Apical outpouching, including wall motion abnormalities and aneurysms, has been described in apical hypertrophic cardiomyopathy (ApHCM).
Between 1976 and 2006, 193 patients with ApHCM (120 men; ...overall mean age, 61 ± 17 years) were evaluated.
Apical outpouching was found in 29 patients (15%) and in 22 of the 78 patients (28%) imaged with contrast echocardiography. Six patients had apical aneurysms, and 23 patients had hypokinesis with apical dilatation but no wall thinning. Apical outpouching was more common in patients with diastolic gradients out of the apex (P < .001), corrected QT interval prolongation (P < .001), increased apical wall thickness (P = .01), and family histories of sudden cardiac death (P = .03). Sudden cardiac death, resuscitated cardiac arrest, or discharge of an automated internal cardiac defibrillator, or a combination, was observed in 11 patients (6%) during follow-up. Atrial fibrillation (28%), ventricular tachycardia (20%), and stroke (11%) were also relatively common in this study. No difference was observed in overall mortality rate comparing patients with ApHCM with and without apical outpouching. Similarly, no differences were found in the rates of sudden cardiac death, resuscitated cardiac arrest, and discharge of an automated internal cardiac defibrillator. The impact of true aneurysms was not assessed in this study.
Cardiac complications appear commonly in patients with ApHCM, but they did not seem to be related to apical outpouching in the present analysis.
OBJECTIVE To test active cancer for an association with venous thromboembolism (VTE) location. PATIENTS AND METHODS Using the resources of the Rochester Epidemiology Project, we identified all ...Olmsted County, MN, residents with incident VTE during the 35-year period 1966-2000 (N=3385). We restricted analyses to residents with objectively diagnosed VTE during the 17-year period from January 1, 1984, to December 31, 2000 (N=1599). For each patient, we reviewed the complete medical records in the community for patient age, gender, and most recent body mass index at VTE onset; VTE event type and location; and previously identified independent VTE risk factors (ie, surgery, hospitalization for acute medical illness, active cancer, leg paresis, superficial venous thrombosis, and varicose veins). Using logistic regression we tested active cancer for an association with each of 4 symptomatic VTE locations (arm or intra-abdominal deep venous thrombosis DVT, intra-abdominal DVT, pulmonary embolism, and bilateral leg DVT), adjusted for age, gender, body mass index, and other VTE risk factors. RESULTS In multivariate analyses, active cancer was independently associated with arm or intra-abdominal DVT (odds ratio OR, 1.76; P =.01), intra-abdominal DVT (OR, 2.22; P =.004), and bilateral leg DVT (OR, 2.09; P =.02), but not pulmonary embolism (OR, 0.93). CONCLUSION Active cancer is associated with VTE location. Location of VTE may be useful in decision making regarding cancer screening.
Arterial stiffness is associated with incident hypertension. We hypothesized that measures of arterial stiffness would predict increases in systolic (SBP), mean (MAP), and pulse pressure (PP) over ...time in treated hypertensives. Blood pressure (BP) was measured a mean of 8.5 ± 0.9 years apart in 414 non-Hispanic white hypertensives (mean age, 60 ± 8 years; 55% women). The average of three supine right brachial BPs was recorded. Measures of arterial stiffness, including carotid-femoral pulse wave velocity (cfPWV), aortic augmentation index (AIx), and central pulse pressure (CPP), were obtained at baseline by applanation tonometry. We performed stepwise multivariable linear regression analyses adjusting for potential confounders to assess the associations of arterial stiffness parameters with BP changes over time. SBP, MAP, and PP increased in 80% of participants. After adjustment for covariates listed, cfPWV (m/s) was associated with increases in SBP (β ± standard error SE, 0.71 ± 0.31) and PP (β ± SE, 1.09 ± 0.27); AIx (%) was associated with increases in SBP (β ± SE, 0.23 ± 0.10) and MAP (β ± SE, 0.27 ± 0.07); and CPP (mmHg) was associated with increases in SBP (β ± SE, 0.44 ± 0.07), MAP (β ± SE, 0.24 ± 0.05), and PP (β ± SE, 0.42 ± 0.06) over time (P ≤ .02 for each). In conclusion, arterial stiffness measures were associated with longitudinal increases in SBP, MAP, and PP in treated hypertensives.
We examined the potential role of Doppler myocardial imaging for early detection of systolic dysfunction in patients with systemic amyloidosis (AL) but without evidence of cardiac involvement by ...standard echocardiography. We identified 42 patients without 2-dimensional echocardiographic or Doppler evidence of cardiac involvement. These patients had normal ventricular wall thickness and normal velocity of the medial mitral annulus. Myocardial images were obtained in these patients and in 32 age- and gender-matched healthy controls. Peak longitudinal systolic tissue velocity (sTVI), systolic strain rate (sSR), and systolic strain (sS) were determined for 16 left ventricular segments. Radial and circumferential sSR and sS were also measured. Compared with controls in this group of patients with AL, peak longitudinal sSR (−1.0 ± 0.2 vs −1.4 ± 0.2, p <0.001) and peak longitudinal sS (−15.6 ± 3.3 vs −22.5 ± 2.0 p <0.001) were significantly decreased. In conclusion, the mean sS from all 6 basal segments, or from all 16 left ventricular segments differentiated patients with AL with normal echocardiography from controls, with similar accuracy for the mean sSR from the 6 basal segments. This distinction was not apparent from peak longitudinal sTVI or from radial or circumferential sSI or sSR.
