Aortic augmentation index and pulse wave velocity in response to head-up tilting: effect of autonomic failure.

Item does not contain fulltextBACKGROUND: Aortic augmentation index (AIx) but not carotid-femoral pulse wave velocity (cfPWV) has reported to decrease in response to vasodilators, which has been related to changes in the timing and/or intensity of wave reflection. Yet, recent evidence indicates that arterial reservoir pressure rather than wave reflection is the most important determinant of AIx. METHODS: Using radial artery applanation tonometry and a general transfer function AIx, aortic pulse wave reflection time and cfPWV (foot-to-foot method) were determined in 10 patients with severe autonomic failure and in 14 healthy individuals during supine rest and graded head-up tilting. RESULTS: During supine rest, mean blood pressure (BP) (127.6 +/- 21.5 and 97.5 +/- 9.4 mmHg), AIx (32.4 +/- 13.0 and 23.1 +/- 8.7%) and cfPWV (12.1 +/- 3.6 and 8.9 +/- 1.6 m/s) were higher in patients than in controls. In patients, BP decreased by 18.7 +/- 9.8 and 39.6 +/- 11.7%, AIx by 39.2 +/- 27.5 and 100.9 +/- 78.1% and cfPWV by 12.0 +/- 10.5 and 27.7 +/- 13.5% in response to 30 and 60 degrees head-up tilting. Decreases in AIx and cfPWV correlated with the BP fall (r = 0.67, P = 0.001 and r = 0.75, P < 0.001), but changes in AIx and cfPWV were unrelated. In controls, AIx during head-up tilting decreased despite increases in vascular tone and cfPWV. Aortic reflection time in patients and controls during tilting did not change. Stepwise regression analysis revealed that 68% of the variation in AIx could be explained by the BP fall and reflection time and 76% of the variation in cfPWV by the BP fall and sex. CONCLUSION: In a clinical model of autonomic failure, both AIx and cfPWV largely depend on instantaneous BP, but these two variables are unrelated, supporting the contention that aortic reservoir pressure rather than wave reflection is the main determinant of AIx.1 februari 201

Progression rate and early surgical experience in the new aggressive aneurysms-osteoarthritis syndrome

Item does not contain fulltextBACKGROUND: Aneurysms-osteoarthritis syndrome (AOS), caused by SMAD3 mutations, is a recently described autosomal dominant condition characterized by aneurysms throughout the arterial tree in combination with osteoarthritis. The objective of the present study was to evaluate progression rate of aortic dilation and surgical outcome in AOS patients. METHODS: All AOS patients are regularly monitored according to our clinical AOS protocol. Patients with at least two follow-up visits or who underwent aortic root surgery during follow-up were included in this cohort study. Clinical and surgical data were obtained from chart abstraction. RESULTS: We included 22 patients (aged 38 +/- 15 years; 41% male) with the molecular diagnosis of AOS. Follow-up duration was 3.3 years (interquartile range, 1.6 to 5.1). In the 17 patients who were managed conservatively, aortic root diameter increased from 37.5 +/- 5.1 mm at baseline to 40.3 +/- 6.2 mm at follow-up (p = 0.008). Progression rate of aortic dilation was highest at the level of the sinus of Valsalva (2.5 +/- 5.8 mm per year) and significantly correlated with the initial diameter (r = 0.603, p = 0.017). Ten patients successfully underwent valve-sparing aortic root replacement, 5 after previous watchful waiting. Mean preoperative aortic diameter was 46.6 +/- 4.0 mm. The operations were not complicated by fragility of tissue. After a postoperative period of 2.8 years (interquartile range, 0.7 to 5.4), no mortality or reoperations had occurred, and all patients remained asymptomatic. CONCLUSIONS: Aneurysm growth in AOS patients can be fast and unpredictable, warranting extensive and frequent cardiovascular monitoring. Valve-sparing aortic root replacement is a safe and effective procedure for the management of aortic root aneurysms in AOS patients

Evaluation of newer risk markers for coronary heart disease risk classification: a cohort study.

Item does not contain fulltextBACKGROUND: Whether newer risk markers for coronary heart disease (CHD) improve CHD risk prediction remains unclear. OBJECTIVE: To assess whether newer risk markers for CHD risk prediction and stratification improve Framingham risk score (FRS) predictions. DESIGN: Prospective population-based study. SETTING: The Rotterdam Study, Rotterdam, the Netherlands. PARTICIPANTS: 5933 asymptomatic, community-dwelling participants (mean age, 69.1 years [SD, 8.5]). MEASUREMENTS: Traditional CHD risk factors used in the FRS (age, sex, systolic blood pressure, treatment of hypertension, total and high-density lipoprotein cholesterol levels, smoking, and diabetes) and newer CHD risk factors (N-terminal fragment of prohormone B-type natriuretic peptide levels, von Willebrand factor antigen levels, fibrinogen levels, chronic kidney disease, leukocyte count, C-reactive protein levels, homocysteine levels, uric acid levels, coronary artery calcium [CAC] scores, carotid intima-media thickness, peripheral arterial disease, and pulse wave velocity). RESULTS: Adding CAC scores to the FRS improved the accuracy of risk predictions (c-statistic increase, 0.05 [95% CI, 0.02 to 0.06]; net reclassification index, 19.3% overall [39.3% in those at intermediate risk, by FRS]). Levels of N-terminal fragment of prohormone B-type natriuretic peptide also improved risk predictions but to a lesser extent (c-statistic increase, 0.02 [CI, 0.01 to 0.04]; net reclassification index, 7.6% overall [33.0% in those at intermediate risk, by FRS]). Improvements in predictions with other newer markers were marginal. LIMITATION: The findings may not be generalizable to younger or nonwhite populations. CONCLUSION: Among 12 CHD risk markers, improvements in FRS predictions were most statistically and clinically significant with the addition of CAC scores. Further investigation is needed to assess whether risk refinements using CAC scores lead to a meaningful change in clinical outcome. Whether to use CAC score screening as a more routine test for risk prediction requires full consideration of the financial and clinical costs of performing versus not performing the test for both persons and health systems. Primary Funding Source: Netherlands Organization for Health Research and Development (ZonMw)