Initial establishment and validation of a predictive model for preeclampsia in twin pregnancies based on maternal characteristics and echocardiographic parameters.

INTRODUCTION: The primary objective of this study was to evaluate the association between maternal echocardiographic changes and the occurrence of preeclampsia (PE) in twin pregnancies. Additionally, we established and validated a prediction model for PE in twin pregnancies. MATERIAL AND METHODS: The first part of this study was retrospective and included data from 854 twin pregnancies that received antenatal care at Peking University Third Hospital from April 2017 to April 2021 (training cohort). Overall, 159 women who underwent transthoracic echocardiography were included in the analysis. To build a predictive model, cardiac findings were compared between normotensive women and those with PE. The model was then validated in a prospective longitudinal cohort (test cohort) that included 109 women with twin pregnancies who underwent two consecutive transthoracic echocardiography examinations during the second and third trimesters. RESULTS: Fifty-four normotensive women and 105 women with PE were analyzed in the retrospective cohort that was used to build the model in which later preeclampsia was associated with higher left ventricular mass index (>61 g/m2 ), interventricular septal thickness (>7.87 mm), left atrial anteroposterior diameter (>33.5 mm), mitral inflow late diastolic velocity (A) (>0.685 m/s), ratio of early diastolic velocity (E) and peak early diastolic myocardial velocity of the lateral mitral annulus (>6.5), and lower peak early diastolic myocardial velocity (<13.1 cm/s). The optimized PE prediction model based on the interventricular septal thickness, left atrial anteroposterior diameter, A, peak early diastolic myocardial velocity and pre-pregnancy bodyweight index was then established (area under the curve [AUC] = 0.840, 95% CI 0.778-0.903, P < 0.001). The model was tested in the prospective cohort including 87 normotensive women and 22 women with PE; the validation test showed that the prediction model in the second (AUC = 0.801) and third (AUC = 0.811) trimesters had high discriminative ability and calibration. CONCLUSIONS: Maternal echocardiographic changes in twin pregnancies are associated with the development of preeclampsia. The model constructed, based on the echocardiographic parameters and body mass index, provides novel ideas for the prediction of PE.

Nicorandil Improves Left Ventricular Myocardial Strain in Patients With Coronary Chronic Total Occlusion.

Background: Nicorandil is recommended as a second-line treatment for stable angina; however, randomized-controlled trials to evaluate the benefit of nicorandil for patients with chronic total occlusion (CTO) are lacking. Objective: To determine whether nicorandil can improve left ventricular (LV) myocardial strain in patients with CTO. Methods: Patients with CTO were included and randomized to the nicorandil group (n = 31) and the control group (n = 30). Nicorandil was given orally at 15 mg/day for 3 months in the nicorandil group. Three-dimensional speckle-tracking echocardiography and the Seattle Angina Questionnaire (SAQ) survey were performed at baseline and at 3 months. The primary study endpoint was the LV global area strain (GAS) at 3 months. Results: The nicorandil and the control groups were well-matched at baseline, including the mean GAS and SAQ scores. At 3 months, GAS in the nicorandil group was significantly higher than that in the control group (-23.7 ± 6.3% vs. -20.3 ± 5.6%, respectively; p = 0.033). There were no significant differences in LV global longitudinal strain, global circumferential strain, global radial strain, LV ejection fraction, LV end-diastolic volume, and LV end-systolic volume at 3 months between the two groups. At 3 months, the SAQ scores for angina stability, angina frequency, and treatment satisfaction in the nicorandil group were significantly higher than those in the control group. Conclusion: Nicorandil treatment can improve GAS and angina symptoms in patients with CTO. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT05087797.

Cardioprotection of Repeated Remote Ischemic Conditioning in Patients With ST-Segment Elevation Myocardial Infarction.

