Increased regional epicardial fat volume associated with reversible myocardial ischemia in patients with suspected coronary artery disease.

Epicardial adipose tissue is a source of pro-inflammatory cytokines and has been linked to the development of coronary artery disease. No study has systematically assessed the relationship between local epicardial fat volume (EFV) and myocardial perfusion defects. We analyzed EFV in patients undergoing SPECT myocardial perfusion imaging combined with computed tomography (CT) for attenuation correction. Low-dose CT without contrast was performed in 396 consecutive patients undergoing SPECT imaging for evaluation of coronary artery disease. Regional thickness, cross-sectional areas, and total EFV were assessed. 295 patients had normal myocardial perfusion scans and 101 had abnormal perfusion scans. Mean EFVs in normal, ischemic, and infarcted hearts were 99.8 ± 82.3 cm(3), 156.4 ± 121.9 cm(3), and 96.3 ± 102.1 cm(3), respectively (P < 0.001). Reversible perfusion defects were associated with increased local EFV compared to normal perfusion in the distribution of the right (69.2 ± 51.5 vs 46.6 ± 32.0 cm(3); P = 0.03) and left anterior descending coronary artery (87.1 ± 76.4 vs 46.7 ± 40.6 cm(3); P = 0.005). Our results demonstrate increased regional epicardial fat in patients with active myocardial ischemia compared to patients with myocardial scar or normal perfusion on nuclear perfusion scans. Our results suggest a potential role for cardiac CT to improve risk stratification in patients with suspected coronary artery disease.

Echocardiographic evaluation in transposition of the great arteries in the adult.

Transposition of the great arteries is marked by ventriculo-arterial discordance and occurs in 2 distinct subtypes. Echocardiography is the primary method of evaluating this condition in the adult. Key elements of the echocardiographic exam include confirming the diagnosis, evaluating ventricular size and function, assessing valvular regurgitation, identifying atrial baffle leaks or obstruction, estimating pulmonary artery pressures, and ruling out residual shunts.

Left Atrial End-Diastolic Volume Index as a Predictor of Cardiovascular Outcomes: The Heart and Soul Study.

BACKGROUND: The left atrial end-systolic volume index (LAESVI) is a predictor of cardiovascular outcomes and is the recommended measurement of left atrial size. The left atrial end-diastolic volume index (LAEDVI), representing the minimum or residual left atrial volume, has not been fully evaluated as a predictor of cardiovascular events. This study evaluated the predictive power of LAEDVI compared with LAESVI for heart failure (HF) hospitalizations, a composite of HF hospitalizations, myocardial infarction, stroke, and heart disease death, and all-cause mortality. METHODS: We measured LAESVI and LAEDVI in subjects without atrial fibrillation or flutter or significant mitral valve disease. Using Cox proportional-hazard models, the association of LAESVI and LAEDVI with the stated outcomes was examined. RESULTS: After a mean of 7.3±2.6 years of follow-up, there were 147 HF hospitalizations, 118 myocardial infarctions, 45 strokes, 96 heart disease deaths, and 351 deaths from all causes in 938 subjects. When comparing the highest and the lowest quartiles of LAEDVI, there was a near 6-fold increase in the hazard ratio (HR) for HF hospitalization (HR, 5.96; P<0.001). This was higher than what was seen with LAESVI (HR, 4.85; P<0.001). Similar associations were noted for the composite cardiovascular outcome (HR for LAEDVI, 2.97; P<0.001) and for all-cause mortality (HR for LAEDVI, 2.08; P<0.001). In adjusted models, LAEDVI demonstrated equal or better predictive power than LAESVI for HF hospitalization and the composite cardiovascular outcome. CONCLUSIONS: LAEDVI is a strong predictor of cardiovascular events in ambulatory patients with stable coronary heart disease and may merit routine use.

Relationship of Bisphosphonate Therapy and Atrial Fibrillation/Flutter: Outcomes of Sleep Disorders in Older Men (MrOS Sleep) Study.

BACKGROUND: Prior studies suggested an association between bisphosphonates and atrial fibrillation/flutter (AF) in women. This relationship in men, including those with sleep-disordered breathing (SDB), remains unclear. This study evaluated the relationship between bisphosphonate use and prevalent (nocturnal) and incident (clinically relevant) AF in a population of community-dwelling older men. METHODS: A total of 2,911 male participants (mean age, 76 years) of the prospective observational Osteoporotic Fractures in Men Study sleep cohort with overnight in-home polysomnography (PSG) constituted the analytic cohort. Nocturnal AF from ECGs during PSG and incident AF events were centrally adjudicated. The association of bisphosphonate use and AF was examined using multivariable-adjusted logistic regression for prevalent AF and Cox proportional hazards regression for incident AF. RESULTS: A total of 123 (4.2%) men were current bisphosphonate users. Prevalent nocturnal AF was present in 138 participants (4.6%). After multivariable adjustment, there was a significant association between current bisphosphonate use and prevalent AF (OR, 2.33; 95% CI, 1.13-4.79). In the subset of men with moderate to severe SDB, this association was even more pronounced (OR, 3.22; 95% CI, 1.29-8.03). However, the multivariable-adjusted relationship between bisphosphonate use and incident AF did not reach statistical significance (adjusted hazard ratio, 1.53; 95% CI, 0.96-2.45). CONCLUSIONS: These results support an association between bisphosphonate use and prevalent nocturnal AF in community-dwelling older men. The data further suggest that those with moderate to severe SDB may be a particularly vulnerable group susceptible to bisphosphonate-related AF. Similar associations were not seen for bisphosphonate use and clinically relevant incident AF.

