RESUMEN
OBJECTIVES: Obstructive sleep apnoea (OSA) is often linked to cardiovascular disease. A limited number of studies have reported an association between OSA and left ventricular diastolic dysfunction (LVDD). However, prior studies were performed on small patient populations. Studies have shown a high prevalence of OSA among first responders to the 9/11 World Trade Center (WTC) terrorist attack. We investigated the relationship between OSA and LVDD in a large population of WTC responders. DESIGN: Cross-sectional study. SETTING: One-time screening programme as part of the WTC-CHEST Study (NCT10466218), performed at a quaternary medical centre in New York City, from November 2011 to June 2014. PARTICIPANTS: A total of 1007 participants with mean age of 51 years of mostly non-Hispanic white men were evaluated. Patients from the WTC Health Program-Clinical Center of Excellence, who were over the age of 39 years, were eligible to participate. RESULTS: Evaluation of those without OSA diagnosis showed no significant association with LVDD when comparing those screened (Berlin Questionnaire) as OSA high risk versus OSA low risk (p=0.101). Among those diagnosed with LVDD, there was a significant association when comparing those with and without patient-reported OSA (OR 1.50, 95% CI 1.13 to 2.00, p=0.005), but the significance was not maintained after adjusting for pertinent variables (OR 1.3, 0.94 to 1.75, p=0.119). Notably, comparing those with OSA diagnosis and those low risk of OSA, the OR for LVDD was significant (1.69, 1.24 to 2.31, p=0.001), and after adjusting for waist-hip ratio, diabetes and coronary artery calcium score percentile, the relationship remained significant (OR 1.45, 1.03 to 2.04, p=0.032). CONCLUSION: The strong association of OSA with LVDD in this population may inform future guidelines to recommend screening for LVDD in high-risk asymptomatic patients with OSA.
Asunto(s)
Socorristas , Ataques Terroristas del 11 de Septiembre , Apnea Obstructiva del Sueño , Terrorismo , Disfunción Ventricular Izquierda , Adulto , Estudios Transversales , Humanos , Masculino , Persona de Mediana Edad , Apnea Obstructiva del Sueño/complicaciones , Apnea Obstructiva del Sueño/diagnóstico , Apnea Obstructiva del Sueño/epidemiologíaRESUMEN
BACKGROUND: Law enforcement officers (LEOs) experience high rates of cardiovascular events compared with the general US population. Metabolic syndrome (MetS) confers an increased risk of cardiovascular disease and all-cause mortality. Data regarding MetS among LEOs are limited. METHODS: We sought to determine the prevalence of MetS and its associated risk factors as well as gender differences among LEOs who participated in the World Trade Center (WTC) Law Enforcement Cardiovascular Screening (LECS) Program from 2008 to 2010. We evaluated a total of 2,497 participants, 40 years and older, who responded to the 9/11 WTC attacks. RESULTS: The prevalence of MetS was 27%, with abdominal obesity and hypertension being the most frequently occurring risk factors. MetS and its risk factors were significantly higher among male compared to female LEOs, except for reduced HDL-cholesterol levels. CONCLUSIONS: MetS is a rising epidemic in the United States, and importantly, approximately one in four LEOs who worked at the WTC site after 9/11 are affected. Am. J. Ind. Med. 59:752-760, 2016. © 2016 Wiley Periodicals, Inc.
Asunto(s)
Hipertensión/epidemiología , Síndrome Metabólico/epidemiología , Obesidad Abdominal/epidemiología , Policia/estadística & datos numéricos , Ataques Terroristas del 11 de Septiembre/estadística & datos numéricos , Adulto , Femenino , Humanos , Masculino , Persona de Mediana Edad , Ciudad de Nueva York/epidemiología , Encuestas Nutricionales , Prevalencia , Factores de Riesgo , Factores Sexuales , Estados Unidos/epidemiologíaRESUMEN
In this pilot study, we hypothesize that dynamic contrast enhanced magnetic resonance imaging (DCE-MRI) has the potential to evaluate differences in atherosclerosis profiles in patients subjected to high (initial dust cloud) and low (after 13 September 2001) particulate matter (PM) exposure. Exposure to PM may be associated with adverse health effects leading to increased morbidity. Law enforcement workers were exposed to high levels of particulate pollution after working at "Ground Zero" and may exhibit accelerated atherosclerosis. 31 subjects (28 male) with high (n = 19) or low (n = 12) exposure to PM underwent DCE-MRI. Demographics (age, gender, family history, hypertension, diabetes, BMI, and smoking status), biomarkers (lipid profiles, hs-CRP, BP) and ankle-brachial index (ABI) measures (left and right) were obtained from all subjects. Differences between the high and low exposures were compared using independent samples t test. Using linear forward stepwise regression with information criteria model, independent predictors of increased area under curve (AUC) from DCE-MRI were determined using all variables as input. Confidence interval of 95 % was used and variables with p > 0.1 were eliminated. p < 0.05 was considered significant. Subjects with high exposure (HE) had significantly higher DCE-MRI AUC uptake (increased neovascularization) compared to subjects with lower exposure (LE). (AUC: 2.65 ± 0.63 HE vs. 1.88 ± 0.69 LE, p = 0.016). Except for right leg ABI, none of the other parameters were significantly different between the two groups. Regression model indicated that only HE to PM, CRP > 3.0 and total cholesterol were independently associated with increased neovascularization (in decreasing order of importance, all p < 0.026). HE to PM may increase plaque neovascularization, and thereby potentially indicate worsening atherogenic profile of "Ground Zero" workers.
