This study aimed to assess intra- and inter-observer agreement in assessing the systolic and diastolic function with equilibrium radionuclide angiography (ERNA).
Thirty-two adults underwent baseline ...and repeat ERNA. An experienced and a trainee operator analyzed the data by assigning regions of interest manually, fully automatically, and semi-automatically. The Bland-Altman statistic (mean ± 1.96 standard deviations of the differences) was used to assess the repeatability (two different assessments of a single acquisition) and reproducibility (assessments of two different acquisitions).
Using the semi-automated technique the intraobserver repeatability and reproducibility of left ventricular ejection fraction for the experienced physician were − 0.1 ± 3.7 and 0.0 ± 3.8 and for the trainee 2.2 ± 10.6 and 1.9 ± 8.4, respectively. The inter-observer repeatability and reproducibility were − 1.8 ± 6.4 and 0.4 ± 9.0, respectively. Among the parameters of diastolic function, the intraobserver repeatability and reproducibility of the peak filling rate for the experienced physician were − 0.0 ± 1.1 and − 0.1 ± 1.1 and for the trainee 0.2 ± 3.5 and 0.4 ± 3.7, respectively. The inter-observer repeatability and reproducibility were 0.3 ± 1.5 and 0.5 ± 4.0, respectively. Similar was the pattern for the other diastolic indices. In all cases the limits of agreement varied according to the quantification approach.
A good repeatability but a moderate reproducibility was found in the assessment of the LVEF. Less good were the findings in the assessment of diastolic function.
Hypertension in end-stage renal disease patients is highly prevalent and poorly controlled. Data on the ambulatory blood pressure (BP) profile and BP variability (BPV) in peritoneal dialysis (PD) ...patients are absent. This study examined the BP profile and BPV of patients undergoing PD in comparison with hemodialysis (HD) and predialysis chronic kidney disease CKD patients. Thirty-eight PD patients were matched for age, sex, and dialysis vintage with 76 HD patients and for age and sex with 38 patients with CKD stage 2-4. Patients under PD or HD underwent 48-h and CKD patients 24-h ambulatory BP monitoring. BP levels and BPV indices were compared for the 48-h, first and second 24 h, daytime and nighttime periods. Two-way mixed ANOVA for repeated measurements was used to evaluate the effects of dialysis modality and time on ambulatory BP in PD and HD. During all periods studied, SBP and DBP were numerically higher but not significantly different in PD than in HD patients. Systolic BP was significantly higher in PD or HD than in predialysis CKD (PD: 138.38 ± 20.97 mmHg; HD: 133.75 ± 15.5 mmHg; CKD: 125.52 ± 13.4 mmHg, p = 0.003), a difference evident also during daytime and nighttime periods. Repeated-measurements ANOVA showed no effect of dialysis modality on ambulatory BP during any period studied. All BPV indices studied were similar between PD and HD patients, in whom they were higher than in CKD individuals (first 24-h systolic-ARV: PD: 11.86 ± 3.19 mmHg; HD: 11.23 ± 3.45 mmHg; CKD: 9.81 ± 2.49 mmHg, p = 0.016). Average BP levels and BPV indices are similar between PD and HD patients, in whom they are higher than in their CKD counterparts. The dialysis modality has no effect on the ambulatory BP profile. These results suggest that PD is no better than HD with regard to overall BP control or BP fluctuations over time.
OBJECTIVES:An exaggerated blood pressure (BP) response during dynamic exercise testing has been proposed as an additional screening tool to identify systolic masked hypertension (masked-HYP). ...However, masked-HYP in young people is often characterized by an elevated DBP. Static/isometric exercise elicits augmented sympathetic stimulation causing greater increases in both SBP and DBP than dynamic exercise.
AIMS:To examine whether individuals with masked-HYP exhibit exaggerated BP responses during a submaximal handgrip vs. normotensive individuals and individuals with sustained hypertension (true-HYP), and the possible associations of exercise BP with total peripheral resistance (TPR), central/aortic BP, and 24-h-ambulatory BP (24-h BP).
METHODS:Eighty-six participants untreated, newly diagnosed, masked-HYP (n = 27), true-HYP (n = 31), and normotensive individuals (n = 28); 46.3 ± 10.7 years, following evaluation of office BP, central/aortic BP, pulse wave velocity, carotid intima–media thickness, echocardiocardiography, and 24-h BP, underwent a 3-min handgrip (30% maximal voluntary contraction) with beat-by-beat BP and hemodynamics assessment (Finapres Medical Systems).
