In recent years attention has been raised to the fact of increased morbidity and mortality between women who suffer from coronary disease. The identification of the so called Yentl Syndrome has emerged the deeper investigation of the true incidence of coronary disease in women and its outcomes. In this review an effort has been undertaken to understand the interaction of coronary disease and female gender after the implementation of newer therapeutic interventional and pharmaceutics’ approaches of the modern era.
Yentl syndrome; Women coronary disease; Acute coronary syndromes; Female gender; Invasive treatment
The present study attempts to offer insight into the volume, cost, and productivity of the operation of a cardiac echocardiographic laboratory (echo-lab) in a major public hospital of Greece and thus to contribute, on a practical level, to the widening of knowledge in the strategic field of secondary and tertiary healthcare management. The conducted research includes the basic step of the deployment of a primary data registry in the echo-lab and unfolds in three levels, i.e. the variability measurement of the quantity and cost of medical services provided to different patient populations, the assessment of operating costs and the development of productivity indexes. The results show that the mean costs of provision do change among distinct patient populations. The most important, from a financial standpoint, population cluster appears to be the one corresponding to outpatients. Productivity indices presented in this analysis constitute an essential piece of information which the public healthcare system is currently largely lacking, and which, combined with the pricing and the diagnosis-related group coding system of hospitals, can be used to improve efficiency in the management of secondary and tertiary care.
Health economics; Greece; Echocardiography; Cost-effectiveness
Restless Legs Syndrome (RLS) is a sensory-motor neurological disorder that appears to be surprisingly common in the community. Periodic limb movements in sleep are typically encountered in more than 80% of RLS patients and comprise involuntary muscular jerks in the lower limbs, such as flexion of the knees or ankles. Iron deficiency and dopaminergic neuronal dysfunction in the central nervous system are currently thought to be the likely pathophysiological culprits. There is evidence linking RLS to hypertension and cardiovascular disease. This short review will first present a synopsis of epidemiological, clinical, and pathophysiological data concerning the syndrome, and then information on the possible links between RLS and cardiovascular disorders
Cardiovascular Diseases; Restless Legs Syndrome; Hypertension; Dopamine; Stroke; Coronary Artery Disease
Background The extent to which adult height, a biomarker of the interplay of genetic endowment and early-life experiences, is related to risk of chronic diseases in adulthood is uncertain.
Methods We calculated hazard ratios (HRs) for height, assessed in increments of 6.5 cm, using individual–participant data on 174 374 deaths or major non-fatal vascular outcomes recorded among 1 085 949 people in 121 prospective studies.
Results For people born between 1900 and 1960, mean adult height increased 0.5–1 cm with each successive decade of birth. After adjustment for age, sex, smoking and year of birth, HRs per 6.5 cm greater height were 0.97 (95% confidence interval: 0.96–0.99) for death from any cause, 0.94 (0.93–0.96) for death from vascular causes, 1.04 (1.03–1.06) for death from cancer and 0.92 (0.90–0.94) for death from other causes. Height was negatively associated with death from coronary disease, stroke subtypes, heart failure, stomach and oral cancers, chronic obstructive pulmonary disease, mental disorders, liver disease and external causes. In contrast, height was positively associated with death from ruptured aortic aneurysm, pulmonary embolism, melanoma and cancers of the pancreas, endocrine and nervous systems, ovary, breast, prostate, colorectum, blood and lung. HRs per 6.5 cm greater height ranged from 1.26 (1.12–1.42) for risk of melanoma death to 0.84 (0.80–0.89) for risk of death from chronic obstructive pulmonary disease. HRs were not appreciably altered after further adjustment for adiposity, blood pressure, lipids, inflammation biomarkers, diabetes mellitus, alcohol consumption or socio-economic indicators.
Conclusion Adult height has directionally opposing relationships with risk of death from several different major causes of chronic diseases.
