Epicardial adipose tissue thickness is related to early subclinical myocardial dysfunction, particularly in patients with type 2 diabetes mellitus: a case control study.

BACKGROUND: Cardiac myofibrillary dysfunction, which can be measure by echocardiographical strain value, represents an early subclinical manifestation of heart failure. Epicardial Adipose tissue (EAT) is related to low degree inflammation and oxidative damage in the adjacent tissue. AIM: To explore whether EAT affects early myocardial dysfunction, as assessed strain values. METHODS: Case-Control design. Patients lacking clinical significant heart failure, thyroid or renal disease or malignant abnormalities were included. Clinical-demographic and biochemical data were collected. EAT and myofibril deformation were measured by echocardiography. RESULTS: A total of 71 patients were analyzed, and further subdivided according to type 2 Diabetes Mellitus (t2DM). Higher strain value (higher than -22.4%cut-off value) was associated with male sex and higher anthropometric and metabolic risk measures; particularly those with t2DM. Higher EAT was also associated higher strain value (AUC = 0.92 ± 0.06, p = 0.004), and further correlation was evidenced (rho = 0.488, p < 0.001), with significant influence of t2DM. CONCLUSION: EAT was related to strain value, suggesting the influence of cardiac adipose tissue on the deformability of cardiac myofibril, with a more significant effect in the population with t2DM.

The metabolic phenotype of the patient influences the reduction in carotid intima-media thickness achieved following metabolic surgery.

OBJECTIVES: To determine whether metabolic phenotype is associated with the change in carotid intima-media thickness (CIMT) in patients undergoing bariatric /metabolic surgery (BMS). METHODS: We performed a case-control study of BMS candidates who had metabolically unhealthy obesity (MUO) or metabolically healthy obesity (MHO). We measured the change in CIMT during the 9 months following BMS. The plasma tumor necrosis factor-α, interleukin-1ß, adiponectin, leptin, nitric oxide (NO), vascular endothelial growth factor A (VEGF-A), and malondialdehyde concentrations were determined, adipocyte area was measured histologically, and adipose tissue area was estimated using computed tomography. RESULTS: Fifty-six patients (mean age 44.5 years, mean body mass index 44.9 kg/m2, 53% women, and 53% had MUO) were studied. Nine months following BMS, the MUO phenotype was not associated with a significant reduction in CIMT, and that of the MHO group was larger. In addition, fewer participants achieved a 10% reduction in CIMT in the MUO group. A CIMT reduction was associated with lower VEGF-A and NO in the MUO group, while that in the MHO group was associated with a higher NO concentration. CONCLUSION: The metabolic phenotype of patients may influence their change in CIMT following BMS, probably through circulating vasodilatory and pro-inflammatory molecules.

Diagnostic Performance of AST Scale in Mexican Male Population for Alcohol Withdrawal Syndrome.

Alcohol withdrawal syndrome (AWS) represents an adverse consequence of chronic alcohol use that may lead to serious complications. Therefore, AWS requires timely attention based on its early recognition, where easy-to-apply diagnostic tools are desirable. Our aim was to characterize the performance of a short-scale AST (Anxiety, Sweats, Tremors) in patients from public general hospitals. We conducted a cross-sectional study of patients attended at the Emergency Department diagnosed with AWS. Three scales were applied: CIWA-Ar (Clinical Institute Retirement Assessment Scale-Revised), GMAWS (Glasgow Modified Alcohol Withdrawal Syndrome) and AST. Cronbach's alpha and Cohen's kappa tests were used for reliability and concordance. Factorial analysis and diagnostic performance including ROC curve were carried out. Sixty-eight males with a mean age of 41.2 years old, with high school education and robust alcohol consumption, were included. Mean scores for CIWA-Ar, GMWAS and AST were 17.4 ± 11.2, 3.9 ± 2.3 and 3.8 ± 2.6, respectively, without significant differences. The AST scale showed an acceptable reliability and concordance (0.852 and 0.439; p < 0.0001) compared with CIWA-Ar and GMAWS. AST component analysis evidenced tremor (77.5% variance), sweat (12.1% variance) and anxiety (10.4% variance). Diagnostic performance of the AST scale was similar to the GMAWS scale, evidencing a sensitivity of 84%, specificity of 83.3% and Area Under the Curve (AUC) of 0.837 to discriminate severe AWS, according to CIWA-Ar. The performance of the AST scale to evaluate AWS is comparable with the commonly used CIWA-Ar and GMAWS scales. AST further represents an easy-to-apply instrument.