RESULTS:Despite similar baseline-BP in masked-HYP and normotensive individuals, during exercise masked-HYP exhibited a markedly greater (P < 0.01) SBP and DBP vs. normotensive individuals, and similar BP to true-HYP. TPR significantly increased (P < 0.001) during exercise, in masked-HYP and true-HYP. The exaggerated BP responses in masked-HYP were evident from the 1st minute of exercise and correlated (P < 0.05) with central/aortic-BP, aortic stiffness, 24-h BP, day-BP, night-time-BP, and interventricular septum thickness.
CONCLUSION:During handgrip, masked-HYP exhibited exaggerated BP and TPR responses, similar to those of true-HYP. These responses were evident from the 1st minute of exercise and correlated with 24-h BP, suggesting that systolic and diastolic masked-HYP can be ‘unmasked’ during a brief, submaximal, handgrip test.
Cardiovascular disease is the leading cause of mortality in patients with end‐stage‐kidney disease. Evidence on the possible echocardiographic differences between hemodialysis and peritoneal dialysis ...(PD) is scarce. This study aimed to evaluate differences in left (LA) and right atrial (RA), left (LV) and right ventricular (RV) geometry, systolic and diastolic function in hemodialysis, and PD patients. Thirty‐eight hemodialysis and 38 PD patients were matched for age, sex, and dialysis vintage. Two‐dimensional and tissue‐Doppler echocardiography, and lung ultrasound were performed during an interdialytic day in hemodialysis and before a programmed follow‐up visit in PD patients. Vena cava diameter (11.09 ± 4.53 vs. 14.91 ± 4.30 mm; p < 0.001) was significantly lower in hemodialysis patients. Indices of LA, RA, LV, and RV dimensions were similar between the two groups. LVMi (116.91 38.56 vs. 122.83 52.33 g/m2; p = 0.767) was similar, but relative wall thickness was marginally (0.40 0.14 vs. 0.45 0.15 cm; p = 0.055) lower in hemodialysis patients. LV hypertrophy prevalence was similar between groups (73.7% vs. 71.1%; p = 0.798), but hemodialysis patients presented eccentric and PD patients concentric LVH. Regarding ventricular systolic function, stroke volume (p = 0.030) and cardiac output (p = 0.036) were higher in hemodialysis, while RV systolic pressure (RVSP) (20.37 22.54 vs. 27.68 14.32 mm Hg; p = 0.009) was higher in PD. No significant differences were evidenced in diastolic function indices and lung water excess between the two groups. A moderate association was noted between ultrasound B‐lines score and LA volume index (r = 0.465, p < 0.001), RVSP (r = 0.431, p < 0.001), and E/e′ ratio (r = 0.304, p = 0.009). Hemodialysis and PD patients present largely similar echocardiographic indices reflecting cardiac geometry, systolic, and diastolic function, but different patterns of abnormal LV remodeling.
Myocardial wall rupture should be considered in patients presenting with hypotension and STEMI especially of delayed onset. Diagnosing this entity in the COVID‐19 era can be challenging—handheld ...echocardiography may aid toward this end.
Myocardial wall rupture should be considered in patients presenting with hypotension and STEMI especially of delayed onset. Diagnosing this entity in the COVID‐19 era can be challenging—handheld echocardiography may aid toward this end.
Approximately 85% of hemodialysis patients are hypertensive, but less than 30% achieve adequate blood pressure (BP) control. Reduction of volume overload is fundamental for BP control, but clinical ...criteria to estimate dry-weight are inaccurate. In the present study we examined the effect of dry-weight reduction with a lung-ultrasound-guided strategy on ambulatory BP in 71 clinically euvolemic hemodialysis patients with hypertension. Patients were equally randomized into an active group, following a strategy for dry-weight reduction guided by pre-hemodialysis lung ultrasound, and a control group with standard-of-care treatment. All patients underwent 48-hour ambulatory BP monitoring (ABPM) at baseline and after eight weeks. Overall, more patients in the active than in the control group had dry weight reduction, 54.3% compared to 13.9%, respectively. The ultrasonographic-B line change during follow-up was significantly different (-5.3±12.5 in active versus +2.2±7.6 in control group), which corresponded to significant differences in dry weight changes between the groups. The magnitude of reductions in 48-hour systolic BP (-6.61±9.57 vs. -0.67±13.07) and diastolic BP (-3.85±6.34 vs. -0.55±8.28) was significantly greater in the active group. Similarly, intradialytic BP, 44-hour BP, and daytime or night-time systolic/diastolic BP during both days of the interdialytic interval were significantly reduced in the active group but remained unchanged in the control group. The percentage of patients experiencing one or more intradialytic hypotensive episodes was marginally lower in the active group (34.3% vs. 55.6%). Thus, a lung-ultrasound-guided strategy for dry-weight reduction can effectively and safely reduce ambulatory BP levels in hemodialysis patients. Clinical implementation of this simple technique can help increase BP control in this population.
