Questionable validity of left ventricular hypertrophy cutoff values in morbidly and super-morbidly obese patients.

BACKGROUND: Current diagnostic ECG criteria of left ventricular hypertrophy in obese patients are still lacking. OBJECTIVE: To assess the current ECG diagnostic criteria of LVH, and to validate our previously proposed criteria in a group of patients with morbid obesity. METHODS: A group of consecutive 429 obese patients (MOP) with BMI of at least 35 kg/m2 (mean age 38.6 ± 8.9 years, BMI 48.7 ± 9.0 kg/m2 ; 323 females, 106 males) were included. RESULTS: The diagnosis of LVH in MOPs was confirmed only by RaVL of 7.5 mm, Cornell index of 12.5 mm; Cornell index × QRS duration of 1,125 mm × ms and Romhilt-Estes score of 1. None of the criteria proposed to date is appropriate in super-morbidly obese patients. CONCLUSION: Our study confirmed that none of the currently used voltage-based ECG criteria is appropriate for diagnosing LVH in morbidly obese patients. Further studies are required.

Cardiac autonomic function in type 1 and type 2 myotonic dystrophy.

OBJECTIVE: The aim of this study was to evaluate cardiac autonomic nervous system function using Holter-derived and standard electrocardiographic parameters in patients with myotonic dystrophy (dystrophia myotonica, DM) and no clinically overt heart involvement. METHODS: Eighty-four DM patients without conditions potentially influencing cardiac autonomic function were enrolled in the study: 44 with DM type 1 and 40 with DM type 2 (mean age 34.9 ± 11.5 and 47.8 ± 13.5 years, respectively). Two corresponding control groups of aged-matched healthy subjects were selected for DM1 (n = 35) and for DM2 (n = 30). Standard electrocardiography for QT interval dispersion and 24-h Holter monitoring with time-domain heart rate variability and heart rate turbulence were performed. RESULTS: No significant differences in time-domain heart rate variability parameters between DM1 or DM2 subjects and controls were observed. However, heart rate turbulence parameters were significantly impaired in DM1 patients as compared to their controls: turbulence onset (p = 0.025), and turbulence slope (p = 0.018). Moreover, turbulence slope was also impaired in DM2 patients (p = 0.042). As compared to controls, we observed an increased QT dispersion, both in DM1 (p = 0.003) and also in DM2 patients (p < 0.0001). No relationship between disease duration or neurological status and time-domain heart rate variability, heart rate turbulence, and QT dispersion was observed. INTERPRETATION: Despite normal time-domain heart rate parameters, impaired heart rate turbulence and increased QT dispersion may suggest cardiac autonomic nervous system dysfunction in DM patients. The present study is the first one in which heart rate turbulence and QT dispersion assessment were examined both in DM1 and DM2 patients.

Supraventricular and Ventricular Arrhythmias Are Related to the Type of Myotonic Dystrophy but Not to Disease Duration or Neurological Status.

BACKGROUND: Patients with myotonic muscular dystrophy (dystrophia myotonica, DM) are at risk of sudden cardiac death due to diverse arrhythmias, especially progressive atrioventricular (AV) conduction abnormalities. However, there are limited data on supraventricular and potentially life-threatening ventricular arrhythmias, especially according to type 1 and type 2 DM. METHODS: A group of 94 unselected consecutive patients with genetically confirmed DM and 45 healthy controls underwent electrocardiography, echocardiography, and 24-hour Holter monitoring. DM1 was diagnosed in 51, while DM2 in 43 patients (with mean age of 37.3 ± 12.5 and 48.3 ± 13.3 years, respectively). RESULTS: DM1 subjects presented more frequently intraventricular conduction defects (29.4% vs 6.6%, P = 0.0003) and first-degree AV block (25.0% vs 4.6%, P = 0.008) than DM2 patients. Nonsustained supraventricular tachycardia (37.2% vs 3.8%, P = 0.001) and nonsustained ventricular tachycardia and/or R-on-T ventricular beats (23.2% vs 7.8%, P = 0.04) were more frequently observed in DM2 than in DM1. No relationship between disease duration and neurological status and occurrence of arrhythmias was observed. Multivariate analysis showed that independent predictor for bradyarrhythmias occurrence was DM1 only (odds ratio [OR] 6.4, 95% confidence interval [CI] 2.0-20.8, P = 0.002), while for supraventricular or ventricular arrhythmias occurrence it was DM2 (OR 4.1, 95% CI 1.5-11.4, P = 0.007) and increased age (OR 1.09, 95% CI 1.05-1.15, P < 0.0001). CONCLUSIONS: In the relatively large groups of DM1 and DM2 patients, we observed frequent various arrhythmias, which warrant their close cardiac monitoring. DM1 subjects when compared to DM2 presented more frequently intraventricular and AV conduction defects. However, all types of tachyarrhythmias (except atrial fibrillation) were more frequently observed in DM2 patients.

