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Pubblicazioni recenti - cardiac disease
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Subclinical cardiac stiffness is associated with arterial stiffness in healthy young nulligravid women: Potential links to preeclampsia.
Pregnancy Hypertens2019 Sep;18():49-54. doi: S2210-7789(19)30349-6.
Cooper Kylie M, Barrett Trace, McBride Carole A, Badger Gary J, Steiner Johannes, LeWinter Martin M, Bernstein Ira M,
Abstract
OBJECTIVES:
Preeclampsia is an independent risk factor for subsequent cardiovascular disease and diastolic dysfunction and has been linked to arterial stiffness. We hypothesized that arterial stiffness would be associated with echocardiographic markers of diastolic dysfunction in healthy nulligravid women.
STUDY DESIGN:
31 healthy nulligravid women underwent assessment of peripheral arterial stiffness via aorto-femoral pulse wave velocity, popliteal distensibility and ? stiffness measures as well as hemodynamic response to volume challenge. 22 underwent cardiac assessment via conventional and stress echocardiography with a focus on diastolic function utilizing tissue/pulse wave Doppler imaging and 3D speckle tracking. Bivariate associations between variables were evaluated using correlation coefficients (Pearson r) and Student's t-tests.
RESULTS:
No participants had echocardiographic values meeting criteria for overt diastolic dysfunction. Baseline global circumferential strain was significantly correlated with distensibility and ? stiffness (n?=?18, r?=?-0.61, p?=?0.007, n?=?18, r?=?0.56, p?=?0.01). Peak deceleration time was correlated with ?stiffness (n?=?9; r?=?0.80, p?=?0.01). Pulse wave velocity was not significantly correlated with cardiac measures (p?>?0.05). Family history of a first or second degree relative with myocardial infarction or hypertension was associated with decreased popliteal artery distensibility (p?=?0.02 and p?=?0.03, respectively).
CONCLUSIONS:
In healthy nulligravid women there is evidence that markers of decreased left ventricular relaxation are associated with increased peripheral vascular stiffness as is a family history of myocardial infarction or hypertension. These findings raise the possibility that the diastolic dysfunction and arterial stiffness observed in the setting of preeclampsia are driven by underlying properties present prior to pregnancy and contribute to lifetime cardiovascular risk.
Copyright © 2019 International Society for the Study of Hypertension in Pregnancy. Published by Elsevier B.V. All rights reserved.
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Redox signaling in ischemic postconditioning protection involves PKC? and Erk1/2 pathways and converges indirectly in Nrf2 activation.
Cell Signal2019 Sep;():109417. doi: S0898-6568(19)30213-X.
Díaz-Ruíz Jorge-Luis, Macías-López Arturo, Alcalá-Vargas Francisco, Guevara-Chávez José-Guadalupe, Mejía-Uribe Aída, Silva-Palacios Alejandro, Zúñiga-Muñoz Alejandra, Zazueta Cecilia, Buelna-Chontal Mabel,
Abstract
Ischemic-postconditioning (iPostC) exerts cardioprotection by preserving redox homeostasis in the reperfused heart. This protective effect has been associated with the activation of endogenous antioxidant response driven by transcription factor Nrf2 and with the activation of 'reperfusion injury salvage kinases' (RISK) as PI3K, PKC and Erk1/2. Redox homeostasis is essential for normal cell physiology since reactive oxygen species (ROS) are crucial for processes that involve protein signaling. Thus, it has become clear that not only the perturbation of redox balance to oxidative state is deleterious but also towards a reductive state contributing to pathogenesis of diseases. However, there is still a scarce knowledge about the role of ROS in the cardioprotective signals mediated by RISK in postconditioned hearts. Therefore, we studied the role of ROS as initiator of RISK signaling molecules in iPostC-conferred cardioprotection. With the aim to study the relationship between redox-dependent RISK activation and the downstream activation of the transcription factor Nrf2, we evaluated the effect of redox signaling disruption by the effect of ascorbic acid in iPostC hearts. Our results showed that PKC? and Erk1/2 activation is redox-dependent and that concurs downstream with Nrf2 deficient activation. Besides, using inhibitors we found that neither PI3K nor Erk1/2 are directly related with Nrf2 activation, indicating that these kinases have other targets. We conclude that redox signaling participates in cardioprotection triggered by iPostC through the action of kinase-dependent and -independent mechanisms and concurred with the downstream regulation of Nrf2-mediated antioxidant response to prolonged redox balance during long reperfusion.
Copyright © 2018. Published by Elsevier Inc.
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Hemodynamic Phenotypes of Hypertension Based on Cardiac Output and Systemic Vascular Resistance.
Am J Med2019 Sep;():. doi: S0002-9343(19)30766-1.
Mahajan Shiwani, Gu Jianlei, Lu Yuan, Khera Rohan, Spatz Erica S, Zhang MaoZhen, Sun NingLing, Zheng Xin, Zhao Hongyu, Lu Hui, Ma Zheng J, Krumholz Harlan M,
Abstract
BACKGROUND:
Blood pressure is a physiologic measure that reflects cardiac output and systemic vascular resistance. Classification by these components could be useful in characterizing subtypes of hypertension which may have a role in selecting treatment strategies. However, hemodynamic phenotypes of a large, stable, outpatient population with hypertension remain unknown.