Background: Repeated remote ischemic conditioning (RIC) after myocardial infarction (MI) has been shown to improve left ventricular (LV) remodeling in the experimental studies, but its cardioprotective effect in patients with ST-segment elevation myocardial infarction (STEMI) is still unknown. Objective: To investigate whether repeated RIC started early after primary percutaneous coronary intervention (PCI) can improve LV function in patients with STEMI. Methods: Patients with STEMI treated by primary PCI were included and randomized to the repeated RIC group (n = 30) or the control group (n = 30). RIC was started within 24 h after PCI and repeated daily for 1 week, using an Auto RIC device. 3D speckle-tracking echocardiography (STE) was used to assessed LV function. The primary study endpoint was the change in LV global longitudinal strain (GLS) from baseline to 1 month after PCI. Results: The repeated RIC group and the control group were well-matched at baseline including mean GLS (-9.8 ± 2.6% vs. -10.1 ± 2.5%, P = 0.62). Despite there was no significant difference in mean GLS at 1 month between the two groups (-11.9 ± 2.1% vs. -10.9 ± 2.7%, P = 0.13), the mean change in GLS from baseline to 1 month was significantly higher in the treatment group than in the control group (-2.1 ± 2.5% vs. -0.8 ± 2.3%, P = 0.04). There were no significant differences in the changes in global circumferential strain (GCS), global area strain (GAS), global radial strain (GRS), LV ejection fraction (LVEF), LV end-diastolic volume (LVEDV), and LV end-systolic volume (LVESV) between the two groups. Peak creatine kinase isoenzyme-MB, peak high-sensitivity troponin T, and plasma N-terminal pro-brain natriuretic peptide (NT-proBNP) levels at 24 h after PCI did not differ significantly between the two groups, but NT-proBNP levels at 1 week were significantly lower in the treatment group than in the control group [357.5 (184.8-762.8) vs. 465.0 (305.8-1525.8) pg/ml, P = 0.04]. Conclusion: Daily repeated RIC started within 24 h after PCI can improve GLS and reduce plasma NT proBNP levels in patients with STEMI.

Excitation-Contraction Coupling Time is More Sensitive in Evaluating Cardiac Systolic Function.

BACKGROUND: Pressure overload-induced myocardial hypertrophy is a key step leading to heart failure. Previous cellular and animal studies demonstrated that deteriorated excitation-contraction coupling occurs as early as the compensated stage of hypertrophy before the global decrease in left ventricular ejection fraction (LVEF). This study was to evaluate the cardiac electromechanical coupling time in evaluating cardiac systolic function in the early stage of heart failure. METHODS: Twenty-six patients with Stage B heart failure (SBHF) and 31 healthy controls (CONs) were enrolled in this study. M-mode echocardiography was performed to measure LVEF. Tissue Doppler imaging (TDI) combined with electrocardiography (ECG) was used to measure cardiac electromechanical coupling time. RESULTS: There was no significant difference in LVEF between SBHF patients and CONs (64.23 ± 8.91% vs. 64.52 ± 5.90%; P = 0.886). However, all four electromechanical coupling time courses (Qsb: onset of Q wave on ECG to beginning of S wave on TDI, Qst: onset of Q wave on ECG to top of S wave on TDI, Rsb: top of R wave on ECG to beginning of S wave on TDI, and Rst: top of R wave on ECG to top of S wave on TDI) of SBHF patients were significantly longer than those of CONs (Qsb: 119.19 ± 35.68 ms vs. 80.30 ± 14.81 ms, P < 0.001; Qst: 165.42 ± 60.93 ms vs. 129.04 ± 16.97 ms, P = 0.006; Rsb: 82.43 ± 33.66 ms vs. 48.30 ± 15.18 ms, P < 0.001; and Rst: 122.37 ± 36.66 ms vs. 93.25 ± 16.72 ms, P = 0.001), and the Qsb, Rsb, and Rst time showed a significantly higher sensitivity than LVEF (Rst: P =0.032; Rsb: P = 0.003; and Qsb: P = 0.004). CONCLUSIONS: The cardiac electromechanical coupling time is more sensitive than LVEF in evaluating cardiac systolic function.

Left atrial area index predicts adverse cardiovascular events in patients with unstable angina pectoris.

BACKGROUND: The left atrial size has been considered as a useful marker of adverse cardiovascular outcomes. However, it is not well known whether left atrial area index (LAAI) has predictive value for prognosis in patients with unstable angina pectoris (UAP). This study was aimed to assess the association between LAAI and outcomes in UAP patients. METHODS: We enrolled a total of 391 in-hospital patients diagnosed as UAP. Clinical and echocardiographic data at baseline were collected. The patients were followed for the development of adverse cardiovascular (CV) events, including hospital readmission for angina pectoris, acute myocardial infarction (AMI), congestive heart failure (CHF), stroke and all-cause mortality. RESULTS: During a mean follow-up time of 26.3 ± 8.6 months, 98 adverse CV events occurred (84 hospital readmission for angina pectoris, four AMI, four CHF, one stroke and five all-cause mortality). In a multivariate Cox model, LAAI [OR: 1.140, 95% CI: 1.016-1.279, P = 0.026], diastolic blood pressure (OR: 0.976, 95% CI: 0.956-0.996, P = 0.020) and pulse pressure (OR: 1.020, 95% CI: 1.007-1.034, P = 0.004) were independent predictors for adverse CV events in UAP patients. CONCLUSIONS: LAAI is a predictor of adverse CV events independent of clinical and other echocardiographic parameters in UAP patients.