Diastolic function assessed by cardiac MRI using longitudinal left ventricular fractional shortening.

INTRODUCTION: Diastolic dysfunction contributes significantly to diastolic heart failure. We examined the use of cardiac magnetic resonance imaging (CMR) using midwall longitudinal fractional shortening (MLFS) in the evaluation of transthoracic echocardiogram (TTE)-evidenced diastolic dysfunction. METHODS: A total of 80 patients with CMR within 6 months of TTE and normal ejection fraction were identified. MLFS was calculated as percentage change in distance from the anterior mitral leaflet base to the apical endocardium in systole and diastole. RESULTS: MLFS of grade II/III [0.14 (0.12-0.16)] was significantly lower than that of grade 0/I [0.20 (0.19-0.21)], P=.001. MLFS detected age-related changes with grade 0 [0.22 (0.21-0.23)] significantly lower than grade I [0.18 (0.16-0.20)], P=.001. CONCLUSION: TTE-evidenced diastolic dysfunction can be reliably identified by CMR using MLFS.

Quantitative assessment of asymmetric aortic dilation with valve-related aortic disease.

RATIONALE AND OBJECTIVES: Previous work suggests that ascending aortic (AsAo) dilation can be asymmetric and is potentially related to valve-related blood flow abnormalities. The aim of this study was to investigate the relationship between the aortic valve and AsAo dilation using a quantitative, three-dimensional assessment of aortic shapes. MATERIALS AND METHODS: Computed tomographic and magnetic resonance images of the thorax were retrospectively reviewed. Four groups with aortic dilation were studied: those with tricuspid aortic valves (TAVs) with and without stenosis and those with bicuspid aortic valves (BAVs) with and without stenosis. Controls had either TAVs or BAVs but no aortic stenosis or dilation. In additional to standard orthogonal diameters, a unique measurement of AsAo asymmetry was used: the ratio of the greater to lesser curvatures measured using three-dimensional reformats in a "candy-cane" orientation. RESULTS: A total of 105 patients were identified. Ratios of greater to lesser curvature in patients with aortic dilation and nonstenotic TAVs were not significantly different from those in controls (1.69 vs 1.55, P > .20), but the asymmetry reflected by this ratio was markedly increased in patients with aortic dilation and stenotic TAVs (1.94, P < .001). Patients with aortic dilation and BAVs had significantly elevated ratios regardless of the status of the aortic valve (1.96 for nonstenotic and 2.05 for stenotic vs 1.53 for controls, P < .001). CONCLUSIONS: Asymmetric AsAo dilation with relative bulging of the greater curvature is linked to aortic stenosis, but it is also seen with nonstenotic BAVs. This suggests that the hemodynamic forces that contribute to aortic dilation are not fully revealed by conventional assessment of the aortic valve.

Epicardial fat volume in patients with left ventricular systolic dysfunction.

Epicardial adipose tissue has been linked to cardiovascular metabolism and inflammation and has been shown to predict prevalence and progression of coronary artery disease. Only limited data are available on the role of epicardial fat in patients with heart failure (HF). We analyzed cardiac adiposity and its relation to markers of morbidity and clinical outcome in patients with normal and impaired left ventricular (LV) function. Epicardial fat volume (EFV) and coronary artery calcium were measured in 381 patients (210 women and 171 men, mean age 55 ± 10 years) who underwent low-dose computed tomography. HF was defined by LV ejection fraction (EF) <55%. Three hundred twenty-one patients had an EF >55% (mean 63 ± 6) and 60 patients had an EF <55% (mean 41 ± 12). Subgroup analysis was performed according to degree of LV dysfunction in patients with HF (LVEF 35% to 55% or <35%). Mean EFVs were 114.5 ± 98.5 cm(3) in patients with normal EF and 83.5 ± 67.1 cm(3) in those with decreased EF (p <0.05). Mean EFVs were 96.1 ± 73.9 cm(3) in patients with moderate HF and 52.2 ± 29.7 cm(3) in patients with severe HF (p <0.05). Subgroup analysis revealed a persistently smaller EFV in patients with HF regardless of coronary artery calcium scores, markers of renal function, lipid metabolism, fasting blood glucose, or body mass index. In conclusion, our data demonstrate a stepwise decrease in EFV in patients with impaired cardiac function.

Electronic screening improves efficiency in clinical trial recruitment.

This study evaluated the performance of an electronic screening (E-screening) method and used it to recruit patients for the NIH sponsored ACCORD trial. Out of the 193 E-screened patients, 125 met the age criterion ("age>or=40"). For all of these 125 patients, the performance of E-screening was compared with investigator review. E-screening achieved a negative predictive accuracy of 100% (95% CI: 98-100%), a positive predictive accuracy of 13% (95% CI: 6-13%), a sensitivity of 100% (95% CI: 45-100%), and a specificity of 84% (95% CI: 82-84%). The method maximized the use of a patient database query (i.e., excluded ineligible patients with a 100% accuracy and automatically assembled patient information to facilitate manual review of only patients who were classified as "potentially eligible" by E-screening) and significantly reduced the screening burden associated with the ACCORD trial.