Echocardiographic assessment of the cardio-renal connection: is left ventricular hypertrophy or diastolic function more closely correlated with estimated glomerular filtration rate in patients with cardiovascular risk factors?

Although left ventricular (LV) hypertrophy and diastolic function assessed by echocardiography and chronic kidney disease (CKD) have been established as predictors of cardiovascular events in hypertensive patients, the relationships between the echocardiographic parameters and renal function have not been fully examined. We examined which echocardiographic parameter correlates best with estimated glomerular filtration rate (eGFR) in patients with cardiovascular risk factors. Enrolled in the study were 309 patients (mean age 67 +/- 13 y) with cardiovascular risk factors. Echocardiography was performed to measure left ventricular mass index (LVMI) as an index of LV hypertrophy. Transmitral early to atrial velocity (E/A) ratio and peak early diastolic mitral annular velocity (E') were measured as indexes of LV diastolic function. E/E' was calculated as a parameter of LV preload. eGFR was measured using the equation proposed by the Japanese Society of Nephrology. The correlations of LVMI (r = -0.333, p < 0.001) and hypertension (r = -0.326, p < 0.001) to eGFR were closer than those of E' (r = 0.276, p < 0.001) and E/A (r = 0.224, p < 0.001) to eGFR. Stepwise regression analysis showed that hypertension (beta coefficient = -0.211, p < 0.001) and LVMI (beta coefficient = -0.206, p < 0.001) were independently associated with eGFR. The E/E' increased with a decrease in eGFR, and E/E' in CKD stage 5 (16.0 +/- 6.8) was significantly higher than that in patients in whom eGFR > or = 90 mL/min/1.73 m(2) (10.5 +/- 4.5) (p < 0.001). Left ventricular diastolic function may be influenced by the increase in LV preload due to progression of CKD stage. Therefore, LV hypertrophy may be superior to LV diastolic dysfunction in predicting low eGFR in patients with CKD using echocardiography.

Acute superior mesenteric venous thrombosis with advanced gastric cancer: a case report.

Although the advanced stages of neoplasms have a risk of superior mesenteric venous thrombosis (MVT), an initial clinical diagnosis of MVT is sometimes difficult and it can be treated as a cancer-related pain using NSAIDs and/or opioids.We herein present a case of palliative stage of cancer with acute MVT, which was successfully treated with immediate anticoagulant therapy. We believe this case provides an important clinical lesson, which is that we should remember that MVT is one of the potential causes of abdominal pain with cancer patients and the thrombosis can be easily identified by US and CT.

Seasonal blood pressure variation and its relationship to environmental temperature in healthy elderly Japanese studied by home measurements.

The purpose of the present study was to examine seasonal blood pressure variation and its relationship to environmental temperature in healthy elderly Japanese, as studied by home measurements. Fifteen healthy elderly Japanese (79.3 +/- 5.9 yrs) measured their blood pressure at home each morning for more than 25 times per month for 3 years. Monthly mean outdoor temperatures were obtained from the Takamatsu meteorological Observatory. The highest levels of systolic and diastolic blood pressure measured at home were observed in February (129 +/- 14 and 81 +/- 13 mmHg). The lowest levels of systolic and diastolic blood pressure measured at home were observed in August (117 +/- 11 and 73 +/- 10 mmHg). Likewise, the lowest and highest means of outdoor temperature were observed in February (5.0 degrees C) and August (29.2 degrees C), respectively. Hence, both systolic and diastolic blood pressure demonstrated a close inverse correlation with the means of outdoor temperature (r = -0.973, p < 0.001 and r = -0.985, p < 0.001, respectively). A 1 degree C decrease in the mean outdoor temperature was associated with rises of 0.43 mmHg in systolic blood pressure (SBP) and 0.29 mmHg in diastolic blood pressure (DBP). Seasonal variations in home blood pressure and outdoor temperature showed complete correspondence in healthy elderly Japanese, with the blood pressures being inversely related to the ambient temperature. These seasonal home blood pressure variations should be kept in mind when controlling blood pressure in elderly patients.

Influences of hypertension and diabetes on normal age-related changes in left ventricular function as assessed by tissue Doppler echocardiography.