Relationship between exercise induced elevation of left ventricular filling pressure and exercise intolerance in patients with atrial fibrillation.

BACKGROUND: Elevated left ventricular filling pressure (LVFP) is an important cause of exercise intolerance in patients with atrial fibrillation (AF). Exercise stress echocardiography could assess LVFP during exercise. The objective of this study was to investigate the relationship between exercise induced elevation of LVFP and exercise capacity in patients with AF. METHODS: This study included 145 consecutive patients (81 men and 64 women; mean age 65.5 ± 8.0 years) with persistent non-valvular AF and normal left ventricular systolic function (left ventricular ejection fraction ≥ 50%). All patients underwent a symptom-limited cardiopulmonary exercise test (CPET). Doppler echocardiography was performed both at rest and immediately after exercise. Five consecutive measurements of early diastolic mitral inflow velocity (E) and early diastolic mitral annular velocity (e') were taken and averaged. E/e' ratio was calculated. Elevated LVFP was defined as E/e' > 9, and patients with elevated LVFP at rest were excluded. RESULTS: Patients were classified into two groups according to LVFP estimated by E/e' ratio after exercise: 39 (26.9%) with elevated LVFP after exercise and 106 (73.1%) with normal LVFP. As compared with patients with normal LVFP, the ones with elevated LVFP after exercise had significantly lower peak oxygen uptake (VO2 peak) (21.7 ± 2.3 vs. 26.4 ± 3.8 mL/min per kilogram, P < 0.001), lower anaerobic threshold (19.9 ± 2.5 vs. 26.0 ± 4.0 mL/min per kilogram, P < 0.001), and shorter exercise time duration (6.2 ± 0.8 vs. 7.0 ± 1.3 min, P < 0.001). Multivariate analysis showed that age, gender and E/e' after exercise were significantly correlated with VO2 peak. CONCLUSION: Elevated LVFP estimated by E/e' ratio after exercise is independently associated with reduced exercise capacity in AF patients.

Exenatide exerts direct protective effects on endothelial cells through the AMPK/Akt/eNOS pathway in a GLP-1 receptor-dependent manner.

Glucagon-like peptide-1 (GLP-1) may have direct favorable effects on cardiovascular system. The aim of this study was to investigate the effects of the GLP-1 analog exenatide on improving coronary endothelial function in patients with type 2 diabetes and to investigate the underlying mechanisms. The newly diagnosed type 2 diabetic subjects were enrolled and given either lifestyle intervention or lifestyle intervention plus exenatide treatment. After 12-wk treatment, coronary flow velocity reserve (CFVR), an important indicator of coronary endothelial function, was improved significantly, and serum levels of soluble intercellular adhesion molecule-1 (sICAM-1) and soluble vascular cell adhesion molecule-1 (sVCAM-1) were remarkably decreased in the exenatide treatment group compared with the baseline and the control group. Notably, CFVR was correlated inversely with hemoglobin A1c (Hb A1c) and positively with high-density lipoprotein cholesterol (HDL-C). In human umbilical vein endothelial cells, exendin-4 (a form of exenatide) significantly increased NO production, endothelial NO synthase (eNOS) phosphorylation, and GTP cyclohydrolase 1 (GTPCH1) level in a dose-dependent manner. The GLP-1 receptor (GLP-1R) antagonist exendin (9-39) or GLP-1R siRNA, adenylyl cyclase inhibitor SQ-22536, AMPK inhibitor compound C, and PI3K inhibitor LY-294002 abolished the effects of exendin-4. Furthermore, exendin-4 reversed homocysteine-induced endothelial dysfunction by decreasing sICAM-1 and reactive oxygen species (ROS) levels and upregulating NO production and eNOS phosphorylation. Likewise, exendin (9-39) diminished the protective effects of exendin-4 on the homocysteine-induced endothelial dysfunction. In conclusion, exenatide significantly improves coronary endothelial function in patients with newly diagnosed type 2 diabetes. The effect may be mediated through activation of AMPK/PI3K-Akt/eNOS pathway via a GLP-1R/cAMP-dependent mechanism.

[Relationship between ambulatory blood pressure and myocardial performance index in hypertensive patients].

