Φλεγμονή των καρωτιδικών αθηρωματικών πλακών: Συσχέτιση των ευρημάτων της ακτινομετρίας μικροκυμάτων και της ποζιτρονικής/αξονικής τομογραφίας (PET/CT)

Σκοπός: Η διερεύνηση της σχέσης μεταξύ των μετρήσεων θερμοκρασίας με την ακτινομετρία μικροκυμάτων (microwave radiometry-MWR) και της πρόσληψης φθοριοδεοξυγλυκόζης (fluorodeoxyglucose-FDG) στο καρωτιδικό τοίχωμα και η εκτίμηση της συσχέτισής τους με τα ευρήματα της ιστολογικής και ανοσοϊστοχημικής ανάλυσης σε ασθενείς με σημαντικού βαθμού καρωτιδική στένωση. Μέθοδος και αποτελέσματα: Σε 21 ασθενείς οι οποίοι υπεβλήθησαν σε ενδαρτηρεκτομή καρωτίδας, η φλεγμονή του καρωτιδικού τοιχώματος εκτιμήθηκε τόσο με FDG ποζιτρονική/αξονική τομογραφία (FDG-PET/CT), όσο και με τις μετρήσεις της ακτινομετρίας μικροκυμάτων. Η εκτίμηση της φλεγμονής των καρωτίδων με FDG-PET/CT ημιποσοτικοποιήθηκε ως ο λόγος στόχου προς τον περιβάλλοντα ιστό (target-to-background ratio-TBR) σε διαδοχικές μετρήσεις σε εγκάρσιες τομές 2 εκατοστά κάτωθεν έως 2 εκατοστά άνωθεν του καρωτιδικού διχασμού. Η διαφορά θερμοκρασίας (ΔΤ) με την ακτινομετρία μικροκυμάτων υπολογίσθηκε ως η διαφορά της μέγιστης μείον την ελάχιστη τιμή θερμοκρασίας στα αντίστοιχα καρωτιδικά τμήματα. Η έκταση του λιπώδους πυρήνα, η επασβέστωση καθώς και τα επίπεδα CD68 και CD31 προσδιορίσθηκαν στα εκταμηθέντα καρωτιδικά ιστολογικά τμήματα. Παρατηρήθηκε μια σημαντική συσχέτιση μεταξύ των τιμών ΔΤ και της πρόσληψης FDG (R =0.40, P = 0.01), αλλά όχι μεταξύ του βαθμού της αγγειογραφικής στένωσης και των τιμών ΔΤ (R = 0.02, P = 0.91) ή πρόσληψης ραδιοφαρμάκουω(R = - 0.28, P = 0.86). Οι ασθενείς με αθηρωματικές πλάκες πλούσιες σε λιπώδη πυρήνα ή χαμηλή επασβέστωση είχαν υψηλότερες τιμές ΔΤ (P = 0.001 και P < 0.001, αντίστοιχα) και πρόσληψης ραδιοφαρμάκου (P = 0.02 and P = 0.02, αντίστοιχα). Οι ασθενείς με αθηρωματικές πλάκες που περιείχαν αυξημένα επίπεδα CD68 είχαν υψηλότερες τιμές ΔΤ και πρόσληψης ραδιοφαρμάκου. Συμπέρασμα: Οι μετρήσεις θερμοκρασίας ως δείκτης φλεγμονής της καρωτιδικής πλάκας συσχετίσθηκαν με τους απεικονιστικούς βιοδείκτες της ποζιτρονικής/τομογραφίας. Η ανωτέρω συσχέτιση επιβεβαιώθηκε από τα ευρήματα της ιστολογικής και ανοσοϊστοχημικής ανάλυσης. Οι δομικές αλλαγές δεν συνδέονται με τη φλεγμονώδη διεργασία. Η σημασία των ανωτέρω ευρημάτων στη δαιστρωμάτωση κινδύνου και στην αντιμετώπιση ασθενών με αθηροσκλήρωση καρωτίδων καθώς και ο ακριβής αλγόριθμος για δυνητική χρήση της MWR και της PET/CT στην κλινική πράξη θα πρέπει να διερευνηθεί.Aims: To explore the relationship between temperature measurements derived by microwave radiometry (MWR) and carotid flurodeoxyglucose (FDG) uptake and assess their association with histological and immunohistochemistry findings in patients with high-grade carotid stenosis. Methods and results: In 21 patients undergoing carotid endarterectomy, carotid inflammation was evaluated by both FDG positron emission/computed tomography (FDG-PET/CT) imaging and MWR measurements. Carotid inflammation was assessed by PET/CT as target-to-background ratio (TBR) by obtaining measurements in consecutive axial slices 2 cm below to 2 cm above the carotid bifurcation. Temperature difference (DT) by MWR was assigned as the maximum–minimum temperature measurements over the corresponding carotid segments. The extent of lipid core, calcification as well as CD68 and CD31 levels were also assessed. There was a significant correlation between DT values and FDG uptake (R =0.40, P = 0.01), but no correlation between the degree of angiographic stenosis and DT values (R = -0.02, P = 0.91) or PET/CT measurements (R = - 0.28, P = 0.86). Patients with plaques containing high lipid core extension or low calcification exhibited higher DT (P = 0.001 and P < 0.001, respectively) and FDG uptake values (P = 0.02 and P = 0.02, respectively). Patients with plaques containing increased CD68 expression exhibited higher DT and FDG uptake measurements. Conclusion: Carotid plaque inflammation was evaluated by temperature measurements, which were correlated with FDG-PET/CT indices, confirmed by histopathology and immunohistochemistry findings. Structural changes did not predict inflammatory process. The implications of these findings in risk stratification and management of patients with carotid atherosclerosis and the precise algorithm for potential clinical utilization of MWR and PET/CT remain to be determined