METHODS:
We included 34,238 people, with systolic blood pressure of ?130mmHg, who underwent impedance cardiography at 51 sites of iKang Health Checkup Centers throughout China between 2012 and 2018. Hemodynamic parameters measured included: stroke volume, stroke volume index, heart rate, cardiac output, cardiac index, systemic vascular resistance, and systemic vascular resistance index. We characterized these by systolic blood pressure categories and assessed patient characteristics associated with the ratio of cardiac index to systemic vascular resistance index.
RESULTS:
Among the study cohort (n=33,414; mean age 52±13years; 36.6% female), 49%, 40%, and 11% had systolic blood pressure130-139, 140-159, and?160mmHg, respectively. Among patients with systolic blood pressure 140-159mmHg, 9353 (70%) had high systemic vascular resistance index but normal/low cardiac index, 1949 (15%) had high cardiac index but low/normal systemic vascular resistance index, and 2053 (15%) had low/normal cardiac index and systemic vascular resistance index. Using multivariable analysis, we found that cardiac index to systemic vascular resistance index ratio was negatively associated with age and body mass index (all P<0.05; R-square 0.16, 0.12 and 0.09 for systolic blood pressure 130-139, 140-159 and?160mmHg, respectively).
CONCLUSIONS:
Different hemodynamic blood pressure phenotypes were identified across all hypertensive blood pressure categories. While individual characteristics were associated with the cardiac index to systemic vascular resistance index ratio, they only weakly explained the variation.
Copyright © 2019. Published by Elsevier Inc.
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Maternal folic acid supplementation does not counteract the deleterious impact of prenatal exposure to environmental pollutants on lipid homeostasis in male rat descendants.
J Dev Orig Health Dis2019 Sep;():1-11. doi: 10.1017/S2040174419000497.
Navarro Pauline, Dalvai Mathieu, Charest Phanie L, Herst Pauline M, Lessard Maryse, Marcotte Bruno, Mitchell Patricia L, Leblanc Nadine, Kimmins Sarah, Trasler Jacquetta, MacFarlane Amanda J, Marette André, Bailey Janice L, Jacques Hélène,
Abstract
Prenatal exposure to persistent organic pollutants (POPs) has been associated with the development of metabolic syndrome-related diseases in offspring. According to epidemiological studies, father's transmission of environmental effects in addition to mother's can influence offspring health. Moreover, maternal prenatal dietary folic acid (FA) may beneficially impact offspring health. The objective is to investigate whether prenatal FA supplementation can overcome the deleterious effects of prenatal exposure to POPs on lipid homeostasis and inflammation in three generations of male rat descendants through the paternal lineage. Female Sprague-Dawley rats (F0) were exposed to a POPs mixture (or corn oil) +/- FA supplementation for 9 weeks before and during gestation. F1 and F2 males were mated with untreated females. Plasma and hepatic lipids were measured in F1, F2, and F3 males after 12-h fast. Gene expression of inflammatory cytokines was determined by qPCR in epididymal adipose tissue. In F1 males, prenatal POPs exposure increased plasma lipids at 14 weeks old and hepatic lipids at 28 weeks old and prenatal FA supplementation decreased plasma total cholesterol at 14 weeks old. Prenatal POPs exposure decreased plasma triglycerides at 14 weeks old in F2 males. No change was observed in inflammatory markers. Our results show an impact of the paternal lineage on lipid homeostasis in rats up to the F2 male generation. FA supplementation of the F0 diet, regardless of POPs exposure, lowered plasma cholesterol in F1 males but failed to attenuate the deleterious effects of prenatal POPs exposure on plasma and hepatic lipids in F1 males.
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The homozygous variant c.245G>A/p.G82D in PNPLA2 is associated with arrhythmogenic cardiomyopathy phenotypic manifestations.
Clin Genet2019 Sep;():. doi: 10.1111/cge.13642.
Rao Man, Guo Guang-Ran, Li Meng-Meng, Chen Shi, Chen Kai, Chen Xiao, Song Jiang-Ping, Hu Sheng-Shou,
Abstract
Arrhythmogenic cardiomyopathy (ACM) is a familial cardiomyopathy featured by fibro-fatty replacement of cardiomyocytes. Responsible genetic factors are not discernible in approximately one third of ACM probands. To investigate this further, we performed whole genome sequencing (WGS) in 14 mutation-negative ACM probands who underwent cardiac transplantation, and we identified one ACM proband with a rare homozygous missense variant in PNPLA2 (c.245G>A, p.G82D), a rate-limiting enzyme that hydrolyzes triglycerides into fatty-acids and diacylglycerol. Bioinformatic analysis suggested that this missense variant may lead to loss-of-function and therefore impair lipid catabolism. Genetic screening in this proband's family also inferred that the homozygous variant co-segregated with disease. To validate the pathogenicity of this variant and confirm its association with ACM, we established a knock-in mouse model carrying the orthologous human homozygous PNPLA2 variant. Interestingly, mice with the homozygous variant presented with arrhythmias and significant cardiac dysfunction at 12-weeks, whereas heterozygous mice were not affected. Moreover, those homozygous mice suffered sudden death and/or heart failure by age of 14-weeks. Pathological examination showed that extensive lipogenesis in cardiomyocytes and cardiac fibrosis were prominent in the myocardium. Herein, our data demonstrated that the homozygous missense variant PNPLA2 (c.245G>A, p.G82D) associated with a recessive form of ACM. This article is protected by copyright. All rights reserved.