OBJECTIVE: To explore the relationship between ambulatory blood pressure and myocardial performance index (MPI) in hypertensive patients. METHODS: A total of 76 hospitalized patients with untreated hypertension from January to June 2013 were recruited. They received the examinations of office blood pressure, 24 h ambulatory blood pressure and echocardiography. MPI was determined by the following formula: MPI=(isovolumic contraction time+isovolumic relaxation time)/ejection time. Based upon left ventricular MPI, they were divided into two groups of MPI>0.47 (n=38) and MPI≤0.47 (n=38). The mean levels of office blood pressure, ambulatory blood pressure, blood pressure load, morning blood pressure surge (early morning blood pressure minus the lowest night-time blood pressure) and nocturnal blood pressure changes were compared between two groups. And the determinants of MPI were identified by multivariate regression analysis. RESULTS: As compared to those with MPI≤0.47, patients with MPI>0.47 had higher 24 h and daytime systolic blood pressures, 24 h, daytime and nighttime diastolic blood pressures, 24 h, daytime and nighttime systolic blood pressure loads, 24 h, daytime and nighttime diastolic blood pressure loads and morning systolic blood pressure surges (all P<0.05). No inter-group differences existed in the mean levels of office blood pressure, nighttime systolic blood pressure, morning diastolic blood pressure surge, nocturnal systolic or diastolic blood pressure changes (all P>0.05). Multivariate regression analysis showed that nocturnal diastolic blood pressure (ß=0.285, P=0.005) and daytime systolic blood pressure load (ß=0.397, P<0.001) were independently associated with MPI. And other factors independently associated with MPI were left ventricular mass index (LVMI) and early diastolic mitral annular velocity (Em). CONCLUSION: The increases of blood pressure level and blood pressure load are associated with an elevation of left ventricular MPI.

[Association between ambulatory blood pressure levels and blood pressure variability with myocardial performance index in untreated hypertensive patients].

OBJECTIVE: To observe the association between ambulatory blood pressure levels and blood pressure variability (BPV) with myocardial performance index (MPI) in untreated hypertensive patients. METHODS: From January to September 2013, a total of 81 untreated hypertensive patients were included in this study. All patients received ambulatory blood pressure monitoring and echocardiography measurements. MPI was determined in all patients by the following formula: MPI = (isovolumic contraction time + isovolumic relaxation time)/ejection time. The patients were divided into two groups according to left ventricular MPI: patients with MPI < 0.47 (n = 39) and patients with MPI ≤ 0.47 (n = 42). The mean levels and standard deviation (SD) of 24 h, daytime and nighttime blood pressures were compared between the two groups. SD was used to express BPV. Determinants of MPI were identified by multivariate regression analysis. RESULTS: 24 h and daytime systolic blood pressure, 24 h, daytime and nighttime diastolic blood pressure, as well as SD of 24 h and daytime systolic blood pressure ((130.1±8.7), (134.0±8.2), (89.1±6.3), (90.9±6.4), (83.1±9.9), (13.7±3.3) and (14.2±3.5) mmHg (1 mmHg = 0.133 kPa), respectively) were significantly higher in patients with MPI > 0.47 than those ((124.8±8.7), (126.7±8.8), (84.5±7.1), (86.2±7.4), (76.4±7.5), (11.8±2.1) and (10.4±1.9) mmHg, respectively) in patients with MPI ≤ 0.47 (all P < 0.05). Multivariate regression analysis showed that 24 h diastolic blood pressure (ß = 0.239, P = 0.007) and SD of 24 h systolic blood pressure (ß = 0.333, P < 0.001), left ventricular mass index and early diastolic mitral annular velocity were independently associated with MPI. CONCLUSION: The increase of diastolic blood pressure and systolic BPV are associated with the deterioration of left ventricular function.

Serial changes of mean platelet volume in relation to Killip Class in patients with acute myocardial infarction and primary percutaneous coronary intervention.

INTRODUCTION: Mean platelet volume (MPV) is related to the reactivity of platelets. Among survivors of acute myocardial infarction (MI), greater MPV is known to be associated with impaired reperfusion and higher mortality. The aims of the study is to investigate the dynamic changes of MPV and the relation between MPV and cardiac function in patients with acute MI and received primary percutaneous coronary intervention (PCI). MATERIALS AND METHODS: This retrospective cohort study included patients presented during January 2008 to March 2011 to Peking University Third Hospital with ST-segment elevation MI. All patients received successful PCI. MPV was measured serially, using a Sysmex XE2100 haematology analyser, from admission to day-7 after MI. RESULTS: In 375 patients, MPV was at its highest value (10.2±1.0 fL) and correlated well with platelet distribution width (PDW, r=0.833, p<0.0001) at the admission, and then reduced by 16% within the 24 hours, together with marked weakening of its correlation with PDW. Patients with poorer ventricular function, estimated by high Killip Class (≥2, n=96), had higher MPV values at all-time points. By logistic regression model and after adjusting for related confounders, high MPV remained as an independent predictor of Killip Class ≥2 (OR 1.873, CI 95% 1.373-2.673, p=0.001). Clopidogrel pre-usage resulted in significant MPV reduction on admission. CONCLUSIONS: MPV undergoes rapid and dynamic changes during the acute phase of MI, and was higher in patients with high Killip Class, suggesting a predictive value of MPV in ventricular dysfunction and clinical outcome of acute phase of MI.

