Association between plasma homocysteine concentration and the risk of all-cause death in adults with diastolic dysfunction in a community: A 13-year cohort study.

Hyperhomocysteinemia (HHCYS) has been associated with systolic heart failure. However, it is still unknown that serum homocycsteine level was useful in predicting the outcome in patients with diastolic dysfunction. We conducted a cohort study to determine if HHCYS was associated with poor prognosis in diastolic dysfunction patients. The Chin-Shan Community Cardiovascular Cohort (CCCC) study was designated to investigate the trends of cardiovascular morbidity and mortality in a community. Individuals who were 35 years and above were enrolled. Participants were categorized by homocysteine concentration quartiles. We used multivariate Cox proportional hazards models to calculate the hazard ratio (HR) of the 4th quartiles versus the 1st quartile. Area under the receiver-operating characteristic (ROC) curve was to compare prediction measures. A total of 2020 participants had completed the echocardiography examination, and 231 individuals were diagnosed as diastolic dysfunction. A total 75 participants had died during follow-up period. HHCYS was found to be significantly associated with poor prognosis. The adjusted HR for homocysteine level was 1.07 (95% confidence interval [CI], 1.01-1.14). Participants in the highest quartile had a 1.90 (95% CI, 0.88-4.12, P for trend, .026) fold risk for all cause death, compared with those in the lowest quartiles. The HR was 1.88 (95% CI, 1.07-3.29) using 11.11 µmol/L as cut point for hyperhomocysteine. HHCYS was significantly associated with poor prognosis in diastolic dysfunction participants in the community.

Type A aortic dissection manifesting as acute myocardial infarction: still a lesson to learn.

OBJECTIVE: Type A aortic dissection manifesting as acute myocardial infarction (AMI) is relatively rare but could be catastrophic if the management is not appropriate. This study investigated the incidence, outcome and potential diagnostic pitfalls of patients with such manifestations, and proposes a useful diagnostic paradigm. METHODS AND RESULTS: From 1 January 1995 to 31 July 2006, 531 patients admitted to our hospital with the initial or later diagnosis of acute aortic dissection were reviewed. Two hundred and thirty-nine patients were diagnosed as Stanford type A aortic dissection with a mortality rate of 17% (41/239). Eleven (5%) of the 239 patients had initial presentation of AMI (chest pain and elevation of cardiac enzymes, with or without ST-segment elevation) and a high mortality rate of 36% (4/11). All six patients with ST-segment elevation underwent coronary angiography without awareness of type A aortic dissection; three patients were detected to have eccentric aortic regurgitation by transthoracic echocardiography (TTE) before angiography but type A aortic dissection was neglected at that time. Three of the five patients without ST-segment elevation also had eccentric aortic regurgitation by TTE before the confirmative diagnosis was made; prompt suspicion of type A aortic dissection was assisted with an elevation of D-dimer value in one of these three patients. The presence of eccentric aortic regurgitation by TTE, and the increased D-dimer value provided hints of the coexistence of AMI and type A aortic dissection. CONCLUSIONS: Type A aortic dissection manifesting as AMI is a catastrophe in disguise. Prompt checks of TTE and the D-dimer value would bring the hidden diagnosis of acute aortic dissection more to the forefront.

Intravenous leiomyomatosis with intracardiac extension.

Whereas uterine leiomyoma is a common woman disease, intravenous leiomyomatosis with intracaval and intracardiac complications is a rare condition. The initial presentation is dependent upon the severity of the intracardiac involvement, although complete surgery is the best treatment. The case of a 39-year-old woman is described here, with an initial presentation of dyspnea and right heart failure. Leiomyomatosis originating from the uterus and extending to the inferior vena cava and right atrium was diagnosed from various preoperative studies. The patient was resuscitated because of respiratory failure and severe right heart failure. However, she was operated successfully through a two-stage approach and remained well postoperatively. This case illustrates an intriguing presentation of intravenous leiomyomatosis and a curative surgical intervention even in critical condition.

Genetic polymorphisms of the angiotensin II type 1 receptor gene and diastolic heart failure.

OBJECTIVES: The aim of the study was to investigate the association between angiotensin II type 1 receptor (AGTR1) gene polymorphisms and diastolic heart failure (DHF) in a case controlled study. METHODS: Of 1752 consecutive patients analyzed, 176 diagnosed with DHF and confirmed by echocardiography were recruited. Controls were matched one-to-one by age, sex, hypertension, diabetes, renal function, and medication use. We genotyped 11 single nucleotide polymorphisms (SNPs) according to the HapMap Han Chinese Beijing databank across the AGTR1 gene to capture 96% of the haplotype variance in all SNPs with minor allele frequencies at least 5%. We also genotyped A1166C (rs5186) SNP with known associations with cardiovascular disease and analyzed associations of SNPs and haplotypes with DHF and linkage disequilibrium structure of the AGTR1 gene. RESULTS: In a single locus analysis, SNP rs16860760, rs389566, and rs5186 were associated with DHF (allele specific P = 0.004, 0.002, 0.002, respectively; permuted P = 0.045, 0.022, 0.027, respectively). SNP rs389566, with a minor allele frequency of 20.17%, had an odds ratio (OR) 2.03 for the autosomal dominant model [AA + AT: TT, 95% confidence interval (CI) 1.29-3.19; P = 0.0012] and 1.73 for the additive model (95% CI 1.21-2.48; P = 0.0018) corresponding to a population attributable risk fraction of 27.21%. The haplotypes in a linkage disequilibrium block of rs389566 (T-A-G and A-A-G) were also significantly associated with DHF (permuted P = 0.0125 and 0.0105, respectively). CONCLUSION: We identified risk-conferring genetic variants of the AGTR1 gene for DHF in a Chinese population.

A propensity score-based case-control study of renin-angiotensin system gene polymorphisms and diastolic heart failure.

Angiotensin II plays an important role in diastolic heart failure (DHF). However, genetic studies of DHF are scarce in the literature. We hypothesized that RAS genes might be the susceptible genes for DHF and conducted a propensity score-based case-control study to prove this hypothesis. A total of 666 subjects (285 diagnosed with DHF confirmed by echocardiography and 381 without diastolic dysfunction) were recruited. Genotyped were: the angiotensin-converting enzyme (ACE) gene insertion/deletion polymorphism; the T174M, M235T, G-6A, A-20C, G-152A and G-217A polymorphisms of the angiotensinogen (AGT) gene; and the A1166C polymorphisms of the angiotensin II type I receptor (AT1R) gene. Propensity scores (PS) were used to find patients with and without DHF with equalized characteristics. We also assembled another set of PS matched groups for all characteristics except left ventricular mass (LVM) to detect the genetic association with DHF through the effect of left ventricular hypertrophy. PS matched 210 patients with DHF to 210 without. In a single-locus analysis, the odds ratios (ORs) for DHF were significant with the ACE DD genotype (OR=1.30, 95% CI=1.13-1.49, permuted P=0.003) and the AT1R 1166 CC genotype (OR=2.61, 95% CI=1.52-4.45, permuted P<0.001). Significant gene-gene interaction between the two genes was also detected. However, the ACE gene effect was diminished if LVM was not controlled in the propensity scores. We concluded that genetic variants in the RAS genes may determine individual risk to develop DHF through different pathways. Concomitant presence of ACE DD and AT1R 1166 CC genotypes synergistically increased the predisposition to DHF.