Effect of dipping and nondipping pattern of blood pressure on subclinical left ventricular dysfunction assessed by two-dimensional speckle tracking in hypertensive patients.

OBJECTIVE: The aim of this study was to evaluate the left ventricular (LV) function by conventional two-dimensional speckle tracking echocardiography (2D STE) to detect subclinical LV systolic dysfunction in patients with dipper and nondipper hypertension. METHODS: One hundred consecutive patients with hypertension were included in our study. Clinical evaluation, baseline laboratory investigations, 24 ambulatory blood pressure monitoring 2D echocardiographic examination and 2D STE were performed for all patients. Patients were classified as dippers and nondippers according to their nighttime MAP (mean arterial blood pressure) reduction rate of ≥10 or <10%, respectively. RESULTS: Of 100 patients, 71% were nondippers while 29% were dippers. Nondippers had a significantly lower global longitudinal strain (LS) value (-22.45 ± 3.26 vs. -18.2 ± 3.3, P < 0.001), global circumferential strain (CS) value (-24.23 ± 3.56 vs. -19.16 ± 8.25, P < 0.001) and global radial strain (RS) value (35.04 ± 11.16 vs. 29.58 ± 8.44, P = 0.009). It was found that nondipper status was associated with worsening of LS by 2.737, (P = 0.001), CS by 3.446, (P = 0.002), RS by -3.256, (P = 0.158) and DM also was found associated with worsening of LS by 1.849, (P = 0.062), CS by 3.284 (P = 0.018), RS by -2.499 (P = 0.381). CONCLUSION: The nondipping hypertension pattern is associated with subclinical LV systolic dysfunction as shown by the impaired global myocardial strain in all three directions.

Prospective Study of Tricuspid Regurgitation Associated With Permanent Leads After Cardiac Rhythm Device Implantation.

BACKGROUND: Tricuspid regurgitation (TR) has been associated with cardiac rhythm device (CRD) implantation with intracardiac lead insertion. However, data on the incidence of postdevice TR are limited and largely from retrospective studies. We hypothesized that permanent lead implantation would be associated with an increase in TR. METHODS: We prospectively included consecutive patients with a clinical indication for CRD. Patients underwent transthoracic echocardiography 1 month before and 1 year after CRD implantation. RESULTS: A total of 328 patients were prospectively enrolled (69 ± 15 years, 38% female). Echocardiograms before and 1 year after CRD were available in 290 patients (15 died, 23 lost to follow-up). Compared with baseline, there was a significant change in TR grade 1 year after CRD insertion (no/trivial TR: 66% vs 29%; mild TR: 29% vs 61%; moderate TR: 3% vs 8%; severe TR 2% vs 2%; P < 0.001 for an increase in TR by at least 1 grade). Compared with baseline, there was a higher prevalence of moderate or severe TR in the 247 patients with CRD without cardiac resynchronization therapy (4% vs 10%, P = 0.004), but no progression in the 43 patients who received cardiac resynchronization therapy (14% vs 11%, P = 1). Multivariable analysis in the patients with less than moderate TR at baseline (n = 274) showed that only a history of atrial fibrillation was independently associated with progression to moderate or severe TR after correction for baseline TR grade (P = 0.013). CONCLUSIONS: One year after endocardial lead insertion, there was a 5% increase in the prevalence of moderate or severe TR, which may be clinically relevant.

Factors Associated with Low Flow in Aortic Valve Stenosis.

BACKGROUND: Low-flow low-gradient aortic stenosis (AS) is a predictor of worse outcome compared with normal-flow AS. Although depressed left ventricular ejection fraction (LVEF) is associated with low flow, there is less evidence to support the role of other indices of cardiac structure and function. METHODS: Clinical and echocardiographic data from patients with native AS and valve areas ≤ 1.0 cm(2) were retrospectively analyzed to identify characteristics that are associated with low-flow low-gradient AS. RESULTS: In total, 941 patients were included. On multivariate analysis, factors independently associated with low flow (stroke volume index < 35 mL/m(2)) included worse right ventricular systolic function, atrial fibrillation, lower LVEF, and higher left ventricular mass, with moderate or severe mitral regurgitation independently associated with low flow in the 694 patients (74%) with preserved LVEFs. CONCLUSIONS: Right ventricular dysfunction and atrial fibrillation are independently associated with low-flow low-gradient AS, while moderate or severe MR is independently associated with low flow in patients with preserved LVEF. These associations with low flow in AS are clinically important to recognize, to avoid underestimation of AS severity.

Prospective study of tricuspid valve regurgitation associated with permanent leads in patients undergoing cardiac rhythm device implantation: Background, rationale, and design.

Given the increasing numbers of cardiac device implantations worldwide, it is important to determine whether permanent endocardial leads across the tricuspid valve can promote tricuspid regurgitation (TR). Virtually all current data is retrospective, and indicates a signal of TR being increased after permanent lead implantation. However, the precise incidence of moderate or greater TR post-procedure, the exact mechanisms (mechanical, traumatic, functional), and the hemodynamic burden and clinical effects of this putative increase in TR, remain uncertain. We have therefore designed a multicenter, international, prospective study of 300 consecutive patients (recruitment completed, baseline data presented) who will undergo echocardiography and clinical assessment prior to, and at 1-year post device insertion. This prospective study will help determine whether cardiac device-associated TR is real, what are its potential mechanisms, and whether it has an important clinical impact on cardiac device patients.

An audit of inpatient management of community-acquired pneumonia in Oman: a comparison with regional clinical guidelines.

OBJECTIVE: Community-acquired pneumonia (CAP) is a major cause of morbidity and mortality worldwide. Herein, we present the findings from an audit of CAP management at a tertiary hospital in Oman. The main objective was to evaluate the quality of care given to patients and compare it with the standards in the Gulf Cooperation Council (GCC) CAP guidelines. METHODS: A retrospective case study of all patients admitted with CAP from June 2006 to September 2008 examined the adherence to standards for the diagnosis, investigation, and management of CAP, including the documentation of illness severity. RESULTS: The case notes of 342 patients were reviewed. Of these, 170 patients were excluded from the study, and 172 patients met the diagnostic criteria for inclusion. A CURB-65 severity score was documented for only 4 (2.3%) patients, and a smoking history was documented for 56 (32.6%) patients. Although 17 different antibiotic regimens were used, 115 (67%) patients received co-amoxiclav and clarithromycin, which is the standard of care. Additionally, 139 (81%) patients received their first dose of antibiotics within four hours of hospital admission. There was no documentation of offering influenza or pneumococcal vaccine to high risk patients. CONCLUSION: The clinical coding of CAP diagnosis was poor. There was very poor adherence to the CAP severity assessment and the provision of preventive measures upon hospital discharge. The development and implementation of a local hospital-based integrated care pathway may lead to more successful implementation of the guidelines.