Population-based studies have been hampered in exploring hypothalamic-pituitary-adrenal axis (HPA) activity as a potential explanatory link between stressrelated and metabolic disorders due to their ...lack of incorporation of reliable measures of chronic cortisol exposure. The purpose of this review is to summarize current literature on the reliability of HPA axis measures and to discuss the feasibility of performing them in population-based studies. We identified articles through PubMed using search terms related to cortisol, HPA axis, adrenal imaging, and reliability. The diurnal salivary cortisol curve (generated from multiple salivary samples from awakening to midnight) and 11 p. m. salivary cortisol had the highest between-visit reliabilities (r = 0.63-0.84 and 0.78, respectively). The cortisol awakening response and dexamethasone-suppressed cortisol had the next highest between-visit reliabilities (r = 0.33-0.67 and 0.42-0.66, respectively). Based on our own data, the inter-reader reliability (r s ) of adrenal gland volume from non-contrast CT was 0.67-0.71 for the left and 0.47-0.70 for the right adrenal glands. While a single 8 a.m. salivary cortisol is one of the easiest measures to perform, it had the lowest between-visit reliability (R = 0.18-0.47). Based on the current literature, use of sampling multiple salivary cortisol measures across the diurnal curve (with awakening cortisol), dexamethasone-suppressed cortisol, and adrenal gland volume are measures of HPA axis tone with similar between-visit reliabilities which likely reflect chronic cortisol burden and are feasible to perform in populationbased studies.
Background: The diagnostic and prognostic value of appropriate use criteria (AUC) for coronary artery disease (CAD) is well established. Whether the diagnostic yield of AUC for predicting CAD is ...preserved among the elderly is not known.Methods: We analyzed a multisite
prospective cohort of 1511 consecutive patients (age 59±13 years, 57% males) who underwent outpatient, community-based single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI). Appropriateness of the studies was determined on the basis of the 2013 multimodality
AUC for detection and risk assessment of stable ischemic heart disease. Abnormal SPECT MPI was defined by either a summed stress score of 4 or greater or a summed difference score of 2 or greater.Results: Abnormal SPECT MPI was present in 190 patients (12.5%), while ischemia on
MPI alone was present in 122 patients (8%). In multivariate logistic regression analysis, age of 60 years or greater, male sex, hypertension, diabetes mellitus, and known CAD were independent predictors of abnormal SPET MPI, while appropriate indication for testing was not. Age of 60 years
or greater was also an independent predictor of inducible myocardial ischemia, while appropriate indication for testing was not. Among the elderly (≥60 years), regardless of appropriateness of testing, there was no difference in the prevalence of abnormal SPECT (19 vs. 14%, P=0.14) or prevalence
of SPECT ischemia (11 vs. 11%, P=1.00). Among younger patients, however, appropriate testing predicted a greater prevalence of abnormal SPECT (12 vs. 7%, P=0.013).Conclusion: In this multisite cohort, testing based on AUC did not discriminate the risk of abnormal SPECT MPI among
the elderly. Caution is advised when relying on AUC for referral of elderly patients for SPECT MPI.
The life expectancy of people infected with human immunodeficiency virus (HIV) is rising due to better access to combination anti-retroviral therapy (ART). Although ART has reduced acquired immune ...deficiency syndrome (AIDS) related mortality and morbidity, there has been an increase in non-AIDS defining illnesses such as diabetes mellitus, hypercholesterolemia and coronary artery disease (CAD). HIV is a disease marked by inflammation which has been associated with specific biological vascular processes increasing the risk of premature atherosclerosis. The combination of pre-existing risk factors, atherosclerosis, ART, opportunistic infections and coagulopathy contributes to rising CAD incidence. The prevalence of CAD has emerged as a major contributor of morbidity in these patients due to longer life expectancy. However, ART has been associated with lipodystrophy, dyslipidemia, insulin resistance, diabetes mellitus and CAD. These adverse effects, along with drug–drug interactions when ART is combined with cardiovascular drugs, result in significant challenges in the care of this group of patients. Exercise tolerance testing, echocardiography, myocardial perfusion imaging, coronary computed tomography angiography and magnetic resonance imaging help in the diagnosis of CAD and heart failure and help predict cardiovascular outcomes in a manner similar to non-infected individuals. This review will highlight the pathogenesis and factors that link HIV to CAD, presentation and treatment of HIV-patients presenting with CAD and review briefly the cardiac imaging modalities used to identify this entity and help prognosticate future outcomes.
Infection with human immunodeficiency virus (HIV) has become the pandemic of the new century. About 36.9 million people are living with HIV worldwide. The introduction of antiretroviral therapy in ...1996 has dramatically changed the global landscape of HIV care, resulting in significantly improved survival and changing HIV to a chronic disease. With near-normal life expectancy, contemporary cardiac care faces multiple challenges of cardiovascular diseases, disorders specific to HIV/AIDS, and those related to aging and higher prevalence of traditional risk factors. Non-ischemic cardiovascular diseases are major components of cardiovascular morbidity and mortality in HIV/AIDS. Non-invasive cardiac imaging plays a pivotal role in the management of these diseases. This review summarizes the non-ischemic presentation of the HIV cardiovascular spectrum focusing on the role of cardiac imaging in the management of these disorders.
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