bluuebunny/crossref_metadata_2025 huggingface dataset:
Exercise stress echocardiography with probe fixated on patient's chest
Authors: Wdowiak-Okrojek K , Lipiec P , Wejner-Mik P , Bednarkiewicz Z , Kasprzak J.D
Published: October 2021

Background

Stress echocardiography (SE) has been widely used in clinical practice for decades and recently has gained even more importance in diagnostic approach to ischemic heart disease. However, it still has numerous limitations. Despite advantages of physical exercise as most physiologic stressor, it is impossible to continuously monitor the cardiac function during treadmill test and difficult to maintain an optimal acoustic window during cycle ergometer exercise test. We aimed to assess the feasibility of probe fixation for the use during exercise echocardiography.

Methods

48 subjects (47 men, mean age 42±17 years, 25 healthy volunteers, 23 patients with suspected coronary artery disease) were included in this study. All subjects underwent exercise stress test on treadmill (32 cases) or cycle ergometer (16 cases). Both sector and matrix probes were used (in 17 and 31 tests, respectively). We assessed semi-quantitatively the quality of acquired apical views at each stage using four-point grading system (0 = poor, 1 = suboptimal, 2 = acceptable, 3 = optimal).

Results

The mean time required for probe fixation was 9±2 min. At baseline, 10 patients had at least one apical window of quality precluding reliable analysis. 25 patients probe repositioning during exercise (more often on treadmill). During peak exercise quality of images in all views declined, but it remained sufficient in 29 patients for diagnostic purposes. Thus, 76% of performed tests (60% for all study population) were of sufficient image quality.

Conclusion

Probe fixation offers the possibility of continuous acquisition of echocardiographic images during physical exercise. However the device is suitable almost exclusively for male patients. Moreover, in some patients it requires repositioning.

Funding Acknowledgement

Type of funding sources: None.
Echocardiographic determinants of ventricular arrhythmia in sickle cell disease adults
Authors: Dupuy M , Saba J , Codiat R , Derumeaux G , Alassaad L , Abou Chakra L , Odouard S , Deux J.F , Guillet H , Savale L , De Luna G , Bartolucci P , D'Humieres T
Published: October 2021

Background

Unexplained sudden death remains one of the leading causes of death in sickle cell disease (SCD) adults. Ventricular arrhythmia is a well-known risk factor for sudden death but its prevalence and determinants in the context of SCD remain understudied.

Purpose

The aim of this study was to identify echocardiographic predictors of ventricular arrhythmia in SCD.

Methods

From January 2019 to March 2021, consecutive adult patients with SCD referred to ambulatory cardiology department for possible cardiac involvement were prospectively included (Drepacoeur cohort). All patients that had 24-hour ECG monitoring (24h-holter) and thransthoracic echocardiography (TTE) on the same day were analysed in this study. The primary end point was the occurrence of ventricular arrhythmia, defined as sustained or non-sustained ventricular tachycardia (VT), more than 500 premature ventricular contractions (PVC) on 24h-holter, or history of VT ablation.

Results

Overall, 90 patients were included and 54 (60%) were analysed. Mean age was 47.6±11.6 years (range 21–69), 53% were male. Heart function was mainly preserved with a mean left ventricular ejection fraction (LVEF) of 57.9±4.9% and a mean global longitudinal strain (GLS) of −18±2.8%. Mean tricuspid regurgitation velocity was 2.6±0.4m/s.

Ventricular arrhythmia was observed in 13 (24.1%) patients (4 non-sustained VT [range 4–121 consecutive PVC], 9 with more than 500 PVC [range 500–13000 PVC/24h] and 1 history of VT ablation). Regarding echocardiographic parameters, ventricular arrhythmia was associated with lower GLS (−15.8±1.8% vs. −19±2.7%, P<0,001), lower tricuspid annular plane systolic excursion (TAPSE, 23±5.7mm vs. 26.9±4.6mm, P=0,02) and more dilated right ventricle assessed by tricuspid annulus diameter (38.2±6.1mm vs. 34.2±4.5mm, P=0,02). In multivariate analysis, GLS was independently associated with ventricular arrhythmia (OR=2,1 CI95% [1,3; 3,3], P=0,004) with a moderate exponential correlation with PVC load on 24h-holter (R=0,5, P<0,001). Interestingly, ventricular arrhythmia was not associated with corrected QT interval nor with age or hemoglobin serum level.

Conclusion

In SCD adults with preserved LVEF, GLS was the only independent echocardiographic predictor of ventricular arrhythmia.

Funding Acknowledgement

Type of funding sources: None.
Arrhythmias caused by mutations in SCN5A in children
Authors: Polyakova E , Shcherbakova N
Published: October 2021

Pathogenic genetic variants of the sodium channel alpha-subunit gene (SCN5A) is the leading cause of familial bradyarrhythmias. These diseases often manifest with syncope, have family segregation, and needs antiarrhythmic devices implantation, even in children. However, phenotypically these mutations can manifest as sick sinus syndrome (SSS), atrial fibrillation (AF), Brugada syndrome, and long QT syndrome. There are no studies on the prevalence of SCN5A mutations in children with arrhythmias.

The aim is to study phenotypic and electrocardiographic manifestations of SCN5A-mutations in children with bradyarrhythmias.

Methods

We analyzed the data of 26 patients with bradyarrhythmias, who underwent genetic testing, from the database of the Russian Pediatric Arrhythmia Center. Seventeen were the probands, and nine - family members. The average age was 15.4±4.5 (from 2 to 17). Whole-exome sequencing was performed for 18 patients, cardiovascular panels for others.

Results

Variants of the sodium channel gene were detected in 3 family cases of arrhythmias and one sporadic case. In total, variants in SCN5A gene were found in 9 patients out of 26 (35%).