Identification of adipose tissue-related predictors of the reduction in cardiovascular risk induced by metabolic surgery.

OBJECTIVES: We aimed to determine whether parameters associated with adipose tissue (adipocyte density and the circulating concentrations of markers of adipose tissue pathology) predict cardiovascular risk (CVR) modification after metabolic surgery (MS). METHODS: We performed a case-control study of patients with morbid obesity who were candidates for MS. CVR was defined using flow-mediated dilation (FMD) and carotid intima media thickness (CIMT), which were measured during the 9 months following MS. Subgroups of CVR reduction were defined using the following cut-offs: CIMT 10% and/or a two-fold increase in FMD. RESULTS: We studied 40 patients with morbid obesity (mean age 44.5 years, 75% women, mean body mass index 46.4 kg/m2) and high prevalences of the metabolically unhealthy obesity phenotype, hypertension, and diabetes mellitus. A significant reduction in CVR was associated with lower vascular endothelial growth factor-A concentration (6.20 vs. 1.59 pg/mL, respectively), low adipocyte density in visceral adipose tissue (100 vs. 80 cells/field), low infiltration with CD68+ cells (18 vs. 8 cells/field) and higher concentrations of lipid peroxidation markers and malondialdehyde (313.7 vs. 405.7 ng/mL). CONCLUSION: The characteristics of adipose tissue and the circulating concentrations of markers of adipose pathology might represent useful predictors of the reduction in CVR following MS.Clinical trial registration number: NCT0356198 (https://clinicaltrials.gov).

Enlarged adipocytes from subcutaneous vs. visceral adipose tissue differentially contribute to metabolic dysfunction and atherogenic risk of patients with obesity.

Morphological characteristics and source of adipose tissue as well as adipokines may increase cardiometabolic risk. This study aimed to explore whether adipose tissue characteristics may impact metabolic and atherogenic risks. Subcutaneous Adipose Tissue (SAT), Visceral Adipose Tissue (VAT) and peripheral blood were obtained from obese patients submitted to bariatric surgery. Adipose tissue (morphometry), plasma adiponectin, TNF-α, resistin (multiplexing) and biochemical chemistry were analyzed; as well as endothelial dysfunction (Flow Mediated Dilation, FMD) and atherogenesis (Carotid Intima Media Thickness, CIMT). Subgroups divided by adipocyte size and source were compared; as well as correlation and multivariate analysis. Sixty patients 36.6% males, aged 44 years-old, BMI 46.7 kg/m2 were included. SAT's adipocytes showed a lower range of size expandability than VAT's adipocytes. Independent from their source, larger adipocytes were associated with higher glucose, lower adiponectin and higher CIMT. Particularly, larger adipocytes from SAT were associated with higher blood pressure, lower insulin and HDL-cholesterol; and showed positive correlation with glucose, HbA1c, systolic/diastolic values, and negatively correlated with insulin and adiponectin. VAT's larger adipocytes particularly associated with lower resistin and lower FMD values. Gender and Diabetes Mellitus significantly impacted the relation of adipocyte size/source with the metabolic and atherogenic risk. Multivariable analysis suggested hypertension-resistin-HbA1c interactions associated with SAT's larger adipocytes; whereas potential insulin-adiponectin associations were observed for VAT's larger adipocytes. Adipocyte morphology and source are differentially related with cardiometabolic and atherogenic risk in population with obesity, which are potentially affected by gender and Diabetes Mellitus.

Predicting Amputation using Local Circulating Mononuclear Progenitor Cells in Angioplasty-treated Patients with Critical Limb Ischemia.

Critical limb ischemia (CLI) represents an advanced stage of the peripheral arterial disease. Angioplasty improves the blood flow to the lower limb; however, some patients irreversibly progress to limb amputation. The extent of vascular damage and the mechanisms of vascular repair are factors affecting post-angioplasty outcome. Mononuclear Progenitor Cells (MPCs) are reactive to vascular damage and repair, with the ability to reflect vascular diseases. The present protocol describes quantification of MPCs obtained from blood circulation from vessel close to the angioplasty site, as well as its relationship with endothelial dysfunction and its predictive ability for limb amputation in the next 30 days after angioplasty in patients with CLI.