This article is protected by copyright. All rights reserved.
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Myocardial Adaptations to Competitive Swim Training.
Med Sci Sports Exerc2019 Oct;51(10):1987-1994. doi: 10.1249/MSS.0000000000002022.
Wasfy Meagan M, Weiner Rory B, Wang Francis, Berkstresser Brant, Deluca James, Hutter Adolph M, Picard Michael H, Baggish Aaron L,
Abstract
PURPOSE:
Swim training is performed in the prone or supine position and obligates water immersion, factors that may augment cardiac volume loading more than other endurance sports. At present, prospective data defining the cardiac responses to swim training are lacking. We therefore studied myocardial adaptations among competitive swimmers to establish a causal relationship between swim training and left ventricular (LV) remodeling.
METHODS:
Collegiate swimmers were studied before and after a 90-d period of training intensification. Transthoracic echocardiography was used to examine LV structural and functional adaptations under resting conditions and during an acute LV afterload challenge generated by isometric handgrip testing (IHGT). A sedentary control population was identically studied with IHGT.
RESULTS:
In response to a discrete period of swim training intensification, athletes (n = 17, 47% female, 19 ± 0.4 yr old) experienced eccentric LV remodeling, characterized by proportionally more chamber dilation than wall thickening, with attendant enhancements of resting LV systolic (LV twist) and diastolic (early and late phase tissue velocities) function. Compared with baseline and controls, athletes posttraining demonstrated greater systolic twist impairment during IHGT. However, training-induced LV dilation coupled with gains in diastolic function offsets this acquired systolic susceptibility to acute afterload, resulting in the relative preservation of stroke volume during IHGT.
CONCLUSION:
Swim training, a sport characterized by unique cardiac loading conditions, stimulates eccentric LV remodeling with the concomitant augmentation of systolic twist and diastolic relaxation. This volume-mediated cardiac remodeling appears to result in greater systolic susceptibility to acute afterload challenge. Further work is required to establish how training-induced changes in function translate to human performance and whether these are accompanied by physiologic trade-offs with relevance to common forms of heart disease.
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Prognostic Value of Coronary Microvascular Function Measured Immediately After Percutaneous Coronary Intervention in Stable Coronary Artery Disease: An International Multicenter Study.
Circ Cardiovasc Interv2019 Sep;12(9):e007889. doi: 10.1161/CIRCINTERVENTIONS.119.007889.
Nishi Takeshi, Murai Tadashi, Ciccarelli Giovanni, Shah Sonia V, Kobayashi Yuhei, Derimay François, Waseda Katsuhisa, Moonen Avalon, Hoshino Masahiro, Hirohata Atsushi, Yong Andy S C, Ng Martin K C, Amano Tetsuya, Barbato Emanuele, Kakuta Tsunekazu, Fearon William F,
Abstract
BACKGROUND:
The prognostic impact of coronary microvascular dysfunction after percutaneous coronary intervention (PCI) remains unclear in patients with stable coronary artery disease. This study sought to investigate the prognostic value of microvascular function measured immediately after PCI in patients with stable coronary artery disease.
METHODS:
We enrolled 572 patients with stable coronary artery disease who underwent PCI and elective measurement of the index of microcirculatory resistance (IMR) immediately after PCI from 8 centers in 4 countries. Impaired microvascular function was defined as IMR?25 (high IMR). Major adverse cardiac events, including death, myocardial infarction (MI) and target vessel revascularization, were evaluated.
RESULTS:
During a median follow-up duration of 4.0 years, the cumulative major adverse cardiac events rate was significantly higher in the high IMR group (n=66/148) compared with the low IMR group (n=128/424; hazard ratio [HR], 1.56; 95% CI, 1.16-2.105; =0.001), primarily due to a higher rate of periprocedural MI (HR, 1.59; 95% CI, 1.11-2.28; =0.004) but also due to higher rates of mortality (HR, 1.59; 95% CI, 0.76-3.35; =0.22), spontaneous MI (HR, 2.10; 95% CI, 0.67-6.63; =0.20) and target vessel revascularization (HR, 1.40; 95% CI, 0.77-2.54; =0.27). Cumulative risk for death, spontaneous MI, and target vessel revascularization was higher in the high IMR group (HR, 1.55; 95% CI, 0.99-2.43; =0.056), as was death and spontaneous MI alone (HR, 1.79; 95% CI, 0.96-3.36; =0.065). On multivariable analysis, high IMR post-PCI was an independent predictor of major adverse cardiac events.
CONCLUSIONS:
IMR measured immediately after PCI predicts adverse events in patients with stable coronary artery disease.
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Long-Term Effect of Ultrathin-Strut Versus Thin-Strut Drug-Eluting Stents in Patients With Small Vessel Coronary Artery Disease Undergoing Percutaneous Coronary Intervention: A Subgroup Analysis of the BIOSCIENCE Randomized Trial.
Circ Cardiovasc Interv2019 Aug;12(8):e008024. doi: 10.1161/CIRCINTERVENTIONS.119.008024.
