Appropriate use criteria for echocardiography in the Netherlands.

INTRODUCTION: Appropriate use criteria (AUC) for echocardiography based on clinical scenarios were previously published by an American Task Force. We determined whether members of the Dutch Working Group on Echocardiography (WGE) would rate these scenarios in a similar way. METHODS: All 32 members of the WGE were invited to judge clinical scenarios independently using a blanked version of the previously published American version of AUC for echocardiography. During a face-to-face meeting, consensus about the final rating was reached by open discussion for each indication. For reasons of simplicity, the scores were reduced from a 9-point scale to a 3-point scale (indicating an appropriate, uncertain or inappropriate echo indication, respectively). RESULTS: Nine cardiologist members of the WGE reported their judgment on the echo cases (n = 153). Seventy-one indications were rated as appropriate, 35 were rated as uncertain, and 47 were rated as inappropriate. In 5% of the cases the rating was opposite to that in the original (appropriate compared with inappropriate and vice versa), whereas in 20% judgements differed by 1 level of appropriateness. After the consensus meeting, the appropriateness of 7 (5%) cases was judged differently compared with the original paper. CONCLUSIONS: Echocardiography was rated appropriate when it is applied for an initial diagnosis, a change in clinical status or a change in patient management. However, in about 5% of the listed clinical scenarios, members of the Dutch WGE rated the AUC for echocardiography differently as compared with their American counterparts. Further research is warranted to analyse this decreased external validity.

Clinical Characteristics of Patients Undergoing Right Heart Catheterizations in Community Hospitals.

Background Recognition of precapillary pulmonary hypertension (PH) has significant implications for patient management. However, the low a priori chance to find this rare condition in community hospitals may create a barrier against performing a right heart catheterization (RHC). This could result in misclassification of PH and delayed diagnosis/treatment of precapillary PH. Therefore, we investigated patient characteristics and echocardiographic parameters associated with the decision whether to perform an RHC in patients with incident PH in 12 Dutch community hospitals. Methods and Results In total, 275 patients were included from the OPTICS (Optimizing PH Diagnostic Network in Community Hospitals) registry, a prospective cohort study with patients with incident PH; 157 patients were diagnosed with RHC (34 chronic thromboembolic PH, 38 pulmonary arterial hypertension, 81 postcapillary PH, 4 miscellaneous PH), while 118 patients were labeled as probable postcapillary PH without hemodynamic confirmation. Multivariable analysis showed that older age (>60 years), left ventricular diastolic dysfunction grade 2-3, left atrial dilatation were independently associated with the decision to not perform an RHC, while presence of prior venous thromboembolic events or pulmonary arterial hypertension-associated conditions, right atrial dilatation, and tricuspid regurgitation velocity ≥3.7 m/s favor an RHC performance. Conclusions Older age and echocardiographic parameters of left heart disease were independently associated with the decision to not perform an RHC, while presence of prior venous thromboembolic events or pulmonary arterial hypertension-associated conditions, right atrial dilation, and severe PH on echocardiography favored an RHC performance. As such, especially elderly patients may be at an increased risk of diagnostic delays and missed diagnoses of treatable precapillary PH, which could lead to a worse prognosis.

Anabolic Androgenic Steroids Induce Reversible Left Ventricular Hypertrophy and Cardiac Dysfunction. Echocardiography Results of the HAARLEM Study.

