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Epicardial adipose tissue (EAT) may enhance the risk of coronary artery disease (CAD). We investigated the relationship between EAT density (a maker of local inflammation) and coronary plaque characteristics in stable CAD patients. This study included 123 individuals who underwent coronary artery calcium scan and coronary CT angiography to evaluate CAD. Plaque characteristics were analyzed by semi-automated software (QAngio, Leiden, Netherlands). Non-contrast CT scans were used to measure EAT density (HU) and volume (cc) (Philips, Cleveland, OH). Multivariate regression models were used to evaluate the association of EAT density and volume with different plaque types. The mean (SD) age was 59.4±10.1 years, 53% were male, the mean (SD) EAT density was -77.2±4.6 HU and the volume was 118.5±41.2 cc. After adjustment for cardiovascular risk factors, EAT density was associated with fibrous fatty (FF) plaque (p<0.03). A 1 unit increase in HU was associated with a 7% higher FF plaque, and lower EAT density is independently associated to FF plaque. The association between EAT density and fibrous (p=0.08), and total noncalcified (p=0.09) plaque trended toward but did not reach significance. There was no association between EAT volume and any plaque type. These results suggest that inflammatory EAT may promote coronary atherosclerosis. Therefore, non-contrast cardiac CT evaluation of EAT quality can help better assess cardiovascular risk.
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BACKGROUND: Left ventricular systolic dysfunction in patients with severe aortic stenosis (AS) may result in low transvalvular gradients and underestimation of AS severity. A low-flow state may occur with reduced LVEF. Little is known about the implications of low compared to normal flow in patients with reduced LVEF undergoing transcatheter aortic valve replacement (TAVR). OBJECTIVES: We compared survival rates with degree of flow across stenosed aortic valves and left ventricular dysfunction. We hypothesized that the stroke volume index (SVI) offers essential information regarding survival following TAVR. METHODS: We retrospectively reviewed patients with LVEF <50 % undergoing TAVR at the Gates Vascular Institute in Buffalo, New York, from 2012 to 2017. We performed Receiver Operator Characteristics to examine the value of SVI in predicting the postoperative outcome of patients. Kaplan-Meier and Cox regression analyses were used to investigate the effect of a low-flow state on five-year survival in patients with systolic dysfunction undergoing TAVR. RESULTS: Five-year survival following TAVR was decreased in patients with low-flow AS (SVI <35 mL/m2) compared to patients with normal flow. Seventy-four percent (n = 50) of patients with low-flow compared to 43 % (n = 22) of patients with normal flow were deceased five years post-TAVR (p ≤0.001). ROC curve indicated SVI to be a clinical predictor of five year survival (AUC 0.732, 95 % CI: 0.641-0.823, p < 0.001). CONCLUSION: Patients with systolic dysfunction and low transvalvular flow AS had increased mortality five years following TAVR. These findings highlight a better prognosis in patients with normal flow and LV systolic dysfunction. CONDENSED ABSTRACT: Low-flow aortic stenosis can occur with reduced left ventricular function. We compared survival rates of patients with known reduced left ventricular function in low-flow and normal flow aortic stenosis. This retrospective single-center study examined mortality rates following transcatheter aortic valve replacement. The mean gradient was not a predictor of mortality. This study shows patients with low-flow aortic stenosis have decreased five-year survival following valve replacement.
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This study compared the prognostic value of quantified thoracic artery calcium (TAC) including aortic arch on chest CT and coronary artery calcium (CAC) score on ECG-gated cardiac CT. METHODS: A total of 2412 participants who underwent both chest CT and ECG-gated cardiac CT at the same period were included in the Multi-Ethnic Study of Atherosclerosis Exam 5. All participants were monitored for incident atherosclerotic cardiovascular disease (ASCVD) events. TAC is defined as calcification in the ascending aorta, aortic arch and descending aorta on chest CT. The quantification of TAC was measured using the Agatston method. Time-dependent receiver-operating characteristic (ROC) curves were used to compare the prognostic value of TAC and CAC scores. RESULTS: Participants were 69±9 years of age and 47% were male. The Spearman correlation between TAC and CAC scores was 0.46 (p<0.001). During the median follow-up period of 8.8 years, 234 participants (9.7%) experienced ASCVD events. In multivariable Cox regression analysis, TAC score was independently associated with increased risk of ASCVD events (HR 1.31, 95% CI 1.09 to 1.58) as well as CAC score (HR 1.82, 95% CI 1.53 to 2.17). However, the area under the time-dependent ROC curve for CAC score was greater than that for TAC score in all participants (0.698 and 0.641, p=0.031). This was particularly pronounced in participants with borderline/intermediate and high 10-year ASCVD risk scores. CONCLUSION: Our study demonstrated a significant association between TAC and CAC scores but a superior prognostic value of CAC score for ASCVD events. These findings suggest TAC on chest CT provides supplementary data to estimate ASCVD risk but does not replace CAC on ECG-gated cardiac CT.
