M Ruscazio

Detection of early impairment of coronary flow reserve in patients with systemic sclerosis

Objective: To investigate whether coronary flow reserve (CFR), measured by a new non-invasive method, is impaired early in patients with systemic sclerosis (SSc) and whether CFR impairment correlates with clinical or functional measures, or both. Methods: 27 patients with SSc without clinical evidence of ischaemic heart disease and 23 control group subjects matched for age and sex were studied. CFR was evaluated in the left anterior descending coronary artery (LAD) with a new non-invasive method: contrast (Levovist) enhanced transthoracic Doppler during adenosine infusion. The pulsed wave Doppler examination of blood flow velocity was recorded in the LAD at rest and after maximum vasodilatation by adenosine infusion. Results: In patients with SSc, without clinical evidence of ischaemic heart disease, CFR was impaired (p=0.0001). 14/27 patients with SSc had severe reduction of the CFR (⩽2.5) compared with controls (p=0.002). A non-significant trend between mean CFR and the severity and duration of the disease was also seen. Conclusions: CFR is often reduced in patients with SSc, suggesting early preclinical cardiac involvement in SSc. This impairment in coronary microvasculature is detectable by a non-invasive echocardiographic method and in this study was more common in the diffuse form of SSc.

Coronary flow reserve by contrast-enhanced echocardiography : A new noninvasive diagnostic tool for cardiac allograft vasculopathy

Noninvasive tests have proven unsatisfactory in cardiac allograft vasculopathy (CAV) diagnosis. We assessed coronary flow reserve (CFR) by contrast‐enhanced transthoracic echocardiography (CE‐TTE) in heart transplantation (HT). CFR was assessed in the left anterior descending coronary artery in 73 HT recipients (59 male, aged 50 ± 12 years at HT), at 8 ± 4.5 years post‐HT. CFR measurements were taken blindly from coronary angiographies. CFR cut points were the standard value of ≤2 and those defined by receiver operating characteristics (ROC) curve analysis. CFR was lower in patients with CAV (2.3 ± 0.7 vs. 3.2 ± 0.5, p < 0.0001). The ≤2 cut point was 100% specific and 38% sensitive. The ≤2.7 cut point, optimal by ROC analysis, was 87% specific and 82% sensitive. Accuracy rose from 71% with the standard ≤2 cut point to 85% with the optimal cut point of ≤2.7. CFR by CE‐TTE may offer promise as a novel, easily repeatable and accurate noninvasive tool in CAV detection. However, further longitudinal studies in larger patient cohorts are warranted before widespread adoption can be advocated.

Bosentan therapy of pulmonary arterial hypertension in connective tissue diseases

Backgroundu2002 Pulmonary arterial hypertension (PAH) is a life‐threatening and debilitating complication of several connective tissue diseases. We aimed to evaluate the effects of long‐term treatment with bosentan, an oral dual endothelin ETA/ETB receptor antagonist, in a cohort of patients with PAH related to connective tissue diseases.

Determinants of Coronary Flow Reserve in Heart Transplantation: A Study Performed With Contrast-enhanced Echocardiography

BACKGROUNDnDetermination of coronary flow reserve (CFR) is increasingly being used in cardiac allograft vasculopathy (CAV). We aimed to identify determinants of CFR in heart transplantation (HT).nnnMETHODSnCFR was measured by transthoracic echocardiography in 119 HT recipients (97 men, 22 women; 50 +/- 12 years of age at HT and 8 +/- 5 years post-HT). CFR was expressed as the ratio of hyperemic (adenosine infusion at a rate of 0.14 mg/kg) to basal diastolic flow velocity. Rejection scores (RS) on endomyocardial biopsy were calculated. Angiographic CAV was analyzed using a qualitative grading system. The coronary tree was divided into 17 traits and a CAV severity/diffusion index (SDI) was calculated for each patient, summing the scores assigned to all lesions.nnnRESULTSnUpon multivariate analysis, CFR was related to CAV (p = 0.001), interventricular septum thickness (p = 0.01), ischemic heart disease pre-HT (p = 0.02) and SDI and SDI/segment number (p < 0.0001 and p = 0.003, respectively). In patients without CAV, CFR was related only to RS for severe grades (p = 0.01).nnnCONCLUSIONSnLeft ventricular hypertrophy, CAV and its severity/diffusion independently contribute to reduced CFR. In patients without angiographic CAV, CFR was only independently related to RS. Because a high rejection burden is associated with increased risk of CAV, CFR reduction may be an early marker of CAV. Microvascular dysfunction may contribute to the late morbidity and mortality seen in HT.

Expanding the noninvasive coronary physiology assessment with transthoracic Doppler echocardiography.

Please see page 214 for the article by Auriti et al. (doi: 10.1016/S1525-2167(03)00014-3) to which this editorial pertains .nnCoronary angiography has been considered the ‘gold standard’ for defining coronary anatomy for more than four decades. Nevertheless, this technique has intrinsic limitations because it only delineates coronary ‘luminology’, and it has been clearly shown that there is marked disparity between the severity of lesions and their physiological effects in ischemic heart disease (CAD)[1]. Both coronary angiography and intravascular ultrasound can only give anatomic information and cannot provide sufficient functional information which is crucial for clinical decision making, especially in intermediate stenoses. It conveys that physiologic variables, such as coronary flow velocity reserve (CFVR), are more widely accepted and used as an additional approach to complement coronary ‘luminology’ and assess the functional status of a patient as much as or more than anatomic variables[2]. Methods of measurement of coronary flow and CFVR including intracoronary Doppler flow wire, nuclear technique such as PET and echo technique such as transesophageal echocardiography (TEE) have been explored in the past years[2–5]. In the clinical setting CFVR is usually measured in the cardiac catheterization laboratory by means of small Doppler guide-wires positioned in the coronary lumen. This method is certainly very precise, but not repeatable for its obvious invasivity and high cost. PET is a promising technique of the noninvasive measurement of CFVR, but since it is extremely expensive, it is scarcely available. Recently, accurate noninvasive assessment of CFVR by means of the transthoracic second-harmonic …