In the first family, two sisters aged 6 and 17 have two biallelic variants of unknown significance in SCN5A gene. Both girls periodically have a Brugada marker on their ECG. The sisters both had syncope before the implantation of defibrillators. The girls' parents and older sister are clinically healthy, but the father previously had syncope. In the second family, a boy with a binodal disease, syncope, and an implanted pacemaker has two biallelic likely pathogenic variants in SCN5A gene. The boy's sister inherited only the mother's of SCN5A variant, showed a normal ECG in the first year of life, but then developed bradycardia within one year, and then joined the AVB of the 1st degree. Both parents had no clinical manifestations and no complaints. The third family included a mother and daughter with SSS and the heterozygous missense variant of unknown significance in SCN5A gene. Both of them do not need pacemaker implantation. The 12-year-old girl with two heterozygous variants of unknown significance in SCN5A gene had SSS, AF and underwent pacemaker implantation.

Conclusion

Genetic variants of SCN5A were detected in 35% of patients with bradyarrhythmias. Electrocardiographic manifestations of arrhythmias in our patients with SCN5A variants are diverse – SSS, Brugada syndrome, atrial fibrillation. Phenotypic variability in the manifestation of the SCN5A mutation requires a more thorough study of bradyarrhythmias' genetic causes in children.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Clinical Research Institute of Pediatrics named after acad. Y.E.Veltishev at the Pirogov Russian National Research Medical University, Moscow, Russia
VT recurrence and predictors in patients with VT inducibility at the end of VT ablation
Authors: Nakasone K , Fukuzawa K , Kiuchi K , Takami M , Takemoto M , Sakai J , Nakamura T , Yatomi A , Sonoda Y , Takahara H , Yamamoto K , Suzuki Y , Tani K , Hirata K
Published: October 2021

Background

A successful Radiofrequency (RF) ablation of ventricular tachycardia (VT) can prevent VT recurrence. It has been reported that VT non-inducibility at the end of RF ablation is associated with less likely VT recurrence in ischemic cardiomyopathy (ICM) and non-ICM (NCIM). However, it is not clear whether we should use VT non-inducibility as routine end point in RF ablation of VT.

Purpose

The aim of this study was to evaluate VT recurrence in patients who couldn't be achieved VT non-inducibility at the end of RF ablation and the factors attributed to VT recurrence in ICM and NICM patients.

Methods

Between January 2009 and April 2020, 84 consecutive patients (ICM: 34, NICM: 50) underwent RF ablation for drug-resistant VT in our hospital. VT non-inducibility was defined as any ventricular tachy-arrhythmia, including clinical VT, non-clinical VT, and VF, was not induced by programed stimuli at the end of session. Non-inducibility was achieved in 37 patients but it was not achieved in 47 patients (ICM: 18, NICM: 29). To evaluate the validity of “non-inducibility” as an end point of VT ablation, 47 patients (male: 40, mean age: 66±15 years) in whom non-inducibility of any ventricular tachyarrhythmia was not achieved were studied. The primary endpoint was recurrence of any sustained VT and VF during follow up period (mean follow-up period was 1.4 (range, 0.0, 2.0) years.)

Results

Mean left ventricular ejection fraction (LVEF) was 36±13%. Epicardial ablation was required in 8 patients. 32 patients had electrical storm at the time of ablation. Among them, 21 patients had VT recurrence and 26 patients had non-VT recurrence during follow-up period. VT recurrence rate was significantly lower in patients with LVEF≥35% than those with LVEF<35% (HR=0.31, 95% CI 1.25–9.92). Multivariate survival analysis identified LVEF≥35% (HR=0.34, 95% CI 0.10–0.98) and ablation of VT isthmus (HR=0.18, 95% CI 0.02–0.78) as independent predictors of non-VT recurrence.

Conclusions

Even if non-inducibility of any ventricular tachyarrhythmia wasn't achieved at the end of ablation, the patients with LVEF≥35% or who had ablated of VT isthmus might prevent VT recurrence. The validity of non-inducibility of any ventricular tachyarrhythmia should be evaluated in each patient's background.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Abbott, Medtronic
Ventricular tachycardia ablation in nonischemic cardiomyopathy
Authors: Nascimento Matos D , Cavaco D , Cavaco D , Carmo P , Carmo P , Carvalho M.S , Carvalho M.S , Rodrigues G , Rodrigues G , Carmo J , Carmo J , Galvao Santos P , Galvao Santos P , Costa F.M , Costa F.M , Mendes M , Mendes M , Morgado F , Morgado F , Adragao P , Adragao P
Published: October 2021

Introduction

Catheter ablation outcomes for drug-resistant ventricular tachycardia (VT) in nonischemic cardiomyopathy (NICM) are suboptimal when compared to ischemic cardiomyopathy. We aimed to analyse the long-term efficacy and safety of percutaneous catheter ablation in this subset of patients.

Methods

Single-center observational retrospective registry including consecutive NICM patients who underwent catheter ablation for drug-resistant VT during a 10-year period. The efficacy endpoint was defined as VT-free survival after catheter ablation, while safety outcomes were defined by 30-days mortality and procedure-related complications. Independent predictors of VT recurrence were assessed by Cox regression.

Results

In a population of 68 patients, most were male (85%), mean left ventricular ejection fraction (LVEF) was 34±12%, and mean age was 58±15 years. All patients had an implantable cardioverter-defibrillator. Twenty-six (38%) patients underwent epicardial ablation (table 1). Over a median follow-up of 3 years (IQR 1–8), 41% (n=31) patients had VT recurrence and 28% died (n=19). Multivariate survival analysis identified LVEF (HR= 0.98; 95% CI 0.92–0.99, p=0.046) and VT storm at presentation (HR=2.38; 95% CI 1.04–5.46, p=0.041) as independent predictors of VT recurrence. The yearly rates of VT recurrence and overall mortality were 21%/year and 10%/year, respectively. No patients died at 30-days post-procedure, and mean hospital length of stay was 5±6 days. The complication rate was 7% (n=5, table 1), mostly in patients undergoing epicardial ablation (4 vs 1 in endocardial ablation, P=0.046).

