Background
Arterial elastance to left ventricular elastance ratio assessed by echocardiography is widely used as a marker of ventricular‐arterial coupling.
Materials and methods
We investigated ...whether the ratio of carotid‐femoral pulse wave velocity, as a marker of arterial stiffness, to global longitudinal strain, as a marker of left ventricular performance, could be better associated with vascular and cardiac damage than the established arterial elastance/left ventricular elastance index. In 299 newly‐diagnosed untreated hypertensives we measured, carotid‐femoral pulse wave velocity, and carotid intima‐media thickness, coronary‐flow reserve, arterial elastance/left ventricular elastance, global longitudinal strain, and markers of left ventricular diastolic function (E/A and E’) by echocardiography.
Results
Pulse wave velocity‐to‐global longitudinal strain ratio (PWV/GLS) was lower in hypertensives than controls (−0.61 ± 0.21 vs −0.45 ± 0.11 m/sec%, P < 0.001). Low PWV/GLS values were associated with carotid‐intima media thickness > 0.9 mm (P = 0.003), E/A ≤ 0.8 (P = 0.019) and E’ ≤ 9 cm/sec (P = 0.002) and coronary‐flow reserve < 2.5 (P = 0.017), after adjustment for age, sex and mean arterial pressure. Low PWV/GLS was also associated with increased left ventricular mass and left atrial volume in the univariate (P = 0.003 and 0.038) but not in the multivariate model. In hypertensives, there was no significant association of arterial elastance‐to‐left ventricular elastance index with carotid intima media thickness, coronary flow reserve, E/A, E’, or left atrial volume with the exception of an inverse association with left ventricular mass (P = 0.027).
Conclusions
Pulse wave velocity‐to‐global longitudinal strain ratio but not the echocardiography‐derived arterial elastance‐to left ventricular elastance index is related to impaired carotid‐intima media thickness, coronary‐flow reserve and diastolic function in hypertensives.
Objective
Patent foramen ovale (PFO) can be detected in up to 43% of patients with cryptogenic cerebral ischemia undergoing investigation with transesophageal echocardiography (TEE). The diagnostic ...value of transthoracic echocardiography (TTE) in the detection of PFO in patients with cryptogenic ischemic stroke or transient ischemic attack has not been compared with that of transcranial Doppler (TCD) using a comprehensive meta‐analytical approach.
Methods
We performed a systematic literature review to identify all prospective observational studies of patients with cryptogenic cerebral ischemia that provided both sensitivity and specificity measures of TTE, TCD, or both compared to the gold standard of TEE.
Results
Our literature search identified 35 eligible studies including 3,067 patients. The pooled sensitivity and specificity for TCD was 96.1% (95% confidence interval CI = 93.0–97.8%) and 92.4% (95% CI = 85.5–96.1%), whereas the respective measures for TTE were 45.1% (95% CI = 30.8–60.3%) and 99.6% (95% CI = 96.5–99.9%). TTE was superior in terms of higher positive likelihood ratio values (LR+ = 106.61, 95% CI = 15.09–753.30 for TTE vs LR+ = 12.62, 95% CI = 6.52–24.43 for TCD; p = 0.043), whereas TCD demonstrated lower negative likelihood values (LR− = 0.04, 95% CI = 0.02–0.08) compared to TTE (LR− = 0.55, 95% CI = 0.42–0.72; p < 0.001). Finally, the area under the summary receiver operating curve (AUC) was significantly greater (p < 0.001) in TCD (AUC = 0.98, 95% CI = 0.97–0.99) compared to TTE studies (AUC = 0.86, 95% CI = 0.82–0.89).
Interpretation
TCD is more sensitive but less specific compared to TTE for the detection of PFO in patients with cryptogenic cerebral ischemia. The overall diagnostic yield of TCD appears to outweigh that of TTE. Ann Neurol 2016;79:625–635
Cerebral small vessel disease is a common manifestation among patients with Fabry disease (FD). As a biomarker of cerebral small vessel disease, the prevalence of impaired cerebral autoregulation as ...assessed by transcranial Doppler (TCD) ultrasonography was evaluated in FD patients and healthy controls.
TCD was performed to assess pulsatility index (PI) and vasomotor reactivity expressed by breath-holding index (BHI) for the middle cerebral arteries of included FD patients and healthy controls. Prevalence of increased PI (>1.2) and decreased BHI (<0.69) and ultrasound indices of cerebral autoregulation were compared in FD patients and controls. The potential association of ultrasound indices of impaired cerebral autoregulation with white matter lesions and leukoencephalopathy on brain MRI in FD patients was also evaluated.