Severity of arterial and chronic thromboembolic pulmonary hypertension is associated with impairment of heart rate turbulence.

BACKGROUND: Heart rate turbulence (HRT) impairment is a validated and an independent indicator of cardiovascular death. There are limited data on HRT in pulmonary hypertension (PH), so we assessed potential HRT alterations in PH, especially in relation to its severity. METHODS: Thirty-three out of 41 patients were enrolled in the study aged 49.7 ± 15.9 years (22 with arterial, 11 with chronic thromboembolic PH). Routine evaluations, right heart catheterization, and 24-hour Holter monitoring with heart rate variability and HRT assessment were performed. RESULTS: HRT was significantly impaired in PH patients, as compared to 25 healthy controls: mean turbulence onset (TO) was -0.27% versus -2.60% (P < 0.0001), and median turbulence slope (TS) was 3.13 versus 13.5 msRR (P < 0.0001). Abnormal HRT (TO ≥ 0.0% and/or TS ≤ 2.5 ms/RR) was found in 63.3% of PH patients. Patients with PH and abnormal HRT presented more compromised functional, biochemical, and hemodynamic status than PH patients with normal TO and TS values. Multivariate stepwise regression analysis showed that TO value was related to oxygen desaturation <90% in 6-minute walking test (6-MWT; OR 0.41, P < 0.001) and was related to N-Terminal pro-B type Natriuretic Peptide concentration (OR 0.40, P < 0.001); TS was related to 6-MWT distance (OR 0.53, P < 0.0001). CONCLUSIONS: Patients with arterial or chronic thromboembolic PH are characterized by significant impairment of HRT which is related to the disease severity. We hypothesize that patients with abnormal HRT could be considered as subjects with an increased risk of cardiovascular death, however, it needs further investigation.

Functional class and type of pulmonary hypertension determinate severity of cardiac autonomic dysfunction assessed by heart rate variability and turbulence.

OBJECTIVE: Heart rate variability (HRV) and turbulence (HRT) are validated methods of evaluation of cardiac autonomic nervous system (cANS) dysfunction which is associated with sudden cardiac death. There is limited data on cANS imbalance and its significance,in patients with pulmonary hypertension (PH), so we assessed HRV and especially HRT alterations in PH. METHODS AND RESULTS: Thirty-three out of 41 PH patients were enrolled in the study: 22 (66.7%) with pulmonary arterial hypertension (PAH) and 11 (33.3%) with chronic thromboembolic PH (CTEPH), 11 patients were in World Health Organization Functional Class (WHO-FC) I-II, and 22 others in WHO-FC III-IV. The control group consisted of 25 healthy persons. Routine evaluations, echocardiography, right heart catheterization and 24-hour Holter monitoring with time-domain HRV and HRT evaluation were performed. Most of HRV indices and both of HRT parameters were significantly impaired in PH patients, as compared to control subjects. Abnormal HRT (turbulence onset 0.0% and/or turbulence slope 2.5 ms/RR) was found in 36.4% WHO-FC I-II and in 77.3% WHO-FC III-IV patients (P=0.05). Patients in WHO-FC III-IV or with CTEPH presented compromised HRV and HRT values when compared to patients in WHO-FC I-II or with PAH, respectively. Multivariate analysis showed that abnormal HRT occurrence in PH was influenced by higher WHO-FC only (odds ratio 5.3, 95% CI 1.4-19.9, P= 0.01). CONCLUSION: Higher WHO-FC and probably type of pulmonary hypertension (CTEPH more than PAH) determinate the severity of cANS dysfunction assessed by heart rate variability and turbulence. Potential clinical consequences of our findings need further investigations.

