Socioeconomic status and cardiovascular mortality in over 170,000 cancer survivors.

AIMS: Cardiovascular health is acknowledged as a crucial concern among cancer survivors. Socioeconomic status (SES) is an essential but often neglected risk factor for cardiovascular disease (CVD). We conducted this study to identify the relationship between SES and CVD mortality in cancer survivors. METHODS AND RESULTS: Using the National Health Insurance Service-National Health Examinee database, we identified cancer survivors diagnosed and surviving beyond 5 years post-diagnosis. SES was assessed based on insurance premiums and classified into 5 groups. The primary outcome was overall CVD mortality. This study analyzed 170 555 individuals (mean age 60.7 ± 11.9 years, 57.8% female). A gradual increase in risk was observed across SES groups: adjusted hazard ratios (95% confidence intervals) for overall CVD mortality were 1.15 (1.04-1.26), 1.28 (1.15-1.44), 1.31 (1.18-1.46), and 2.13 (1.30-3.49) for the second, third, and fourth quartile, and medical aid group (the lowest SES group) compared to the highest SES group, respectively (p for trend < 0.001). The lowest SES group with hypertension exhibited a 3.4-fold higher risk of CVD mortality compared to the highest SES group without hypertension. Interaction analyses revealed that low SES synergistically interacts with hypertension, heightening the risk of CVD mortality (synergy index 1.62). CONCLUSION: This study demonstrates a significant correlation between low SES and increased CVD mortality among cancer survivors. Particularly, the lowest SES group, when combined with hypertension, significantly escalates CVD mortality. Our findings underscore the critical importance of recognizing SES as a significant risk factor for CVD mortality in this population of cancer survivors.

Our population-based cohort study, involving over 170 000 cancer survivors, demonstrates a significant association between socioeconomic status (SES) and cardiovascular disease (CVD) mortality.

Genetic predisposition in chemotherapy-induced cardiomyopathy in a 65-year-old female with metastatic breast cancer.

The prevention and management of cancer therapy-related cardiac dysfunction (CTRCD) have become increasingly important. Recent studies have revealed the crucial role of genetics in determining the susceptibility to development of CTRCD. We present a case of a 65-year-old woman with breast cancer who developed recurrent CTRCD following low-dose chemotherapy, despite lacking conventional cardiovascular risk factors. Her medical history included anthracycline-associated cardiomyopathy, and her condition deteriorated significantly after treatment with HER2-targeted therapies. Through the use of multimodal imaging, we detected severe left ventricular systolic dysfunction. Further investigation with genetic testing revealed a likely pathogenic variant in the TNNT2 gene, suggesting a genetic predisposition to CTRCD. This case implies the potential role of genetic screening in identifying patients at risk for CTRCD and advocates for personalized chemotherapy and cardioprotective strategies.

Antihypertensive Medication Adherence and Cardiovascular Outcomes in Patients With Cancer: A Nationwide Population-Based Cohort Study.

Background Hypertension is an important cause of morbidity, which predisposes patients to major cardiovascular events and mortality. The aim of this study was to explore the association between adherence to antihypertensive medication and clinical outcomes in adult patients with cancer. Methods and Results Using the 2002 to 2013 Korean National Health Insurance Service-National Sample Cohort, we extracted adult patients with cancer treated with antihypertensive medications. Based on the medication possession ratio value, participants were divided into 3 groups: good (medication possession ratio ≥0.8), moderate (0.5≤ medication possession ratio <0.8), and poor (medication possession ratio <0.5) adherence groups. The primary outcomes were overall and cardiovascular mortality. The secondary outcome was cardiovascular events requiring hospitalization due to major cardiovascular diseases. Among 19 246 patients with cancer with concomitant hypertension, 66.4% were in the nonadherence group (26.3% were moderate and 40.0% were poor adherence group). Over a median of 8.4 years of follow-up, 2752 deaths and 6057 cardiovascular events occurred. Compared with the good adherence group, the moderate and poor adherence groups had a 1.85-fold and 2.19-fold increased risk for overall mortality, and 1.72-fold and 1.71-fold elevated risk for cardiovascular mortality, respectively, after adjustment for possible confounders. Furthermore, the moderate and poor adherence groups had a 1.33-fold and 1.34-fold elevated risk of new-onset cardiovascular events, respectively. These trends were consistent across cardiovascular event subtypes. Conclusions Nonadherence to antihypertensive medication was common in patients with cancer and was associated with worse clinical outcomes in adult patients with cancer with hypertension. More attention should be paid to improving adherence to antihypertensive medication among patients with cancer.