Although the impact of hypertension (HT) and type 2 diabetes mellitus (DM) on left ventricular (LV) function has recently been studied using tissue Doppler echocardiography (TDE), there are few studies discriminating between the impact of the disease and that of normal aging on LV function. The purpose of the present study was to elucidate the LV function in patients with HT and DM in various age strata in order to assess the independent roles of HT and DM on normal age-related changes in cardiac function. The population of the study consisted of four groups: 20 control subjects (Control), 20 patients with hypertension alone (HTN), 20 patients with type 2 diabetes alone (DM), and 20 patients with both hypertension and diabetes (HTN+DM) in each of five age strata-the 40s, 50s, 60s, 70s, and 80s. The strain and strain rate, which reflected both LV systolic and diastolic function, were assessed by TDE. The strain and strain rate decreased with advancing age in healthy control subjects and in all the patient groups. The strain and strain rate in the HTN group and the DM group showed lower values than those in the healthy control subjects in each age stratum. Furthermore, the strain and strain rate in the HTN+DM group showed the lowest values among all four groups in each age stratum. These results indicate that LV function as assessed by TDE demonstrates age-related deterioration with normal aging. Although HT or DM affects normal age-related changes in LV function, the co-existence of HT and DM has a more harmful effect on the normal age-related changes than HT alone or DM alone.

Cytomegalovirus-associated acute gastric mucosal lesion in an immunocompetent host.

Involvement of the gastrointestinal tract in cytomegalovirus (CMV) infection is commonly observed in immunocompromised hosts. We encountered an immunocompetent patient with CMV associated-acute gastric mucosal lesion (AGML). The emergence of inclusion bodies characteristic of CMV infection in the specimens obtained from the patient's gastric ulcers was helpful in identifying the cause of AGML. The patient recovered without the administration of antiviral drugs. This case illustrates that CMV infection can be one of the causative agents that trigger AGML even in immunocompetent hosts, and that gastric biopsies are extremely useful for ascertaining the etiology of AGML.

Independent determinants of the Tei index in hypertensive patients with preserved left ventricular systolic function.

The clinical usefulness of the Tei index, which reflects left ventricular (LV) systolic and diastolic function, is known to have prognostic value in patients with overt heart disease such as ischemic heart disease or congestive heart failure. Additionally, LV diastolic functional parameters such as the transmitral E/A (early to atrial velocity) ratio have been shown to have prognostic value in hypertensive patients. However, the clinical usefulness of the Tei index for hypertensive patients without overt heart disease has not yet been fully studied. We compared the Tei index between hypertensive and normotensive patients and examined independent determinants of the Tei index in hypertensive patients with preserved LV systolic function. Our subjects were 319 patients with cardiovascular risk factors including hypertension and diabetes, all of whom had preserved LV systolic function (LV ejection fraction > or = 55%). They were divided into two groups: 100 normotensives (67 +/- 11 years) and 219 hypertensives (69 +/- 13 years). LV structural and functional parameters including transmitral E/A ratio and the Tei index were measured with Doppler echocardiography. The correlations of the transmitral E velocity to the Tei index (r = -0.311, P < 0.001) were the closest in all echocardiographic parameters in hypertensives. Stepwise regression analysis showed that E velocity (beta coefficient = -0.315, P < 0.001) and relative wall thickness (beta coefficient = 0.262, P < 0.001) were independently associated with the Tei index. The Tei index in hypertensives with preserved LV systolic function may be determined primarily by LV diastolic dysfunction during early diastole with LV concentric remodeling and may, together with the E/A ratio, have prognostic value in hypertensive patients.

Early detection of hypertension in a patient treated with sunitinib by measuring cardio-ankle vascular index.

Cardio-ankle vascular index (CAVI) has been established as a marker of arterial stiffness, which is increased in hypertensive patients. CAVI reflects the stiffness of the aorta, femoral artery, and tibial artery. Sunitinib, multi-targeted tyrosine kinase inhibitor with both anti-angiogenic and anti-tumor activities, has been proved effective in patients with gastrointestinal stromal tumors. However, the treatment with sunitinib is often complicated by side effects such as hypertension. We describe an 84-year-old woman with gastrointestinal stromal tumor, who showed changes in arterial stiffness preceding the appearance of hypertension in the early phase after sunitinib initiation. The patient received sunitinib (50 mg given daily) for gastrointestinal stromal tumor. We assessed the influence of sunitinib on arterial stiffness every 7 days by measuring CAVI. The CAVI, which reflects arterial stiffness, was increased from 9.95 at baseline to 11.65 at 7 days after the initiation of sunitinib, whereas the blood pressure remained unchanged (117/72 and 119/76 mmHg). At 14 days after sunitinib initiation, the blood pressure was increased to 159/89 mmHg, indicating the occurrence of hypertension, while the CAVI was 11.90, the similar level detected at 7 days. Subsequently, sunitinib treatment was discontinued, because of the marked decrease in blood platelets. Both blood pressure and CAVI, together with blood platelets, were restored to the baseline values at 12 days after cessation of sunitinib. In conclusion, the increase in the CAVI preceded the appearance of sunitinib-induced hypertension. Arterial stiffness assessed by CAVI may be useful for early detection of sunitinib-induced hypertension.