Six-minute walk test reflects neurohormonal activation and right ventricular function in systemic sclerosis patients.

OBJECTIVES: Heart and pulmonary involvement is a leading cause of systemic sclerosis (SSc)-related deaths. The six-minute walk test (6MWT) is a simple and reproducible test commonly used to evaluate exercise capacity. We tried to assess a potential relationship between exercise capacity assessed by 6MWT, echocardiographic parameters of right ventricular function and serum levels of endothelin-1 and NTproBNP. METHODS: We prospectively studied 111 consecutive patients (101F, 10M, age 54.2±13.8 years) with diagnosed SSc (mean disease duration 9±12.4 years) and a group of 21 age-matched subjects (18F, 3M, age 49.3±10.5 years). In addition to routine evaluation, 6MWT and transthoracic echocardiography (Phillips iE 33) were performed. We also measured serum endothelin-1 (Human Endothelin-1 immunoassay R & D Systems) and NT-proBNP levels (Elecsys pro-BNP immunoassay; Roche Diagnostics). RESULTS: The mean 6MWT distance was significantly shorter in the SSc group than in the controls (562.8±60.3 vs. 514.7±102.5 m, p=0.03). In the SSc group 6MWT distance correlated with ET-1 (r=-0.5, p<0.0001), NTproBNP (r=-0.4, p=0.0008) levels, and echocardiographic indices AcT (r=0.4, p=0.0002) and TRPG (r=-0.4, p=0.0011). Moreover, in patients with 6MWT distance <450 m NTproBNP and endotothelin-1 levels were significantly higher than in patients with distance >450 m (311.2, 31.1-17237 vs. 105.3, 5-17670 pg/ml, p=0.0138 and 2.9±2.2 vs. 1.4±0.7 pg/ml, p=0.0032). CONCLUSIONS: Decreased exercise capacity significantly correlates with biochemical and echocardiographic parameters of right ventricular dysfunction and neurohormonal activation providing a potential link for neuroendocrine derangement in patients with SSc.

Holter-Derived Autonomic Function, Arrhythmias and Carbohydrate Metabolism in Patients with Class III Obesity Treated with Laparoscopic Sleeve Gastrectomy.

The effects of weight loss following bariatric surgery on autonomic balance, arrhythmias and insulin resistance are still of interest. We prospectively investigated 50 patients with BMI > 40 kg/m2, aged 36.5 (18-56) years who underwent laparoscopic sleeve gastrectomy. Among other examinations, all subjects had 24-h Holter monitoring with heart rate variability (HRV) and heart rate turbulence (HRT) evaluation. After a median of 15 months, BMI decreased from 43.9 to 29.7 kg/m2, the incidence of hypertension decreased from 54 to 32% (p = 0.04) and any carbohydrate disorders decreased from 24 to 6% (p = 0.02). Fasting insulin concentration and insulin resistance index improved significantly (p < 0.001). Improvements in HRV parameters related to the sympathetic autonomic division were also observed (p < 0.001), while HRT evaluation was not conclusive. The enhancement of autonomic tone indices was correlated with reduction of BMI (SDNN-I r = 0.281 p = 0.04; SDNN r = 0.267 p = 0.05), but not with reduction of waist circumference, and it was also associated with decrease of mean heart rate (OR 0.02, 95%CI 0.0-0.1, p < 0.001). The incidence of arrhythmias was low and similar before and after follow-up. In conclusion, improvement of homeostasis of carbohydrate metabolism and autonomic function is observed in relatively young patients after weight loss due to laparoscopic sleeve gastrectomy.

Assessment of arrhythmias and cardiac autonomic tone at a relatively young age patients with obesity class III.

