Prevalence of Diastolic Dysfunction in Critically Ill Patients Admitted to Intensive Care Unit from a Tertiary Care Hospital: A Prospective Observational Study.

Aim: Critically ill individuals may have left ventricular diastolic dysfunction (LVDD) which can prolong their intensive care unit (ICU) stay. The purpose of this study was to determine the prevalence of LVDD in critically ill adult patients requiring mechanical ventilation in ICU, the effect of LVDD on 28-day survival, and weaning from mechanical ventilation. Methodology: A total of 227 adults who had been on mechanical ventilation for more than 48 hours in an ICU were recruited for this study. The study's parameters were recorded on the third day of mechanical ventilation using a low-frequency phased array probe. A simplified definition of LVDD in critically ill adults was utilized to determine the presence or absence of LVDD. Weaning failure and 28-day mortality were noted. Results: The prevalence of LVDD in adults requiring mechanical ventilation in the ICU was found to be 35.4% (n = 79). Patients with LVDD had the odds of having a 28-day mortality increase by 7.48 (95% CI: 3.24-17.26, p < 0.0001). Patients with LVDD had the odds of having weaning failure increase by 5.37 (95% CI: 2.17-13.26, p = 0.0003). Conclusion: Measures should be taken to detect critically ill adults with LVDD with systolic dysfunction or heart failure with preserved ejection fraction early so that their fluid balance, myocardial contractility, and afterload can be optimized to minimize their morbidity and mortality. Highlights: Critically ill adults with LVDD may have adverse outcomes. Hence, protocol should be in place for diagnosing LVDD early in critically ill adults thereby, measures can be taken to minimize morbidity in those patients. How to cite this article: Luitel B, Senthilnathan M, Cherian A, Suganya S, Adole PS. Prevalence of Diastolic Dysfunction in Critically Ill Patients Admitted to Intensive Care Unit from a Tertiary Care Hospital: A Prospective Observational Study. Indian J Crit Care Med 2024;28(9):832-836.

Left Ventricular Diastolic Dysfunction in the Critically Ill: The Rubik's Cube of Echocardiography.

How to cite this article: Kumar V. Left Ventricular Diastolic Dysfunction in the Critically Ill: The Rubik's Cube of Echocardiography. Indian J Crit Care Med 2024;28(9):813-815.

Right ventricular function in mitral stenosis: plays a fundamental role.

The importance of the right ventricle (RV) was neglected or forgotten for decades. The RV has an essential function in cardiovascular physiology and pathology. The RV dysfunction is one of the causes of morbidity and mortality in valvular heart disease (VHD), especially in mitral stenosis (MS). Right ventricular systolic and diastolic function are important for the determination of clinical symptoms, exercise functional capacity, pre-procedure survival, and post-procedure outcome in patients with MS. Right ventricular dysfunction in MS with a sign of systemic venous congestion is easy to recognize, but MS without clinical evidence of RV dysfunction has not been studied. Detecting RV dysfunction earlier in MS is important in clinical practice.

Equine exercise-induced pulmonary hemorrhage: the role of high left-heart pressures secondary to exercise-induced hypervolemia, and high inspiratory pressures.

Exercise-induced hypervolemia is normal in racehorses. Stress failure of the blood-gas barrier causes EIPH and occurs when the transmural pulmonary capillary (Pcap)-alveolar pressure difference (Ptm) exceeds the barrier's stress failure threshold. Why Pcap increases is incompletely understood. We hypothesized that alterations in blood volume (BV) affect left ventricular (LV) and pulmonary arterial wedge (PAW) pressures, and Pcap, and correspondingly affect EIPH severity. Six thoroughbreds with EIPH underwent treadmill exercise at the same speed (≈11.9m/s [11.1, 12.2]; median [IQR]) before (≈119%V̇O2max; B), 2hr after 14L depletion of blood (≈132%V̇O2max; D) and 2hr after reinfusing the blood (≈111%V̇O2max; R). LV, pulmonary arterial (PAP), PAW and intrapleural (Ppl) pressures were measured throughout exercise. Pcap = (PAP+PAW)/2 and Ptm = Pcap - Ppl. EIPH severity was assessed 60min post-exercise by tracheoendoscopy (EIPHgrade) and bronchoalveolar lavage erythrocyte count (BALRBC). A mixed-effect model and Tukey post-hoc test analyzed effects of BV changes on LV, PAW, Pcap, Ppl, Ptm and EIPH. p≤0.05 was significant. EIPH severity was affected by BV (EIPHgrade: p=0.01, BALRBC: p=0.003). Peak Ptm was not different between B (146mmHg [140; 151]) and R (151mmHg [137; 160]) but was lower for D (128mmHg [127; 130]; B: p=0.005, R: p=0.02). LV end diastolic pressure (LVED) was correlated with maxPcap (r2=0.52, p=0.001). Ppl was unaffected by changes in BV. Vascular pressures and Ppl fluctuated constantly during exercise and independently influenced Ptm. Circulating BV but not exercise intensity had a major effect on LVED, Pcap and Ptm, and was correlated with EIPH severity in thoroughbred racehorses (r2=0.48, p=0.001).