Height; cardiovascular disease; cancer; cause-specific mortality; epidemiological study; meta-analysis
Pseudoexfoliation syndrome is a primarily ophthalmological disorder caused by deposition of whitish-gray protein on the lens, iris, and multiple other eye tissues. There is increasing evidence over the previous years that pseudoexfoliation syndrome is a systemic disorder with various extraocular manifestations and has recently been linked to several cardiovascular disorders. The present article aims to summarize the current knowledge on cardiovascular implications of this well-described clinical entity.
Cardiovascular; Coronary disease; Pseudoexfoliation syndrome
The tricuspid valve (TV) is inseparably connected with the mitral valve (MV) in terms of function. Any pathophysiological condition concerning the MV is potentially a threat for the normal function of the TV as well. One of the most challenging cases is functional tricuspid regurgitation (TR) after surgical MV correction. In the past, TR was considered to progressively revert with time after left-sided valve restoration. Nevertheless, more recent studies showed that TR could develop and evolve postoperatively over time, as well as being closely associated with a poorer prognosis in terms of morbidity and mortality. Pressure and volume overload are usually the underlying pathophysiological mechanisms; structural alterations, like tricuspid annulus dilatation, increased leaflet tethering and right ventricular remodelling are almost always present when regurgitation develops. The most important risk factors associated with a higher probability of late TR development involve the elderly, female gender, larger left atrial size, atrial fibrillation, right chamber dilatation, higher pulmonary artery systolic pressures, longer times from the onset of MV disease to surgery, history of rheumatic heart disease, ischaemic heart disease and prosthetic valve malfunction. The time of TR manifestation can be up to 10 years or more after an MV surgery. Echocardiography, including the novel 3D Echo techniques, is crucial in the early diagnosis and prognosis of future TV disease development. Appropriate surgical technique and timing still need to be clarified.
Functional tricuspid regurgitation; Mitral valve surgery
A diseased heart causes numerous adverse effects on kidney function, and vice versa renal disease can significantly impair cardiac function. Beyond these heart-kidney interrelationships at the clinical level, a reciprocal association has been suggested to exist even in the early stages of those organs' dysfunction. The aim of the present review is to provide evidence of the presence of a preclinical cardiorenal syndrome in the particular setting of essential hypertension, focusing on the subsequent hypertensive sequelae on heart and kidneys. In particular, a plethora of studies have demonstrated not only the predictive role of kidney damage, as expressed by either decreased glomerular filtration or increased urine albumin excretion, for adverse left ventricular functional and structural adaptations but also preclinical heart disease, i.e. left ventricular hypertrophy that is associated with deterioration of renal function. Notably, these reciprocal interactions seem to exist even at the level of microcirculation, since both coronary flow reserve and renal hemodynamics are strongly related with clinical and preclinical renal and cardiac damage, respectively. In this preclinical setting, common pathophysiological denominators, including the increased hemodynamic load, sympathetic and renin-angiotensin system overactivity, increased subclinical inflammatory reaction, and endothelial dysfunction, account not only for the reported associations between overt cardiac and renal damage but also for the parallel changes that occur in coronary and renal microcirculation.
Cardiorenal syndrome; Hypertension; Preclinical organ damage
A 65 year old man was transferred to our cath lab for primary PCI about two hours after the onset of pain in the context of acute, anterior myocardial infarction. Thrombus aspiration of the proximal LAD and balloon angioplasty with a DES implantation were performed. After a few days, although the patient was under treatment with unfractioned heparin, he sustained a transient ischemic attack. The echocardiographic study revealed a large, mobile, protruding thrombus in the apex. Four days later, the patient complained of mild abdominal pain with a gradual deterioration. Abdominal CT scan revealed embolism of the superior mesenteric artery and urgent embolectomy was scheduled.
