Usefulness of the Global Echo-Doppler Score (GEDS) in selection of patients with mitral stenosis for percutaneous balloon mitral valvuloplasty

Background: We aimed to create a novel modified score by combining anatomic and hemodynamic Doppler-echocardiographic measures for selection of suitable patients with mitral stenosis for percutaneous balloon mitral valvuloplasty (PBMV) and its impact in prediction of outcome. Methods: 262 consecutive patients candidate for PBMV were enrolled. Wilkins score and a global score based on anatomical parameters (Wilkins score, posterior to anterior mitral leaflet ratio [PMVL/AMVL ratio]; left atrial diameter [LAD]) and hemodynamic parameters (mitral regurgitation [MR]; atrioventricular compliance [CN]; systolic pulmonary artery pressure [SPAP]) were assessed. Patients were classified into two groups according to their outcomes. Results: Global Echo-Doppler Score (GEDS) for patients with favorable vs. those with unfavorable outcomes was (5.0 ± 0.9 vs. 8.9 ± 1.3; p < 0.001). Sensitivity, specificity, and accuracy of a GEDS ≥ 7 for prediction of cardiac events were 97.5%, 88%, and 97.5%, respectively. The area under the receiver operating characteristic curve was 0.95 (p < 0.001). The correlation coefficient was 0.852 (p < 0.0001) for GEDS 0.531 (p < 0.002), for Wilkins score 0.315 (p < 0.02), for PMVL/AMVL 0.460 (p < 0.01), for LAD; MR: Pre-PBMV (r = 0.348, p < 0.03); CN [mL/mm Hg] (r = 0.579, p < 0.01) and SPAP [mm Hg] (r = 0.499, p < 0.01). In the regression analysis, GEDS, Wilkins score, and LAD were entered into the model. The regression coefficient (r = 0.695) of GEDS was much higher than those of the other 2 factors. Conclusions: GEDS is an independent predictor of PBMV success and clinical outcome and may be formulated in a scoring system that would help to identify the proper timing and best candidates for PBMV

The association between right ventricular function and exercise capacity for hypertensive patients

Background: Transthoracic echocardiography (TTE) would be used to evaluate right ventricular (RV) function in patients with arterial hypertension, and the link between RV dysfunction and exercise capacity was studied in the study population.Objective: To establish a correlation with exercise capability in the study group by using transthoracic echocardiography (TTE) to evaluate RV function in patients with arterial hypertension.Patients and Methods: Patients with hypertension were surveyed in a cross-sectional research; those known and treated; whether controlled or not and patients who were recently discovered to be hypertensive. Ninety patients were included; gender and age were taken into account. A thorough examination was performed on each patient (TTE) as well as six minute walking distance (6MWD). For all we had a written informed consent prior to enrollment. Results: Patients with untreated and uncontrolled hypertension showed significantly reduced right ventricular systolic and diastolic functions compared to those with well-controlled hypertension. Patients with untreated or uncontrolled hypertension had significant (P <0.001) deterioration on S', wave and diastolic dysfunction parameters (E/A, DTt, E/e t and IVRT). Untreated and uncontrolled hypertension patients showed a significant decrease in 6MWD compared to the well-controlled individuals (P <0.001). Conclusion: Untreated or ineffectively treated hypertension individuals had considerably reduced right ventricular function and exercise capacity, according to our findings. In the entire research population, right ventricular functions are strongly linked to exercise ability

Determinants and impact of masked hypertension in offspring of patients with diabetes: relation with coronary flow and cardiac function