Impact of Right Ventricular Dysfunction on Outcomes in Acute Myocardial Infarction and Cardiogenic Shock: Insights from the National Cardiogenic Shock Initiative.

BACKGROUND: Right ventricular dysfunction (RVD) complicates 30%-40% of cases in acute myocardial infarction (AMI) and cardiogenic shock (CS). There are sparse data on the effects of RVD on outcomes and the impact of providing early left ventricular (LV) mechanical circulatory support (MCS) on RV function and hemodynamics. METHODS AND RESULTS: Between July 2016 and December 2020, 80 sites participated in the study. All centers agreed to treat patients with AMI-CS using a standard protocol emphasizing invasive hemodynamic monitoring and rapid initiation of LV-MCS. RVD was defined as a right atrial (RA) pressure of >12 mm Hg and a pulmonary artery pulsatility index (PAPI) of <1 within 24 hours of the index procedure. The primary outcome was survival to discharge. In a subgroup analysis, data available from the Automated Impella Controller console was used to analyze diastolic suction alarms from LV placement signal and its relation to RVD. A total of 361 patients were included in the analysis, of whom 28% had RVD. The median age was 64 years (interquartile range 55-72 years), 22.7% were female and 75.7% were White. There was no difference in age, sex, or comorbidities between those with or without RVD. Patients with RVD had a higher probability of active CPR during LV-MCS implant (14.7% vs 6.3%), Society for Cardiovascular Angiography and Interventions stage E shock (39.2% vs 23.2%), and higher admission lactate levels (5.1 mg/dL vs 3.0 mg/dL). Survival to discharge was significantly lower among those with RVD (61.8% vs 73.4%, odds ratio 0.89, 95% confidence interval 0.36-0.95, P = .031). This association remained significant in the multivariate analysis. There was no significant difference in hemodynamic variables within 24 hours of LV-MCS support among those with or without RVD. At 24 hours, patients with a CPO of >0.6 W and a PAPi of >1 had a trend toward better survival to discharge compared with those with a CPO of ≤0.6 W and a PAPi of ≤1 (77.1% vs 54.6%, P = .092). Patients with RVD were significantly more likely to have diastolic suction alarms within 24 hours of LV-MCS initiation. CONCLUSIONS: RVD in AMI-CS is common and associated with worse survival to discharge. Early LV-MCS decreases filling pressures rapidly within the first 24 hours and decreases the rate of RVD. Achieving a CPO of >0.6 W and a PAPi of >1 within 24 hours is associated with high survival. Diastolic suction alarms may have usefulness as an early marker of RVD.

Single-arm study of testosterone gel replacement therapy and ambulatory blood pressure outcomes in men with hypogonadism.