Atrial Flutter Mimicking Acute Myocardial Infarction

A 37-year old male came to the emergency room complaining of atypical chest pain of a few hours duration. Initial ECG displayed atrial flutter with 3:1 atrioventricular (AV) conduction with mostly pronounced inferior-wall but also diffuse ST-T changes suspect of acute ST elevation myocardial infarction (STEMI) (Figure, panel A) with already established inferior Q waves. However, due to non-convincing clinical history, further investigation was undertaken, which showed a normal bedside echocardiogram, while determination of cardiac enzymes confirmed normal values which remained normal at subsequent measurements... (excerpt

Atrial Flutter Mimicking Acute Myocardial Infarction

A case of ST-elevation myocardial infarction (STEMI) mimic produced by prominent atrial flutter waves is being presented and discussed

Familial hypercholesterolaemia in children and adolescents from 48 countries: a cross-sectional study

Background: Approximately 450 000 children are born with familial hypercholesterolaemia worldwide every year, yet only 2·1% of adults with familial hypercholesterolaemia were diagnosed before age 18 years via current diagnostic approaches, which are derived from observations in adults. We aimed to characterise children and adolescents with heterozygous familial hypercholesterolaemia (HeFH) and understand current approaches to the identification and management of familial hypercholesterolaemia to inform future public health strategies. Methods: For this cross-sectional study, we assessed children and adolescents younger than 18 years with a clinical or genetic diagnosis of HeFH at the time of entry into the Familial Hypercholesterolaemia Studies Collaboration (FHSC) registry between Oct 1, 2015, and Jan 31, 2021. Data in the registry were collected from 55 regional or national registries in 48 countries. Diagnoses relying on self-reported history of familial hypercholesterolaemia and suspected secondary hypercholesterolaemia were excluded from the registry; people with untreated LDL cholesterol (LDL-C) of at least 13·0 mmol/L were excluded from this study. Data were assessed overall and by WHO region, World Bank country income status, age, diagnostic criteria, and index-case status. The main outcome of this study was to assess current identification and management of children and adolescents with familial hypercholesterolaemia. Findings: Of 63 093 individuals in the FHSC registry, 11 848 (18·8%) were children or adolescents younger than 18 years with HeFH and were included in this study; 5756 (50·2%) of 11 476 included individuals were female and 5720 (49·8%) were male. Sex data were missing for 372 (3·1%) of 11 848 individuals. Median age at registry entry was 9·6 years (IQR 5·8-13·2). 10 099 (89·9%) of 11 235 included individuals had a final genetically confirmed diagnosis of familial hypercholesterolaemia and 1136 (10·1%) had a clinical diagnosis. Genetically confirmed diagnosis data or clinical diagnosis data were missing for 613 (5·2%) of 11 848 individuals. Genetic diagnosis was more common in children and adolescents from high-income countries (9427 [92·4%] of 10 202) than in children and adolescents from non-high-income countries (199 [48·0%] of 415). 3414 (31·6%) of 10 804 children or adolescents were index cases. Familial-hypercholesterolaemia-related physical signs, cardiovascular risk factors, and cardiovascular disease were uncommon, but were more common in non-high-income countries. 7557 (72·4%) of 10 428 included children or adolescents were not taking lipid-lowering medication (LLM) and had a median LDL-C of 5·00 mmol/L (IQR 4·05-6·08). Compared with genetic diagnosis, the use of unadapted clinical criteria intended for use in adults and reliant on more extreme phenotypes could result in 50-75% of children and adolescents with familial hypercholesterolaemia not being identified. Interpretation: Clinical characteristics observed in adults with familial hypercholesterolaemia are uncommon in children and adolescents with familial hypercholesterolaemia, hence detection in this age group relies on measurement of LDL-C and genetic confirmation. Where genetic testing is unavailable, increased availability and use of LDL-C measurements in the first few years of life could help reduce the current gap between prevalence and detection, enabling increased use of combination LLM to reach recommended LDL-C targets early in life