El enojo como factor asociado con el síndrome coronario agudo de tipo infarto agudo de miocardio con o sin elevación del segmento ST / Anger as a factor associated with acute coronary syndrome of acute myocardial infarction with or without ST-segment elevation

Resumen OBJETIVO: Establecer si la exposición al enojo una hora previa es factor de riesgo de infarto agudo de miocardio. MATERIAL Y MÉTODO: Estudio transversal, retrospectivo, analítico, mediante un diseño de caso cruzado. Se aplicó una encuesta y se revisó el expediente de pacientes para conocer sus niveles de enojo basales o habituales y los niveles de enojo 24, 12, 8, 4, 2 y una horas previo a padecer el síndrome coronario agudo. RESULTADOS: Se incluyeron 26 pacientes. El estrés emocional, en este estudio medido por el enojo, mostró no estar asociado con el síndrome coronario agudo de tipo infarto agudo de miocardio con y sin elevación del segmento ST. CONCLUSIONES: El enojo una hora previa funge como factor protector de síndrome coronario agudo de tipo infarto de miocardio. Es probable que nuestro estudio no haya mostrado diferencia debido a un sesgo de memoria o a que el tamaño de la muestra haya sido insuficiente para demostrar tal asociación.

Abstract OBJECTIVE: To establish if the exposure to anger one hour before is a risk factor of acute myocadial infarction. MATERIAL AND METHOD: A cross-sectional, retrospective, analytical, by a design of crossed case. A survey was conducted, and the file was reviewed of patients to know their basal or habitual levels of anger and the levels of anger 24, 12, 8, 4, 2, one hours prior to presenting the acute coronary syndrome, to assess if there is a relationship between these and between associated factors (dyslipidemia, smoking, uncontrolled glycemia). RESULTS: There were included 26 patients. Emotional stress, in this study measured by anger, showed not to be associated with acute coronary syndrome of acute myocardial infarction type with and without ST-segment elevation. CONCLUSIONS: Anger one hour prior acts as a protective factor of acute myocardial infarction coronary syndrome. It is likely that our study showed no difference due to a memory bias or that the sample size was insufficient to demonstrate such an association.

Neutrophil-to-lymphocyte ratio and its relation with pro-inflammatory mediators, visceral adiposity and carotid intima-media thickness in population with obesity.

BACKGROUND: Atherosclerosis represents a cardiovascular risk. Chronic inflammation is a key factor for atherogenic progression. Neutrophil-to-lymphocyte ratio (NLR) has been proposed as a novel biomarker for cardiovascular risks. We aimed to explore whether NLR was related to surrogate pro-atherogenic promoters driving atherogenic progression, as measured by carotid intima-media thickness (CIMT). STUDY DESIGN: Thirty-one patients with obesity candidates for bariatric surgery were recruited from Centro Médico Nacional "20 de Noviembre", ISSSTE, Mexico City. The results are part of the "CROP" study (NCT03561987). NLR was calculated from routine complete blood count, and its relation with plasma pro-inflammatory mediators (hsCRP, TNF-α and IL-1ß), adipokines (adiponectin and leptin), adiposity markers (visceral adipose tissue [VAT] determined from CT scan image and VAT individual adipocyte area at histological sample) and CIMT were determined. RESULTS: Neutrophil-to-lymphocyte ratio correlated with hsCRP (Spearman's r = 0.70 [95% CI 0.46 to 0.85], P < 0.01), TNF-α (r = 0.69 [0.44 to 0.84], P < 0.0001) and adiponectin (r = -0.69 [-0.84 to -0.45], P < 0.03), as well as with VAT individual adipocyte area (r = 0.64 [0.37 to 0.81], P < 0.0001) and with VAT area (r = 0.43; [0.07 to 0.68], P < 0.01). Leptin and adiponectin showed further independent association with higher NLR (multivariate regression analysis OR 7.9 [95% CI 1.1 to 56.2] P = 0.03 and 0.1 [0.01 to 1.0] P = 0.05, respectively). Moreover, NLR distribution significantly varied between subgroups divided according to progressive CIMT (P = 0.05); whereas adiponectin and VAT adipocyte area associated with CIMT > 0.9 mm (univariate analysis OR 0.1 [0.01 to 1.0] P = 0.05 and 13.1 [1.4 to 126.3] P = 0.03, respectively). CONCLUSION: Neutrophil-to-lymphocyte ratio was related to pro-inflammatory, adiposity biomarkers and progressive subclinical atherogenesis.