Primary angioplasty; left ventricular thrombus; embolism; thrombophilia
Atherosclerosis and its consequences are the most rapidly growing vascular pathology, with myocardial infarction and ischemic cerebrovascular accident to remain a major cause of premature morbidity and death. In order to detect the morphological and functional characteristics of the vulnerable plaques, new imaging modalities have been developed. Intravascular thermography (IVT) is an invasive method, which provides information on the identification of the high-risk atheromatic plaques in coronary arteries. However, the invasive character of IVT excludes the method from primary prevention. Microwave radiometry (MR) is a new non-invasive method, which detects with high accuracy relative changes of temperature in human tissues whereas this thermal heterogeneity is indicative of inflammatory atherosclerotic plaque. Both experimental and clinical studies have proved the effectiveness of MR in detecting vulnerable plaque whereas recent studies have also revealed its association with plaque neoangiogenesis as assessed by contrast enhanced carotid ultrasound (CEUS).
Microwave radiometry (MR); intravascular thermography (IVT), neoangiogenesis; vulnerable plaque
There is strong evidence that left atrial (LA) size is a prognostic marker in a variety of heart diseases. Recently, real-time three-dimensional echocardiography (RT3DE) has been reported as a useful tool for studying the phasic changes of the left atrial volumes. The aim of this study was to investigate the performance of the left atrium in beta-thalassemic patients with preserved left ventricular ejection fraction (EF) and no iron overload, using RT3DE.
Twenty-eight asymptomatic b-thalassemic patients (32.2 ± 4.3 years old, 17 men) who were on iron chelating therapy, as well as 20 age- and sex-matched healthy controls underwent transthoracic RT3DE. The patient group had normal echocardiographic systolic and diastolic indices, while there was no myocardial iron disposition according to MRI. Apical full volume data sets were obtained and LA volumes were measured at 3 time points of the cardiac cycle: (1) maximum volume (LAmax) at end-systole, just before mitral valve opening; (2) minimum volume (LAmin) at end-diastole, just before mitral valve closure; and (3) volume before atrial active contraction (LApreA) obtained from the last frame before mitral valve reopening or at time of the P wave on the surface electrocardiogram. From the derived values, left atrial active and passive emptying volumes, as well as the respective emptying fractions were calculated.
Left ventricular EF (59.2 ± 2.5% patients vs. 60.1 ± 2.1% controls), E/A, E/E' were similar between the two groups. Differences in the LAmax, LAmin and LApreA between b-thalassemic patients and controls were non-significant, LAmax:(35.5 ± 13.4 vs 31.8 ± 9.8)cm3, LAmin:(16.0 ± 6.0 vs. 13.5 ±4.2)cm3, and LApreA:(25.4 ± 9.8 vs. 24.3 ± 7.2)cm3. However, left atrial active emptying fraction was reduced in the patient group as compared to the healthy population (34.3 ± 16.4% vs. 43.2 ± 11.4%, p < 0.05).
RT3DE may be a novel technique for the evaluation of LA function in asymptomatic patients with b-Thalassemia Major. Among three-dimensional volumes and indices, left atrial active emptying fraction may be an early index of LA dysfunction in the specific patient population.
Real-time 3D echocardiography; b-Thalassemia major; left atrial function
The importance of diabetes in the epidemiology of cardiovascular diseases cannot be overemphasized. About one third of acute myocardial infarction patients have diabetes, and its prevalence is steadily increasing. The decrease in cardiac mortality in people with diabetes is lagging behind that of the general population. Cardiovascular disease is a broad term which includes any condition causing pathological changes in blood vessels, cardiac muscle or valves, and cardiac rhythm. The ECG offers a quick, noninvasive clinical and research screen for the early detection of cardiovascular disease in diabetes. In this paper, the clinical and research value of the ECG is readdressed in diabetes and in the presence of cardiac autonomic neuropathy.