Objective: We aimed to evaluate the prevalence, determinants and clinical impact of masked hypertension in offspring of patients with diabetes. Masked hypertension was defined according to guidelines as daytime ambulatory blood pressure monitoring “ABPM” ≥135/85 mmHg and clinic BP <140/90 mmHg. Methods: 100 nondiabetic offspring of patients with diabetes and 60 offspring of healthy people were enrolled; 24-h ABPM was applied to evaluate mean 24-h systolic/diastolic blood pressure “BP”, daytime, nighttime and night dipping readings. Left ventricular parameters and coronary flow reserve of the left anterior descending artery (induced by adenosine 0.14 mg/kg/min) was calculated in all offspring. Results: 29% of offspring of patients with diabetes had masked hypertension compared to only 3.3% offspring in healthy people (p < 0.001). Compared with those without masked hypertension, offspring with masked hypertension had a significantly reduced coronary flow reserve (p < 0.001), significantly higher E/e' (p < 0.01), [a surrogate marker of left ventricular filling pressure], more microalbuminuria (p < 0.01), and higher values of high-sensitive C-reactive protein “CRP” (p < 0.001). Multivariate regression analysis showed that, fasting blood glucose, and high-sensitive CRP, were independently associated with masked hypertension, whilst daytime systolic BP and non-dipping systolic BP were the strongest predictors for masked hypertension. Logistic regression analysis revealed that masked hypertension was independently associated with reduced coronary flow reserve (p < 0.0001) and diastolic dysfunction (p < 0.001). Conclusion: Masked hypertension is prevalent in offspring of patients with diabetes and significantly associated with reduced coronary flow reserve and left ventricular diastolic dysfunction. These findings suggest that offspring of patients with diabetes constitute a high risk group and deserve close follow up, mainly with the use of ABPM

Associations of fractional pulse pressure to aortic stiffness and their impact on diastolic function and coronary flow reserve in asymptomatic diabetic patients with normal coronary angiography

Background: We aimed to assess the relation of fractional pulse pressure (PPf) to aortic stiffness index and their impact on coronary fl ow reserve (CFR) and left ventricular diastolic function in asymptomatic diabetic patients.Methods: One hundred and thirty five consecutive asymptomatic diabetic patients (aged 48.8 ± 7.84 years), were included. CFR was calculated noninvasively using transthoracic echo-Doppler assessment with hyperemia induced by infusion of dipyridamole at a rate of 0.56 mg/kg over 4 min. PPf was calculated as pulse pressure divided by mean arterial pressure (SBP – DBP/MAP), while diastolic function was evaluated by means of transmitral flow and tissue Doppler imaging. Aortic stiffness indices (ASI) were measured as previously described.Results: Diabetic patients with low CFR (n = 52) compared with those with normal CFR (n = 83) exhibited signifi cantly increased PPf (75.2 ± 11.4 vs. 64.5 ± 6.7, p &lt; 0.001). PPf was significantly correlated with ASI (r = 0.520, p &lt; 0.001), E/Em ratio (r = 0.425,p &lt; 0.001) and left atrial volume index (r = 0.462, p &lt; 0.001). CFR was negatively correlated with both PPf (r = –0.68, p &lt; 0.0001). After applying multivariate linear regression analysis,after correction for cardiovascular risk factors, importantly, PPf and ASI remained significant predictors of CFR (p &lt; 0.0001 and p &lt; 0.001, respectively).Conclusions: PPf was significantly correlated to ASI in asymptomatic diabetic patients. Likewise, increased PPf was associated with impaired CFR and subclinical diastolic dysfunction in diabetic patients. PPf could be utilized as a simple non-invasive predictor of occult atherosclerosis and diastolic dysfunction in diabetic patients

Association between fragmented QRS and exercise intolerance in hypertensive patients: the relation with coronary flow

Objective: We aimed to investigate the relation between the presence of fragmented QRS (FQRS) and exercise intolerance as assessed by 6 minute walking test (6MWT) and its association with coronary flow reserve (CFR). Methods: One hundred and twenty patients with hypertension (age: 47.3 + 6.9) who were never treated and without left ventricular hypertrophy underwent 6MWT. Echocardiographic examination was obtained for all patients. CFR was calculated as the hyperemic to baseline mean velocity ratio (hyperemia was induced by intravenous adenosine 0.14 mg/kg/min). Patients were stratified into one group with FQRS and another group without FQRS. Forty-eight normotensive subjects with a mean age of 45.7 + 5.3 were recruited and served as a control group. Results: The frequency of FQRS was 49% in hypertensive patients versus 2% in control subjects. Patients with FQRS had higher systolic blood pressure (p < .05; <.01), a significant lower 6MWTD (p < .001), increased LAVI (p <.05), increased E/e' ratio (p < .01) and lower CFR (p < .001) compared with those without FQRS and controls. FQRS was inversely correlated with CFR (−0.531; p < .001) and 6 MWTD (−0.415; p < .001) and positively correlated with E/e' (0.352, p < .02) and LAVI (0.296; p < .05). By a multivariate regression analysis, FQRS (OR = 6.13; p < .001) and CFR (OR = 3.28; p < .001) were the only two independent predictors for decreased 6 MWTD in hypertensive patients. Importantly the ≥3 cutoff number of leads was found to be the best predictor of CFR < 2.0 in hypertensive patients. Conclusion: FQRS is frequent and an independent predictor of reduced exercise tolerance in hypertensive patients. More so, it is significantly associated with decreased CFR and left ventricular diastolic dysfunction. In light of these findings, fragmented QRS might be considered a simple marker for risk stratification of hypertensive patients