PRE-OPerative ECHOcardiograhy for prevention of cardiovascular events after non-cardiac surgery in intermediate- and high-risk patients: protocol for a low-interventional, mixed-cohort prospective study design (PREOP-ECHO).

BACKGROUND: Cardiac evaluation using transthoracic echocardiography before noncardiac surgery is common in real-world practice. However, evidence supporting preoperative echocardiography is lacking. This study aims to evaluate the additional benefit of preoperative echocardiography in predicting postoperative cardiovascular events (CVE) in noncardiac surgery. METHODS: This study is designed as a multicenter, prospective study to assess the utility of preoperative echocardiography in patients undergoing intermediate- or high-risk noncardiac surgery. This trial comprises two studies: (1) a randomized controlled trial (RCT) for patients undergoing intermediate-risk surgery with fewer than three clinical risk factors from the revised cardiac risk index (intermediate-risk group) and (2) a prospective cohort study for patients undergoing intermediate-risk surgery with three or more clinical risk factors, or who undergo high-risk surgery regardless of the number of clinical risk factors (high-risk group). We hypothesize that the use of preoperative echocardiography will reduce postoperative CVEs in patients undergoing intermediate- to high-risk surgery through discovery of and further intervention for unexpected cardiac abnormalities before elective surgery. A total of 2330 and 2184 patients will be enrolled in the two studies. The primary endpoint is a composite of all-cause death; aborted sudden cardiac arrest; type I acute myocardial infarction; clinically diagnosed unstable angina; stress-induced cardiomyopathy; lethal arrhythmia, such as sustained ventricular tachycardia or ventricular fibrillation; and/or newly diagnosed or acutely decompensated heart failure within 30 days after surgery. DISCUSSION: This study will be the first large-scale prospective study examining the benefit of preoperative echocardiography in predicting postoperative CVE. The PREOP-ECHO trial will help doctors identify patients at risk of postoperative CVE using echocardiography and thereby reduce postoperative CVEs. TRIAL REGISTRATION: The Clinical Research Information Service KCT0006279 for RCT and KCT0006280 for prospective cohort study. Registered on June 21, 2021.

Associations between the triglyceride-glucose index and cardiovascular disease in over 150,000 cancer survivors: a population-based cohort study.

