Amir Lerman

Università di Pisa, Pisa, Tuscany, Italy

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Publications (631)4815.73 Total impact

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    ABSTRACT: Introduction Apical ballooning syndrome (ABS) is typically associated with an antecedent stressful situation. Affected patients have been reported to have higher frequencies of premorbid affective disorders. We hypothesised that patients with ABS would have elevated levels of neuroticism (tendency to experience negative affect) and greater vulnerability to stress. Methods In this cross-sectional study, all active participants in the Mayo Clinic ABS prospective follow-up registry were invited to complete the third edition of the NEO Personality Inventory (NEO-PI-3). The NEO-PI-3 is the universally accepted measure of the ‘Five-Factor Model’ of personality. Inventory responses were scored using the NEO-PI-3 computer program and the data were compared with US normative sample used in standardisation of the inventory. Significance was set at 0.0014 to account for multiple comparisons. Results Of 106 registry participants approached, 53 completed the inventory. There was no difference in age, gender, time from ABS diagnosis, type of antecedent stressor (emotional, physical or none) or severity of initial illness between the responders and non-responders. Responders had mean Neuroticism T-scores of 48.0±10.6 (95% CI 45.1 to 50.9); p=0.18, when compared with the normal mean of 50. There was also no significant difference in the facet scale of Vulnerability: 46.9±8.4 (44.6 to 49.2), p=0.038, at α=0.0014. Conclusions Contrary to our hypothesis, patients with ABS do not manifest higher levels of neuroticism and do not have greater vulnerability to stress than the general population. These findings have implications for the clinicians’ perception of, and approach to, patients with ABS.
    Full-text · Article · Feb 2016
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    ABSTRACT: Renal function in patients with atherosclerosis and renal artery stenosis (ARAS) deteriorates more frequently than in non-atherosclerotic RAS. We hypothesized that ARAS aggravates stenotic kidney microvascular loss compared to RAS.
    No preview · Article · Jan 2016
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    ABSTRACT: Aims: The aim of this study was to investigate the association between hypothyroidism and major adverse cardiovascular and cerebral events (MACCE) in patients undergoing percutaneous coronary intervention (PCI). Methods and results: Two thousand four hundred and thirty patients who underwent PCI were included. Subjects were divided into two groups: hypothyroidism (n = 686) defined either as a history of hypothyroidism or thyroid-stimulating hormone (TSH) ≥5.0 mU/mL, and euthyroidism (n = 1744) defined as no history of hypothyroidism and/or 0.3 mU/mL ≤ TSH < 5.0 mU/mL. Patients with hypothyroidism were further categorized as untreated (n = 193), or those taking thyroid replacement therapy (TRT) with adequate replacement (0.3 mU/mL ≤ TSH < 5.0 mU/mL, n = 175) or inadequate replacement (TSH ≥ 5.0 mU/mL, n = 318). Adjusted hazard ratios (HRs) were calculated using Cox proportional hazards models. Median follow-up was 3.0 years (interquartile range, 0.5-7.0). After adjustment for covariates, the risk of MACCE and its constituent parts was higher in patients with hypothyroidism compared with those with euthyroidism (MACCE: HR: 1.28, P = 0.0001; myocardial infarction (MI): HR: 1.25, P = 0.037; heart failure: HR: 1.46, P = 0.004; revascularization: HR: 1.26, P = 0.0008; stroke: HR: 1.62, P = 0.04). Compared with untreated patients or those with inadequate replacement, adequately treated hypothyroid patients had a lower risk of MACCE (HR: 0.69, P = 0.005; HR: 0.78, P = 0.045), cardiac death (HR: 0.43, P = 0.008), MI (HR: 0.50, P = 0.0004; HR: 0.60, P = 0.02), and heart failure (HR: 0.50, P = 0.02; HR: 0.52, P = 0.017). Conclusion: Hypothyroidism is associated with a higher incidence of MACCE compared with euthyroidism in patients undergoing PCI. Maintaining adequate control on TRT is beneficial in preventing MACCE.