Association of morning blood pressure surge with carotid intima-media thickness and cardiac dysfunction in patients with cardiac syndrome-X

Background & hypothesis: We hypothesized that exaggerated morning blood pressure surge, may contribute in cardiac dysfunction and arterial stiffness in patients with cardiac syndrome X. Thus we investigated the impact of morning blood pressure surge on cardiac function and carotid intima-media thickness in subjects with cardiac syndrome X. Methods: We studied patients with cardiac syndrome X using ambulatory blood pressure monitoring and investigated the association of morning blood pressure surge with carotid intima thickness, left atrial volume index and left ventricular filling (E/e'). Seventy patients with cardiac syndrome X were enrolled for the study and compared with 70 age and sex matched controls. Results: Patients with cardiac syndrome X were stratified based on the systolic morning blood pressure surge value of control subjects to patients with exaggerated blood pressure surge (n = 42) and those with normal morning blood pressure surge (n = 28). Basal heart rate (p < .05), high sensitive C-reactive protein (p < .01), left atrial volume index (p < .01), E/e' (p < .01); carotid intima-media thickness (p < .001) and percentage of detected plaque (p < .005) were significantly higher in patients with exaggerated morning blood pressure surge group than those with morning blood pressure surge group. Morning blood pressure surge was significantly correlated with carotid intima-media thickness, high sensitive C-reactive protein, left atrial volume index and E/e' ratio in patients with cardiac syndrome X. In multivariate analysis, exaggerated morning blood pressure surge was the only independent predictor of increased carotid intima-media thickness (OR = 2.379; p < .001), and diastolic dysfunction (OR = 2.464; p < .001) in patients with cardiac syndrome X. Conclusion: Our data suggest that excessive morning blood pressure surge is an independent predictor for arterial stiffness and diastolic dysfunction in patients with cardiac syndrome X

Atrial electromechanical delay, and left ventricular strain in pre-diabetic patients

Objectives: The aim of this study was to investigate the subclinical myocardial affection in prediabetics with the evaluation of left ventricular (LV) systolic strain and strain rate by speckle tracking echocardiography (STE), and atrial electromechanical delay. Study design: Global Longitudinal strain (GLS) and strain rate (GLSR) were assessed by STE, and Intra- and interatrial electromechanical delay (EMD) were measured utilizing tissue Doppler imaging (TDI) in 108 pre-diabetic patients and 72 age and gender matched healthy volunteers. Results: The GLS (−19.4 ± 2.8 vs. 23.8 ± 2.1%; p < 0.001) and GLSR () were significantly lower in prediabetics when compared with the healthy control. Pre-diabetic patients had significantly prolonged PA lateral, PA septum and PA tricuspid. The intra- (PA septum-PA tricuspid) and interatrial (PA lateral-PA tricuspid) electromechanical delays were prolonged compared to controls (p < 0.0001, p < 0.05, p < 0.001, and p < 0.002, respectively). The GLS%, GLSR and atrial electromechanical delay were highly significantly correlated with fasting blood glucose, and modestly correlated to systolic blood pressure, total cholesterol, triglycerides, and left ventricular mass index. Conclusion: GLS%; GLSR assessed by STE was decreased; intra- and interatrial electromechanical delays were prolonged, in pre-diabetic subjects. These non-invasive indices broaden the spectrum of subclinical myocardial dysfunction in pre-diabetic patients