BACKGROUND: The prevention of subsequent cardiovascular disease (CVD) is an essential part of cancer survivorship care. We conducted the present study to investigate the association between the TyG index (a surrogate marker of insulin resistance) and the risk of cardiovascular disease (CVD) events in cancer survivors. METHODS: Adult cancer patients, who underwent routine health examinations during 2009-2010 and were survived for more than 5 years as of January 1, 2011, were followed for hospitalization of CVD (either ischemic heart disease, stroke, or heart failure) until December 2020. Cox model was used to calculate hazard ratios associated with baseline TyG index (loge [fasting triglyceride (mg) × fasting glucose (mg)/2]) for the CVD hospitalization. RESULTS: A total of 155,167 cancer survivors (mean age 59.9 ± 12.0 years, female 59.1%) were included in this study. A graded positive association was observed between TyG and CVD hospitalization. An 8% elevated risk for CVD hospitalization was observed for a TyG index of 8-8.4 (aHR 1.08 [95% CI 1.01-1.14]); 10% elevated risk for a TyG index of 8.5-8.9 (aHR 1.10 [95% CI 1.03-1.17]); 23% elevated risk for a TyG index of 9.0-9.4 (aHR 1.23 [95% CI 1.15-1.31]); 34% elevated risk for a TyG index of 9.5-9.9 (aHR 1.34 [95% CI 1.23-1.47]); and 55% elevated risk for a TyG index ≥ 10 compared to the reference group (TyG index < 8). Per 1-unit increase in the TyG index, a 16% increase in CVD hospitalization and a 45% increase in acute myocardial infarction hospitalization were demonstrated. Graded positive associations were evident for atherosclerotic CVD subtypes, such as ischemic heart disease, acute myocardial infarction, and ischemic stroke, but not for hemorrhagic stroke or heart failure. CONCLUSIONS: The TyG index may serve as a simple surrogate marker for the risk stratification of future CVD events, particularly atherosclerotic subtypes, in cancer survivors.

Concurrent smoking and alcohol consumers had higher triglyceride glucose indices than either only smokers or alcohol consumers: a cross-sectional study in Korea.

BACKGROUND: The triglyceride glucose (TyG) index is a noninsulin-based marker for insulin resistance (IR) in general practice. Although smoking and heavy drinking have been regarded as major risk factors for various chronic diseases, there is limited evidence regarding the combined effects of smoking and alcohol consumption on IR. This study aimed to investigate the relationship between the TyG index and smoking and alcohol consumption using two Korean population-based datasets. METHODS: This study included 10,568 adults in the Korean National Health and Nutrition Examination Survey (KNHANES) and 9586 adults in the Korean Initiatives on Coronary Artery Calcification (KOICA) registry datasets. Multivariate logistic analysis was conducted to explore the relationship between smoking and alcohol consumption and the TyG index. To assess the predictive value of smoking and alcohol consumption on high TyG index, the area under the curve (AUC) were compared and net reclassification improvement (NRI) and integrated discrimination improvement (IDI) analyses were derived. RESULTS: The combined effect of smoking and alcohol consumption was an independent risk factor of a higher TyG index in the KNHANES (adjusted odds ratio: 4.33, P < .001) and KOICA (adjusted odds ratio: 1.94, P < .001) datasets. Adding smoking and alcohol consumption to the multivariate logistic models improved the model performance for the TyG index in the KNHANES (AUC: from 0.817 to 0.829, P < .001; NRI: 0.040, P < .001; IDI: 0.017, P < .001) and KOICA (AUC: from 0.822 to 0.826, P < .001; NRI: 0.025, P = .006; IDI: 0.005, P < .001) datasets. CONCLUSIONS: Smoking and alcohol consumption were independently associated with the TyG index. Concurrent smokers and alcohol consumers were more likely to have a TyG index that was ≥8.8 and higher than the TyG indices of non-users and those who exclusively consumed alcohol or smoking tobacco.

Association between blood pressure classification defined by the 2017 ACC/AHA guidelines and coronary artery calcification progression in an asymptomatic adult population.

