Evaluation of the Relationship Between Vitamin D Deficiency and Subclinical Cardiac Dysfunction Using 2D/3D Strain Echocardiography in Healthy People.

AIM: Vitamin D deficiency has a high prevalence in the population and is highly associated with cardiovascular diseases. The aim of this study was to evaluate subclinical left ventricular (LV) function using strain analysis in healthy individuals with vitamin D deficiency. MATERIAL AND METHODS: 113 healthy volunteers were enrolled in the study (age, 44.1±7 yrs, 34 male). All volunteers underwent two-dimensional (2D) and three-dimensional (3D) speckle tracking echocardiography after conventional echocardiographic evaluation. The subjects were divided into two groups according to their vitamin D concentrations. 61 subjects with vitamin D less than 20 ng / ml were included in the vitamin D deficiency group. The baseline clinical characteristics, laboratory measurements, echocardiographic data, including 2D and 3D global longitudinal strain (GLS) values, were compared between the groups. RESULTS: The 2D GLS values of the subjects with vitamin D deficiency were lower (mathematically less negative) than subjects with normal vitamin D (-16.1±3.4 vs -19.3±4.2, p<0.001). Similarly, the 3D GLS results were lower in subjects with vitamin D deficiency (-18.3±5.2 vs -24.1±6.9, p<0.001). A significant correlation was detected between the vitamin D concentrations and the 2D and 3D GLS measurements. (r=0.765 and r=0.628, respectively, p<0.001). Vitamin D was found to be an independent predictor of impaired 2D and 3D LV GLS (p=0.031, p=0.023, respectively). CONCLUSION: Subclinical LV dysfunction in healthy individuals with vitamin D deficiency was demonstrated by 3D and 2D strain analysis. Due to potential negative effects of vitamin D deficiency on cardiac function, more attention should be paid to healthy individuals with vitamin D deficiency.

Current barriers and recommendations on the diagnosis of transthyretin amyloid cardiomyopathy: a Delphi study.

Objectives: This study has been conducted to investigate the non-invasive diagnostic journey of patients with a transthyretin amyloid cardiomyopathy (aTTR-CM) in Turkey, identify the challenges and uncertainties encountered on the path to diagnosis from the perspectives of expert physicians, and develop recommendations that can be applied in such cases. Methods: This study employed a three-round modified Delphi method and included 10 cardiologists and five nuclear medicine specialists. Two hematologists also shared their expert opinions on the survey results related to hematological tests during a final face-to-face discussion. A consensus was reached when 80% or more of the panel members marked the "agree/strongly agree" or "disagree/strongly disagree" option. Results: The panelists unanimously agreed that the aTTR-CM diagnosis could be established through scintigraphy (using either 99mTc-PYP, 99mTc-DPD, or 99mTc-HMPD) in a patient with suspected cardiac amyloidosis (CA) without a further investigation if AL amyloidosis is ruled out (by sFLC, SPIE and UPIE). In addition, scintigraphy imaging performed by SPECT or SPECT-CT should reveal a myocardial uptake of Grade ≥2 with a heart-to-contralateral (H/CL) ratio of ≥1.5. The cardiology panelists recommended using cardiovascular magnetic resonance (CMR) and a detailed echocardiographic scoring as a last resort before considering an endomyocardial biopsy in patients with suspected CA whose scintigraphy results were discordant/inconclusive or negative but still carried a high clinical suspicion of aTTR-CM. Conclusion: The diagnostic approach for aTTR-CM should be customized based on the availability of diagnostic tools/methods in each expert clinic to achieve a timely and definitive diagnosis.

Nano solid phase micro membrane tip and electrochemical methods for vanillin analysis in chocolate samples.

