Prognostic significance of left ventricular end diastolic pressure using E/E' in patients with hypertrophic cardiomyopathy.

BACKGROUND: Left ventricular (LV) diastolic dysfunction is a prominent feature of hypertrophic cardiomyopathy (HCM). Prediction of LV filling pressure using the ratio between early diastolic transmitral flow and mitral annular velocity (E/e') had proved a good accuracy. AIM OF THIS STUDY: We investigated the value of E/e' to predict cardiovascular (CV) mortality in patients with HCM. METHODS: A total of 243 patients with HCM had E/e' measured in combination with clinical evaluation, conventional echocardiographic measurements, cardiopulmonary exercise evaluation, and Holter monitoring. RESULTS: During a mean follow-up of (3.2 ± 1.2 years), 17 (7%) patients died. Non survivors had significantly higher SBP, DBP, left ventricular outflow tract obstruction (LVOTO) gradient, mitral E, and E/e', but lower e' of mitral annulus and more prevalent restrictive filling pattern. E/e' was directly correlated with age (r = .24, P < .005), left atrial volume index (r = .44, P < .0001), LVMI (r=0.23,P<.005), LVOT gradient (r = .43, P < .0001), NYHA class (r = .19, P < .006), pulmonary artery pressure (r = .24, P < .005), positive family history of HCM (r = .22, P < .005), and inversely related to peak systolic velocity (S) (r = .44, P < .0001). By multivariate analysis, only LVOTO ([RR] 4.11, 95% CI 1.002 to 1.148, P < .04) and E/e' were independent predictors for overall mortality in HCM (relative risk [RR] 5.27, 95% CI 1.002 to 1.024, P < .02). The risk of dying increased with increasing E/e' ratio, being approximately 4 times higher for patients in the highest quartile (HR 3.8 (CI 1.38-5.12, log-rank < 0.002)). CONCLUSIONS: In hypertrophic cardiomyopathy, the E/e' ratio remains a powerful predictor of all-cause mortality, particularly if it is associated with LVOT obstruction.

Characterization of Left Atrial Mechanics in Hypertrophic Cardiomyopathy and Essential Hypertension Using Vector Velocity Imaging.

BACKGROUND: Systemic hypertension (HTN) and hypertrophic cardiomyopathy (HCM) may be associated with left atrial (LA) dilation, but whether LA functional abnormalities are characteristic to each disease or not, is unknown. The aim of this study was to characterize LA mechanical changes in patients with HTN and HCM using vector velocity imaging (VVI). METHODS: VVI-derived longitudinal LA function was acquired from apical views in 76 CM patients, 33 hypertension patients and 30 age-matched controls. Peak atrial longitudinal strain (ɛsys ), atrial strain rate during systole (SRsys ), early diastole (SRe ), and late diastole (SRa ) were measured (corresponding to LA reservoir, conduit and contractile functions, respectively). Similar parameters were used to assess left ventricular (LV) function. RESULTS: LV mass and LA volume index were higher in HCM and HTN than in controls. Both LA Reservoir function (LA ɛsys SRsys ) and conduit function (SRe ) were more declined in HCM patients, in comparison to HTN patients and controls (P < 0.0001),whereas conduit function was the only function deteriorated in the HTN group. LA contractile function was preserved among patient groups. In HCM, LV ɛsys and SRa [P < 0.001] are independent predictors for LA ɛsys . While in hypertension, only LVMI is an independent predictor for LA dysfunction (P < 0.01). By receiver operating characteristic analyses, only atrial reservoir function was extrapolative and appeared to be accurate in discriminating HCM from both hypertension and controls, with LA ɛsys ≤ 33% being more sensitive (71.8%) and specific (75%). CONCLUSIONS: Response of LA mechanics to pathologic hypertrophy is entirely different. In HCM LA reservoir and conduit functions are more deteriorated and related to the severity of phenotype, while in hypertension the conduit function is chiefly affected and LA dysfunction is linked to a more advanced disease.

Unified adult transthoracic echocardiographic report: an expert consensus document of the Egyptian Working Group of Echocardiography.

