Predictive value of echocardiography in Type 2 diabetes

AIMS

Echocardiography is suggested in the diagnostic work-up of patients with Type 2 diabetes (T2D). We investigated which echocardiographic parameters that best predicted cardiovascular disease (CVD) and whether this was persistent in both genders in a large cohort of outpatients with T2D.

METHODS AND RESULTS

We performed comprehensive echocardiography in 933 patients with T2D followed at specialized out-patients clinics in Copenhagen, Denmark. Follow-up was performed using national registries and included admission with future CVD events and non-CVD death as competing risk. Median follow-up was 4.8 years and 138 CVD events occurred. In univariable and multivariable analyses, a wide range of structural, diastolic, and systolic measurements predicted CVD including mean E/e' [hazard ratio (HR) 1.06, 95% confidence interval: (1.03-1.10), P < 0.001, C-statistics 0.74 (0.70-0.78)] and global longitudinal strain (GLS) [1.10 (1.01-1.20), P = 0.03, C-statistics 0.73 (0.69-0.77)]. However, this was modified by gender. In men, mean E/e' remained the strongest predictor in multivariable analyses and performed best measured by highest C-statistics [HR 1.15, 95% confidence interval: (1.08-1.21), P < 0.001, C-statistics 0.75 (0.71-0.80)] whereas in women this was GLS [1.39 (1.14-1.70), P = 0.001, C-statistics 0.79 (0.70-0.87)]. These findings persisted when excluding patients with known heart disease and when regarding all-cause mortality as a competing risk.

CONCLUSION

A range of echocardiographic parameters predicted CVD in patients with Type 2 diabetes, however, in multivariable analyses, mean E/e' was the strongest predictor and had the highest model performance. Importantly, this study identifies a hitherto undescribed gender interaction as mean E/e' performed best in men, whereas in women this was GLS.

New-onset atrial fibrillation: incidence, characteristics, and related events following a national COVID-19 lockdown of 5.6 million people

AIM

To determine the incidence, patient characteristics, and related events associated with new-onset atrial fibrillation (AF) during a national COVID-19 lockdown.

METHODS AND RESULTS

Using nationwide Danish registries, we included all patients, aged 18-90 years, receiving a new-onset AF diagnosis during the first 3 months of 2019 and 2020. The main comparison was between patients diagnosed during lockdown (12 March 12-1 April 2020) and patients diagnosed in the corresponding period 1 year previously. We found a lower incidence of new-onset AF during the 3 weeks of lockdown compared with the corresponding weeks in 2019 [incidence rate ratios with 95% confidence intervals (CIs) for the 3 weeks: 0.66 (0.56-0.78), 0.53 (0.45-0.64), and 0.41 (0.34-0.50)]. There was a 47% drop in total numbers (562 vs. 1053). Patients diagnosed during lockdown were younger and with a lower CHA2DS2-VASc score, while history of cancer, heart failure, and vascular disease were more prevalent. During lockdown, 30 (5.3%) patients with new-onset AF suffered an ischaemic stroke and 15 (2.7%) died, compared with 45 (4.3%) and 14 (1.3%) patients during the corresponding 2019 period, respectively. The adjusted odds ratio of a related event (ischaemic stroke or all-cause death) during lock-down compared with the corresponding weeks was 1.41 (95% CI 0.93-2.12).

CONCLUSIONS

Following a national lockdown in Denmark, a 47% drop in registered new-onset AF cases was observed. In the event of prolonged or subsequent lockdowns, the risk of undiagnosed AF patients developing complications could potentially translate into poorer outcomes in patients with AF during the COVID-19 pandemic.

Sex differences in the association between myocardial function and prognosis in type 1 diabetes without known heart disease: the Thousand & 1 Study

AIMS

In type 1 diabetes mellitus (T1DM), recent findings suggest that women have a greater excess risk of cardiovascular diseases (CVDs) compared to men. Impaired diastolic function is a common feature in T1DM. We investigated the association between myocardial function by echocardiography and outcomes in T1DM males and females without known heart disease.