Inflammation of carotid atherosclerotic plaques: correlation of the findings of the microwave radiometry and the positron/computed tomography (PET/CT)

Aims: To explore the relationship between temperature measurements derived by microwave radiometry (MWR) and carotid flurodeoxyglucose (FDG) uptake and assess their association with histological and immunohistochemistry findings in patients with high-grade carotid stenosis. Methods and results: In 21 patients undergoing carotid endarterectomy, carotid inflammation was evaluated by both FDG positron emission/computed tomography (FDG-PET/CT) imaging and MWR measurements. Carotid inflammation was assessed by PET/CT as target-to-background ratio (TBR) by obtaining measurements in consecutive axial slices 2 cm below to 2 cm above the carotid bifurcation. Temperature difference (DT) by MWR was assigned as the maximum–minimum temperature measurements over the corresponding carotid segments. The extent of lipid core, calcification as well as CD68 and CD31 levels were also assessed. There was a significant correlation between DT values and FDG uptake (R =0.40, P = 0.01), but no correlation between the degree of angiographic stenosis and DT values (R = -0.02, P = 0.91) or PET/CT measurements (R = - 0.28, P = 0.86). Patients with plaques containing high lipid core extension or low calcification exhibited higher DT (P = 0.001 and P < 0.001, respectively) and FDG uptake values (P = 0.02 and P = 0.02, respectively). Patients with plaques containing increased CD68 expression exhibitedhigher DT and FDG uptake measurements. Conclusion: Carotid plaque inflammation was evaluated by temperature measurements, which were correlated with FDG-PET/CT indices, confirmed by histopathology and immunohistochemistry findings. Structural changes did not predict inflammatory process. The implications of these findings in risk stratification and management of patients with carotid atherosclerosis and the precise algorithm for potential clinical utilization of MWR and PET/CT remain to be determined.Σκοπός: Η διερεύνηση της σχέσης μεταξύ των μετρήσεων θερμοκρασίας με την ακτινομετρία μικροκυμάτων (microwave radiometry-MWR) και της πρόσληψης φθοριοδεοξυγλυκόζης (fluorodeoxyglucose-FDG) στο καρωτιδικό τοίχωμα και η εκτίμηση της συσχέτισής τους με τα ευρήματα της ιστολογικής και ανοσοϊστοχημικής ανάλυσης σε ασθενείς με σημαντικού βαθμού καρωτιδική στένωση. Μέθοδος και αποτελέσματα: Σε 21 ασθενείς οι οποίοι υπεβλήθησαν σε ενδαρτηρεκτομή καρωτίδας, η φλεγμονή του καρωτιδικού τοιχώματος εκτιμήθηκε τόσο με FDG ποζιτρονική/αξονική τομογραφία (FDG-PET/CT), όσο και με τις μετρήσεις της ακτινομετρίας μικροκυμάτων. Η εκτίμηση της φλεγμονής των καρωτίδων με FDG-PET/CT ημιποσοτικοποιήθηκε ως ο λόγος στόχου προς τον περιβάλλοντα ιστό (target-to-background ratio-TBR) σε διαδοχικές μετρήσεις σε εγκάρσιες τομές 2 εκατοστά κάτωθεν έως 2 εκατοστά άνωθεν του καρωτιδικού διχασμού. Η διαφορά θερμοκρασίας (ΔΤ) με την ακτινομετρία μικροκυμάτων υπολογίσθηκε ως η διαφορά της μέγιστης μείον την ελάχιστη τιμή θερμοκρασίας στα αντίστοιχα καρωτιδικά τμήματα. Η έκταση του λιπώδους πυρήνα, η επασβέστωση καθώς και τα επίπεδα CD68 και CD31 προσδιορίσθηκαν στα εκταμηθέντα καρωτιδικά ιστολογικά τμήματα. Παρατηρήθηκε μια σημαντική συσχέτιση μεταξύ των τιμών ΔΤ και της πρόσληψης FDG (R =0.40, P = 0.01), αλλά όχι μεταξύ του βαθμού της αγγειογραφικής στένωσης και των τιμών ΔΤ (R = 0.02, P = 0.91) ή πρόσληψης ραδιοφαρμάκουω(R = - 0.28, P = 0.86). Οι ασθενείς με αθηρωματικές πλάκες πλούσιες σε λιπώδη πυρήνα ή χαμηλή επασβέστωση είχαν υψηλότερες τιμές ΔΤ (P = 0.001 και P < 0.001, αντίστοιχα) και πρόσληψης ραδιοφαρμάκου (P = 0.02 and P = 0.02, αντίστοιχα). Οι ασθενείς με αθηρωματικές πλάκες που περιείχαν αυξημένα επίπεδα CD68 είχαν υψηλότερες τιμές ΔΤ και πρόσληψης ραδιοφαρμάκου. Συμπέρασμα: Οι μετρήσεις θερμοκρασίας ως δείκτης φλεγμονής της καρωτιδικής πλάκας συσχετίσθηκαν με τους απεικονιστικούς βιοδείκτες της ποζιτρονικής/τομογραφίας. Η ανωτέρω συσχέτιση επιβεβαιώθηκε από τα ευρήματα της ιστολογικής και ανοσοϊστοχημικής ανάλυσης. Οι δομικές αλλαγές δεν συνδέονται με τη φλεγμονώδη διεργασία. Η σημασία των ανωτέρω ευρημάτων στη δαιστρωμάτωση κινδύνου και στην αντιμετώπιση ασθενών με αθηροσκλήρωση καρωτίδων καθώς και ο ακριβής αλγόριθμος για δυνητική χρήση της MWR και της PET/CT στην κλινική πράξη θα πρέπει να διερευνηθεί