Iglesias Juan F, Heg Dik, Roffi Marco, Tüller David, Noble Stéphane, Muller Olivier, Moarof Igal, Cook Stéphane, Weilenmann Daniel, Kaiser Christoph, Cuculi Florim, Häner Jonas, Jüni Peter, Windecker Stephan, Pilgrim Thomas,
Abstract
BACKGROUND:
Randomized trials evaluating the Orsiro biodegradable polymer sirolimus-eluting stent (BP-SES; 60 and 80 ?m strut thickness for stent diameters ?3 and >3 mm, respectively) did not stratify according to vessel size and failed to specify the impact of ultrathin-strut thickness on long-term clinical outcomes compared with durable polymer everolimus-eluting stents (DP-EES). We sought to assess the long-term effect of ultrathin-strut (60 ?m) BP-SES versus thin-strut (81 ?m) DP-EES on long-term outcomes in patients undergoing percutaneous coronary revascularization for small vessel disease.
METHODS:
In a subgroup analysis of the randomized, multicenter, noninferiority BIOSCIENCE trial, patients with stable coronary artery disease or acute coronary syndrome randomly assigned to treatment with BP-SES or DP-EES were stratified according to vessel size (?3 mm versus >3 mm) as a surrogate to compare patients treated with ultrathin-strut versus thin-strut drug-eluting stent. The primary end point was target lesion failure, a composite of cardiac death, target vessel myocardial infarction, and clinically indicated target lesion revascularization, within 5 years.
RESULTS:
Among 2109 patients, 1234 (59%) were treated for small vessel disease. At 5 years, target lesion failure occurred in 124 patients (cumulative incidence, 22.3%) treated with ultrathin-strut BP-SES and 109 patients (18.3%) treated with thin-strut DP-EES (rate ratio, 1.22; 95% CI, 0.94-1.58; =0.13). Cumulative incidences of cardiac death, target vessel myocardial infarction, and clinically indicated target lesion revascularization and definite stent thrombosis at 5 years were similar in patients treated with ultrathin-strut BP-SES and thin-strut DP-EES. After adjustment for potential confounders, there was no significant interaction between vessel size and treatment effect of BP-SES versus DP-EES.
CONCLUSIONS:
We found no significant difference in clinical outcomes throughout 5 years between patients with small vessel disease treated with ultrathin-strut BP-SES versus thin-strut DP-EES.
CLINICAL TRIAL REGISTRATION:
URL: https://www.clinicaltrials.gov. Unique identifier: NCT01443104.
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Automated and Interpretable Patient ECG Profiles for Disease Detection, Tracking, and Discovery.
Circ Cardiovasc Qual Outcomes2019 Sep;12(9):e005289. doi: 10.1161/CIRCOUTCOMES.118.005289.
Tison Geoffrey H, Zhang Jeffrey, Delling Francesca N, Deo Rahul C,
Abstract
BACKGROUND:
The ECG remains the most widely used diagnostic test for characterization of cardiac structure and electrical activity. We hypothesized that parallel advances in computing power, machine learning algorithms, and availability of large-scale data could substantially expand the clinical inferences derived from the ECG while at the same time preserving interpretability for medical decision-making.
METHODS AND RESULTS:
We identified 36?186 ECGs from the University of California, San Francisco database that would enable training of models for estimation of cardiac structure or function or detection of disease. We segmented the ECG into standard component waveforms and intervals using a novel combination of convolutional neural networks and hidden Markov models and evaluated this segmentation by comparing resulting electrical intervals against 141?864 measurements produced during the clinical workflow. We then built a patient-level ECG profile, a 725-element feature vector and used this profile to train and interpret machine learning models for examples of cardiac structure (left ventricular mass, left atrial volume, and mitral annulus e-prime) and disease (pulmonary arterial hypertension, hypertrophic cardiomyopathy, cardiac amyloid, and mitral valve prolapse). ECG measurements derived from the convolutional neural network-hidden Markov model segmentation agreed with clinical estimates, with median absolute deviations as a fraction of observed value of 0.6% for heart rate and 4% for QT interval. Models trained using patient-level ECG profiles enabled surprising quantitative estimates of left ventricular mass and mitral annulus e' velocity (median absolute deviation of 16% and 19%, respectively) with good discrimination for left ventricular hypertrophy and diastolic dysfunction as binary traits. Model performance using our approach for disease detection demonstrated areas under the receiver operating characteristic curve of 0.94 for pulmonary arterial hypertension, 0.91 for hypertrophic cardiomyopathy, 0.86 for cardiac amyloid, and 0.77 for mitral valve prolapse.
CONCLUSIONS:
Modern machine learning methods can extend the 12-lead ECG to quantitative applications well beyond its current uses while preserving the transparency that is so fundamental to clinical care.
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Saphenous Vein Graft Pseudoaneurysm Causing External Compression of the Pulmonary Artery.
Circ Cardiovasc Imaging2019 Aug;12(8):e009377. doi: 10.1161/CIRCIMAGING.119.009377.
Duran Crane Alejandro, Newtown Emily, Cremer Paul, Edward Montané Bryce, Xu Bo,
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Effect of Baseline Left Ventricular Ejection Fraction on 2-Year Outcomes After Transcatheter Aortic Valve Replacement: Analysis of the PARTNER 2 Trials.
Circ Heart Fail2019 Aug;12(8):e005809. doi: 10.1161/CIRCHEARTFAILURE.118.005809.