There is no sufficient data on arrhythmias occurrence in obesity class III. The influence of hyperinsulinemia and insulin resistance on arrhythmias and cardiac autonomic tone is also of ongoing interest in these subjects. We prospectively studied 81 selected patients with body mass index >40 kg/m2 , aged 34 (18-65) years. Among other examinations all subjects underwent electrocardiography and Holter monitoring with heart rate variability (HRV) and turbulence (HRT) evaluation. Controls consisted of 45 healthy, sex- and aged-matched lean volunteers. In patients median BMI was 44.5 kg/m2 (40.1-58.1), benign arterial hypertension was present in 43.2% and dysglycemia in 27.2% of cases. In the group with obesity longer PR interval (P < .001) and corrected QT interval (P < .001) were observed, while in Holter monitoring no significant differences in supraventricular or ventricular arrhythmias and also bradyarrhythmias prevalence were observed in comparison to controls. In individuals with obesity HRV indices associated with sympathetic tone were significantly impaired and also abnormal HRT values (21.9 vs 0%, P = .04) were more frequently observed. There were no significant correlations between anthropometric obesity parameters and fasting insulin concentration, insulin resistance index and also HRV/HRT parameters in studied individuals. Univariate regression analysis revealed that only age influenced abnormal HRT occurrence (OR 1.69, 95%CI 1.08-2.98, P = .04). In conclusions, patients with obesity class III at a relatively young age who reported they felt healthy, do not present increased prevalence of arrhythmias, including life-threatening ones. Cardiac autonomic dysfunction is observed in these patients, however it has not been shown to be associated with anthropometric measurements.

Biventricular noncompaction associated with left ventricular systolic and diastolic dysfunction and severe pulmonary hypertension in a young man.

Noncompaction of the ventricular myocardium is a recently recognized genetic cardiomyopathy. The left ventricle is the most affected site, but right ventricular involvement has been reported in some cases. Diagnosis is made with 2-dimensional echocardiography or cardiac magnetic resonance imaging. The major clinical manifestations are heart failure, arrhythmias and embolic events. A 20-year old man had left and right ventricular noncompaction complicated by severe pulmonary hypertension, which is one of the first cases of biventricular noncompaction associated with severe pulmonary hypertension. Pulmonary hypertension may be a consequence of increased pulmonary venous pressures caused by systolic and diastolic heart dysfunction secondary to noncompaction.

The short-term effect of bariatric surgery on non-invasive markers of artery function in patients with metabolic syndrome.

BACKGROUND: An improved understanding of the vascular function, measured in non-invasive way, in constantly growing group of patients at increased risk of cardiovascular events is necessary. To evaluate the effects of metabolic syndrome in morbidly obese patients and body mass reduction secondary to gastric bypass surgery on convenient and new non-invasive markers of artery function: pulse wave velocity (PWV), flow- and nitroglycerin-mediated dilatation (FMD, NTG). METHODS: There were 40 patients included into prospective study, who were qualified for bariatric surgery (OB1) and evaluated again 6 m after surgery (OB2). A control group (CG) consisted of 15 healthy women. A second control group (CG2) consisted of 15 women with grade 1 obesity. PWV, FMD, NTG were assessed. RESULTS: The reduction of BMI (kg/m(2)) from 47.73 ± 6.18 (OB1) to 35.22 ± 5.20 (OB2) was observed. The PWV turned out to be higher before bariatric surgery (OB1 vs. OB2 8.53 ± 1.76 vs. 7.82 ± 1.49 m/s; p < 0.001), however it was no different than PWV in CG. In OB1 group PWV showed correlation with age (r = 0.492, p = 0.001), HR (r = 0.324, p = 0.04), %FM (r = 0.328; p = 0.039), NTG% (r = -0.332, p = 0.036) as well as hsCRP (r = 0.394, p = 0.014). A multivariate analysis showed that the most significant factors influencing PWV were age (p = 0.0005) and hsCRP (p = 0.0014), pseudo R(2) index 0.44365. The values of FMD differed between OB1 and OB2 groups (12.83 ± 5.15 vs. 17.52 ± 5.50 %; p < 0.0001), however, they were similar to results obtained in CG (14.45 ± 6.14 %; NS). The values of nitroglycerin-mediated dilatation differed between OB1 and OB2 groups (21.47 ± 8.31 vs. 28.54 ± 8.16 %; p < 0.0001) and were lower as compared with CG (31.42 ± 5.95 %; p = 0.0005). CONCLUSION: Body mass reduction secondary to bariatric surgery in patients with severe obesity and metabolic syndrome results in improvement of functional markers of artery function and advantageous metabolic changes. The improvement in functional markers of artery function (NTG%) was correlated with change in triglyceride blood concentration.

