Prediction of Preclinical Myocardial Dysfunction among Obese Diabetics with Preserved Ejection Fraction Using Tissue Doppler Imaging and Speckle Tracking Echocardiography

Background. Obesity and type 2 diabetes mellitus (T2DM) are two interrelated and preventable disorders. However, they are responsible for significant global mortality from cardiovascular diseases (CVDs). Clinical studies have demonstrated that global longitudinal strain (GLS) using speckle tracking echocardiography (STE), can assess myocardial function accurately in apparently, healthy patients with diabetes and obesity in the settings of acute and chronic ischemia and suspected cardiomyopathy without heart failure. No such studies have been published to date regarding subclinical detection of cardiac dysfunction among obese patients with T2DM. This study aims to investigate the role of STE in the early pre-clinical diagnosis of impairment of diastolic and systolic dysfunction in obese patients with T2DM. This study also investigated whether it is possible to detect early pre-clinical impairment of diastolic and systolic dysfunction in obese T2DM patients, via Tissue Doppler Imaging (TDI), maximum rate of left ventricular pressure development (peak dP/dt) and GLS using STE for comparison. Subjects and Methods. After clearance from the review board of Dibba- Hospital, Alfujairah, UAE, all the available records of patients with the diagnosis of obesity and diabetes were examined. The study included 214 patients presenting with obesity in conjunction with diabetes and 93 age-matched healthy control subjects. STE was performed among all the patients and subjects along with Tissue Doppler Imaging (TDI). This study assessed maximal rate of pressure rise during ventricular contraction (peak dP/dt) and global longitudinal strain (GLS) using STE methods. Transthoracic echocardiography, myocardial Doppler-derived systolic (sm), early diastolic velocity (em) and GLS were also obtained, among all the subjects. Results. The results show that cardiac functions via conventional echocardiography (CE) were similar in the 2 groups. Using TDI and conventional mitral Doppler flow, obese subjects with diabetes showed an evidence of diastolic function abnormalities in the form of lower Ea velocity (9.5 ± 2.9 vs. 18.4 ± 3.5 cm/s, p < 0.0001), an increased Aa velocity (16.5 ± 2.4 vs. 14.1 ± 2.2 cm/s p < 0.05), higher left ventricular filling pressure (E/Ea = 12 ± 4.4 vs 8±3.1), p 35) (n = 26) had reduced LV systolic and diastolic function compared with healthy controls. Regarding, systolic function indices, the findings revealed lower average longitudinal peak systolic strain, sm and reduced em, although, LV ejection fraction remained normal (56.48% ± 8.81). Among subjects with severe obesity (n = 26), the findings reveal that global longitudinal presystolic strain (GLPSS) is highly correlated with maximum rate of pressure development of LV (dp/dt), although the LVEF remained normal, in comparison to systolic strain and dp/dt. (.5% ±1.4 vs -19.54% ± 4.5; p < 0.001), in the age-matched healthy subjects. However, the frequency/grade of DCM detected by STE, among patients having obesity with T2DM, correlated closely with the degree of obesity, metabolic abnormalities and clustering of other major risk factors, especially high blood pressure. The findings also revealed that chest pain due to coronary heart disease (CAD), dyspnea and DCM were more common among female patients compared to men. Conclusion. The results indicate that patients having obesity with T2DM should be advised to undertake early TDI and STE for early diagnosis of decreased cardiac diastolic and systolic dysfunctions and cardiomyopathy, which is likely to be missed by conventional echocardiography. Significant differences in regional and global strain were also identified between the severely obese diabetic (BMI ≥ 35), (GLPSS (-13) patients compared to less obese subjects

Myocardial Deformation Imaging Meta-Analysis in Two Cohorts of Patients from UAE and Heart Hospital Hamadmedical Corporation: A Potential Role in Assessment of Coronary Artery Disease Severity and Myocardial Viability