Periodontitis is a bacterially-induced, localized chronic inflammatory disease destroying both the connective tissue and the supporting bone of the teeth. In the general population, severe forms of the disease demonstrate a prevalence of almost 5%, whereas initial epidemiological evidence suggests an association between periodontitis and coronary artery disease (CAD). Both the infectious nature of periodontitis and the yet etiologically unconfirmed infectious hypothesis of CAD, question their potential association. Ephemeral bacteremia, systemic inflammation and immune-pathological reactions constitute a triad of mechanisms supporting a cross-talk between periodontal and vascular damage. To which extent each of these periodontitis-mediated components contribute to vascular damage still remains uncertain. More than twenty years from the initial epidemiological association, the positive weight of evidence remains still alive but rather debated, because of both the presence of many uncontrolled confounding factors and the different assessment of periodontal disease. From the clinical point of view, advising periodontal prevention or treatment targeting on the prevention of CAD it is unjustified. By contrast, oral hygiene including periodontal health might contribute to the overall well-being and healthy lifestyle and hence as might at least partially contribute to cardiovascular prevention.
Periodontitis; periodontal disease; coronary artery disease; prevention; bacteremia; atherosclerosis
Aims. We evaluated the interaction effect between depressive symptoms and dietary habits on 30-day development of cardiovascular disease (CVD) (death or rehospitalization) in elderly, acute coronary syndrome (ACS) survivors. Methods. During 2006–2008, we recorded 277 nonfatal, consecutive ACS admissions (75 ± 6 years, 70% males, 70% had diagnosis of myocardial infarction) with complete 30-day follow-up. Assessment of recent depressive symptoms was based on the CES-D scale. Among sociodemographic, bioclinical, lifestyle characteristics, the MedDietScore that assesses the inherent characteristics of the Mediterranean diet was applied. Results. 22% of the ACS pts developed a CVD event during the first 30 days (14.8% rehospitalization and 9.4% death). Patients in the upper tertile of the CES-D scale (i.e., >18) had higher incidence of CVD events as compared with those in the lowest tertile (21% versus 8%, P = .01). Multiple logistic regression analysis revealed that 1-unit increase in CES-D was associated with 4% higher odds (95% CI 1.008–1.076, P = .01) of CVD events; however, when MedDietScore was entered in the model, CES-D lost its significance (P = .20). Conclusion. Short-term depressive symptoms are related to a worsen 30-day prognosis of ACS patients; however, this relationship was mediated by Mediterranean diet adherence.
Increased vascular calcification and tortuosity are rather common in end-stage renal failure patients who are on hemodialysis. It renders manipulation of catheters and performance of percutaneous transluminal interventions more difficult than expected. Such vascular alterations may be evident in large veins and pose significant difficulties in placement of pacing leads as shown in our case. To overcome such difficulties, we demonstrated in this patient case that long guiding catheters may be of particular value.
ABPM constitutes a valuable tool in the diagnosis of RH. The identification of white coat RH and masked hypertension (which may fulfill or not the definition of RH) is of great importance in the clinical management of such patients. Moreover, the various ABPM components such as average BP values, circadian BP variability patterns, and ambulatory BP-derived indices, such as ambulatory arterial stiffness index (AASI), add significantly to the risk stratification of RH. Lastly, ABPM may indicate the need for implementation of specific therapeutic strategies, such as chronotherapy, that is, administration-time dependent therapy, and the evaluation of their efficacy.
Background. There are places around the world where people live longer and they are active past the age of 100 years, sharing common behavioral characteristics; these places (i.e., Sardinia in Italy, Okinawa in Japan, Loma Linda in California and Nicoya Peninsula in Costa Rica) have been named the “Blue Zones”. Recently it was reported that people in Ikaria Island, Greece, have also one of the highest life expectancies in the world, and joined the “Blue Zones”. The aim of this work work was to evaluate various demographic, lifestyle and psychological characteristics of very old (>80 years) people participated in Ikaria Study. Methods. During 2009, 1420 people (aged 30+) men and women from Ikaria Island, Greece, were voluntarily enrolled in the study. For this work, 89 males and 98 females over the age of 80 yrs were studied (13% of the sample). Socio-demographic, clinical, psychological and lifestyle characteristics were assessed using standard questionnaires and procedures. Results. A large proportion of the Ikaria Study's sample was over the age of 80; moreover, the percent of people over 90 were much higher than the European population average. The majority of the oldest old participants reported daily physical activities, healthy eating habits, avoidance of smoking, frequent socializing, mid-day naps and extremely low rates of depression. Conclusion. Modifiable risk factors, such as physical activity, diet, smoking cessation and mid-day naps, might depict the “secrets” of the long-livers; these findings suggest that the interaction of environmental, behavioral together with clinical characteristics may determine longevity. This concept must be further explored in order to understand how these factors relate and which are the most important in shaping prolonged life.
