Longitudinal levels of apolipoproteins and antibodies against phosphorylcholine are independently associated with carotid artery atherosclerosis 5 years after rheumatoid arthritis onset--a prospective cohort study.

OBJECTIVE: RA is associated with premature atherosclerosis. Here, we determined the associations of apolipoproteins and immunoglobulin M (IgM) antibodies against phosphorylcholine (anti-PC) with carotid artery atherosclerosis in a prospective cohort of patients with early RA. METHODS: In all 114 patients, age 50.6 (11.2) years, 68.4% women, with recent RA (<12 months after symptoms onset) were included and assessed at 0, 3, 12, 24 and 60 months after RA diagnosis. At the same time points, apolipoproteins were determined by immunoturbidimetry, and IgM anti-PC by ELISA. Carotid intima-media thickness (cIMT) (common carotid) and occurrence of plaques (common, internal and external carotids) were the principal study outcomes, which were examined with high-resolution B-mode ultrasonography after 5 years of RA disease. Mixed linear modelling and generalized estimating equations (GEEs) were used for longitudinal statistical analyses. RESULTS: Multivariate regression analyses showed that age, male gender, smoking (ever) and history of cardiovascular disease (CVD), hypertension or diabetes mellitus, but no other baseline variables, had independent associations with cIMT (P < 0.05). Plaque detection was positively associated with age and smoking (ever). After adjustment, a longitudinal approach demonstrated an independent negative prediction of cIMT by apoA1 (P = 0.047), but a positive by apoB/apoA1 ratio (P = 0.030). Higher levels of pro-atherogenic apolipoproteins over time, apoB and apoB/apoA1 ratio, and low anti-PC tertile were independently associated with enhanced detection of bilateral carotid plaque (P = 0.002, 0.026 and 0.000, respectively). Both baseline and longitudinal levels of inflammatory/disease-related factors failed to show significant associations with the study outcomes. CONCLUSION: Apolipoproteins and anti-PC may have independent roles in subclinical atherosclerosis in patients with RA.

Heavy snoring is a risk factor for case fatality and poor short-term prognosis after a first acute myocardial infarction.

STUDY OBJECTIVES: Sleep disordered breathing has been associated with an increased risk for developing coronary heart disease. Data on the effects of sleep disordered breathing on case fatality and prognosis of a myocardial infarction are sparse. The present study aimed to investigate a possible relationship of snoring and case fatality and mortality after an acute myocardial infarction. DESIGN, SETTINGS, PATIENTS, AND MEASUREMENTS: In this study, we enrolled 1660 first acute myocardial infarction cases and examined the effects of self- or relative-reported heavy snoring on case fatality and prognosis. The average follow-up time was 8 years, SD = 262 days. RESULTS: There was a variation in the association between snoring and mortality with time, with a strong association in the first 28 days after infarction but not later during the follow-up. Occasional and regular heavy snorers, when compared to those never having heavy snoring, had a 2.04 (95% confidence interval, 1.50 to 2.79) and 3.30 (95% confidence interval, 2.37 to 4.58) hazard ratio for mortality within the first 28 days after controlling for age, gender, obesity, history of diabetes and hypertension, physical activity, smoking, and education, respectively. There was no association between snoring and new myocardial infarction, stroke, or hospitalization for heart failure during the follow-up. CONCLUSIONS: Heavy snoring is associated with case fatality and short-term mortality in patients with a first acute myocardial infarction.

Atrial fibrillation among patients under investigation for suspected obstructive sleep apnea.

