almost equally influenced by RVEF and left ventricular ejection fraction (LVEF). Consequently, when the RVEF and LVEF were discordant, only the lateral annular systolic velocity and MPI determined RVEF. CONCLUSION Average systolic velocity from 2 tricuspid annular sites provides the most accurate estimate of RVEF if the RVEF and LVEF are not discordant.