John Barbetseas

Effects of pravastatin on thoracic aortic atherosclerosis in patients with heterozygous familial hypercholesterolemia

Data regarding the effects of plasma lipid lowering on the evolution of thoracic aortic atherosclerosis (TAA) are scarce. In this study, we performed transesophageal echocardiography to characterize TAA in 16 newly diagnosed patients with heterozygous familial hypercholesterolemia and to follow its evolution after 2 years of statin treatment. TAA was graded as follows: grade I = normal intima; grade II = increased intimal echo density without thickening; grade IIIA = increased intimal echo density with single atheromatous plaque < or = 3 mm; grade IIIB = multiple plaques < or = 3mm; grade IV = > or = 1 plaque >3 mm; and grade V = mobile or ulcerated plaques. Baseline aortic intimal morphology was grade I in one patient, grade II in 4, grade IIIA in 6, grade IIIB in 3, and grade IV in 2 patients. Hypolipidemic treatment resulted in significant reductions in plasma total cholesterol and low-density lipoprotein (LDL) cholesterol. Follow-up aortic morphology was grade I in 5 patients, grade II in 2, grade IIIA in 3, grade IIIB in 3, and grade IV in 3 patients. TAA remained stable in 7 patients, progressed in 3, and regressed in 6 patients. TAA evolved in a uniform manner in the ascending aorta, aortic arch, and descending aorta. Patients with TAA regression were younger (39+/-14 vs 52+/-8 years, p=0.038) and had a greater decrease in plasma LDL cholesterol as a result of treatment (138+/-56 vs 73+/-55 mg/dl, p=0.036) than patients with TAA stability or progression. These observations support the hypothesis that hypolipidemic treatment may favorably affect the course of TAA in patients with heterozygous familial hypercholesterolemia.

Chronic systemic inflammation accompanies impaired ventricular diastolic function, detected by Doppler imaging, in patients with newly diagnosed systolic heart failure (Hellenic Heart Failure Study)

We sought to evaluate the relationship between plasma cytokine levels (sCD14, tumor necrosis factor [TNF]-α, and interleukin [IL]-6) and tissue Doppler derived indices of left ventricular systolic and diastolic function in patients with newly diagnosed heart failure. We enrolled 101 consecutive patients (mean age 65 ± 13 years) with newly diagnosed heart failure who were hospitalized in our institute. Echocardiographic assessment was performed in all patients during the third day of their initial hospitalization. The pulsed tissue Doppler imaging (TDI) of the systolic and diastolic function of mitral annulus was characterized by the systolic wave Smv, and the diastolic waves: Emv and Amv. Left atrial kinetic energy (LAKE), an index of left atrial function, was calculated using the equation 1/2 × LASV × 1.06 × Amv2; where LASV is left atrial systolic volume. Furthermore the ratio E/Emv and the flow propagation velocity were also calculated; where E is the rapid mitral filling wave, detected by pulse Doppler. Soluble plasma levels of CD14, TNF-α, and IL-6 were measured in all patients during their third day of hospitalization. Linear regression analysis, after adjustment for sex, age, left ventricular ejection function, body mass index, arterial hypertension, smoking, physical activity, creatinine clearance, diabetes mellitus, and blood lipid levels, revealed that IL-6 levels were inversely associated with LAKE (b = − 5422.4 ± 2031.5, P = 0.03), Sm (b= −0.375 ± 0.1, P = 0.03), and flow propagation (b = −5.404 ±0.621, P = 0.001). CD14 levels were inversely associated with flow propagation (b = −17.655 ±2.6, P = 0.001), and positively associated with E/Emv ratio (b = 2.58 ± 3.6, P = 0.002) and A/Amv ratio (b = 0.629 ± 0.6, P = 0.04). TNF-α was inversely associated with Smv (b−1.189 ± 0.3, P = 0.005). This study reveals that increased plasma levels of CD14, IL-6 and TNF-α are associated with impaired left atrial function and more advanced left ventricular diastolic and systolic dysfunction, in patients with newly diagnosed heart failure.

Echocardiographic features of left atrium in elite male athletes.

In athletes, an increase in left atrial volumes is observed, associated with decreased atrial contractile performance and enhanced conduit function.

Neck circumference is correlated with triglycerides and inversely related with HDL cholesterol beyond BMI and waist circumference.

Neck circumference, beyond a measure of obesity, is a unique fat depot with increasing significance. This study aimed to investigate the association between neck circumference and biomarkers, indicators of cardiovascular risk.