[Effect of metformin on ventricular remodeling in patients with primary hypertension and type 2 diabetes mellitus].

OBJECTIVE: To explore the effects of metformin on left ventricular remodeling in patients with primary hypertension and type 2 diabetes mellitus, and to investigate the effects of hypertension duration and duration of drug administration on metformin's cardiac action. METHODS: The clinical and echocardiographic data of 176 patients with primary hypertension and type 2 diabetes mellitus who were admitted to department of cardiology from January to December 2012 were retrospectively analyzed. The follow-up period was 6 to 24 months (the median follow-up time was 11 months). The patients were classified into two groups according to the usage of metformin: metformin group (n=84) and control group (n=92). The clinical data and echocardiography findings were evaluated both at baseline and follow-up. Subgroup analyses were used to assess the effects of hypertension duration and duration of drug medication on metfomin's action. RESULTS: At baseline, there was no significant difference in interventricular septum depth (IVSD), left ventricular posterior wall depth (LVPWD), and left ventricular mass index (LVMI) between the two groups. At the follow-up period, IVSD (P=0.001), LVPWD (P=0.04) and LVMI (P=0.01) were lower in metformin group. Multiple linear regression indicated that metformin had significant influence on LVPWD (P=0.02) and LVMI (P=0.04). At the follow-up period, LVMI was lower in two metformin subgroups. Additionally, LVMI was lower in the group which the patients took metformin for more than one year than that in control group (P=0.04). For patients whose hypertension duration was not shorter than 5 years, IVSD (P=0.01) and LVMI (P=0.02) were lower in metformin group at the follow-up period, compared with control group. CONCLUSIONS: Metformin may attenuate hypertrophy of left ventricular in patients with primary hypertension and type 2 diabetes mellitus. In patients with longer hypertension duration and longer duration of metformin use, metformin may show more obvious effects.

[Relationship between E/Em ratio and exercise capacity in patients with atrial fibrillation].

OBJECTIVE: To explore the relationship between the ratio of early diastolic transmitral velocity to early diastolic mitral annular velocity (E/Em) and exercise capacity in patients with atrial fibrillation. METHODS: A total of 94 consecutive patients with non-valvular atrial fibrillation and preserved left ventricular ejection fraction admitted into our department from December 2011 to June 2013 were included. Echocardiography and cardiopulmonary exercise test were performed. According to E/Em, they were divided into two groups of normal E/Em (E/Em ≤ 9) and elevated E/Em (E/Em>9). The parameters of exercise capacity, including VO2max/kg, anaerobic threshold/kg (AT/kg) and exercise time duration were compared between two groups. And the determinants of VO2max/kg were identified by multivariate regression analysis. RESULTS: The number of patients was 57(60.6%) with normal E/Em and 37 (39.4%) with elevated E/Em. As compared to those with normal E/Em, the patients with elevated E/Em had lower VO2max/kg [(26 ± 4) vs (20 ± 4) ml × min⁻¹ × kg⁻¹, P < 0.001], lower AT/kg [(25 ± 4) vs (19 ± 5) ml ×min⁻¹ × kg⁻¹, P < 0.001] and shorter exercise time duration [(7.2 ± 1.3) vs (5.8 ± 1.3) min, P < 0.001]. Multivariate regression analysis revealed that three significant variables were independently associated with VO2max/kg: age (r = -0.412, P < 0.001), gender ((25 ± 5) and (21 ± 4) ml × min⁻¹ × kg⁻¹ for males and females separately, P < 0.001) and E/Em (r = -0.535, P < 0.001). CONCLUSION: E/Em was independently associated with exercise capacity in patients with atrial fibrillation.

Left ventricular filling pressure assessed by exercise TDI was correlated with early HFNEF in patients with non-obstructive hypertrophic cardiomyopathy.

