Journal of the American Heart Association, Jan 5, 2017
The independent prognostic impact of diabetes mellitus (DM) and prediabetes mellitus (pre-DM) on ... more The independent prognostic impact of diabetes mellitus (DM) and prediabetes mellitus (pre-DM) on survival outcomes in patients with chronic heart failure has been investigated in observational registries and randomized, clinical trials, but the results have been often inconclusive or conflicting. We examined the independent prognostic impact of DM and pre-DM on survival outcomes in the GISSI-HF (Gruppo Italiano per lo Studio della Sopravvivenza nella Insufficienza Cardiaca-Heart Failure) trial. We assessed the risk of all-cause death and the composite of all-cause death or cardiovascular hospitalization over a median follow-up period of 3.9 years among the 6935 chronic heart failure participants of the GISSI-HF trial, who were stratified by presence of DM (n=2852), pre-DM (n=2013), and non-DM (n=2070) at baseline. Compared with non-DM patients, those with DM had remarkably higher incidence rates of all-cause death (34.5% versus 24.6%) and the composite end point (63.6% versus 54.7%)...
The case of a non diabetic 6-year-old boy affected by Down's syndrome, who developed hyperosmolar... more The case of a non diabetic 6-year-old boy affected by Down's syndrome, who developed hyperosmolar hyperglycemic non-ketotic coma following the infusion of hypertonic dextrose solution during general anesthesia for a surgical procedure for cryptorchidism is reported. Following surgery, the patient remained deeply comatose and generalized seizures occurred. Hyperosmolarity due to hyperglycemia and acidosis were reduced by administration of insulin at low rate, hypotonic saline and sodium-bicarbonate solutions. The patient's clinical conditions promptly improved following normalization of blood glucose levels. An oral glucose tolerance test performed three months later was normal. The authors emphasize the potential risk of hyperosmolar hyperglycemic non-ketotic coma also in non diabetic patients treated with hypertonic dextrose solutions, during surgery events.
Recent research indicates that the level of left ventricular (LV) mass, commonly measured by echo... more Recent research indicates that the level of left ventricular (LV) mass, commonly measured by echocardiography, reflects the combined effects of a variety of factors involved in the pathophysiology of hypertension, including obesity, blood pressure responses to everyday activity, high sodium intake and blood viscosity, the volume work load of the heart, and genetic factors predisposing to hypertension. Prospective studies indicate that LV mass is a stronger predictor of subsequent morbid events and death than blood pressure or other conventional risk factors except age. Preliminary findings of close relations between LV mass and arterial disease and between the change in LV mass during antihypertensive treatment and subsequent events contribute to explaining the strong predictive value of LV mass. Further research is needed to clarify the biologic basis of these observations and to determine whether stratification of hypertensive patients based on their level of LV mass can improve the treatment of hypertension.
Objective: To provide a coherent overview of the stimuli to development of abnormal left ventricu... more Objective: To provide a coherent overview of the stimuli to development of abnormal left ventricular geometric patterns, their impact on cardiac function and their relationship to the prognosis of hypertension, studies performed by the authors and other investigators are reviewed. Results: Clinical and experimental studies have shown that an elevated left ventricular mass reflects the additive effects on the heart of higher arterial pressure over time, increased cardiac volume load related to obesity, sodium intake or other stimuli, reduced contractile efficiency of the myocardium and altered arterial hemodynamics related to vascular hypertrophy and atherosclerosis. The heart may adapt to hypertension by developing concentric or eccentric left ventricular hypertrophy, or the newly described pattern of concentric left ventricular remodeling, or by retaining normal left ventricular geometry. Each geometric pattern is associated with a distinct combination of pressure and volume stimuli, contractile efficiency (reduced in those with concentric left ventricular hypertrophy or remodeling) and prognosis (worst with concentric hypertrophy and best with normal left ventricular geometry). An appraisal of left ventricular mechanics by a physiologically appropriate midwall-shortening/end-systolic stress relationship can identify impaired contractility in an appreciable proportion of hypertensive patients. Numerous studies have shown that increased left ventricular mass and abnormal geometry have a strong predictive value for cardiovascular death, myocardial infarction and stroke. Conclusions: Increasing evidence has demonstrated the central importance of left ventricular mass and geometry in the pathophysiology and prognosis of hypertension. These measures of preclinical disease can aid clinical decision-making by separating patients into those with a high or a relatively low risk, and hence a need for pharmacological treatment or its intensification, as well as providing useful bioassays for a spectrum of clinical and experimental research.
