Wan-Jing Ho

Association between endothelial dysfunction and hyperuricaemia

OBJECTIVE We used high-resolution peripheral vascular ultrasound imaging to assess endothelial function in hyperuricaemic patients. METHODS Hyperuricaemia was defined as a serum uric acid concentration of > 7.7 mg/dl in men or > 6.6 mg/dl in women. Measurements of endothelium-dependent flow-mediated vasodilation (FMD) and endothelium-independent nitroglycerin-mediated vasodilation were performed in 46 hyperuricaemic patients and an equal number of healthy age- and gender-matched normal controls by high-resolution two-dimensional ultrasonographic imaging of the brachial artery. The serum levels of glucose, creatinine, alanine aminotransferase (ALT), lipid profiles and high-sensitivity CRP were measured for both the study groups. RESULTS The serum uric acid levels averaged 9.24 (1.16) and 6.18 (0.99)  mg/dl in the hyperuricaemic and control groups, respectively. Body weight and BMI were significantly higher in the hyperuricaemic group than in the control group. The serum levels of creatinine, ALT, triglyceride and high-sensitivity CRP were significantly different between the two groups. The FMD values were significantly lower in the hyperuricaemic patients than in the controls [4.45% (3.13%) vs 7.10% (2.48%); P < 0.001]. The FMD values were negatively associated with serum uric acid levels (r = -0.273; P = 0.009). Multivariate regression analysis showed that the presence of hyperuricaemia (β = -0.384; P < 0.001) and body weight (β = 0.215; P = 0.017) were independent determinants of low FMD values. CONCLUSION Hyperuricaemia is associated with endothelial dysfunction. Decreased nitric oxide bioavailability may be the main reason.

Recoordination Rather than Resynchronization Predicts Reverse Remodeling after Cardiac Resynchronization Therapy

BACKGROUND Mechanical discoordination as studied by magnetic resonance imaging has been shown to be a better predictor of left ventricular (LV) reverse remodeling after cardiac resynchronization therapy (CRT) compared with mechanical dyssynchrony. MATERIALS AND METHODS This study assessed the value of acute recoordination derived from speckle-tracking echocardiography for predicting response to CRT compared with acute resynchronization. Thirty patients with heart failure scheduled for CRT were studied at baseline, immediately after CRT, and after 6 months of CRT. Acute recoordination after CRT was indexed by an acute reduction in radial discoordination index (RDI), defined as the ratio of average myocardial thinning to thickening during the ejection phase. RESULTS CRT responders were defined as those patients whose LV end-systolic volume decreased by >or= 15% at the 6-month follow-up. Immediately after CRT, the responders (n = 18) demonstrated a significant reduction in RDI (P < .001), which was sustained at the 6-month follow-up (P < .001). The nonresponders, however, did not show a significant change in RDI after CRT. LV reverse remodeling at the 6-month follow-up was significantly correlated with acute recoordination (r = 0.75, P < .001) but weakly correlated with acute resynchronization (r = 0.43; P = .02). CONCLUSIONS Receiver operating characteristic analysis revealed that acute recoordination provided the best separation for prediction of CRT responders compared with acute resynchronization, baseline dyssynchrony, or baseline discoordination. LV recoordination after CRT is an acute phenomenon and predicts response to CRT at 6-month follow-up better than resynchronization.

Incremental Value of Inefficient Deformation Indices for Predicting Response to Cardiac Resynchronization Therapy

BACKGROUND Previous studies have identified four clinical characteristics associated with a favorable response to cardiac resynchronization therapy (CRT): female gender, left bundle branch block (LBBB), QRS duration ≥ 150 msec, and nonischemic etiology of heart failure. The aim of this study was to evaluate the incremental value of baseline inefficient deformation and time delay indices over clinical characteristics for predicting CRT response. METHODS Speckle-tracking longitudinal strain was analyzed in 119 CRT candidates. Patients were divided into subgroups according to sex (male vs. female), QRS morphology (LBBB vs. non-LBBB), QRS duration (≥150 vs. <150 msec), and heart failure etiology (ischemic vs nonischemic). Inefficient deformation was indexed by the septal systolic stretching that occurred after prematurely terminated shortening (systolic rebound stretch in the septal wall) and the absolute differences between peak strain and end-systolic strain across 16 segments (strain delay index). Time to peak strain was measured to derive the septal-to-lateral delay and the 12-segment standard deviation of time to peak strain. CRT response was defined as 6-month end-systolic volume reduction ≥ 15%. RESULTS Patients with one of the four favorable characteristics were more likely to exhibit other favorable characteristics and had greater amounts of inefficient deformation than those without. In contrast, time delay indices were not significantly different in any pairwise comparison except for that between patients with and those without LBBB. Of the 43 patients for whom 6-month follow-up data were available, CRT response was found in 26 (60%). Systolic rebound stretch in the septal wall and strain delay index rather than time delay indices provided significant incremental value over clinical characteristics when predicting CRT response. CONCLUSIONS Combined systolic rebound stretch in the septal wall (or strain delay index) and favorable characteristics may help identify CRT responders.