To evaluate arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D) in affected families with desmosome mutations on the basis of the recently revised Task Force Criteria (TFC).
Methods and results
One hundred and three consecutive carriers of pathogenic desmosome mutations and 102 mutation-negative relatives belonging to 22 families with dominant and 14 families with recessive ARVC/D were evaluated according to the original and revised TFC. Serial cardiac assessment with 12-lead, signal-averaged, and 24 h ambulatory ECG and two-dimensional echocardiography was performed. Clinical events and outcome were prospectively analysed up to 24 years (median 4 years). With the revised criteria, 16 carriers were newly diagnosed on the basis of ECG abnormalities in 100%, ventricular arrhythmias in 79%, and functional/structural alterations in 31%, increasing diagnostic sensitivity from 57 to 71% (P = 0.001). Task Force Criteria specificity improved from 92 to 99% (P = 0.016). In dominant mutation carriers, penetrance changed significantly (61 vs. 42%, P = 0.001); no changes were observed in recessive homozygous carriers (97 vs. 97%, P = 1.00). Affected carriers according to the revised TFC (n = 73) had 12-lead ECG abnormalities in 96%, ventricular arrhythmias in 91%, and functional/structural alterations fulfilling echocardiographic criteria in 76%. Cumulative and event-free survival did not differ significantly between dominant and recessive affected carriers, being at 78.6 vs. 76 and 51.7 vs. 55.4%, respectively, by the age of 40 years.
Revised TFC increased diagnostic sensitivity particularly in dominant ARVC/D. Serial family evaluation may rely on electrocardiography which seems to have the best diagnostic utility particularly in early disease that is not detectable by two-dimensional echocardiography.
Cardiomyopathy; Arrhythmogenic right ventricular cardiomyopathy/dysplasia; Diagnostic criteria; Desmosome mutations
Resistant hypertension (RH) is a powerful risk factor for cardiovascular morbidity and mortality. Among the characteristics of patients with RH, obesity, obstructive sleep apnea, and aldosterone excess are covering a great area of the mosaic of RH phenotype. Increased sympathetic nervous system (SNS) activity is present in all these underlying conditions, supporting its crucial role in the pathophysiology of antihypertensive treatment resistance. Current clinical and experimental knowledge points towards an impact of several factors on SNS activation, namely, insulin resistance, adipokines, endothelial dysfunction, cyclic intermittent hypoxaemia, aldosterone effects on central nervous system, chemoreceptors, and baroreceptors dysregulation. The further investigation and understanding of the mechanisms leading to SNS activation could reveal novel therapeutic targets and expand our treatment options in the challenging management of RH.
Background. The aim was to examine the association of depressive symptoms with fish eating habits, in elderly individuals. Methods. From June to October of 2009, we studied 330 men and 343 women, aged 65 to 100 years, permanent inhabitants of Ikaria Island. Among several characteristics, depression was assessed with the Geriatric Depression scale (GDS range 0–15), while dietary habits through a valid semiquantitative food frequency questionnaire. Results. Women had significantly higher values of the GDS compared to men (4.8 ± 3.5 versus 3.3 ± 3.1, P = .001). Participants in the upper tertile of depression scale ate less frequent fish and consumed higher quantities of alcohol, compared to those in the lowest tertile (all P < .05). Regarding fish consumption, 50% of the individuals reported consuming 1-2 times weekly, 32% 3 to 5 times weekly, 11% 2-3 times monthly, while the rest reported rare (4.5%) and everyday (1.2%) consumption. Logistic regression showed that increased fish consumption (>3 times/week versus never/rare) was inversely associated with the odds of having GDS greater the median value (i.e., 4) (odds ratio = 0.34, 95% CI: 0.19, 0.61), after controlling for several cofounders. Conclusion. Frequent fish consumption in elderly seems to moderate depression mood.