Decline of plasma brain natriuretic peptide during enzyme replacement therapy in a female patient with heterozygous Fabry's disease.

There are no data regarding changes in plasma brain natriuretic peptide (BNP) levels in patients with Fabry's diseases during enzyme replacement therapy (ERT). We describe a patient with Fabry's disease who demonstrated the improvement in plasma brain BNP levels in response to ERT. Fabry's disease is an X-linked lysosomal storage disorder caused by a deficiency of the enzyme alpha-galactosidase A, which results in progressive intracellular accumulation of globotriaosylceramide (Gb3) in various organs including the heart. Cardiac involvement is frequent in Fabry's disease, resulting in cardiac dysfunction due to hypertrophic changes of the myocardium and thickening of the valves. Although ERT has been reported to improve cardiac function, no consensus has been reached regarding the effectiveness of ERT in female patients with heterozygous Fabry's disease. We report a 44-year-old woman having heterozygous Fabry's disease, who showed mitral valve thickening and regurgitation on echocardiogram. ERT was performed by intravenous infusion of recombinant alpha-galactosidase A every 2 weeks. We assessed the influences of ERT on cardiac function by measuring echocardiograhic parameters and monitoring BNP levels, which show treatment-induced drop in patients with heart failure. Although her cardiac function and mitral regurgitation assessed by echocardiography had not improved 18 months after the beginning of ERT, the plasma BNP level, which was 91.5 pg/ml before ERT, fell to 18.9 pg/ml. In conclusion, plasma BNP levels may be useful for evaluating the effectiveness of ERT for heterozygous Fabry's disease, even in patients who demonstrate no improvement in echocardiographic parameters of cardiac structure and function.

Tissue Doppler echocardiography for predicting arterial stiffness assessed by cardio-ankle vascular index.

It has been reported that left ventricular (LV) diastolic functional parameters assessed by conventional Doppler echocardiography, which measures blood flow velocities in cardiac cavity, correlate with arterial stiffness assessed by the cardio-ankle vascular index (CAVI) and are markers for increased risk of cardiovascular events. Recently, tissue Doppler echocardiography, which measures velocities of regional cardiac wall, has been widely used for assessment of LV diastolic function because of more accuracy than conventional Doppler echocardiography. However, there are no data regarding the ability of tissue Doppler echocardiography for predicting increased arterial stiffness. We investigated the correlation of LV diastolic functional parameters from tissue Doppler echocardiography to CAVI in order to clarify the ability of tissue Doppler echocardiography for predicting increased arterial stiffness in patients with cardiovascular risk factors. Enrolled in the study were 70 patients (69 +/- 8 years) who had no overt heart disease, but had at least one of hypertension, diabetes, and dyslipidemia. The peak early diastolic mitral annular velocity (E') was measured as an index of LV diastolic function using tissue Doppler echocardiography. The E' was correlated with CAVI (r = -0.518, p < 0.001). The optimal cut-off point for the detection of abnormal CAVI (> or = 8.81) was 5.6 cm/s for E' (sensitivity 71%, specificity 71%). The decrease in E' correlated with both LV diastolic dysfunction and increased arterial stiffness. Therefore, the LV diastolic dysfunction assessed by tissue Doppler echocardiography may be useful for predicting increased arterial stiffness and cardiovascular events in the patients with risk factors.

Cardiac diastolic dysfunction is associated with cerebral white matter lesions in elderly patients with risk factors for atherosclerosis.