Short-term outcome of octogenarian patients with acute coronary syndrome

Background: Extreme left ventricular hypertrophy (LVH) has been associated with a poor prognosis and a risk factor of sudden cardiac death in hypertrophic cardiomyopathy(HCM). Severe right ventricular hypertrophy(RVH) is rare and whether it also be linked to a poor outcome is unknown. The aim of this study was to investigate the differences of the prevalence and long-term outcomes between patients with extreme RVH and extreme LVH in HCM. Methods: A retrospective study of 30 patients with extreme RVH (maximum RV wall thickness >10 mm)and 143 patients with extreme LVH (maximum LV wall thickness ≥30 mm) identified in a consecutive cohort consisting of 2320 patients with HCM was performed. Any other diseases capable of producing such right or left hypertrophy were excluded. The prevalence and natural history of the2 groups were compared.

Tako tsubo cardiomyopathy: socio- demographic, psychological and outcomes

Background: Extreme left ventricular hypertrophy (LVH) has been associated with a poor prognosis and a risk factor of sudden cardiac death in hypertrophic cardiomyopathy(HCM). Severe right ventricular hypertrophy(RVH) is rare and whether it also be linked to a poor outcome is unknown. The aim of this study was to investigate the differences of the prevalence and long-term outcomes between patients with extreme RVH and extreme LVH in HCM. Methods: A retrospective study of 30 patients with extreme RVH (maximum RV wall thickness >10 mm)and 143 patients with extreme LVH (maximum LV wall thickness ≥30 mm) identified in a consecutive cohort consisting of 2320 patients with HCM was performed. Any other diseases capable of producing such right or left hypertrophy were excluded. The prevalence and natural history of the2 groups were compared.

423 Effects of androgenic-anabolic steroids in myocardial function evaluated by pulsed Doppler tissue imaging in bodybuilders athlets

Background: The impact of blood pressure elevation and obesity on cardiac lunction in children and adolescents has not been studied. New non-invasive echo technique, such as Strain (S) (%) and Strain Rate (SR) (l/s) imaging has enhanced our ability to study regional systolic myocardial functions. Methods: In all we studied 150 subjects, 30 untreated hypertensive children (Group H: mean age 124-3 years, 50% males,), 50 obese (BMI > 95th percentile for age and s~0() children (Group O: mean age 114-3 years, 43% males), 40 obese and hypertensive children (Group He: mean age 134-3 years, 56% males), and 30 age sex comparable heallhy children (clrls: mean age 124-3 years, 50% males). All patients underwent slandard echocardiographic sludy and SR imaging evalulioa. Peak systolic SR values were used for INs analysis. Hypertension was defined as office syslolic or diastolic blood pressure >951h percenlile for age, se~ and heighl on at least 2, diflerenl occasions. Results: Group O (294-6 kg/n~) and He (314-6 kg/n~) presented increased BMI compared to ctrls (184-3 kg/n~) and Group H pts (194-2 kg/m2). Systolic blood pressure was higher in Group H (1314-17mmHg) than He (1294-25mmHg) than in ctrls (1204-16 mmHg, p<0.05) and in Group O (1224-15 mmHg, p<0.05). Left venlricular mass corrected for height 2.7 was increased (p<0.01) in pts compared to ctrls, and among pts was significantly (p<0.01) higher in Group He. Global indices el systolic lunction were similar in the 4 groups. Longitudinal deformation properties were significantly reduced in pts (Group O: SR= -1.64-1 ; H: SR= -1.54-0.9; Group He: SR= -1.44-0.8; Clrls: SR= -1.94-0.3), bul in Group He also myocardial radial deformalion properlies (Group He: SR= 1.74-0.9) were significantly reduced compared to clrls (SR= .3.24-1 ) and Group H (SR= 2.94-0.7) and Group O (SR= 2.64-0.9). Right venlricle regional myocardial deformalion properties were comparable Io ctrls in Group H, while in Group O and He were signilicantly reduced (p<0.01 vs ctrls, p<0.01 vs Group H). Both radial and righl ventricular myocardial delormation properties were significantly correlaled Io lasting glycaemia (r=0.70; p<0.01). Conclusions: This study shows thal children with obesity and hypertension have a more severe reduction in myocardial delormation properties involving both radial and longitudinal function as well as right and left ventricular lunction compared to those with one disease or the other. SR imaging may be used as a relevant loci to assess the influence el cardiovascular risk laclors on cardiac lunclion in high-risk children.

Letter Regarding Article by Pellikka et al, “Severe Asymptomatic Aortic Stenosis”

To the Editor:nnWe read with interest the article of Pellikka et al,1 a remarkable follow-up of 622 patients with hemodynamically significant aortic stenosis.nnThe authors conservatively conclude that “the majority of patients with asymptomatic, hemodynamically significant aortic stenosis will develop symptoms within 5 years,” with no further recommendation about surgery. We think the analysis of their data could suggest a more straightforward conclusion. nn1. In Figure 2 of the article, they show that 72% of asymptomatic patients who underwent surgery survived, versus only 43% of those treated medically (a mortality of approximately 12% per year) ( P <0.001).nn2. Death was of cardiac causes in 9.8% of surgical patients versus 30.5% of medical patients (see Table 3).nn3. They state in the Discussion section that …