METHODS AND RESULTS

A prospective cohort of individuals with T1DM without known heart disease from the outpatient clinic of Steno Diabetes Center Copenhagen. Follow-up was performed through Danish national registers. Outcomes, major adverse cardiovascular events (MACE) and all-cause mortality, were investigated. A total of 1079 participants (mean age: 49.6 ± 14.5 years, 52.6% male, mean duration of diabetes 25.8 ± 14.6 years) were included in the study. During follow-up (median 6.3 years, interquartile range 5.7-6.9), 142 (13.2%) experienced MACE and 63 (5.8%) died. Gender modified the relationship between E/e' and both MACE and all-cause mortality (P = 0.016 and 0.007, respectively). In females, after multivariable adjustment, both E/e' and global longitudinal strain (GLS) were significantly associated with MACE [E/e': hazard ratio (HR) 1.15 confidence interval (CI) 95%: 1.07-1.24, per 1unit increase; and GLS: HR 1.19 CI 95%: 1.04-1.35, per 1% decrease] and with all-cause mortality (E/e': HR 1.26 CI 95%: 1.11-1.44; and GLS: HR 1.27 CI 95%: 1.03-1.56). In males, the association between E/e' and GLS and outcomes did not reach statistical significance.

CONCLUSION

In female individuals with T1DM both E/e' and GLS provided independent prognostic information, whereas the associations were not significant in males. These results suggest that T1DM affects myocardial function differently in males and females, which may be related to the observed sex difference in CVD risk in T1DM.

Influenza Vaccination Is Associated With Reduced Cardiovascular Mortality in Adults With Diabetes: A Nationwide Cohort Study

OBJECTIVE

Recent influenza infection is associated with an increased risk of atherothrombotic events, including acute myocardial infarction (AMI) and stroke. Little is known about the association between influenza vaccination and cardiovascular outcomes in patients with diabetes.

RESEARCH DESIGN AND METHODS

We used nationwide register data to identify patients with diabetes in Denmark during nine consecutive influenza seasons in the period 2007-2016. Diabetes was defined as use of glucose-lowering medication. Patients who were not 18-100 years old or had ischemic heart disease, heart failure, chronic obstructive lung disease, cancer, or cerebrovascular disease were excluded. Patient exposure to influenza vaccination was assessed before each influenza season. We considered the outcomes of death from all causes, death from cardiovascular causes, and death from AMI or stroke. For each season, patients were monitored from December 1 until April 1 the next year.

RESULTS

A total of 241,551 patients were monitored for a median of four seasons (interquartile range two to eight seasons) for a total follow-up of 425,318 person-years. The vaccine coverage during study seasons ranged from 24% to 36%. During follow-up, 8,207 patients died of all causes (3.4%), 4,127 patients died of cardiovascular causes (1.7%), and 1,439 patients died of AMI/stroke (0.6%). After adjustment for confounders, vaccination was significantly associated with reduced risks of all-cause death (hazard ratio [HR] 0.83, P < 0.001), cardiovascular death (HR 0.84, P < 0.001), and death from AMI or stroke (HR 0.85, P = 0.028) and a reduced risk of being admitted to hospital with acute complications associated with diabetes (diabetic ketoacidosis, hypoglycemia, or coma) (HR 0.89, P = 0.006).

CONCLUSIONS

In patients with diabetes, influenza vaccination was associated with a reduced risk of all-cause death, cardiovascular death, and death from AMI or stroke. Influenza vaccination may improve outcome in patients with diabetes.

Echocardiographic predictors of cardiovascular morbidity and mortality in women from the general population

AIMS

Global longitudinal strain (GLS) is a strong predictor of adverse cardiovascular outcome in men. However, studies have indicated that GLS may not predict cardiovascular outcomes as effectively in women. The aim of this study was to identify echocardiographic predictors of cardiovascular morbidity and mortality in women from the general population.