Aims: Coronary artery calcium score (CACS) is widely used for cardiovascular risk stratification in asymptomatic population. We assessed the association of new blood pressure (BP) classification using the 2017 American College of Cardiology/American Heart Association guidelines with coronary artery calcification (CAC) progression according to age in asymptomatic adults. Methods and results: Overall, 10 839 asymptomatic Korean adults (23.4% aged ≤45 years) who underwent at least two CACS evaluations for health check-up were enrolled. Participants were categorized by age (≤45 and >45 years) and BP [normal (<120/<80 mmHg, untreated), elevated (120-129/<80 mmHg, untreated), Stage 1 hypertension (untreated BP 130-139/80-89 mmHg) or Stage 2 hypertension (BP ≥140/≥90 mmHg or anti-hypertensive use)] groups. CAC progression was defined as a difference of ≥2.5 between the square root (√) of the baseline and follow-up CACS. During a mean 3.3-year follow-up, the incidence of CAC progression was 13.5% and 36.3% in individuals aged ≤45 and >45 years, respectively. After adjustment for age, sex, diabetes, dyslipidaemia, obesity, current smoking, and baseline CACS, hazard ratios (95% confidence interval) for CAC progression in elevated BP, Stage 1 hypertension, and Stage 2 hypertension compared to normal BP were 1.43 (0.96-2.14) (P = 0.077), 1.64 (1.20-2.23) (P = 0.002), and 2.38 (1.82-3.12) (P < 0.001) in the ≤45 years group and 1.11 (0.95-1.30) (P = 0.179), 1.17 (1.04-1.32) (P = 0.009), and 1.52 (1.39-1.66) (P < 0.001) in the >45 years group, respectively. Conclusion: Newly defined Stage 1 hypertension is independently associated with CAC progression in asymptomatic adults regardless of age.

Sex-specific associations of obesity with exercise capacity and diastolic function in Koreans.

BACKGROUND AND AIMS: Women with obesity are highly predominant among patients with heart failure with preserved ejection fraction (HFpEF). We aimed to elucidate sex-specific associations of obesity with exercise capacity and diastolic function. METHODS AND RESULTS: Healthy individuals without known cardiovascular diseases undergoing cardiopulmonary exercise test and echocardiography (n = 736) were included and categorized into 4 groups according to their sex and obesity. Exercise capacity was lower in women than men. Obesity was associated with a lower exercise capacity in women (23.5 ± 7.3 vs. 21.3 ± 5.4 ml/kg/min, p < 0.05) but not in men (28.2 ± 7.8 vs. 28.0 ± 6.6 ml/kg/min, p > 0.10). Overall, women had a higher E/e' than men. Women without obesity had a similar E/e' to men with obesity (8.2 ± 1.8 vs. 8.4 ± 2.1, p > 0.10), and women with obesity had the highest E/e'. Among 5 risk factors (aging, obesity, elevated blood pressure, elevated heart rate, and elevated fasting glucose), obesity was a significant determinant of exercise intolerance in women but not men. Furthermore, obesity was associated with a greater risk of diastolic dysfunction in women than men (women, adjusted odds ratio 4.35 [95% confidence interval 2.44-7.74]; men, adjusted odds ratio 2.91 [95% confidence interval 1.42-5.95]). CONCLUSION: Obesity had a more deleterious effect on exercise capacity and diastolic function in women than men, even in a healthy cohort. These subclinical changes might contribute to the development of a female predominance among HFpEF patients, particularly among individuals with obesity.

Cardiovascular disease burden in adult patients with cancer: An 11-year nationwide population-based cohort study.

BACKGROUND: Cardiovascular disease (CVD) is an important cause of morbidity and mortality in patients with cancer. However, the real-world CVD burden of adult cancer patients has not been well established. This study aimed to evaluate the prevalence and mortality of pre-existing and new-onset CVD in patients with cancers. METHODS: We analysed the prevalence and mortality of pre-existing and new-onset CVD in 41,034 adult patients with ten common solid cancers in a single payer system using data from the Korean National Health Insurance Service-National Sample Cohort from 2002 to 2013. RESULTS: When all types of cancer were included, 11.3% (n = 4647) of patients had pre-existing CVD when they were diagnosed with cancer. After excluding patients with pre-existing CVD, 15.7% of cancer patients (n = 5703) were newly diagnosed with CVD during the follow-up period (median 68 months). Both pre-existing and new-onset CVD were associated with increased risk of overall mortality and 5-year mortality. Multivariate analysis to predict all-cause mortality indicated both pre-existing and new-onset CVD, male sex, old age, prior history of diabetes or chronic kidney disease, suburban residential area, and low-income status as significant factors. CONCLUSIONS: Eleven percent of cancer patients had pre-existing CVD at the time of cancer diagnosis, and about 16% of cancer patients without pre-existing CVD were newly diagnosed with CVD, mostly within 5 years after the cancer diagnosis. Proper management of pre-existing CVD is necessary and pre-emptive prevention of new-onset CVD may alter treatment options and outcomes.

