Echocardiographic Assessment of Cardiac Structural and Functional Abnormalities in Patients With End-Stage Renal Disease Receiving Chronic Hemodialysis.

BACKGROUND: The aim of this study was to assess the echocardiographic characteristics of chronic hemodialysis (HD) patients with end-stage renal disease (ESRD) in a multicenter prospective cohort study.Methods and Results:Three hundred and fifteen patients with ESRD (67.9±10.6 years, 47.6% male) on chronic HD for ≥1 year were examined on transthoracic echocardiography, including Doppler-derived aortic valve area (AVA) measurement. Only 11.5% and 3.4% of all patients had normal left ventricular (LV) geometry and normal LV filling pattern, respectively. The majority of patients had aortic and mitral valvular calcification, and approximately 50% of all 315 patients had aortic valve narrowing with AVA <2.0 cm2. Patients were divided into 3 groups according to AVA index tertile: group 1, highest tertile; group 2, middle tertile; and group 3, lowest tertile. Group 3 was older, had a greater cardiothoracic ratio on chest X-ray, higher plasma brain natriuretic peptide and total LV afterload, and lower stroke volume index than the other 2 groups. Age and intact parathyroid hormone (PTH) level were independently associated with low AVA index. CONCLUSIONS: Patients with ESRD on chronic HD have a high prevalence of cardiac structural and functional abnormalities including calcified aortic sclerosis. High age and PTH were associated with aortic valve narrowing in these patients.

Impact of renal function on the underlying pathophysiology of coronary plaque composition in patients with type 2 diabetes mellitus.

BACKGROUND: Both the progression of diabetic kidney disease and increased glycemic variability play important roles in the pathogenesis of coronary plaque formation via inflammatory pathways in patients with type 2 diabetes mellitus (T2DM). Therefore we evaluated the role of renal function in the contributory effects of blood glucose fluctuations and blood levels of inflammatory cytokine concentrations on the tissue characteristics of coronary plaques in patients with T2DM. METHODS: We prospectively enrolled 71 T2DM patients (mean age: 68 ± 9, male 79%) with 153 coronary artery lesions. Patients were divided into 2 groups according to their estimated glomerular filtration rate (eGFR) levels: Group 1 (≥ 60 mL/min/1.73 m2, n = 40) and Group 2 (< 60 mL/min/1.73 m2, n = 31). All patients underwent continuous glucose monitoring (CGM) for 120 h and the mean amplitude of glycemic excursions (MAGE) was calculated. Serum tumor necrosis factor (TNF)-α was also measured. In addition, gray-scale coronary intravascular ultrasound (IVUS) and iMap-IVUS were performed in the coronary lesions with < 50% luminal reduction. RESULTS: In Group 1, MAGE correlated with percent lipidic volume (%LV) (r = 0.477, p = 0.002). In this group, stepwise multivariate linear regression analyses showed that only MAGE was independently associated with %LV (ß = 0.477, p = 0.002). In contrast, in Group 2, only serum TNF-α correlated with percent fibrotic volume (%FV) (r = - 0.471, p = 0.007), %LV (r = 0.496, p = 0.005) and percent necrotic volume (%NV) (r = 0.426, p = 0.017). In this group, stepwise multivariate linear regression analyses showed that only serum TNF-α was independently associated with each tissue characteristic (%FV ß = - 0.471 and p = 0.007, %LV ß = 0.496 and p = 0.005, %NV: ß = 0.426 and p = 0.017). CONCLUSIONS: In T2DM patients, the tissue characteristics of coronary plaques were associated with MAGE in patients with eGFR ≥ 60 mL/min/1.73 m2 and with serum TNF-α in those with eGFR < 60 mL/min/1.73 m2.

Coronary Microvascular Dysfunction Restored After Surgery in Inflammatory Bowel Disease: A Prospective Observational Study.

Background We aimed to investigate the presence and severity of coronary microvascular dysfunction (CMD) in inflammatory bowel disease (IBD) including Crohn disease and ulcerative colitis and to elucidate the influence of surgical resection of the diseased intestines on CMD by assessing coronary flow velocity reserve (CFVR) using transthoracic Doppler echocardiography. Methods and Results Thirty-seven patients with IBD (aged 44±15 years; 22 patients with Crohn disease and 15 patients with ulcerative colitis) and 30 controls (aged 46±12 years) were enrolled. For CFVR measurement, coronary flow velocity was recorded at rest and during hyperemia by ADP infusion using transthoracic Doppler echocardiography, and CFVR <2.5 defined CMD. CFVR measurement was repeated before and within 1 year after surgery. CFVR was similarly and significantly lower in patients with Crohn disease and those with ulcerative colitis than controls (Crohn disease: 2.92±1.03 [P<0.05 versus controls], ulcerative colitis: 2.99±0.65 [P<0.05 versus controls], and controls: 3.84±0.75). Multiple linear regression analysis showed that the presence of IBD and baseline hs-CRP (high-sensitivity C-reactive protein) were independently associated with low CFVR among all study participants (ß=-0.403 [P=0.001] and -0.237 [P=0.037], respectively). Hyperemic coronary flow velocity significantly improved after surgery only in patients with IBD who had CMD. CFVR significantly improved in patients with IBD who had both CMD and non-CMD, and the extent of CFVR improvements were greater in patients with CMD than non-CMD. Multiple linear regression analysis showed that the reduction of hs-CRP was independently associated with improvement of hyperemic coronary flow velocity and CFVR among all patients with IBD (ß=-0.481 [P=0.003] and ß=-0.334 [P=0.043], respectively). Conclusions IBD is associated with CMD, which improved after surgical resection of diseased intestines.