BACKGROUND: Hypertrophic cardiomyopathy (HCM) patients are more susceptible to suffer from heart failure with normal ejection fraction (HFNEF). Therefore, it is critical to evaluate the relationship between left ventricular filling pressure (LVFP) and HFNEF, even if a large proportion of HCM patients have normal LVFP at rest. The objective was to assess the correlation between exercise tissue Doppler imaging (TDI) and early HFNEF in HCM patients by treadmill exercise echocardiography combined with cardiopulmonary exercise test (CPET). METHOD: Twenty-seven non-obstructive HCM patients and 31 age- and gender-matched healthy volunteers were enrolled in this study. All subjects underwent treadmill exercise echocardiography combined with CPET. N-terminal pro-brain natriuretic peptide (NT-proBNP) levels were analyzed before and after exercise. RESULT: Five HCM patients had normal LVFP at rest and increased after exercise. For this subgroup, the relationship between minute ventilation and carbon dioxide production (VE/VCO2 slope) and NT-proBNP levels were higher compared with controls and the subgroup with normal resting and stress LVFP, but was similar to the subgroup with elevated LVFP both at rest and after exercise. CONCLUSION: Elevated LVFP after exercise suggested the occurrence of early HFNEF in patients with non-obstructive HCM.

[Correlation of low density lipoprotein cholesterol with coronary flow reserve in patients with type 2 diabetes].

OBJECTIVE: To investigate whether plasma levels of low density lipoprotein cholesterol (LDL-C), high density lipoprotein cholesterol (HDL-C) are associated with coronary flow reserve (CFR) in patients with type 2 diabetes mellitus (DM). METHODS: Between October 2007 and March 2012,we continuously enrolled 200 participants registered to Department of Cardiology, Peking University Third Hospital, who were divided into 2 groups: DM group (n = 95) and control group (n = 105). Quantification of CFR was administrated after rest and after adenosine by noninvasive Doppler echocardiography in all the subjects. The CFR, which was performed in the distal part of left descending artery, was used as an indicator of coronary endothelial dysfunction. RESULTS: The plasma levels of LDL-C were significantly higher in the patients with DM than in the controls [(3.05 ± 0.73) mmo/L vs. (2.74 ± 0.72) mmo/L, P = 0.003)], while the plasma levels of HDL-C were significantly lower in the patients with DM than in the controls [(1.08 ± 0.24) mmo/L vs. (1.17 ± 0.29) mmo/L, P = 0.044]. Furthermore, a lower CFR value was seen in the patients with DM than in the controls [(2.74 ± 0.63) vs. (3.20 ± 0.69), P < 0.001]. The plasma levels of LDL-C were negatively correlated with the CFR values in all the subjects (r = -0.17, P = 0.015) and in the DM group (r = -0.23, P = 0.021). The LDL-C remained independently correlated with the CFR in the DM group (P = 0.036). However,no significantly correlation was found between HDL-C and CFR in the DM group or in all the subjects. CONCLUSION: LDL-C is independently associated with CFR in patients with diabetic mellitus.

Low density lipoprotein cholesterol level inversely correlated with coronary flow velocity reserve in patients with Type 2 diabetes.

OBJECTIVES: To evaluate the association of coronary artery endothelial function and plasma levels of low density lipoprotein cholesterol (LDL-C) and high density lipoprotein cholesterol (HDL-C) in patients with Type 2 Diabetes Mellitus (DM). METHODS: We investigated 90 participants from our institution between October 2007 to March 2010: non-DM (n = 60) and DM (n = 30). As an indicator of coronary endothelial dysfunction, we used non-invasive Doppler echocardiography to quantify coronary flow velocity reserve (CFVR) in the distal part of the left descending artery after rest and after intravenous adenosine administration. RESULTS: Plasma level of LDL-C was significantly higher in patients with DM than in non-DM (3.21 ± 0.64 vs. 2.86 ± 0.72 mmo/L, P < 0.05), but HDL-C level did not differ between the groups (1.01 ± 0.17 vs. 1.05 ± 0.19 mmo/L). Furthermore, the CFVR value was lower in DM patients than non-diabetics (2.45 ± 0.62 vs. 2.98 ± 0.68, P < 0.001). Plasma levels of LDL-C were negatively correlated with CFVR in all subjects (r = -0.35, P < 0.001; 95% confidence interval (CI): -0.52 - -0.15) and in the non-DM (r = -0.29, P < 0.05; 95% CI: -0.51- -0.05), with an even stronger negative correlation in the DM group (r = -0.42, P < 0.05; 95% CI: -0.68 - -0.06). Age (ß = -0.019, s = 0.007, sß = -0.435, 95% CI: -0.033 - -0.005, P = 0.008), LDL-C (ß = -0.217, s = 0.105, sß = -0.282, 95% CI: -0.428 - -0.005, P = 0.045) remained independently correlated with CFVR in the DM group. However, we found no correlation between HDL-C level and CFVR in any group. CONCLUSIONS: Diabetes may contribute to coronary artery disease (CAD) by inducing dysfunction of the coronary artery endothelium. Increased LDL-C level may adversely impair coronary endothelial function in DM. HDL-C may lose its endothelial-protective effects, in part as a result of pathological conditions, especially under abnormal glucose metabolism.