Peripheral vascular endothelial dysfunction in glaucomatocyclitic crisis: a preliminary study.

PURPOSE Glaucomatocyclitic crisis (GCC) is a syndrome of recurrent unilateral increased intraocular pressure associated with mild cyclitis and few clinical symptoms. This study was undertaken to assess brachial artery endothelium-dependent flow-mediated vasodilation (FMD) as an indicator of vascular endothelial function, to describe the association between GCC and endothelial dysfunction excluding age effects. METHODS This prospective study was conducted from January 2007 to April 2009 and included 12 patients with GCC and 15 age-matched normal control subjects. Detailed clinical parameters were reviewed, including highly sensitive C-reactive protein (hs-CRP), homocysteine, anti-SSA, anti-cardiolipin antibodies, and HLA type. Brachial artery FMD and endothelium-independent, nitroglycerin-mediated vasodilation (NMD) were studied by using high-resolution, two-dimensional (2-D) ultrasonic imaging. RESULTS Twelve patients with GCC were evaluated. The mean age of the patients was 36.3 years including 5 (41.6%) women and 7 (58.4%) men. There were no significant differences between patients with GCC and control subjects with regard to basal data, including body mass index, smoking, blood pressure, complete blood count, and routine blood biochemistries. Homocysteine and hs-CRP were within normal limits. Two (16.7%) patients were positive for HLA-B27, anti-SSA, and anti-cardiolipin antibodies. The nitroglycerin-mediated vasodilation in the patients with GCC was not significantly different from that of the control group. The FMD was much lower in the GCC group than in the control groups (mean 4.81% vs. 7.89%, P < 0.01). CONCLUSIONS The significantly lower FMD in patients with GCC implies peripheral vascular endothelial dysfunction. However, in the 16.7% positive for the HLA-B27, anti-SSA, and anti-cardiolipin antibodies, these parameters are associated with GCC and abnormal FMD.

Systemic high-sensitivity C-reactive protein levels in normal-tension glaucoma and primary open-angle glaucoma.

Purpose To determine the systemic high-sensitivity C-reactive protein (hsCRP) level in patients with normal tension glaucoma (NTG) and primary open-angle glaucoma (POAG). Materials and Methods With the exclusion of patients with cardiovascular and other systemic diseases, 40 patients with NTG, 40 with POAG, and 40 normal controls were enrolled in this study. Each patient underwent blood sampling for hsCRP, biochemistry, and lipid profile analysis. Results Each group had similar demographic parameters including the age, sex, body mass index, heart rate, and blood pressure. There was no statistically significant difference in the hsCRP and biochemistry results between the 3 groups. The lipid profile exhibited a mild elevation in the patients with POAG. Conclusions Our data revealed no difference in the hsCRP level between NTG, POAG, and normal controls after exclusion of patients with cardiovascular and other systemic diseases. Systemic vascular inflammation may not be a major cause in the pathogenesis of glaucoma in those without histories of cardiovascular diseases.

Incremental value of radial discoordination index for the prediction of response to cardiac resynchronization therapy