The cardiovascular risk factors associated with the plaque pattern on coronary computed tomographic angiography in subjects for health check-up.

BACKGROUND: Although it is known that coronary computed tomographic angiography (CCTA) offers highly negative predictive value to exclude obstructive coronary lesions, the plaque pattern on CCTA has not been fully understood. The purpose of this study was to explore the difference of the plaque patterns on CCTA and to assess the cardiovascular risks in healthy subjects. METHODS: A total of 3914 subjects (mean age: 55 ± 10 years, M : F = 2649 : 1265) who underwent CCTA for health check-up between January 2009 and December 2012 were enrolled. According to coronary artery calcium score (CACS) and plaque pattern on CCTA, subjects were categorized into four groups (group 1: normal; group 2: "non-calcified" plaque; group 3: "calcified" plaque; group 4: mixed plaque). We analyzed cardiovascular risks and Framingham risk score (FRS) among the groups. RESULTS: The incidence of each group was group 1 in 55.0% (2152/3914), group 2 in 5.1% (200/3914), group 3 in 8.2% (319/3914), and group 4 in 7.2% (280/3914), respectively. There was no difference of FRS among the groups (6.4 ± 6.4%; 6.5 ± 4.6%; 8.2 ± 5.8%; 7.7 ± 5.7% p = 0.086). In multivariate analysis, HbA1c (OR = 2.285; 95%CI = 1.029 - 5.071; p = 0.042) in group 2; age (OR = 1.115; 95%CI = 1.034 - 1.202; p = 0.005) and smoking status (OR = 3.386; 95%CI = 1.124 - 10.202; p = 0.030) in group 3; and age (OR = 1.054; 95%CI = 1.011 - 1.099; p = 0.014) and hypertension (OR = 3.087; 95%CI = 1.536 - 6.202; p = 0.001) in group 4 were independent factors. CONCLUSIONS: Our data suggest that more individualized therapy for reduction of cardiovascular risks associated with plaque pattern on CCTA could be considered in healthy subjects.

Association between left ventricular function and paraprotein type in patients with multiple myeloma.

BACKGROUND/AIMS: Multiple myeloma (MM)-associated cardiac damage, particularly according to the type of monoclonal (M) protein has not been elucidated. We sought to investigate relationship between elevated serum M protein levels and echocardiographic indices of cardiac structure and function in patients with MM. METHODS: We evaluated a total of 184 consecutive MM patients who underwent echocardiography for bone marrow pre-transplant screening. Serum levels of intact immunoglobulin M protein and free light chain kappa/lambda (FLC-κ/-λ) were measured. RESULTS: One hundred thirty-nine patients were non-light chain MM (non-LCMM) and 45 patients belonged to LCMM. In patients with non-LCMM, significant correlations were found between serum M protein and left atrial volume index (LAVi; r = 0.720, p < 0.0001), E/e' (r = 0.511, p < 0.0001), and systolic pulmonary arterial pressure (r = 0.485, p < 0.0001). In patients with LCMM, log-transformed FLC-λ (log-λ) was correlated with left ventricular ejection fraction (LVEF, r = -0.536, p = 0.010), left ventricular (LV) end-systolic dimension (r = 0.500, p = 0.018), and LV end-systolic volume (r = 0.444, p = 0.038). On multivariate analyses, hematocrit and serum M protein were independent predictors of LAVi in patients with non-LCMM. In patient with LCMM, FLC-λ isotype was only found to be an independent determinant of LVEF. CONCLUSIONS: An increase in serum M protein was associated with LV diastolic dysfunction, whereas an increase in serum FLC-λ concentration showed a negative correlation with the echocardiographic parameters of LV systolic function. These findings also suggest that serum M protein has different effects on LV function according to the type of paraproteins in patients with MM.