Echocardiographic measurements of epicardial adipose tissue and comparative ability to predict adverse cardiovascular outcomes in patients with coronary artery disease.

The present study aimed to compare echocardiography measurements of epicardial adipose tissue (EAT) thickness and other risk factors regarding their ability to predict adverse cardiovascular outcomes in patients with coronary artery disease (CAD). Outcomes of 107 patients (86 males, 21 females, mean age 63.6 years old) submitted to diagnostic echocardiography and coronary angiography were prospectively analyzed. EAT (measures over the right ventricle, interventricular groove and complete bulk of EAT) and left ventricle ejection fraction (LVEF) were performed by echocardiography. Coronary complexity was evaluated by Syntax score. Primary endpoints were major adverse cardiovascular events (MACE's), composite of cardiovascular death, myocardial infarction, unstable angina, intra-stent re-stenosis and episodes of decompensate heart failure requiring hospital attention during a mean follow up of 15.94 ± 3.6 months. Mean EAT thickness was 4.6 ± 1.9 mm; and correlated with Syntax score and body mass index; negatively correlated with LVEF. Twenty-three cases of MACE's were recorded during follow up, who showed higher EAT. Diagnostic ability of EAT to discriminate MACE's was comparable to LVEF (AUROC > 0.5); but higher than Syntax score. Quartile comparison of EAT revealed that measurement of the complete bulk of EAT provided a better discrimination range for MACE's, and higher, more significant adjusted risk (cutoff 4.6 mm, RR = 3.91; 95% CI 1.01-15.08; p = 0.04) than the other risk factors. We concluded that echocardiographic measurement of EAT showed higher predicting ability for MACE's than the other markers tested, in patients with CAD. Whether location for echocardiographic measurement of EAT impacts the diagnostic performance of this method deserves further study.

Pro-atherogenic mediators and subclinical atherogenesis are related to epicardial adipose tissue thickness in patients with cardiovascular risk.

Objective To evaluate the relationship between pro-atherogenic biomarkers and epicardial adipose tissue (EAT) thickness in patients with cardiovascular risk factors. Methods Plasma nitric oxide (NO), soluble intercellular adhesion molecule-1 and malondialdehyde (MDA) levels, EAT thickness, flow-mediated dilation (FMD) and carotid intima media thickness (CIMT) were determined in patients aged >18 years who were referred for echocardiography for heart ischemia or non-ischemic diseases. Cardiovascular risk factors (Framingham score [FS] ≥ 20) were weighted. Results Hypertension, dyslipidaemia and type 2 diabetes mellitus were prevalent (≥55% of 40 patients). Patients with FS ≥ 20 ( n = 21) showed significantly higher EAT and CIMT values. Globally, MDA, CIMT, age, waist circumference, high-density lipoprotein cholesterol (HDL-C) and FS were associated with EAT thickness. EAT was significantly associated with NO in patients with FS ≥ 20. Significant differences in EAT thickness were found between patients stratified by NO value, FMD, age, smoking status, dyslipidaemia, type 2 diabetes mellitus and FS. An EAT-associated atherogenic risk (CIMT ≥ 1 mm) model was statistically significant when MDA and type 2 diabetes mellitus were included. Conclusion EAT thickness was associated with MDA, CIMT, age, waist circumference, HDL-C and FS globally, but with NO only in patients with FS≥20. EAT may be used to identify vascular damage stage, possibly influenced by MDA and type 2 diabetes mellitus.

Low serum levels of alpha1 anti-trypsin (α1-AT) and risk of airflow obstruction in non-primary α1-AT-deficient patients with compensated chronic liver disease.