Furer Ariel, Chen Shmuel, Redfors Bjorn, Elmariah Sammy, Pibarot Philippe, Herrmann Howard C, Hahn Rebecca T, Kodali Susheel, Thourani Vinod H, Douglas Pamela S, Alu Maria C, Fearon William F, Passeri Jonathan, Malaisrie S Chris, Crowley Aaron, McAndrew Thomas, Genereux Philippe, Ben-Yehuda Ori, Leon Martin B, Burkhoff Daniel,
Abstract
BACKGROUND:
Impaired left ventricular function is associated with worse prognosis among patients with aortic stenosis treated medically or with surgical aortic valve replacement. It is unclear whether reduced left ventricular ejection fraction (LVEF) is an independent predictor of adverse outcomes after transcatheter aortic valve replacement.
METHODS AND RESULTS:
Patients who underwent transcatheter aortic valve replacement in the PARTNER 2 trials (Placement of Aortic Transcatheter Valves) and registries were stratified according to presence of reduced LVEF (<50%) at baseline, and 2-year risk of cardiovascular mortality was compared using Kaplan-Meier methods and multivariable Cox proportional hazards regression. Of 2991 patients, 839 (28%) had reduced LVEF. These patients were younger, more often males, and were more likely to have comorbidities, such as coronary disease, diabetes mellitus, and renal insufficiency. Compared with patients with normal LVEF, patients with low LVEF had higher crude rates of 2-year cardiovascular mortality (19.8% versus 12.0%, <0.0001) and all-cause mortality (27.4% versus 19.2%, <0.0001). Mean aortic valve gradient was not associated with clinical outcomes other than heart failure hospitalizations (hazard ratio [HR], 0.99; CI, 0.99-1.00; =0.03). After multivariable adjustment, patients with reduced versus normal LVEF had significantly higher adjusted risk of cardiovascular death (adjusted HR, 1.42, 95% CI, 1.11-1.81; =0.005), but not all-cause death (adjusted HR, 1.20; 95% CI, 0.99-1.47; =0.07). When LVEF was treated as continuous variable, it was associated with increased 2-year risk of both cardiovascular mortality (adjusted HR per 10% decrease in LVEF, 1.16; 95% CI, 1.07-1.27; =0.0006) and all-cause mortality (adjusted HR, 1.09; 95% CI, 1.01-1.16; =0.02).
CONCLUSIONS:
In this patient-level pooled analysis of PARTNER 2 patients who underwent transcatheter aortic valve replacement, baseline LVEF was an independent predictor of 2-year cardiovascular mortality.
CLINICAL TRIAL REGISTRATION:
URL: https://www.clinicaltrials.gov. Unique identifiers: NCT01314313, NCT02184442, NCT03222128, and NCT02184441.
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Change in Physical Activity and Cardiac Structure over 10 Years: The Multi-Ethnic Study of Atherosclerosis.
Med Sci Sports Exerc2019 Oct;51(10):2033-2040. doi: 10.1249/MSS.0000000000002027.
Florido Roberta, Zhao D I, Ndumele Chiadi E, Bluemke David A, Heckbert Susan R, Allison Matthew A, Ambale-Venkatesh Bharath, Liu Chia-Ying, Lima Joao, Michos Erin D,
Abstract
INTRODUCTION:
Physical activity (PA) is inversely associated with risk of heart failure and cardiovascular disease (CVD), whereas increased left ventricular (LV) mass and mass to volume (m:v) ratio are unfavorable CVD risk factors. We assessed whether changes in leisure time PA were associated with longitudinal changes in cardiac structure in a community-based population.
METHODS:
We included 2779 Multi-Ethnic Study of Atherosclerosis participants, free of baseline CVD, who had available data on PA and cardiac magnetic resonance imaging at examinations 1 (2000-2002) and 5 (2010-2012). Physical activity was measured by a Typical Week PA Survey and converted to MET-minutes per week of moderate+vigorous activity. We used linear mixed effect models to estimate the associations of baseline and change in PA with baseline and change in cardiac structure, adjusting for CVD risk factors and body size.
RESULTS:
At baseline, the mean age was 59 yr, 53% were women, and 58% of nonwhite race/ethnicity. During average 10-yr follow-up, and after accounting for baseline PA levels, the highest quintiles of PA increase were significantly associated with increases in LV mass (2.3 g; 95% confidence interval [CI], 0.4-4.2), LV end-diastolic volume (4.7 mL; 95% CI, 2.4-7.0), and stroke volume (3.3 mL; 95% CI, 1.6-5.1), but lower M:V ratio (-2.9; 95% CI, -5.0 to -0.8) compared with the lowest quintiles. Increasing exercise PA was associated with increases in LV diameter and reductions in M:V ratio, whereas occupational PA was associated with increases in m:v ratio. Increasing PA over 10 yr was also associated with greater risk of eccentric dilated LV hypertrophy at examination 5.
CONCLUSIONS:
After accounting for baseline PA, greater positive changes in leisure-time PA levels were associated with a more eccentric-type of LV remodeling pattern over 10 yr. The clinical implications of such findings remain to be determined.
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Salvage of Exposed Cardiac Implants Using Fasciocutaneous Rotation Flaps.
Ann Plast Surg2019 Sep;():. doi: 10.1097/SAP.0000000000001985.
Da?delen Da?han, Aksoy Alper,
Abstract
INTRODUCTION:
Implantation rates of cardiac implantable electrophysiological devices (CIEDs) are rising, mainly because of the expansion of implantable cardioverter-defibrillators indications for primary prevention. As the CIED usage increases, CIED-related complications are also in rise. Transvenous approach and laser utilization techniques are replacing the open heart surgeries, for removal of CIED systems that are suspected to be infected. In this study, we aimed to share our new method of fasciocutaneous flap coverage results of patients with exposed CIED systems who were not eligible for the CIED replacement surgery for various reasons.