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An exaggerated blood pressure (BP) response during dynamic exercise testing has been proposed as an additional screening tool to identify systolic masked hypertension (masked-HYP). However, ...masked-HYP in young people is often characterized by an elevated DBP. Static/isometric exercise elicits augmented sympathetic stimulation causing greater increases in both SBP and DBP than dynamic exercise.
To examine whether individuals with masked-HYP exhibit exaggerated BP responses during a submaximal handgrip vs. normotensive individuals and individuals with sustained hypertension (true-HYP), and the possible associations of exercise BP with total peripheral resistance (TPR), central/aortic BP, and 24-h-ambulatory BP (24-h BP).
Eighty-six participants untreated, newly diagnosed, masked-HYP (n = 27), true-HYP (n = 31), and normotensive individuals (n = 28); 46.3 ± 10.7 years, following evaluation of office BP, central/aortic BP, pulse wave velocity, carotid intima-media thickness, echocardiocardiography, and 24-h BP, underwent a 3-min handgrip (30% maximal voluntary contraction) with beat-by-beat BP and hemodynamics assessment (Finapres Medical Systems).
Despite similar baseline-BP in masked-HYP and normotensive individuals, during exercise masked-HYP exhibited a markedly greater (P < 0.01) SBP and DBP vs. normotensive individuals, and similar BP to true-HYP. TPR significantly increased (P < 0.001) during exercise, in masked-HYP and true-HYP. The exaggerated BP responses in masked-HYP were evident from the 1st minute of exercise and correlated (P < 0.05) with central/aortic-BP, aortic stiffness, 24-h BP, day-BP, night-time-BP, and interventricular septum thickness.
During handgrip, masked-HYP exhibited exaggerated BP and TPR responses, similar to those of true-HYP. These responses were evident from the 1st minute of exercise and correlated with 24-h BP, suggesting that systolic and diastolic masked-HYP can be 'unmasked' during a brief, submaximal, handgrip test.
To assess the intra- and inter-observer repeatability of popular software packages for the quantitative determination of abnormality size in stress myocardial perfusion scintigraphy.
A total of 182 ...tomographic stress myocardial perfusion scans were processed in duplicate by an experienced and trainee observer to assess SSSext (summed stress score multiplied by 100/68) and total defect extent (TDE), as % of the left ventricle, with 4 dimension-myocardial (4DM), emory cardiac toolbox (ECTb) and quantitative perfusion SPECT (QPS) packages. The Bland-Altman (B-A) analysis and Lin's concordance correlation coefficient (CCC) were used to assess agreement.
In SSSext's intra-observer repeatability, CCC showed substantial agreement for 4DM and QPS, and moderate agreement for ECTb for both observers. In inter-observer repeatability, CCC revealed substantial agreement for 4DM and QPS, and poor agreement for ECTb. Regarding TDE, CCC showed substantial intra-observer repeatability for both operators using all packages, while the inter-observer repeatability was substantial for 4DM and QPS, and moderate for ECTb.In SSSext's intra-observer repeatability for 4DM, ECTb and QPS, the B-A analysis provided (mean±1.96SD of paired measurements) 0.0±4.3, 0.2±7.8, -0.6±7.6 for the experienced physician and 0.2±5.9, 0.0±7.5, -0.5±5.4 for the trainee, respectively; in inter-observer repeatability it provided 0.2±5.4, 0.1±9.6, 0.2±8.1, respectively. Regarding TDE, the B-A values for intra-observer repeatability were 0.1±5.2, 0.1±7.9, 0.1±2.8 for the experienced reader and 0.3±6.6, -0.1±6.4, -0.1±2.4 for the trainee, respectively; in inter-observer agreement the B-A provided 0.6±6.4, -0.2±10.3, -0.1±4.3, respectively.