STUDY OBJECTIVES: Obstructive sleep apnea is common among patients with atrial fibrillation, but the prevalence and risk factors for atrial fibrillation among patients who are being investigated on suspicion of sleep apnea are not well known. The aim of the study was to estimate the prevalence of atrial fibrillation among patients investigated for suspected obstructive sleep apnea and to identify risk factors for atrial fibrillation among them. METHODS: The prevalence of atrial fibrillation was investigated among 201 patients referred for suspected obstructive sleep apnea. Patients without known atrial fibrillation were investigated with a standard 12-lead ECG at hospital and short intermittent handheld ECG recordings at home, during 14 days. RESULTS: Atrial fibrillation occurred in 13 of 201 subjects (6.5%), and in 12 of 61 men aged 60 years and older (20%). The prevalence of atrial fibrillation increased with sleep apnea severity (p = 0.038). All patients with atrial fibrillation were men and all had sleep apnea. Age 60 or older, the occurrence of central sleep apnea and diabetes mellitus were independent risk factors for atrial fibrillation after adjustments for body mass index, gender, sleep apnea and cardiovascular disease. CONCLUSIONS: Atrial fibrillation is common among subjects referred for sleep apnea investigation and the prevalence of atrial fibrillation increases with sleep apnea severity. Independent risk factors for atrial fibrillation among patients investigated for suspected obstructive sleep apnea include the occurrence of coexisting central sleep apnea, age 60 years or older and diabetes mellitus.

Interrelation between the extent of atherosclerosis in the thoracic aorta, carotid intima-media thickness and the extent of coronary artery disease.

Intima-media thickness (IMT) of the common carotid artery and atherosclerosis of the thoracic aorta have been shown to correlate with coronary artery disease (CAD). This study compares the relation between wall changes in the thoracic aorta and the carotid arteries and the angiographic severity and extent of atherosclerotic lesions in the coronary arteries in patients with verified CAD. Atherosclerotic wall changes in the carotid arteries and the thoracic aorta were measured by B-mode ultrasonography and transesophageal echocardiography (TEE), respectively, in 37 subjects aged 65+/-10 years with angiographically verified CAD. The mean value of the common carotid IMT of the right and left sides was 0.87+/-0.21 mm. All subjects had carotid plaques. TEE detected grades II-IV atherosclerotic plaques in the thoracic aorta in 32 of the 37 (86%) patients. A significant correlation was seen between the extent of coronary artery stenosis and aortic plaques score (r=0.46, p=0.008). Mean carotid IMT was also significantly correlated with coronary artery stenosis extent score (r=0.44, p=0.007). Moreover, a significant correlation was seen between the aortic plaque score and the mean carotid IMT (r=0.39, p=0.02). In conclusion, we found a clear and significant relationship between wall changes in the thoracic aorta, common carotid IMT and the angiographic extent of coronary artery stenosis in patients with severe CAD. These findings indicate a potential of B-mode ultrasonography of the carotid arteries and transesophageal echocardiographic aortic examination in the diagnostic and prognostic evaluation of patients with suspected CAD.

Morphological changes rather than flow-mediated dilatation in the brachial artery are better indicators of the extent and severity of coronary artery disease.

OBJECTIVES: The aim of this study was to examine the relationship between morphological and functional parameters of the brachial and carotid arteries and the angiographic extent and severity of coronary artery stenosis in patients with severe coronary artery disease (CAD). DESIGN: A cross-sectional study. SETTING: University hospital. MAIN OUTCOME MEASURES: Flow-mediated dilatation (FMD), intima-media thickness (IMT) in the brachial artery and atherosclerotic wall changes in the carotid arteries were measured by B-mode high-resolution ultrasound in 58 patients who had undergone coronary angiography. RESULTS: A significant correlation was seen between the extent of coronary artery stenosis defined as the coronary angiographic score and both the mean brachial artery IMT and intima-media area (IMa; P = 0.01 and P = 0.04, respectively). There was no significant correlation between FMD and the extent of coronary artery stenosis. A significant correlation was seen between the mean carotid artery IMT and the mean brachial artery IMT (r = 0.30, P = 0.03). However, there was no significant correlation between FMD and the mean carotid artery IMT or IMa (r = 0.16, P = 0.23 and r = 0.17, P = 0.24, respectively). CONCLUSIONS: Morphological but not functional parameters of the brachial artery are associated with the extent of coronary artery stenosis and atherosclerotic wall changes in the carotid arteries in patients with severe CAD. These findings indicate a potential of B-mode ultrasonography of morphological parameters in the brachial artery in the diagnostic and prognostic evaluation of patients with suspected CAD.

