Validity of the Triglyceride-Glucose Indices for Predicting the Severity of Coronary Artery Disease in Patients with Nondiabetic Chronic Coronary Syndrome.

BACKGROUND: The triglyceride-glucose (TyG) index was shown to be an independent predictor of coronary artery disease (CAD) progression and prognosis. However, whether the TyG index can predict the severity of CAD in nondiabetic patients with chronic coronary syndrome (CCS) remains unclear. METHODS: A total of 118 individuals who underwent elective coronary angiography (CA) were classified into group A (59 with coronary lesions) and group B (59 with normal coronary arteries; as a control group) after CA, laboratory tests for fasting and the postprandial (PP) TyG index. The complexity of CAD was determined by the SYNTAX score (SYNTAX score > 22 indicated moderate-high risk), and patients diagnosed diabetes or prediabetes were excluded. RESULTS: The TyG index was not related to the SYNTAX score in groups A and B; however, in the CAD group with an LDL concentration <70 mg/dl (group A1), a fasting TyG index ≥ 8.25 and a PP TyG index ≥ 11 could predict moderate-high SYNTAX risk score; in addition, the odds ratio was 4.3 times higher, and the relative risk was 1.8 times greater (OR=4.3, RR=1.8, 95% CI=1.4-13.5 p<0.05) for individuals with a higher fasting TyG index ≥8.25 to have a moderate-high SYNTAX risk score. Individuals with a higher PP TyG index ≥11 had odds ratio of 2.6 times higher and a relative risk of 1.4 times greater to have moderate-high SYNTAX risk score. CONCLUSIONS: Both fasting and postprandial TyG levels were associated with greater coronary anatomical complexity (SYNTAX score > 22) in nondiabetic chronic coronary patients with LDL <70 mg/dL. Fasting and the postprandial TyG indices can serve as noninvasive predictors of CAD complexity in nondiabetic patients with LDL <70 mg/dl and could change the management and therapeutic approach.

The Use of Global Longitudinal Strain to Detect Subclinical Reduction in Left Ventricular Pump Function.

BACKGROUND: Left ventricular (LV) ejection fraction (LVEF) is not a sensitive marker of LV systolic function in a subset of patients with preserved EF. The relation between LV pump function and global longitudinal strain (GLS) has not been elucidated well in patients with objectively preserved EF and no apparent heart failure (HF). We aimed to detect whether LV GLS can discover impaired LV pump function [presented as low stroke volume index (SVI) and low cardiac output (COP)] in patients with objectively preserved EF and no apparent clinical HF and its practice utility. METHODS: In total, 100 participants with LVEF of ≥50% were studied for demographic and echocardiographic data, including LVEF, stroke volume, SVI, COP, LV longitudinal strain assessments, apical 4-, 3-, and 2-chamber views averaged for GLS, and were classified into 2 groups: group 1: normal GLS (more negative than -18%) and group 2: low GLS (less negative than -18%). RESULTS: Reduced LV GLS was associated with lower SVI (35.6 ± 13.6 vs. 43.8 ± 12.7 mL/m 2 ; P = 0.01), lesser COP (5.4 ± 1.9 vs. 6.5 ± 2.1 l/min; P = 0.02), GLS had strong positive correlations with SVI ( r = 0.75; P < 0.001), and COP ( r = 0.66; P < 0.001). LV GLS at a cutoff value less negative than -15% is a strong predictor of SVI ≤35 mL/m 2 (76% sensitivity and 79% specificity) and at a cutoff value less negative than -13.5% it is a strong predictor of COP ≤4 L/min (76% sensitivity and 73% specificity). LV GLS was the best independent predictor of low SVI (<35 mL/m 2 ) and low COP (<4 L/min). CONCLUSION: Impaired LV strain is associated with lower LV pump function, presented as lower COP and lower SVI in patients with preserved EF even in the absence of clinical HF. It is of great importance to incorporate GLS in the routine evaluation of LV function hand-by-hand with the noninvasive assessment of LV stroke volume and COP that can replace GLS on evaluation of LV pump function in old machines with no GLS modalities, for early pick-up of patients with impaired LV pump function before apparent HF.

Atrial electromechanical delay in post-COVID-19 postural orthostatic tachycardia: Innocent bystander or pathologic factor.