BACKGROUND: Physicians face complexity in interpreting the results of echocardiography (ECHO) due to the variability across ECHO laboratories. Many international organizations published reports to reduce the inter-variability in ECHO reporting. However, with the evolution of imaging modalities, significant improvements in ECHO reporting are essential to eliminate any previous discrepancies. The Egyptian Working Group of Echocardiography (EEWG) aimed to prepare a standardized, updated, simple, and comprehensive ECHO reporting in Egypt to offer consistency, guarantee that all the crucial features are fulfilled, and ease practitioners' communication to maximize clinical decision-making. MAIN TEXT: Relevant articles were retrieved and reviewed to explore the current state of TTE reporting practices, existing guidelines, and challenges faced by physicians in interpreting TTE results. Identified gaps and areas for improvement were then employed to establish the outline for the standardization approach. This report addresses crucial components such as demographic data, measurements, and interpretative summaries. It emphasizes left ventricle measurements and systolic function assessment, incorporating advanced techniques like speckle tracking and three-dimensional imaging. The significance of evaluating diastolic function, examining the right ventricle, and assessing valves, pericardium, and aorta are also discussed. CONCLUSION: The current consensus goals to streamline communication among practitioners contribute to a more unified approach to interpreting ECHO results. Our initiative marks a significant step forward in enhancing the standardization and quality of ECHO reporting in Egypt. By introducing this report and encouraging continuous learning, the working group aims to raise the overall reporting quality and facilitate interpretation across diverse echocardiographic settings. This concerted effort improves patient care by ensuring consistency, accuracy, and relevance in interpreting echocardiographic findings.

2024 Egyptian consensus statement on the role of non-statin therapies for LDL cholesterol lowering in different patient risk categories.

BACKGROUND: The new millennium has witnessed increased understanding of cardiovascular (CV) risk factors and improvement in atherosclerotic cardiovascular disease (ASCVD) management. The role of LDL cholesterol and other atherogenic lipid particles in the development of atherosclerosis is now beyond doubt. MAIN BODY: Statins have been widely used and recommended in guidelines for preventing and managing ischemic events. However, statins have side effects, and many patients do not achieve their low-density lipoprotein cholesterol (LDL-C) goals. In recent years, non-statin lipid-lowering agents have gained increasing use as adjuncts to statins or as alternatives in patients who cannot tolerate statins. This consensus proposes a simple approach for initiating non-statin lipid-lowering therapy and provides evidence-based recommendations. Our key advancements include the identification of patients at extreme risk for CV events, the consideration of initial combination therapy of statin and ezetimibe in very high-risk and extreme-risk groups and the extended use of bempedoic acid in patients not reaching LDL-C targets especially in resource-limited settings. CONCLUSIONS: Overall, this consensus statement provides valuable insights into the expanding field of non-statin therapies and offers practical recommendations to enhance CV care, specifically focusing on improving LDL-C control in Egypt. While these recommendations hold promise, further research and real-world data are needed for validation and refinement.

Boosting protection for patients with non-acute cardiovascular disease: a focus on antithrombotic regimen (a consensus expert opinion from the Egyptian Society of Cardiology working group of thrombosis and prevention).

BACKGROUND: Till the moment of this document writing, no Egyptian consensus is there to guide selection of additional antithrombotic in stable patients with established CVD. Despite use of lifestyle measures and statins, those patients with established CVD still face a considerable burden of residual risk. MAIN BODY: With the evolvement of evidence-based medicine, there have been a lot of recommendations to use additional antithrombotic medications to maximize protection for those patients. Accordingly, the Egyptian Society of Cardiology working group of thrombosis and prevention took the responsibility of providing an expert consensus on the current recommendations for using antithrombotic medications to maximize protection in stable patients with established CVD. For stable patients with established CVD, in addition to proper lifestyle measures and appropriate dose statins, we recommend long-term aspirin therapy. In patients who are unable to take aspirin and in those with a history of gastrointestinal bleeding, clopidogrel is a reasonable alternative. CONCLUSIONS: For some stable atherosclerotic CVD patients who are at high risk of cardiovascular events and at low risk for bleeding, a regimen of rivaroxaban and aspirin might be taken into consideration.

Egyptian practical guidance in lipid management 2020.