Introduction: The increasing prevalence of heart failure (HF) in coronary artery disease (CAD) urgently requires the establishment of new imaging techniques for early diagnosis and also to guide treatment of patients presented with acute coronary syndromes (ACS). Conventional echocardiography (CE) and electrocardiogram (ECG) are the gold standard methods in assessing myocardial ischemia (MI) and the function of the heart in patients with coronary artery disease (CAD). The lack of ST elevation by ECG and regional wall motion abnormalities by CE in non-ST segment elevation myocardial infarction (NSTEACS) in ACS patients reflect limited sensitivity of ECG and CE in identifying patients with acute coronary occlusion (ACO) and proper assessment of myocardial viability. Aim of this study: This study now evaluates the ability of strain parameters in grading the severity of CAD to detect myocardial viability in ACS through a comparative meta-analysis in two cohorts of patients living in the UAE and Qatar. The study investigates the diagnostic accuracy of left ventricular longitudinal systolic strain function (GLS) by 2D-speckle tracking echocardiography (2D-STE), Territorial Longitudinal Strain (TLS) analysis and post systolic strain (PSS) in ACS patients admitted at the emergency departments. All the patients had acute chest pain which is highly suggestive of NSTEACS along with coronary angiography (CA). Methods: The study recruited two groups, comprising of 347 patients, who were presented with acute coronary syndrome (NSTEACS) at the emergency department. The first group had 214 consecutive patients who had acute chest pain and high-risk profile and they were admitted to the emergency department at Eastern Emirates Hospitals, El-Fujairah-Dibba (EEEH), UAE. The second group consisted of 133 from emergency department at Heart Hospital- Hamad Medical Corporation (HHHMC), Qatar. In both groups, 85% of the patients were men with ages from 32 to 65 years (mean ± SD: 49.4 ± 9.5 years). Significant CAD was defined as having at least one epicardial vessel with ≥ 70% or left main>50% stenosis. All patients enrolled in this study underwent basic echocardiography, speckle tracking analysis, and coronary angiography. In 70 patients, PSS was calculated and myocardial perfusion imaging (MPI) was utilized as gold standards for the assessment of myocardial viability in patients with documented NSTEACS. The sensitivity, specificity, positive and negative predictive values of peak longitudinal systolic strain (2D-STE) and PSS were calculated. Left ventricular systolic strain was displayed as bull’s eye plot and territorial longitudinal strain (TLS) in the territory of the infarct-related artery. They were obtained within 24 hours from admission. Coronary angiography (CA) was performed within 24 hours from admission and used as a reference tests to assess the severity of CAD. Results: Echocardiogram obtained from the patients showed any no wall motion abnormalities at rest, although speckle tracking analysis was abnormal in 167 patients. In the first group of patients from the UAE, GLS showed a high sensitivity of 80% and a very high specificity of 93% for detection of significant CAD. In addition, PSS demonstrated a high sensitivity of 80% with an average specificity of 57%. The combination of GLS and PSS showed a further increase in sensitivity, specificity with positive and negative predictive values of 98%, 91%, 99% and 97%, respectively. Therefore, a very high correlation of GLS and PSS with coronary angiography was demonstrated: =0.90, p<0.0001 and R=0.88, p<0.0001, respectively. Furthermore, PSS showed a very high concordance with MPI scan (stress-rest-re injection studies) in detection of ischemic viable myocardium with very high sensitivity of 85%, r=0.79. In the Qatari (HHHMC) patients, a multi-vessel disease or left main disease (MV) was documented in 53.6%, and those with single vessel disease (SV) in 46.4%. LAD, circumflex and RCA lesions were found in 65, 50 and 39 patients, respectively. A control group of 129 cases was selected from outpatients referred to the echocardiography unit. The results showed that in comparison to CA, GLS sensitivity and specificity were 84% and 70%, respectively in all the patients. The sensitivity of GLS was 87% in MV and 80% in SV. Territorial strain sensitivity was 50%, 74% and 84.6% for the left anterior descending artery (LAD), circumflex and right coronary artery (RCA), respectively compared to specificity values of 64%, 65% and 61.7%, respectively. Conclusion: It is concluded that GLS by speckle tracking analysis is definitely an accurate method in early diagnosis of the severity of CAD in patients presenting with NSTE ACS. The combined use of GLS and PSS showed very high diagnostic accuracy for the identification of significant CAD in these patients. Strain imaging by STE may be applied to diagnose the severity of myocardial ischemia by showing reduction in peak systolic strain. Moreover, it is equally important to demonstrate post-systolic shortening which is a characteristic feature of ischemic viable myocardium after ACS requiring revascularization