BACKGROUND: Post-COVID-19 syndrome represents a wide range of ongoing symptoms that persist beyond weeks or even months, after recovery from the acute phase. Postural orthostatic tachycardia (POT) is one of these symptoms with a poorly recognized underlying pathophysiology. PURPOSE: We aimed to investigate atrial electromechanical delay (AEMD), demonstrated by electrocardiographic P wave dispersion (PWD) and tissue Doppler echocardiography (TDE) in patients with POST-COVID-19 POT (PCPOT). METHODS: 94 post-COVID-19 patients were enrolled and classified into two groups; PCPOT group, 34 (36.1%) patients, and normal heart rate (NR group), 60 (63.9%) patients. 31.9% of them were males and 68.1% were females, with a mean age of 35 ± 9 years. Both groups were compared in terms of PWD and AEMD. RESULTS: As compared to the NR group, the PCPOT group showed a significant increase in PWD (49 ± 6 versus 25.6 ± 7.8, p < 0.001), higher CRP (37 ± 9 versus 30 ± 6, p = 0.04), prolonged left-atrial EMD, right-atrial EMD and inter-atrial EMD at (p = 0.006, 0.001, 0.002 respectively). Multivariate logistic regression analysis revealed that P wave dispersion (ß 0.505, CI (0.224-1.138), p = 0.023), PA lateral (ß 0.357, CI (0.214-0.697), p = 0.005), PA septal (ß 0.651, CI. (0.325-0.861), p = 0.021), and intra-left atrial EMD (ß 0.535, CI (0.353-1.346) p < 0.012) were independent predictors of PCPOT. CONCLUSION: Atrial heterogenicity in the form of prolonged AEMD and PWD seems to be a reasonable underlying pathophysiology of PCPOT. This could provide a new concern during the management and novel pharmacological approaches in these patients.

Can we explore AF-pacemakers' relationship using clinical and echocardiographic parameters in patients with permanent pacemaker? (Echocardiography and subclinical AF in permanent pacemaker).

Patients on implanted permanent pacemakers frequently develop atrial fibrillation (AF). We aimed to determine the Echocardiographic and clinical parameters predicting AF in patients with a dual-chamber (DDD) pacemaker. This retrospective study included 208 patients with permanent pacemaker, classified according to development of AF during follow up into 2 groups: AF (77, 37%) and non AF (131, 63%), baseline: clinical, ECG(P-wave dispersion) and echo {diastolic wall strain (DWS),left arial volume index (LAVI), left ventricular stiffness index(LVSI)} data were assessed. AF group were older with more P wave dispersion, lesser DWS, greater LVSI& LAVI, LVSI at a cut off > 0.13 and DWS at a cut off < 0.34 were predictors of AF in patients with DDD pacemakers. LVSI and DWS could be used as simple good predictors for AF in patients with DDD pacemakers, for timely initiation of anticoagulants according to CHA2DS2VASc score to decrease ischemic stroke burden.

Sex-Age Interplay among Young Aged Egyptians with First Acute Myocardial Infarction.

BACKGROUND: The burden of modifiable risk factors in young Egyptian adults presenting with first acute myocardial infarction (AMI), sex differences, sex-age interplay and its relationship with demographic, angiographic characteristics and type of AMI is a good topic for discussion. METHODS: The study enrolled 165 young (≤45 years old) consecutive, eligible patients diagnosed with first AMI (ST-elevation myocardial infarction (STEMI), non-ST-elevation myocardial infarction (NSTEMI), for their demographic, angiographic, echocardiographic and laboratory investigations and gender differences. RESULTS: Our population was 29-45 years, 12.1% females, most of whom had STEMI, obesity in females and smoking in males were the most prevalent, the younger the age of females presenting with AMI the more aggressive underlying risk factors, and the more reduction in LV EF. Most of the female culprit lesions were thrombotic and the severity of atherosclerotic culprit lesions correlated positively with blood pressure. CONCLUSION: The age paradox in young females (regarding LV EF and the traditional risk factors) and the thrombotic nature of the culprit lesion mandate early intensive 1ry and 2ry preventive strategies against coronary heart disease (CHD) with special concern for obesity as the main trigger early in life with proper control of blood pressure. In males, smoking cessation programs are the main target to ameliorate the progress of CHD hand in hand with the other 1ry and 2ry preventive strategies of CHD.

Pulmonary vascular resistance and proper timing of percutaneous balloon mitral valvotomy.