BACKGROUND AND OBJECTIVE: Studies examining ambulatory blood pressure (BP) response to testosterone replacement therapy are needed owing to inconsistent prior findings across formulations. This study assessed testosterone gel 1.62% and 24-h ambulatory BP. MATERIALS AND METHODS: Single-arm non-inferiority trial (NCT04274894) conducted at 36 US sites enrolled 246 men with hypogonadism (mean age, 57.6 years; mean office systolic/diastolic BP [SBP/DBP], 129.8/79.5 mm Hg) who were treated for 16 weeks with once-daily testosterone gel treatment (starting dose, 40.5 mg/day; min, max dose, 20.25, 81.0 mg/day) to achieve testosterone concentration of 350-750 ng/dL. Main outcome measures included mean change in 24-h average SBP (primary endpoint) and DBP from baseline to week 16. The non-inferiority threshold was a two-sided 95% confidence interval (CI) upper limit <3.0 mm Hg for 24-h average SBP. RESULTS: Increase in mean ± SD serum testosterone concentration to a physiologic level (baseline, 244.4 ± 93.9 ng/dL; week 16, 502.5 ± 394.4 ng/dL) was associated with a 1.9-mm Hg mean change in 24-h average SBP observed in the primary analysis (baseline, 123.5 mm Hg; week 16, 125.4 mm Hg; 95% CI, 0.63-3.13 mm Hg; n = 169). As the upper CI limit modestly exceeded the non-inferiority margin (3 mm Hg), study drug effect on SBP could not be ruled out. Non-inferiority was observed in subgroups without hypertension or diabetes (95% CI, upper limit <3.0 mm Hg) and was not observed in those with hypertension or diabetes. Daytime SBP and DBP changes were larger compared with nighttime. No clear cardiovascular adverse events or new safety signals were identified. DISCUSSION AND CONCLUSIONS: While the effect of testosterone gel 1.62% on 24-h average SBP could not be ruled out based on the study's non-inferiority margin, the clinical relevance of the small-magnitude mean increase of 1.9 mm Hg is anticipated to be minimal considering the results of the TRAVERSE study of testosterone gel 1.62% and major adverse cardiac events. CLINICAL TRIAL INFORMATION: ClinicalTrials.gov identifier: NCT04274894 (registered February 17, 2020).

Importance of environmental signals for cardiac morphological development in Atlantic salmon.

The hearts of salmonids display remarkable plasticity, adapting to various environmental factors that influence cardiac function and demand. For instance, in response to cold temperature, the salmonid heart undergoes growth and remodeling to counterbalance the reduced contractile function associated with dropping temperatures. Alongside heart size, the distinct pyramidal shape of the wild salmonid heart is essential for optimal cardiac performance, yet the environmental drivers behind this optimal cardiac morphology remain to be fully understood. Intriguingly, farmed salmonids often have rounded, asymmetrical ventricles and misaligned bulbi from an early age. These deformities are noteworthy given that farmed salmon are often not exposed to natural cues, such as a gradual temperature increase and changing day lengths, during critical developmental stages. In this study, we investigated whether natural environmental conditions during early life stages are pivotal for proper cardiac morphology. Atlantic salmon were raised under simulated natural conditions (low temperature with a natural photoperiod; SIMNAT) and compared with those reared under simulated farming conditions (SIMFARM). Our findings reveal that the ventricle shape and bulbus alignment in SIMNAT fish closely resemble those of wild salmon, while functional analyses indicate significant differences between SIMNAT and SIMFARM hearts, suggesting diastolic dysfunction and higher cardiac workload in SIMFARM hearts. These findings highlight the profound influence of environmental factors such as water temperature and photoperiod on the structural development of the salmonid heart, underscoring the importance of early environmental conditions for cardiac health.

The Agreement Between Transthoracic and Transesophageal Echocardiography in the Assessment of Right Ventricular Diastolic Dysfunction Grades in Adult Patients Undergoing Cardiac Surgery: A Prospective Observational Study.