BACKGROUND: Numerous epidemiological investigations and randomized clinical studies have determined that dyslipidemia is a major contributor to atherosclerotic cardiovascular disease (ASCVD). Consequently, the management of serum cholesterol and low-density lipoprotein levels has become a central objective in the effort to prevent cardiovascular events. MAIN BODY: Many guidelines were issued by different organizations and societies to define patient risk and establish important recommendations for management strategies. Newer cholesterol-lowering agents (non-statin drugs) are described, and their use is directed primarily to secondary prevention in patients at very high risk of new ASCVD. CONCLUSION: The present guidance summarizes the current methods for risk estimation and outlines the most recent data on lipid management in a simple user-friendly format, to improve physician awareness and help implement guidelines in the daily practice.

Platelet/lymphocyte ratio for prediction of no-reflow phenomenon in ST-elevation myocardial infarction managed with primary percutaneous coronary intervention.

BACKGROUND: Coronary no-reflow phenomenon in ST-segment elevation myocardial infarction (STEMI) is associated with a poor clinical outcome. Although its pathophysiology is not fully understood, a deregulated systemic inflammatory response plays an important role. We aimed to explore the relationship between platelet\lymphocyte ratio (PLR) and no-reflow in patients with acute STEMI who were treated with a primary percutaneous coronary intervention (PPCI). METHODS: A total of 200 patients with STEMI undergoing PPCI were included in the study. Transthoracic echocardiographic examination was performed to assess left ventricular (LV) ejection fraction (EF) and wall motion score index. Blood samples were assayed for platelet and lymphocyte count before PPCI. No-reflow was defined as coronary blood flow thrombolysis in myocardial infarction grade ≤II. RESULTS: No-reflow was observed in 58 (29%) of STEMI patients following PPCI. PLR was significantly higher in hypertensive patients compared to normotensive patients (144.7±91.6 vs. 109.1±47.1, respectively, P<0.001) and in the no-reflow group compared to the normal reflow group (214±93 vs. 101.6±51.3, respectively, P<0.0001). Logistic regression analysis revealed that PLR (ß: 0.485, 95% CI: -0.006-0.001, P<0.002) and LV EF (ß: 0.272, 95% CI: 0.009-0.034, P<0.001) were independent predictors of no-reflow after PPCI. CONCLUSION: Pre-procedural increase in PLR is predictive of the no-reflow phenomenon following PPCI in STEMI patients. RELEVANCE FOR PATIENTS: No reflow phenomenon is an unfavorable complication following PPCI in patients with acute STEMI. High pre-procedural PLR is an independent predictor of reperfusion failure and helps to identify patients who require prophylactic treatment.

Impact of the left anterior descending artery wrapping around the left ventricular apex on cardiac mechanics in patients with normal coronary angiography.

BACKGROUND: We examined the impact of left anterior descending (LAD) wrapping on left ventricular (LV) mechanics in patients with normal coronary angiography. Seventy-one patients with evidence of normal coronary angiography (LAD wrapping: n = 52, 73%) and LAD non-wrapping (n = 19, 27%) were included in the study. Using 2D-strain imaging, we measured LV longitudinal and circumferential (circ) strain (εsys), systolic strain rate (SRsys), early (SRe) and atrial (SRa) diastolic SR, LV electromechanical dyssynchrony (TTP-SD), and LV twist and torsion in study groups. RESULTS: No significant difference in age, gender, body surface area (BSA), or ejection fraction (EF%) between groups. LAD-wrapping group showed higher deceleration time (DT) (P < 0.0001), global longitudinal εsys % (P < 0.02), circ SRa at the basal segments (P < .02), circ SRsys and SRe, and SRa (P < 0.0001) at the apical segments and apical rotation compared with the non-wrapped group. LV twist was correlated negatively with LV electromechanical dyssynchrony (r = .25, P < 0.03) and positively with longitudinal εsys (r = .47, P < .0001), circ εsys% (r = .55, P < .0001), circ SRsys (r = .23, P < .05), and circ SRe (r = .55, P < .0001). Using multivariate regression analysis, DT: OR 0.932, CI 0.877-0.991, and P < 0.02 and circ at atrial diastole (SRa): OR 0.000, CI .000-.271, and P < 0.03 were independent predictors of LAD wrapping around LV apex. CONCLUSION: Wrapped LAD is associated with better myocardial relaxation and rotational mechanics in patients with normal coronary angiography. This could explain the worse prognosis in such population when LAD occlusion acutely emerges.