Micro Vascular and Macro Vascular Disease in Systemic Hypertension: The Role of Cardiac Imaging and Nitric Oxide Synthase Gene Polymorphism

Systemic Hypertension (HTN) accounts for the largest amount of attributable Cardiovascular (CV) mortality worldwide. There are several factors responsible for the development of HTN and its CV complications. Multicenter trials revealed that risk factors responsible for Micro Vascular Disease (MVD) are similar for those attributable to Coronary Artery Disease (CAD) which include tobacco use, unhealthy cholesterol levels, HTN, obesity and overweight, physical inactivity, unhealthy diet, diabetes, insulin resistance, increasing age and genetic predisposition. In addition, the defective release of Nitric Oxide (NO) could be a putative candidate for HTN and MVD. This study reviewed the risk stratification of hypertensive population employing cardiac imaging modalities which are of crucial importance in diagnosis. It further emphasized the proper used of cardiac imaging to determine patients at increased CV risk and identify the management strategy. It is now known that NO has an important eff ect on blood pressure, and the basal release of endothelial Nitric Oxide (eNOS) in HTN may be reduced. Although there are diff erent forms of eNOS gene allele, there is no solid data revealing the potential role of the polymorphism of the eNOS in patients with HTN and coronary vascular diseases. In the present article, the prevalence of eNOS G298 allele in hypertensive patients with micro vascular angina will be demonstrated. This review provides an update on appropriate and justified use of non-invasive imaging tests in hypertensive patients and its important role in proper diagnosis of MVD and CAD. Second, eNOS gene allele and its relation to essential hypertension and angina pectoris are also highlighted

Advanced Carotid Atherosclerosis and the Risk of Subsequent Major Cardiovascular Events: Carotid Ultrasound Study

Introduction: Very little is known about the role of atherosclerotic carotid plaque morphology, vulnerability, and Total Plaque Area (TPA) in the development of Major Cardiovascular Events (MCVE). Aim of this study: To assess the role of carotid atherosclerosis and the plaque morphology in the prediction of MCVE. Importance of the study: A better understanding of the role of detection of atherosclerosis and unstable plaque morphology can help to improve strategies for prevention of Acute Cardiovascular Events (ACVE) worldwide. Methods: This study analyzed the medical records of 452 patients with 2.5-years follow-up. The primary outcomes were the composite of first occurrence of stroke, cardiovascular death, and Acute Coronary Syndromes (ACS) hospitalization. Results: The results show that carotid atherosclerosis was present in 44% of patients (n=103) and this was associated with increasing conventional cardiovascular risk factors and extent of symptomatic vascular disease. During 2.5 years follow-up, 10% of patients experienced ≥ 2 MCVE. After adjustment for cardiovascular risk factors, the risk of ACS and stroke increased by 23% (95% Confidence Interval [CI]), and 45% (95% confidence interval), respectively in patients with carotid ultrasonic (US) evidence of advanced carotid atherosclerosis in comparison to control (P<0.001). The relative increase of cerebrovascular events was 22% in patients with carotid US evidence of vulnerable plaque morphology versus benign morphology. The high risk for all-cause and cardiovascular death of these patients remained significant after adjustment for various established cardiovascular risk factors in multivariable regression analysis (adjusted hazard ratio 2.4, P<0.001; compared to patients without US evidence of advanced carotid atherosclerosis features). Conclusion: It is concluded that carotid TPA and features of vulnerability were associated with an increased risk of MCVE

Dilated Cardiomyopathy in Children and Adults: What is New?

Dilated cardiomyopathy (DCM) is the most common form of cardiomyopathy and cause of cardiac transplantation in children and young adults; mortality is high among this patient population. However, mortality, clinical course, and illustrative echocardiographic data of DCM in children and adults are not well established. Our objective was to provide a research article of detailed descriptions of the incidence, causes, outcomes, related risk factors, and new echocardiographic criteria of risk of death from DCM. Our results showed that independent risk factors at DCM diagnosis for subsequent death or transplantation in children cohorts were older age, congestive heart failure, lower left ventricular ejection fraction (EF ≤ 25%), low global strain, significant mitral valve incompetence, pulmonary hypertension, diastolic dysfunction, right ventricular involvement, and cause of DCM (p < 0.001 for all). In adults, low ejection fraction (<30–35%), global peak systolic strain <-7.6%, increased EDV, ESV, LBBB, diastolic dysfunction, and left ventricle dyssynchrony were the main independent risk factors for major cardiac events and need for CRT or transplantation (p < 0.001 for all). Our conclusions were that in children and adults, DCM is a diverse disorder with outcomes that depend largely on cause, age, heart failure status at presentation, and echocardiographic parameters of the heart (systolic and diastolic function of left ventricle, pulmonary artery pressure, global strain, and valvular function of the mitral valve). This study will present new findings in the diagnostic area

