Evaluation of cardiac biomarkers and right ventricular dysfunction in patients with acute pulmonary embolism

Objective: Right ventricular dysfunction (RVD) with myocardial damage may lead to fatal complications in patients with acute pulmonary embolism (PE). Cytoplasmic heart-type fatty acid-binding protein (HFABP) and the N-terminal fragment of its prohormone (NT-proBNP) are sensitive and specific biomarkers of myocardial damage. We evaluated RVD and cardiac biomarkers for myocardial damage and short-term mortality in patients with acute PE. Methods: We analyzed 41 patients (24 females, 17 males) with confirmed acute PE prospective. Three groups (massive, submassive, and nonmassive) of patients were defined, based on systemic systolic blood pressure measured on admission and RVD by transthoracic echocardiography (TTE). Also, systolic (s) and mean (m) pulmonary artery pressures (PAPs) were recorded by TTE, and plasma concentrations of cardiac troponin T (cTn-T), NT-proBNP, and HFABP were evaluated 6 month follow-up. Results: Seventeen (41.5%) patients experienced a complicated clinical course in the 6-month follow-up for the combined end-point, including at least one of the following: death (n=12, 29.3%; 3 PE-related), chronic PE (n=4, 9.8%), pulmonary hypertension (n=2, 4.9%), and recurrent PE (n=1, 2.4%). Multivariate hazard ratio analysis revealed HFABP, NT-proBNP, and PAPs as the 6-month mortality predictors (HR 1.02, 95% CI 1.01- 1.05; HR 1.01, 95% CI 1.01-1.04; and HR 1.02, 95% CI 1.02-1.05, respectively). Conclusion: HFABP, NT-proBNP, and PAPs measured on admission may be useful for short-term risk stratification and in the prediction of 6-month PE-related mortality in patients with acute PE. © 2016 by Turkish Society of Cardiology

Rescue surgical embolectomy in acute massive pulmonary embolism presenting with supraventricular tachycardia

Acute massive pulmonary embolism (PE) has a high mortality rate despite the advances in the diagnosis and therapy. Patients with PE need rapid diagnosis, risk stratification and an appropriate management for reducing mortality and morbidity. Patients with massive PE could be admitted to the emergency room presenting with not only dyspnea but also with predominant supraventricular tachycardia (SVT). In such case, heart rate control with drugs may be more difficult, and may lead to hemodynamic instability, in addition to the overloaded right heart depends on PE. A rapid computed tomography pulmonary angiography is demanded to confirm PE. Transthoracic echocardiography may play an important role for risk stratification of patients with PE, in order to show dilated right chambers, paradoxical movement of interventricular septum, and increased pulmonary arterial pressures presenting with the overloaded right heart. Although lifesaving treatment, thrombolytics has potential bleeding risk, especially intracranial hemorrhagia. Rescue surgical pulmonary embolectomy may be a life-saving altenative therapy in patients with massive PE who have not responded to thrombolysis. Hereby, we report a case with acute massive PE presenting with SVT, rescued via surgical embolectomy. © 2017 by Türkiye Klinikleri

Relatively high levels of serum adiponectin in obese women, a potential indicator of anti-inflammatory dysfunction: Relation to sex hormone-binding globulin

It is unclear whether serum adiponectin concentrations diminish linearly with increasing adiposity and, if not, which factors codetermine this association. These issues were investigated cross-sectionally in 1188 men and women, representative of middle-aged and elderly Turkish adults. Serum total adiponectin was assayed by ELISA. Serum adiponectin values in men, though declining significantly in transition from the bottom to the mid tertile of body mass index (BMI) and waist circumference (WC), were similar in the two respective upper tertiles. In women, serum adiponectin concentrations were not significantly different in any tertile of these indices, were significantly correlated with BMI or WC within the low tertiles and not within the two higher tertiles. In a linear regression analysis for WC (or BMI) in a subset of the sample in which serum sex hormone-binding globulin (SHBG) was available and which additionally comprised adiponectin, fasting insulin and other confounders, only insulin and, in women SHBG, were significantly associated, but not adiponectin. In linear regression analyses for covariates of adiponectin in two models comprising 12 variables, insulin and SHBG concentrations were significantly associated in both genders though not BMI. Whereas in men HDL-cholesterol and CRP were covariates of adiponectin (both p<0.01), SHBG and apolipoprotein B positively associated in women (p<0.001), independent of BMI and fasting insulin levels