Effect of Short-Term L-Thyroxine Therapy on Left Ventricular Mechanics in Idiopathic Dilated Cardiomyopathy.

OBJECTIVE: Previous experimental studies have provided evidence of notable changes in thyroid hormone signaling that corresponds to alterations in myocardial function in animal models of heart failure (HF). The present study further explores whether oral thyroid hormone treatment can change left ventricular (LV) mechanics and functional status in patients with idiopathic dilated cardiomyopathy (IDCM) or not. METHODS: Sixty IDCM patients who were receiving conventional HF treatment were randomized to oral L-thyroxine (n = 40) or placebo (n = 20) for 3 months. Fifty-two (86.7%) of all IDCM patients were symptomatic, their mean age was 41 ± 12 years, and their ejection fraction was 32% ± 7%. At baseline, the two groups were comparable in clinical and echocardiographic variables. Vector velocity imaging was utilized to assess LV mechanics. Myocardial longitudinal peak systolic strain, systolic strain rate, early and late diastolic strain rate, circumferential strain, LV dyssynchrony, plasma tri-iodothyronine, thyroxine, and thyroid stimulating hormone levels were measured at baseline and 3 months after treatment. RESULTS: All patients receiving L-thyroxine significantly improved in functional status (New York Heart Association class; P < .001) and echocardiographic parameters including end-diastolic diameter (P < .001), end-systolic diameter (P < .001), mitral regurgitation severity reduction (P < .001), and increased ejection fraction (P < .001). Left ventricular mechanics showed marked improvement at segmental and global levels of both longitudinal and circumferential myocardial strain (P < .005) when compared with placebo group. CONCLUSIONS: Short-term L-thyroxine therapy is well tolerated in IDCM patients. It improves cardiac mechanics and functional status, which might support the potential role of synthetic thyroid hormones in HF treatment.

Arterial mechanics in ischemic versus nonischemic cardiomyopathy: clinical and diagnostic impact.

BACKGROUND: Differential diagnosis between ischemic (IDCM) and the nonischemic type (NIDCM) of cardiomyopathy constitutes a challenge in the daily medical practice. Carotid and aortic elastic properties deteriorate in patients with coronary artery disease. However, their predictive role in differentiating IDCM from NIDCM has not been addressed so far. AIM OF THE WORK: To examine carotid and aortic mechanical functions using conventional and Doppler tissue echocardiography in the distinction between IDCM and NIDCM in patients with clinically undetermined etiology. METHODS: 70 patients with dilatation and diffuse impairment of the left ventricular (LV) contraction were studied. All patients underwent carotid duplex for measuring intima-media (IMT) thickness, peak systolic velocity (PSV), and luminal diameters (LD). Aortic distensibility, strain, and aortic wall velocities (systolic (Sa), early diastolic (Ea), late diastolic (Aa) velocities, Sa(t), and Ea(t)) were measured. According to coronary angiographic results, patients were categorized into IDCM (n = 36) (age 57.9 +/- 9.2 years) and NIDCM groups (n = 34) (age 56.0 +/- 8.3 years); they were compared to 30 age- and sex-matched healthy individuals as a control group. RESULTS: The aortic pulsatile change, aortic strain, and distensibility were significantly reduced in both patient groups in comparison to control (P < 0.001). These parameters were much impaired in patients with IDCM compared with NIDCM (P < 0.001). IDCM have more deterioration of Sa, Ea, and Aa compared with NIDCM group (7.6 +/- 2.4 vs. 8.9 +/- 1.58, 7.5 +/- 2.8 vs. 10.6 +/- 1.5, 9.0 +/- 1.4 vs. 6.9 +/- 2.4 cm/sec; P < 0.001), respectively. In IDCM, the variables of aortic elastic properties were correlated only to age, while in NIDCM they were correlated to hemodynamics, LV volumes, wall thickness, and mass. Both carotid diameter and IMT were significantly increased in IDCM in comparison to NIDCM and control (P < 0.001). Carotid distensibility was significantly reduced in IDCM compared with NIDCM and control (P < 0.001). However, the carotid properties strongly correlated to risk factors in IDCM and to hemodynamics and LV function in NIDCM. Using ROC curve, a cutoff value < or =4.7 (cm(2)/dyne/10(3)) for aortic distensibility, value <8 cm/sec for Sa and IMT >0.8 mm predicted IDCM with 94.4%, 72.7%, and 97.2% sensitivity and 88.2%, 85.3%, and 97.1% specificity, respectively. CONCLUSION: Both carotid and aortic mechanical functions are more deteriorated in ischemic compared with nonischemic dilated cardiomyopathy. Different functional and structural mechanisms might be responsible for the deterioration of arterial elastic properties in each category.