Demographics and vascular risk factors were similar in 23 FD patients (43% women, mean age: 51 ± 13 years) and 46 healthy controls (43% women, mean age: 51 ± 13 years). The prevalence of increased PI (39%; 95% confidence interval CI: 20%-61%), decreased BHI (39%; 95% CI: 20%-61%), and the combination of increased PI and/or decreased BHI (61%; 95% CI: 39%-80%) was significantly (p < .001) higher in FD patients compared to healthy controls (2% 95% CI: 0.1%-12%, 2% 95% CI: 0.1%-12%, and 4% 95% CI: 0.1%-15%, respectively). However, indices of abnormal cerebral autoregulation were not associated independently with white matter hyperintensities and presented a low-to-moderate predictive ability for the discrimination of FD patients with and without white matter hyperintensities.
Impaired cerebral autoregulation as assessed by TCD appears to be highly more prevalent among FD patients compared to healthy controls.
Current recommendations do not specifically address the optimal blood pressure (BP) reduction for secondary stroke prevention in patients with previous cerebrovascular events. We conducted a ...systematic review and metaregression analysis on the association of BP reduction with recurrent stroke and cardiovascular events using data from randomized controlled clinical trials of secondary stroke prevention. For all reported events during each eligible study period, we calculated the corresponding risk ratios to express the comparison of event occurrence risk between patients randomized to antihypertensive treatment and those randomized to placebo. On the basis of the reported BP values, we performed univariate metaregression analyses according to the achieved BP values under the random-effects model (Method of Moments) for those adverse events reported in ≥10 total subgroups of included randomized controlled clinical trials. In pairwise meta-analyses, antihypertensive treatment lowered the risk for recurrent stroke (risk ratio, 0.73; 95% confidence interval, 0.62–0.87; P<0.001), disabling or fatal stroke (risk ratio, 0.71; 95% confidence interval, 0.59–0.85; P<0.001), and cardiovascular death (risk ratio, 0.85; 95% confidence interval, 0.75–0.96; P=0.01). In metaregression analyses, systolic BP reduction was linearly related to the lower risk of recurrent stroke (P=0.049), myocardial infarction (P=0.024), death from any cause (P=0.001), and cardiovascular death (P<0.001). Similarly, diastolic BP reduction was linearly related to a lower risk of recurrent stroke (P=0.026) and all-cause mortality (P=0.009). Funnel plot inspection and Egger statistical test revealed no evidence of publication bias. The extent of BP reduction is linearly associated with the magnitude of risk reduction in recurrent cerebrovascular and cardiovascular events. Strict and aggressive BP control seems to be essential for effective secondary stroke prevention.
OBJECTIVE:Our aim was to evaluate the diagnostic yield of transesophageal echocardiography (TEE) in consecutive patients with ischemic stroke (IS) fulfilling the diagnostic criteria of embolic ...strokes of undetermined source (ESUS).
METHODS:We prospectively evaluated consecutive patients with acute IS satisfying ESUS criteria who underwent in-hospital TEE examination in 3 tertiary care stroke centers during a 12-month period. We also performed a systematic review and meta-analysis estimating the cumulative effect of TEE findings on therapeutic management for secondary stroke prevention among different IS subgroups.
RESULTS:We identified 61 patients with ESUS who underwent investigation with TEE (mean age 44 ± 12 years, 49% men, median NIH Stroke Scale score = 5 points interquartile range3–8). TEE revealed additional findings in 52% (95% confidence interval CI40%–65%) of the study population. TEE findings changed management (initiation of anticoagulation therapy, administration of IV antibiotic therapy, and patent foramen ovale closure) in 10 (16% 95% CI9%–28%) patients. The pooled rate of reported anticoagulation therapy attributed to abnormal TEE findings among 3,562 acute IS patients included in the meta-analysis (12 studies) was 8.7% (95% CI7.3%–10.4%). In subgroup analysis, the rates of initiation of anticoagulation therapy on the basis of TEE investigation did not differ (p = 0.315) among patients with cryptogenic stroke (6.9% 95% CI4.9%–9.6%), ESUS (8.1% 95% CI3.4%–18.1%), and IS (9.4% 95% CI7.5%–11.8%).