Emerging markers of atherosclerosis before and after bariatric surgery.

OBJECTIVE: The objective of this study was to assess the emerging biochemical markers of arterial remodeling in patients with morbid obesity before and after surgical treatment and to compare the results to a control group. MATERIAL AND METHODS: The prospective study included 40 patients with BMI 47.73 ± 6.18 kg/m(2), qualified for elective bariatric surgery and re-examined 6 months after the surgery. The control group consisted of non obese, age and sex matched 15 subjects. Following laboratory examinations were performed in all patients: basic laboratory examinations, MMP-2, MMP-9, adiponectin, PAI-1, CD40L, E-selectin. RESULTS: Examination of patients 6 m after bariatric surgery revealed a 34.57 ± 9.71 reduction in excess body weight. Comparison of the study group at two time points revealed differences in adiponectin, MMP-2 and MMP-9 levels. Hypoadiponectinemia was observed in 35 % patients 6 months after bariatric surgery compared to 90 % patients before the surgery. In addition, a strong correlation was observed between body fat mass and adiponectin levels (r = -0.504, p = 0.055). Moderate correlations were demonstrated between E-selectin levels and BMI (r = 0.361; p = 0.022), and metalloproteinase-9 levels (r = 0.326; p = 0.040). In addition, strong relationship was demonstrated between MMP-2 and MMP-9 (r = 0.502; p = 0.001), and moderate between MMP-2 and adiponectin levels (r = 0.449; p = 0.003). MMP-9 levels were moderately correlated with HDL-cholesterol levels (r = 0.316; p = 0.046). CONCLUSIONS: Assessment of laboratory markers of arterial remodeling and metabolism suggest their adverse changes in patients with morbid obesity. However, body mass reduction due to bariatric surgery decreases inflammatory status, improves biochemical markers of arterial remodeling as well as to beneficial changes in the metabolism.

Correlation between clinical parameters of periodontal disease and mean platelet volume in patients with coronary artery disease: a pilot study.

BACKGROUND: Cardiovascular diseases as well as periodontitis can be regarded as current epidemics and have become a social problem. Mean platelet volume (MPV) is a simple, routinely assessed biochemical parameter, which is becoming regarded asa new, independent risk factor of acute coronary syndromes and stroke. AIM: Assessment of a potential relationship between clinical indices of periodontal disease and MPV in relation to the presence of coronary artery disease (CAD) and chronic periodontitis. METHODS: The study included 57 individuals aged from 50 to 65 years. Patients were divided into three groups. Group 1 consisted of 19 patients with previously diagnosed CAD and coexisting chronic periodontitis. Group 2 included 18 patients with diagnosed chronic periodontitis with excluded CAD. Group 3 was a control group and consisted of 20 healthy individuals without CAD or periodontitis. RESULTS: Unsatisfactory oral hygiene defined by plaque index (PI) was observed in all patients. Mean PI was significantly higher in Groups 1 and 2 than in Group 3 (76.7% vs. 45.7%, p < 0.01). Mean bleeding index (BI) was significantly higher in Group 2 than in Groups 1 and 3 (46.4% vs. 29.8%, p < 0.05). Mean periodontal pocket depths (PD) (2.75 mm, 2.93 mm,1.97 mm, respectively, p < 0.05, p < 0.01) and clinical attachment loss (CAL) were significantly higher in Groups 1 and 2 than in Group 3 (5.13 mm, 4.79 mm, 1.31 mm, respectively, p < 0.01). Mean WBC, fibrinogen and hsCRP were not significantly different among the examined groups (WBC 6.81 G/L vs. 6.71 G/L vs. 6.18 G/L, fibrinogen concentration 4.31 g/L vs. 3.94 g/L vs. 3.67 g/L; hsCRP concentration 4.08 mg/dL vs. 6.61 mg/dL vs. 4.33 mg/dL). In Group 1, MPV was significantly higher than in Group 3 (10.39 fL vs. 9.39 fL, p < 0.01). There was a weak, although significant, correlation between periodontal parameters and MPV and correlations between MPV and PD as well as CAL (MPV-PD: r = 0.45, p < 0.05; MPV-CAL: r = 0.42, p < 0.05). CONCLUSIONS: Chronic periodontitis in patients with CAD results in an increased MPV that may suggest increased platelet activity. This observation could indicate a potential pathophysiological link between chronic periodontitis and an increased risk of acute coronary syndromes.