Uncommon ultrasound findings due to extensive bicuspid aortic valve endocarditis

We report the case of a 32-year-old man, who was presented with dyspnoea and diffuse abdominal pain with associated vomiting about two months after surgery for aortic valve replacement due to endocarditis. The echocardiographic examination of the patient revealed uncommon findings such as pseudoaneurysm of the aortic intervalvular fibrosa (MAIVF), perforation of the anterior mitral leaflet, large aneurysm of the perimembranous inlet ventricular septum, Gerboden flow through the perimembranous aneurysm and finally abnormal position of the tricuspid valve towards the ventricular apex

Prediction of cardiovascular events with levels of proprotein convertase subtilisin/kexin type 9: A systematic review and meta-analysis

Background and aims: Inhibition of proprotein convertase subtilisin/kexin type 9 (PCSK9) reduces atherogenic lipoproteins and could lead to reduction of cardiovascular (CV) events. However, it is unclear whether blood PCSK9 levels predict future CV events. We performed a meta-analysis of all longitudinal studies to determine the ability of PCSK9 levels to predict risk of future CV events. Methods: A comprehensive search of electronic databases was conducted up to February 2016. Longitudinal studies that reported events or relative risk (RR) estimates with 95% confidence intervals (CI) were included. Results: All 9 studies included (12,081 participants, mean follow-up 6.62 years) reported results on total CV events. The pooled RR of total CV events for an increase in baseline PCSK9 by 1 standard deviation (SD) was 1.098 (95% CI, 1.02-1.18), corresponding to a risk increase of 10% (Z = 2.43, p = 0.015). The pooled RR of total CV events for subjects categorized in the highest tertile of baseline PCSK9 was 1.228 (95% CI, 1.035-1.457), corresponding to a risk increase of 23% (Z = 2.35, p = 0.019). When pooled estimates were derived independently for low-and high-CV risk populations, baseline PCSK9 levels predicted total CV events only in apparently healthy subjects (RR = 1.13, 95% CI: 1.050-1.222, Z = 3.21, p = 0.001) and not in populations with established CV or renal disease (RR = 1.09, 95% CI: 0.961-1.23, Z = 1.33, p = 0.182). Conclusions: PCSK9 levels are modestly but significantly associated with increased risk of total CV events. These results suggest a predictive role of PCSK9 levels on CV health and support the possible clinical role of PCSK9 inhibitors. (C) 2016 Elsevier Ireland Ltd. All rights reserved