    No preview · Article · Jan 2016 · European Heart Journal
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    ABSTRACT: Background: Revascularization of a stenotic renal artery improves kidney function only in select patients with renovascular hypertension (HT) secondary to atherosclerosis. However, the effects of reversal of renovascular HT (RRHT) on the nonstenotic kidney are unclear. We hypothesized that concurrent hypercholesterolemia (HC) attenuates nonstenotic kidney recovery. Methods: Female domestic pigs were randomized as Normal, renovascular HT, HT+RRHT, HTC (renovascular HT and HC), and HTC+RHT (n = 7 each). RRHT or sham was performed after 6 weeks of HT. Nonstenotic renal blood flow, glomerular filtration rate, and injurious pathways were studied 4 weeks later. Results: Mean arterial pressure increased similarly in HT and HTC and decreased after RRHT. Oxidative stress increased in HT and HTC kidneys, and decreased in HT+RRHT, but remained elevated in HTC+RRHT. Renal interstitial fibrosis, glomerulosclerosis, and tubular injury were all attenuated in HT+RRHT, but not HTC+RRHT. Endothelin-1 signaling and PGF2α isoprostane levels were elevated in both HTC and HTC+RRHT pigs. Conclusions: RRHT reverses nonstenotic kidney injury in experimental renovascular HT, but concurrent HC blunts regression of kidney injury, possibly due to predominant vasoconstrictors and oxidative stress. These findings reinforce the contribution of the nonstenotic kidney and of prevailing cardiovascular risk factors to irreversibility of kidney dysfunction after revascularization.
    No preview · Article · Jan 2016 · American Journal of Hypertension
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    ABSTRACT: Background: Coronary microvascular dysfunction (CMD) causes ischemia and is linked to adverse cardiovascular events. Acute transmural ischemia is associated with QT prolongation, but whether CMD affects repolarization is unknown. The aim of this study was to determine if CMD is associated with prolongation of resting heart rate corrected QT interval (QTc). Methods: In patients presenting to the catheterization laboratory with chest pain and non-obstructive coronary artery disease (CAD) at angiography, coronary flow reserve (CFR) in response to intracoronary adenosine was measured and compared to baseline to give a CFR ratio. The Bazett's-derived QTc was manually derived from patients' 12-lead ECG obtained prior to the procedure. QTc was compared between patients with normal and abnormal (CFR ratio <= 2.5) coronary microvascular function. Results: Of the 926 patients included in this study, 281 patients (30%) had CMD (mean age 53.2 years [SD 12.7], 25% male). QTc was significantly longer in those with an abnormal CFR response to adenosine (median [Q1, Q3] ms: 420 [409, 438] vs. 416 [405, 432]; p value < 0.001) and patients in the lowest quartile of CFR had a significantly longer QTc compared to those in the highest quartile (median [Q1, Q3] ms: 420 [409, 439] vs. 413 [402, 426];p < 0.001). In a linear regression model adjusting for age and sex, CMD was associated with an increase in QTc of 3.09 ms (p = 0.055). Conclusion: Our data suggest that CMD may be associated with an increase in baseline QTc, however the precise clinical relevance of this finding needs to be better investigated in larger clinical studies.