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Enfermedad de la Arteria Coronaria , Calcificación Vascular , Humanos , Masculino , Femenino , Anciano , Calcificación Vascular/diagnóstico por imagen , Calcificación Vascular/epidemiología , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/epidemiología , Enfermedad de la Arteria Coronaria/diagnóstico , Pronóstico , Persona de Mediana Edad , Medición de Riesgo/métodos , Angiografía por Tomografía Computarizada , Valor Predictivo de las Pruebas , Aorta Torácica/diagnóstico por imagen , Factores de Riesgo , Enfermedades de la Aorta/diagnóstico por imagen , Enfermedades de la Aorta/epidemiología , Enfermedades de la Aorta/diagnóstico , Curva ROC , Vasos Coronarios/diagnóstico por imagen , Técnicas de Imagen Sincronizada Cardíacas , Estados Unidos/epidemiología , Electrocardiografía , Incidencia , Angiografía Coronaria/métodos , Tomografía Computarizada por Rayos X , Aterosclerosis/epidemiología , Aterosclerosis/diagnósticoRESUMEN
BACKGROUND AND AIMS: Use of coronary artery calcium (CAC) continues to expand, and several different categories of risk have been developed. Some categorize CAC as <10, 11-100 and â> â100, while others use CAC â= â0,1-10, 11-100 and â> â100 as categories. We sought to evaluate the plaque burden in patients with CAC 0, 1-10 and 11-100 to evaluate the best use of CAC scoring for risk assessment. METHODS: Patients were recruited from existing prospective CCTA trials with CAC scores ≤100 and quantitative coronary plaque analysis (QAngio, Medis). CAC was categorized into three groups: zero (CAC â= â0), minimal (CAC 1-10), and mild (CAC 11-100). Plaque levels (low attenuated, fibrous, fibro-fatty, dense calcified, total non-calcified) were assessed using multivariable linear regression adjusted for cardiovascular risk factors (age, ethnicity, BMI, gender, hypertension, dyslipidemia, diabetes mellitus, past smoking). RESULTS: 378 subjects were included, with an average age of 53.9 â± â10.7 years and 53 â% female. Among them, 51 â% had 0 CAC, 16 â% had minimal CAC (scores 1-10), and 33 â% had mild CAC (scores 11-100). The minimal and mild CAC groups were significantly older, with higher rates of diabetes, hypertension, and hyperlipidemia. Multivariable analysis found no significant difference in low attenuated, fibro-fatty, and dense calcified plaque levels between the minimal and zero CAC groups. However, minimal CAC subjects had significantly higher fibrous, total non-calcified, and total plaque volumes than zero CAC. All plaque types were significantly higher in the mild group when comparing mild CAC to minimal CAC. CONCLUSION: Individuals with minimal calcium scores (1-10) had greater noncalcified coronary plaque (NCAP) and total plaque volume than individuals with a calcium score of zero. The increased presence of NCAP and total plaque volume in the minimal CAC (1-10) is clinically significant and place those patients at higher coronary vascular disease (CVD) risk than individuals with absent CAC (CAC â= âzero). Therefore, the use of CAC â= â0, 1-10 and 11-100 is prudent to better categorize CVD risk.
