Background
Excess epicardial fat volume (EFV) has been recently implicated in cardiovascular structural and functional abnormalities. It has been associated with abnormal microvascular stiffness (as ...reflected by radial artery waveform; C2), which may result in microvascular dysfunction and contribute to the atypical chest pain syndrome without obstructive coronary artery disease (CAD). Women have been statistically shown to present with atypical chest pain more often than men and specifically without obstructive CAD. The aim of this study is to assess whether excess EFV in female subjects is associated with significant microvascular dysfunction (i.e., C2), in subjects without obstructive CAD.
Results
We screened 596 asymptomatic subjects, ages 20–79, using the Early Cardiovascular Health Risk Scoring System (ECVHRS), which has been reported. Out of the 596 total subjects, 230 subjects had a CACS. Out of these 230 subjects, 77 subjects (45 females; 32 males) had a 0 CACS. The 45 females from this cohort were the subjects of this study, and they were further categorized into 3 groups: group 1 (normal EFV, non-obese female subjects;
n
=16), females with ECVHRS < 3 and ACC/AHA risk score < 5%; group 2 (
n
= 9), females with elevated EFV and no abdominal visceral obesity; and group 3 (
n
=20), females with elevated EFV and abdominal visceral obesity. The average EFV was determined to be 72±20 cm
3
among group 1, which indicates the values for normal EFV. The results in group 2 indicate that excess EFV is contributing to the development of microvascular dysfunction, resulting in abnormal micro-arterial (C2) elasticity (
p
< 0.00001), increase in resting blood pressure (
p
=0.0001), an abnormal rise in blood pressure (BP) at rest and post-mild protocol exercise (PME) (
p
= < 0.00001), and abnormal increase in carotid intima-media thickness (CIMT) (
p
= 0.000164).
Conclusion
Excess EFV appears to be not only a novel cardiovascular risk marker, but also the culprit for other cardiovascular risk markers. Based on these findings, elevated EFV may contribute to the development of the atypical chest pain syndrome in females without obstructive CAD. Additionally, EFV is emerging as a potential clinically relevant significant cardiovascular risk biomarker and may become a target to reduce cardiovascular morbidity and mortality.
Abstract
Patient presentation and follow-up
A 33-year-old woman was admitted to the ER of our hospital because of syncope without prodromes during her routine cycling training.
The patient's clinical ...history is characterized by congenital heart disease, interventional and cardiac surgical procedures in 1992-2021: percutaneous aortic valve (AoV) reconstruction for severe aortic stenosis in bicuspid AoV; conservative surgical Ao valvuloplasty and mitral valve (MV) commissuroplasty; MV substitution surgery; surgical AoV and MV replacement; surgical iatrogenic IVD closure. Atrial fibrillation became chronic and, following repeated interventions, an iatrogenic AV block developed requiring pacemaker implantation. In Dec. 2019, a submuscular PM (epicardial leads) was implanted (Medtronic Adapta DDDRR programmed in VVIRR for permanent atrial fibrillation). 2 years later, a transvenous-lead PM was implanted (Biotronik Evity 8 SR-T VVI-RR MRI conditional) without extracting the Medtronic PM (re-programmed in “back-up” VVI 30 bpm).
Patient management and treatment
A conservative strategy was adopted by programming the Biotronik/endocardial device in VOO-R mode stimulation only, while waiting for the total discharge of the old (Medtronic/epicardial) device. An alternative strategy could have been the removal of the epicardial PM. PM follow-up was performed via “remote” control and clinical checks in our Congenital Heart Disease Center.
The complex clinical history and the choice of up-grading to an endocardial device without removing the epicardial device, has caused a predictable condition that was overlooked.
The entry into operation of the ERI VOO 65 bpm mode of the epicardial device, in addition to causing a physiological increase in the pacing threshold of the epicardial catheter itself, produced the inhibition of the endocardial device whenever there was a pacing capture failure of the epicardial system. This situation set asystole off and consequent patient's loss of consciousness.
Conclusions
The traditional nitroglycerin (NTG) head-up tilt test (HUTT) is time-consuming and the test duration is a barrier to widespread utilization in clinical practice. It was hypothesized that a ...short-duration protocol is not inferior to the traditional protocol regarding the positivity rate and has a similar distribution of hemodynamic response.
Patients undergoing HUTT were randomized 1:1 to a 10 min passive phase plus a 10 min 0.3 mg NTG if the passive phase was negative (Fast) or to a 20 min passive phase plus a 15 min 0.3 mg NTG if the passive phase was negative (Traditional). A sample size of 277 patients for each group achieved 80% power to detect an expected difference of 0% with a non-inferiority margin of -10% using a one-sided t-test and assuming a significant level alpha of 0.025. A total of 554 consecutive patients (mean age 46.6 ± 19.3 years, 47.6% males) undergoing HUTT for suspected vasovagal syncope were randomly assigned to the Fast (n = 277) or Traditional (n = 277) protocol. A positive response was defined as the induction of syncope in presence of hypotension/bradycardia, and was observed in 167 (60.3%) patients with Fast and in 162 (58.5%) patients with the Traditional protocol. There was a trend of lesser vasodepressor response (14.8% Fast vs. 20.6% Traditional) which was significant during the passive phase (P = 0.01).
The diagnostic value of the Fast HUTT protocol is similar to that of the Traditional protocol and therefore the Fast protocol can be used instead of the Traditional protocol.
The objective of this work is to illustrate an active portfolio management methodology reducing the risk of the portfolio through stabilization of returns, by applying the proportional, integral, ...derivative (PID) control on the pure portfolio return variable. Two portfolios are analyzed and their financial performance is compared: the PID methodology implementation yielding the experimental portfolio on one side, and its corresponding benchmark, the DJ Euro Stoxx 50 Index on the other side. The experimental portfolio is able to diminish the volatility, and in particular, to accomplish a smaller down side risk than its corresponding benchmark.
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