BACKGROUND: Alpha1 anti-trypsin (α1-AT), a serine protease inhibitor synthesized in the liver, is a major circulating antiprotease that provides defense against proteolytic damage in several tissues. Its deficiency is associated with airflow obstruction. The present study aimed to explore the role of α1-AT as a biomarker of airflow performance in chronic liver disease (CLD). MATERIAL/METHODS: Serum α1-AT levels and lung function (spirometry) were evaluated in non-primary α1-AT-deficient, alcoholic CLD patients without evident respiratory limitations. RESULTS: Thirty-four patients with airflow obstruction (n=11), airflow restriction (n=12), and normal airflow (n=11, age-matched controls) were eligible. α1-AT was decreased in the airflow obstruction group. ROC-cutoff α1-AT=24 mg/dL effectively discriminated airflow obstruction (AUC=0.687) and was associated with a 10-fold higher risk (p=0.0007). CONCLUSIONS: Lower α1-AT increased the risk of airflow obstruction in CLD patients without primary α1-AT deficiency.

Uso de marcadores bioquímicos para valoración de riesgo de crisis convulsivas en el síndrome de supresión etílica / Biochemical markers for risk assessment of seizures in withdrawal syndrome

Withdrawal signs and symptoms are frequently minor but can develop into a severe, even fatal, condition. Clinical manifestations of the AWS begin as soon as the alcohol consumption is interrupted or diminished after a long period of ingestion of great quantities of alcohol. The clinical manifestations include symptoms of autonomic hyperactivity, like sweating, tachycardia over 100 bpm, tremor, insomnia, nausea or vomiting, transitive visual, tactile, or hearing hallucinations, or even illusions, psychomotor agitation, anxiety and epileptic crisis. Objective Our aim is to assess the usefulness of several biochemical markers and the risk of seizures associated with alcohol withdrawal. Methods This study included 52 inpatients which were assessed with the Ciwa-Ar scale in order to determine the severity of the withdrawal. They were assessed too with the AUDIT scale to determine the risk and abuse of the intake of alcohol. We also obtained a blood sample to determine the levels of several biomarkers (AST, ALT, GGT, FA, HOM-OCISTEINE, and MCV). We compared the two groups (patients with seizures vs. patients without seizures). Student T and Mann Whitney's U tests, and ROC curves were applied. Results We observed a statistical difference between the groups in the levels of alkaline phosphatase. The levels were higher in patients without seizures (148.8±69.58UI) compared with the patients with seizures (113±55.1UI). No differences were observed in other groups. Conclusion The patients with higher levels of alkaline phosphatase had major risk of seizures. There were no elevations in the serum level of homocisteine in both groups.

El síndrome de supresión etílica (SSE) incluye tanto una variedad de signos y síntomas orgánicos y cambios conductuales como modificaciones en la actividad electrofisiológica del Sistema Nervioso Central. No existen estudios clínicos que evalúen el uso de biomarcadores en pacientes con comorbilidades agudas, convulsiones ni delirium tremens, así que su utilidad en estos casos no ha sido valorada. Objetivo Nuestro objetivo es el de valorar el uso de diversos marcadores bioquímicos para determinar el riesgo de convulsiones en el síndrome de supresión etílica. Material y métodos Este estudio incluyó a 52 pacientes, evaluados a su ingreso con la escala Ciwa-Ar para determinar la gravedad de la supresión y la escala AUDIT para detectar riesgo y abuso en el consumo de alcohol. También se tomó una muestra sanguínea para determinar los niveles séricos de los biomarcadores (AST, ALT, GGT, FA, HOMOCISTEINA, VCM). La muestra se dividió en dos grupos (pacientes que convulsionaron vs. pacientes que no convulsionaron). Se utilizó la t de Student y U de Mann Whitney, así como curvas COR para determinar la sensibilidad y especificidad de los biomarcadores, así como la correlación de Pearson. Resultados La única diferencia significativa entre ambos grupos estuvo dada por la fosfatasa alcalina, cuyos niveles fueron más altos en los pacientes que no presentaron crisis convulsiva (148.8±69.58UI) que en aquellos que las presentaron (113±55.1UI). No se encontraron diferencias estadísticamente significativas para el resto de los biomarcadores. Conclusiones Los niveles bajos de fosfatasa alcalina traducen un riesgo mayor de presentar crisis convulsivas. No hubo elevación de los niveles de homocisteína en ninguno de los grupos.