Gender differences in prevalence and prognostic value of fragmented QRS complex

Background: Fragmented QRS (fQRS) on 12-lead electrocardiogram(ECG) is associated with scarred myocardium and adverse outcome. However, the data on gender differences in terms of its prevalence and prognostic value is sparse. The aim of this study was to evaluate whether gender differences in fQRS exist among subjects drawn from populations with different risk profiles. Methods: We analyzed fQRS from 12-lead ECG in 953 autopsy-confirmed victims of sudden cardiac death (SCD) (78% men; 67.0 +/- 11.4 yrs), 1900 coronary artery disease (CAD) patients with angiographically confirmed stenosis of >= 50% (70% men; 66.6 +/- 9.0 yrs, 43% with previous myocardial infarction [MI]), and in 10,904 adults drawn from the Finnish adult general population (52% men; 44.0 +/- 8.5 yrs). Results: Prevalence of fQRS was associated with older age, male sex and the history and severity of prior cardiac disease of subjects. Among the general population fQRS was more commonly found among men in comparison to women (20.5% vs. 14.8%, p <0.001). The prevalence of fQRS rose gradually along with the severity of prior cardiac disease in both genders, yet remained significantly higher in the male population: subjects with suspected or known cardiac disease (25.4% vs. 15.8% p <0.001), CAD patients without prior MI (39.9% vs. 26.4%, p <0.001), CAD patients with prior MI (42.9% vs. 31.2%, p <0.001), and victims of SCD (56.4% vs. 44.4%, p <0.001). Conclusions: The prevalence of QRS fragmentation varies in different populations. The fragmentation is clearly related to the underlying cardiac disease in both genders, however women seem to have significantly lower prevalence of fQRS in each patient population in comparison to men. (C) 2020 The Authors. Published by Elsevier Inc.Peer reviewe