Conclusion

LVEF and VT storm at presentation were independent predictors of VT recurrence in NICM patients after catheter ablation. While clinical outcomes can be improved with further technical and scientific development, a tailored endocardial/epicardial approach was safe, with low overall number of complications and no 30-days mortality.

Funding Acknowledgement

Type of funding sources: None.
Prodromal symptoms of out-of-hospital cardiac arrest among patients calling emergency and non-emergency medical help services
Authors: Zylyftari N , Lee C.J.-Y , Gnesin F , Moeller A.L , Mills E.H.A , Moeller S.G , Jensen B , Ringgren K.B , Christensen H.C , Blomberg N.F , Tan H.L , Folke F , Koeber L , Gislason G.H , Torp-Pedersen C
Published: October 2021

Background

Early identification of individuals at risk of out-of-hospital cardiac arrest (OHCA) remains difficult. Little is known about symptoms presented when contacting a medical helpline prior to OHCA.

Aim

To examine the registered prodromal symptoms when patients phoned to seek medical help prior to OHCA.

Methods

OHCA patients (≥18 years) were identified from the Danish Cardiac Arrest Registry (2014–2018) and linked with calls to the non-emergency (1813-Medical Helpline) and Emergency Medical Services 1–1-2 (112). We examined (1) symptoms registered within 30 days before OHCA, categorized into eight groups and stratified by time-period and call-type; (2) hospital diagnoses and medical prescriptions according to symptom groups within 180 days before these calls.

Results

Among 974 OHCA patients who called in total within 30 days before OHCA, 816 OHCA patients (males 57%, median age 76 years [Q1-Q3: 65–84]) had a registered symptom and some of them called more than once (1,145 calls by 816 patients). Overall, the most reported group of symptoms was “Other” (29%), containing a diverse group of prodromal symptoms registered by the caregiver that did not fit into the other categories (Figure), followed by breathing problems (15%). When stratified by time-period (Figure) the most common symptom group remained “Other”. This was followed by symptoms related to the Central Nervous System (CNS)/Unconsciousness (17%) for the time-period within 0–7 days before OHCA, and by breathing problems (19%) and trauma/exposure (17%) for the time-period within 8–30 days before OHCA (Figure). When stratified by call-type, most patients (60.8%) called the 1813-Medical Helpline, where “Other” (35%) and abdominal/back/urinary (14%) symptom groups were the most common. While breathing problems (24%) and CNS/Unconsciousness (21%) were highly reported among calls to 112. Within 180-days before contact with the medical helpline, independently of the symptom group presented, respiratory-related hospital diagnoses and antibiotic medications were common.

Conclusions

Patients with OHCA who called emergency and non-emergency medical helpline 30 days before OHCA had diverse prodromal symptoms; the largest category were “Other” symptoms, followed by breathing-related symptoms.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): European Union's Horizon 2020 under the ESCAPE-NET program;Helsefonden Figure 1. Classification of the prodromal symptoms among patients that called for medical assistance. Stratified by the time-period within 0–7 days and 8–30 days before OHCA. The number of calls within 0–7 days before OHCA = 471 (399 patients), and the number of calls within 8–30 days before OHCA = 674 (500 patients).
The frequency of electrodes replacement in patients undergoing cardiac resynchronizaton therapy during long term follow up
Authors: Jedrzejczyk-Patej E , Mazurek M , Sokal A , Kotalczyk A , Gumprecht J , Szulik M , Pruszkowska-Skrzep P , Kowalski O , Lenarczyk R , Kalarus Z
Published: October 2021

Background

Cardiac resynchronization therapy (CRT) is an effective method of treatment in patients with HF, but as complex device with three electrodes, it is prone to electrode dysfunctions and the need to replace them. However little is known about the frequency of need for leads replacement in subjects undergone CRT in a very long-term follow up.

Aim

To determine the frequency of leads replacement in patients undergoing CRT during long term follow-up.

Methods

Study population consisted of 1059 consecutive patients with CRT implanted between 2002 and 2019 in tertiary care university hospital, in a densely inhabited, urban region of Poland. The data about lead replacement was collected.

Results

During the median follow-up of 1661 days (IQR: 815–2792) for non-infectious reasons (dislocation, dysfunction, fracture etc.) a total of 324 leads in 251 patients (23.7%) were replaced. Median time from CRT implantation to the first lead replacement was 359 days (42–1413). The electrode replacement within first year after CRT implantation was performed in 126 subjects (50.2%), in the rest of patients (49.8%) the leads were replaced after one year of device implantation. In patients with above ten years of follow up (n=143; 13.5%) 67 subjects (46.8%) had one or more lead replacement during follow up.

Patients with electrode replacement during follow-up were younger (63 vs 66 years, P<0.001), more often with nonischemic cardiomyopathy (52.6% vs 41.6%, P=0.002), less often with permanent atrial fibrillation (12.4% vs 24.4%, P<0.001) and had higher left ventricle end-diastolic diameter (68 vs 67 mm, P=0.02). The duration of the first CRT device implantation were longer with higher fluoroscopy time in comparison with patients without lead replacement during follow up (135 vs 120 min, P<0.001 and 20.5 vs 16 min, P<0.001, respectively) and these were an independent predictors of lead replacement during FU (HR 1.002, 95% CI 1.000–1.006, P=0.03 and HR 1.005, 95% CI 1.002–1.008, P<0.001, respectively).

