Ruxandra Jurcut

Focus cardiac ultrasound: the European Association of Cardiovascular Imaging viewpoint

The concept of point-of-care, problem-oriented focus cardiac ultrasound examination (FoCUS) is increasingly applied in the settings of medical emergencies, including cardiac diseases. The European Association of Cardiovascular Imaging (EACVI) recognizes that cardiologists are not the only medical professionals dealing with cardiovascular emergencies. In reality, emergency cardiac diagnostics and treatment are also carried out by a wide range of specialists. For the benefit of the patients, the EACVI encourages any medical professional, sufficiently trained to obtain valuable information from FoCUS, to use it in emergency settings. These medical professionals need to have the necessary knowledge to understand the obtained information entirely, and to use it correctly, thoughtfully and with care. In this document, the EACVI underlines major differences between echocardiography and FoCUS, and underscores the need for specific education and training in order to fully utilize advantages and minimize drawbacks of this type of cardiac ultrasound examination in the critically ill patients.

Vascular disease in rheumatoid arthritis: from subclinical lesions to cardiovascular risk.

Rheumatoid arthritis (RA) is one of the most prevalent and complex inflammatory diseases affecting primarily the joints, but also associating several extra-articular features. The vascular disease in RA encompasses a large spectrum of lesions, from rheumatoid vasculitis to atherosclerotic lesions. During the last years the importance of the vascular disease related to atherosclerosis in terms of cardiovascular morbidity and global mortality became evident in RA. The inflammatory hypothesis of atherosclerosis in RA implies that mediators originating from the inflamed synovial tissue or from the liver may have systemic vascular consequences, leading to endothelial dysfunction and structural abnormalities of the vessels. Hence, the global management of patients with RA must include the improvement of cardiovascular risk in parallel with the management of joint disease.

Accuracy of handheld echocardiography for bedside diagnostic evaluation in a tertiary cardiology center: comparison with standard echocardiography.

Aims: We aimed to assess the clinical role of a basic handheld echocardiographic device (HHE) used during cardiology training in evaluating different functional and morphological elements of the heart. Methods and results: 56 consecutive patients (pts), 26 women, mean age 60.0 ± 11.9 years admitted in our Cardiology Department had an echocardiogram performed by both cardiology trainees using a HHE with B‐mode capabilities only and by cardiologists with advanced training in echocardiography using a standard echocardiography device (SE). Several parameters were analyzed: the presence of wall motion abnormalities (WMA), aortic valve abnormalities (AVAbn), mitral valve abnormalities (MVAbn), the presence of pericardial effusion (PE), as well as the presence of a dilated (LVD) or hypertrophied left ventricle (LVH). The Kappa coefficient of correlation between the two methods (k) was determined, along with the sensitivity (Sn), specificity (Sp), negative predictive value (NPV), and positive predictive value (PPV). Both HHE and SED examinations were possible in 52 of the 56 pts (92.8% feasibility). There was a moderate correlation in the assessment of WMA (k = 0.56) with a substantial agreement for MVAbn (k = 0.72), AVAbn (k = 0.76), LVH (k = 0.67) There was excellent agreement for LVD (k = 0.81). Valvular diseases were determined by HHE with good Sp (MVAbn – 97.4%, AVAbn – 100%), although the Sn and NPV were lower. Conclusions: Bedside evaluation using HHE is helpful for assessing LV chamber and walls dimensions, LV regional function, and morphological abnormalities of the valves. The device can be used by cardiology trainees with limited experience in echocardiography but only in combination with a standard examination. (Echocardiography 2011;28:136‐141)

Shone's syndrome diagnosed with echocardiography and confirmed at pathology

The Shones complex, defined by four cardiovascular defects such as a supravalvular mitral membrane, valvular mitral stenosis by a parachute mitral valve, subaortic stenosis, and aortic coarctation, is a rare entity, which occurs most frequently in its incomplete form. We report the case of a 19-year-old female patient who presented at the emergency room for progressively worsening dyspnoea, orthopnoea, fever, and productive cough, due to bronchopneumonia. Echocardiography revealed the co-existence of aortic coarctation with bicuspid aortic valves, mitral supravalvular ring, and dysplastic mitral valves producing severe mitral stenosis and severe pulmonary hypertension. Although wide spectrum antibiotics were administered from the first day of hospitalization, the patient developed severe sepsis and died. The components of the Shones complex diagnosed by echocardiography were confirmed at pathology.