Considerable differences in intra- and inter- observer agreement were noted for the quantitative determination of defect size using widely employed software packages, suggesting limitations in the clinical use of these measurements. Quantitative perfusion SPECT appears preferable, but with no significant advantage over 4DM. There were no significant differences between the observers.
The aim of this study was to evaluate the ability of a novel handheld echocardiography (HHE) device with continuous-wave Doppler (CWD) capability to measure aortic valve peak jet velocity (Vmax) and ...facilitate aortic stenosis (AS) severity grading.
One hundred twenty-one consecutive patients with known or suspected AS were prospectively included. All patients were scanned with the HHE device and a high-end echocardiography system (the reference standard) to obtain CWD signal across the aortic valve. Aortic Vmax measurements were acquired from the apical five-chamber view using both methods and were compared to assess method agreement using the intraclass correlation coefficient, linear regression analysis, and Bland-Altman analysis. Diagnostic accuracy for the detection of at least moderate AS (Vmax ≥ 3 m/sec) was calculated. Also, the utility of HHE with CWD to reclassify patients compared with the visual estimation of AS severity was assessed.
The acquisition of CWD signal using HHE was feasible in 118 of 121 patients (mean age, 68 ± 17 years; 57% men). There was excellent agreement between the HHE CWD and the cart-based measurements (intraclass correlation coefficient = 0.97 95% CI: 0.83-0.99 and r = 0.98 95% CI: 0.91-0.99, P < .001 for both). The Bland-Altman plot showed a small underestimation bias of −0.2 m/sec (P < .001), with limits of agreement ±0.44 m/sec for Vmax. Detection of at least moderate AS using HHE with CWD was feasible with sensitivity of 93% (95% CI: 83%-98%), specificity of 98% (95% CI: 91%-100%), positive predictive value of 98% (95% CI: 88%-100%), negative predictive value of 94% (95% CI: 85%-97%), and total diagnostic accuracy of 96%. Patients visually assessed as having mild AS were reclassified as having no stenosis (17%), mild AS (72%), or moderate AS (11%) with the addition of CWD imaging.
Use of a novel HHE device with CWD spectral analysis by experienced operators can reliably detect clinically significant AS and facilitate AS grading. This technology may improve screening and diagnostic workup of AS compared with current practice.
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•Aortic peak jet velocity measurement using an HHE device with CW Doppler is feasible.•Excellent agreement between HHE and high-end systems for AS grading was observed.•HHE with CW Doppler detects clinically significant AS with high diagnostic accuracy.•HHE CW Doppler can reliably reclassify patients with imaging features of mild AS.
This study examined in vivo (1) skeletal muscle oxygenation and microvascular function, at rest and during handgrip exercise, and (2) their association with macrovascular function and exercise blood ...pressure (BP), in newly diagnosed, never-treated patients with hypertension and normotensive individuals. Ninety-one individuals (51 hypertensives and 40 normotensives) underwent office and 24-hour ambulatory BP, arterial stiffness, and central aortic BP assessment, followed by a 5-minute arterial occlusion and a 3-minute submaximal handgrip exercise. Changes in muscle oxygenated and deoxygenated hemoglobin and tissue oxygen saturation were continuously monitored by near-infrared spectroscopy and beat-by-beat BP by Finapres. Hypertensives had higher (
<0.001) central aortic BP and pulse wave velocity versus normotensives and exhibited (1) a blunted tissue oxygen saturation response during occlusion, with slower (
=0.006) deoxygenation rate, suggesting reduced muscle oxidative capacity, and (2) a slower reoxygenation rate and blunted hyperemic response (
<0.05), showing reduced microvascular reactivity. Muscle oxygenation responses were correlated with aortic systolic and pulse pressure and augmentation index (
<0.05; age and body mass index (BMI) adjusted). When exercising at the same submaximal intensity, hypertensives required a significantly greater (
<0.001) increase in BP for achieving similar muscle oxygenation levels as normotensives. This response was correlated with the magnitude of microvascular hyperemia and aortic BP. In conclusion, nontreated patients with hypertension exhibit prominent reductions in in vivo indices of skeletal muscle oxidative capacity, suggestive of mitochondrial dysfunction, and blunted muscle microvascular reactivity. These dysfunctions were associated with higher aortic systolic BP and arterial stiffness. Dysregulations in muscle oxygen delivery/utilization and microvascular stiffness, in hypertensive patients, partially contribute to their exaggerated BP during exercise.
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