Conclusions

The need for leads replacement due to non-infectious reasons reaches almost 25% of patients with CRT within 4.5 years. Half of the patients have lead replacement within one year after CRT implantation and the other half during long term follow up. The duration of the first procedure (CRT device implantation) is strong predictor of lead replacement during follow up.

Funding Acknowledgement

Type of funding sources: None.
Low level transcutaneous vagus nerve stimulation reverses cardiac dysfunction and changes left ventricular gene expression in a rat model of heart failure with preserved ejection fraction
Authors: Niewiadomska M , Elkholey K , Morris L , Houser J , Flor Ramirez M , Humphrey M.B , Stavrakis S
Published: October 2021

Introduction

Heart failure with preserved ejection fraction (HFpEF) has become a major public health concern, accounting for approximately half of all heart failure patients. Despite normal or near normal left ventricular ejection fraction, HFpEF is associated with increased morbidity and mortality. The complex pathophysiology of HFpEF is not yet fully understood. Inflammation and fibrosis play a central role in the development of HFpEF. We have previously shown that low-level transcutaneous vagus nerve stimulation (LLTS) is anti-inflammatory. The goal of this study was to determine the effect of chronic intermittent LLTS on cardiac fibrosis, diastolic dysfunction, and left ventricular (LV) gene expression in a rat model of HFpEF.

Methods

Dahl salt-sensitive (DSS) rats were randomized into high salt (HS, 8% NaCl) or low salt (LS) diet (0.3% NaCl) at 7 weeks of age. The animals were monitored for the development of HFpEF on a daily basis. After 6 weeks of LS or HS diets, HS rats were randomized into 4 groups: HS active LLTS (n=50), HS sham LLTS (n=48), HS plus olmesartan (n=14) and HS active LLTS plus methyllycaconitine (MLA) (n=36), a specific blocker of the α7-nicotinic acetylcholine receptor (a7nAChR), which mediates the anti-inflammatory effects of LLTS. Stimulation was delivered for 30 min daily (20Hz, 3mA) for 4 weeks. Echocardiography was performed at 13 weeks (baseline) and 17 weeks (endpoint). At endpoint, LV histology and gene expression were examined.

Results

After 6 weeks of diets, HS rats developed hypertension and LV hypertrophy compared to LS rats. At endpoint, LLTS significantly attenuated blood pressure elevation, prevented the deterioration of diastolic function and improved LV circumferential strain, compared to the HS sham LLTS group. LV fibrosis was decreased in the HS active LLTS compared to HS sham LLTS group. MLA attenuated this effect, suggesting that the anti-inflammatory effect of LLTS is necessary to prevent fibrosis in this model (Figure 1). RNA-seq analysis revealed that LLTS significantly changed the expression of genes involved in mitochondrial dysfunction, sitruin signaling pathway, and oxidative phosphorylation.

Conclusion

Autonomic modulation with LLTS attenuates the unfavorable changes of echocardiographic parameters and LV fibrosis induced by HS diet through its anti-inflammatory effects. The results support our hypothesis that inhibiting the anti-inflammatory effect of LLTS attenuates the antifibrotic effect. The obtained data suggest that LLTS may be used clinically as a novel non-invasive neuromodulation therapy for the treatment of HFpEF.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Institutes of Health (NIH)
The right ventricle: pairing structural with functional assessment
Authors: Rocha B , Cunha G , Strong C , Maltes S , Brizido C , Aguiar C , Mendes M
Published: October 2021

Background

Right Ventricular (RV) dysfunction is a well-recognized prognostic marker in the natural history of left-sided Heart Failure (HF). Common experience dictates that structural and functional evaluation are often seemingly discrepant. We aimed to evaluate the correlation between RV function by transthoracic echocardiography (TTE) and Right Heart Catheterization (RHC) parameters, and their prognostic value in patients with HF.

Methods

We designed a retrospective single-centre study of patients with advanced HF referred to TTE and RHC as part of Heart Transplant candidacy evaluation, from 2010 to 2019. Pulmonary Hypertension (PH) was defined by a mean pulmonary artery pressure (mPAP) ≥25mmHg. Patients with PH other than Group II (WHO) PH were excluded. In appropriate cases, vasodilator challenge with inhaled NO was performed. The primary endpoint was a composite of death, heart transplant or HF hospitalization at 6 months.

Results

The cohort was comprised of 68 patients (mean age 56±11 years, 73.5% male, ischaemic HF 44.1%). Most patients had PH (n=61) and TTE evidence of RV dysfunction (n=46). The strongest correlations between RHC and TTE parameters were moderate at best – mPAP, pulmonary capillary wedge pressure and central venous pressure with E/A ratio (Pearson r 0,461, 0,533 and 0,543, respectively; p<0.05); and RV stroke work index and mPAP with non-invasive estimated systolic pulmonary artery (PA) pressure (Pearson r 0,483 and 0,481, respectively; p<0.05). Over a median follow-up of 26 (12–42) months, 53 patients had a primary endpoint event, of whom 36 within 6 months. The best model integrating data from structural and functional assessment to predict the primary endpoint included the systolic PA pressure to stroke volume ratio – i.e. PA elastance (HR per 0.10 units: 2.817; 95% CI 1.030–1.338; p=0.016) – and RV free wall longitudinal strain (HR per −1%: 0.792; 95% CI 0.656–0.956; p=0.015). ROC curve analysis disclosed the best cut-off values as follows: 1.3 (sensitivity 77.2%, specificity 65.6%) and −18% (sensitivity 10.7%, specificity 86.4%), respectively.

Conclusion

In a cohort of patients with advanced HF, who were potential candidates for heart transplantation, RV dysfunction was often noted. The model with highest accuracy to predict the primary outcome integrated RV structural with functional data. Additional studies are warranted to define well-validated scores useful in the algorithmic therapeutic decision of advanced HF.