Background: The use of anabolic androgenic steroids (AAS) is not uncommon among strength athletes. Several cross-sectional studies have linked AAS use to heart disease, but a causal role for AAS is not certain and it is unknown whether cardiac changes are reversible. Methods: Men of at least 18 years old intending to start an AAS cycle on short notice were included for comprehensive 3D echocardiographic examination before (T0), at the end of the cycle (T1), and 1 year after inclusion (T2) after a recovery period. Details of the AAS cycle performed and the use of other performance and image-enhancing drugs (PIEDs) as well as illicit drug use were recorded. Trend analysis and multivariable regression analysis were performed with mixed effects linear models. Results: Thirty-one subjects were included. Between start (T0) and end of the cycle (T1), after a median AAS cycle duration of 16 weeks, 3D left ventricular ejection fraction declined with 4.9% (CI -7.2 to -2.5, P < 0.001), E/A-ratio declined with-0.45 (CI -0.69 to -0.21, P < 0.001), and 3D left atrial volume increased with 9.2 ml (CI 2.9-15.4, P = 0.004). Left ventricular mass increased with 28.3 g (CI 14.2-42.4, P < 0.001) and was positively correlated with AAS average weekly dose. After a median recovery time of 8 months (T2), all parameters returned to baseline. Conclusion: AAS induce left ventricular hypertrophy and impaired systolic and diastolic function in amateur strength athletes. The structural cardiac changes are positively associated with AAS dose and complete recovery occurred after AAS were discontinued.

[A 24-year-old man with chest pain]. / Een 24-jarige man met pijn op de borst.

A 24-year-old man was seen with position dependent chest pain and fever. Electrocardiography showed typical diffuse repolarisation changes matching with perimyocarditis. Local petechiae developed on the left leg and bloodcultures were positive for Neisseria meningitidis serogroup C, which provided the diagnosis perimyocarditis caused by Neisseria meningitidis.

Reproducibility of twenty-four-hour finger arterial blood pressure, variability and systemic hemodynamics.

OBJECTIVE: At present, non-invasive continuous monitoring of finger arterial blood pressure by the volume-clamp technique is considered the best approach to obtain reliable assessments of beat-to-beat blood pressure. However, data on the reproducibility (accuracy and precision) of prolonged recordings and of the hemodynamics derived from wave-form analysis are not available. DESIGN: Ten patients with untreated essential hypertension and eight normotensive subjects were monitored by Portapres over 24 h in the hospital on two occasions with 1-4 weeks in-between. Physical and mental activities were standardized as far as possible to minimize intra- and intersubject biological variability. Stroke volume was obtained by the Modelflow method. Differences between the two recordings were computed separately for the day (0700 to 2300 h) and the night (2300 to 0700 h) and for all hours. Differences in stroke volume were calculated as percentage change from the first recording. RESULTS: Accuracy was good in both groups and bias was close to zero. Precision was also remarkable in the daytime, and at least as good as values reported in studies that used the standard intra-arterial recording. The SD of the differences in systolic and diastolic pressure in the hypertensives in the daytime were 6.6 and 4.7 mmHg, respectively. At night, precision was less good, possibly because of the 30 min finger-cuff switching: 12.5 and 6.5 mmHg for systolic and diastolic pressure, respectively. The average stroke volume did not change more than 8% at most between the first and the second recordings. CONCLUSION: These results indicate that the Finapres and Portapres devices are a reliable substitute for intra-arterial recording, and are most useful instruments for the study of blood pressure regulation.

Orthostatic hypotension due to suppression of vasomotor outflow after amphetamine intoxication.

Ten hours after ingestion of amphetamines, a previously healthy 17-year-old female adolescent experienced dizziness on standing. Examination revealed pronounced drowsiness and severe orthostatic hypotension. Assessment of arterial baroreflex function suggested that suppressed sympathetic vasomotor drive was the cause of the orthostatic hypotension. Within 3 days, the baroreflex failure resolved spontaneously. To our knowledge, suppressed vasomotor outflow after ingestion of amphetamines has been previously observed only in animal studies.

Feasibility of cognitive screening of patients with ischaemic stroke using the CAMCOG. A hospital-based study.