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Enfermedades Cardiovasculares , Enfermedad de la Arteria Coronaria , Diabetes Mellitus , Hipertensión , Placa Aterosclerótica , Humanos , Femenino , Adulto , Persona de Mediana Edad , Masculino , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Calcio , Vasos Coronarios/diagnóstico por imagen , Estudios Prospectivos , Angiografía Coronaria , Factores de Riesgo , Tomografía Computarizada por Rayos X , Valor Predictivo de las Pruebas , Medición de RiesgoRESUMEN
Introduction: Volatile anesthetics offer protection when administered throughout an ischemic injury. We examined how volatile anesthetics modulate the cardiac myocytic injury associated with hydrogen peroxide. Methods: Forty-eight Long-Evans rats were divided into four groups depending on the treatment: none (CONT), Glibenclamide (GLB); Sevoflurane (SEV); or GLB+SEV. Each group was further divided into two, one of which was exposed to hydrogen peroxide (H2O2). Oral GLB was administered 48 hours before myocardial isolation. All rats were anesthetized by intraperitoneal injection of Ketamine, and the hearts were harvested after heparinization. Cardiomyocytes were isolated using a combination of mechanical mincing and enzymatic digestion. After isolation, the aliquots of cells were exposed to H2O2 and FeSO4 for 30 minutes. The cell suspensions were then bubbled for 10 minutes with 100% oxygen and 1.5% SEV if appropriate. Apoptosis was detected by fluorescein-bound annexin-V (ANX-V), necrosis by propidium iodide, and ELISA assessed caspase-3 activity in all groups. Results: There was an increase in apoptosis, necrosis, and caspase-3 activity in the cells following exposure to hydrogen peroxide. SEV reduced the rate of cell necrosis and apoptosis. Pretreatment with GLB did not alter the effects of SEV. Similarly, caspase-3 activity did not change with GLB, although SEV administration reduced this enzymatic activity in response to hydrogen peroxide. Conclusion: In this oxidant injury model, we demonstrated that incubating isolated cardiomyocytes with SEV profoundly diminished H2O2-induced apoptotic and necrotic cells compared to their CONTs. These results support the hypothesis that KATP channels are not the sole mediators associated with anesthetic preconditioning.
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BACKGROUND: Nonalcoholic fatty liver disease (NAFLD) is associated with an increased risk of atherosclerotic cardiovascular disease (ASCVD) events; thus, a diagnostic approach to help identify NAFLD patients at high risk is needed. In this study, we hypothesized that coronary artery calcium (CAC) screening could help stratify the risk of ASCVD events in participants with suspected nonalcoholic hepatic steatosis. METHODS: A total of 713 participants with suspected nonalcoholic hepatic steatosis without previous cardiovascular events from the Multi-Ethnic Study of Atherosclerosis (MESA) were followed for the occurrence of incident ASCVD. Nonalcoholic hepatic steatosis was defined using nonenhanced computed tomography and liver/spleen attenuation ratio <1. Cox proportional hazards regression models were used to estimate hazard ratios (HR). C-statistics and areas under the time-dependent receiver operating characteristic curves (tAUC) were used to compare incremental contributions of CAC score when added to the clinical risk factors. RESULTS: In multivariable analyses, CAC score was found to be independently associated with incident ASCVD (HR = 1.33, 95% CI = 1.22-1.44, P < .001). The addition of CAC score to clinical risk factors increased the C-statistic from 0.677 to 0.739 (P < .001) and tAUC at 10 years from 0.668 to 0.771, respectively. In subgroup analyses, the incremental prognostic value of CAC score was more significant in participants with low/borderline- (<7.5%) and intermediate- (7.5%-20%) 10-year ASCVD risk scores. CONCLUSIONS: The inclusion of CAC score in global risk assessment was found to significantly improve the classification of incident ASCVD events in participants with suspected nonalcoholic hepatic steatosis, indicating a potential role for CAC screening in risk assessment.
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Aterosclerosis , Enfermedades Cardiovasculares , Enfermedad de la Arteria Coronaria , Enfermedad del Hígado Graso no Alcohólico , Calcificación Vascular , Humanos , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/epidemiología , Enfermedad del Hígado Graso no Alcohólico/complicaciones , Enfermedad del Hígado Graso no Alcohólico/diagnóstico , Calcio , Enfermedades Cardiovasculares/epidemiología , Pronóstico , Vasos Coronarios/diagnóstico por imagen , Aterosclerosis/complicaciones , Aterosclerosis/diagnóstico , Aterosclerosis/epidemiología , Factores de Riesgo , Medición de Riesgo/métodos , Calcificación Vascular/diagnóstico por imagen , Calcificación Vascular/epidemiologíaRESUMEN
Cryptococcal endocarditis is an exceedingly rare entity associated with high mortality and morbidity. Hereby, we present a 37-year-old patient with underlying systemic lupus erythematosus and end-stage renal disease who was diagnosed with cryptococcal endocarditis involving native mitral valve. Her blood culture grew Cryptococcus neoformans. Echocardiography confirmed presence of vegetations and patient underwent mitral valve replacement and received appropriate anti-fungal treatment. Her course was further complicated by sternal wound dehiscence and infection of hemodialysis site as well as atrial flutter. Unfortunately, patient passed 2 weeks after discharge from hospital. C. neoformans is typically known to cause serious central nervous system. However, this pathogen can rarely cause serious infective endocarditis case particularly in immune compromised patients or those with prosthetic valves. Fungal endocarditis is usually treated with a combination of surgery and anti-fungal medications.