Asunto(s)
Enfermedades de las Arterias Carótidas/inducido químicamente , Enfermedades de las Arterias Carótidas/diagnóstico , Medios de Contraste , Socorristas , Imagen por Resonancia Magnética , Enfermedades Profesionales/inducido químicamente , Enfermedades Profesionales/diagnóstico , Material Particulado/efectos adversos , Ataques Terroristas del 11 de Septiembre , Adulto , Área Bajo la Curva , Enfermedades de las Arterias Carótidas/patología , Femenino , Humanos , Modelos Lineales , Masculino , Persona de Mediana Edad , Análisis Multivariante , Neovascularización Patológica , Ciudad de Nueva York , Exposición Profesional/efectos adversos , Salud Laboral , Proyectos Piloto , Valor Predictivo de las Pruebas , Medición de Riesgo , Factores de RiesgoRESUMEN
Left atrial appendage (LAA) contrast filling defects are commonly found in patients undergoing multidetector cardiac computed tomography (CCT) before catheter ablation of atrial fibrillation. Delayed CCT allows quantification of the LAA delayed/initial attenuation ratio and improves accuracy for LAA thrombus detection, which may obviate routine transesophageal echocardiography (TEE) before ablation. CCT with contrast-enhanced scans (initial CCT) and with noncontrast-enhanced scans (delayed CCT) was performed in 176 patients. LAA was evaluated for filling defects. LAA apex, left atrial (LA) body, and ascending aorta (AA) attenuations (Hounsfield units) were measured on initial and delayed cardiac computed tomograms to calculate LAA, LA, LAA/LA, and LAA/AA attenuation ratios. LAA, initial LAA/LA, and initial LAA/AA attenuation ratios differed significantly in patients with versus without filling defects on cardiac computed tomogram, those with atrial fibrillation versus normal sinus rhythm, and those with abnormal left ventricular ejection fraction versus larger LA volumes (p <0.05). In 70 patients (40%) who underwent TEE, 13 LAA filling defects were seen on initial cardiac computed tomogram. Two defects persisted on delayed cardiac computed tomogram and thrombus was confirmed on transesophageal echocardiogram. Sensitivity, specificity, and positive and negative predictive values of initial CCT for LAA thrombi detection were 100%, 84%, 15%, and 100%, respectively. With delayed CCT these values increased to 100%. Intraobserver and interobserver reproducibilities for cardiac computed tomographic measurements were good (intraclass correlation 0.72 to 0.97, kappa coefficients 0.93 to 1.00). In conclusion, delayed CCT provided an increase in diagnostic accuracy of CCT for detection of LAA thrombus in patients with atrial fibrillation before ablation, which may decrease the need for routine TEE before the procedure.
Asunto(s)
Apéndice Atrial/diagnóstico por imagen , Fibrilación Atrial/cirugía , Ablación por Catéter , Medios de Contraste , Sistema de Conducción Cardíaco/cirugía , Tomografía Computarizada Multidetector/métodos , Venas Pulmonares/cirugía , Anciano , Fibrilación Atrial/diagnóstico por imagen , Ecocardiografía Transesofágica , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Periodo Preoperatorio , Venas Pulmonares/diagnóstico por imagen , Curva ROC , Reproducibilidad de los Resultados , Estudios Retrospectivos , Factores de TiempoRESUMEN
OBJECTIVE: To quantify right ventriculo-arterial coupling in pulmonary hypertension by combining standard right heart catheterisation (RHC) and cardiac magnetic resonance (CMR) and to estimate it non-invasively with CMR alone. DESIGN: Cross-sectional analysis in a retrospective cohort of consecutive patients. SETTING: Tertiary care centre. PATIENTS: 139 adults referred for pulmonary hypertension evaluation. INTERVENTIONS: CMR and RHC within 2 days (n=151 test pairs). MAIN OUTCOME MEASURES: Right ventriculo-arterial coupling was quantified as the ratio of pulmonary artery (PA) effective elastance (E(a), index of arterial load) to right ventricular maximal end-systolic elastance (E(max), index of contractility). Right ventricular end-systolic volume (ESV) and stroke volume (SV) were obtained from CMR and adjusted to body surface area. RHC provided mean PA pressure (mPAP) as a surrogate of right ventricular end-systolic pressure, pulmonary capillary wedge pressure (PCWP) and pulmonary vascular resistance index (PVRI). E(a) was calculated as (mPAP - PCWP)/SV and E(max) as mPAP/ESV. RESULTS: E(a) increased linearly with advancing severity as defined by PVRI quartiles (0.19, 0.50, 0.93 and 1.63 mm Hg/ml/m(2), respectively; p<0.001 for trend) whereas E(max) increased initially and subsequently tended to decrease (0.52, 0.67, 0.54 and 0.56 mm Hg/ml/m(2); p=0.7). E(a)/E(max) was maintained early but increased markedly with severe hypertension (0.35, 0.72, 1.76 and 2.85; p<0.001), indicating uncoupling. E(a)/E(max) approximated non-invasively with CMR as ESV/SV was 0.75, 1.17, 2.28 and 3.51, respectively (p<0.001). CONCLUSIONS: Right ventriculo-arterial coupling in pulmonary hypertension can be studied with standard RHC and CMR. Arterial load increases with disease severity whereas contractility cannot progress in parallel, leading to severe uncoupling.
