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We present a clinical case of a 63-year old Caucasian man with Ehlers-Danlos syndrome who was admitted with atrial fibrillation and arterial hypertension. We present this not as a cardiological case but instead address the key questions of differential diagnosis, diagnosis criteria, management and improving the patient's quality of life.
Sleep-disordered breathing (SDB) is a complex syndrome with a high prevalence and a significant impact on the general well-being of the overall population. Heart failure (HF) is a major health issue with an increasing incidence, a high rate of hospitalizations, and high mortality in developing countries. Focusing on early recognition and management of HF comorbidities may have an important role in reducing the economic burden and public health impact of HF. The close interconnection between HF, heart rhythm disturbances, and sleep apnea is supported by the mutual risk factors such as age, smoking, obesity, and male sex. Central sleep apnea (CSA) may be considered a marker of advanced HF, often being associated with elevated pulmonary capillary wedge pressure, brain natriuretic peptide (BNP), and noradrenaline levels and with low left ventricular ejection fraction. In the same way, there is an important correlation between CSA and different types of arrhythmias. The large intraindividual rhythm variability reported in patients with SDB who underwent continuous monitoring by implantable loop recorder (ILR) demonstrated the incapacity of 24-hour and 48-hour Holter monitoring to accurately determine the incidence of cardiac arrhythmias. In patients with HF and CSA, the extended cardiac monitoring by ILR becomes compulsory because in-time interventions could be life saving, but with the absolute lack of solid evidence in this field, there is an acute need for extensive randomized trials to further highlight the potential beneficial effect of ILR monitoring in patients with CSA and HF.
Background Metabolic syndrome (MetS) and visceral obesity represent important cardiometabolic risk factors. Right ventricular (RV) function is affected in MetS. Epicardial adipose tissue is a metabolically active organ which might influence cardiac morphology and function, especially in patients with MetS. Epicardial fat thickness (EFT) is proposed as a new marker of visceral obesity. Purpose The objective of our study was to evaluate the role of EFT and RV hypertrophy in global (determined by Tei index) and diastolic function of RV in patients with MetS. Methods The study included 85 subjects with MetS (mean age 52±9.1 years) and 85 controls without MetS (mean age 50±8.9 years, P=0.06). MetS was defined by ≥3 criteria of International Diabetes Federation and American Heart Association/National Heart, Lung, and Blood Institute. All the subjects underwent complete 2D echocardiography with the assessment of the ratio of early and late diastolic tricuspid flow velocities (Et/At), the ratio of early diastolic tricuspid flow velocity and early diastolic tricuspid annular velocity (Et/e't), Et deceleration time (DT), RV end-diastolic free wall thickness (EDWT) and EFT. We determined Tei index of RV by pulsed and pulsed tissue Doppler. Results All the parameters of RV diastolic function, as well as Tei index, were significantly changed in MetS group: Et/At 0.85±0.39 vs. 1.17±0.43, P<0.001; Et/e't 5.1±1.3 vs. 4.5±0.8, P<0.001; DT 235±8 ms vs. 208±14 ms, P<0.001; Tei index by pulsed Doppler (0.48±0.05 vs. 0.34±0.06, P<0.001) and by pulsed tissue Doppler (0.58±0.05 vs. 0.46±0.04, P<0.001). Also, RV EDWT was significantly higher in MetS patients (6.3±0.8 mm vs. 4.6±1.2 mm, P<0.001) and positively correlated with Tei index (r=0.658, P<0.001; fig.1.A), Et/e't (r=0.269, P<0.001) and EFT (r=0.547, P<0.001). EFT was higher in MetS subjects (7.9±0.07 mm vs. 5.4±1.2 mm, P<0.001) and correlated with RV Tei index (r=0.614, P<0.001; fig.1.B), Et/e't (r=0.432, P<0.001). Multivariate regression analysis showed that systolic blood pressure, plasma glucose level, EFT and RV EDWT were independently associated with RV global and diastolic dysfunction in patients with MetS (P<0.05 for all parameters). Conclusions Our findings support that MetS is associated with diastolic and global dysfunction of RV. In subjects with MetS increased EFT and RV hypertrophy are independently associated with RV diastolic and global function. Funding Acknowledgement Type of funding source: None
Background The importance of the evaluation of right compartments of the heart is beyond doubts. Right ventricle (RV) plays one of the leading roles in assessing the prognosis of the patients, especially in the context of metabolic syndrome (MS), insulin resistance and visceral obesity. Several trials highlight the epicardial fat thickness (EFT) as a novel marker of visceral obesity and the proximity to the RV does not exclude its direct effect on ventricular function. More of that, EFT represents a metabolically active organ with a wide range of bioeffects that could potentiate cardiometabolic risk profile in patients with MS and visceral obesity. Purpose The objective of the present study was to evaluate the impact of visceral obesity, RV hypertrophy and RV diastolic and global function on exercise capacity (i.e., exercise duration (ED), metabolic equivalents (METs)) in patients with MS and persevered left ventricular function. Methods We included 97 subjects with MS (mean age 54±8.7 years) and 97 controls without MS (mean age 53±9.6 years, P=0.13). MS was defined by ≥3 criteria of International Diabetes Federation and American Heart Association/National Heart, Lung, and Blood Institute. Using 2D echocardiography we assessed RV diastolic function: the ratio of early and late diastolic tricuspid flow velocities (Et/At), the ratio of early diastolic tricuspid flow velocity and early diastolic tricuspid annular velocity (Et/e't), Et deceleration time (DT); Tei index of RV by pulsed tissue Doppler; RV free wall thickness; epicardial fat thickness (EFT). All the participants underwent exercise ECG stress test (cycle ergometry) and the exercise capacity was determined by ED and METs. Results Et/At, Et/e't, EtDT and Tei index were significantly deteriorated in MS group (all P<0.05). Also, RV free wall thickness and EFT showed significant correlations with parameters of RV diastolic function in patients with MS, respectively: Et/At (r=−0.432, P<0.05; r=−0.523, P<0.01), Et/e't (r=0.334, P<0.01; r=0.291, P<0.01), EtDT (r=0.411, P<0.05; r=0.593, P<0.001). RV Tei index positively correlated with RV free wall thickness (r=0.628, P<0.001) and EFT (r=0.623, P<0.001). In bivariate analysis we found that METs were negatively associated to Et/e't (r=−0.208, P=0.033), EtDT (r=−0.295, P<0.01), RV Tei index (r=−0.515, P<0.001), RV free wall thickness (r=−0.504, P<0.001), EFT (r=−0.646, P<0.05) in MS group. Also, ED showed important negative correlation with the same parameters (all P<0.05). Systolic function of RV did not show statistically significant correlations with METs or ED. Multivariate regression analysis showed that RV free wall thickness, RV Tei index and EFT were independently associated with METs in patients with MS (P<0.05). Conclusions Our findings support that epicardial fat thickness, right ventricular Tei index and right ventricular hypertrophy impact exercise tolerance in patients with metabolic syndrome. Funding Acknowledgement Type of funding sources: None.
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