Usefulness of echocardiography in the identification of an excessive increase in pulmonary arterial pressure in patients with systemic sclerosis.

BACKGROUND: In systemic sclerosis (SSc), changes in the lungs and pulmonary hypertension (PH) are complications most adversely affecting the prognosis. Given the availability of specific treatment, early diagnosis of PH is very important. Exercise echocardiography, by increasing the patient's cardiac output, makes it possible to identify patients with elevated pulmonary artery pressure (PAP) during exercise. The diagnostic role of exercise echocardiography is still unclear, mainly because of the lack of prospective studies. AIM: To identify SSc patients with abnormally elevated PAP at rest or with a significant increase PAP during exercise, subsequently verified by right heart catheterisation (RHC). METHODS: A total of 71 consecutive patients (67 females and 4 males, mean age 56.9 ± 17.1 years) with SSc diagnosed according to the American College of Rheumatology criteria were enrolled in this prospective study. The patients underwent transthoracic echocardiography (Philips iE33) with the measurement of tricuspid regurgitation peak gradient (TRPG) and an exercise test involving the standard treadmill exercise according to the Bruce protocol with the evaluation of TRPG at 1 min following the completion of exercise. The PH was suspected when TRPG at rest was 〉 31 mm Hg (V(max) 〉 2.8 m/s) or increased by at least 20 mm Hg from baseline following exercise. Patients with suspected PH were referred for resting and exercise RHC. RESULTS: The exercise testing was performed in 67 patients revealing normal left ventricular (LV) systolic function in all of them. The mean LV ejection fraction was 66.1% ± 3.9%. The TRPG at rest could be recorded in 65 (97%) patients with the mean value of 26.9 ± ± 7.6 mm Hg (range 17-57 mm Hg). A resting TRPG of 〉 31 mm Hg, suggestive of possible PH, was demonstrated in 14 (21%) patients. During exercise test 56 (84%) patients achieved the maximum heart rate. A Doppler spectrum enabling the measurement of TRPG following the exercise was obtained in 66 (98.5%) patients. The gradient following the exercise could not be measured in one patient with a resting TRPG of 30 mm Hg. The mean post-exercise TRPG was 40.3 ± 4.1 mm Hg (range 17-70) and the mean post-exercise increase in TRPG was 12.9 ± 8.5 mm Hg (range 2-38). A TRPG increase of 〉 20 mm Hg was found in 11 (16%) patients (including 4 patients with resting values exceeding 31 mm Hg and 7 patients with normal resting values). Twenty-one (31%) patients with echocardiographic suspicion of PH (TRPG 〉 31 mm Hg at rest and/or a post-exercise increase in TRPG of more than 20 mm Hg) were referred for RHC with 16 patients actually undergoing the procedure. Four out of these 16 patients were qualified because of the "positive" exercise echocardiography in the presence of normal TRPG values. During catheterisation arterial PH was found in 2 patients, and an excessive precapillary PAP elevation in 2 further patients. Resting venous PH was found in 1 patient and an excessive postcapillary PAP elevation at rest was demonstrated in 11 patients. CONCLUSIONS: Exercise echocardiography is a safe and useful screening tool for PH diagnosis in patients with SSc. It enables to identify patients with normal systolic PAP at rest but a significant increase during exercise. The final confirmation of PH and differentiation between precapillary arterial and postcapillary venous PH requires RHC.