    No preview · Article · Jan 2016 · Journal of Electrocardiology

  • No preview · Article · Dec 2015 · Circulation Cardiovascular Imaging
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    ABSTRACT: Background: The objective of this study was to investigate cardiovascular disease risk factor (cvRF) profiles and compare their trends over 17 years in patients with and without acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI). Hypothesis: Time trends of cvRF are different between ACS and non-ACS patients. Methods: This study was a time-trend analysis from 1994 to 2010 within the Mayo Clinic PCI registry. Outcome measures were incidence and prevalence of cvRF, including the Framingham Risk Score (FRS), at the time of admission for PCI. Results: Age of non-ACS patients was higher than that of ACS patients, and age distribution slightly shifted toward older age in both groups (P for trend <0.001). There was no difference in FRS between the 2 groups; however, 10-year cardiovascular disease risk (%) remained higher in non-ACS than in ACS patients, decreasing over time. Diastolic blood pressure and high-density lipoprotein cholesterol were higher in non-ACS patients, but total cholesterol and low-density lipoprotein cholesterol were higher in ACS patients, with an improving trend over time. Prevalence of diabetes mellitus, hypertension, and history of hypercholesterolemia were higher in non-ACS patients, increasing over time. Smoking did not change over time. Use of most medications increased over time in both groups. Conclusions: Most cvRFs and their time trends exhibited statistically significant differences between ACS and non-ACS patients, except systolic blood pressure, body mass index, and history of myocardial infarction. A new risk-factor profile assessment may be needed for stratification of PCI patients according to ACS and non-ACS status. Clinical and public-health interventions should consider different approaches to ACS and non-ACS patients.
    Preview · Article · Dec 2015 · Clinical Cardiology
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    ABSTRACT: Aims: The current study was designed to test that vasa vasorum (VV) plays a role in the progression of cardiac allograft vasculopathy (CAV) in patients with heart transplantation (HTX). Methods and results: Intravascular ultrasound (IVUS) and optical coherence tomography (OCT) were performed in the left anterior descending artery in 19 segments of 19 HTX patients (median 2.1 years from HTX). Each segment is composed of both the continuous lesions: (i) CAV area: intimal thickness >0.5 mm with 5 mm length and (ii) VV area: intimal thickness ≤0.5 mm with 5 mm length. The per cent VV volume (VV volume/vessel volume × 100, %VV) was evaluated in the VV area with OCT (in CAV area VV cannot be assessed because of limited penetration power of OCT). A year later, the association between the baseline %VV and the change in per cent plaque volume (plaque volume/vessel volume × 100, %PV) was evaluated with IVUS. To a normal distribution, Δ%PV (follow-up %PV-initial %PV) was undergone square root transformation. The correlations between the %VV at baseline study and square root-Δ%PV were significant both in the CAV area and in the VV area (r = 0.787, P < 0.001 and r = 0.701, P < 0.001, respectively). In multivariable analysis, only the %VV was significantly correlated with square root-Δ%PV in both areas. Conclusion: The current study demonstrated a significant association between the VV volume and the progression of plaque volume in both the CAV area and the VV area. Thus, VV may be a potential predictor and possible therapeutic target to attenuate CAV.
    No preview · Article · Dec 2015 · European Heart Journal Cardiovascular Imaging
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    ABSTRACT: Normal endothelial function is central to physiologic anticoagulation mechanisms. Endothelial dysfunction may predispose to venous thromboembolism (VTE). We aimed to investigate if coronary endothelial dysfunction (CED) predicts development of VTE in patients presenting with coronary atherosclerosis without critical stenoses.
    No preview · Article · Dec 2015 · Thrombosis Research
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    ABSTRACT: Ghrelin is a growth hormone-releasing peptide, isolated from the stomach. Researches in progress documented that ghrelin participates in the stimulation of the hypothalamus-pituitary-adrenal axis at the hypothalamic level and in the regulation of energy balance. Growth hormone-independent functions have been ascribed to ghrelin. Among others, a large body of literature demonstrated the presence of specific receptors for ghrelin, distributed at the level of cardiomyocytes and endothelial cells. Therefore, a link between ghrelin and cardiovascular system has been hypothesized and, then, demonstrated in both experimental and clinical studies. Ghrelin has largely documented cardiac beneficial effects, including protection from ischemia/reperfusion injury, attenuation of left ventricular remodeling following myocardial infarction, and improvement of left ventricular function. Exercise level in patients with chronic heart failure had also been seen. Ghrelin exerts these effects through several mechanisms, including the inhibition of apoptosis. At the level of blood vessels, ghrelin exerts a significant impact on vascular function. In particular, acutely infused, ghrelin reverses endothelial dysfunction by increasing NO availability and restores the endothelin-1/nitric oxide imbalance in the peripheral microcirculation of patients with metabolic syndrome. Antioxidant/anti-inflammatory effects, and-or an ameliorated insulin sensitivity are proposed mechanisms whereby ghrelin exerts its vascular protective actions. At higher doses, ghrelin also decreases blood pressure, by mechanisms that involve the modulation of sympathetic nervous system. This finding highlights the ghrelin system as a promising candidate for cardiovascular drug discovery.