Chronic Inflammatory Disease Is an Independent Risk Factor for Coronary Flow Velocity Reserve Impairment Unrelated to the Processes of Coronary Artery Calcium Deposition.

BACKGROUND: Chronic inflammatory disease (CID) is a complex multisystem disease characterized by chronic inflammation, which can lead to coronary microvascular dysfunction (CMD) and can also predispose to coronary artery calcium deposition, even in the absence of obstructive coronary artery disease. METHODS: Twenty-one patients with systemic lupus erythematosus (SLE; mean age, 60 ± 11 years), 21 patients with systemic sclerosis (SSc; mean age, 66 ± 11 years), 32 patients with rheumatoid arthritis (RA; mean age, 65 ± 9 years), and 23 control subjects with comparable traditional risk factors for coronary artery disease (mean age, 65 ± 10 years) were prospectively enrolled in the outpatient clinic. All study participants underwent transthoracic Doppler-derived echocardiography for coronary flow velocity reserve (CFVR) measurement in the left anterior descending coronary artery; CFVR < 2.5 defined CMD. Coronary artery calcium score in the left anterior descending coronary artery was also assessed by computed tomography. RESULTS: None of study participants had obstructive coronary artery disease. The prevalence of CMD was 26% in the control group, 67% in the SLE group, 76% in the SSc group, and 63% in the RA group (P < .05, CID groups vs control group). CFVR was significantly lower in all three CID groups than in the control group (control group, 3.01 ± 0.72; SLE group, 2.23 ± 0.71; SSc group, 2.14 ± 0.54; RA group, 2.33 ± 0.62; P < .05, CID groups vs control group). In contrast, coronary artery calcium scores were similar in the four groups and had no relation to CMD. The odds ratios for CMD in patients with SLE, SSc, and RA were 16.70, 25.78, and 8.44 (P < .05) after adjusting for age, body mass index, the presence or absence of anemia, and hemoglobin level. Multiple linear regression analysis showed that only the presence of CID was independently associated with reduced CFVR among all study participants. CONCLUSIONS: CID strongly contributes to CMD identified by qualitative evaluation of CFVR independently of traditional coronary risk factors of atherosclerosis but does not predispose to coronary artery calcification.

Detection of coronary artery disease using coronary flow velocity reserve by transthoracic Doppler echocardiography versus multidetector computed tomography coronary angiography: influence of calcium score.

BACKGROUND: There have been no clinical data specifying the degree of calcium deposition at which coronary flow velocity reserve (CFVR) measurement using transthoracic Doppler echocardiography surpasses 320-row multidetector computed tomographic coronary angiography (CTCA) in detecting obstructive coronary artery disease. METHODS: One hundred seventy patients who underwent invasive coronary angiography, transthoracic Doppler echocardiography, and CTCA were prospectively enrolled. Coronary artery stenosis was defined as percentage diameter stenosis ≥ 50% on invasive coronary angiography. CFVR < 2.0 and narrowing ≥ 50% measured with CTCA were the thresholds indicating the presence of coronary artery stenosis. The degree of coronary artery calcification was also assessed using the Agatston calcium score method by computed tomography. RESULTS: The majority of patients (89%) were classified as having either high or intermediate pretest probability of coronary artery disease. Significant coronary artery stenoses by invasive coronary angiography were found in 71 patients and 104 vessels. Although the overall diagnostic performance of CTCA was comparable with that of CFVR measurement for detecting coronary artery stenosis, only the diagnostic performance of CTCA was negatively affected by the extent of a patient's coronary artery calcification. Receiver operating characteristic curve analysis indicated that only CFVR measurement is diagnostically accurate when calcium scores are >319 in the patient-based assessment, 189 for the left anterior descending coronary artery, 98 for the left circumflex coronary artery and 282 for the right coronary artery. CONCLUSIONS: Transthoracic Doppler echocardiography and 320-row multidetector CTCA successfully diagnosed significant coronary artery stenosis with high feasibility and accuracy. However, only the diagnostic performance of CTCA was negatively affected by the extent of a patient's coronary artery calcification, and therefore the diagnostic performance of CFVR measurement for detecting coronary artery stenosis surpassed that of CTCA when the calcium score exceeded specified cutoff values.

Comparison of coronary flow velocity reserve measurement by transthoracic Doppler echocardiography with 320-row multidetector computed tomographic coronary angiography in the detection of in-stent restenosis in the three major coronary arteries.

We sought to compare the diagnostic accuracy and feasibility of coronary flow velocity reserve (CFVR) measurement using transthoracic Doppler echocardiography (TTDE) and 320-row multidetector computed tomographic coronary angiography (CTCA) for predicting in-stent restenosis (ISR). We enrolled 126 consecutive patients with 309 implanted coronary stents in the 3 major coronary arteries. TTDE and CTCA were performed within the 2-week period before follow-up invasive coronary angiography. Binary ISR was defined as percent diameter stenosis ≥50% on invasive coronary angiogram. A CFVR <2.0 using TTDE and a narrowing of ≥50% measured with CTCA were the thresholds indicating the presence of binary ISR. Presence of ISR using invasive coronary angiography was observed in 26 (8%) stents and 26 (14%) vessels. Feasibilities of CFVR measurement and CTCA for predicting ISR in the 3 major vessels were 94% and 91%, respectively. A CFVR <2.0 revealed a 95% diagnostic accuracy with sensitivity of 87%, specificity of 96%, positive predictive value of 77%, and negative predictive value of 98%. Diagnostic accuracy of CTCA was comparable to that of CFVR measurement; however, CTC angiographic results were confounded by metal artifacts in the assessment of small-diameter stents. In conclusion, noninvasive CFVR measurement has high feasibility and accuracy for predicting ISR and is comparable to 320-row CTCA.