Objectives. Mitral valve prolapse (MVP) is a known cause for false positive exercise test (ET). The purpose of this study was to establish additional electrocardiographic criteria to distinguish the false positive exercise results in patients with MVP. Methods. We studied 218 consecutive patients (53 ± 6 years, 103 males) with MVP (according to echocardiographic study), and positive treadmill ET was performed due to multiple cardiovascular risk factors or angina-like symptoms. A coronary angiography was performed to detect coronary artery disease (CAD). Results. From 218 patients, 90 (group A) presented with normal coronary arteries according to the angiography (false positive ET) while the rest 128 (group B) presented with CAD. ST-segment depression in hyperventilation phase was present in 54 patients of group A (60%) while only in 14 patients of group B (11%), P < .05. Conclusions. Presence of ST-segment depression in hyperventilation phase favors a false positive ET in patients with MVP.
Recent immunohistochemical studies observed the loss of plakoglobin (PG) from the intercalated disc (ID) as a hallmark of arrhythmogenic right ventricular cardiomyopathy (ARVC), suggesting a final common pathway for this disease. However, the underlying molecular processes are poorly understood.
Methods and results
We have identified novel mutations in the desmosomal cadherin desmocollin 2 (DSC2 R203C, L229X, T275M, and G371fsX378). The two missense mutations (DSC2 R203C and T275M) have been functionally characterized, together with a previously reported frameshift variant (DSC2 A897fsX900), to examine their pathogenic potential towards PG's functions at the ID. The three mutant proteins were transiently expressed in various cellular systems and assayed for expression, processing, localization, and binding to other desmosomal components in comparison to wild-type DSC2a protein. The two missense mutations showed defects in proteolytic cleavage, a process which is required for the functional activation of mature cadherins. In both cases, this is thought to cause a reduction of functional DSC2 at the desmosomes in cardiac cells. In contrast, the frameshift variant was incorporated into cardiac desmosomes; however, it showed reduced binding to PG.
Despite different modes of action, for all three variants, the reduced ability to provide a ligand for PG at the desmosomes was observed. This is in agreement with the reduced intensity of PG at these structures observed in ARVC patients.
Arrhythmogenic right ventricular cardiomyopathy; Desmocollin-2; Desmosome; Functional studies; Mutation
We studied the association of physical activity and adherence to the Mediterranean diet, in total antioxidant capacity (TAC). A random sample of 1514 men and 1528 women was selected from Attica region. Physical activity was assessed with a translated version of the validated “International Physical Activity Questionnaire” (iPAQ), and dietary intake through a validated Food Frequency Questionnaire (FFQ). Adherence to the Mediterranean diet was assessed by the MedDietScore that incorporated the inherent characteristics of this diet. TAC was positively correlated with the degree of physical activity (P < .05). TAC was also positively correlated with MedDietScore (r = 0.24, P < .001). Stratified analysis by diet status revealed that the most beneficial results were observed to highly active people as compared to inactive, who also followed the Mediterranean diet (288 ± 70 μmol/L, 230 ± 50 μmol/L, resp.), after adjusting for various confounders. Increased physical activity and greater adherence to the Mediterranean diet were associated with increased total antioxidant capacity.
Carcinoid is a rare malignancy originating from enterochromaffin cells and is clinically characterized by flushing, diarrhea and bronchospasm, due to secretion of vasoactive substances. A dreaded complication is carcinoid heart disease, which mainly affects right cardiac chambers, resulting in thickened, immobile and retracted tricuspid and pulmonary valves. In the current report, a case of a 60-year old female presenting with symptoms of right heart failure is described. Transthoracic two-dimensional and real-time three-dimensional echocardiography findings, as well as biochemical markers, including pro-BNP and NT-pro-BNP, were consistent with carcinoid syndrome. The histological diagnosis of carcinoid was confirmed after surgical resection of an ovarian mass.