Why and How the Indo-Mediterranean Diet May Be Superior to Other Diets: The Role of Antioxidants in the Diet

The Seven Countries Study showed that traditional Japanese and Mediterranean diets are protective against cardiovascular diseases (CVDs). The Japanese diet is considered the healthiest because it provides Japanese populations with the highest longevity and health. DASH and Mediterranean-style diets are also considered healthy diets, although the Indo-Mediterranean-style diet may provide better protective effects among patients with CVDs compared to other diets. The concept of the Indo-Mediterranean type of diet was developed after examining its role in the prevention of CVDs in India, the value of which was confirmed by a landmark study from France: the Lyon Heart Study. These workers found that consuming an alpha-linolenic acid-rich Mediterranean-style diet can cause a significant decline in CVDs and all-cause mortality. Later in 2018, the PREDIMED study from Spain also reported that a modified Mediterranean-style diet can cause a significant decline in CVDs, type 2 diabetes mellitus (T2DM), and cancer. The Indo-Mediterranean diet may be superior to DASH and Mediterranean diets because it contains millets, porridge, and beans, as well as spices such as turmeric, cumin, fenugreek, and coriander, which may have better anti-inflammatory and cardioprotective effects. These foods are rich sources of nutrients, flavonoids, calcium, and iron, as well as proteins, which are useful in the prevention of under- and overnutrition and related diseases. It is known that DASH and Mediterranean-style diets have a similar influence on CVDs. However, the Indo-Mediterranean-style diet may be as good as the Japanese diet due to improved food diversity and the high content of antioxidants

Genetic Risk Factors of Coronary Artery Disease

Detecting genetic risk factors for better targeting of statin administration can further enhance the benefit of this therapy. Coronary artery disease (CAD) is a polygenic disorder with multiple genetic variants. A composite of some of these variants could ascertain the risk of both incident and recurrent CAD events and help in the diagnosis of patients at greater risk who could get greater clinical benefit from statin treatment [1]. The role of genetic risk factors in CAD has become more relevant with the discovery of the proprotein convertase subtilisin kexin type 9 (PCSK9) enzyme, which is responsible for regulating cholesterol metabolism [2, 3]. Gain-of-function mutations of the PCSK9 gene may be associated with increased cholesterol and increased risk of CVDs, whereas loss-of-function mutations are linked to lower blood cholesterol and a reduction of CVDs risk without any known adverse effects [2-5]. This included a community-based landmark assessment employing multiple studies involving 48,421 individuals and 3,477 events [1]. This analysis examined the association of a genetic risk score based on 27 genetic variants with either incident or recurrent CAD, adjusting for traditional clinical risk factors. All subjects were divided into low (quintile 1), intermediate (quintiles 2–4), and high (quintile 5) genetic risk categories, to demonstrate a significant gradient in risk for incident or recurrent CAD. The multivariable-adjusted hazard ratio for CAD events for the intermediate genetic risk category was 1.34 (95% CI: 1.22–1.47, p < 0.0001) and that for the high genetic risk category was 1.72 (1.55–1.92, p < 0.0001) compared with the low genetic risk subjects [1]. There was a significant gradient (p = 0.0277) of increasing relative risk across the low (13%), intermediate (29%), and high (48%) genetic risk categories. Absolute risk reduction from statin treatment was greater in some patients with higher genetic risk categories (p = 0.0101). In the primary prevention trials, the number needed to treat to prevent one CAD event in 10 years was 66 in people at low genetic risk, 42 in those at intermediate genetic risk, and 25 in those at high genetic risk in the JUPITER, and 57, 47, and 20, respectively, in the ASCOT trial. We can conclude from this analysis that a genetic risk score can identify the high risk subjects with increased risk for both incident and recurrent CAD events. Patients with the highest burden of genetic risk obtained the greatest relative and absolute clinical benefit from statin treatment. We propose that patients with highest genetic risk might also get greatest benefit by treatment with PCSK9 inhibitors