Relationship of left atrial mechanics to electrical activity on surface electrocardiography in idiopathic dilated cardiomyopathy.

Aim: (1) Assess left atrial (LA) mechanics and electromechanical delay in patients with idiopathic dilated cardiomyopathy (IDCM), and (2) examine the relationship between atrial electromechanical delay and atrial electrical activity [P-wave duration, P-wave dispersion (PWD) and P terminal force (PTF)] on surface ECG. Methods: 73 IDCM patients (age 36  ±  17 years); 63% men,25 age & sex matched healthy subjects were studied. LA atrial electromechanical delay & mechanics (εsys, SRsys, SRe, SRa) were measured with 2D-strain. From 12-lead electrocardiograms, P-wave duration, PWD and PTF calculated. Results: Reservoir, conduit and contractile functions were predominantly reduced compared to control (P < 0.001). Intra-atrial electromechanical delay was 88.9 ± 84.6 in IDCM versus 27.4 ± 16.5 in control (P < 0.0001). In IDCM, PWD (52.89 ± 15), Pmax(98 ± 17.5) and PTF(58.2 ± 36) were significantly increased compared to control (36.20 ± 8.9, 79 ± 9.9, 25.22 ± 8.76) respectively (P < 0.0001). A positive correlation was detected between intra-atrial electromechanical delay and PWD &PTF (r = 0.5, P < 0.0001). By stepwise multiple linear regression analyses, LA reservoir function (LA εsys) [ß = 0.754; CI at 95%:0.356-0.780, P < 0.001] and LA volume [ß = 0.743; CI 95%:0.423-0.75, P < 0.001], and PWD [ß=0.848; CI 95%:0.311-0.644, P < 0.0001], and PTF [ß = 0.927; CI 95%: 0.357-0.722, P < 0.0001] are independent predictors for LA electromechanical delay in IDCM. Conclusion: In addition to altered LA mechanics, atrial electromechanical delay gets longer in IDCM and is correlated with PWD and PTF. Atrial electrical dispersion on surface ECG could be early index of LA dysfunction that deserves further study.

Clinical characteristics and in-hospital outcome of heart failure in women: a single center registry from Egyptian cardiac care unit.

BACKGROUND: This study represents figures from a cardiac care unit (CCU) of a university hospital; it describes an example of a tertiary academic center in Egypt and provides an epidemiological view of the female HF patients, their risk profile, and short-term outcome during hospitalization. RESULTS: It is a local single-center cross-sectional observational registry of CCU patients 1 year from July 2015 to July 2016. Patient's data were collected through a special software program. Women with evidence of HF were thoroughly studied. Among the 1006 patients admitted to CCU in 1 year, 345 (34.2%) patients were females and 118 (34.2%) had evidence of HF, whereas 661 (65.7%) were males and 178 (26.9%) of them had HF. Women with HF showed 11.7% prevalence of the total population admitted to CCU. 72.7% were HFrEF and 27.3% were HFpEF. Compared to men, women with HF were older in age, more obese, less symptomatic than men, had higher incidence of associated co-morbidities, less likely to be re-admitted for HF, and less likely to have ACS and PCI. Valvular heart diseases and cardiomyopathies were the commonest etiologies of their HF. Women had more frequent normal ECG, higher EF%, and smaller LA size. There is no difference in medications and CCU procedures. While females had shorter stay, there is no significant difference in hospital mortality compared to male patients. CONCLUSIONS: Despite higher prevalence of HF in females admitted to CCU and different clinical characteristics and etiology of HF, female gender was associated with similar prognosis during hospital course compared to male gender.

Comparison of vector velocity imaging and three-dimensional speckle tracking echocardiography for assessment of left ventricular longitudinal strain in hypertrophic cardiomyopathy.