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BACKGROUND: As transcatheter aortic valve replacement (TAVR) procedures become more widely available, there is a growing need to monitor and evaluate postoperative outcomes accurately. The energy loss index (ELI) of the ascending aorta has been commonly used to examine the agreement between the echocardiographic and Gorlin measurement of the aortic valve area. OBJECTIVES: This project aims to demonstrate a link between ELI values and mortality following implanted TAVR valves and determine an ELI cutoff value associated with post-TAVR events. METHOD: We retrospectively reviewed patients undergoing TAVR from 2012 to 2017. We calculated ELI values for patients immediately postoperative after a TAVR procedure. Using Receiver-Operator Characteristic and Cox Regression analyses, we identified a cutoff value to distinguish between "High ELI" (≥ 1.34) and "Low ELI" (< 1.34) patients. RESULTS: This study showed low ELI (hazard ratio, 2.30; 95% confidence interval 1.57-3.36, p < .001) as representative of patients with a high risk of mortality post-TAVR. Additionally, post-TAVR, ejection fraction increased by 3.6% (p < .001), and the aortic valve effective orifice area increased by 1.41 cm squared (p < .001) while the mean transvalvular gradient decreased by 32.8 mmHg (p < .001) and the peak transvalvular gradient decreased by 49.0 mmHg (p < .001). CONCLUSION: ELI is an additional prognostic factor that should be considered during risk assessment before TAVR. This study shows that patients with Low ELI had decreased cumulative survival post-TAVR. These patients almost had a fivefold increased risk of death following TAVR.
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Estenosis de la Válvula Aórtica , Reemplazo de la Válvula Aórtica Transcatéter , Humanos , Reemplazo de la Válvula Aórtica Transcatéter/métodos , Estudios de Seguimiento , Estenosis de la Válvula Aórtica/etiología , Estudios Retrospectivos , Resultado del Tratamiento , Válvula Aórtica/cirugía , Factores de Riesgo , Índice de Severidad de la EnfermedadRESUMEN
OBJECTIVE: We describe a rare case of pseudohyponatremia in the setting of hypercholesterolemia caused by cholestasis due to metastatic liver disease and provide a review of the published cases in the literature. CASE REPORT: We report a case of pseudohyponatremia in a 60-year-old man with rectal cancer with extensive metastasis to the liver. While assessing the patient for hyponatremia, extremely elevated serum cholesterol with normal serum osmolality was detected leading to the diagnosis of pseudohyponatremia. This is one of very few reports of pseudohyponatremia in patients with elevated cholesterol in cholestatic liver disease. CONCLUSION: Hypercholesterolemia is an exceedingly rare cause for pseudohyponatremia. Although pseudohyponatremia per se does not carry a risk to the patient, the delay in diagnosis and treatment plans may pose additional risks. Pseudohyponatremia needs to be considered in patients with low sodium and co-existing cholestasis from metastatic liver disease.
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Colestasis Intrahepática , Colestasis , Hipercolesterolemia , Hiponatremia , Neoplasias , Masculino , Humanos , Persona de Mediana Edad , Hipercolesterolemia/complicaciones , Hiponatremia/diagnóstico , Hiponatremia/etiología , Colestasis Intrahepática/complicaciones , Colestasis/complicaciones , Neoplasias/complicacionesRESUMEN
BACKGROUND: Covid-19 disease is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Although corticosteroids have shown some promising results in Covid-19 patients, their effectiveness remains controversial. In this systematic review, we evaluated the effect of corticosteroids in mortality, Hospitalization, ICU admission, intubation, and mechanical ventilation in Covid-19 patients. METHODS: We searched major databases from March-2020 to Jan-2021. Twenty-nine studies were included after evaluating the eligibility of the literature. The extracted data for mortality, hospitalization, admission to the ICU, intubation, and mechanical ventilation were analyzed with RevMan® 5.4. Categorical variables are presented with odds ratios (OR), and numerical variables are shown with the mean difference. RESULT: Corticosteroid treatment had no impact on mortality in 18,190 covid patients with OR = 1.12[0.83-1.50]. When we include the randomized controlled trials, corticosteroids reduced the mortality by 20% (OR = 0.80 [0.73, 0.88]; P < 0.001). Additionally, the risk of admission to the ICU, the need for endotracheal intubation, and mechanical ventilation were comparable between patients receiving corticosteroids and controls. The duration of hospitalization was also similar in the two groups. CONCLUSION: Corticosteroid therapy may not be effective for reducing mortality, length of hospitalization, the likelihood of intubation and mechanical ventilation, and ICU admission in patients suffering from Covid-19 pneumonia.