Introduction The importance of right ventricular (RV) diastolic function in cardiac surgery cannot be overstated, as it significantly affects prognosis and long-term outcomes. Conventionally, RV diastolic dysfunction (RVDD) is assessed and graded using criteria from either the American Society of Echocardiography (ASE) or the British Society of Echocardiography (BSE), with measurements done by transthoracic echocardiography (TTE). However, during cardiac surgery, perioperative echocardiographic evaluation is done predominantly by transesophageal echocardiography (TEE). This study aimed to assess the agreement between TTE and TEE in grading RVDD using both ASE and BSE criteria. Methods Key two-dimensional (2D) and Doppler parameters were measured in 81 patients undergoing cardiac surgery by both TTE and TEE after anesthesia induction within 10 minutes of each other, under similar hemodynamic, anesthetic, and ventilatory conditions. RVDD gradings were done separately by TTE and TEE with both ASE and BSE criteria using the measured values of the key parameters by TTE and TEE, respectively. RVDD gradings derived from TTE were compared with those derived from TEE. The tricuspid inflow Doppler and tricuspid annular tissue Doppler parameters were measured in TEE in both mid-esophageal RV inflow-outflow (MERVIO) and deep transgastric RV inflow-outflow (DTGRVIO) views. Gradings were done separately for both views of TEE by using the Doppler values measured in the respective views (TEE-MERVIO and TEE-DTGRVIO). The TTE-derived RVDD grades were compared with those derived by both TEE-MERVIO and TEE-DTGRVIO. Weighted κ values were used to assess observed agreement beyond chance. Inter-rater reliability of the RVDD grades derived by both TTE and TEE (both views) was also checked. Individual 2D and Doppler parameters were compared between TTE and TEE in terms of Bland-Altman limits of agreement. Results As per ASE criteria, disagreement of RVDD by ≥1 grade was seen in 43 (53.1%) patients and by 2 grades in eight (9%) patients when comparing TTE and TEE-MERVIO, yielding a weighted κ of 0.14 (p=0.123). Disagreement by ≥1 grade was observed in 32 (39.5%) patients and by 2 grades in 10 (12.3%) patients when comparing TTE and TEE-DTGRVIO, yielding a weighted κ of 0.3 (p=0.002). Using the BSE Criteria, disagreement of RVDD grades occurred in nine (11.1%) patients when comparing TTE and TEE-MERVIO, yielding an unweighted κ of 0.25 (p=0.295). Disagreement occurred in 12 (14.8%) patients when comparing TTE and TEE-DTGRVIO, yielding an unweighted κ of 0.260 (p=0.187). There was almost perfect agreement between independent raters regarding both TTE- and TEE-derived RVDD grades per the ASE criteria, and substantial to almost perfect agreement per BSE criteria. Bland-Altman analysis of paired data between the TTE- and TEE-measured values of individual 2D and Doppler parameters showed wide limits of agreement. Conclusions This study revealed, at best, only fair agreement between TTE and TEE in grading RVDD. The measured 2D and Doppler echocardiographic parameters showed wide limits of agreement between TTE and TEE. We recommend further research to develop a TEE-based algorithm for grading RVDD, and to evaluate the prognostic effectiveness of perioperative TEE for predicting adverse clinical outcomes associated with RVDD.

N-terminal pro-brain natriuretic peptide is associated with pulmonary hypertension or diastolic dysfunction in patients with systemic sclerosis: An Australian prospective cross-sectional study.

Introduction: Pulmonary arterial hypertension and left ventricular diastolic dysfunction are associated with significant morbidity and mortality in systemic sclerosis. N-terminal pro-brain natriuretic peptide has been proposed as part of composite screening algorithms for pulmonary arterial hypertension. Our aim was to assess the prevalence of pulmonary hypertension and diastolic dysfunction, and evaluate their association with serum N-terminal pro-brain natriuretic peptide in systemic sclerosis patients. Methods: Patients with systemic sclerosis were prospectively enrolled to undergo N-terminal pro-brain natriuretic peptide testing and transthoracic echocardiography at a tertiary Australian centre from January to October 2022. We collected demographic and transthoracic echocardiography variables including pulmonary hypertension estimated by tricuspid regurgitant velocity and diastolic dysfunction assessed by the ASE/EACVI 2016 guidelines. Pearson's correlation coefficient was used to evaluate association between N-terminal pro-brain natriuretic peptide and echocardiographic parameters. Results: Sixty-one patients were enrolled (median age = 62 years (interquartile range = 55-69 years); 84% female). Two-thirds of patients had limited systemic sclerosis (40/61). Five patients (8%) had high likelihood of pulmonary hypertension by transthoracic echocardiography. Seven patients (11%) had diastolic dysfunction; however, seven patients (11%) had indeterminate diastology. Six patients underwent right heart catheterisation, with five patients diagnosed with pulmonary hypertension. N-terminal pro-brain natriuretic peptide in patients with pulmonary hypertension or diastolic dysfunction was significantly higher (median = 207 and 226 pg/mL, respectively) compared to patients without either condition (median = 69 pg/mL, p = 0.01). N-terminal pro-brain natriuretic peptide showed a statistically significant although limited correlation with estimated pulmonary pressures measured by tricuspid regurgitant velocity (r = 0.44, p = 0.002) and left ventricular filling pressures (r = 0.27, p = 0.04). Conclusion: Pulmonary hypertension and diastolic dysfunction are both observed in systemic sclerosis. N-terminal pro-brain natriuretic peptide is associated with both conditions; however, it cannot distinguish between the two disease processes. Right heart catheterisation may be required to make this distinction.