Funding Acknowledgement

Type of funding sources: None.
Right ventricular remodeling and prognostic relevance after ST-segment elevation myocardial infarction in patients treated with primary percutaneous coronary intervention
Authors: Chimed S , Van Der Bijl P , Lustosa R , Hirasawa K , Yedidya I , Fortuni F , Montero J.M , Marsan N.A , Delgado V , Bax J.J
Published: October 2021

Background

ST-segment elevation myocardial infarction (STEMI) often involves changes in right ventricular (RV) function and size over time. However, the prognostic implications of RV remodeling after STEMI are unknown. The aim of current study was to characterize RV remodeling in post-STEMI patients and to investigate it's prognostic relevance.

Methods

RV remodeling in post-STEMI patients who underwent primary percutaneous coronary intervention (PCI) was defined by RV end-systolic area (RV ESA) change at 6 months after STEMI, compared to baseline. The optimal threshold of RV ESA change (≥40%) to define RV remodeling was derived from spline curve analysis (Figure 1A). The primary endpoint was the composite of all-cause mortality and heart failure (HF) hospitalization. Long term outcomes were compared between patients with and without RV remodeling by means of a log rank test.

Results

A total of 2280 patients were analyzed (mean age 60±11 years, 76% male) and RV remodeling was present in 320 patients (14%). After a median follow-up of 75 months (interquartile range 50–106 months), the composite endpoint of all-cause mortality and HF hospitalization occurred in 292 patients (13%). After adjustment for various risk factors, including tricuspid annular plane systolic excursion (TAPSE), post-STEMI RV remodeling was independently associated with a higher risk of all-cause mortality and HF hospitalization (HR=1.37, 95% CI 1.00–1.87, p=0.049. Finally, patients with RV remodeling were had a significantly lower event-free survival rate compared with patients without RV remodeling during follow-up (log-rank test p=0.009) (Figure 1B).

Conclusion

RV post-infarct remodeling is associated with mortality and HF hospitalization, independent of RV systolic function.

Funding Acknowledgement

Type of funding sources: None. Figure 1. A) Spline and B) Kaplan-Meier curve
Impact of high platelet reactivity on left ventricular remodeling in patients with acute coronary syndrome
Authors: Tsuji M , Kuroda K , Saito E , Kawamura K , Ono T , Tokioka K , Ohe T , Kawai Y
Published: October 2021

Background/Introduction

Previous studies demonstrated that high platelet reactivity (HPR) predicts future cardiovascular death and coronary events in patients undergoing percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS). However, few studies have focused on the impact of HPR on left ventricular remodeling (LVR) and each echocardiographic parameter.

Purpose

The purpose of this study was to investigate the impact of HPR in ACS patients on LVR and changes in echocardiographic volume indexes and LV ejection fraction.

Methods

This is a retrospective cohort study of prospectively collected data in a single center that enrolled patients who underwent emergency PCI for ACS including STEMI and NSTEMI with prasugrel loading. The primary outcome of the study was LVR associated with HPR. Secondary endpoints were changes in indexed LVESV, LVEDV, LVEF, E/e' and LAVI between baseline and follow-up. The P2Y12 reaction unit (PRU) value in response to prasugrel was assessed by the VerifyNow P2Y12 assay. Blood samples were collected once per procedure immediately after PCI. LVR index was calculated as the relative change in LVEDV observed at follow-up compared with baseline. LVR was defined as a relative increase in LVEDV ≥20%, measured at follow-up visit compared with the baseline value before discharge.

Results

A total of 196 ACS patients who underwent emergency PCI between January 2016 and July 2020 were enrolled in the study. The mean age of the study population was 69.9 years, and 76.0% were male. On echocardiography at follow up visit of mean duration of 7.0±4.0 months, LVR was found in 38 patients (19.4%). The optimal cutoff for PRU associated with increased LVR assessed by receiver-operating characteristic curve analysis was 245.5 (AUC: 0.656; 95% CI: 0.564 to 0.749; p=0.003). On the basis of this cutoff, HPR was found in 82 patients (42.1%) and the prevalence of LVR was significantly higher in the HPR group compared to the non-HPR group (30.5% vs. 11.4%; p=0.001). Multiple Cox regression analysis showed that HPR was an independent predictor of LVR (OR 4.22, 95% CI 1.83–9.71, p=0.001). In addition, Δ% EDV and Δ% ESV increased in the HPR group, and decreased in the non-HPR group with significant differences (5.8±32.6% vs. −8.0±26.2% in Δ% EDV; p=0.002, 2.0±37.5% vs. −13.3±33.0% in Δ% ESV; p=0.004, respectively). Δ%EF, Δ%E/e', Δ%LAVI were numerically improved in the non-HPR group compared with the HPR group, but this difference did not reach statistical significance.

Conclusion

In patients with ACS, HPR defined as PRU ≥246 immediately after emergency PCI was an independent predictor of LVR in the chronic phase.

Funding Acknowledgement

Type of funding sources: None. Predictors of the presence of LVRChanges (Δ%) of LVEDV and LVESV
Sacubitril/Valsartan in heart failure with reduced ejection fraction: clinical and echocardiographic insights from a real world population
Authors: Valli F , Bursi F , Santangelo G , Toriello F , Rusconi I , Mondellini G , Vella A.M , Faggiano A , Persampieri S , Carugo S , Guazzi M
Published: October 2021

Background

Following the PARADIGM trial, some studies have identified cardiac remodeling as major background for hard end point benefits of Sacubitril/Valsartan (S/V), but few adopted a well described definition in the literature.

Purpose

We aimed at a comprehensive evaluation of the effects of S/V on echo-derived measures of cardiac remodeling along with clinical and laboratory data over a medium-term follow-up pointing to a real-world HFrEF population.