METHODS AND RESULTS

A total of 1245 women from the general population free of heart failure (HF) and atrial fibrillation had an echocardiographic examination performed including tissue Doppler imaging. In this subset, 747 women had images eligible for strain analysis. Endpoint was a composite of acute myocardial infarction, HF, and cardiovascular death. During follow-up (median 12.5 years), 162 women (13.0%) reached the composite outcome. These women had higher left ventricular (LV) mass index (LVMI), more LV hypertrophy, lower E/A, higher E/e', larger LV dimensions, and longer deceleration time. LVMI and e' remained as significant predictors of the composite outcome [LVMI: hazard ratio (HR) 1.10, 95% confidence interval (CI) 1.03-1.17, P = 0.004, per 5 g/m2 increase] (e': HR 1.53, 95% CI 1.07-2.20, P = 0.020, per 1 cm/s decrease) after adjusting for age, hypertension, systolic blood pressure, diabetes mellitus, total cholesterol, smoking status, prevalent ischaemic heart disease, LV ejection fraction, E/e', E, E/A, interventricular septum thickness in diastole, left ventricular posterior wall in diastole, a', body surface area, and pro-brain natriuretic peptide. GLS was not an independent predictor of outcome after multivariable adjustment.

CONCLUSION

The degree of LV hypertrophy assessed as LVMI and diastolic dysfunction evaluated by e' are associated with adverse cardiovascular outcome in women from the general population.

Right Ventricular Function Evaluated by Tricuspid Annular Plane Systolic Excursion Predicts Cardiovascular Death in the General Population

Background Cardiovascular disease remains a leading cause of death. Right ventricular ( RV ) function is a strong predictor of outcome in many cardiovascular diseases, but its significance is often neglected. Little is known about the prognostic value of RV systolic function in the general population. Therefore, we aimed to determine the prognostic value of RV systolic function, evaluated by tricuspid annular plane systolic excursion ( TAPSE ), in predicting cardiovascular death ( CVD ) in the general population. Methods and Results A total of 1039 participants from the general population without heart failure or atrial fibrillation had an echocardiogram performed and TAPSE measured. The end point was CVD . During a median follow-up of 12.7 years (interquartile range, 12.0-12.9 years), 69 participants (6.6%) experienced CVD , whereas 162 participants (15.6%) experienced non-CVD. Decreasing RV systolic function, assessed as TAPSE , was a univariable predictor of CVD (hazard ratio, 1.13; 95% CI , 1.07-1.20; P<0.001, per 1-mm decrease). TAPSE remained an independent predictor of CVD after adjusting for clinical and echocardiographic parameters (hazard ratio, 1.08; 95% CI , 1.01-1.15; P=0.017, per 1-mm decrease). Furthermore, in net reclassification analysis, decreasing RV systolic function, assessed as TAPSE, significantly improved risk classification with respect to CVD when added to established cardiovascular risk factors from the Systematic Coronary Risk Evaluation chart or a modified version of the American Heart Association/American College of Cardiology Pooled Cohort Equation. Decreasing RV systolic function, assessed as TAPSE , did not predict non-CVD, indicating specificity for CVD . Conclusions RV systolic function, as assessed by TAPSE , is associated with CVD in the general population. In the general population, assessment of RV systolic function may provide novel prognostic information about the risk of CVD .

Prevention of heart failure events with intensive versus standard blood pressure lowering across the spectrum of kidney function and albuminuria: a SPRINT substudy

AIMS

To determine whether a strategy of intensive blood pressure control reduces the risk of heart failure (HF) events consistently across the spectrum of kidney function and albuminuria.

METHODS AND RESULTS

SPRINT was a randomized clinical trial in which 9361 individuals ≥50 years, at high risk for or with cardiovascular disease, a systolic blood pressure of 130-180 mmHg, but without diabetes, were randomized to intensive (target <120 mmHg) vs. standard (target <140 mmHg) blood pressure control. We assessed whether estimated glomerular filtration rate (eGFR) and urine albumin-to-creatinine ratio (UACR) modified the effects of the blood pressure control strategy in reducing HF events (either hospitalization or emergency department visits) and the composite of HF events or cardiovascular death, using Cox proportional hazards regression and restricted cubic splines. Of the 9361 individuals included in SPRINT, eGFR and UACR were available for 9324 (99.6%) and 8913 (95.2%) subjects, respectively, including 2650 (28.4%) with eGFR <60 mL/min/1.73 m² and 248 (2.8%) with UACR >300 mg/g. During a median follow-up of 3.2 years (range 0-4.8 years), 160 (1.8%) participants had HF events and 233 (2.6%) had HF events or cardiovascular death. Risks of HF events or cardiovascular death increased from 0.42 (0.34-0.53) per 100 patient-years in patients with eGFR ≥60 mL/min/1.73 m² and UACR <30 mg/g to 4.55 (3.00-6.91) per 100 patient-years in patients with eGFR <60 mL/min/1.73 m² and UACR >300 mg/g. A similar gradient was observed for HF events alone. Both eGFR and UACR were independently, non-linearly associated with HF hospitalization and HF hospitalization or cardiovascular death (test for overall trend, P < 0.001). While the effects of intensive blood pressure control on HF event risk appeared to attenuate at lower eGFR and higher UACR, there was no significant interaction between eGFR or UACR and blood pressure control strategy (continuous and categorical interaction P > 0.05).