Blood Flow of the Infraspinatus Muscle in Individuals With and Without Shoulder Pain and Myofascial Trigger Points: A Color Doppler Ultrasound and Reliability Study.

OBJECTIVES: Myofascial trigger points (MTrPs) are potential contributors to shoulder pain and can lead to local ischemia and hypoxia, thus causing pain. Color Doppler ultrasound (US) has been used to examine the vascular environment around MTrPs, but has not been used to examine blood flow impairments in patients with shoulder pain and MTrPs. The reliability of color Doppler US for measuring infraspinatus muscle blood flow also has not been established. This study aimed to investigate differences in blood flow between individuals with and without shoulder pain and the reliability of Doppler US for measuring infraspinatus muscle blood flow. METHODS: Forty participants were enrolled, 20 with shoulder pain and MTrPs and 20 without. Color Doppler US examination was performed twice on each participant to measure peak systolic velocity (PSV), end-diastolic velocity (EDV), resistive index (RI), and pulsatile index (PI) of the infraspinatus muscle. RESULTS: The symptomatic participants had significantly higher PSV (ie, impaired blood flow) than the asymptomatic participants. There were no significant between-group differences in EDV, RI, and PI. The results also demonstrated good-to-excellent intra-rater reliability for color Doppler US measurements of PSV, EDV, RI, and PI for both groups. CONCLUSION: This study demonstrated differences in blood flow near MTrPs in the infraspinatus muscle between individuals with and without shoulder pain. It also established good-to-excellent reliability of color Doppler US in measuring infraspinatus muscle blood flow. These findings suggest color Doppler US is a useful tool to identify vascular impairments for shoulder pain associated with MTrPs.

Assessment of Biventricular Systolic and Diastolic Function Using Conventional and Strain Echocardiography in Children with Sickle Cell Disease Surviving 1-year After Hematopoietic Stem Cell Transplant.

Hematopoietic stem cell transplant (HSCT) is a potentially curative therapy for children with sickle cell disease (SCD). The effects of HSCT on ventricular function are not well characterized in children with SCD. Echocardiograms from children with SCD who underwent HSCT between 2007 and 2017 were retrospectively analyzed before and 1-year after HSCT. Left ventricular (LV) volumes, mass, and ejection fraction were calculated by the 5/6 area*length method. LV end-diastolic and systolic dimensions, septal, and posterior wall thickness, and fractional shortening were measured by M-mode. Mitral and tricuspid inflow Dopplers (E and A waves) as well as mitral, tricuspid, and septal tissue Dopplers (E', A') were assessed. E/A, E'/A' and E/E' ratios were calculated. Biventricular strain imaging was performed using speckle-tracking echocardiography. Peak global systolic longitudinal and circumferential LV strain, and global longitudinal right ventricular strain, as well as early and late diastolic strain rate, were measured on LV apical 4-chamber, LV short-axis mid-papillary, and RV apical views, respectively. Forty-seven children (9.7 ± 5.5 years, 60% male) met inclusion criteria. Pre-HSCT, subjects had mild LV dilation with normal LV systolic function by conventional measure of ejection fraction and fractional shortening. There was a significant reduction in LV volume, mass, and ejection fraction after HSCT, but measurements remained within normal range. LV longitudinal and circumferential strain were normal pre-HSCT and showed no significant change post-HSCT. RV strain decreased after HSCT, but the absolute change was small, and mean values were normal both pre- and post-HSCT. Conventional measures of diastolic function were all normal pre-HSCT. Post-HSCT there was a reduction in select parameters, but all parameters remained within normal range. Early and late diastolic strain rate parameters showed no significant change from pre- to post-HSCT. At one-year after HSCT in children with SCD conventional measures of systolic and diastolic function are within normal limits. Except for a small decrease in RV systolic strain with values remaining within normal limits, systolic strain and diastolic strain rate values did not significantly change 1-year after HSCT.