Background: Vector velocity imaging (VVI) is a two-dimensional wall motion tracking method that can measure cardiac mechanics in hypertrophic cardiomyopathy (HCM). 3D-speckle tracking echocardiography (3D-STE) has been proven to be superior to conventional measures in assessment of LV function. The aim of this study was to compare the two technologies in the assessment of LV longitudinal strain (LS) in HCM patients. Methods: A total of 50 patients with HCM were investigated using VVI and 3D-STE in same setting. 3D-STE allows obtaining longitudinal, circumferential, radial and area strains (AS). Values of longitudinal strain (LS) and AS by 3D-STE were compared to VVI- derived analyses. Thereafter, VVI-LS values were correlated with LV phenotype. Last, the variability of VVI versus 3DE strain measurements as well as recorded time of analysis was assessed. Results: The absolute value of 3D-STE LS and AS is significantly higher than VVI-LS (P < 0.0001). VVI provided complete longitudinal LV strain information, similar to 3D-STE. There is excellent agreement between the two technologies-derived values, however, a greater number of segments could be analyzed using VVI (94.7%), compared with 3DE (62.1%). Despite VVI being more time consuming, VVI-LS is more correlated to LV mass index, mitral regurgitation severity and functional class when compared with 3D-STE LS and AS. Conclusions: VVI is a feasible modality for assessing LV longitudinal strain. Although VVI agreed well with 3D-STE for most of regional and global LS, a better correlation was found between VVI-LS and HCM phenotype. It is hypothesized that this discrepancy originates from the inferior imaging quality using 3D tracking algorithms.

A comparative study between transthoracic and transesophageal echo modalities in evaluation of left ventricular deformation.

BACKGROUND: 2D strain imaging has been proved as an accurate technique for the assessment of left ventricular (LV) function using transthoracic echocardiography (TTE). Transesophageal echocardiography (TEE) has become a standard and essential technique in clinical practice especially when TTE is inconclusive. Adding 2D strain imaging to TEE might be valuable in the evaluation of cardiac performance. The aim of the present study was to compare 2D strain imaging using TTE and TEE in the assessment of left ventricular deformation in patients with cardiovascular diseases. RESULTS: This study was conducted on sixty patients, who were referred for TEE for various clinical indications. All patients were examined with both TTE and TEE 2D strain imaging. Global and regional strain parameters including longitudinal (LS), circumferential (CS), and radial (RS) were examined. Analysis of 2D strain using TTE was time sparing than TEE (16 ± 1 vs 19 ± 2 min, P < 0.001). From 1020 segments explored using TTE, 97% (LS) and 93% (CS and RS) of the segments were fully analyzed versus 90% and 88% using TEE respectively (P < 0.01). TEE longitudinal strain has an excellent agreement with TTE-derived measurements and a modest agreement in circumferential strain but a notable disparity in radial strain values. Both regional and global LS and RS measured by TTE showed higher values (P < 0.01, < 0.03) compared with its corresponding values measured by TEE. Whereas segmental and global values of CS were higher using TTE modes, the difference with the analogous TEE values did not reach statistical significance. LS and CS measured by TTE and TEE showed excellent but similar correlation with LV EF and wall motion score index. CONCLUSION: 2D strain using TTE is user friendly compared to TEE. However, because of the good agreement, TEE 2D strain might represent an appropriate alternative in the evaluation of global LV deformation.

Dysautonomia rhinitis: associated otolaryngologic manifestations and characterization based on autonomic function tests.

CONCLUSIONS: Dysautonomia is a multisystem disorder. Beside the nasal symptoms, some otolaryngological disorders may be explained on the basis of autonomic dysfunction. Testing of the autonomic nervous system (ANS) complements the clinical findings and provides objective measurements to substantiate the presence of ANS dysfunction. The term dysautonomia rhinitis may be used to specify this autonomic-related rhinitis. OBJECTIVES: Nonallergic, noninfectious perennial rhinitis is a heterogeneous disorder comprising several pathophysiological entities. This study was designed to objectively investigate the relation of idiopathic perennial rhinitis to ANS dysfunction. PATIENTS AND METHODS: This was a prospective controlled clinical study; 78 patients, carefully diagnosed as having idiopathic perennial rhinitis, were enrolled. Workshop protocol included diagnostic measures for exclusion of other causes of rhinitis and autonomic function assessment at a clinical cardiology laboratory. Results were compared with those of 20 age- and sex-matched normal control subjects. RESULTS: In addition to their nasal symptoms, all patients reported more than one regional and multisystem complaint. Each patient had at least one autonomic function test that displayed a hypervagal response and the overall response score was as follows: 46 (59%) had hypervagal response, 32 (41%) had mixed response and none had a normal or hyperadrenergic response.