[Diagnostic accuracy of adenosine triphosphate stress echocardiography derived coronary flow reserve for detecting significant coronary stenosis].

OBJECTIVE: To assess the diagnostic accuracy of coronary flow reserve measured by transthoracic Doppler echocardiography (TTDE) associated with adenosine triphosphate (ATP) stress for detecting coronary stenosis in patients with chest pain. METHODS: A total of 125 patients scheduled for elective coronary angiography (CAG) due to chest pain were recruited. ATP stress echocardiography were performed to measure CFR in left anterior descending (LAD) by TTDE with 2 days pre-CAG. Coronary flow reserve (CFR) was calculated as peak diastolic velocity during maximum hyperemia (PDV2) divided by baseline (PDV1). According to the coronary angiography results, all patients were divided into group A (stenosis < 50% in LAD, n = 57), group B (stenosis of 50% - 75% in LAD, n = 20) and group C (stenosis > 75% in LAD, n = 48). Then CFR was compared among three groups. The receiver operating characteristic curve (ROC) was used to assess the value of CFR for detecting LAD stenosis. RESULTS: CFR was significantly different among three groups (group A: 3.02 ± 0.85, group B: 2.49 ± 0.65, group C: 1.82 ± 0.56; all P < 0.01). With ROC analysis, CFR < 2.2 was the best cut-off value for diagnosing significant LAD stenosis (area under curve: 0.86 (95% CI 0.80 to 0.93)), with sensitivity of 81%, specificity of 83% and accuracy of 82%; CFR < 2.2 for diagnosing LAD stenosis > 50% (area under curve: 0.81 (95%CI 0.74 - 0.89, P < 0.01)), with a sensitivity of 59%, a specificity of 82% and an accuracy of 70%. CONCLUSIONS: CFR measured by TTDE associated with ATP stress is a valuable tool for screening significant stenosis in patients with chest pain. Its advantages are non-invasiveness, easy availability, safety and inexpensiveness.

[Value of left atrial area index for diagnosing left ventricular diastolic dysfunction in hypertensive patients with preserved left ventricular systolic function].

OBJECTIVE: To investigate the correlation between left atrial size and left ventricular filling pressure (LVFP) and the value of left atrial size assessment on detecting diastolic dysfunction in hypertensive patients with preserved LVEF by echocardiography. METHODS: Echocardiography was performed in 346 hypertensive patients with preserved LVEF(≥ 50%), left atrial size including left atrial diameter (LAD) and left atrial area (LAA) was measured and indexed to body surface area (LADI, LAAI). The ratio of early diastolic transmitral velocity to early diastolic mitral annular velocity (E/Em) was determined and LVFP was calculated with the formula: LVFP = 1.24×E/Em + 1.9. Patients were divided into diastolic dysfunction group [DD group, LVFP > 15 mm Hg (1 mm Hg = 0.133 kPa), n = 81] and normal diastolic function group (NDF group, LVFP ≤ 15 mm Hg, n = 265). RESULTS: As compared to patients in NDF group, the patients in DD group had larger LA [LADI: (21.4 ± 2.6) mm/m(2) vs. (19.6 ± 2.4) mm/m(2); LAAI: (12.1 ± 2.6) cm(2)/m(2) vs. (10.4 ± 1.7)cm(2)/m(2); all P < 0.01]. LA size parameters were positively correlated with LVFP (r = 0.211-0.450, all P < 0.01), LAAI was best correlated with LVFP (r = 0.450, P < 0.01). ROC analysis showed that LAAI ≥ 11.4 cm(2)/m(2) diagnosed DD with a sensitivity of 63%, specificity of 74% and accuracy of 72%. CONCLUSION: Left atrium dilation correlates positively with LVFP in hypertensive patients with preserved LVEF. The LAAI is a more accurate parameter for identifying patients with diastolic dysfunction in this cohort.

Impact of uncontrolled blood pressure on diagnostic accuracy of coronary flow reserve for detecting significant coronary stenosis in hypertensive patients.

