Influence of Differential Calcification in the Descending Thoracic Aorta on Aortic Pulse Pressure

Purpose: Multiple studies have shown pulse pressure (PP) to be a strong predictor of aortic calcification. However, no studies are available that correlate PP with aortic calcification at the segmental level. Methods: We identified 37 patients with aortic PP measured during cardiac catheterization. Their noncontrast chest computed tomography scans were evaluated for the presence of calcium in different segments (ascending aorta, arch of aorta [arch], descending aorta) and quantified. Patients with calcification (Calcified Group A) were compared against patients without calcification (Noncalcified Group B) in terms of PP, calcification and compliance. Results: The mean of the total calcium score was higher in the descending aorta than the arch or ascending aorta (691 vs 571 vs 131, respectively, P < 0.0001). PP had the strongest correlation with calcification in the descending aorta (r = 0.47, P = 0.004). Calcified Group A had a much higher PP than Noncalcified Group B, with the greatest difference in the descending aorta (20 mmHg, P < 0.0001), lesser in the ascending aorta (10 mmHg, P = 0.12) and the least in the arch (5 mmHg, P = 0.38). Calcified Group A patients also had much lower compliance than Noncalcified Group B patients, with the greatest difference among groups seen in the descending aorta (0.7 mL/mmHg, P = 0.002), followed by the ascending aorta, then arch. Conclusions: These are the first data to evaluate the relative impact of aortic segments in PP. Finding the greatest amount of calcification along with greatest change in PP and compliance in the descending aorta makes a case that the descending aorta plays a major role in PP as compared to other segments of the thoracic aorta

Factors associated with low bone mineral density in postmenopausal women with rheumatoid arthritis

Objective: To determine the factors related to low bone density in postmenopausal women with rheumatoid arthritis. Method: The prospective cross-sectional study was conducted at the Rheumatology Department of Fauji Foundation Hospital, Rawalpindi, Pakistan, from June 1 to November 30, 2020, and comprised postmenopausal women with rheumatoid arthritis. On the basis of dual-energy X-ray absorptiometry scan of total hip, femoral neck, and lumbar spine, the subjects were categorised into osteoporosis, osteopenia and normal bone density groups. The risk factors were compared across these subgroups. Data was analysed using SPSS 21. Results: Of the 114 women, 74(64.9%) had osteoporosis, 31(27.2%) had osteopenia and 9(7.9%) had normal bone mineral density. Those with osteoporosis were older (p<0.05), had low body mass index (p<0.002) and had a longer duration since menopause (p<0.004) compared to the other groups. Age and body mass index were significant factors associated with the condition (p<0.05). Conclusion: Older age, lesser body mass index and time since menopause were the factors significantly associated with osteoporosis. Key Words: Rheumatoid arthritis, DXA, Bone mineral density

Normal diameter of the ascending aorta in adults: the impact of stricter criteria on selection of subjects free of disease

BACKGROUND: The American Society of Echocardiography 2015 guidelines for measurement of the aorta utilized studies, including one by Devereaux et al., that suffered from smaller sample sizes and lax criteria for selection of normal subjects, using absence of clinical etiologies of aortic aneurysm without consideration of echocardiographic normalcy. This study was carried out to determine the normal dimension of the ascending thoracic aorta in a large population using stricter selection criteria. METHODS: Echocardiographic studies of patients ≥15 years of age performed at a large tertiary care hospital over the last four years were retrospectively evaluated. Only those who did not fulfill any of the 28 causes of aortic dilatation, as defined by AHA 2010 guidelines, either in their clinical records or echocardiograms were included as “normal subjects.” The dimensions of the mid-ascending thoracic aorta were measured by standardized echocardiography in a plane perpendicular to that of the long axis of the aorta, at end-diastole, using leading edge–to–leading edge technique. RESULTS: Out of 3,201 normal subjects, 974 were men and 2,227 were women. The mean age was 37.91±14.94 years. The mean diameter of the ascending aorta (Asc Ao) in men was 2.91±0.40 cm, compared with 3.34±0.34 cm in prior studies. The mean diameter of Asc Ao in women was 2.70±0.36 cm, compared with 2.98±0.34 cm in prior studies. CONCLUSIONS: These data suggest that in a larger population with more stringent criteria for normalcy, the prevalence of dilated aorta will be higher than those suggested by the current guidelines, if the suggested cutoffs are applied

Abstract P230: The influence of calcification of ascending aorta on dicrotic notch of thoracic aorta