Regression of biventricular hypertrophy in acromegalic cardiomyopathy following management of excessive growth hormone secretion.

Acromegalic cardiomyopathy is a significant cardiovascular complication associated with acromegaly, caused by excessive growth hormone production from a pituitary adenoma. Early diagnosis can be challenging due to its insidious nature. This case underscores the critical significance of timely medical intervention, illustrating favorable outcomes resulting from prompt therapeutic measures.

Global longitudinal strain is a surrogate marker for time constant of isovolumic relaxation in post-Fontan operation patients with single right ventricle and preserved ejection fraction.

BACKGROUND: The time constant of isovolumic relaxation is an established index of ventricular relaxation, a major component of diastolic function, even in a single right ventricle. However, the specific echocardiographic parameters for estimating diastolic dysfunction are insufficient for a single right ventricle. This study aimed to investigate the echocardiographic indices associated with time constant of isovolumic relaxation in post-Fontan operation patients with a single right ventricle. METHODS: We included 39 patients with hypoplastic left heart syndrome after Fontan operation with an ejection fraction ≥45% and preserved valve function. First, the correlation between echocardiographic parameters and time constant of isovolumic relaxation was examined, and partial correlation coefficients were calculated using age and heart rate as covariates. Next, univariate regression analysis was performed using time constant of isovolumic relaxation as the objective variable and echocardiographic parameters as independent variables, followed by multivariate regression analysis incorporating parameters with p < 0.10. RESULTS: Among the echocardiographic parameters, global longitudinal strain correlated most strongly with time constant of isovolumic relaxation (r = 0.778, p < 0.001). This was consistent with the partial correlation coefficients (r = 0.707, p < 0.001). Using stepwise multivariate regression analysis, only global longitudinal strain was found to be an independent predictor of time constant of isovolumic relaxation (adjusted R2 = 0.551). CONCLUSIONS: Global longitudinal strain could be used as a surrogate marker of time constant of isovolumic relaxation, an invasive indicator of relaxation impairment, in post-Fontan operation patients with a single right ventricle, preserved ejection fraction, and valve function.

Association of diastolic and systolic blood pressure with depression: a cross-sectional study from NHANES 2005-2018.

Background: Many studies worldwide have reported the association between mental health and blood pressure, but the results are mixed, and even contradictory. We aim to investigate the relationship between systolic and diastolic blood pressure and depression in the entire US population. Methods: This study analyzed cross-sectional data from the National Health and Nutrition Examination Survey (NHANES) from 2005 to 2018. All adults completed 3-4 blood pressure measurements after sitting quietly for 5 minutes. Depression was diagnosed based on the Patient Health Questionnaire (PHQ-9), with a score ≥10 defined as depression. Weighted logistic regression and restricted cubic splines (RCS) were used to assess the relationship between blood pressure and depression. Two-piecewise linear regression was used to determine the inflection point. Additionally, subgroup analyses and interaction tests were conducted to identify potential subgroups. Finally, two sensitivity analyses were conducted. Results: A total of 26,581 American adults were included, with a mean age of 47.2 years, of whom 13,354 (49.54%) were male; 2,261 individuals were defined as depressed, with a weighted prevalence of 7.41%. All participants' mean systolic blood pressure (SBP) was 121.7 mmHg, and the mean diastolic blood pressure (DBP) was 70.9 mmHg. RCS showed a nonlinear association between SBP and depression, while DBP showed a positive linear association with depression. Two-piecewise linear regression showed that the inflection point of the association between SBP and depression was 129.7 mmHg. Weighted logistic regression showed that after fully adjusting for depression-related risk factors, there was a significant positive correlation between per 10 mmHg increase in DBP and depression (OR: 1.06, 95% CI: 1.00-1.12, P=0.04); however, only on the left side of the inflection point, SBP tended to decrease the odds of depression (P =0.09). Furthermore, interaction analysis showed that the association between DBP and depression was significantly stronger in cancer patients (P for interaction=0.02); on the left side of the inflection point (<129.7 mmHg), current smokers also significantly interacted with SBP (P for interaction=0.018). Finally, two sensitivity analyses also supported our findings. Conclusion: In the adult population of the United States, there is a positive linear association between DBP and depression, while the association between SBP and depression exhibits a significant threshold effect, maintaining SBP at 129.7 mmHg is associated with the lowest prevalence of depression.