    No preview · Article · Nov 2015 · Current pharmaceutical design
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    ABSTRACT: Background: Endothelial dysfunction plays a pivotal role in cardiovascular disease progression, and is associated with adverse events. The purpose of this systematic review and meta-analysis was to investigate the prognostic magnitude of noninvasive peripheral endothelial function tests, brachial artery flow-mediated dilation (FMD), and reactive hyperemia--peripheral arterial tonometry (RH-PAT) for future cardiovascular events. Methods and results: Databases of MEDLINE, EMBASE, and the Cochrane Library were systematically searched. Clinical studies reporting the predictive value of FMD or RH-PAT for cardiovascular events were identified. Two authors selected studies and extracted data independently. Pooled effects were calculated as risk ratio (RR) for continuous value of FMD and natural logarithm of RH-PAT index (Ln_RHI) using random-effects models. Thirty-five FMD studies of 17 280 participants and 6 RH-PAT studies of 1602 participants were included in the meta-analysis. Both endothelial function tests significantly predicted cardiovascular events (adjusted relative risk [95% CI]: 1% increase in FMD 0.88 [0.84-0.91], P<0.001, 0.1 increase in Ln_RHI 0.79 [0.71-0.87], P<0.001). There was significant heterogeneity in the magnitude of the association across studies. The magnitude of the prognostic value in cardiovascular disease subjects was comparable between these 2 methods; a 1 SD worsening in endothelial function was associated with doubled cardiovascular risk. Conclusions: Noninvasive peripheral endothelial function tests, FMD and RH-PAT, significantly predicted cardiovascular events, with similar prognostic magnitude. Further research is required to determine whether the prognostic values of these 2 methods are independent of each other and whether an endothelial function-guided strategy can provide benefit in improving cardiovascular outcomes.
    Preview · Article · Nov 2015 · Journal of the American Heart Association
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    ABSTRACT: Objectives: To determine the feasibility of automated co-registration of angiography and intravascular ultrasound (IVUS) to facilitate integration of these two imaging modalities in a synchronous manner. Background: IVUS provides cross-sectional imaging of coronary arteries but lacks overview of the vascular territory provided by angiography. Co-registration of angiography and IVUS would increase utility of IVUS in the clinical setting. Methods: Forty-nine consecutive patients undergoing surveillance for cardiac allograft vasculopathy with angiography and IVUS of the left anterior descending artery (LAD) were enrolled. A pre-IVUS angiogram of the LAD was performed followed by an ECG-triggered fluoroscopy (ECGTF) during IVUS pullback at 0.5 mm/s using an automatic pullback device. ECGTF was used to track the IVUS catheter during pullback and establish a spatial relationship to the pre-IVUS angiogram. Angio-IVUS co-registration was performed with a research prototype (Siemens Healthcare, Germany) and accuracy was evaluated by distance mismatch between angiography and IVUS images at vessel bifurcations. Results: Median age was 54 (44.5, 67) years. The population was 82.6% male with minimal risk factors. The median (IQR) co-registration distance mismatch measured at 108 bifurcations in 42 (85%) patients was 0.35 (0.00-1.16) mm. Seven patients were excluded due to inappropriate data acquisition (n=3) and failure of tracking (n=4), e.g., due to overlapping sternal wires. Estimated effective radiation dose for ECGTF was 0.09 mSv. Conclusion: This study demonstrates the feasibility of angio-IVUS co-registration which may be used as a clinical tool for localizing IVUS cross-sections along an angiographic roadmap.