Cerebral white matter lesions on magnetic resonance imaging (MRI) are considered to be the result of brain ischemic injury and a risk factor for clinical stroke. The purpose of this study was to elucidate the relationship between the cardiac diastolic function and cerebral white matter lesions in elderly patients with risk factors for atherosclerosis. The study subjects were 55 patients (75 +/- 7 years) with risk factors for atherosclerosis including hypertension, diabetes mellitus, and dyslipidemia. Patients with symptomatic cerebrovascular events were excluded from the study. Cerebral white matter lesions, which were defined as exhibiting high intensity regions on brain MRI, were evaluated with the degrees of periventricular hyperintensity (PVH) according to the Japanese Brain Dock Guidelines of 2003. Peak early diastolic mitral annular velocity (E' velocity) was measured by tissue Doppler echocardiography, and was used as a parameter of cardiac diastolic function. The mean value of E' velocity was decreased due to the cardiac diastolic dysfunction (5.2 +/- 1.4 cm/s). In addition, the E' velocity was inversely correlated with the degree of PVH (rho = -0.701, p < 0.001). Stepwise regression analysis showed that the decrease in the E' velocity (beta coefficient = -0.42, p < 0.001) and the presence of hypertension (beta coefficient = 0.31, p = 0.001) were independent determinants of the degree of PVH. Thus, cardiac diastolic dysfunction is correlated to the severity of cerebral white matter lesions, suggesting the cardio-cerebral connection in elderly patients with risk factors for atherosclerosis.

Relationship of cardiac hypertrophy and diastolic dysfunction assessed by echocardiography with atherosclerosis in retinal arteries in hypertensive patients.

Although left ventricular (LV) hypertrophy and diastolic dysfunction assessed by echocardiography are established risk markers of cardiovascular events in hypertensive patients, relationships between these echocardiographic findings and atherosclerosis have not been fully elucidated. The purpose of this study was to examine the relationships between atherosclerosis of the retinal arteries and echocardiographic findings in hypertensive patients. Forty hypertensive patients were divided into two groups according to Scheie's classification by ophthalmologists: 20 patients with stage 1 changes (visible broadening of the light reflex from the artery with minimal arteriovenous compression) and 20 patients with stage 2 changes (more prominent than those in stage 1). Standard echocardiography was performed to measure LV mass index for evaluating LV hypertrophy and conventional diastolic transmitral flow velocities for assessing LV diastolic function. Mitral annular velocities were also measured for evaluating LV diastolic function using tissue Doppler echocardiography. The LV mass index was larger in stage 2 (130 +/- 39 g/m(2)) than stage 1 (96 +/- 16 g/m(2)) patients (p = 0.001). Peak early diastolic mitral annular velocity (E') was lower in stage 2 (5.9 +/- 0.9 cm/s) than stage 1 (7.9 +/- 1.7 cm/s) patients (p = 0.001). The optimal cutoff points for the diagnosis of Scheie stage 2 were 6.6 cm/sec for E' (sensitivity 75%, specificity 85%) and 111 g/m(2) for LV mass index (sensitivity 70%, specificity 90%). In conclusion, in hypertensive patients, the extent of atherosclerosis in the retinal arteries can be estimated by LV hypertrophy and diastolic dysfunction assessed by echocardiography.

Differences in left ventricular hypertrophy and dysfunction between patients with cerebral hemorrhage and those with cerebral infarction.

Left ventricular (LV) hypertrophy and dysfunction due to hypertension have been established as risk markers for stroke in hypertensive patients. The purpose of this study was to examine the differences in LV hypertrophy and dysfunction between patients with cerebral hemorrhage and those with cerebral infarction. The study enrolled 23 hypertensive patients with cerebral infarction, 25 hypertensive patients with cerebral hemorrhage, and 24 normotensive controls (controls). Standard echocardiography was performed; LV mass index was measured to evaluate LV hypertrophy, and conventional diastolic transmitral flow velocities were measured to assess LV diastolic function, which was also evaluated by measuring mitral annular velocities using tissue Doppler echocardiography. The Tei index, which reflects both the diastolic and systolic function of LV, was also calculated. The LV mass index and Tei index were significantly higher in cerebral hemorrhage (116 +/- 38 g/m(2) and 0.57 +/- 0.13) than those in controls (92 +/- 20 g/m(2) and 0.46 +/- 0.10) (p < 0.05). In contrast, the LV mass index and Tei index in cerebral infarction (100 +/- 27 g/m(2) and 0.46 +/- 0.12) were not different from those in controls. Thus, the Tei index was significantly worse in the patients with cerebral hemorrhage than in those with cerebral infarction (p < 0.05). On the other hand, the parameters, which reflect diastolic function, showed no significant differences between cerebral hemorrhage and cerebral infarction. These results indicate that LV hypertrophy and dysfunction due to hypertension are more apparent in patients with cerebral hemorrhage than in those with cerebral infarction.