Leukemic infiltration presenting as myocardial hypertrophy after complete remission of acute myeloid leukemia.

Here, we report a rare case of isolated leukemic infiltrate of the myocardium (extramedullary involvement) presenting as restrictive cardiomyopathy in a patient in complete remission of acute myeloid leukemia. It was evaluated with multimodality imaging studies (echocardiography and cardiac MRI) and further confirmed by pathology. The present case highlights the importance of maintaining a high degree of clinical suspicion when evaluating patients with progressive ventricular hypertrophy of unknown cause, including recognition of the potential involvement by recurrent hematologic malignancy.

Impact of prolapsing leaflet location on exercise pulmonary hypertension in mitral regurgitation.

AIMS: We aimed to evaluate whether prolapsing leaflet-specific exercise pulmonary hypertension (PHT) exists and to identify the related mechanisms. METHODS AND RESULTS: Resting and bicycle exercise transthoracic echocardiography was performed in 35 consecutive patients (aged 56 ± 11, 69% men) with asymptomatic, moderate-to-severe, and degenerative mitral regurgitation (MR). The patients were classified into two groups according to the prolapsing leaflet: an anterior mitral leaflet (AML) group (n = 17) and a posterior mitral leaflet (PML) group (n = 18). At rest, the MR severity and systolic pulmonary artery pressure (SPAP) were similar between the two groups. During exercise, changes in the regurgitant volume (ΔRV) were markedly increased in the PML group compared with the AML group (23.9 ± 13.6 vs. 13.9 ± 10.5 mL, P= 0.022). Moreover, exercise-induced changes in SPAP (ΔSPAP) were more significant in the PML group (35.8 ± 10.7 vs. 26.7 ± 8.7 mmHg, P= 0.009). Further analysis of the resting left atrial (LA) characteristics revealed decreased LA reservoir function and a more ellipsoid left atrium in the PML group. Multiple linear regression analysis revealed that ΔRV was an independent determinant of ΔSPAP (ß= 0.34, P= 0.013) after adjustment for other confounding factors. CONCLUSION: PML prolapse is associated with a greater increase in exercise-induced SPAP, and the prominent increase in MR severity in PML prolapse is thought to be the main mechanism responsible for this increase. The current study suggests the need for more frequent follow-up of patients with PML prolapse.

Is carotid artery evaluation necessary for primary prevention in asymptomatic high-risk patients without atherosclerotic cardiovascular disease?

OBJECTIVE: Routine measurement of the carotid intima-media thickness is not recommended in recent clinical practice guidelines for risk assessment of the first atherosclerotic cardiovascular disease (ASCVD) event (the definition of which includes acute coronary syndromes, a history of myocardial infarction, stable or unstable angina, coronary or other arterial revascularization, stroke, transient ischemic attack, or peripheral arterial disease presumed to be of atherosclerotic origin). The aim of the present study was to elucidate the role of carotid artery evaluation for primary prevention of ASCVD in asymptomatic high-risk patients visiting a teaching hospital. METHODS: Eight hundred seventy-three patients (487 male [55.8%], mean age 59.4±11.5 years) who were statin-naive and without ASCVD, which was proven by coronary angiography or coronary CT angiography, were enrolled in this study. The patients underwent carotid scanning in the Medical Department of St Mary's Hospital from September 2003 to March 2009. ASCVD outcomes were evaluated for median follow-up of 1,402 days. RESULTS: A total of 119 participants experienced ASCVD events. In multivariate Cox regression analysis, age (hazard ratio [HR] =1.026, 95% confidence interval [CI] =1.002-1.050, P=0.033), history of smoking (HR =1.751, 95% CI =1.089-2.815, P=0.021), statin therapy (HR =0.388, 95% CI =0.205-0.734, P=0.004), and carotid plaques (HR =1.556, 95% CI =1.009-2.400, P=0.045) were associated with ASCVD events. In middle-aged group (45≤ age <65, n=473), history of smoking (HR =1.995, 95% CI =1.142-3.485, P=0.015), statin therapy (HR =0.320, 95% CI =0.131-0.780, P=0.012), and carotid plaques (HR =1.993, 95% CI =1.116-3.560, P=0.020) were associated with ASCVD events. CONCLUSION: The presence of carotid plaques, history of smoking, and statin therapy might be important factors for primary prevention of ASCVD in asymptomatic high-risk patients, especially in middle-aged patients. Therefore, the results suggest that carotid artery parameters may have an additional predictive value for primary prevention of ASCVD in the middle-aged high-risk patients.