Background: Dicrotic Notch (DN) is known to dampen with age, with increasing arterial stiffness probably due to arterial calcification. Since arterial calcification has recently been shown to predominantly involve descending thoracic aorta, we hypothesized that calcification in different segments of thoracic aorta will have a different impact on DN. Methods: A sample of 44 patients with invasive thoracic aortic pressure tracings during cardiac catheterization was selected for this study. Non-contrast CT scans were evaluated for presence of calcification in aortic segments (ascending aorta (AA), aortic arch (arch) and descending aorta (DA)) and then quantified. DN was categorized based on aortic pressure tracings into 4 grades. Grade 1 represented normal DN; grades 2, 3 and 4 represented progressively diminishing DN, where grade 4 represented absent DN. Compliance was calculated as a change in stroke volume over aortic pulse pressure with both measurements obtained from echocardiography reports done within one year of catheterization. Results: The mean age of the sample population was 64.6 ± 10.5 years. Out of the 44 patients, 14 (32%) had a calcified AA, 25 (56%) had a calcified DA and n=28 (63%) had a calcified arch. Furthermore, 14 (32%) patients had only one segment calcified, whereas 10 (23%) had two and 11 (25%) had all three segments calcified. Abnormal DN was present in 16 (36%) patients. The odds of having an abnormal DN in the presence of calcified AA were more than 3 times (OR: 3.67; p=0.05). Compliance was higher in those with a normal DN versus those with an abnormal DN (1.64 ml/mmHg vs. 1.21 ml/mmHg) (p = 0.09). There was no significant association between calcification in the DA or arch of aorta. Conclusion: There was no association between dicrotic notch and presence of calcification in the arch of the aorta and descending aorta

Distal dicrotic notch in the coronary artery. Is it a function of stenosis vs. stiffness? A computed tomography and angiography correlation study

Background: A single small study (n=97) has suggested that absence of dicrotic notch (DN) in the coronary artery, distal to an intermediate stenosis, may indicate a significant stenosis, proven by an abnormal fractional flow reserve (FFR). This finding has neither been evaluated by other studies nor compared against other, more established, non hyperemic indices like Pd/Pa. It is unclear if DN is representative of coronary stenosis or coronary stiffness. Methods: Of the 926 FFR measurements performed in a large tertiary care center over last 4 years, we included 405 measurements after excluding tracings with inadequate baseline data and absent aortic DN. Tracings with pre-adenosine measurement with 8 cardiac cycles were printed and distal dicrotic notch (DDN) was characterized visually into four types, i.e., full notch, partial notch, definite change in angle of descending limb at the end of systole, and absent DN, by two different observers. Operating test characteristics of DDN were measured against the criterion standard of FFR ≤0.8 to detect significant ischemia. Coronary calcium score (CaSc), as a marker for coronary stiffness of the vessels, was evaluated by CT. Results: Out of 405 patients, 52 had absent DDN. The mean FFR in those with absent DDN was significantly lower (0.79 versus 0.86; p= \u3c0.0001) compared to those with a DDN. The receiver operating area under the curve (AUC) for predicting FFR \u3c0.80 was 0.59 (p\u3c0.0001) for DDN, as compared to 0.89 (p= \u3c0.0001) for baseline Pd/Pa. The sensitivity, specificity, PPV and NPV of DDN were 26%, 92%, 56%, 76%, respectively as compared to 79%, 82%, 63% and 91% for Pd/Pa \u3c 0.93. Those with absent DDN (n=5) had a much higher CaSc (897 vs. 463; p=0.11) than those with DDN (n=32). The AUC to predict absence of DDN by CaSc was 0.62. A CaSc of 82 or lower successfully ruled out an absent DDN. Conclusion: While DDN is associated with an abnormal FFR, our data suggest meaningfully lower performance in prediction of an abnormal FFR as compared to Pd/Pa, indicating that Pd/Pa should be preferred over DDN in clinical practice. DDN appears to be partially explained by coronary stiffness. Further studies to define the relative role of stenosis vs stiffness in regression of DDN are underway

The increasing burden of amyloidosis from apex to base: new insights from technetium-99m pyrophosphate imaging