Methods

This is a prospective observational study of HFrEF patients on optimal medical therapy (OMT) initiated with S/V at Heart Failure Clinic of our institute (January 2017-January 2020). In 62 HFrEF, echocardiographic, laboratory and clinical data were collected at baseline and over 10 (Q1-Q3 8–13) months after S/V initiation. Mean age was 68±12 years, 79% men. Left ventricular reverse remodeling (LVRR) was defined as: 1) an absolute increase in LVEF ≥10 points or a LVEF ≥50% at follow-up and 2) a relative decrease in indexed left ventricular end-diastolic diameter of at least 10% or an indexed left ventricular end-diastolic diameter ≤33 mm/m2.

Results

Compared to baseline, S/V promoted a significant improvement of LV ejection fraction (LVEF, from 30% to 37%; p<0,0001) with an absolute median increase in LVEF of 8 points. Parallel significant reductions in left ventricular and atrial volumes, lower mitral regurgitation degree and a better diastolic dysfunction along with clinical improvement (NYHA class and NT-proBNP values) were observed at follow up. sPAP (systolic Pulmonary Arterial Pressure) was significantly decreased at follow-up evaluation (37 mmHg vs 31 mmHg p=0,005) (Table 1). Overall, LVRR as defined above was observed in 30% of patients. Younger age (64 vs 74 years, p=0,007), a shorter duration of the disease (7 vs 23 months, p=0,009), and non ischaemic etiology (79% vs 33% p=0,003), along with a smaller baseline LAESVi (Left Atrial End Systolic Volume, 41 vs 48 ml/m2 p=0,012) were more common in patients with LVRR. sPAP and Right Ventricular (RV) function estimated by tricuspid annular plane systolic excursion (TAPSE) were significantly better in LVRR patients along with TAPSE/sPAP ratio (Table 2).

Conclusions

Our data point to a remarkable medium-term reverse remodeling effect by S/V in HFrEF. Findings reinforce the concept that the main benefits of S/V on hard end-points are mediated by its cardiac-related effects. Both a left and right reverse remodeling occur in HFrEF patients who start S/V in the most adaptable phase of the disease supporting an early administration.

Funding Acknowledgement

Type of funding sources: None.
Deformation imaging by strain in chronic heart failure over sacubitril/valsartan: a multicenter echocardiographic registry (DISCOVER) ARNI
Authors: Mandoli G.E , Pastore M.C , Giannoni A , Benfari G , Dini F.L , Correale M , Carluccio E , Guaricci A.I , Citro R , Novo G , Pasquini A , Degiovanni A , Santoro C , Malagoli A , Cameli M
Published: October 2021

Background

Sacubitril/valsartan changed the treatment of heart failure with reduced ejection fraction (HFrEF), due to the positive effects morbidity and mortality partly mediated by left ventricular reverse remodeling (LVRR). The aim of this multicenter study was to identify echocardiographic predictors of LVRR after sacubitril/valsartan administration.

Methods

Patients with HFrEF requiring therapy with sacubitril/valsartan from 13 Italian centers were included. Echocardiographic indexes including speckle tracking echocardiography (STE) were used to predict LVRR (defined as LV end-systolic volume reduction and ejection fraction [LVEF] improvement >10% at follow-up) at 6 months follow-up as the primary endpoint. Changes in symptoms (NYHA class) and neurohormonal activations (N-terminal-pro-brain natriuretic peptide [NTproBNP]) were also evaluated as secondary endpoints. Patients with poor acoustic windows and missing data were excluded.

Results

The final population consisted of 341 patients (mean age: 65±10 years; 18% female, median LVEF 30% [interquartile range:25; 34]. At 6 months follow-up, cardiac dimensions and function, including left heart STE parameters, improved (Table 1). Moreover, 82 (24%) patients showed early complete response (LVRR and LVEF ≥35%), 55 (16%) early incomplete response (LVRR and LVEF <35%), 204 (60%) no response (no LVRR and LVEF <35%) after 6 months of sacubitril/valsartan. Among patients with ischemic etiology, 68% (108) did not develop LV RR. Age, sex, general characteristics, baseline NYHA class and NT-pro BNP did not significantly differ between the groups.Conversely, baseline LV dimensions and LVEF showed significant differences between the groups (p<0.0001). Also, STE parameters were considerably better in group 1 compared to group 2 and 3 both at baseline and follow-up. Non-ischemic etiology, a lower left atrial volume index and a higher global longitudinal strain were all independent predictors of LVRR at multivariable logistic analysis (all p<0.01). With ROC and spline curves, LV GLS >−9.3% showed a good accuracy in predicting LV RR (Figure 1). LA strain was the best predictor of positive changes in NYHA class and NT-proBNP (all p<0.05).

Conclusions

STE parameters at baseline could be useful to predict LVRR and early clinical response to sacubitril-valsartan, and thus could be used as a guide for treatment in patients with HFrEF.

Funding Acknowledgement

Type of funding sources: None. Table 1Figure 1
Patterns of left ventricular recovery in patients with heart failure with mid-range ejection fraction
Authors: Chen H.H.L , Lee C , Dhamoon K , Bhat A , Gan G.C.H , Tan T.C
Published: October 2021

Background

Heart failure with mid-range ejection fraction (HFmEF) represents a new classification of heart failure with intermediate clinical characteristics to those with HF with reduced ejection fraction (HFrEF) and HF with preserved ejection fraction (HFpEF). A proportion of HFmEF is attributed to atrio-ventricular dyssynchrony from atrial fibrillation (AF) as opposed to a primary cardiomyopathy with intrinsic cardiac myocyte dysfunction.

Purpose

We aim to compare the rate of left ventricular ejection fraction (LVEF) recovery in those with AF-mediated cardiomyopathy compared to those with primary myocyte dysfunction.