Reversible Pulmonary Arterial Hypertension Associated with Dasatinib for Chronic Myeloid Leukemia.

We describe two cases of pulmonary arterial hypertension (PAH) that occurred under dasatinib treatment and were resolved after dasatinib discontinuation. Two patients with chronic phase chronic myeloid leukemia (CML) were switched to dasatinib therapy because of hematological progress while receiving imatinib. These patients had New York Heart Association (NYHA) functional class II dyspnea with elevated right ventricular systolic pressure (RVSP), which progressed under dasatinib treatment. After dasatinib treatment was discontinued, subjective symptoms were improved to NYHA functional class I and the follow-up transthoracic Doppler echocardiography showed improved RVSP. Treatment with an alternate tyrosine kinase inhibitor was initiated and had been continued without development of dyspnea or elevation of RVSP. This report suggests that dasatinib can cause the reversible PAH, therefore, routine cardiopulmonary evaluation before and during treatment with dasatinib may be needed in CML patients with clinical manifestations.

Aortic valve calcium score is associated with coronary calcified plaque burden.

The aim of this study was to investigate the association between the aortic valve calcium score (AVCS) and the coronary plaque burden using 64-slice multi-detector computed tomography (MDCT). Calcification of the aortic valve without significant aortic stenosis itself has been suggested to be a marker of atherosclerosis. In this study, we attempted to identify a quantitative correlation between AVCS and the coronary plaque burden assumed by the Gensini score. We retrospectively evaluated 200 patients (aged 40 - 88 years) who underwent MDCT and coronary angiography for chest pain. After exclusion of an aortic stenosis (peak velocity ≥ 2.0 m/s), the plaque burden of the coronary artery was determined by the Gensini score based on the plaque composition (calcified, mixed, or noncalcified plaque) of the CT angiogram. The calcific aortic valve group (AVCS > 0) showed no significant difference in the total plaque burden compared to the noncalcific aortic valve group (AVC = 0) (Gensini score 23.6 ± 15.1 versus 21.2 ± 17.5, P = 0.31). However, the calcified plaque burden was higher in the calcific aortic valve group (Gensini score by calcified plaque 9.1 ± 10.4 versus 5.5 ± 8.6, P = 0.008). In the subgroup of patients who had an AVCS of more than 90.0 (upper 75th percentile, n = 20), the AVCS showed a more significant correlation with the Gensini score by calcified plaque (r = 0.618, P < 0.01). Our results suggest that a high level of AVCS is associated with the calcified plaque burden of the coronary artery rather than the total plaque burden.

Left atrial eccentricity in chronic mitral regurgitation: relation to left atrial function.