Utility of QRS width and echocardiography parameters in an integrative algorithm for selecting heart failure patients with cardiac dyssynchrony

BACKGROUND Cardiac resynchronization therapy (CRT) is an effective treatment in dilated cardiomyopathy (DCM). However, it has been demonstrated that mechanical dyssynchrony is not related to electrical dyssynchrony. We hypothesized that a new QRS width cutoff could be easier to use as a first step in the selection of patients with inter- and intraventricular dyssynchrony. METHODS We included 58 patients with DCM. Electrocardiographic (PR interval and QRS width) and echocardiographic (left ventricular dimensions, systolic and diastolic function, dyssynchrony parameters) data were evaluated in all patients. RESULTS According to QRS width, we divided the study population in two groups: Group 1, 25 patients having a narrow QRS (<or=120 ms), and Group 2, 33 patients having a wide QRS (>120 ms). Patients in Group 2 had larger left ventricles, with similar systolic function and more severe diastolic dysfunction than patients with narrow QRS. Interventricular dyssynchrony was more frequent in group 2 (54.5% vs 20%, p=0.01), while intraventricular dyssynchrony was highly prevalent in both groups (82.1% vs 72%, p=0.48). A QRS>140 ms best predicted the presence of interventricular dyssynchrony (sensitivity 78.2% and specificity 63.6%), while a QRS>150 ms best predicts intraventricular dyssynchrony (sensitivity 48.6% and specificity 80%). CONCLUSIONS Intraventricular dyssynchrony has a high prevalence in patients with DCM, irrespective of the QRS width. Using a higher QRS width cutoff (150 ms) might help in patient selection for CRT. Electrocardiography and echocardiography can be combined into a selection algorithm for patients receiving resynchronization therapy.

Images in cardiovascular medicine: Primary cardiac leiomyosarcoma: when valvular disease becomes a vascular surgical emergency.

A 50-year-old previously healthy woman was referred to our department for suspected mitral valve endocarditis because of a 3-week history of fever, weight loss, and the echocardiographic discovery of a mitral valve mass. On admission, the patient was cachectic (body mass index of 18 kg/m2) and subfebrile (37.5°C) with dyspnea at rest, jugular vein distension, and tender liver enlargement. Her heart examination showed regular tachycardia (100 bpm), apical systolic murmur (3/6 degree), and diastolic rumble. The ECG showed sinus tachycardia (105 bpm) and signs of left atrial abnormality (wide, notched P wave measuring 140 ms; Figure 1). Chest x-ray revealed a cardiothoracic index of 0.6, with left atrial enlargement and interstitial edema (Figure 2). Figure 1. Twelve-lead ECG shows sinus rhythm, signs of left atrial abnormality (wide, notched P wave measuring 140 ms), and nonspecific ST-T changes. Figure 2. Posteroanterior chest x-ray reveals a cardiothoracic index of 0.6, signs of left atrial enlargement, and interstitial edema. Echocardiography showed an enlarged left atrium and a partially mobile mass on the mitral valve involving mainly the anterior leaflet and the anterolateral commissure (Figure 3A and 3B and Movies I and II in the online-only Data Supplement). …A 50-year-old previously healthy woman was referred to our department for suspected mitral valve endocarditis because of a 3-week history of fever, weight loss, and the echocardiographic discovery of a mitral valve mass. On admission, the patient was cachectic (body mass index of 18 kg/m2) and subfebrile (37.5°C) with dyspnea at rest, jugular vein distension, and tender liver enlargement. Her heart examination showed regular tachycardia (100 bpm), apical systolic murmur (3/6 degree), and diastolic rumble. The ECG showed sinus tachycardia (105 bpm) and signs of left atrial abnormality (wide, notched P wave measuring 140 ms; Figure 1). Chest x-ray revealed a cardiothoracic index of 0.6, with left atrial enlargement and interstitial edema (Figure 2). Figure 1. Twelve-lead ECG shows sinus rhythm, signs of left atrial abnormality (wide, notched P wave measuring 140 ms), and nonspecific ST-T changes. Figure 2. Posteroanterior chest x-ray reveals a cardiothoracic index of 0.6, signs of left atrial enlargement, and interstitial edema. Echocardiography showed an enlarged left atrium and a partially mobile mass on the mitral valve involving mainly the anterior leaflet and the anterolateral commissure (Figure 3A and 3B and Movies I and II in the online-only Data Supplement). …