Impact of Angiotensin Receptor Blockers (ARB) versus Other Antihypertensive Medication on Blood Pressure in Patients on Dialysis: A Meta-Analysis.

Introduction: Hypertension is an important factor driving mortality among dialysis patients. Angiotensin-II receptor blocker (ARB) has been effective similarly to angiotensin-converting enzymes (ACEs) but with a low incidence of side effects. Methodology: The meta-analysis included all published studies that investigated the effect of ARB on the hypertension in adult dialysis patients (≥18 years). Data extraction was guided by a predetermined checklist. Data sources of the retrieved studies were PubMed, MEDLINE, ScienceDirect, SCOPUS, Cochrane, Web of knowledge, and Google Scholar were systematically searched until February 2023. Using the RevMan 5 software, the mean difference for systolic and diastolic BP (SBP and DBP) and the risk ratio (RR) of the adverse events (AEs) were pooled from the selected studies. The random-effects model was used to compare the difference in the pre-and post-dialysis of the SBP and DBP. Data analyses were performed from December 2022 to February 2023. The primary outcome was the reduction in SBP and DBP in dialysis hypertensive patients who were on anti-hypertensive agents, and the secondary outcome was assessment of AE associated with the drug after dialysis (PROSPERO Registration: CRD42022355369). Results: The initial search yielded 1,679 records, of which 84 studies underwent full-text evaluation, which identified 13 studies and 1,462 patients. The pooled standard MD for losartan with other anti-hypertensive agents, where the pre-dialysis SBP was 0.17 (95% confidence interval [CI]: -0.21-0.55) and the post-dialysis was 0.35 (95% CI: -0.17-1.02); yet, both are statistically non-significant, implies that there was no difference between Losartan and ARB drugs regarding the effect on the SBP. Diastolic BP for predialysis was -0.01 (95% CI: -0.65-0.63) and post-dialysis was 0.03 (95% CI: -0.24-0.30) and statistically non-significant. AEs by the ARB agents were lower compared to other anti-antihypertensive agents (relative risk [RR]: 1.01; 95% CI: 0.59-1.75) and statistically non-significant. Conclusion: This systematic review and meta-analysis of RCT demonstrated that ARB and other anti-hypertensive medications had similar impacts on the treatment of hypertension.

Stress Echocardiography for Assessment of Diastolic Function.

PURPOSE OF REVIEW: Diastolic dysfunction is an important, though often underappreciated, cause for exertional dyspnea. Echocardiography enables noninvasive evaluation of diastolic function and filling pressure, but images acquired at rest may be insensitive for detection of exertional abnormalities. This review focuses on stress echocardiography to assess diastolic function, including traditional and novel techniques, with emphasis on specific patient sub-groups in whom this testing may be valuable. RECENT FINDINGS: Emerging data informs patient selection for diastolic stress testing. Further, increasing literature provides considerations for performance and interpretation of diastolic metrics relevant to patients with heart failure with preserved ejection fraction, hypertrophic cardiomyopathy, athletes, and those with microvascular coronary dysfunction. Methods, such as speckle-tracking and multi-modality imaging, provide additional and complementary information for non-invasive diastolic assessment. This review serves as a guide to optimally utilize existing and novel techniques of stress echocardiography for diastolic assessment across a broad range of patients.

Effects of voluntarily consumed sweetened alcohol and naringin on cardiac function in male and female Sprague-Dawley rats.

This study assessed the impact of sweetened alcohol and naringin on cardiac function in Sprague-Dawley rats. Male (n = 40) and female (n = 40) rats were allocated to control, sweetened alcohol (SOH), naringin (NA), and sweetened alcohol with naringin (SOH + NA) groups. SOH and SOH + NA rats received 10% alcohol + 20% fructose in gelatine; SOH + NA and NA rats received 50 mg/kg naringin in gelatine daily for 10 weeks. Echocardiography was performed to assess left ventricular (LV) function. LV cardiomyocyte diameters and collagen area fraction were determined by H&E and picrosirius-red staining, respectively. In males, sweetened alcohol and naringin did not affect cardiac function. Female SOH rats had increased LV end-diastolic posterior wall (p = 0.04), relative wall thicknesses (p = 0.01), and LV cardiomyocyte diameters (p = 0.005) compared with control. Female SOH and SOH + NA had reduced lateral e' and e'/a' and increased E/e' (p < 0.0001). Female SOH (p = 0.01) and SOH + NA (p = 0.04) rats had increased LV collagen area fraction compared with controls. In males, neither sweetened alcohol nor naringin affected cardiac geometry or diastolic function. In females, sweetened alcohol induced concentric remodelling, impaired LV relaxation, and elevated filling pressures. Naringin may have the potential to improve the sweetened alcohol-induced concentric remodelling; however, it did not ameliorate diastolic dysfunction in females.