Asunto(s)
Hipertensión Pulmonar/diagnóstico , Contracción Miocárdica/fisiología , Función Ventricular Derecha , Cateterismo Cardíaco , Estudios Transversales , Femenino , Estudios de Seguimiento , Humanos , Hipertensión Pulmonar/fisiopatología , Imagen por Resonancia Cinemagnética , Masculino , Persona de Mediana Edad , Modelos Teóricos , Pronóstico , Arteria Pulmonar/fisiopatología , Presión Esfenoidal Pulmonar/fisiología , Estudios Retrospectivos , Índice de Severidad de la EnfermedadRESUMEN
BACKGROUND: Right ventricular (RV) failure is a major contributor to morbidity and mortality after left ventricular assist device (LVAD) implantation. Accurate evaluation of RV function in patients with LVAD remains challenging. We hypothesized that, after LVAD implantation, electrocardiographic-gated cardiac computed tomography (CCT) allows RV evaluation with higher feasibility and reproducibility compared with echocardiography. METHODS: Thirty-six patients with an implanted LVAD who had 2-dimensional echocardiography and CCT evaluation were studied. RV end-diastolic and end-systolic volumes and ejection fraction were quantified using CCT. RV fractional area change, tricuspid annular plane systolic excursion and RV end-diastolic short-to-long axis ratio were calculated by echocardiography. Intraclass correlation coefficients (ICCs) and Bland-Altman analysis were used to assess intra- and interobserver reproducibility for all measurements. RESULTS: The quality of CCT studies was good in all cases except for one. Intra- and interobserver reproducibility for all CCT measurements was high (interobserver ICC for RV ejection fraction = 0.89, 95% confidence interval 0.74 to 0.95). Echocardiographic indices of RV function and geometry had lower reproducibility. The echocardiographic index that best correlated with the CCT-determined RV ejection fraction was RV fractional area change (r = 0.80, p < 0.001). In addition, CCT detected relevant post-operative findings in 50% of the patients. CONCLUSIONS: CCT is highly effective and reproducible compared with echocardiography for the evaluation of RV function in patients with LVAD support and provides relevant information on post-operative findings. Our results suggest that CCT should be considered as a useful imaging modality in this clinical setting.
Asunto(s)
Electrocardiografía/métodos , Insuficiencia Cardíaca/terapia , Ventrículos Cardíacos/diagnóstico por imagen , Ventrículos Cardíacos/fisiopatología , Corazón Auxiliar , Tomografía Computarizada por Rayos X/métodos , Adulto , Anciano , Ecocardiografía , Femenino , Insuficiencia Cardíaca/fisiopatología , Humanos , Masculino , Persona de Mediana Edad , Variaciones Dependientes del Observador , Periodo Posoperatorio , Reproducibilidad de los Resultados , Volumen Sistólico/fisiología , Disfunción Ventricular Derecha/diagnóstico por imagen , Disfunción Ventricular Derecha/fisiopatologíaRESUMEN
Early and accurate triage of patients with possible ischemic chest pain remains challenging in the emergency department because current risk stratification techniques have significant cost and limited availability. The aim of this study was to determine the diagnostic value of the coronary artery calcium score (CACS) for the detection of obstructive coronary artery disease (CAD) in low- to intermediate-risk patients evaluated in the emergency department for suspected acute coronary syndromes. A total of 225 patients presenting to the emergency department with acute chest pain and Thrombolysis In Myocardial Infarction (TIMI) scores <4 who underwent non-contrast- and contrast-enhanced coronary computed tomographic angiography were included. CACS was calculated from the noncontrast scan using the Agatston method. The prevalence of obstructive CAD (defined from the contrast scan as ≥ 50% maximal reduction in luminal diameter in any segment) was 9% and increased significantly with higher scores (p <0.01 for trend). CACS of 0 were observed in 133 patients (59%), of whom only 2 (1.5%) had obstructive CAD. The diagnostic accuracy of CACS to detect obstructive CAD was good, with an area under the receiver-operating characteristic curve of 0.88 and a negative predictive value of 99% for a CACS of 0. In a multivariate model, CACS was independently associated with obstructive CAD (odds ratio 7.01, p = 0.02) and provided additional diagnostic value over traditional CAD risk factors. In conclusion, CACS appears to be an effective initial tool for risk stratification of low- to intermediate-risk patients with possible acute coronary syndromes, on the basis of its high negative predictive value and additive diagnostic value.