Methods

Consecutive patients with stable non-ischaemic cardiomyopathy with LVEF 40–49% on transthoracic echocardiography (TTE) were recruited from our institution's heart failure clinic and followed for 18 months. Patients with ischaemic, valvular or congenital heart disease, incomplete follow-up or poor quality TTE images were excluded. Eligible patients were separated into two groups: AF-mediated (n=44); and primary myocyte dysfunction (n=116).

Results

A total of 160 patients (62.1±16.4 years, 62% men) were included. There was no significant difference in age (p=0.06) and gender (p=0.59). Comorbid AF was higher in those with AF-mediated HFmEF (100 vs 28.4%; p<0.01), otherwise no significant differences in clinical history was found between groups. AF-mediated HFmEF had lower rates of cardiac-specific beta-blocker use (15.9 vs 47.4%; p<0.01). Baseline TTE showed similar LVEF and LV global longitudinal strain. On log-rank analysis there was no significant difference in all-cause death (p=0.75), or HF-related hospitalisation (p=0.14), however, higher rates of LVEF recovery were observed in the AF-mediated HFmEF group (p<0.01). See figure 1.

Conclusion

There were higher rates of LVEF recovery in those with AF-mediated HFmEF compared to those with a primary myocardial disorder despite lower rates of cardiac-specific beta-blocker use. This did not translate to improvements in intermediate-term survival or HF related hospitalisation. These findings provide insight into the natural history of the disorder and its clinical phenotype.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Rate of LVEF Recovery
Differences in long-term all-cause and cardiovascular mortality according to heart failure aetiology in ambulatory patients
Authors: Spitaleri G , Cediel G , Santiago-Vacas E , Codina P , Domingo M , Zamora E , Santesmases J , Diez-Quevedo C , Troya M , Boldo M , Altimir S , Alonso N , Rivas C , Lupon J , Bayes-Genis A
Published: October 2021

Background

Heart failure (HF) is the final stage of many cardiac disorders. Mortality in heart HF remains challenging despite improvement in outcomes proved in clinical trials in HF with reduced ejection fraction and it can be influenced by the aetiology of HF.

Purpose

To assess differences in long-term mortality (up to 18 years) in a real-life cohort of HF outpatients according to the aetiology of HF.

Methods

Consecutive patients with HF admitted at the HF Clinic from August 2001 to September 2019 were included. Follow-up was closed at 30.9.2020. HF aetiology was divided into ischemic heart disease (IHD), dilated cardiomyopathy (CM) –including non-compaction CM–, hypertensive CM, alcohol-derived CM, drug-derived CM, valvular disease, hypertrophic CM and others. For the present analysis, this latter group was excluded due to the big heterogeneity and limited number of patients in each subtype of aetiology. All-cause death and cardiovascular death were the primary end-points. Fine & Gray method for competing risk was used for cardiovascular mortality analysis.

Results

Out of 2387 patients included (age 66.5±12.5 years, 71.3% men, LVEF 35.4%±14.2, mainly in NYHA class II [65.5%] and III [26.5%]), 1317 deaths were recorded (731 from cardiovascular cause) during a maximum follow-up of 18 years (median 4.1 years [IQR 2–7.8] for the total cohort, 5.3 years [IQR 2.6–9.7] for survivors). Figure 1 shows Cox regression multivariable analysis for all-cause death and cardiovascular mortality. Considering IHD aetiology as reference, only dilated CM showed significantly lower risk of all-cause death, and only drug-induced CM showed higher risk of all-cause death. However, when cardiovascular mortality was considered almost all aetiologies showed significant lower risk of cardiovascular death than IHD. Figure 2 shows adjusted survival curves (A) and adjusted incidence curves of cardiovascular death (B) based on HF aetiology.

Conclusions

After adjusting for multiple prognostic factors among the studied HF aetiologies, dilated CM and drug-related CM showed the lowest and the highest risk of all-cause death, respectively. Patients with IHD showed the highest adjusted risk of cardiovascular death.

Funding Acknowledgement

Type of funding sources: None.
Cardiorenal syndrome and death risk in patients with heart failure or chronic kidney disease: an unmet cardiorenal need?
Authors: Taveira Gomes T , Santos Araujo C , Valente F , Bernardo F , Seabra Carvalho D , Bodegard J , Gavina C
Published: October 2021

Introduction

Heart failure (HF) and chronic kidney disease (CKD) have interlinked pathophysiological pathways and patients having both conditions simultaneously are defined as having cardiorenal syndrome (CRS).

Purpose

To estimate the risk of CRS in patients with initial presentation of HF (without prior CKD) or CKD (without prior HF) compared to mean age overall population in a real-world clinical setting. Also, to estimate the risk of all-cause death, cardiovascular (CV) death and non-fatal major CV events (MACE) in patients with HF, CKD and CRS compared to the mean-age overall population.

Methods

Clinical database analysis of a single primary and secondary healthcare institution from 2008–2019. We defined 4 incident cohorts: Control - patients at age 75; HF - HF patients without prior CKD; CKD - CKD patients without prior HF; CRS - patients with HF and CKD. Patients were indexed at the date of first event and followed one year. We defined HF as either: i) Ejection Fraction (EF)≤40% and NT-proBNP≥200pg/mL (≥600pg/mL if atrial fibrillation (AF)) OR BNP≥100pg/mL (≥125pg/mL if AF); ii) EF>40% in the presence of structural cardiac abnormalities. We defined CKD as eGFR≤60mL/min using EPI-CKD formula. All definitions were constructed using laboratory-level data complemented with episode-level data. Hazard ratios (HR) and 95% confidence intervals were estimated using Cox regression models adjusted for age, sex, age-sex interaction, prior history of hypertension, myocardial infarction, stroke, peripheral artery disease and type 2 diabetes.