Echocardiographic meridional wall stress-endocardial shortening relations provide estimates of le... more Echocardiographic meridional wall stress-endocardial shortening relations provide estimates of left ventricular (LV) contractility that do not uniformly detect myocardial dysfunction despite severe symptoms in dilated cardiomyopathy. To improve detection of myocardial dysfunction in patients with congestive heart failure (CHF) due to dilated cardiomyopathy, echocardiographic meridional and circumferential end-systolic stress were related to endocardial and midwall shortening in 42 patients (95% dead within a mean of 22 months) with dilated cardiomyopathy and 140 normal subjects. A method to estimate LV long-axis dimension from M-mode minor-axis epicardial measurements was developed in a separate series of 115 subjects. Endocardial shortening to meridional wall stress relation identified 31 of 42 CHF patients falling below the 95% normal confidence interval of the reference population; use of midwall shortening decreased this number to 26 (p = NS). The use of circumferential wall stress identified 39 of 42 patients with subnormal endocardial LV shortening and 41 of 42 patients with depressed midwall performance (p < 0.01 vs use of meridional stress). The circumferential/meridional wall stress ratio was 2.6 +/- 0.5 in normal subjects and 1.3 +/- 0.2 in CHF patients (p < 0.0001). Thus, use of circumferential end-systolic stress as the measure of afterload improves the detection of myocardial dysfunction by stress/shortening relations in patients with CHF. The ratio between the 2 stresses decreases with more spherical LV shape. Midwall and endocardial shortening measurements are equivalent in the setting of thin LV walls as occurs in dilated cardiomyopathy.
The appropriateness of left ventricular (LV) mass to cardiac workload may be calculated by the ra... more The appropriateness of left ventricular (LV) mass to cardiac workload may be calculated by the ratio of observed LV mass to the value predicted for an individual's sex, height, and stroke work at rest. To investigate test-retest reproducibility of observed/predicted LV mass in a single patient. We measured intraclass correlation and interval of agreement between two M-mode tracings, recorded both at the same session and 3-10 days apart in 200 participants (45 +/- 13 years, body mass index 25 +/- 4 kg/m; 99 hypertensive and 101 normotensive; 50% of each group were women) in 16 centres in Italy. Tracings were read by two observers in each centre. The values of observed/predicted LV mass value ranged from 40.78 to 215.50%. On the same day, the within-observer 90% interval of agreement between tracings 1 and 2 was -23 to +20%. For day-to-day test-retest within-observer variability (average three cycles), the 90% interval of agreement of the observed/predicted LV mass was -30 to +32%. The 90% interval of agreement of test-retest between-observer variability was -25 to +25%. The categorical consistency of retest in the identification of subjects with appropriate LV mass, classified in the first study (i.e. > 73% and < 128%), was 90% (k = 0.87). Measurement of the appropriateness of LV mass in single patients allows acceptable risk stratification, with a coefficient of consistency similar to that reported for LV mass. The probability of a true change (90% chance) in observed/predicted LV mass over time is maximized for a single-reader difference greater than 22%, although lesser differences might also have clinical relevance.
Journal of the American Heart Association, Jan 5, 2017
The independent prognostic impact of diabetes mellitus (DM) and prediabetes mellitus (pre-DM) on ... more The independent prognostic impact of diabetes mellitus (DM) and prediabetes mellitus (pre-DM) on survival outcomes in patients with chronic heart failure has been investigated in observational registries and randomized, clinical trials, but the results have been often inconclusive or conflicting. We examined the independent prognostic impact of DM and pre-DM on survival outcomes in the GISSI-HF (Gruppo Italiano per lo Studio della Sopravvivenza nella Insufficienza Cardiaca-Heart Failure) trial. We assessed the risk of all-cause death and the composite of all-cause death or cardiovascular hospitalization over a median follow-up period of 3.9 years among the 6935 chronic heart failure participants of the GISSI-HF trial, who were stratified by presence of DM (n=2852), pre-DM (n=2013), and non-DM (n=2070) at baseline. Compared with non-DM patients, those with DM had remarkably higher incidence rates of all-cause death (34.5% versus 24.6%) and the composite end point (63.6% versus 54.7%)...
The case of a non diabetic 6-year-old boy affected by Down's syndrome, who developed hyperosmolar... more The case of a non diabetic 6-year-old boy affected by Down's syndrome, who developed hyperosmolar hyperglycemic non-ketotic coma following the infusion of hypertonic dextrose solution during general anesthesia for a surgical procedure for cryptorchidism is reported. Following surgery, the patient remained deeply comatose and generalized seizures occurred. Hyperosmolarity due to hyperglycemia and acidosis were reduced by administration of insulin at low rate, hypotonic saline and sodium-bicarbonate solutions. The patient's clinical conditions promptly improved following normalization of blood glucose levels. An oral glucose tolerance test performed three months later was normal. The authors emphasize the potential risk of hyperosmolar hyperglycemic non-ketotic coma also in non diabetic patients treated with hypertonic dextrose solutions, during surgery events.
Recent research indicates that the level of left ventricular (LV) mass, commonly measured by echo... more Recent research indicates that the level of left ventricular (LV) mass, commonly measured by echocardiography, reflects the combined effects of a variety of factors involved in the pathophysiology of hypertension, including obesity, blood pressure responses to everyday activity, high sodium intake and blood viscosity, the volume work load of the heart, and genetic factors predisposing to hypertension. Prospective studies indicate that LV mass is a stronger predictor of subsequent morbid events and death than blood pressure or other conventional risk factors except age. Preliminary findings of close relations between LV mass and arterial disease and between the change in LV mass during antihypertensive treatment and subsequent events contribute to explaining the strong predictive value of LV mass. Further research is needed to clarify the biologic basis of these observations and to determine whether stratification of hypertensive patients based on their level of LV mass can improve the treatment of hypertension.