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Tratamiento Farmacológico de COVID-19 , Corticoesteroides/uso terapéutico , Hospitalización , Humanos , Respiración Artificial , SARS-CoV-2Asunto(s)
Conducto Arterioso Permeable , Insuficiencia de la Válvula Mitral , Adulto , Conducto Arterioso Permeable/complicaciones , Conducto Arterioso Permeable/diagnóstico por imagen , Conducto Arterioso Permeable/cirugía , Humanos , Válvula Mitral/anomalías , Válvula Mitral/diagnóstico por imagen , Válvula Mitral/cirugía , Insuficiencia de la Válvula Mitral/diagnóstico por imagen , Insuficiencia de la Válvula Mitral/etiología , Insuficiencia de la Válvula Mitral/cirugíaRESUMEN
Introduction: Accurate measurement of the aortic valve annulus is critical for proper valve sizing for the transcatheter aortic valve replacement (TAVR) procedure. While computed tomography angiography (CTA) is the widely-accepted standard, two-dimensional (2D) and three-dimensional(3D) transesophageal echocardiography (TEE) is commonly performed to measure the size of the aortic valve and to verify appropriate seating of prostheses. Methods: Patients undergoing TAVR between 2013-2015 were examined. 2D- and 3D-TEEmeasurements were compared to CTA taken as standard. Patients were followed for at least one year. The presence and effect of discrepancy (defined as a difference of more than 10%) between CTA and TEE measurements on survival were examined. Results: One hundred eighty-five patients (70 men) were included. 2D- and 3D-TEE measurements underestimated the annulus size by -1.49 and -1.32 mm, respectively. Discrepancies > 10% between TEE and CTA methods in estimating the aortic annulus size were associated with a decrease in post implant survival. The peak pressure gradient across the aortic prosthesis measured one year after the implant was higher in patients with an initial discrepancy between 3D-TEE and CTA measurements. In a multivariate cox-regression model, the discrepancy between CTA and 2D-TEE readings and the smaller size of the aortic annular area were the predictors of long-term survival. Conclusion: Both 2D and 3D-TEE underestimate the aortic annulus measurements compared to CTA, with 2D-TEE being relatively more precise than 3D-TEE technology. The presence of a discrepancy between echocardiographic and CTA measurements of the aortic annulus is associated with a lower survival rate.
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Introduction: Considering the role of inflammation in pathogenesis of atherosclerosis, we aimed to investigate the association of presentation neutrophil to lymphocyte ratio (NLR) with complexity of coronary artery lesions determined by SYNTAX score in patients with non-ST-elevation acute coronary syndrome (NSTE-ACS). Methods: From March 2018 to March 2019, we recruited 202 consecutive patients, who were hospitalized for NSTE-ACS and had undergone percutaneous coronary intervention in our hospital. The association of presentation NLR with SYNTAX score was determined in univariate and multivariate linear regression analysis. Results: Higher NLR was significantly associated with higher SYNTAX score (beta = 0.162, P = 0.021). In addition, older age, having hypertension, higher TIMI score, and lower ejection fraction on echocardiographic examination were significantly associated with higher SYNTAX score. TIMI score had the largest beta coefficient among the studied variables (TIMI score beta = 0.302, P < 0.001). In two separate multivariate linear regression models, we assessed the unique contribution of NLR in predicting SYNTAX score in patients with NSTE-ACS. In the first model, NLR was significantly contributed to predicting SYNTAX score after adjustment for age, sex, and hypertension as covariates available on patient presentation (beta = 0.142, P = 0.040). In the second model, NLR was not an independent predictor of SYNTAX score after adjustment for TIMI score (beta = 0.121, P = 0.076). Conclusion: In NSTE-ACS, presentation NLR is associated with SYNTAX score. However, NLR does not contribute significantly to the prediction of SYNTAX score after adjustment for TIMI score. TIMI risk score might be a better predictor of the SYNTAX score in comparison to NLR.