CONCLUSIONS:Abnormal TEE findings may decisively affect the selection of appropriate therapeutic strategy in approximately 1 of 7 patients with ESUS.
There is accumulating evidence in the literature indicating a strong correlation between Fabry disease (FD) phenotypes and specific sequence variations in the Galactosidase Alpha (
) gene. Among ...them, the potential pathogenicity and clinical relevance of
variation in patients with FD remain debated.
We performed a systematic review and meta-analysis of studies reporting
as single occurring variant in the
gene and sought to evaluate (1) the prevalence of
variation in different populations with or without clinical manifestations of FD, (2) the clinical FD phenotype in
-positive patients, and (3) the proportion of
-positive patients presenting abnormal laboratory findings (alpha-galactosidase-A deficiency or globotriaosylceramide accumulation).
Forty cohorts comprising 211 individuals with
variation among 42,723 participants with available
gene-sequencing data were included. Patients highly suspected for FD had a higher prevalence of
variation (4.9%, 95% CI 1.6%-9.9%; I
= 95.5%) compared with the general population (0%, 95% CI 0%-0.1%; I
= 1.9%;
= 0.004). The prevalence of
variation was 0.6% (95% CI 0.3%-1%; I
= 74.1%), 0.4% (95% CI 0.2%-0.7%; I
= 0%), and 0.3% (95% CI 0.2%-0.4%; I
= 0%) in patients presenting with neurologic, cardiac, or renal manifestations, respectively.
was associated with a milder, late-onset FD phenotype, as indicated by the mean patient age of 51 years (95% CI 44-59; I
= 94%) and the evidence of alpha-galactosidase A deficiency and globotriaosylceramide accumulation in 26.7% (95% CI 15.3%-40%; I
= 34%) and 16.2% (95% CI 8%-26.4%; I
= 35%) of cases, respectively.
-positive patients displayed predominantly neurologic FD manifestations (58.1%, 95% CI 37.7%-77.1%; I
= 78%), with central and peripheral nervous system (CNS/PNS) involvement noted in 28.2% (95% CI 15.4%-43.2%; I
= 51%) and 28.5% (95% CI 17.8%-40.5%; I
= 61%) of cases, respectively.
variation seems to correlate with an atypical, mild late-onset phenotype with predominantly neurologic FD manifestations. Monitoring for CNS/PNS involvement is thus paramount to identify
-positive patients with latent or early-FD pathology, which may qualify for enzyme-replacement therapy or chaperone treatment.
The Coronavirus Disease 2019 (COVID-19) pandemic, being caused by an easily and rapidly spreading novel betacoronavirus, has created a state of emergency for people, the scientific community, ...healthcare systems and states, while the global financial consequences are still unfolding. Cardiovascular complications have been reported for COVID-19-infected patients and are associated with a worse prognosis. ECG and biomarkers may raise suspicion of cardiac involvement. However, transthoracic echocardiography is a fast and reliable bedside method to establish the diagnosis of cardiac complications, including acute coronary syndromes, pericarditis, myocarditis, and pulmonary embolism. Early detection of cardiac dysfunction by speckle tracking echocardiography during off-line analysis may be used to identify a high-risk population for development of heart failure in the acute setting. Precautionary measures are mandatory for operators and equipment to avoid viral dispersion. No specific treatment is yet available for severe acute respiratory syndrome coronavirus 2 (SARS-CoV 2), and a variety of antiviral, immune-modifying, and antioxidant agents are therefore under intense investigation. Echocardiography, including assessment of myocardial deformation, may provide a useful tool to monitor the effects of the various treatment regimens on cardiac function both acutely and in the midterm.
Abstract
Background and Purpose
Cardioembolism is a postulated mechanism of embolic stroke of undetermined source (ESUS). We investigated endothelial glycocalyx, aortic elastic properties, oxidative ...stress, and their association with left atrial (LA) function in ESUS and healthy individuals.
Methods
In 90 ESUS patients (age 50.4 ± 13.2) and 90 controls with similar risk factors, we measured: (1) perfused boundary region (PBR) of the sublingual arterial microvessels (range 5–25 µm), a marker inversely related with glycocalyx thickness, (2) pulse wave velocity (PWV), central systolic blood pressure (cSBP), and augmentation index (AIx), (3) LA volume and strain using speckle-tracking imaging, and (4) malondialdehyde (MDA) and protein carbonyls (PCs), as oxidative stress markers.