Normal variation of the tibiotalar joint in dynamic computed tomography

Abstract The normal tibiotalar joint is a stable structure, where only a minor widening of the ankle mortise and rotation of the fibula is caused by normal flexion-extension movements and joint loading. The most common injury mechanism is excessive external rotation of the ankle, which may induce an ankle fracture or an injury of the syndesmosis ligaments, leading to instability of the joint. Subsequent surgical fixation can cause malreduction and dysfunction of the joint by restricting normal motion, which may lead to altered tibiotalar joint loading conditions and cause long-term complications, such as osteoarthritis. In order to correctly evaluate the potential post-traumatic conditions, clinicians must know the normal movements of the fibula in the distal tibiofibular joint and the talus in the upper ankle joint under weight-bearing conditions. Until now, the normal dynamics of the syndesmosis and upper ankle joint, as well as the changes in rotations have been unknown, and the aim was to answer these questions. In the first study, the distal tibiofibular syndesmosis was assessed on non-weight-bearing computed tomography (NWBCT) scans in order to provide standardized measures of the syndesmosis in cross-sectional imaging. Second, a distal tibiofibular syndesmosis was investigated in upright weight-bearing CT (WBCT) scans in the neutral standing position and under maximal internal and external rotational stress. Third, the normal anatomy and rotational dynamics of the upper ankle joint was observed. The first study demonstrated that in axial CT imaging of the syndesmosis, the location of the fibula was either anteriorly or centrally in the tibial incisura in 88–97% of patients in both the supine position with resting ankles, and in the neutral standing position. If the fibula lies posteriorly, malreduction should be considered. The second study demonstrated that when the ankle is maximally rotated, the fibula slides back and forth in the tibial incisura with 1.5 mm total movement and a rotation of 3°, but the distal tibiofibular joint is not widened. In internal rotation of the ankle, the talus is rotated externally, the fibula moves, and the fibula moves to the posterior part of the tibial incisura in 40% of subjects. In external rotation of the ankle, the talus is rotated internally, and the fibula moves concomitantly slightly anteriorly. The results of the third study show that the talus rotates in the ankle mortise 10°, with no change in the medial clear space (MCS) and no significant lateral widening in the joint space. Minimal intrasubject variation (less than 1 mm at all measurement points) was observed in the total rotational range of motion, while in some measurements the intersubject variation was large in both supine, neutral standing, and rotational stress images. Sex or age did not affect most of the measurements; only in maximal external rotation was a minor tilting of the talus seen in the older population. These findings suggest that the contralateral ankle can and probably should be used as a reference when possible malreduction of the syndesmosis or tibiotalar ankle joint instability is suspected.Tiivistelmä Nilkkanivel on sääriluun, pohjeluun ja telaluun muodostama kokonaisuus, jota tiiviit nivelsiderakenteet vakauttavat. Normaalisti nivelen pääasiallinen liike tapahtuu ojennus-koukistussuuntaan ja kuormittumiseen liittyen tapahtuu vain hyvin vähäistä nivelhaarukan leviämistä, eikä telaluu pääse juurikaan kiertymään. Useimmat nilkkavammat taas syntyvät kiertoliikkeessä, joka voi johtaa nivelsidevammaan ja/tai nilkkamurtumaan, johon liittyen telaluu pääsee kiertymään normaalia enemmän ulkokiertoon ja nivelhaarukka leviämään, mikä johtaa nilkan epävakauteen ja poikkeaviin kuormitusolosuhteisiin. Vamman jälkeinen kirurginen hoito taas voi aiheuttaa luisten rakenteiden asettumiseen nivelen toiminnan kannalta epäanatomiseen asentoon ja estää nilkan normaalin liikkumisen. Sekä nivelen liiallinen väljyys että virheasentoon tehty kirurginen kiinnitys voivat aiheuttaa kipua, muuttaa nivelen kuormitusolosuhteita ja johtaa nivelen toimintahäiriöihin tai ennenaikaiseen kulumiseen. Jotta vamman jälkeisiä muutoksia pystyttäisiin arvioimaan sekä sääri- ja pohjeluun välisen sidekudossidoksen eli syndesmoosin alueella että ylemmässä nilkkanivelessä tulisi terveiden nivelten normaalit liikelaajuudet ja kuormituksen aiheuttamat dynaamiset muutokset pystyä mittaamaan luotettavasti. Tämän tutkimuksen tarkoituksena oli selvittää syndesmoosialueen ja ylemmän nilkkanivelen normaali anatomia sekä maaten kuvatuista tietokonetomografia- että seisten kuvatuista kartiokeilatietokonetomografia¬tutkimuksista arvioiden. Lisäksi mitattiin molempien nivelalueiden kiertorasituksessa todettavat normaalit liikelaajuudet seisten kuvatuista kartiokeilatietokonetomografiatutkimuksista. Ensimmäinen tutkimus osoitti, että normaalisti pohjeluu sijaitsee alemman pohjesääriluunivelen etuosassa tai nivelen keskellä 88–97 %:lla tutkituista potilaista. Jos taas pohjeluu on siirtynyt nivelen takaosaan, tulee epäillä virheasentoa. Toisen tutkimuksen tulokset osoittivat, että kiertorasituksissa pohjeluu liikkuu syndesmoosialueella edestakaisin 1.5 mm ja kiertyy 3 astetta, mutta nivel ei levene sivuttaissuuntaan. Telaluun sisäkierrossa pohjeluu liukuu 40 %:lla tutkituista vapaaehtoisista koehenkilöistä syndesmoosialueen takaosaan, ja ulkokierrossa taas nivelen etuosaan. Kolmas tutkimus osoitti, että telaluu kiertyy maksimaalisen ulko- ja sisäkierron välillä 10 astetta ilman merkittävää mediaalisen tai lateraalisen nivelraon leviämistä. Kaikissa tutkimuksissa todettiin, että mikäli koehenkilöitä verrataan keskenään, samojen mittauskohtien väliset erot ovat merkittäviä. Mikäli taas verrataan saman koehenkilön molempia nilkkoja keskenään, mittauksissa ei ole merkittävää puolieroa. Ainoa mittaustulos, johon iällä tai sukupuolella oli vaikutusta, oli vanhemmassa ikäryhmässä todettu telaluun vähäinen kallistuminen maksimaalisessa ulkokierrossa. Tutkimukset tuottivat tietoa alemman pohjesääriluunivelen ja ylemmän nilkkanivelen normaalista anatomiasta ja liikkuvuuksista kiertorasituksissa tietokonetomografiatutkimuksissa. Tutkimusten perusteella todetaan, että potilaan tervettä nilkkaa kannattaa käyttää normaalianatomian vertailukohtana sekä heti vamman jälkeen mahdollisen operatiivisen hoidon tarvetta arvioitaessa että hoidon tulosta arvioitaessa

Assessment of articular cartilage of ankle joint in stable and unstable unilateral weber type-B/SER-type ankle fractures shortly after trauma using T2 relaxation time