AIMS: The aim of this study was to assess the changes in the left atrial (LA) shape and to identify the determinants of these changes in chronic mitral regurgitation (MR). METHODS AND RESULTS: We enrolled 125 consecutive patients (56 ± 16 years, 51% men) with chronic MR caused by myxomatous mitral valve disease in sinus rhythm and 45 control patients (54 ± 15 years, 55% men) undergoing transthoracic Doppler echocardiography. The LA eccentricity index (LAEi) and the LA volume index (LAVi) were used to estimate the LA shape and size, respectively. There were significant decreases in LAEi (r= -0.723, P< 0.001) and increases in LAVi (r= 0.642, P< 0.001) with increasing severity of MR. In multivariate stepwise linear regression analysis, regurgitant fraction (RF) was an independent determinant of the LAE, whereas RF, left ventricular (LV) mass index and LV diastolic dysfunction grade were independent determinants of the LA volume. The LAEi was positively related to the velocity of A' in the entire population (r = 0.238, P = 0.002). On the receiver operating characteristic (ROC) curve analysis, LAEi ≤1.30 was the best cut-off value to reflect the LA systolic dysfunction (A' velocity <7 cm/s; area under the curve was 0.78, P < 0.001). CONCLUSION: LA becomes more spherical with increasing severity of MR, suggesting a decrease in LAE, which is mainly determined by the volume overload. LAE might be closely related to the LA systolic function in chronic MR.

Asymptomatic myxoma originating from the right ventricular outflow tract.

Asymptomatic right ventricular outflow tract (RVOT) myxoma is quite rare. We report an unusual case of asymptomatic myxoma arising from the RVOT which was successfully surgically removed.

Pericardial effusion and pericardiocentesis: role of echocardiography.

Pericardial effusion can develop from any pericardial disease, including pericarditis and several systemic disorders, such as malignancies, pulmonary tuberculosis, chronic renal failure, thyroid diseases, and autoimmune diseases. The causes of large pericardial effusion requiring invasive pericardiocentesis may vary according to the time, country, and hospital. Transthoracic echocardiography is the most important tool for diagnosis, grading, the pericardiocentesis procedure, and follow up of pericardial effusion. Cardiac tamponade is a kind of cardiogenic shock and medical emergency. Clinicians should understand the tamponade physiology, especially because it can develop without large pericardial effusion. In addition, clinicians should correlate the echocardiographic findings of tamponade, such as right ventricular collapse, right atrial collapse, and respiratory variation of mitral and tricuspid flow, with clinical signs of clinical tamponade, such as hypotension or pulsus paradoxus. Percutaneous pericardiocentesis has been the most useful procedure in many cases of large pericardial effusion, cardiac tamponade, or pericardial effusion of unknown etiology. The procedure should be performed with the guidance of echocardiography.

Hydroxychloroquine-induced cardiomyopathy that presented as pulmonary hypertension: a newly noted complication.

We examined a 63-year-old woman with progressive dyspnea. Two years prior to admission to our hospital, she had been diagnosed with rheumatoid arthritis and treated with hydroxychloroquine (HCQ) with a cumulative dose of 164 g. In addition, 2 months earlier, she had been diagnosed with connective tissue disease-related pulmonary artery hypertension. We performed an electrocardiogram and noted complete atrioventricular block. A transthoracic echocardiogram showed pulmonary hypertension. Due to the unclear nature of the pulmonary hypertension, we performed cardiac catheterization and right ventricular endomyocardial biopsy. Cardiac catheterization revealed that pulmonary hypertension was due to left ventricular dysfunction. Electron microscopy of the cardiac biopsy demonstrated a curvilinear body, diagnostic of HCQ toxicity. Thus, we diagnosed pulmonary hypertension owing to left heart disease and complete atrioventricular block that resulted from HCQ toxicity. Insertion of a permanent pacemaker and discontinuation of HCQ dramatically improved the disease state. This is the first report of this type of cardiac complication with HCQ; it raises the awareness that HCQ may cause cardiac complications despite a small cumulative dose relative to doses reported in other cases. Furthermore, we emphasize that cardiac catheterization played a critical role in the differential diagnosis from pulmonary hypertension associated with connective tissue disease.