A polymer-based nanosensor and electrochemical methods were developed for the quantitative analysis of vanillin. The sample preparation was done using nano solid phase micro membrane tip extraction (NSPMMTE). A novel poly(phenylalanine)/TiO2/CPE sensor was built as the working electrode for the first time for the analysis of the vanillin substance. The electrochemical behavior and analytical performance of vanillin were examined in detail by cyclic voltammetry (CV) and differential pulse stripping voltammetry (DPSV) techniques via the oxidation process. The optimized modules of the DPSV technique that affected the vanillin peak current and peak potential were pH, pulse amplitude, step potential, and deposition time. The electroactive surface areas of bare CPE, TiO2/CPE, and poly(phenylalanine)/TiO2/CPE electrodes were found to be 0.135 cm2, 0.155 cm2, and 0.221 cm2, respectively. The limit of detection (LOD) was 32.6 µg/L in the 0.25-15.0 mg/L working range at pH 7.0. The selectivity of the proposed DPSV method for the determination of vanillin on the modified electrode was investigated in the presence of various organic and inorganic substances, and the determination of vanillin with high recovery was achieved with less than 5% relative error. The analytical application was applied in chocolate samples and the DPSV method was found highly efficient, reproducible, and selective.

Association between CHARGE-AF risk score and LA mechanics: LA reservoir strain can be a single parameter for predicting AF risk.

AIMS: Atrial fibrillation (AF) is a prevalent arrhythmia and the leading preventable cause of cardioembolic stroke. Scoring systems for predicting AF risk do not use imaging modalities. We sought to determine whether LA longitudinal strain could be used as a single parameter for predicting the risk of AF. METHODS AND RESULTS: Consecutive patients diagnosed with diastolic dysfunction between December 2019 and March 2020 were included. Two-dimensional, colour flow, continuous pulse-wave, and tissue Doppler transthoracic echocardiography (TTE) were performed using a Vivid E9 imaging system (GE Medical Systems, Chicago, USA). Measurements were obtained in the standard manner recommended by the American Society of Echocardiography. Moreover, LA longitudinal strain was measured using 2D speckle tracking echocardiography in the four-chamber view to evaluate left atrial function. The CHARGE-AF scoring system was used to predict AF risk.A total of 148 patients (mean age: 57.6 ± 11.9; male: 53%) with feasible views for LA strain measurement were divided into two groups based on a 10% CHARGE-AF cut-off score. The >10% group (48 patients; 32%) was defined as having a predicted 5-year AF risk >10%, and the ≤10% group (100 patients; 68%) was defined as having a predicted risk <10%. In the multivariate analysis, LA reservoir strain (LASr) was independently associated with CHARGE-AF score. Furthermore, using the Pearson correlation method, LASr was found to be highly correlated with CHARGE-AF score (r = -0.74, p < 0.0001). CONCLUSIONS: LASr was highly correlated with CHARGE-AF risk score and may be used as a parameter to predict atrial myopathy and hence AF risk.

Evaluation of Cardiac Function in Uncomplicated COVID-19 Survivors by 2-Dimensional Speckle Tracking Imaging.

BACKGROUND: COVID-19 is a multi-systemic infectious disease. Nearly 20%-30% of hospitalized patients have evidence of acute myocardial involvement, portending a poorer prognosis. However, information about the long-term effects of the disease on cardiac functions is sparse. As a result, there is a growing concern about the cardiac sequelae of COVID-19 among survivors. This study aimed to investigate the effects of prior mild-moderate COVID-19 infection on cardiac functions, using speckle tracking echocardiography. METHODS: Patients who have been diagnosed with COVID-19 within the previous 6 months and age-, sex-, and risk factor-matched healthy adults were included. All patients underwent a comprehensive echocardiographic examination. Both conventional and 2-dimensional speckle tracking echocardiographic measurements were performed. Serum cardiac biomarkers were also obtained on the day of the echocardiographic study. RESULTS: Compared with healthy controls, COVID-19 survivors had similar left and right ventricular longitudinal strain values at 6 months. Also, left and right atrial peak systolic strain values did not differ between the groups. CONCLUSION: Our study is valuable in putting forth the unaffected ventricular and atrial functions on long term in uncomplicated COVID-19 cases and may decrease the survivors' anxiety and the number of unnecessary applications to cardiology clinics.