    No preview · Article · Nov 2015 · Catheterization and Cardiovascular Interventions
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    ABSTRACT: Background: Coronary microvascular dysfunction (CMD) is linked to adverse cardiovascular events. Definitive diagnosis of CMD requires invasive provocative testing during angiography. We developed and tested a novel computerized T wave analysis tool to identify electrocardiographic signatures of CMD. Methods: 1552 patients underwent an invasive assessment of coronary microvascular function. Patients with interpretable pre-procedural ECGs were divided into 2 age and sex matched groups (n=261 in each group, 75% female): normal microvascular function, CFR>2.5 (CFR+), and abnormal microvascular function, CFR≤2.5 (CFR-). ECGs were evaluated using a novel T wave program that quantified subtle changes in T wave morphology. Results: T wave repolarization parameters were significantly different between patients with normal and abnormal microvascular function. The top 3 features in males comprised of T wave area in V6 (CFR+: 10091.4mV(2) vs. CFR-: 8152.3mV(2), p<0.05); T1 Y-center of gravity in lead II (CFR+: 17.8mV vs. CFR-: 22.4, p<0.005) and T Peak-T End in lead II (CFR+: 97.6msec vs. CFR-: 91.1msec, p<0.05). These could identify the presence of an abnormal CFR with 74±0.2% accuracy. In females, the top 3 features were T wave right slope lead V6 (CFR+: -2489.1mV/msec vs. CFR-: -2352.3mV/msec, p<0.005); Amplitude in V6 (CFR+: 190.4mV vs. 172.7mV, p=0.05) and Y-center of gravity in lead V1 (CFR+: 33.3 vs. CFR-: 40.0, p=0.001). These features could identify the presence of an abnormal CFR with 67±0.3% accuracy. Conclusion: Our data demonstrates that a computer-based repolarization measurement tool may identify electrocardiographic signatures of CMD.
    Full-text · Article · Nov 2015 · International journal of cardiology
  • Megha Prasad · Lilach O. Lerman · Amir Lerman

    No preview · Article · Nov 2015 · Journal of the American College of Cardiology
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    ABSTRACT: The Framingham Risk Score (FRS) effectively predicts the risk of cardiovascular events in the primary prevention setting. However, its use in identifying the risk of cardiovascular events among patients with established coronary heart disease is unknown. This study aimed to evaluate the utility of the FRS in predicting long-term secondary events in patients following percutaneous coronary intervention (PCI) across a 17-year period.
    No preview · Article · Nov 2015
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    ABSTRACT: Background: Decellularized heart valves are emerging as a potential alternative to current bioprostheses for valve replacement. Whereas techniques of decellularization have been thoroughly examined, terminal sterilization techniques have not received the same scrutiny. Methods: This study evaluated low-dose gamma irradiation as a sterilization method for decellularized heart valves. Incubation of valves and transmission electron microscopy evaluation after different doses of gamma irradiation were used to determine the optimal dose of gamma irradiation. Quantitative evaluation of mechanical properties was done by tensile mechanical testing of isolated cusps. Sterilized decellularized heart valves were tested in a sheep model (n = 3 [1 at 1,500 Gy and 2 at 3,000 Gy]) of pulmonary valve replacement. Results: Valves sterilized with gamma radiation between 1,000 Gy and 3,000 Gy were found to be optimal with in vitro testing. However, in vivo testing showed deteriorating valve function within 2 months. On explant, the valve with 1,500 Gy gamma irradiation showed signs of endocarditis with neutrophils on hematoxylin and eosin staining, and positive gram stain resembling streptococcus infection. The 3,000 Gy valves had no evidence of infection, but the hematoxylin and eosin staining showed evidence of wound remodeling with macrophages and fibroblasts. Tensile strength testing showed decreased strength (0 Gy: 2.53 ± 0.98 MPa, 1,500 Gy: 2.03 ± 1.23 MPa, and 3,000 Gy: 1.26 ± 0.90 MPa) with increasing levels of irradiation. Conclusions: Low-dose gamma irradiation does not maintain the mechanical integrity of valves, and the balance between sterilization and damage may not be able to be achieved with gamma irradiation. Other methods of terminal sterilization must be pursued and evaluated.