Provocation of left ventricular outflow tract obstruction using nitrate inhalation in hypertrophic cardiomyopathy: Relation to electromechanical delay.

BACKGROUND: Left ventricular outflow tract obstruction (LVOT) is an independent predictor of adverse outcome in hypertrophic cardiomyopathy (HCM). It is of major importance that the provocation modalities used are validated against each other. AIM: To define the magnitude of LVOT gradients provocation during both isosorbide dinitrate (ISDN) inhalation and treadmill exercise in non-obstructive HCM and analyze the correlation to the electromechanical delay using speckle tracking. METHODS: We studied 39 HCM pts (64% males, mean age 38 ± 13 years) regional LV longitudinal strain and electromechanical delay (TTP) was analyzed at rest using speckle tracking. LVOT gradient was measured at rest and after ISDN then patients underwent a treadmill exercise echocardiography (EE) and LVOT gradient was measured at peak exercise. RESULTS: The maximum effect of ISDN on LVOT gradient was obtained at 5 minutes, it increased to a significant level in 12 (31%) patients, and in 14 (36%) patients using EE, with 85.6% sensitivity & 100% specificity. Patients with latent obstruction had larger left atrial volume and lower E/A ratio compared to the non-obstructive group (p < 0.01). LVOTG using ISDN was significantly correlated with that using EE (p < 0.0001), resting LVOTG (p < 0.0001), SAM (p < 0.0001), EF% (p < 0.02) and regional electromechanical delay but not related to global LV longitudinal strain. Using multivariate regression, resting LVOTG (p = 0.006) & TTP mid septum (p = 0.01) were found to be independent predictors of latent LVOT obstruction using ISDN. CONCLUSION: There is a comparable diagnostic value of nitrate inhalation to exercise testing in provocation of LVOT obstruction in HCM. Latent obstruction is predominantly dependent on regional electromechanical delay.

Aortic biomechanics in hypertrophic cardiomyopathy.

BACKGROUND: Ventricular-vascular coupling is an important phenomenon in many cardiovascular diseases. The association between aortic mechanical dysfunction and left ventricular (LV) dysfunction is well characterized in many disease entities, but no data are available on how these changes are related in hypertrophic cardiomyopathy (HCM). AIM OF THE WORK: This study examined whether HCM alone is associated with an impaired aortic mechanical function in patients without cardiovascular risk factors and the relation of these changes, if any, to LV deformation and cardiac phenotype. METHODS: 141 patients with HCM were recruited and compared to 66 age- and sex-matched healthy subjects as control group. Pulse pressure, aortic strain, stiffness and distensibility were calculated from the aortic diameters measured by M-mode echocardiography and blood pressure obtained by sphygmomanometer. Aortic wall systolic and diastolic velocities were measured using pulsed wave Doppler tissue imaging (DTI). Cardiac assessment included geometric parameters and myocardial deformation (strain and strain rate) and mechanical dyssynchrony. RESULTS: The pulsatile change in the aortic diameter, distensibility and aortic wall systolic velocity (AWS') were significantly decreased and aortic stiffness index was increased in HCM compared to control (P < .001) In HCM AWS' was inversely correlated to age(r = - .32, P < .0001), MWT (r = - .22, P < .008), LVMI (r = - .20, P < .02), E/Ea (r = - .16, P < .03) LVOT gradient (r = - 19, P < .02) and severity of mitral regurg (r = - .18, P < .03) but not to the concealed LV deformation abnormalities or mechanical dyssynchrony. On multivariate analysis, the key determinant of aortic stiffness was LV mass index and LVOT obstruction while the role LV dysfunction in aortic stiffness is not evident in this population. CONCLUSION: HCM is associated with abnormal aortic mechanical properties. The severity of cardiac phenotype, not LV deformation, is interrelated to aortic stiffness in patients with HCM. The increased aortic stiffness seems to be promising module that can be added as clinical risk parameter in HCM.