Agreement between visually estimated left ventricular ejection fraction on echocardiography and quantitative measurements using cardiac magnetic resonance.

OBJECTIVE: Visual estimation of left ventricular ejection fraction (LVEF) is still used in routine clinical practice. However, most of the studies evaluating the agreement between the visually estimated LVEF (ve-LVEF) and quantitatively measured LVEF (qm-LVEF) either have not used appropriate statistical methods or gold standard imaging modality. In this study, we aimed to assess the agreement between the ve-LVEF and qm-LVEF using contemporary statistical methods and cardiac magnetic resonance imaging (CMRI). METHODS: In 54 subjects who underwent 1.5-T CMRI, echocardiographic images were recorded after the CMRI procedure on the same day. Two independent observers estimated ve-LVEFs on echocardiographic records in a random and blinded fashion, and qm-LVEF was obtained by CMRI. Agreement between the ve-LVEF and qm-LVEF values and intra/interobserver ve-LVEF estimations were assessed using intraclass correlation coefficient (ICC), Bland-Altman analysis, and kappa statistics. RESULTS: There was a high agreement between the ve-LVEF and qm-LVEF (ICC 0.93, 95% confidence interval 0.88-0.96). Bland-Altman analysis also demonstrated a good agreement between ve-LVEF and qm-LVEF with ve-LVEF, on average, being 0.6% lower than that obtained by CMRI (mean -0.6, limits of agreement -10.5 and +9.3). A good agreement was also observed for LVEF categories ≤35%, 36%-54%, and ≥55% (unweighted kappa 0.71, linearly weighted kappa 0.76); and LVEF of <55% and ≥55% (kappa 0.80). Intra/inter observer agreement was good for ve-LVEFs (ICC value 0.96 and 0.91, respectively). CONCLUSION: Visual approach for LVEF assessment may be used for rapid assessment of left ventricular systolic function in clinical practice, particularly in patients with good image quality.

The role of three dimensional transesophageal echocardiography in predicting the effect of cardiac resynchronization therapy on mitral regurgitation in patients with low ejection fraction heart failure.

PURPOSE: Cardiac resynchronization therapy (CRT) positively affects the improvement of functional mitral regurgitation (MR) in patients with heart failure with reduced ejection fraction (HFrEF). However, geometric changes in the mitral valve apparatus, subvalvular structures and their contribution to improving mitral regurgitation after CRT have not been clearly defined. Our study aimed to evaluate the geometric parameters of mitral valve apparatus measured with three-dimensional (3D) transesophageal echocardiography (TEE) before CRT implantation and to determine the parameters predicting the improvement of MR after CRT. METHODS: In this prospective study, we included thirty patients with moderate or severe MR and HFrEF planned for CRT implantation who had an indication for TEE. Before CRT implantation, effective regurgitant orifice (ERO) and regurgitant volume (RV) measurements were performed. Detailed quantitative measurements of the mitral valve were done from recorded images by 3D TEE. ERO and RV measurements were repeated to evaluate MR at the end of the third month. RESULTS: There were no significant changes in left ventricular EF and left ventricular diameters at third-month follow-up, whereas ERO and RV values were decreased. The posterior leaflet angle was higher in the non-responder group than the responder group (28.93 ± 8.41 vs 41.25 ± 10.90, p = 0.006). The posterior leaflet angle was an independent predictor of decreased RV and ERO. CONCLUSION: Among HFrEF patients with moderate or severe functional MR who underwent CRT implantation had a lower posterior leaflet angle, which was measured by 3D TEE, in the patient group whose MR improved after CRT.

Severe Intermittent Transvalvular Mitral Valve Regurgitation: Serious Complication of Mitral Valve Replacement With Subvalvular Preservation.

Mitral valve replacement with subvalvular preservation is a favorable technique to protect left ventricular function and improve long-term survival. However, complications of the procedure should be considered. We report the case of a patient with a history of prosthetic mitral valve replacement with severe intermittent transvalvular mitral regurgitation and reduced ejection fraction. (Level of Difficulty: Advanced.).