PATIENTS AND METHODS:
Patients operated with rotational fasciocutaneous flaps with addition of pectoralis fascia, owing to their exposed CIEDs between June 2016 and January 2019, were enlisted. Patients with signs of infection whether systemic or limited to the CIED pocket with or without positive blood cultures were referred to infectious diseases department and not included in this study. Patients included in the study were evaluated retrospectively in terms of demographic data, implanted CIED type, time elapsed from implantation to exposure, from referral to flap coverage operation, total follow-up time, survival ratios during follow-up, and complications related to flap coverage operation. In addition, indications for CIED implantation, patient comorbidities, and culture results obtained from the capsule encompassing the CIED battery unit were included to the evaluation.
RESULTS:
A total of 13 patients with exposed CIEDs have undergone total capsulectomy and CIED system coverage with rotational fasciocutaneous flaps. The mean patient age ± SD was 60.2 ± 13.4 years. The average time elapsed from CIED implantation to exposure was 27.3 ± 15.4 months. The average time spanned from initial referral to operation was 6 ± 1.6 days. The most prevalent comorbidity was diabetes mellitus. The average time elapsed during operation for pectoral fascia incorporated rotation flaps was 90 ± 10.6 minutes. Coagulase negative staphylococci were the dominant species (46.5%) obtained from capsule cultures. Apart from 1 case of hematoma, no early or late operation-related complication was encountered.
CONCLUSIONS:
A more precise definition of contamination and infection has to be made in guidelines, which may lead the first group to be treated without extraction. Surgical method defined in this study can be used for the treatment of patients in contaminated CIED subgroup, conserving individuals from risks of device extraction.
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Prevention and Management of Supine Hypertension in Patients With Orthostatic Hypotension.
Am J Ther2019 Sep;():. doi: 10.1097/MJT.0000000000001054.
Moroi Morgan K, Ruzieh Mohammed, Ahmed Aamir, Kanjwal Shaffi, Kanjwal Khalil,
Abstract
BACKGROUND:
Orthostatic hypotension (OH) is a potentially debilitating condition caused by dysfunction of the autonomic nervous system, which is essential for the physiologic response to orthostatic posture. In addition to OH, autonomic dysfunction may also be associated with the development of concurrent supine hypertension (SH).
AREAS OF UNCERTAINTY:
This paradoxical effect speaks to the complexity of the pathogenesis of autonomic disease and greatly complicates management of these patients. Clinicians are faced with a dilemma because aggressive treatment of orthostatic intolerance can worsen supine hypertension and attempts to control supine hypertension can worsen orthostatic intolerance.
DATA SOURCES:
Systematic review of the published literature.
PREVENTION OF SUPINE HYPERTENSION:
Patients should aim to avoid known stressors, perform physical maneuvers (eg, slowly getting up from bed, sleeping with head of bed elevated), manage underlying related conditions (eg, diabetes mellitus), and exercise.
MANAGEMENT OF SUPINE HYPERTENSION:
With failure of conservative management, patients may advance to pharmacologic therapy. It is important to understand the underlying suspected etiology of the syndrome of supine hypertension and OH (SH-OH) to select promising pharmacologic agents. This article reviews medical treatment options to work toward achieving a better quality of life for patients afflicted with this disease. Although clonidine and beta-blockers can be used to treat hypertension without causing significant hypotension, midodrine, pyridostigmine, and droxidopa may be helpful in preventing OH.
CONCLUSION:
The etiology and severity of autonomic dysfunction vary widely between patients, suggesting a need for an individualized treatment approach. Achieving perfect blood pressure control is not a realistic goal. Rather, treatment should be aimed at improving the patient's quality of life and decreasing their risk of injury and organ damage.
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Cleft lip repair: are outcomes between unilateral and bilateral clefts comparable?
J Plast Surg Hand Surg2019 Sep;():1-4. doi: 10.1080/2000656X.2019.1661848.
Chouairi Fouad, Mets Elbert J, Torabi Sina J, Alperovich Michael,
Abstract
This study sought to compare patient demographics, operative course, and peri-operative outcomes between unilateral and bilateral cleft patients. Primary cleft lip repairs were isolated from the National Surgical Quality Improvement Program Pediatric Database (NSQIP-P). Unilateral and bilateral cases of primary cleft lip were identified by ICD codes. Demographics, comorbidities, and post-operative outcomes were compared between cohorts. Patients were propensity matched to control for differences before repeating the analysis. About 4550 cleft lip repairs were evaluated over the 5-year period. Of the cases where the cleft type was identifiable, 75.5% were unilateral clefts and 24.5% were bilateral clefts. The bilateral cleft population had significantly more comorbidities including higher rates of ventilator dependence (1.0% versus 0.4%, ?=?0.02), asthma (1.6% versus 0.7%, ?=?0.011), tracheostomy (1.6% versus 0.5%, ?
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Double missense mutations in cardiac myosin-binding protein C and myopalladin genes: A case report with diffuse coronary disease, complete atrioventricular block, and progression to dilated cardiomyopathy.
Ann Noninvasive Electrocardiol2019 Sep;():e12687. doi: 10.1111/anec.12687.