Results

We identified 3973 patients with HF, 13990 with CKD, 6784 with CRS and 16182 controls. Patients were in general 75–77 years old. The majority were females and were well treated with CV risk reducing drugs (Table 1). All-cause death risk was 4.7 (4.1–5.2) for HF and 4.9 (4.5–5.4) for CKD. CV death risk was 8.6 (6.8–10.8) for HF and 8.7 (7.1–10.6) for CKD. Non-fatal MACE risk was 7.4 (6.3–8.7) for HF, 4.6 (4.0–5.3) for CKD, and 7.1 (6.1–8.3) for CRS. CRS was associated with the highest risks of all-cause and CV death when compared with the control group- 7.1 (6.4–7.9) and 13.7 (11.7–17.0), respectively (Figure 1). More than half of events occurred in the first 90 days of follow-up for all outcomes.

Conclusions

Cardiorenal disease (HF or CKD) was associated with very high short-term risk (1 year) of developing CRS or death. Consecutively, patients with established CRS had the highest risk of dying. These results demonstrate serious cardiorenal risks in a real-world setting, supporting an urgent need for improved primary and secondary prevention of cardiorenal disease and cardiorenal syndrome.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): AstraZeneca Produtos Farmacêuticos, Lda. Table 1. Baseline characteristicsFigure 1. Outcomes for CKD, HF and CRS
Long-term evolution of estimated glomerular filtration rate in patients with type 2 diabetes and heart failure
Authors: Escabia C , Codina Verdaguer P , Buchaca D , Spitaleri G , Domingo M , Santiago-Vacas E , Cediel G , Zamora E , Alonso N , Troya M.I , Santesmases J , Crespo E , Nunez J , Lupon J , Bayes-Genis A
Published: October 2021

Background

Limited data are available on the very long-term trajectory of glomerular filtration rate (GFR) in patients with chronic heart failure (HF) and type 2 diabetes mellitus (T2D).

Purpose

To prospectively assess dynamic trajectories of GFR estimated by CKD-EPI in a real-life cohort of HF patients based on the presence or absence of T2D over a 14-year follow-up.

Methods

In a prospective observational registry of real-life HF outpatients, estimated GFR (eGFR) was calculated by CKD-EPI at baseline and on a structured schedule every 3 months up to 14 years. We included in the analysis only eGFR values that were assessed at scheduled visits, discarding urgent renal function assessments. Loess (locally weighted error sum of squares) curves were plotted for the subgroups according to baseline T2D up to 14 years of follow-up. Loess curves are useful to observe a trend or relationship on nonlinear data observed over time.

Results

2386 patients were consecutively included from August 2001 to December 2018. 43.2% of the patients had a history of T2D. Mean age was 67.0±12.6 years, 28.9% were women and 71.0% had HF with reduced ejection fraction (EF<40%). 25080 eGFR values were included in the analysis with a median of 8 values per patient [IQR 4–15] and a range between 1 and 47.

Diabetic patients had a worse baseline eGFR and presented a persistent decline over time. On the contrary non-diabetic patients presented an early decrease, mid-term improvement and a late progressive decline (Figure 1).

Conclusions

eGFR long-term trajectories in diabetic and non-diabetic patients with chronic HF were significantly different.

Funding Acknowledgement

Type of funding sources: None. eGFR evolution according to baseline T2D
Alcohol consumption in young men and risk of heart failure and all-cause mortality- a cohort study
Authors: Habtemichael L.H , Djekic D , Rosengren A.R , Schaufelberger M.S , Aberg M.A , Lindgren M.L , Aberg D.A , Robertson J.R
Published: October 2021

Aim

Wesought to study the association of alcohol consumption with the long-term risk of heart failure and all-cause mortality among adolescent men.

Method

We included 50 460 men (mean age 18.4 years; SD 0.72) that underwent enlistment for military service during 1968–1969. During this period, alcohol consumption was assessed with questionnaires as part of the enlistment protocol. Questionnaire data was transformed to grams of 100% ethanol/week and categorized as light (1–100 g/week), moderate (101–250 g/week), and high (>250 g/week). Follow-up was done through linkage to the nationwide Swedish patient- and cause of death registries. Risk of heart failure and all-cause mortality during follow-up was calculated with cox proportional hazard models, adjusted for age, conscription year, test centre, body mass index, systolic and diastolic blood pressure, parental education, intelligence quotient, cardiorespiratory fitness and muscle strength, and baseline comorbidities (diabetes mellitus and hypertension).

Results

During a median follow-up of 51 years, there were 803 incidentheart failure events (mean age at diagnosis, 61 years) and 6254 deaths (mean age: 55 years). Compared with non-drinkers (0 g/week), the adjusted hazard ratios (HR) for light, moderate and high alcohol consumption were 2.34 (1.24–4.40), 2.38 (1.22–4.68), 5.60 (2.68–11.69) for incident heart failure (Figure 1, model 4)and 1.27 (1.04–1.54), 1.66 (1.35–2.05), 2.25 (1.74–2.91) for all-cause mortality,respectively.

Conclusion

Alcohol consumption in adolescence is strongly associated with heart failure and all-cause mortality in adulthood. Our results suggests that even light alcohol consumption in adolescence is associated with higher long-term risk of heart failure and mortality.

Funding Acknowledgement

Type of funding sources: None. Figure 1. *Model 1 adjusted for age at conscription, conscription year, test center, body mass index and baseline comorbidities (diabetes mellitus and hypertension). †Model 2 as model 1 but additionally adjusted for systolic and diastolic blood pressure at baseline. ‡Model 3 as model 2 but additionally adjusted for parental education. #Model 4 as model 3 but additionally adjusted for intelligence quotient, cardiorespiratory fitness and muscle strength.