Invasive validation of the left ventricular global longitudinal strain for estimating left ventricular filling pressure.

PURPOSE: An elevated left ventricular (LV) filling pressure is the main finding in heart failure patients with preserved ejection fraction, which is estimated with an algorithm using echocardiographic parameters recommended by the recent American Society of Echocardiography (ASE)/European Association of Cardiovascular Imaging (EACVI) guidelines. In this study, we sought to determine the efficacy of the LV global longitudinal strain (GLS) in predicting an elevated LV filling pressure. METHODS AND RESULTS: A total of 73 prospectively selected patients undergoing LV catheterization (mean age 63.19 ± 9.64, 69% male) participated in this study. Using the algorithm, the LV filling pressure was estimated using the echocardiographic parameters obtained within 24 hours before catheterization. The LV GLS was measured using an automated functional imaging system (GE, Vivid E9 USA). Invasive LV pre-A pressure corresponding to the mean left atrial pressure (LAP) was used as a reference, and a LAP of >12 mm Hg was defined as elevated. Invasive LV filling pressure was elevated in 43 patients (59%) and normal in 30 patients (41%). Nine of 73 (12%) patients were defined as indeterminate based on the 2016 algorithm. Using the ROC method, -18.1% of LV GLS determined the elevated LAP (AUC =0.79; specificity, 73%; sensitivity, 84%) with better sensitivity compared to that by the algorithm (AUC =0.76; specificity, 77%; sensitivity, 72%). CONCLUSIONS: We demonstrated that LV GLS was an independent predictor of elevated LAP as the E/e' ratio and TR jet velocity and may be used as a major criterion for the diagnosis of HFpEF.

LA reservoir strain: a sensitive parameter for estimating LV filling pressure in patients with preserved EF.

An elevated left ventricular (LV) filling pressure is the main finding in patients with heart failure with preserved ejection fraction (HFpEF), and LV filling pressure is estimated with an algorithm in the recent American Society of Echocardiography (ASE)/European Association of Cardiovascular Imaging (EACVI) guideline. In this study, we sought to determine the efficacy of LA global longitudinal strain to estimate elevated LV filling pressure. Seventy-one consecutive patients (mean age of 63.2  ±  9.75, 70% male) who underwent left ventricular catheterization were included. Transthoracic echocardiography was performed within 24 h before catheterization. The LV filling pressure was estimated using echo parameters based on the 2016 ASE/EACVI algorithm. LA GLS was measured using 2D speckle tracking echocardiography in a four-chamber view (GE, Vivid E9 USA). Invasive LV pre-A pressure corresponding to the mean left atrial pressure (LAP) was used as a reference, and > 12 mm Hg was defined as elevated. Invasive LV filling pressure was defined as elevated in 41 (58%) and normal in 30 patients (42%). The LV filling pressure of 9 (13%) of 71 patients was defined as indeterminate based on the 2016 algorithm. Using the ROC method, 25.5% of LA reservoir strain (LASr) had a higher sensitivity (AUC = 0.79, specificity 77%, sensitivity 80%) in estimating LV filling pressure than the 2016 ASE/EACVI algorithm (AUC = 0.75, specificity 77%, sensitivity 70%). LASr, with higher sensitivity than 2016 ASE/EACVI algorithm, may be used as a single parameter to estimate LV filling pressure and hence may add incremental value toHFpEF diagnosis.

Heart transplant recipient survivor from COVID-19: The first case of Turkey.