Mastroianno Sandra, Palumbo Pietro, Castellana Stefano, Leone Maria Pia, Massaro Raimondo, Potenza Domenico Rosario, Mazza Tommaso, Russo Aldo, Castori Marco, Carella Massimo, Di Stolfo Giuseppe,
Abstract
Cardiomyopathies caused by double gene mutations are rare but conferred a remarkably increased risk of end-stage progression, arrhythmias, and poor outcome. Compound genetic mutations leading to complex phenotype in the setting of cardiomyopathies represent an important challenge in clinical practice, and genetic tests allow risk stratification and personalized clinical management of patients. We report a case of a 50-year-old woman with congestive heart failure characterized by dilated cardiomyopathy, diffuse coronary disease, complete atrioventricular block, and missense mutations in cardiac myosin-binding protein C (MYBPC3) and myopalladin (MYPN). We discuss the plausible role of genetic profile in phenotype determination.
© 2019 Wiley Periodicals, Inc.
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Hydrogen-rich saline alleviates inflammation and apoptosis in myocardial I/R injury via PINK-mediated autophagy.
Int J Mol Med2019 Jul;():. doi: 10.3892/ijmm.2019.4264.
Yao Li, Chen Hongguang, Wu Qinghua, Xie Keliang,
Abstract
Ischemia/reperfusion (I/R)?induced inflammatory reaction is one of the most important elements in myocardial I/R injury. In addition, autophagy serves an important role in normal cardiac homeostasis, and obstructions to the autophagy process lead to severe consequences for the heart. Hydrogen exerts an effective therapeutic role in numerous diseases associated with I/R injury via its anti?inflammation, anti?apoptosis and anti?oxidative properties. Therefore, the present study investigated the effect of hydrogen on the myocardial inflammation response and apoptosis in myocardial ischemic/reperfusion (MI/R) injury, and further explored the mechanism of PTEN?induced kinase 1 (PINK1)/Parkin?induced mitophagy in the protection of hydrogen on MI/R injury. MI/R injury was performed by surgical ligation of the left coronary artery in vivo and H9C2 cell injury was performed by hypoxia/reoxygenation (H/R) in vitro. Hydrogen?rich saline was administered twice through intraperitoneal injection at a daily dose of 10 ml/kg following the operation in the in vivo model, and hydrogen?rich medium culture was used for cells instead of normal medium in vitro. The infarction size of hearts, the levels of creatinine kinase?muscle/brain (CK?MB) and cardiac troponin I (cTnI), cardiac function, cell viability and lactate dehydrogenase (LDH) release, levels of cytokines, apoptosis and the expression of autophagy?associated proteins were detected in the different treatment groups in vivo and in vitro. The results demonstrated that treatment with hydrogen improved the myocardial infarction size of hearts, cardiac function, apoptosis and cytokine release following MI/R in rats. In vitro, hydrogen improved cell viability and LDH release following hypoxia/reoxygenation in myocardial cells. In addition, it was demonstrated that hydrogen exerted an anti?inflammatory and anti?apoptotic effect in myocardial cells induced by H/R via PINK1/Parkin mediated autophagy. These results suggested that hydrogen?rich saline alleviated the inflammation response and apoptosis induced by MI/R or H/R in vivo or in vitro, and that hydrogen?rich saline contributed to the increased expression of proteins associated with autophagy. In summary, the present study indicated that treatment with hydrogen?rich saline improved the inflammatory response and apoptosis in MI/R via PINK1/Parkin?mediated mitophagy.
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Sarcopenia: A Time for Action. An SCWD Position Paper.
J Cachexia Sarcopenia Muscle2019 Sep;():. doi: 10.1002/jcsm.12483.
Bauer Juergen, Morley John E, Schols Annemie M W J, Ferrucci Luigi, Cruz-Jentoft Alfonso J, Dent Elsa, Baracos Vickie E, Crawford Jeffrey A, Doehner Wolfram, Heymsfield Steven B, Jatoi Aminah, Kalantar-Zadeh Kamyar, Lainscak Mitja, Landi Francesco, Laviano Alessandro, Mancuso Michelangelo, Muscaritoli Maurizio, Prado Carla M, Strasser Florian, von Haehling Stephan, Coats Andrew J S, Anker Stefan D,
Abstract
The term sarcopenia was introduced in 1988. The original definition was a "muscle loss" of the appendicular muscle mass in the older people as measured by dual energy x-ray absorptiometry (DXA). In 2010, the definition was altered to be low muscle mass together with low muscle function and this was agreed upon as reported in a number of consensus papers. The Society of Sarcopenia, Cachexia and Wasting Disorders supports the recommendations of more recent consensus conferences, i.e. that rapid screening, such as with the SARC-F questionnaire, should be utilized with a formal diagnosis being made by measuring grip strength or chair stand together with DXA estimation of appendicular muscle mass (indexed for height2). Assessments of the utility of ultrasound and creatine dilution techniques are ongoing. Use of ultrasound may not be easily reproducible. Primary sarcopenia is aging associated (mediated) loss of muscle mass. Secondary sarcopenia (or disease-related sarcopenia) has predominantly focused on loss of muscle mass without the emphasis on muscle function. Diseases that can cause muscle wasting (i.e. secondary sarcopenia) include malignant cancer, COPD, heart failure, and renal failure and others. Management of sarcopenia should consist of resistance exercise in combination with a protein intake of 1 to 1.5 g/kg/day. There is insufficient evidence that vitamin D and anabolic steroids are beneficial. These recommendations apply to both primary (age-related) sarcopenia and secondary (disease related) sarcopenia. Secondary sarcopenia also needs appropriate treatment of the underlying disease. It is important that primary care health professionals become aware of and make the diagnosis of age-related and disease-related sarcopenia. It is important to address the risk factors for sarcopenia, particularly low physical activity and sedentary behavior in the general population, using a life-long approach. There is a need for more clinical research into the appropriate measurement for muscle mass and the management of sarcopenia. Accordingly, this position statement provides recommendations on the management of sarcopenia and how to progress the knowledge and recognition of sarcopenia.