Subclinical atherosclerosis, endothelial function, and serum inflammatory markers in chronic kidney disease stages 3 to 4.

Different inflammatory markers, brachial artery flow-mediated dilatation (FMD), and brachial intima-media thickness (bIMT) were measured in 50 patients with chronic kidney disease (CKD) stages 3 to 4 with estimated glomerular filtration rate (eGFR) and 35 age- and gender-matched controls. The bIMT was significantly increased in the patients with CKD compared with controls (0.43 mm [0.42, 0.45] vs 0.34 mm [0.32, 0.36]; P < .001). There was no significant difference in FMD between the study groups (4.7% vs 5.3%; P = .56). There were significant correlations between bIMT and high-sensitive C-reactive protein, vascular cellular adhesion molecule 1, tumor necrosis factor, and interleukin 6 (P < .05). However, eGFR adjusted for age and gender was the best predictor of bIMT. In conclusion, bIMT and inflammatory markers were increased in patients with CKD compared with the controls. Furthermore, significant correlations between bIMT and inflammatory activity in patients with CKD were observed. The eGFR adjusted for age and gender was the best predictor of bIMT.

Effects of low-dose prednisolone on endothelial function, atherosclerosis, and traditional risk factors for atherosclerosis in patients with rheumatoid arthritis--a randomized study.

OBJECTIVE: To determine the influence of low-dose prednisolone on atherosclerosis, endothelial function, and risk factors for atherosclerosis in patients with early rheumatoid arthritis (RA). METHODS: At start of the first disease modifying antirheumatic drug, 67 patients with early, active RA were randomized to either 7.5 mg prednisolone daily (n = 34) or no prednisolone (n = 33). In the prednisolone group, 21 were treated for 2 years and 13 continuously. After a mean of 5 years intima-media thickness (IMT) and calculated intima-media area (cIMa) of the carotid arteries were determined by B-mode ultrasound. Endothelial function was determined by flow-mediated dilatation (FMD) of the brachial artery. RESULTS: IMT [median (interquartile range) 0.675 mm (0.58-0.82) vs 0.673 mm (0.0.62-0.80)], cIMa [13.7 mm2 (11.45-20.37) vs 14.1 mm2 (12.34-17.38)], prevalence of atherosclerotic plaques (82.3% vs 81.9%), and endothelial function [FMD% (mean +/- SD) 3.88% +/- 2.8 vs 3.74% +/- 2.9] did not differ between patients treated with and those not treated with prednisolone. There were no differences in lumen diameter of carotid arteries, or levels of lipoproteins, glucose, and blood pressure. Patients treated for at least 4 years (and currently treated) with prednisolone had a trend to higher systolic blood pressure (157 +/- 29 mm Hg) compared with untreated patients (141 +/- 28 mm Hg; p = 0.06) and had higher cholesterol levels (5.6 mmol/L +/- 1.39 vs 4.9 +/- 28; p = 0.03). In the whole cohort, age and HDL were independently associated with IMT; age, HDL, and blood pressure with cIMa; and age and serum creatinine with presence of atherosclerotic plaques. CONCLUSION: Low-dose prednisolone did not influence endothelial function and atherosclerosis in patients with RA. However, total cholesterol was higher in patients treated with prednisolone.

Left ventricular function in patients with chronic kidney disease evaluated by colour tissue Doppler velocity imaging.

BACKGROUND: Cardiovascular disease is the leading cause of death in chronic kidney disease (CKD) patients. Tissue Doppler velocity imaging (TVI) is a new objective method that accurately quantifies myocardial tissue velocities, deformation, time intervals and left ventricular (LV) filling pressure. In this study, TVI was compared with conventional echocardiography for the assessment of left ventricular (LV) function in pre-dialysis patients with different stages of CKD. The results obtained by TVI were used to analyse possible relationships between LV function and clinical factors such as hyperparathyroidism and hypertension that could influence LV function. METHODS: Conventional echocardiography and TVI images were recorded in 40 patients (36 men and 4 women, mean age 60+/-14 years, range 28-80 years) and in 27 healthy controls (21 men and 6 women, mean age 58+/-17 years, range 28-82 years). Twenty-two patients had mild/moderate CKD (CCr>29 ml/min; Group 1) and 18 patients had severe CKD (CCr

Renal adenocarcinoma with intramyopericardial and right atrial metastasis, latter via coronary sinus: report of a case.