BACKGROUND: Two-dimensional speckle-tracking strain echocardiography (2D STE) in cardiac amyloidosis (CA) patients has shown relatively preserved left ventricle apical systolic function as measured by longitudinal strain (LS). Technetium-99m pyrophosphate ( 99mTc-PYP) myocardial imaging has gained favor in diagnosis of transthyretin amyloidosis. Since 99mTc-PYP binds amyloid fibrils, we hypothesized this technique can elucidate relative distribution of amyloid in the heart. METHODS: We identified 9 patients with CA diagnosis who had had 2D STE and 9mTc-PYP scans. Segmental LS was measured by 2D STE as a measure of systolic function. Segmental uptake of 99mTc-PYP was measured using a 17-segment model as a measure of CA burden in the specific segment. If uptake was 100% of maximum, it was categorized as 0% defect. Results: Mean LS was markedly decreased in CA patients (-8.3) and much lower in normal patients. Strain increased from base to apex on 2D STE (average basal strain [-3.3] vs. mid strain [-8.3] vs. apical strain [-14]); p\u3c0.01 for all comparisons. Percent defect increased gradually from base to mid to apex (10%, 38%, 60% defect, respectively) in CA patients; p\u3c0.0001 for all comparisons. Apical cap percent defect was not significant from apex (48.7 vs 59.5; p=0.7547). CONCLUSIONS: These data provide the first insight into relative distribution of amyloid in the ventricle and suggest the relative apical sparing of systolic strain may be a function of amyloid deposition of the ventricular base

Influence of Differential Calcification in the Descending Thoracic Aorta on Aortic Pulse Pressure

Purpose: Multiple studies have shown pulse pressure (PP) to be a strong predictor of aortic calcification. However, no studies are available that correlate PP with aortic calcification at the segmental level. Methods: We identified 37 patients with aortic PP measured during cardiac catheterization. Their noncontrast chest computed tomography scans were evaluated for the presence of calcium in different segments (ascending aorta, arch of aorta [arch], descending aorta) and quantified. Patients with calcification (Calcified Group A) were compared against patients without calcification (Noncalcified Group B) in terms of PP, calcification and compliance. Results: The mean of the total calcium score was higher in the descending aorta than the arch or ascending aorta (691 vs 571 vs 131, respectively, P \u3c 0.0001). PP had the strongest correlation with calcification in the descending aorta (r = 0.47, P = 0.004). Calcified Group A had a much higher PP than Noncalcified Group B, with the greatest difference in the descending aorta (20 mmHg, P \u3c 0.0001), lesser in the ascending aorta (10 mmHg, P = 0.12) and the least in the arch (5 mmHg, P = 0.38). Calcified Group A patients also had much lower compliance than Noncalcified Group B patients, with the greatest difference among groups seen in the descending aorta (0.7 mL/mmHg, P = 0.002), followed by the ascending aorta, then arch. Conclusions: These are the first data to evaluate the relative impact of aortic segments in PP. Finding the greatest amount of calcification along with greatest change in PP and compliance in the descending aorta makes a case that the descending aorta plays a major role in PP as compared to other segments of the thoracic aorta

Influence of differential calcification in the descending thoracic aorta on aortic pulse pressure

Purpose: Multiple studies have shown pulse pressure (PP) to be a strong predictor of aortic calcification. However, no studies are available that correlate PP with aortic calcification at the segmental level. Methods: We identified 37 patients with aortic PP measured during cardiac catheterization. Their noncontrast chest computed tomography scans were evaluated for the presence of calcium in different segments (ascending aorta, arch of aorta [arch], descending aorta) and quantified. Patients with calcification (Calcified Group A) were compared against patients without calcification (Noncalcified Group B) in terms of PP, calcification and compliance. Results: The mean of the total calcium score was higher in the descending aorta than the arch or ascending aorta (691 vs 571 vs 131, respectively, P < 0.0001). PP had the strongest correlation with calcification in the descending aorta (r = 0.47, P = 0.004). Calcified Group A had a much higher PP than Noncalcified Group B, with the greatest difference in the descending aorta (20 mmHg, P < 0.0001), lesser in the ascending aorta (10 mmHg, P = 0.12) and the least in the arch (5 mmHg, P = 0.38). Calcified Group A patients also had much lower compliance than Noncalcified Group B patients, with the greatest difference among groups seen in the descending aorta (0.7 mL/mmHg, P = 0.002), followed by the ascending aorta, then arch. Conclusions: These are the first data to evaluate the relative impact of aortic segments in PP. Finding the greatest amount of calcification along with greatest change in PP and compliance in the descending aorta makes a case that the descending aorta plays a major role in PP as compared to other segments of the thoracic aorta