Changes in Phasic Coronary Blood Flow Velocity Profile and Relative Coronary Flow Reserve in Patients With Hypertrophic Obstructive Cardiomyopathy

BACKGROUND In this study, we both investigated coronary flow velocity in hypertrophic obstructive cardiomyopathy (HOCM) and tested the hypothesis of differing coronary flow reserve (CFR) of coronary arteries perfusing left ventricular regions with nonuniform myocardial hypertrophy by measuring the relative CFR. METHODS AND RESULTS Coronary flow velocity was assessed in left anterior descending coronary (LAD) and left circumflex (LCX) arteries in 18 patients with HOCM and marked hypertrophy only in the ventricular septum, in 13 patients without obstruction (HCM), and in 9 age- and sex-matched normal subjects at rest, during rapid atrial pacing, and after dobutamine infusion (5 to 30 microg/kg per minute). Relative CFR was estimated as the ratio between absolute CFR of the LAD and absolute CFR of the LCX (LAD/LCX(CF)). At the peak of rapid atrial pacing and during dobutamine stress, LAD/LCX(CF) was reversed in HOCM patients (from 1.25+/-0.11 to 0.82+/-0.07 and 0.79+/-0.06, respectively), whereas it remained unchanged in control subjects (from 1.0+/-0.1 to 1.0+/-0.05 and 1.0+/-0.05, respectively; P<.001). In HCM patients, LAD/LCX(CF) at rest was 1.10+/-0.11, whereas during rapid atrial pacing and dobutamine stress, it was 0.92+/-0.08 and 0.90+/-0.09, respectively. Relative CFR was 0.62+/-0.05 in HOCM patients and 1.05+/-0.05 (P<.001) in normal subjects. There was an inverse correlation between relative CFR and peak systolic outflow tract gradient (r2=.74, P<.001). CONCLUSIONS Regional distribution of hypertrophy in some patients with HOCM resulted in regional impairment of coronary flow. Relative CFR can be used to estimate regional disturbances of coronary flow and may help in patient selection for new interventional therapeutic techniques.

Distribution of serum lipids and lipoproteins in patients with beta thalassaemia major; an epidemiological study in young adults from Greece

BackgroundBeta-thalassaemia major (b-TM) has been defined as a combination of chronic hemolytic anemia, iron storage disease and myocarditis, and it has been associated with premature death especially due to heart failure. To the best of our knowledge the status of blood lipids in these patients has rarely been investigated. Thus, we assessed the levels of lipids and lipoproteins in a sample of cardiovascular disease free adult men and women with b-TM.MethodsDuring 2003 we enrolled 192 consecutive patients with b-TM that visited our Institution for routine examinations. The Institution is considered the major reference center for b-TM in Greece. Of the 192 patients, 88 were men (25 ± 6 years old) and 104 women (26 ± 6 years old). Fasting blood lipid levels were measured in all participants.ResultsData analysis revealed that 4% of men and 2% of women had total serum cholesterol levels > 200 mg/dl, and 11% of men and 17% of women had triglyceride levels > 150 mg/dl. In addition, mean HDL cholesterol levels were 32 ± 11 mg/dl in men and 38 ± 10 mg/dl in women, lipoprotein-a levels were 8.3 ± 9 mg/dl in men and 8.8 ± 9 mg/dl in women, apolipoprotein-A1 levels were 111 ± 17 mg/dl in men and 123 ± 29 mg/dl in women, and apolipoprotein-B levels were 60 ± 20 mg/dl in men and 59 ± 14 mg/dl in women. Total-to-HDL cholesterol ratios were 3.7 ± 1.2 and 3.8 ± 1.5 in men and women, respectively.ConclusionsThe majority of the patients had blood lipid levels (by the exception of HDL-cholesterol) within the normal range, and consequently the prevalence of lipid and lipoprotein abnormalities was much lower as compared to the general population of the same age. Interestingly, is that the total – to HDL cholesterol ratio was high in our patients, and may underline the importance of this index for the prognosis of future cardiac events in these patients.

Diastolic function in young patients with beta-thalassemia major: an echocardiographic study.