Primary renal tumors with intracardiac metastasis are not infrequent. Most of the secondary spread is blood-borne and occurs via inferior vena cava. Patients with such a spread often present with cardiac symptoms. We presume that a metastatic spread in the right atrium through coronary sinus has never been reported in the literature according to the result of a Medline search at the time of writing this report.

Assessment of the longitudinal and circumferential left ventricular function at rest and during exercise in healthy elderly individuals by tissue-Doppler echocardiography: relationship with heart rate.

Tissue-Doppler echocardiography (TDE) has been introduced to quantify stress echocardiography by means of assessing the left ventricular (LV) segmental myocardial velocities and excursion. The interaction between LV long- and short-axis function during physical exercise has not been elucidated completely. The aim of the present study was to investigate long- and short-axis LV function, as assessed by myocardial velocities and excursions at rest and during exercise and its possible relationship with heart rate in healthy elderly individuals by TDE. Twenty-seven individuals underwent an exercise test in the supine position on a bicycle ergometer. The initial workload was 30 Watts, followed by 20-Watt increments every third minute. Standard echocardiographic images with super-imposed colour TDE were digitized at the end of each step. The following variables were studied in the LV long- and short-axis: myocardial peak systolic velocity (PSV) and excursion, isovolumic contraction and relaxation times, peak velocity at early diastole (E'-wave) and peak velocity at late diastole (A'-wave) and the E'/A' ratio. Increments in myocardial peak systolic velocity and excursion in the LV long-axis were more pronounced during low workloads. The increase in those variables in the short-axis occurred mainly at higher exercise loads. The improvement in LV long- and short-axis functions was closely related to the increase in the heart rate. Shortening of the isovolumic contraction and relaxation times occurred only at the initial stages of exercise. An increase in the long-axis E'/A' ratio occurred during exercise, whereas this ratio was unchanged in the short-axis. In conclusion, during exercise, the LV long- and short-axis functions behave differently, and increases in LV long- and short-axis functions are related to changes in heart rate. Therefore, in the interpretation of echocardiographic findings during exercise stress echocardiography, these facts have to be taken into account.

Electromechanical coupling, uncoupling, and ventricular function in patients with bundle branch block: a tissue-Doppler echocardiographic study.

BACKGROUND: Left bundle branch block (LBBB) is associated with impaired left ventricular (LV) function and increased morbidity and mortality, especially in patients with structural heart diseases. The mechanisms are poorly understood. SUBJECTS AND METHODS: Subjects with isolated LBBB (n=20), right bundle branch block (RBBB, n=20), and controls (C, n=20) were studied with standard two-dimensional (2D), and color-encoded tissue-Doppler echocardiography (TDE). Inter- and intraventricular systolic and diastolic coordination were assessed from the TDE velocity profiles. LV function was assessed by 2D echocardiography, by TDE-derived peak systolic velocities, and the atrioventricular (AV) plane displacement. RESULTS: Subjects with LBBB had longer electromechanical delays and longer isovolumic relaxation times than did the C and RBBB groups (P <0.001). For the LBBB subjects compared with the RBBB and C groups, ejection times were shorter, peak systolic velocities and AV plane displacements were lower, they had larger LV end-systolic volumes and lower LV ejection fraction (all P <0.001), and the atrial contribution to A-V plane displacement was higher (P <0.01). There were no differences in diastolic or filling times among the groups. CONCLUSIONS: In patients with LBBB, delayed regional electromechanical coupling and uncoupling leads to generalized intra- and interventricular asynchrony, thereby explaining the depressed regional and global LV functions. Assessment of the electromechanical coupling and uncoupling processes and their consequences on cardiac function in patients with BBB and structural heart diseases may be possible using TDE.