High Exogenous Antioxidant, Restorative Treatment (Heart) for Prevention of the Six Stages of Heart Failure: The Heart Diet

The exact pathophysiology of heart failure (HF) is not yet known. Western diet, characterized by highly sweetened foods, as well as being rich in fat, fried foods, red meat and processed meat, eggs, and sweet beverages, may cause inflammation, leading to oxidative dysfunction in the cardiac ultra-structure. Oxidative function of the myocardium and how oxidative dysfunction causes physio-pathological remodeling, leading to HF, is not well known. Antioxidants, such as polyphenolics and flavonoids, omega-3 fatty acids, and other micronutrients that are rich in Indo-Mediterranean-type diets, could be protective in sustaining the oxidative functions of the heart. The cardiomyocytes use glucose and fatty acids for the physiological functions depending upon the metabolic requirements of the heart. Apart from toxicity due to glucose, lipotoxicity also adversely affects the cardiomyocytes, which worsen in the presence of deficiency of endogenous antioxidants and deficiency of exogenous antioxidant nutrients in the diet. The high-sugar-and-high-fat-induced production of ceramide, advanced glycation end products (AGE) and triamino-methyl-N-oxide (TMAO) can predispose individuals to oxidative dysfunction and Ca-overloading. The alteration in the biology may start with normal cardiac cell remodeling to biological remodeling due to inflammation. An increase in the fat content of a diet in combination with inducible nitric oxide synthase (NOSi) via N-arginine methyl ester has been found to preserve the ejection fraction in HF. It is proposed that a greater intake of high exogenous antioxidant restorative treatment (HEART) diet, polyphenolics and flavonoids, as well as cessation of red meat intake and egg, can cause improvement in the oxidative function of the heart, by inhibiting oxidative damage to lipids, proteins and DNA in the cell, resulting in beneficial effects in the early stage of the Six Stages of HF. There is an unmet need to conduct cohort studies and randomized, controlled studies to demonstrate the role of the HEART diet in the treatment of HF

Incidence of Acute Kidney Injury in Patients with Acute ST Elevation Myocardial Infarction

Background: Acute kidney injury (AKI) is an important and one of the most common complications after acute myocardial infarction (AMI), affecting from 10 to 55% of patients globally. However, the mechanisms causing AKI in the first few days after an AMI are multi-factorial in nature. Recent studies suggest that AKI is associated with poor outcomes and independently predicts increasing long-term mortality. However, few studies have investigated the early risk of AKI with AMI. Patient and methods: This was a cross-sectional study involving 110 patient with acute ST elevation during AMI. Those patients who were admitted to the coronary care unit were examined to see if they developed AKI. Complete clinical studies were carried out during the patients’ hospital stay. AKI was defined as an increase in SCr by ≥0.3 mg/dl within 48 h or an increase in SCr to ≥ 1.5 times baseline within the first 7 days of hospitalization (based on the KDIGO criteria). Results: AKI occurred in 14 of the 110 (12.7%) patients; with 8 patients (57%) of AKI in stage 1 and 4 patients (29%) in stage 2 and 2 patients (14%) in stage 3. Patients who developed AKI were significantly more likely to be older, have hypertension, previous CAD, and diabetes mellitus than the non-AKI patients (p < 0.05 for all comparisons). Patients with AKI were significantly more likely to receive diuretics than non-AKI patients (p < 0.00052). Patients with anterior STEMI significantly developed AKI more than other type of MI (p < 0.015). Mortality was found more among STEMI patients who developed AKI (p < 0.0223). AKI in STEMI patients was more prevalent in those patients with increased serum creatinine (p < 0.047) and decreased eGFR (p < 0.0001) at time of admission. Conclusion: AKI occurred in 12.7% (14/110) of patients hospitalized for acute STEMI. This common complication was strongly associated with mortality. The presence of a low eGFR level on admission in patients with AMI-associated AKI was related to a poor short-term survival prognosis. Patients with an impaired eGFR level upon admission who developed AKI require extensive clinical monitoring