Female gender is independently associated with increased carotid temperatures in patients with coronary artery disease

Background : Limited are the data regarding the sex differences in functional carotid artery characteristics. Microwave Radiometry (MWR) is a new noninvasive method, which measures in vivo instantly the internal temperatures of tissues, reflecting inflammation. The aim of the present study was to investigate whether in patients with coronary artery disease (CAD), gender related differences apply in carotid plaque functional characteristics, as assessed by MWR. Methods : Consecutive patients with significant CAD were included in the study. All patients underwent evaluation of both carotid arteries by 1) ultrasound and 2) MWR. During ultrasound common carotid IMT and plaque thickness were assessed according to Mannheim consensus. During MWR measurements, temperature difference (ΔT) was assigned as maximal temperature along the carotid artery minus minimum. ΔT ≥ 0.90 °C was assigned as high ΔT. Results : In total 364 patients with significant CAD were included in the study. Of these 54 were female and 310 were male. Max plaque thickness and ccIMT were similar between males and females (2.38 ± 1.16 vs. 2.46 ± 1.12 mm, p = 0.63 and 0.944 ± 0.172 vs. 0.942 ± 0.169 mm, p = 0.96). Carotid arteries of females showed higher ΔT values (1.16 ± 0.48 vs 0.87 ± 0.45 °C, p < 0.001). Interestingly, females had more commonly high ΔT values bilaterally (35.2% vs 15.5%, p = 0.001). In multivariate analysis, female sex was independently associated with bilateral high ΔT, when adjusted to potential covariates (OR = 2.78, 95% CI = 1.42–5.45, p = 0.003). Conclusions : In patients with CAD, sex specific differences apply in functional but not in structural carotid artery characteristics. Whether this discrepancy has prognostic significance, remains to be clarified in future studies

Carotid Artery Temperature Reduction with Statin Therapy in Patients with Familial Hyperlipidemia Syndromes

Background: Microwave radiometry (MWR) assesses non-invasive carotid artery temperatures reflecting inflammation. In the present study, we aimed to investigate the impact of hypolipidemic therapy either with simvastatin or with combination simvastatin plus ezetimibe on carotid artery temperatures of patients with familial hyperlipidemia syndromes (FHS). Methods: Consecutive patients with diagnosis of either familial heterozygous hypercholesterolemia (heFH) or familial combined hyperlipidemia (FCH) were included in the study. Patients were assigned to either simvastatin 40 mg or simvastatin 40 mg plus ezetimibe 10 mg, according to the discretion of the physician. FHS patients who refused statin therapy were used as a control group. Common carotid intima-media thickness (ccIMT) was measured and ΔΤ (maximum-minimum) temperature measurements were performed across each carotid during MWR evaluation. RESULTS: In total, 115 patients were included in the study. Of them, 40 patients received simvastatin (19 heFH and 21 FCH), 41 simvastatin + ezetimibe (31 heFH and 10 FCH), and 34 (21 heFH and 13 FCH) no statin. Carotid artery temperatures were significantly reduced at 6 months in FH patients who received hypolipidemic treatment (0.83 ± 0.34 versus 0.63 ± 0.24 °C, p = 0.004 for simvastatin, 1.00 ± 0.38 versus 0.69 ± 0.23 °C, p &lt; 0.001 for simvastatin + ezetimibe), but no change was recorded in controls (0.72 ± 0.26 versus 0.70 ± 0.26 °C, p = 0.86). Conclusions: Hypolipidemic therapy reduced carotid temperatures in FHS patients