ECG Abnormalities, Diastolic Blood Pressure, and Adverse Events After Systemic to Pulmonary Artery Shunt in Infants with Congenital Heart Disease.

All patients with Systemic to Pulmonary Artery (SPA) shunt as the index surgical procedure at a single center were studied to determine the association between post-operative ECG repolarization abnormalities, diastolic blood pressure (DBP), and adverse outcomes. Postoperative ECGs were categorized into three grades, Grade 2 defined as ST elevation/depression ≥ 2 mm in ≥ 2 precordial or ≥ 1 mm in ≥ 2 limb leads; Grade 1-T-wave inversion or flattening in ≥ 3 leads; and Grade 0-no criteria for grades 1 or 2. For each patient, time with invasive DBP below 25, 25-29, 30-34, or above 34 mmHg in the first 24 h was calculated. The primary outcome was a pre-discharge composite of death, cardiac arrest, ECMO, unplanned shunt reintervention, and necrotizing enterocolitis after 24 h of surgery. Of the 109 patients included in final analysis, 17 (15.6%) had the composite outcome. Grade 2 ECG abnormality occurred in 12%, and Grade 1 in 37%. There was no association between ECG abnormalities and adverse events. Increasing time with DBP < 30 was not associated with adverse outcomes, while increasing time with DBP 30-34 was associated with decreased odds, and increasing time with DBP > 34 mmHg was associated with increased odds of adverse outcomes on multivariable analysis accounting for indexed shunt size and chromosomal abnormalities. In conclusion, after SPA shunt placement, ECG repolarization abnormalities and low DBP within 24 h were common and not associated with adverse outcomes. Sustained elevation of DBP above 34 mmHg was not protective, especially in patients with high indexed shunt size and chromosomal abnormalities.

Relationship between left atrial/left ventricular diameter ratio and outcomes in patients with hypertrophic cardiomyopathy.

BACKGROUND: Although diastolic dysfunction is the main pathophysiological feature of hypertrophic cardiomyopathy (HCM), it remains to be clarified whether parameters of diastolic function can reliably determine HCM prognosis. In patients with reduced left ventricular (LV) distensibility, chronic elevation of LV diastolic pressure is seen with a smaller than expected LV size. Accordingly, patients with HCM with severe LV diastolic dysfunction typically demonstrate left atrial (LA) dilation and a disproportionately smaller left ventricle. Therefore, we investigated the relationship between LA/LV diameter ratio, as a potential indicator of disease progression, and outcomes in patients with HCM. METHODS: We included 468 patients in whom LA and LV end-diastolic diameter were successfully evaluated by echocardiography at the initial assessment. We divided the patients into two groups: those with an LA/LV diameter ratio > 1 and those with an LA/LV diameter ratio ≤ 1. We compared the HCM-related death rates between the two groups. RESULTS: Of the 468 patients, 96 patients (20.5 %) with HCM showed an LA/LV diameter ratio > 1. In the univariate analysis, patients with an LA/LV diameter ratio > 1 had a significantly greater likelihood of HCM-related death than patients with an LA/LV diameter ratio ≤ 1 (log-rank p = 0.002). In the multivariate Cox proportional hazards analysis, when including LA/LV diameter ratio > 1 and imbalanced baseline variables, an LA/LV diameter ratio > 1 was an independent determinant of HCM-related death (adjusted hazard ratio: 1.87, 95 % confidence interval: 1.08-3.24; p = 0.024). CONCLUSION: LA/LV diameter ratio can be easily evaluated and may be useful for risk stratification of HCM-related death in patients with HCM.