AIMS Previous studies have identified four baseline characteristics associated with a favourable response to cardiac resynchronization therapy (CRT): female, non-ischaemic aetiology of heart failure, left bundle-branch block (LBBB), and QRS duration ≥150 ms. This study evaluated the incremental value of discoordination and dyssynchrony indices over these characteristics for the prediction of the response to CRT. METHODS AND RESULTS The speckle-tracking strain analysis was performed in 120 CRT candidates. Patients were divided into subgroups according to the gender (male vs. female), aetiology of heart failure (ischaemic vs. non-ischaemic), QRS morphology (LBBB vs. non-LBBB), and QRS duration (≥150 vs. <150 ms), respectively. Discoordination was measured using the mid-ventricular radial discoordination index (RDI-M), the ratio of the average mid-ventricular thinning to thickening during ejection. Patients with one of the four favourable characteristics were more likely to exhibit other favourable characteristics and had greater amounts of average myocardial thinning during ejection and RDI-M than those without (all P< 0.05). In contrast, dyssynchrony indices failed to demonstrate significant differences between male and female and between ischaemic and non-ischaemic subjects. Of 39 patients who had 6-month follow-up data after CRT, left ventricular reverse remodelling was found in 22 patients (56%). Combining the favourable characteristics and RDI-M provides the best ability to predict reverse remodelling after CRT (area under the curve = 0.85, 95% confidence interval 0.73-0.98, P < 0.001). CONCLUSION Mechanical discoordination rather than mechanical dyssynchrony provides a significant incremental value over the baseline characteristics for the prediction of the response to CRT.

Combined Global Longitudinal Strain and Intraventricular Mechanical Dyssynchrony Predicts Long-Term Outcome in Patients With Systolic Heart Failure.

BACKGROUND Left ventricular (LV) ejection fraction (EF) and QRS duration enable prediction of outcome in patients with systolic heart failure (SHF). We assessed the predictive value of global longitudinal strain (GLS) and mechanical dyssynchrony for prognosis in SHF patients. METHODS AND RESULTS Two-hundred and forty SHF patients with LVEF ≤40% were studied. Global LV function and intraventricular mechanical dyssynchrony were calculated as GLS and SD of the time to peak longitudinal strain (SDε) over 18 LV segments. The added value of GLS and SDε for outcome prediction was assessed using nested Cox models. Sixty-six patients (28%) reached the study endpoint of all-cause mortality/heart transplantation over a median follow-up period of 45 months. Baseline variables associated with adverse outcome were age, glomerular filtration rate, pulmonary artery systolic pressure, diabetes and LV end-systolic volume (model χ(2)=69.8). The predictive power of the clinical variables was greater with addition of GLS (χ(2)=81.1) or SDε (χ(2)=102.3) than with LVEF (χ(2)=73.9) or QRS duration (χ(2)=75.5; both P<0.005). GLS (HR, 1.88; P=0.03) and SDε (HR, 1.48; P=0.04) were independent predictors after adjustment for the baseline variables. Patients with impaired GLS (≥-7.8%) and mechanical dyssynchrony (SDε ≥72 ms) had poor outcome. CONCLUSIONS Combined assessment of global LV function and mechanical dyssynchrony using speckle-tracking strain enabled the prediction of long-term outcome in SHF patients.

Enhancement of endothelium‐dependent flow‐mediated vasodilation in hyperthyroidism

Objective   Vascular responsiveness changes in hyperthyroid patients remains controversial. This study attempts to determine whether the vasomotor activity can be influenced by hyperthyroid conditions, and, if so, whether changes induced by hyperthyroidism may be restored to normal during the euthyroid state after treatment.

Exercise-induced myocardial ischaemia complicated by paroxysmal complete atrioventricular block

This study describes a case of exercise‐induced myocardial ischaemia accompanied by complete atrioventricular block (CAVB). A 59‐year‐old man with major depression, treated with regular imipramine and lithium for 20 years, experienced syncope episodes during exercise. Exercise, testing initially, identified ST depression in the inferior leads, and later found CAVB resulting in syncope and seizure. The patient recovered completely after resuscitation. Myocardial ischaemic markers were negative, but 35% stenosis was detected in the distal left main coronary artery by angiography. The combined use of verapamil, nitrate and aspirin was treated as the possible coronary spasm. Repeat treadmill caused negative ischaemic study or exercise‐induced arrhythmia, 7 days later. The pathophysiology of the very rare exercise‐induced paroxysmal CAVB has been reviewed.

Heart failure due to giant congenital aorto-right atrial fistula: report of a case.

Coronary arterio‐venous fistula (CAVF) is a rare coronary artery anomaly. We demonstrated the rare findings of a large congenital aorto‐right atrial fistula with initial presentation of heart failure symptoms. Transthoracic echocardiography and transesophageal echocardiography made the accurate diagnosis. Further haemodynamic and angiographic study proved this large CAVF with extraordinary oxygen saturation step‐up (26%) and large pulmonary to systemic shunt (Qp/Qs = 4.25). It was corrected by surgery because of evidence of heart failure and the possible risk of endocarditis and coronary steal effect.