    Full-text · Article · Oct 2015 · The Annals of thoracic surgery
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    ABSTRACT: Background: Coronary microvascular dysfunction (CMD) causes ischemia and is linked to adverse cardiovascular events. Acute transmural ischemia is associated with QT prolongation, but whether CMD affects repolarization is unknown. The aim of this study was to determine if CMD is associated with prolongation of resting heart rate corrected QT interval (QTc). Methods: In patients presenting to the catheterization laboratory with chest pain and non-obstructive coronary artery disease (CAD) at angiography, coronary flow reserve (CFR) in response to intracoronary adenosine was measured and compared to baseline to give a CFR ratio. The Bazett's-derived QTc was manually derived from patients' 12-lead ECG obtained prior to the procedure. QTc was compared between patients with normal and abnormal (CFR ratio≤2.5) coronary microvascular function. Results: Of the 926 patients included in this study, 281 patients (30%) had CMD (mean age 53.2years [SD 12.7], 25% male). QTc was significantly longer in those with an abnormal CFR response to adenosine (median [Q1, Q3] ms: 420 [409, 438] vs. 416 [405, 432]; p value<0.001) and patients in the lowest quartile of CFR had a significantly longer QTc compared to those in the highest quartile (median [Q1, Q3] ms: 420 [409, 439] vs. 413 [402, 426]; p<0.001). In a linear regression model adjusting for age and sex, CMD was associated with an increase in QTc of 3.09ms (p=0.055). Conclusion: Our data suggest that CMD may be associated with an increase in baseline QTc, however the precise clinical relevance of this finding needs to be better investigated in larger clinical studies.
    No preview · Article · Oct 2015 · Journal of electrocardiology
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    ABSTRACT: Purpose: Perirenal fat is associated with poor blood pressure control and chronic kidney disease, but the underlying mechanisms remain elusive. We tested the hypothesis that perirenal fat impairs renal arterial endothelial function in pigs with obesity-metabolic derangements (ObM). Material and methods: Fourteen domestic pigs were studied after 16 weeks of a high-fat/high-fructose diet (ObM) or standard chow (Lean). Renal blood flow (RBF), glomerular filtration rate (GFR), and visceral fat volumes were studied in-vivo with CT. Renal arterial endothelial function was also studied ex-vivo in the organ bath. Results: ObM pigs demonstrated increased body weight, blood pressure, cholesterol, and intra-abdominal fat compared to lean pigs, and perirenal fat volume was significantly larger. RBF and GFR were markedly elevated, while urinary protein level was preserved. Ex-vivo acetylcholine-induced endothelium-dependent vasodilation of renal artery rings was substantially impaired in ObM compared to Lean. Endothelial function was further blunted in both ObM and Lean arterial rings by incubation with perirenal fat harvested from ObM, but not from Lean pigs, and was restored by inhibition of tumor necrosis factor (TNF)-α. ObM perirenal fat also showed increased pro-inflammatory macrophage infiltration and TNF-α expression. Conclusions: ObM perirenal fat directly causes renal artery endothelial dysfunction, partly mediated by TNF-α.
