Ta-Chuan Hung

Independent Effects of Body Fat and Inflammatory Markers on Ventricular Geometry, Midwall Function, and Atrial Remodeling

The effect of body fat distribution on left ventricular (LV) mass and geometry has been recently recognized. However, data regarding circulating inflammatory markers in relation to regional visceral fat deposits, which are metabolically active tissues that can impact cardiac structural remodeling, remain sparse.

Relation of carbohydrate antigen-125 to left atrial remodeling and its prognostic usefulness in patients with heart failure and preserved left ventricular ejection fraction in women.

Carbohydrate antigen-125 (CA-125) has recently been reported to correlate with the severity of systolic heart failure (HF). However, the association between this marker and HF with preserved ejection fraction (HFpEF) remains elusive. We studied 158 consecutive women with preserved ejection fraction, who were categorized into 3 groups: those with HF (HFpEF group, n = 35), those with ≥1 cardiovascular risk (at-risk group, n = 78), and 45 normal controls (n = 45). All subjects underwent echocardiography with serum N-terminal pro-brain type natriuretic peptide (NT-ProBNP), CA-125 level, and other tumor markers obtained. HFpEF group showed significantly greater baseline levels of CA-125 and NT-ProBNP than both normal and at-risk groups (p <0.05). In addition, the serum CA-125 level correlated with the maximum left atrial volume (r = 0.24, p = 0.002). During a mean follow-up of 828.1 days (interquartile range 38 to 1,504.5), those with CA-125 levels >17.29 U/ml had a greatest incidence of HF hospitalization (hazard ratio 6.2, p <0.01) and remained an independent prognosticator in the multivariate Cox models. CA-125 superimposed on NT-ProBNP successfully expanded the receiver operating characteristic curve further in predicting HF hospitalization (area under curve 0.72 to 0.82, c-statistic 0.0049). In conclusion, serum CA-125 might serve as a novel biomarker for HFpEF and predicting HF hospitalization in women.

Cardiac mechanics and ventricular twist by three-dimensional strain analysis in relation to B-type natriuretic peptide as a clinical prognosticator for heart failure patients.

Background Three dimensional (3D) echocardiography-derived measurements of myocardial deformation and twist have recently advanced as novel clinical tools. However, with the exception of left ventricular ejection fraction and mass quantifications in hypertension and heart failure populations, the prognostic value of such imaging techniques remains largely unexplored. Methods We studied 200 subjects (mean age: 60.2±16 years, 54% female, female n = 107) with known hypertension (n = 51), diastolic heart failure (n = 61), or systolic heart failure (n = 30), recruited from heart failure outpatient clinics. Fifty-eight healthy volunteers were used as a control group. All participants underwent 3D-based myocardial deformation and twist analysis (Artida, Toshiba Medical Systems, Tokyo, Japan). We further investigated associations between these measures and brain natriuretic peptide levels and clinical outcomes. Results The global 3D strain measurements of the healthy, hypertension, diastolic heart failure, and systolic heart failure groups were 28.03%, 24.43%, 19.70%, and 11.95%, respectively (all p<0.001). Global twist measurements were estimated to be 9.49°, 9.77°, 8.32°, and 4.56°, respectively. We observed significant differences regarding 3D-derived longitudinal, radial, and global 3D strains between the different disease categories (p<0.05), even when age, gender, BMI and heart rate were matched. In addition, 3D-derived longitudinal, circumferential, and 3D strains were all highly correlated with brain natriuretic peptide levels (p<0.001). At a mean 567.7 days follow-up (25th–75th IQR: 197–909 days), poorer 3D-derived longitudinal, radial, and global 3D strain measurements remained independently associated with a higher risk of cardiovascular related death or hospitalization due to heart failure, after adjusting for age, gender, and left ventricular ejection fraction (all p<0.05). Conclusions 3D-based strain analysis may be a feasible and useful diagnostic tool for discriminating the extent of myocardial dysfunction. Furthermore, it is able to provide a prognostic value beyond traditional echocardiographic parameters in terms of ejection fraction.