Subclinical vascular disease in patients with systemic lupus erythematosus: The additive deleterious effect of the antiphospholipid syndrome

Joint Bone Spine - In Press.Proof corrected by the author Available online since mercredi 7 mars 2012

AB0159 Osteoprotegerin – a Possible Link Between Antiphospholipid Antibodies and Atherosclerosis

Background The antiphospholipid syndrome (APS) and systemic lupus erythematosus (SLE) are known to be associated with increased risk of cardiovascular disease (CVD). However, there are few data regarding the osteoprotegerin (OPG), one of the validated markers of the CVD risk, in patients with APS or SLE. Objectives The aim of this study was to evaluate the correlations between the OPG and antiphospholipid antibodies (APLA). Methods Patients with APS (primary and secondary to SLE) were successively included. The diagnosis was sustained according to the 2006 Sydney APSs criteria, respectively to the 2012 SLICC SLEs criteria. Laboratory workup included the “diagnostic” APLA [IgG and IgM anticardiolipin (aCL), IgG and IgM anti-β2 glycoprotein I (aβ2GPI)] and also the “non-diagnostic” APLA [IgG and IgM antiphosphatidylserine (aPS), IgG and IgM anti phosphatidylethanolamine (aPE), respectively IgG and IgM antiprothrombin (aPT)]. We assessed the SCORE and Framingham risk as the widely used score of CVD risk in general population. We divided the study group in two subgroups: A - patients with low OPG (≤1.5 pg/ml), and B - patients with high OPG (>1.5 pg/ml). Results For the 40 patients included, the mean age at inclusion (SD) was 43.7±10.7 years. OPG values were higher in patients with history of stroke vs patients without stroke (3.44±2.24 vs 2.15±1.5, p=0.02). We did not found differences of OPG values in patients with or without history of stable angina, myocardial infarction or peripheral artery disease. Values of SCORE risk (1.19±1.81 vs 0.43±0.75, p=0.03) and Framingham risk (6.56±6.41 vs 3.9±2.73, p=0.02) were significantly higher in group B comparing with group A. Moreover, in patients associating SLE, the SLEDAI score was higher in group B vs group A (4.47±3.51 vs 4.00±6.21, p=0.04). Also, for the SLE patients, we found a higher prevalence for the anti-DNA and anti-Sm in patients with high OPG (2/5 vs 13/0; p=0.042, respectively 0/7 vs 6/7; p=0.032). OPG values were positively correlates only with the values of IgM aPT (0.35, p=0.02). When we performed the ROC curve analysis, we found that the titers of IgM aPT, IgG aβ2GPI, and IgG aPE were the best predictors of an OPG values>1.5 [AUC (CI) 0.604 (0.418-0.791), 0.578 (0.392-0.795), respectively 0.536 (0.342-0.730)]. For the patients with APS secondary to SLE, IgM aPT and IgG aPE [AUC (CI) 0.632 (0.348-0.915), respectively 0.549 (0.289-0.810)] were the best predictors of high OPG levels. Conclusions OPG levels might be related with CVD risk in patients with APS. The OPG levels were correlated with “non-diagnostic” APLA, raising the hypothesis of “non-diagnostic” APLA involvement in the pathogenesis of CVD risk in patients with APS. Moreover, the anti-DNA and anti-Sm might be to be related with the OPG levels in patients with APS secondary to SLE. This is an interesting finding especially as we do not have yet a clear explanation for the increased CVD risk in SLE. Acknowledgements This paper is supported by the POSDRU/159/1.5/S/137390. Disclosure of Interest None declared

THU0006 Predictors of Low Ankle-Brachial Index in Patients with Antiphospholipid Syndrome