CONCLUSION

In SPRINT, eGFR and albuminuria were strong and additive determinants in forecasting HF risk. The effect of intensive blood pressure control in decreasing HF risk did not significantly vary across the spectrum of kidney function or albuminuria. Multidisciplinary pathways, incorporating blood pressure control, are needed for at-risk patients with chronic kidney disease to attenuate HF risk.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT01206062.

Use of inhaled corticosteroids and the risk of developing type 2 diabetes in patients with chronic obstructive pulmonary disease

AIM

To determine the risk of type 2 diabetes onset associated with accumulated inhaled corticosteroids (ICS) dose during the previous year in patients with chronic obstructive pulmonary disease (COPD).

MATERIALS AND METHODS

We conducted a nationwide observational cohort study based on data from patients with COPD between 1 January 2010 and 31 December 2017 extracted from Danish health databases. Patients were followed for 7 years, until death or a type 2 diabetes event. A propensity-matched Cox model and an adjusted Cox proportional hazards model (stratified on body mass index [BMI]) were used to estimate the hazard ratio (HR) for new-onset type 2 diabetes.

RESULTS

A total of 50 148 patients with COPD were included, 3566 (7.1%) of whom had a type 2 diabetes event. During the previous year before study entry, 35 368 patients (70.5%) used ICS. The propensity-matched Cox model (N = 33 466) showed an increased risk of type 2 diabetes, which progressed with increasing accumulated ICS dose (low-ICS: HR 1.076, confidence interval [CI] 1.075-1.077, P < .0001; medium-ICS: HR 1.106, CI 1.105-1.108, P < .0001; high-ICS: HR 1.150, CI 1.148-1.151, P < .0001), compared with no ICS use. Results were confirmed in the adjusted Cox analysis on the entire study population, but only for patients with BMI <30 kg/m² .

CONCLUSIONS

In patients with COPD, ICS use was associated with a moderate dose-dependent increase in the occurrence of type 2 diabetes.

One-Year Mortality After Intensification of Outpatient Diuretic Therapy

Background

Mortality is increased following a hospitalization for decompensated heart failure (HF), during which diuretics are usually intensified. It is unclear how risk is affected after outpatient intensification of diuretic therapy for HF.

Methods and Results

From nationwide administrative registers, we identified all Danish patients who were diagnosed with HF from 2001 to 2016 and received angiotensin‐converting enzyme inhibitor/angiotensin receptor blocker and β blocker within 120 days. Subsequent follow‐up tracked progressive events of diuretic intensification and HF hospitalization. Intensification events were defined as new addition or doubling of loop diuretic or addition of thiazide to loop diuretic. These events were included in multivariable Cox regression models, calculating 1‐year mortality hazard after each year since inclusion. Patients with an intensification event or hospitalization were risk set matched to 2 nonworsened HF controls and absolute 1‐year mortality risks were calculated using Kaplan‐Meier estimates. We included 74 990 patients, their median age was 71 years, and 36% were women. Intensification events were associated with significantly increased mortality at all times during follow‐up. One‐year mortality was 18.0% after an intensification event, 22.6% after HF hospitalization, and 10.4% for matched controls with neither. In a multivariable Cox model adjusted for age, sex, ischemic heart disease, atrial fibrillation, chronic obstructive pulmonary disease, and diabetes mellitus, the hazard ratio for 1‐year death after an intensification event was 1.75 (95% CI, 1.66–1.85), and it was 2.28 (95% CI, 2.16–2.41) after HF hospitalization.

Conclusions

In a nationwide cohort of patients with HF, outpatient intensification events were associated with almost 2‐fold risk of mortality during the next year. Although HF hospitalization was associated with a higher risk, the need to intensify diuretics in the outpatient setting is a signal to review and intensify efforts to improve HF outcomes.