Brief screening tests would be convenient for the measurement of cognitive impairment in stroke patients. In these patients aphasia can interfere with test procedures. To evaluate the feasibility of examining cognitive functions in stroke patients we examined 129 patients with an ischaemic stroke using the CAMCOG, a standardised neuropsychological screening test, after an interval of at least 3 months. Most patients (88%) were able to complete the CAMCOG. Patients with severe aphasia were significantly more likely to have an abnormal CAMCOG score than patients without aphasia [relative risk (RR) 4.0, 95% confidence interval (CI) 2.8-5.8]. The group of patients with moderate aphasia was not at higher risk of having an abnormal CAMCOG score than patients without aphasia (RR 1.4, 95% CI 0.6-2.8). Looking for other factors that might correlate with the scores, logistic regression analysis revealed age as the only significant factor for the prediction of the CAMCOG score (odds ratio 4.0, 95% CI 1.2-13.2). We concluded that the CAMCOG can conveniently be used for screening cognitive functions in patients with cerebral infarcts, even if there is moderate aphasia.

Effects of antihypertensive drugs on the circadian blood pressure profile.

We compared the effect of beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, and calcium antagonists on the circadian blood pressure (BP) profile in essential hypertension. We reviewed all studies published between 1980 and August 1993 reporting the circadian efficacy of antihypertensive drugs and using ambulatory BP monitoring. In all, 815 patients with essential hypertension were assessed in 51 studies of eight different beta-blockers, six ACE inhibitors, and eight calcium antagonists. As main outcome measures, relative (percentage) BP reductions during the day and at night were compared between the three classes of antihypertensive drugs. Results were also separated for different dosing schemes (once and more than once daily). With all three classes of antihypertensive agents, the percentage night BP reduction was approximately 1-3% less as compared with percentage reductions during the day. Only for systolic BP (SBP) of the calcium antagonists administered once daily was this difference significant [2.2%, confidence interval (CI) 0.3-4.0%, p < 0.05], due to a higher statistical power in this group of agents. Our results show that beta-blockers, ACE inhibitors, and calcium antagonists are comparably effective during the day and at night, and no evidence indicates that either of the three agents is preferable to obtain the best possible antihypertensive effect at night.

Effects of treatment of obstructive sleep apnea on circadian hemodynamics.

INTRODUCTION: The role of obstructive sleep apnea syndrome (OSAS) in the etiology of daytime hypertension is still an issue of debate, which is fed by the high prevalence of the syndrome in hypertensive patients. In this study the anti-hypertensive effect of short-term treatment of obstructive sleep apnea with nasal continuous positive airway pressure (nCPAP) was assessed. PATIENTS AND METHODS: In eight patients with documented OSAS (mean apnea index 62 apneas/h), two 24-h continuous finger blood pressure registrations (Portapres) were performed. At baseline and after 3 weeks of treatment with nCPAP. Ten hypertensive control subjects were studied. Stroke volume (SV), cardiac output (CO) and total peripheral resistance (TPR) were assessed by pulse contour analysis. RESULTS: Hemodynamics were highly reproducible in the controls. nCPAP therapy improved apnea-activity in all OSAS patients. This was associated with a reduction of nighttime systolic (SBP), mean arterial (MAP) and diastolic blood pressure (DBP). Treatment also reduced daytime MAP by -11 mm Hg (ranging from -27 to 1; P < 0.05), and DBP by -7 mm Hg (-24 to 3; P < 0.05). CO was significantly increased in daytime by 9% (-4 to 25; P < 0.05), whereas TPR was reduced by -15% (-34 to 3; P < 0.05). CONCLUSIONS: Treatment of OSAS caused a reduction in daytime MAP and DBP, associated with a reduction of vascular resistance. These findings are consistent with the hypothesis of a reduced sympathetic outflow at night after therapy of obstructive sleep apnea, carrying over to the day.

Finger-to-brachial comparability of 'modelflow' stroke volume improves after pulsewave reconstruction.