© 2019 The Authors. Journal of Cachexia, Sarcopenia and Muscle published by John Wiley & Sons Ltd on behalf of the Society on Sarcopenia, Cachexia and Wasting Disorders.
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Frontline Science: Low regulatory T cells predict perioperative major adverse cardiovascular and cerebrovascular events after noncardiac surgery.
J Leukoc Biol2019 Sep;():. doi: 10.1002/JLB.5HI1018-392RR.
Scholz Anna S, Handke Jessica, Gillmann Hans-Jörg, Zhang Qinya, Dehne Sarah, Janssen Henrike, Arens Christoph, Espeter Florian, Sander Anja, Giannitsis Evangelos, Uhle Florian, Weigand Markus A, Motsch Johann, Larmann Jan,
Abstract
Immune cells drive atherosclerotic lesion progression and plaque destabilization. Coronary heart disease patients undergoing noncardiac surgery are at risk for perioperative major adverse cardiac and cerebrovascular events (MACCE). It is unclear whether differential leukocyte subpopulations contribute to perioperative MACCE and thereby could aid identification of patients prone to perioperative cardiovascular events. First, we performed a hypothesis-generating post hoc analysis of the LeukoCAPE-1 study (n = 38). We analyzed preoperative counts of 6 leukocyte subpopulations in coronary heart disease patients for association with MACCE (composite of cardiac death, myocardial infarction, myocardial ischemia, myocardial injury after noncardiac surgery, thromboembolic stroke) within 30 d after surgery. Regulatory T cells (Tregs) were the only leukocyte subgroup associated with MACCE. We found reduced Tregs in patients experiencing MACCE versus no-MACCE (0.02 [0.01; 0.03] vs. 0.04 [0.03; 0.05] Tregs nl , P = 0.002). Using Youden index, we derived the optimal threshold value for association with MACCE to be 0.027 Tregs nl . Subsequently, we recruited 233 coronary heart disease patients for the prospective, observational LeukoCAPE-2 study and independently validated this Treg cutoff for prediction of MACCE within 30 d after noncardiac surgery. After multivariate logistic regression, Tregs < 0.027 cells nl remained an independent predictor for MACCE (OR = 2.54 [1.22; 5.23], P = 0.012). Tregs improved risk discrimination of the revised cardiac risk index based on ?AUC (area under the curve; ?AUC = 0.09, P = 0.02), NRI (0.26), and IDI (0.06). Preoperative Treg levels below 0.027 cells nl predicted perioperative MACCE and can be measured to increase accuracy of established preoperative cardiac risk stratification in coronary heart disease patients undergoing noncardiac surgery.
©2019 The Authors. Journal of Leukocyte Biology published by Wiley Periodicals, Inc. on behalf of Society for Leukocyte Biology.
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Snorkelling and breath-hold diving fatalities in Australia, 2001 to 2013. Demographics, characteristics and chain of events.
Diving Hyperb Med2019 Sep;49(3):192-203. doi: 10.28920/dhm49.3.192-203.
Lippmann John,
Abstract
INTRODUCTION:
The aim of this study was to identify characteristics of victims of fatal snorkelling and breath-hold diving accidents in Australia from 2001-2013, inclusive, to determine underlying factors and risks associated with such activities and inform appropriate countermeasures.
METHODS:
The National Coronial Information System (NCIS) was searched to identify snorkelling and breath-hold diving-related cases reported to Australian coroners for the years 2001-2013, inclusive. Coronial data in the form of findings, witness and police reports, medical histories and autopsies were collected and collated, and descriptive statistics were used to analyse these data. A chain of events analysis was used to determine the likely sequence of events.
RESULTS:
There were 175 identified snorkelling-related fatalities during the study period. Most victims were middle-aged males (mean age 49 years). Pre-existing health conditions were possible contributors to 41% of the deaths, the main being ischaemic heart disease. The majority of deaths occurred in Queensland in inexperienced snorkellers, often in commercial settings. The victim's plight often went unnoticed as they were alone, or poorly supervised, when the incident occurred. Apnoeic hypoxia appeared to have been associated with at least 12.5% of the deaths. The main disabling injuries were asphyxia (40%) and cardiac incidents (35%).
CONCLUSION:
Human factors, such as chronic health conditions, poor skills and inexperience and poor planning can play a substantial role throughout the chain of events leading to a snorkelling fatality. It is important to educate the community, doctors and dive industry professionals about potential problems associated with the interaction between certain health-related conditions, especially cardiovascular conditions, and snorkelling. Close supervision is strongly recommended for inexperienced snorkellers due to their likely poor skills, as well as for experienced breath-hold divers due to the potential for apnoeic hypoxia.
Copyright: This article is the copyright of the authors who grant Diving and Hyperbaric Medicine a non-exclusive licence to publish the article in electronic and other forms.
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