Impact of obstructive sleep apnoea on left ventricular mass and global function

Obstructive sleep apnoea syndrome (OSAS) might be a cause of heart failure. The present study aimed to assess left ventricular mass and myocardial performance index (MPI) in OSAS patients. A total of 67 subjects without any cardiac or pulmonary disease, referred for evaluation of OSAS, had overnight polysomnography and echocardiography. According to apnoea-hypopnoea index (AHI), subjects were classified into three groups: mild OSAS (AHI: 5-14; n=16), moderate OSAS (AHI: 15-29; n=18), and severe OSAS (AHI: ≥30; n=33). Thickness of interventricular septum (IVS) and posterior wall (LVPW) were measured by M-mode, along with left ventricular mass (LVM) and LVM index (LVMI). Left ventricular MPI was calculated as (isovolumic contraction time+isovolumic relaxation time)/aortic ejection time by Döppler echocardiography. There were no differences in age or body mass index among the groups, but blood pressures were higher in severe OSAS compared with moderate and mild OSAS. In severe OSAS, thickness of IVS (11.2 ± 1.1 mm), LVPW (11.4 ± 0.9 mm), LVM (298.8 ± 83.1 g) and LVMI (144.7 ± 39.8 g·m-2) were higher than in moderate OSAS (10.9 ± 1.3 mm; 10.8 ± 0.9 mm; 287.3 ± 74.6 g; 126.5 ± 41.2 g·m-2, respectively) and mild OSAS (9.9 ± 0.9 mm; 9.8 ± 0.8 mm; 225.6 ± 84.3 g; 100.5 ± 42.3 g·m-2, respectively). In severe OSAS, MPI (0.64 ± 0.14) was significantly higher than in mild OSAS (0.50 ± 0.09), but not significantly higher than moderate OSAS (0.60 ± 0.10). In conclusion, severe and moderate obstructive sleep apnoea syndrome patients had higher left ventricular mass and left ventricular mass index, and also left ventricular global dysfunction. Copyright©ERS Journals Ltd 2005

Do we neglect women with sleep apnea?

Obstructive sleep apnea (OSA) affects approximately 5% of women and 15% of men in the middle-aged adults, and associated with adverse health outcomes. The prevalence and severity of OSA in women increase across the menopause, as the cardiovascular death and events do. Unfortunately, women with OSA might be under-diagnosed due to circumstances related to the family lifestyle and socio-cultural factors in addition to the different OSA clinical expression. Evaluation of cardiovascular global risk assessment in women with OSA is very important to prevent the high potential cardiovascular morbidity and mortality, since they are poorly informed about cardiovascular disease (CVD). So, we should be aware of the clues suspecting OSA and cardiovascular risk in women admitting to sleep clinics. © 2006 Elsevier Ireland Ltd. All rights reserved

Obstructive sleep apnea syndrome, endothelial dysfunction and coronary atherosclerosis

In obstructive sleep apnea syndrome (OSAS), repetitive episodes of apnea cause increased sympathetic nerve activity, increased surges in arterial blood pressure, swings in intrathoracic pressure, oxidative stres, hypoxia and hypercapnia. The association of OSAS with some diseases, having endothelial dysfunction in their physiopathology, such as hypertension, diabetes mellitus, obesity, coronary artery diseases, stroke and heart failure is common. Increased sympathetic nerve activity and also endothelial dysfunction which are the results of hypoxia, have important roles in vascular complications of OSAS. When compared with healthy population, an important endothelial dysfunction in OSAS patients and relationship between OSAS severity and endothelial dysfunction have been shown. In this review, the relationship between OSAS and endothelial dysfunction was overviewed

Effect of CPAP on QT interval dispersion in obstructive sleep apnea patients without hypertension

Objectives: Delayed cardiac repolarization leading to prolongation of the QT interval is a well-characterised precursor of arrhythmias. Obstructive sleep apnea (OSA) might cause arryhthmias, since QT corrected interval dispersion (QTcd) is increased in these patients. We aimed to determine the effect of nasal continuous positive airway pressure (CPAP) therapy on QTcd in OSA patients without hypertension. Methods: An overnight polysomnography (PSG) and a standard 12-lead electrocardiogram (ECG) were performed on 49 subjects without hypertension, diabetes mellitus, cardiac or pulmonary disease or any hormonal, hepatic, renal or electrolyte disorders. In 29 moderate-severe OSA (apnea-hypopnea index: AHI ≥ 15) patients, QTd (defined as the difference between the maximum and minimum QT interval) and QTcd were calculated using the Bazzet formula at baseline and after six months of CPAP therapy. Results: Eighteen patients were compliant with nasal CPAP, and mean age was 46.5 ± 4.9 years. Patients had high body mass index (BMI: 30.6 ± 4.0 kg/m2), but there was no change in either BMI or blood pressure after six months. A strong positive correlation was shown between QTcd and AHI (p &lt; 0.001, r = 0.913). The QTcd at baseline (54.5 ± 8.7 ms) significantly decreased after CPAP therapy (35.5 ± 4.2 ms, p &lt; 0.001), although it did not significantly change in 11 non-compliant patients. Conclusion: In OSA patients without hypertension, CPAP therapy improves the inhomogeneity of repolarization via a significant decrease in QTcd. © 2006 Elsevier B.V. All rights reserved

A rapid decrease in pulmonary arterial pressure by noninvasive positive pressure ventilation in a patient with chronic obstructive pulmonary disease

The natural history of chronic obstructive pulmonary disease (COPD) is characterized by progressive decrements in expiratory airflow, increments in end-expired pulmonary volume, hypoxaemia, hypercapnia and the progression of pulmonary arterial hypertension (PAH). Noninvasive positive pressure ventilation (NPPV) treatment is increasingly used for the treatment of acute and chronic respiratory failure in patients with COPD. NPPV can increase PaO2 and decrease PaCO2 by correcting the gas exchange in such patients. The acute effect of NPPV on decreasing PAP is seen in patients with respiratory failure, probably due to the effect on cardiac output. Here, a case with COPD whose respiratory acidosis and PAH rapidly improved by NPPV was presented and therefore we suggested to perform an echocardiographic assessment to reveal an improvement of PAH as well as respiratory acidosis, hypercapnia and hypoxemia with that treatment