Beyond malignancy: the role of carbohydrate antigen 125 in heart failure

Carbohydrate antigen 125 (CA-125), traditionally a tumor marker for screening, diagnosis, and monitoring in ovarian malignancy, had recently been shown increasing evidence and more extensively recognized/explored as a novel surrogate of heart failure (HF). The exact mechanisms underlying the pathophysiologic link between elevated serum CA-125 concentration and HF may be multi-factorial, with both mechanical and inflammatory process including numerous potential cytokines involved. Accumulating data had consistently indicated its diagnostic and prognostic role in HF patients in various clinical settings, however, there is limited clinical information regarding the incremental value or head-to-head comparison of such marker to other well-established HF markers. In this brief review, we aimed to discuss the biosynthesis, and potential insights of underlying pathophysiologies associated with CA-125 secretion in the scenarios of cardiac structural/functional alterations and HF, and further explored its current usage and roles in several recent reports.

COMPARISON OF THE PREVALENCE OF METABOLIC SYNDROME BETWEEN THE CRITERIA FOR TAIWANESE AND JAPANESE AND THE PROJECTED PROBABILITY OF STROKE IN ELDERLY HYPERTENSIVE TAIWANESE

SUMMARY Background: The cutoff of abdominal circumference for metabolic syndrome (MS) defined by the Bureau of Health Promotion (BHP) of Taiwan for Taiwanese (men, 90 cm; women, 80 cm) and by the International Diabetes Federation (IDF) for Japanese (men, 85 cm; women, 90 cm) differs. This study aimed to examine the impact of this difference on the prevalence of MS and the impact of an MS diagnosis on the projected risk of stroke in hypertensive Taiwanese. Methods: MS was examined in a sample of 3,472 hypertensive patients (aged 55–80 years; 1,709 women) across Taiwan. The 10-year probability of stroke estimated from the Framingham equation was compared between MS and non-MS patients. Results: The prevalence of MS using the BHP criteria was 59.2% using the BHP criteria (95% confidence interval, CI, 57.6–60.8%; men, 52.5%; women, 66.1%) and 48.9% by the IDF criteria (95% CI, 47.2–50.5%; men, 61.3%; women, 36.1%). Both criteria showed that, compared with non-MS, MS has higher predicted 10-year probability of stroke (BHP, 0.153 ± 0.115 vs. 0.133 ± 0.105; IDF, 0.159 ± 0.109 vs. 0.132 ± 0.112; both p < 0.001) because of the difference in women (BHP, 0.143 ± 0.124 vs. 0.102 ± 0.091; IDF, 0.147 ± 0.121 vs. 0.118 ± 0.110; both p < 0.001) rather than men (BHP, p = 0.21; IDF, p = 0.29). Conclusion: Both criteria demonstrate that MS is highly prevalent in elderly hypertensive patients in Taiwan. Additionally in women, but not men, the predicted probability of stroke is higher in MS than in non-MS patients. The diagnosis of MS is potentially useful for identifying elderly hypertensive females with an elevated risk of stroke in Taiwan. [International Journal of Gerontology 2009; 3(4): 233–240]

Real-Time Three-Dimensional Echocardiography in the Evaluation of Left Atrial Structure and Function in Normal, Aging, Hypertensive and Heart Failure Patients: New Insights into Left Atrial Adaptation and Remodeling