OBJECTIVE To establish the incidence and correlation of increased left atrial volume index (LAVI) in patients with first-ever ischemic stroke. PARTICIPANTS AND METHODS Using our institution's ...epidemiological database, we defined a cohort of 432 patients (cases) who underwent transthoracic echocardiography within 60 days of first ischemic stroke between January 1, 1985, and December 31, 1994. Left atrial volume was measured with the biplane area-length method, indexed to body surface area (LAVI, expressed as mL/m2 ). The control group consisted of 416 community residents who underwent transthoracic echocardiography as participants in a stroke risk factor study. Increased LAVI was defined as 28 mL/m2 or higher. Survival in patients was compared with expected survival among white Minnesotans and was further modeled as a function of age, sex, LAVI, and clinical risk factors. RESULTS Among the included 306 patients, 230 (75%) had increased LAVI (mean ± SD, 49±21 mL/m2 ). Patients with increased LAVI were older than those with normal LAVI (mean ± SD age, 76±11 vs 71±13 years; P =.003) and had more cardiovascular risk factors (mean ± SD number, 1.8±0.07 vs 1.3±0.89; P <.001). Mean LAVI was higher in cases than in age- and sex-matched controls ( P <.001). At 5-year follow-up, cases showed excess mortality compared with age-matched controls ( P =.001). After variables were adjusted for age, sex, and clinical risk factors, LAVI was independently associated with mortality. CONCLUSION A useful index for prediction of adverse cardiovascular events, LAVI might also predict first ischemic stroke and subsequent mortality.
We examined the potential role of Doppler myocardial imaging including tissue velocity imaging, strain imaging, and strain rate imaging for detection of left ventricular systolic dysfunction in ...cardiac amyloidosis (CA) and determined the minimum dataset required to make the diagnosis.
Doppler myocardial imaging was performed in 103 patients with amyloidosis (AL). Peak longitudinal systolic tissue velocity, systolic strain rate (sSR), and systolic strain (sS) were determined for 16 left ventricular segments. Radial and circumferential sSR and sS were also measured. Patients with increased left ventricular wall thickness were classified with advanced-CA, and the remainder of the patients were classified with AL-normal-wall-thickness. The global means of peak systolic tissue velocity (3.6 +/- 1.0 vs. 3.9 +/- 0.9, P = .007), sSR (-0.8 +/- 0.3 vs. -1.0 +/- 0.2, P < .001), and sS (-9.9 +/- 3.7 vs. -15.6 +/- 3.3, P < .001) were significantly lower in advanced-CA compared with AL-normal-wall-thickness. The mean of either sSR or sS from 6 middle or all 16 segments similarly differentiated patients with advanced-CA from AL-normal-wall-thickness.
Longitudinal sS most accurately detects longitudinal systolic dysfunction in AL and best differentiates patients with advanced-CA with increased ventricular thickness from patients with AL-normal-wall-thickness. Interrogation of six middle segments was sufficient in identifying patients with advanced-CA. Further studies are warranted to define the incremental prognostic value of these new parameters in predicting outcomes for patients with AL.
A marked increase in hospitalization for patients with atrial fibrillation (AF) has previously been noted. Whether this increase is related to a change in the prevalence of AF or a change in the ...pattern of practice with respect to the management of AF remains unclear. To determine the trends in hospital utilization after first AF in a community-based setting (Olmsted County, Minnesota), residents diagnosed with first AF from 1980 to 2000 were identified and followed until 2004. The primary outcome of interest was hospital admission for cardiovascular reasons. Of a total of 4,498 subjects (73 ± 14 years old, 51% men), 2,503 (56%) were admitted to the hospital for cardiovascular causes ≥1 time during a mean follow-up of 5.5 ± 5.0 years. Risk of first hospitalization was greatest during the first year of AF (cumulative incidence 31%, 95% confidence interval CI 30 to 32). First hospitalization was strongly related to age (p <0.0001) but not to sex (p = 0.38). From 1980 to 2000, the age-and sex-adjusted rate of first hospitalization increased, on average, by 2.5% a year (95% CI 1.8 to 3.2, p <0.0001), even after multivariable adjustment for co-morbidities. When we excluded all hospital admissions for the purposes of AF management, the increase in hospitalization was only 0.8% per year (95% CI 0.05 to 1.6, p = 0.04), which was no longer significant after multivariable adjustment for co-morbidities (p = 0.25). In conclusion, the marked increase in hospitalization after first AF diagnosis from 1980 to 2000 appeared to be largely driven by the changing practice pattern in AF management.
Exercise testing provides valuable information but is rarely integrated to derive a risk prediction model in a referral population. In this study, we assessed the predictive value of conventional ...cardiovascular risk factors and exercise test parameters in 6,546 consecutive adults referred for exercise testing, who were followed for a period of 8.1 ± 3.7 years for incident myocardial infarction, coronary revascularization, and cardiovascular death. A risk prediction model was developed, and cross-validation of model was performed by splitting the data set into 10 equal random subsets, with model fitting based on 9 of the 10 subsets and testing in of the remaining subset, repeated in all 10 possible ways. The best performing model was chosen based on measurements of model discrimination and stability. A risk score was constructed from the final model, with points assigned for the presence of each predictor based on the regression coefficients. Using both conventional risk factors and exercise test parameters, a total of 9 variables were identified as independent and robust predictors and were included in a risk score. The prognostic ability of this model was compared with that of the Adult Treatment Panel III model using the net reclassification and integrated discrimination index. From the cross-validation results, the c statistic of 0.77 for the final model indicated strong predictive power. In conclusion, we developed, tested, and internally validated a novel risk prediction model using exercise treadmill testing parameters.
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