Any highly infectious and rapidly spreading disease is a primary concern for immunocompromised solid organ transplant recipients. The number of data about the spectrum of clinical illness, the treatment modalities, and the outcomes of COVID-19 in this vulnerable population is scant and still remains empirical. Herein, we report the first COVID-19 case of a heart transplant recipient in Turkey who presented with fever, postnasal discharge, and myalgias for two days. The possibility of lung involvement was ruled out by thoracic computed tomography. Despite stable vital signs, we reduced the intensity of immunosuppressive therapy and maintained home self-isolation promptly. We also commenced a five-day course of hydroxychloroquine 200 mg q12h initially. After confirmation of real-time reverse-transcriptase-polymerasechain- reaction testing of the nasopharyngeal swab positive for COVID-19, the patient was hospitalized. After a loading dose of favipiravir 1,600 mg b.i.d., the patient received a five-day course of favipiravir 600 mg q12h. He was discharged with cure after 23 days of hospital isolation and treatment. In conclusion, treatment process can be affected by the daily electrocardiography, hand-held portable echocardiography, myocardial injury markers, and pulse oximeter for selfmonitoring in the follow-up of previous heart transplant recipients suffering from COVID-19. The lack of treatment protocols in the solid organ transplant recipients with COVID-19 infection and the controversies about the protective effect of immunosuppression invite a global and update discussion.

Heart failure due to aorto-right atrial fistula and successful treatment with percutaneous closure.

Aorto-atrial fistula is a rare anomaly of the heart that may be the result of congenital or acquired conditions, such as bacterial endocarditis, paravalvular abscess, aortic dissection, or a complication of cardiac surgery. A 50-year-old female patient presented at the clinic with the complaint of dyspnea and abdominal distention due to ascites. On admission, her functional capacity was New York Heart Association (NYHA) class III. A physical examination revealed a systolic murmur, which was best audible in the right parasternal side, ascites, and hepatomegaly. An aorto-right atrial fistula was detected using transthoracic echocardiography and confirmed with transesophageal echocardiography and aortography. The patient had a history of previous cardiac surgery, anticoagulant use, and heart failure; therefore, percutaneous intervention was preferred to surgery as a result of the high surgical risk. A successful closure of the fistula was performed with an Amplatzer Duct Occluder II device. The patient demonstrated a dramatic response to the treatment, resulting in a decrease in the ascites and halving of her diuretic dose within 1 week. Her functional capacity improved to NYHA class II, and right atrial pressure decreased to 8 mmHg after a month.

Sutureless Valve Replacement Through a Right Anterior Mini-thoracotomy in Elderly Patients With Stenotic Bicuspid Aortic Valve.

Several indications for sutureless aortic valve replacement (SU-AVR) have been a matter of debate. We evaluated our experience with Perceval-S (LivaNova group, Saluggia, Italy) SU-AVR in patients with severe aortic stenosis (AS) involving bicuspid aortic valve (BAV), even though presence of BAV is still considered to be a contraindication for sutureless valves. From January 2013 through March 2018, 13 patients with severe AS involving BAV underwent SU-AVR with the Perceval-S (LivaNova group, Saluggia, Italy) prosthesis in a single center. Preoperative evaluation included coronary catheterization and multisliced computerized tomography was performed in all patients. Three-dimensional transthoracic echocardiography was used to evaluate for obtaining the anatomy and phenotype of BAV. Minimally invasive approach through right anterior thoracotomy from third intercostal space was performed for all patients. The mean age was 72.8 ± 2.26 years ranging from 70 to 77, and 53.8% (n = 7) were male. The mean aortic valve gradient decreased from 46.4 ± 13.8 to 13.6 ± 4.4 mmHg postoperatively. The mean aortic valve area increased from 0.69 ± 0.22 to 1.81 ± 0.38 cm2. There was no in-hospital mortality. One patient (7.6%) had third-degree atrioventricular block requiring permanent pacemaker implantation. Mean follow-up was 15.1 ± 6.3 months (maximum 2 years). No major paravalvular leakage or valve migration occurred postoperatively. This study shows that SU-AVR is a technically feasible and safe procedure in patients with severe AS and BAV with acceptable good surgical outcomes. Presence of BAV in AS should not be considered a contraindication to Perceval-S prosthesis (LivaNova group, Saluggia, Italy).

Right ventricular free wall longitudinal strain and stroke work index for predicting right heart failure after left ventricular assist device therapy.