    No preview · Article · Sep 2015 · The Journal of urology
  • Amir Lerman · Taek-Geun Kwon · Lilach O Lerman

    No preview · Article · Sep 2015 · JACC. Cardiovascular imaging
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    ABSTRACT: Epicardial adipose tissue (EAT) has been recognized as a sensitive marker of cardiometabolic risk. Recent evidence suggests efficacy of long-term statin therapy in reducing EAT in patients with coronary artery disease. Whether short-term statin therapy is associated with changes in the volume of EAT is currently unknown. A cohort of patients with atrial fibrillation who underwent pulmonary vein isolation were randomized to receive either 80 mg/day of atorvastatin (n = 38, 32 men, age 56 ± 11 years) or placebo (n = 41, 33 men, age 56 ± 10 years) for a 3-month period. EAT volume was assessed by cardiac computed tomography at baseline and at follow-up. Patients randomized to statin treatment exhibited a modest but significant decrease in median EAT volume (baseline vs follow-up: 92.3 cm(3) [62.0 to 133.3] vs 86.9 cm(3) [64.1 to 124.8], p <0.05), whereas median EAT remained unchanged in the placebo group (81.9 cm(3) [55.5 to 110.9] vs 81.3 cm(3) [57.1 to 110.5], p = NS). Changes in median systemic inflammatory markers and lipid profile were also seen with statin treatment: C-reactive protein (2.4 mg/L [0.7 to 3.7] vs 1.1 mg/L [0.5 to 2.7], p <0.05), total cholesterol (186 mg/dL [162.5 to 201] vs 123 mg/dL [99 to 162.5], p <0.001), and low-density lipoprotein cholesterol (116 mg/dL [96.5 to 132.5] vs 56 [40.5 to 81] mg/dL, p <0.001) diminished, whereas median body mass index did not change (27.8 kg/m(2) [25 to 30] versus 27.6 kg/m(2) [25.7 to 30.5], p = NS). No variations occurred in the placebo group. In conclusion, short-term intensive statin therapy significantly reduced the volume of EAT in patients with atrial fibrillation.
    No preview · Article · Sep 2015 · The American journal of cardiology

Publication Stats

27k Citations
4,815.73 Total Impact Points

Institutions

  • 2015
    • Università di Pisa
      Pisa, Tuscany, Italy
    • St. Mary's Hospital (WI, USA)
      Madison, Wisconsin, United States
  • 2013-2015
    • Sun Yat-Sen University
      • Department of Vascular Surgery
      Shengcheng, Guangdong, China
    • Konyang University Hospital
      Gaigeturi, Jeju-do, South Korea
  • 2000-2015
    • Mayo Foundation for Medical Education and Research
      • Division of Cardiovascular Diseases
      Рочестер, Michigan, United States
    • University of Pennsylvania
      • Department of Pediatrics
      Filadelfia, Pennsylvania, United States
  • 1990-2015
    • Mayo Clinic - Rochester
      • • Department of Cardiovascular Diseases
      • • Department of Internal Medicine
      Рочестер, Minnesota, United States
  • 2012
    • University of California, Los Angeles
      Los Angeles, California, United States
  • 2010-2012
    • Rochester College
      Rochester, New York, United States
  • 2011
    • University of Florida
      Gainesville, Florida, United States
  • 2002-2009
    • University of Minnesota Rochester
      Rochester, Minnesota, United States
    • Saint Louis University
      Сент-Луис, Michigan, United States
    • University Hospital Essen
      Essen, North Rhine-Westphalia, Germany
  • 2008
    • Duke University Medical Center
      Durham, North Carolina, United States
    • Vanderbilt University
      Нашвилл, Michigan, United States
  • 2003
    • Second University of Naples
      Caserta, Campania, Italy
    • Technion - Israel Institute of Technology
      H̱efa, Haifa District, Israel
    • Aarhus University
      Aarhus, Central Jutland, Denmark
  • 1998
    • University of Zurich
      Zürich, Zurich, Switzerland
    • University of Rome Tor Vergata
      Roma, Latium, Italy