Modelflow is a method that determines stroke volume (SV) from central or peripheral continuous blood pressure signals. Pulsewaves are changed along the arterial tree; distortion occurs as the mean pressure level gradually declines. These changes might jeopardize the determination of SV from a distal measurement site. Techniques have been assessed to reconstruct brachial artery pressures (BAPs) from non-invasive finger blood pressure (FIN) waveforms. In this study, we determined the effect of different forms of brachial reconstruction techniques on the comparability of modelflow SV from FIN and BAP. Supine resting FIN and BAP were measured simultaneously in 57 subjects, covering a wide range of blood pressures and degrees of vascular disease. SV from the two sites were compared before correction and after correction for pulsewave distortion or pressure gradient. The latter was determined by a regression formula and by a return to flow (RTF) method, using the brachial cuff pressure at the moment of reappearance of FIN during cuff deflation. SV from unfiltered FIN exceeded BAP-derived SV by 4.6 (SD 11) ml. This difference was positively related to the subjects' age. Correction for pulsewave distortion increased the average difference to 13 (12) ml (P < 0.05 to the unfiltered condition). Adjustment for the pressure gradient reduced the difference to -2.5 (7) ml (P < 0.01). RTF had no additional effect. We concluded that the FIN-to-BAP comparability can be increased by brachial reconstruction techniques, which correct for the pressure gradient. This can be adequately performed without additional measurements, allowing its application to measurements already taken.

Circadian rhythms in systemic hemodynamics and renal function in healthy subjects and patients with nephrotic syndrome.

BACKGROUND: The resemblance of the circadian rhythm of glomerular filtration rate (GFR) to that of arterial blood pressure (BP) suggests that systemic hemodynamic factors contribute to this variation. In the present study, this was investigated using continuous BP monitoring and pulse wave analysis. The study was performed in eight healthy subjects and in seven patients with nephrotic syndrome who had normal or reversed rhythms of GFR. METHODS: Circadian variations of renal function (continuous infusion of inulin/paraaminohippuric acid), noninvasive finger arterial pressure (Portapres), and vasoactive hormone levels were monitored during 27 hours. With stepwise backward regression analysis, the contributions of the measured variables to the circadian variation of GFR were investigated. RESULTS: Both groups showed a reduction of BP at night. In the controls, this was related to a drop in cardiac output, while in the patients, total peripheral resistance decreased at night. None of the hemodynamic variables explained the circadian GFR variation in both groups. In the controls, only 6% of the effective renal plasma flow (ERPF) rhythm was associated with variations in cardiac output (P = 0.03). In the patients, atrial natriuretic peptide and plasma renin activity were responsible for 36% of the variation in GFR (P < 0.01). CONCLUSIONS: These results indicate that the circadian variation of GFR does not result directly from changes in BP or cardiac output. An inverted GFR rhythm in patients with nephrotic syndrome may originate from hormonal mechanisms rather than directly from the hemodynamic effects of edema mobilization.

Circadian blood pressure and systemic haemodynamics during 42 days of 6 degrees head-down tilt.

Head-down tilted bedrest is a ground-based microgravity simulation model. Since in this position the influence of chief external determinants of circadian blood pressure variation, i.e. activity and posture, are reduced, it may reveal endogenous oscillatory factors. The effects of 42 days of 6 degrees head-down tilt on the circadian profiles of continuous finger blood pressure, heart rate, stroke volume, cardiac output and total peripheral resistance were analysed. In seven healthy volunteers (25-31 years) twelve 22 h Portapres registrations were performed: two in an ambulatory baseline period, eight during 42 days of head-down tilt, and two during recovery. Stroke volume was estimated by a pulse contour method ('Modelflow') from the finger arterial blood pressure tracing. Head-down tilt rapidly reduced circadian BP variation, especially for diastolic blood pressure. No effect of long-term head-down tilt on blood pressure level was observed. The day-night difference in heart rate was essentially unaffected. Cardiac output was maintained through an increase of heart rate and simultaneous decline of stroke volume. Our observations confirm the overriding importance of physical activity and orthostatic load on the diurnal variation of BP. The time-frame of the changes in stroke volume and heart rate during head-down tilt might point to a contribution of other factors besides a reduction of circulating blood volume affecting cardiovascular performance under these conditions.