SUMMARY Background: Precise left atrial (LA) volume quantification, representative of LA function, is of extraordinary clinical prognostic value. However, a detailed description of pathophysiology in different disease populations and interactions with aging by real-time three-dimensional echocardiography (RT-3DE) is lacking. Methods: This study consisted of three protocols: (1) to test the impact of different LA cutting planes on LA volume quantification in different disease populations (n = 61) by RT-3DE; (2) to examine the impact of aging, hypertension (n = 145), the interaction on LA remodeling; and (3) to further depict the LA regional and global remodeling process in different disease entities (n = 68), including heart failure (HF). Results: Bias and percentage error in LA volume quantification tended to decrease significantly when compared with the automatic border detection method at eight cutting planes. A linear relationship was apparent between maximal LA volume and age in the hypertensive group (r = 0.26, p = 0.03), but not in the normal aging group (r = 0.16, p = 0.19). A significantly reduced pumping fraction and enlarged LA volume was observed in HF patients (p < 0.01), with a trend toward less LA pumping volume (p = 0.1). Conclusion: Eight cut planes provided sufficient accuracy in LA volume quantification using the RT-3DE method. Compared with normal aging, LA volume tends to increase with higher pumping volume to compensate for impaired left ventricular relaxation in hypertension. Relatively preserved total LA pumping volume may exist in heart failure patients at the expense of further adaptive volume expansion with a subsequently reduced total emptying fraction. [International Journal of Gerontology 2009; 3(1): 53–65]

PATTERN AND IMPACT OF ALTERED REGIONAL MYOCARDIAL EXCURSION ON GLOBAL VENTRICULAR PERFORMANCE AFTER FIRST-TIME ACUTE ANTERIOR WALL MYOCARDIAL INFARCTION BY REAL-TIME THREE-DIMENSIONAL ECHOCARDIOGRAPHY

SUMMARY Background The regional wall motion score index obtained by two-dimensional echocardiography in myocardial infarction (MI) has a significant impact on left ventricular (LV) global contractility and is of extraordinary prognostic value, whereas data regarding real-time three-dimensional echocardiography (RT-3DE) are lacking. We sought to clarify the relationship between RT-3DE and LV contractility in patients after MI. Methods RT-3DE was performed in 50 patients with anterior wall acute myocardial infarction and 30 normal controls. Global (16 segments) and regional ring-based LV systolic excursions were analyzed offline using the commercially available software Q-Lab version 5.0. The correlations between the LV global and regional systolic excursions and the global LV contractile performance were examined in the MI patients, and further compared with the control group. Results The global and regional (basal and middle ring-based) LV systolic excursions were lower in the MI patients (age, 61.8 ± 13.1 years) than in the normal controls (age, 40.0 ± 15.4 years). Global excursion showed inverse linear relationships with LV end-systolic volume ( r =-0.26, p r =-0.22, p p = 0.08) and stroke volume ( p = 0.49). Conclusion Regional wall motion abnormalities quantified by RT-3DE are clinically convenient and feasible in both MI patients and the normal population. This rapid and objective quantification may also help discriminate abnormal from normal regional and global functions after infarction and, therefore, has the potential to be an attractive solution for clinical diagnosis.

ACUTE PULMONARY EMBOLISM MIMICS ACUTE CORONARY SYNDROME IN OLDER PATIENT

SUMMARY Acute pulmonary embolism is a fatal disease and an often missed diagnosis. There are no specific symptoms or signs. Accurate diagnosis followed by effective therapy can reduce mortality. We report on a 67-year-old man who underwent lumbar laminectomy and developed an acute anterior compressive-like chest pain and jaw numbness rather than dyspnea on the fifth postoperative day. Owing to refractory chest pain with suspicious posterior myocardial infarction or unstable angina on surface electrocardiogram, the patient received emergency coronary catheterization, which demonstrated normal coronary arteries. Further investigation provided a final diagnosis of acute pulmonary embolism. Acute pulmonary embolism with simultaneous recent neurosurgery was a therapeutic dilemma because of the risk of postoperative hemorrhage threatening neurologic function. After treatment with enoxaparin and close monitoring of his neurologic condition, his symptoms were eliminated. Clinicians must keep in mind a differential diagnosis of pulmonary embolism in a postoperative high-risk patient. [International Journal of Gerontology 2009; 3(4): 251–255]