It is frequent to see pulmonary hypertension (PH) in patients with mitral stenosis (MS) secondary to increased pulmonary vascular resistance (PVR), data about the effect of PVR on the results of percutaneous balloon mitral valvotomy (PBMV) are insufficient. To detect the role of PVR in predicting residual PH immediately after PBMV. This prospective study comprised 49 consecutive patients with moderate to severe MS who were investigated pre and within 48 h post a successful PBMV for the first time. Echocardiography was used to assess the mitral valve area (MVA), mean transmitral pressure gradient (MPG), mitral valve resistance (MVR), right ventricular systolic pressure (RVSP) and PVR. Patients were classified into two groups according to the pre PVR (≥ 1.6 WU as group I and < 1.6 as group II). At baseline compared to group II (32 patients), Group I (17 patients) had higher MPG (13.6 ± 5.2 vs. 11.7 ± 3.7 mmHg, P < 0.05), RVSP (45.6 vs. 37.9 mmHg, P < 0.001) and PVR (2.2 ± 0.1 vs. 1.2 ± 0.1WU, P < 0.001) with no significant difference regarding age, gender, MVS, MVA and MVR. Patients of group I had comparatively lower improvement immediate post procedural of RVSP and PVR with no significant difference in immediate post procedural improvement in NYHA classification, MVA, MPG and MVR. Basal PVR > 1.8WU was proved to be a highly specific (91%), a good predictor (AUC 0.78) of persistent elevation of RVSP > 50 mmHg post PMV. Pathological rise of PVR that associates MS had provided a strong and an independent predictor of persistent pulmonary hypertension post PBMV and by this aspect it could be used as a valuable tool as MVA and MPG to send patients earlier for PBMV even with less severe MS. PVR > 1.81 WU could be used as a noninvasive parameter for predicting regression of PH immediately after PBMV.

Left atrial and left atrial appendage functional recovery after cardioversion in patients with recent atrial fibrillation: Serial echocardiographic study.

BACKGROUND: The aim of this study is to point out timing of left atrium and its appendage functional recovery after cardioversion (CV) in recent onset atrial fibrillation (AF). METHODS: Fifty patients; 27 within 48-h (group I) and 23 after 48-h (group II), of AF onset, who had successful CV underwent transthoracic echocardiography (TTE), before and immediately after CV, then 15, 30 and 90 days later. Transesophageal echocardiography (TEE) was performed for group II before and for all patients immediately after CV and 1 month later. Mitral peak A velocity and left atrial (LA) reversal (Ar) velocity, tissue Doppler imaging (TDI) of septal mitral annular velocity (A1) and LA free wall velocity (A3) were recorded. Absence or peak A velocity < 50 cm/s was taken as a cut off value for atrial stunning. Intra-atrial conduction time (IACT) was measured. LA appendage late emptying (LAALE) velocity was measured by TEE-pulsed TDI of LA appendage. RESULTS: Post CV, all group II and 34% of group I experienced stunning. In both groups, peak A, Ar, A1, A3 and LAALE velocities increased (p = 0.000), while IACT decreased (p = 0.000) progressively over time. Partial recovery occurred after 15 and 30 days, while full recovery occurred 30 and 90 days post CV in groups I and II, respectively. IACT1 and IACT2 correlated with LA diameter (r = 0.2778 and r = 0.227, respectively, p < 0.01). CONCLUSIONS: Stunning and functional recovery of the LA and its appendage are strongly determined by the duration being in AF. Serial IACT by TDI was a good new parameter for detection of functional recovery of LA and LA appendage.

Value of the mitral valve resistance in evaluation of symptomatic patients with mild and moderate mitral stenosis--a dobutamine stress echocardiographic study.

BACKGROUND: Conventional stenosis indexes poorly reflect the major hemodynamic consequence of mitral stenosis (MS). Valve resistance (VR) is a physiologic expression of stenosis. OBJECTIVES: This study aimed to demonstrate whether the mitral valve resistance (MVR) and its changes, relate to restricted exercise capacity in patients with mild and moderate mitral stenosis. METHODS: Twenty-four patients with rheumatic mild-to-moderate MS underwent transthoracic echocardiographic study (resting and dobutamine stress echocardiography [DSE]), divided into two groups; group I: symptomatic (12 patients) and group II: asymptomatic (12 patients). Mitral valve area (MVA), mean transmitral diastolic pressure gradient (TMPG), cardiac output (CO), and MVR were measured in all patients at rest and at peak DSE. Changes (∆) in MVA, TMPG, CO, and MVR were calculated. Data underwent statistical analysis. RESULTS: From resting to peak dobutamine infusion, the MVR significantly decreased from 111.4 ± 28.2 to 83.6 ± 27.0 dynes sec/cm(5) in group II (P < 0.001). The increase in MVR in group I (13.8 ± 10.3 dynes sec/cm(5)) compared with its reduction (-27.8 ± 15.6 dynes sec/cm(5)) in group II were highly significant different (P < 0.001). A reduction in MVR by less than 21.5 dynes sec/cm(5) at peak dobutamine infusion reflect a cutoff value considered to detect the hemodynamic significance of mild-to-moderate MS with a sensitivity of 92% and a specificity of 73%. CONCLUSION: The changes in the MVR can be used as a DSE parameter for expression of stenosis severity and to describe discrepancy in symptom status in patients with mild-to-moderate mitral stenosis.