Objective: We aimed to evaluate myocardial diastolic function in patients with beta‐thalassemia major (β‐TM) using pulsed‐tissue Doppler imaging (TDI) and flow propagation (VP), in relation to BNP levels. Methods: We enrolled 192 consecutive patients with β‐TM (88 men (25 ± 6 years) and 104 women (26 ± 6 years), with normal left ventricular (LV) systolic function. By TDI, diastolic myocardial velocities were sampled at the lateral section of the mitral annulus (Smv, Emv, Amv). From the apical four‐chamber view diastolic transmitral flow velocities, including measures of E‐ and A‐waves were performed. The propagation velocity of early flow into the LV cavity was measured by color M‐mode Doppler. Plasma BNP levels were measured in all patients. Results: A nonlinear relationship was found between BNP levels and E/A ratio (beta coefficient for the second‐order term = 1.4 ± 0.4, P = 0.001). We also found a positive association of BNP levels with Amv (r = 0.28, P = 0.023), and a reverse with Smv (r =−0.59, P = 0.01) and Emv/Amv (r =−0.36, P = 0.019). Moreover, an inverse relationship was observed between BNP and Vp (r =−0.43, P = 0.012) levels. Finally, a strong positive linear relationship was found between E/Vp ratio and BNP levels (r = 0.76, P < 0.001). Conclusion: A U‐curved association of E/A ratio of transmitral Doppler velocity was revealed with BNP levels, while the tissue Doppler of the Emv/Amv of the mitral annulus movement showed a negative linear association with BNP levels.

Sex differences in the anatomy of coronary artery disease

In a prospective study, the extent and severity of coronary artery disease (CAD) as well as the location of coronary stenoses were studied comparatively, in relation to age and sex, in 192 consecutive women vs 543 selected men, who all underwent coronary angiography during the same time period, and who were found to have significant CAD. Overall, the age of women (59 +/- 8 years) was higher than that of men (55 +/- 8 years), p < 0.001. Also, the prevalence of smoking was higher in men (81% vs 31%, p = 0.0000) and that of diabetes mellitus in women (29% vs 12%, p = 4 x 10(-6)). In addition, women over 50 years old had a higher incidence of hypertension (51% vs 32%, p = 6 x 10(-5)). Although in both sexes the prevalence of multivessel CAD increased with age, the prevalence of one-vessel CAD was significantly more and that of three-vessel CAD significantly less common in women than in men, both overall (35% vs 16%, p = 4 x 10(-8) and 36% vs 54%, p = 2 x 10(-5), respectively) and in all age subgroups. However, the location of coronary stenoses did not show important differences between men and women with the left anterior descending being the most frequently involved artery. Furthermore, the calculated Gensini index, which reflects cumulatively the extent, severity and location of coronary stenoses, was significantly higher in men (59.2 +/- 34.6 vs 52.2 +/- 36.2, p = 0.03), implying more severe and extensive CAD.(ABSTRACT TRUNCATED AT 250 WORDS)

Usefulness of Dobutamine Stress Echocardiography with Tissue Doppler Imaging for the Evaluation and Follow-Up of Patients with Repaired Tetralogy of Fallot

BACKGROUND The longstanding pulmonary regurgitation in patients with repaired tetralogy of Fallot (RTOF) results in right ventricular (RV) failure. The estimation of RV function and reserve in these patients is of great importance, especially for the determination of the proper timing of pulmonary valve replacement. Tissue Doppler imaging (TDI) of the tricuspid annulus has been proved a valuable tool in the evaluation of these patients. Dobutamine stress echocardiography (DSE) in low doses detects the contractility reserve of cardiac myocytes. The aim of our study was to estimate RV reserve in patients with RTOF with the use of DSE and TDI and to examine whether this is related to baseline TDI indices of the tricuspid annulus. METHODS We studied 21 patients with RTOF and 21 age- and gender-matched controls with TDI Doppler at the tricuspid annulus during DSE. TDI measurements were made at baseline and at infusion rates of 10 and 20 microg x kg x min. RESULTS Patients with RTOF had lower values of TDI indices at baseline and during dobutamine infusion and smaller dobutamine-induced increase of Sa (DeltaSa) (3.8 +/- 1.2 vs. 10.8 +/- 3.6 cm/sec, P < .001) and Aa (3.5 +/- 2.2 vs. 10.0 +/- 3.2 cm/sec, P < .001). A value of DeltaSa < or = 6 cm/sec clearly discriminated patients from controls and could be predicted by values of Sa < 11.5 cm/sec with sensitivity of 95% and specificity of 100%. CONCLUSIONS In patients with RTOF, impaired RV contractile reserve can be documented with TDI of tricuspid annular motion during DSE and is predicted by TDI indices at rest. Its serial estimation may contribute to optimal timing of reoperation.

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.