Results
Compared with controls, ESUS had higher PWV, PBR, MDA, and PC levels as well as higher LA volume and reduced reservoir LA strain (
p
< 0.05). PBR > 1.2 μm of microvessel ranging from 5 to 9 μm and PWV > 10.2 m/s were associated with ESUS on multivariable analysis (odds ratio: 2.374 and 5.429,
p
< 0.05, respectively) and increased the c-statistic of the initial model from 0.54 to 0.71. In ESUS, glycocalyx damage (increased PBR) was related with increased PWV (
p
< 0.01) which was linked with LA reservoir strain after controlling for age, sex, and risk factors (
p
= 0.03). Increased MDA and PC were related with glycocalyx damage, increased PWV (
r
= 0.67 and
r
= 0.52), AIx, cSBP, and aortic atheroma (
p
< 0.01).
Conclusion
Arterial function and endothelial glycocalyx are severely impaired in ESUS and are linked to LA dysfunction suggesting their contribution to ESUS pathogenesis.
Clinical Trial Registration
URL-
http://www.clinicaltrials.gov
. Unique identifier: NCT03609437.
OBJECTIVECurrent guidelines report no benefit for patent foramen ovale (PFO) closure compared to medical treatment in patients with cryptogenic ischemic stroke (IS) or TIA. Two recent randomized ...controlled clinical trials have challenged these recommendations.
METHODSWe performed a systematic review and network meta-analysis of randomized controlled trials to estimate the safety and efficacy of closure compared to medical treatment, and to compare available devices. We conducted pairwise meta-analyses for closure vs medical therapy, irrespective of the device used, and for each device vs medical therapy.
RESULTSOur literature search highlighted 6 studies. PFO occlusion was associated with reduced risk of recurrent IS (risk ratio RR 0.42, 95% confidence interval CI 0.20–0.91) and IS/TIA (RR 0.65, 95% CI 0.48–0.88) but with increased risk of new-onset atrial fibrillation (AF) (RR 4.59, 95% CI 2.01–10.45) compared to medical treatment. In indirect analyses, both Amplatzer (AMP) and GORE devices were found to be associated with a lower risk of new-onset AF compared to STARFlex (SFX) (RR 0.25, 95% CI 0.10–0.65 and RR 0.28, 95% CI 0.08–0.95). Moreover, AMP was found to be associated with a lower risk of recurrent IS/TIA events compared to the SFX device (RR 0.35, 95% CI 0.14–0.91). In the clustered ranking plot on the risk of IS against new-onset AF, GORE was comparable to AMP; however, on the risk of IS/TIA against new-onset AF, AMP appeared to be superior to the GORE device. In both ranking plots, SFX was highlighted as the worst option.
CONCLUSIONPFO closure is associated with reduced risk of recurrent IS or IS/TIA and with increased risk of new-onset AF.
Abstract Heart failure (HF) is known to be a major risk factor for first-ever ischemic stroke (IS), and is associated with greater stroke severity and higher rates of early mortality and residual ...disability. There are limited data regarding the association of HF with stroke recurrence. We sought to evaluate the relationship between HF and recurrent IS using a comprehensive meta-analytical approach. We performed a systematic literature review according to PRISMA guidelines to identify all prospective study protocols (randomized clinical trials or observational cohorts) that reported rates of IS recurrence in patients with concomitant HF. We pooled independently the reported corresponding risk ratios (RRs) and hazard ratios (HRs) from each study protocol using the random effects model. Heterogeneity across included studies was evaluated using Cochran Q and I2 statistics. Our literature search identified 7 eligible studies including 9173 IS patients (18.2% with HF). The reported mean follow-up period in the included studies ranged from 7 days to 5 years. The pooled estimate of RRs and HRs for recurrent IS was 1.96 (95% CI: 1.49–2.60; p < 0.0001) and 1.93 (95% CI: 1.47–2.53; p < 0.0001). We found no evidence of heterogeneity within studies in both the RR (I2 = 13.5%, p for Cochran Q statistic: 0.325) and HR (I2 = 0%, p for Cochran Q statistic: 0.629) analyses. HF is associated with a continuous two-fold increase in the risk of IS recurrence in patients with prior history of cerebral ischemia. The benefit of anticoagulation in this high-risk group of patients may be studied along with additional risk factor modifications.
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