OBJECTIVES: Right heart failure (RHF) is an important prognostic factor in continuous-flow left ventricular assist device (LVAD) therapy. We aimed to assess the clinical variables associated with RHF after LVAD implantation and to compare their performance against currently available RHF predictive scoring systems. METHODS: The study cohort comprised 57 patients who underwent LVAD therapy between January 2012 and May 2018 in our centre. The mean age of the patients was 39.9 ± 18.3 years, and 43 (81.1%) of them were men. Thirty-eight patients (66.6%) were in the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profile I or II. The study cohort was divided into the patients with RHF postoperatively (n = 20, 35.1%) and without RHF (n = 37, 64.9%). RESULTS: Independent predictors for RHF were preoperative right ventricular ejection fraction <25% [odds ratio (OR) 4.68, 95% confidence interval (CI) 1.41-15.5; P = 0.01], right ventricular stroke work index <400 mmHg ml-1 (OR 3.73, 95% CI 1.01-13.7; P = 0.04), right ventricular outflow tract systolic excursion <7 mm (OR 1.55, 95% CI 0.31-0.84; P = 0.002), right ventricular outflow tract fractional shortening <15% (OR 1.62, 95% CI 0.34-0.78; P = 0.02), right ventricular free wall longitudinal strain ≤19% (OR 3.13, 95% CI 1.01-2.43; P = 0.003), right ventricular fractional area change <27% (OR 3.71, 95% CI 1.15-11.9; P = 0.02) and prealbumin <14 mg/dl (OR 3.45, 95% CI 1.07-11.03; P = 0.03). Modest diagnostic performance for RHF was detected in 4 of 7 validated scoring systems with resulting area under the curve values of 0.70 (95% CI 0.55-0.84; P = 0.001) for the Seattle Heart Failure Model; 0.68 (95% CI 0.49-0.81, P = 0.03) for the Fitzpatrick's; 0.68 (95% CI 0.53-0.83, P = 0.028) for the acute physiology and chronic health evaluation (APACHE) II; and 0.66 (95% CI 0.50-0.82, P = 0.04) for the model for end-stage liver disease scoring systems. However, we found best discrimination performance of the score with a resulting area under the curve value of 0.94 (95% CI 0.55-0.89, P = 0.03) for right ventricular free wall longitudinal strain ≥-15.5% and 0.82 for right ventricular stroke work index <400 mmHg ml-1 m-2 in predicting RHF. CONCLUSIONS: Right ventricular free wall longitudinal strain ≥-15.5% and right ventricular stroke work index <400 mmHg ml-1 m-2 were independent predictors of RHF following LVAD implantation. Currently available prediction risk scores had the modest power of accuracy in the low INTERMACS profile Turkish population.

Effects of Hemodialysis on Tei Index: Comparison between Flow Doppler and Tissue Doppler Imaging.

OBJECTIVE: Myocardial performance index (MPI, Tei index) has been described as a noninvasive measurement of left ventricle (LV) function. Our aim was to investigate the influence of preload on the LV MPI obtained by pulsed-wave tissue Doppler imaging (PWTDI) and determined by flow Doppler waveforms in patients with end-stage chronic renal failure (CRF). The second aim of this study was to investigate the relationship between the Tei indices obtained by both methods. METHODS: Eighty-four patients on regular hemodialysis (HD) treatment were included (mean age of 45.3 ± 14.5 years). Standard echocardiographic measurements, the Tei indices obtained by conventional flow Doppler and PWTDI methods, mitral inflow velocities, and mitral lateral annulus tissue Doppler velocities were measured immediately before and after hemodialysis. RESULTS: After HD, weight loss in patients was significantly revealed (predialysis 63.6 ± 13.3 kg; postdialysis 60.9 ± 13.0 kg; P < 0.001). Left ventricle and left atrium diameters were significantly decreased after HD. Transmitral E and A velocities decreased after HD. Although Tei index measuring by conventional flow Doppler method significantly increased, Tei index measuring by PWTDI did not change after HD. CONCLUSIONS: The conventional flow Doppler-derived LV Tei index is influenced by hemodialysis. However, PWTDI-derived LV Tei index is not influenced by hemodialysis. The loading status of a patient should be taken into account during the application of the Tei index to the evaluation of myocardial performance.