BACKGROUND: Impaired coronary flow reserve (CFR) in patients with hypertension may be caused by epicardial coronary stenosis or microvascular dysfunction. Antihypertensive treatment has been shown to improve coronary microvascular dysfunction. The aim of this study was to evaluate the impact of uncontrolled blood pressure (BP) on diagnostic accuracy of CFR for detecting significant coronary stenosis. METHODS: A total of 98 hypertensive patients scheduled for coronary angiography (CAG) due to chest pain were studied. Of them, 45 patients had uncontrolled BP (defined as the office BP ≥ 140/90 mmHg (1 mmHg = 0.133 kPa) in general hypertensive patients, or ≥ 130/80 mmHg in hypertensive individuals with diabetes mellitus), and the remaining 53 patients had well-controlled BP. CFR was measured in the left anterior descending coronary artery (LAD) during adenosine triphosphate-induced hyperemia by non-invasive transthoracic Doppler echocardiography (TTDE) within 48 hours prior to CAG. Significant LAD stenosis was defined as > 70% luminal narrowing. Diagnostic accuracy of CFR for detecting significant coronary stenosis was analyzed with a receiver operating characteristic analysis. RESULTS: CFR was significantly lower in patients with uncontrolled BP than in those with well-controlled BP (2.1 ± 0.6 vs. 2.6 ± 0.9, P < 0.01). Multivariate linear regression analysis of the study showed that the value of CFR was independently associated with the angiographically determined degree of LAD stenosis (ß = -0.445, P < 0.0001) and the presence of uncontrolled BP (ß = -0.272, P = 0.014). With a receiver operating characteristic analysis, CFR < 2.2 was the optimal cut-off value for detecting LAD stenosis in all hypertensive patients (AUC 0.83, 95%CI 0.75 - 0.91) with a sensitivity of 75%, a specificity of 78%, and an accuracy of 77%. A significant reduction of diagnostic specificity was observed in patients with uncontrolled BP compared with those with well-controlled BP (67% vs. 93%, P = 0.031). CONCLUSIONS: CFR measurement by TTDE is valuable in the diagnosis of significant coronary stenosis in hypertensive patients. However, the diagnostic specificity is reduced in patients with uncontrolled BP.

Coronary flow velocity reserve is improved by PPAR-α agonist fenofibrate in patients with hypertriglyceridemia.

INTRODUCTION: Fenofibrate, an agonist of peroxisome proliferator-activated receptor-α (PPAR-α), has a vascular protective effect. AIMS: We investigated the effect of the PPAR-α agonist on coronary artery endothelial function in patients with hypertriglyceridemia. METHODS: Fifty-eight patients with hypertriglyceridemia were divided into two groups: control (no treatment; n = 23) and fenofibrate treatment (n = 35), 200 mg/d, for 6 months. The patients had undergone rest and adenosine treatment to induce hyperemia for quantification of coronary flow velocity reserve (CFVR) by noninvasive Doppler echocardiography before treatment and at 6-month follow-up. Pulse wave velocity (PWV) was measured before treatment and at 6-month follow-up. RESULTS: CFVR was significantly improved with fenofibrate treatment as compared with baseline level and control group (3.14 ± 0.36 vs. 2.80 ± 0.58 and 2.79 ± 0.65, P < 0.01 and 0.05, respectively), with no difference between baseline levels and untreated controls. In addition, at 6 months, plasma level of homocysteine was significantly increased with fenofibrate treatment as compared with at baseline and control group (median 18.13 [range 14.46-22.02]µmol/L vs. 14.09 [12.01-18.81] and 13.34 [9.69-17.06]µmol/L, P < 0.001 and 0.01, respectively). Furthermore, at 6 months, PWV was significantly decreased with fenofibrate treatment as compared with control group (1446 ± 136 cm/s vs. 1570 ± 203 cm/s, P < 0.05). CONCLUSIONS: Treatment with PPAR-α agonist fenofibrate significantly improved CFVR and arterial stiffness in patients with hypertriglyceridemia. This endothelial protective effect may be reduced in part by the side effect of increasing homocysteine.

[Anesthesia for caesarean section in a gravida with peripartum cardiomyopathy combined with acute heart failure: a case report].

Peripartum cardiomyopathy(PPCM) is a rare but serious form of cardiac failure affecting women in the last month of pregnancy or early puerperium within six months. Clinical presentation of PPCM is similar to that of idiopathic dilated cardiomyopathy, and maternal mortality is high. An 18 year-old primigravida was admitted to our hospital at the end of forty-one weeks of gestation. She was diagnosed with PPCM complicated with heart failure. Preoperative optimization was done with a view to managing left ventricular failure. Continuous epidural anesthesia in the sitting position with lidocaine was used for cesarean section. The baby was delivered successfully. Intravenous furosemide 20 mg, morphine 10 mg, cedilanid 0.4 mg were given. Nitroglycerin and milinone infusions continued throughout the surgery titrated to the hemodynamics. The patient received inotropic agents, dieresis, vasodilators and anticoagulants post-operatively. Both the mother and the baby were discharged safely 9 days after operation.