Objective: To provide a coherent overview of the stimuli to development of abnormal left ventricu... more Objective: To provide a coherent overview of the stimuli to development of abnormal left ventricular geometric patterns, their impact on cardiac function and their relationship to the prognosis of hypertension, studies performed by the authors and other investigators are reviewed. Results: Clinical and experimental studies have shown that an elevated left ventricular mass reflects the additive effects on the heart of higher arterial pressure over time, increased cardiac volume load related to obesity, sodium intake or other stimuli, reduced contractile efficiency of the myocardium and altered arterial hemodynamics related to vascular hypertrophy and atherosclerosis. The heart may adapt to hypertension by developing concentric or eccentric left ventricular hypertrophy, or the newly described pattern of concentric left ventricular remodeling, or by retaining normal left ventricular geometry. Each geometric pattern is associated with a distinct combination of pressure and volume stimuli, contractile efficiency (reduced in those with concentric left ventricular hypertrophy or remodeling) and prognosis (worst with concentric hypertrophy and best with normal left ventricular geometry). An appraisal of left ventricular mechanics by a physiologically appropriate midwall-shortening/end-systolic stress relationship can identify impaired contractility in an appreciable proportion of hypertensive patients. Numerous studies have shown that increased left ventricular mass and abnormal geometry have a strong predictive value for cardiovascular death, myocardial infarction and stroke. Conclusions: Increasing evidence has demonstrated the central importance of left ventricular mass and geometry in the pathophysiology and prognosis of hypertension. These measures of preclinical disease can aid clinical decision-making by separating patients into those with a high or a relatively low risk, and hence a need for pharmacological treatment or its intensification, as well as providing useful bioassays for a spectrum of clinical and experimental research.
Echocardiographic meridional wall stress-endocardial shortening relations provide estimates of le... more Echocardiographic meridional wall stress-endocardial shortening relations provide estimates of left ventricular (LV) contractility that do not uniformly detect myocardial dysfunction despite severe symptoms in dilated cardiomyopathy. To improve detection of myocardial dysfunction in patients with congestive heart failure (CHF) due to dilated cardiomyopathy, echocardiographic meridional and circumferential end-systolic stress were related to endocardial and midwall shortening in 42 patients (95% dead within a mean of 22 months) with dilated cardiomyopathy and 140 normal subjects. A method to estimate LV long-axis dimension from M-mode minor-axis epicardial measurements was developed in a separate series of 115 subjects. Endocardial shortening to meridional wall stress relation identified 31 of 42 CHF patients falling below the 95% normal confidence interval of the reference population; use of midwall shortening decreased this number to 26 (p = NS). The use of circumferential wall stress identified 39 of 42 patients with subnormal endocardial LV shortening and 41 of 42 patients with depressed midwall performance (p < 0.01 vs use of meridional stress). The circumferential/meridional wall stress ratio was 2.6 +/- 0.5 in normal subjects and 1.3 +/- 0.2 in CHF patients (p < 0.0001). Thus, use of circumferential end-systolic stress as the measure of afterload improves the detection of myocardial dysfunction by stress/shortening relations in patients with CHF. The ratio between the 2 stresses decreases with more spherical LV shape. Midwall and endocardial shortening measurements are equivalent in the setting of thin LV walls as occurs in dilated cardiomyopathy.
The appropriateness of left ventricular (LV) mass to cardiac workload may be calculated by the ra... more The appropriateness of left ventricular (LV) mass to cardiac workload may be calculated by the ratio of observed LV mass to the value predicted for an individual's sex, height, and stroke work at rest. To investigate test-retest reproducibility of observed/predicted LV mass in a single patient. We measured intraclass correlation and interval of agreement between two M-mode tracings, recorded both at the same session and 3-10 days apart in 200 participants (45 +/- 13 years, body mass index 25 +/- 4 kg/m; 99 hypertensive and 101 normotensive; 50% of each group were women) in 16 centres in Italy. Tracings were read by two observers in each centre. The values of observed/predicted LV mass value ranged from 40.78 to 215.50%. On the same day, the within-observer 90% interval of agreement between tracings 1 and 2 was -23 to +20%. For day-to-day test-retest within-observer variability (average three cycles), the 90% interval of agreement of the observed/predicted LV mass was -30 to +32%. The 90% interval of agreement of test-retest between-observer variability was -25 to +25%. The categorical consistency of retest in the identification of subjects with appropriate LV mass, classified in the first study (i.e. > 73% and < 128%), was 90% (k = 0.87). Measurement of the appropriateness of LV mass in single patients allows acceptable risk stratification, with a coefficient of consistency similar to that reported for LV mass. The probability of a true change (90% chance) in observed/predicted LV mass over time is maximized for a single-reader difference greater than 22%, although lesser differences might also have clinical relevance.
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