Pulmonary arterial hypertension and systemic sclerosis relation: a single centre experience.

AIM: In systemic sclerosis (SSc), this single-centre study aimed to define the frequency and association of pulmonary arterial hypertension (PAH), occurring either alone in SSc-PAH or together with interstitial lung disease (ILD-PH). MATERIAL-METHODS: SSc cases between the years 1990-2011 were reviewed, retrospectively. Patients' clinical, laboratory findings, Modified Rodnan Skin Score and Medsger score, 6-minute walk distance (6MWD), carbon monoxide diffusion test (DLCO), echocardiography, thorax HRCT, and right heart catheterisation findings were recorded. RESULTS: One hundred and forty-one cases (F/M:124/17, diffuse cutaneous SSc (DcSSc)/limited cutaneous SSc (LcSSc): 84/57) were included in the study with the mean age of 52.70±15.17 years and disease duration of 107.07±99.44 months. PaO2, FEV1 and FVC were lower in DcSSc (p<0.05) as compared to LcSSc, but DLCO and 6MWD did not differ significantly, between the two forms. Ground glass opacity (64.7%) and interlobular septal thickening (58.8%) were the most frequent findings on HRCT of such subjects. PAH was detected in 34 subjects (24.1%). Seven of them had SSc associated PAH (SSc-PAH) and 27 ILD-PH. Both frequencies were similar between DcSSc and LcSSc. Mean sPAP was higher in SSc-PAH. CONCLUSION: PAH was observed in approximately one fourth of patients; therefore advanced cardio-pulmonary investigation should be routinely performed in the SSc patients' management.

A potential link between endothelial function, cardiovascular risk, and metabolic syndrome in patients with Non-alcoholic fatty liver disease.

BACKGROUND: Asymmetric dimethylarginine (ADMA) is an endogenous competitive inhibitor of nitric oxide (NO) synthetase. Elevated ADMA reduces NO formation and is associated with endothelial dysfunction. The aims of this study were to evaluate endothelial function and the cardiovascular risk (CVR) profile in patients with non-alcoholic fatty liver disease (NAFLD), and to determine whether or not an association with metabolic syndrome (MS) increases these parameters. METHODS: A total of 100 consecutive patients with NAFLD, who were seen in Liver Disease Outpatient clinic and 45 age- and sex-matched controls were included. Endothelial function was evaluated based on the serum ADMA level measured using a validated ELISA kit (DLD Diagnostika GMBH, Hamburg, Germany) and flow-mediated vasodilatation (FMV) measured via high-resolution external ultrasonography. The CVR profile was calculated according to the Framingham equation. RESULTS: At baseline there weren't any significant differences in brachial artery diameter between the NAFLD and control groups (3.7 ± 0.6 mm vs. 3.6 ± 0.6 mm, respectively). FMV and flow-independent vasodilatation in response to sublingual nitroglycerin did not differ between the NAFLD and control groups (mean: 16% ± 9.4% vs. 17.9% ± 12.4%, and 21.4% ± 14% vs. 17.8% ± 11.3%, respectively, p > 0.05). No significant difference in the serum ADMA concentration between the NAFLD and control groups was observed (mean: 0.8 ± 0.07 µmol L(-1) vs. 0.74 ± 0.2 µmol L(-1), respectively). The CVR profile was significantly higher in the NAFLD group than in the control group (mean: 9% ± 6.9% vs. 4.6% ± 3.8%, P = 0.000). MS associated with NAFLD significantly increased the CVR profile (mean: 11.2% ± 7.4%, P = 0.000). An abnormal serum alanine aminotransferase level (>37 IU L(-1)) and the presence of fibrosis did not increase the CVR profile (p > 0.05). CONCLUSIONS: The risk of cardiovascular events is increased in patients with NAFLD. The association with MS is further increased such risk.