Non-invasive assessment of coronary flow reserve and ADMA levels: a case-control study of early rheumatoid arthritis patients.

OBJECTIVE: Plasma concentration of asymmetric dimethylarginine (ADMA), a major endogenous inhibitor of nitric oxide synthase, is considered a novel risk factor for endothelial dysfunction associated with enhanced atherosclerosis. Coronary microcirculation abnormalities have been demonstrated in patients with early rheumatoid arthritis (ERA) without any signs or symptoms of coronary artery disease (CAD). The aim of the study was to compare the ERA and control groups with ADMA, intima-media thickness (IMT) and coronary flow reserve (CFR) levels. It assessed whether ERA patients have more cardiovascular risk (endothelial dysfunction and coronary microvascular abnormalities), and evaluated whether any difference in IMT/CFR between ERA and controls can be explained by any difference in ADMA levels between the groups. METHODS: The study involved 25 ERA patients (female/male 21/4; mean age 52.04 +/- 14.05 years; disease duration

Preclinical impairment of coronary flow reserve in patients with rheumatoid arthritis.

Cardiovascular involvement in rheumatoid arthritis (RA) is common, although the true prevalence of cardiac abnormalities is difficult to measure, as much disease remains clinically silent. The pathogenesis of cardiac lesions in RA is related to the primary disorder of microcirculation with diffuse arteriolar and capillary lesions. Previous studies demonstrated that coronary flow reserve (CFR) is impaired in patients with connective tissue diseases (CTD). This review focuses on transthoracic Doppler echocardiography as a noninvasive method used to assess CFR in RA patients. CFR is early reduced in RA patients without clinical evidence of heart disease as a result of impaired microcirculation. CFR seems a useful technique able to follow-up and to assess effects of new drugs on RA patients.

The role of echocardiographic techniques in connective tissue diseases.

Connective tissue diseases (CTD) lead to a high prevalence of common cardiac manifestations (pericarditis and myocarditis) and of ischemic coronary events with a considerable increase in cardiac mortality related to premature atherosclerosis. Although there are several techniques able to detect cardiac involvement in CTD patients, the most useful and non-invasive technique is echocardiographic exam which is able to detect not only valvular abnormalities, pericardial diseases and pulmonary hypertension but also left ventricular (LV) systolic or diastolic (regional or global) wall motion dysfunction. It is also well known that transesophageal echocardiography (TEE) can better identify cardiac abnormalities, vegetations and embolic sources. Symptomatic patients with positive stress echocardiographic exam or dipyridamole thallium imaging test should be referred for possible cardiac catheterization, especially if a large ischemic territory is involved. Until now, the echocardiographic evaluation of coronary artery tree consisted of assessing regional and global left ventricular systolic and diastolic function at rest and during pharmacological stress test. Recently, a new echocardiographic noninvasive method that allows direct assessment of coronary flow velocity in the mid-distal portion of left anterior descending artery (LAD) has been developed and validated. Advanced ultrasound technology (high-frequency broadband transducer with second harmonic capability) has now made possible a direct arterial visualization and measurement of coronary artery flow in left anterior descending in CTD patients with the assessment of coronary flow reserve (CFR).

[In patients with heart failure, do implantable cardioverter-defibrillators delay death or save lives?]. / Nei pazienti con insufficienza cardiaca il cardioverter-defibrillatore impiantabile ritarda la morte o salva la vita?

Heart failure is one of the most important public health problems in western countries because of its frequent association with cardiac death and with rehospitalization. Patients with heart failure generally die of sudden arrhythmic death (SD) and progressive pump failure with a SD incidence inversely related to the severity of the underlying heart disease. SD occurs approximately in one half of the patients in New York Heart Association (NYHA) functional classes II-II/III and in one third of those in NYHA classes III/IV-IV, respectively. In the last decade, numerous studies have shown that the automatic implantable cardioverter-defibrillator (ICD) significantly reduces the incidence of SD in those patients who are identified as being at risk. Unfortunately, little is known on whether the ICD actually prolongs the survival of the subgroup of patients with most severe heart failure. The main reasons for such a paucity of information are the small number of available studies, the unavailability of randomized and controlled investigations and the difficulty in comparing the results of such studies owing to the lack of homogeneity. In patients with severe heart failure, both the perioperative mortality and morbidity related to transvenous ICD implantation are similar to those of patient subgroups with moderate or slight heart failure. The defibrillation threshold at implantation and the frequency of intractable ventricular arrhythmias during follow-up (2% of all ICD implantations) are slightly higher than in the patient subgroup with moderate or no heart failure. In the patient subgroup with severe heart failure or with a very poor left ventricular function, ICD implantation is unable to prolong the 1- and 2-year survival despite a clear reduction in the incidence of SD. On the other hand, in the patient subgroup with moderate left ventricular dysfunction, ICD implantation prolongs survival and reduces the incidence of SD. No information is available regarding the primary prevention of SD in patients with heart failure.

Cardiovascular involvement in systemic autoimmune diseases.

Autoimmune diseases, including rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), primary antiphospholipid syndrome (APS), systemic sclerosis and systemic vasculitis, affect a large number of people in whom one of the leading causes of morbidity and mortality is cardiovascular disease. Cardiovascular disease is associated with the development of accelerated atherosclerosis. It seems to occur at a younger age than in the general population, is often asymptomatic and, in addition to traditional risk factors, also involves specific risk factors as chronic inflammation, the duration and activity of the autoimmune disease, and immunosuppressive therapy. The early phases of cardiovascular involvement in patients with autoimmune diseases may be clinically silent, with only a microcirculation disorder present. There are various means of detecting morphological cardiac damage: coronary angiography remains the gold standard for diagnosing coronary stenosis, but new, non invasive and more reliable methods have been introduced into clinical practice in order to detect subclinical microcirculation abnormalities.

Reduced coronary flow reserve in young adults with renal transplant.

BACKGROUND: Some degree of cardiovascular disease should be suspected in young adults who have been paediatric renal transplant recipients also if no systematic data collection is routinely performed in clinical setting. The aim of our work was to evaluate the degree of cardiovascular damage in these young patients, using a minimally invasive technique. We then evaluated coronary flow reserve (CFR) and carotid intima-media thickness (IMT) in 25 patients (13 males, median age 23.7 years). METHODS: Coronary flow velocity on the left anterior descending coronary artery was assessed by transthoracic echocardiography, before and after dipyridamole, after standard echocardiography. CFR was compared with that of a small control group (n = 16; median age 25 yrs). RESULTS: In this relatively young sample, mean CFR was 2.8 +/- 0.6 (median 2.75), and half of the patients had reduced coronary reserve (P = 0.01). Mean IMT (0.48 +/- 0.08 mm) was only slightly, though significantly larger compared with the reference standard (P < 0.05) but was significantly thinner in normotensive than in hypertensive patients (0.42 +/- 0.06 vs 0.49 +/- 0.05 mm, P < 0.05). The time on dialysis prior to transplantation, hypertension and age at the time of CFR evaluation affect CFR. IMT did not correlate with CFR. CONCLUSIONS: CFR and IMT abnormalities are common in young transplant recipients, in spite of the fact that our paediatric population has much less of the atherosclerotic 'legacy' common to adult patients.