Abstract Background: Early detection of post-traumatic cartilage damage in the ankle joint in magnetic resonance images can be difficult due to disturbances to structures usually appearing over time. Purpose: To study the articular cartilage of unilateral Weber type-B/SER-type ankle fractures shortly post-trauma using T2 relaxation time. Material and Methods: Fifty one fractured ankles were gathered from consecutively screened patients, compiled initially for RCT studies, and treated at Oulu University Hospital and classified as stable (n = 28) and unstable fractures (n = 23) based on external-rotation stress test: medial clear space of ≥5 mm was interpreted as unstable. A control group of healthy young individuals (n = 19) was also gathered. All ankles were imaged on average 9 (range: 1 to 25) days after injury on a 3.0T MRI unit for T2 relaxation time assessment, and the cartilage was divided into sub-regions for comparison. Results: Control group displayed significantly higher T2 values in tibial cartilage compared to stable (six out of nine regions, p-values = .003–.043) and unstable (six out of nine regions, p-values = .001–.037) ankle fractures. No differences were detected in talar cartilage. Also, no differences were observed between stable and unstable fractures in tibial or talar cartilage. Conclusions: Lower T2 relaxation times of tibial cartilage in fractured ankles suggest intact extra cellular matrix (ECM) of the cartilage. Severity of the ankle fracture, measured by ankle stability, does not seem to increase ECM degradation immediately after trauma

Liver X Receptor Agonist 4β‐Hydroxycholesterol as a Prognostic Factor in Coronary Artery Disease

Background Regardless of progress in treatment of coronary artery disease (CAD), there is still a significant residual risk of death in patients with CAD, highlighting the need for additional risk stratification markers. Our previous study provided evidence for a novel blood pressure–regulating mechanism involving 4β‐hydroxycholesterol (4βHC), an agonist for liver X receptors, as a hypotensive factor. The aim was to determine the role of 4βHC as a prognostic factor in CAD. Methods and Results The ARTEMIS (Innovation to Reduce Cardiovascular Complications of Diabetes at the Intersection) cohort consists of 1946 patients with CAD. Men and women were analyzed separately in quartiles according to plasma 4βHC. Basic characteristics, medications, ECG, and echocardiography parameters as well as mortality rate were analyzed. At baseline, subjects with a beneficial cardiovascular profile, as assessed with traditional markers such as body mass index, exercise capacity, prevalence of diabetes, and use of antihypertensives, had the highest plasma 4βHC concentrations. However, in men, high plasma 4βHC was associated with all‐cause death, cardiac death, and especially sudden cardiac death (SCD) in a median follow‐up of 8.8 years. Univariate and comprehensively adjusted hazard ratios for SCD in the highest quartile were 3.76 (95% CI, 1.6–8.7; P=0.002) and 4.18 (95% CI, 1.5–11.4; P=0.005), respectively. In contrast, the association of cardiac death and SCD in women showed the lowest risk in the highest 4βHC quartile. Conclusions High plasma 4βHC concentration was associated with death and especially SCD in men, while an inverse association was detected in women. Our results suggest 4βHC as a novel sex‐specific risk marker of cardiac death and especially SCD in chronic CAD. Registration Information clinicaltrials.gov. Identifier NCT01426685

Serum PINP, PIIINP, galectin-3 and ST2 as Surrogates of Myocardial Fibrosis and Echocardiographic Left Venticular Diastolic Filling Properties

Objectives and Background. Serum biomarkers have been proposed to reflect fibrosis of several human tissues, but their specific role in the detection of myocardial fibrosis has not been well established. We studied the association between N-terminal propeptide of type I and III procollagen (PINP, PIIINP, respectively), galectin-3 (gal-3), soluble ST2 (ST2) and myocardial fibrosis measured by late gadolinium enhanced cardiac magnetic resonance imaging (LGE CMR) and their relation to left ventricular diastolic filling properties measured by tissue Doppler echocardiography (E/e´) in patients with stable coronary artery disease (CAD).Methods and Results. We determined the PINP, PIIINP, gal-3 and ST2 serum levels and performed LGE CMR and echocardiography on 63 patients with stable CAD without a history of prior myocardial infarction. Myocardial late gadolinium enhancement T1 relaxation time was defined as a specific marker of myocardial fibrosis. ST2, PINP and PIIINP did not have a significant correlation with the post-LGE T1 relaxation time tertiles (NS for all), but the lowest post-LGE T1 relaxation time tertile had significantly higher gal-3 values than the other two tertiles (p= 0,002 and 0.002) and higher E/é values (p= 0,009) compared to the highest T1 relaxation time tertile. ST2 (p= 0.025 and 0.029), gal-3 (p= 0.003 and < 0.001) and PIIINP (p= 0.001 and 0.007) levels were also significantly higher in the highest E/é tertile, compared to the other two tertiles.Conclusions. Elevated serum levels of gal-3 reflect the degree of myocardial fibrosis assessed by LGE CMR. Gal-3, ST2 and PIIINP are also elevated in patients with impaired LV diastolic function, suggesting that these biomarkers are useful surrogates of structural and functional abnormality of the myocardium