Background Large studies validated the ankle-brachial index (ABI) as an important clinical marker of peripheral atherosclerosis in general population. However there are few studies regarding ABI in patients with antiphospholipid syndrome (APLS), a clinical condition associated with an increased cardiovascular risk. Objectives The aim of this study was to evaluate the predictors of an abnormal ABI in patients with APLS. Methods In 106 patients with APLS (primary and secondary) we performed the evaluation of the ABI according to standard recommendations. Traditional cardiovascular risk factors, along with a large spectrum of antiphospholipid antibodies (including the antiphosphatidylserine, antiphosphatidylethanolamine and antiprothrombine antibodies) and lupus anticoagulant were assessed. We calculated the pulse pressure as the difference between systolic and diastolic blood pressure – as a marker of arterial stiffness. We divided the study group in two subgroups: A- patients with an abnormal ABI (defined by a value below 0.9); and B - patients with normal ABI. Results In our study, 30 pts (28.3%) were found to have a low ABI. Mean age (51.1±13.2 in subgroup A vs 42.1±11.0 yo in subgroup B, p=0.001), mean age at diagnostic (42.9±13.4 vs 36.1±10.6 yo, p=0.007), prevalence of arterial hypertension (63.3 vs 32.8%, p=0.008), diabetes (23.3 vs 6.5%, p=0.02), pulse pressure (53.8±12.3 vs 48.6±9.8 mmHg, p=0.02), fasting glucose (95.2±17.5 vs 84.6±15.9 mg/dl, p=0.004) and values of HDL-cholesterol in men (43.1±7.9 vs 58.4±10.1, p=0.01) were associated with an abnormal ABI. Anti-beta 2-glycoprotein I IgG antibodies [median values (interval): 4.00 (1.00-79.00) vs 3.00 (0.00-29.00), p=0.02] and anti-prothrombin IgM antibodies [4.50 (0.00-82.00) vs 3.00 (0.00-14.00), p=0.05] were found to have higher values in patients with abnormal ABI. The anti-beta 2-glycoprotein IgG antibodies has had the higher AUC (area under the curve) for the prediction of low ABI (AUC=0.660). In multivariate analysis, only the titer of anti-beta 2-glycoprotein I IgG were significantly associated with an abnormal ABI (p=0.04). Conclusions In our study group of APLS patients we found a high prevalence of an abnormal ABI. As expected, the traditional cardiovascular risk factors are associated with more important vascular changes in these patients. However, only the titer of anti-beta 2-glycoprotein I IgG was independently associated with a low ABI in patients with APLS reflecting the role of disease itself in the pathogenesis of atherosclerosis. Disclosure of Interest : None declared DOI 10.1136/annrheumdis-2014-eular.4529

AB0509 Deep Vein Thrombosis in Patients with Antiphospholipidic Syndrome and Lupus: the Role of Systemic Inflammation

Background Antiphospholipid syndrome (APLS) is classically associated venous or arterial thrombotic events. However, the predictors for occurrence of deep vein thrombosis in patients with APLS and systemic lupus erythematosus (SLE) are incompletely evaluated. Objectives The aim of this study was to evaluate the impact of systemic inflammation in patients with APLS secondary to SLE. Methods In 47 patients with APLS secondary to SLE, we performed the evaluation of traditional risk factors associated with DVT. We assessed the inflammation parameters [erythrocyte sedimentation rate (ESR), fibrinogen and C-reactive protein (CRP) levels]. We divided the study group in two subgroups: A- patients with DVT; and B- patients without DVT or any other thrombotic event. Results In our study group 18 (38.3%) patients were diagnosed with DVT. Mean age, sex distribution, smoking rate, obesity parameters (body mass index, abdominal circumference, wais-to-hip ratio) were similar in both subgroups. ESR (29.76±4.71 vs 19.71±2.63, p=0.05), fibrinogen (375.88±18.26 vs 326.71±12.45, p=0.02), CRP (12.09±3.68 vs 3.35±0.70, p=0.006) were found to have higher values in patients with DVT. However, in multivariate analysis, only CRP was independently associated with DVT (p=0.03). Conclusions Inflammation seems to be one of the pathogenic pathways in patients with APLS secondary to SLE and DVT. Further studies are required in order to have valid conclusions. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.5743