Presence of atrial fibrillation is associated with liver stiffness in an elderly Finnish population

Abstract Background: Chronic liver injury from different etiologies drives liver fibrosis. However, little is known about the associated factors, systemic factors in particular. Recently, non-alcoholic fatty liver disease (NAFLD) and atrial fibrillation have been shown to be associated with each other. Thereby, we aimed to study the association between atrial fibrillation and liver stiffness. Study: Extensive clinical measurements including echocardiography of the heart, transient elastography (TE) of the liver and the presence of atrial fibrillation were determined in elderly Finnish study subjects (n = 76, mean age 73 years) from OPERA (Oulu Project Elucidating the Risk of Atherosclerosis) study cohort. Half of the study subjects had non-alcoholic fatty liver disease, whereas others did not have any known hepatic morbidity. The present study was cross-sectional by nature. Results: The subjects with atrial fibrillation had higher TE values (with atrial fibrillation TE = 9.3kPa, without atrial fibrillation TE = 6.3kPa, p = 0.018). When the cohort was divided to four subgroups (those without NAFLD or atrial fibrillation, with NAFLD but without atrial fibrillation, with both conditions, and with atrial fibrillation but without NAFLD), the TE value was the highest in the subjects with both conditions (5.3kPa, 7.4kPa, 10.8kPa and 7.8kPa, respectively, p = 0.019). Moreover, the higher the TE value, the more prevalent atrial fibrillation was (the atrial fibrillation prevalence by tertiles of TE 27% / 36% / 77%, p = 0.001). Likewise, the greater the TE value, the greater the left atrial diameter, a collateral of atrial fibrillation (left atrial diameters by tertiles of TE 39mm / 45mm / 48mm, p"&lt;"0.001) was. All these p-values for continuous variables remained statistically significant even after adjustment for common clinically relevant risk factors. Conclusions: There is an association between atrial fibrillation and liver stiffness. This novel association may have multiple explanations and mechanistic links, which are discussed here and need further studies, prospective studies in particular

Type 2 diabetes and coronary artery disease: Preserved ejection fraction and sudden cardiac death

Previous studies have shown that type 2 diabetes (DM2) is associated with sudden cardiac death (SCD) risk in post–myocardial infarction patients. The treatment of coronary artery disease (CAD) as well as DM2 has changed over time. The purpose of this study was to compare the incidence of SCD in DM2 and nondiabetic patients with CAD and preserved ejection fraction (EF) in a prospective observational study (ARTEMIS study). In 834 DM2 patients and 1112 nondiabetic patients with CAD enrolled, the EF measured ≥3 months after qualifying was 63% ± 10% in DM2 patients and 65% ± 8% in nondiabetic patients (P < .01). The primary end point was SCD or resuscitation from sudden cardiac arrest (SCA). All-cause mortality, cardiac mortality, non-SCD, hospitalization for heart failure, and acute coronary syndrome were secondary end points. During a mean follow-up of 6.3 ± 1.6 years, SCDs/SCAs occurred in 50 patients. The prevalence of SCD/SCA was higher in DM2 patients (4.1%) than in nondiabetic patients (1.4%) (adjusted hazard ratio 2.6; 95% confidence interval 1.3–5.3; P < .01). However, the non-SCD component of cardiac mortality was not significantly different between DM2 and nondiabetic patients. In addition, heart failure hospitalizations were more common in DM2 patients (8.4%) than in nondiabetic patients (2.9%) (P < .001). The annual cardiac mortality in nondiabetic patients with CAD was 0.50%, which was lower than the 0.59% reported in the general Finnish population. DM2 is an independent risk factor for SCD/SCA in CAD patients with preserved EF. Cardiac mortality in nondiabetic CAD patients is slightly lower than that in the general population in the present treatment era