Usefulness of left atrial speckle tracking echocardiography in predicting recurrence of atrial fibrillation after radiofrequency ablation: a systematic review and meta-analysis

The usefulness of peak atrial longitudinal strain (PALS) in identifying patients at high risk of atrial fibrillation (AF) recurrence after radiofrequency ablation (RFA) has been investigated in several small AF populations. The aim of this systematic review and meta-analysis was to investigate whether PALS predicts recurrence of AF after RFA treatment. MEDLINE, EMBASE and the Cochrane Library were searched. Studies investigating the value of PALS in predicting successful RFA in AF patients were selected. Patients underwent echocardiography prior to RFA. Risk of bias was evaluated using the Quality in Prognosis Studies (QUIPS) Tool. Twelve studies and a total of 1025 patients suffering from paroxysmal or persistent AF were included. Odds ratios (OR) were assessed in a random and fixed effects model for univariable and multivariable pooled analyses respectively. PALS was found to be a significant predictor of AF recurrence after RFA across study populations (Univariable: OR: 1.17, CI95% [1.03-1.34], p = 0.018, per 1% decrease) (Multivariable: OR: 1.16, CI95% [1.09-1.24], p < 0.001, per 1% decrease). Patients with recurrence had significantly lower PALS prior to RFA than patients who maintained sinus rhythm (15.7 ± 5.7% vs. 23.0 ± 7.0%, p = 0.016). A pooled analysis of weighted mean differences (WMD) also showed a significant difference in PALS between the two groups (WMD: - 6.57, CI95% [- 8.49: - 4.65], p < 0.001). Lower values of PALS are associated with an increased risk of AF recurrence after RFA. PALS provides prognostic value in clinical practice.

Proactive Prophylaxis With Azithromycin and HydroxyChloroquine in Hospitalised Patients With COVID-19 (ProPAC-COVID): A structured summary of a study protocol for a randomised controlled trial

Objectives

The aim of this randomised GCP-controlled trial is to clarify whether combination therapy with the antibiotic azithromycin and hydroxychloroquine via anti-inflammation/immune modulation, antiviral efficacy and pre-emptive treatment of supra-infections can shorten hospitalisation duration for patients with COVID-19 (measured as "days alive and out of hospital" as the primary outcome), reduce the risk of non- invasive ventilation, treatment in the intensive care unit and death.

Trial design

This is a multi-centre, randomised, Placebo-controlled, 2-arm ratio 1:1, parallel group double-blind study.

Participants

226 participants are recruited at the trial sites/hospitals, where the study will take place in Denmark: Aalborg, Bispebjerg, Gentofte, Herlev, Hillerød, Hvidovre, Odense and Slagelse hospitals.

Inclusion criteria:

• Patient admitted to Danish emergency departments, respiratory medicine departments or internal medicine departments

• Age≥ 18 years

• Hospitalized ≤48 hours

• Positive COVID-19 test / diagnosis during the hospitalization (confirmed).

• Men or non-fertile women. Fertile women* must not be pregnant, i.e. negative pregnancy test must be available at inclusion

• Informed consent signed by the patient

*Defined as after menarche and until postmenopausal (no menstruation for 12 months)

Exclusion criteria:

• At the time of recruitment, the patient uses >5 LO2/min (equivalent to 40% FiO2 if measured)

• Known intolerance/allergy to azithromycin or hydroxychloroquine or hypersensitivity to quinine or 4-aminoquinoline derivatives

• Neurogenic hearing loss

• Psoriasis

• Retinopathy

• Maculopathy

• Visual field changes

• Breastfeeding

• Severe liver diseases other than amoebiasis (INR> 1.5 spontaneously)

• Severe gastrointestinal, neurological and hematological disorders (investigator-assessed)

• eGFR <45 ml/min/1.73 m2

• Clinically significant cardiac conduction disorders/arrhythmias or prolonged QTc interval (QTc (f) of> 480/470 ms).

• Myasthenia gravis

• Treatment with digoxin*

• Glucose-6-phosphate dehydrogenase deficiency

• Porphyria

• Hypoglycaemia (Blood glucose at any time since hospitalization of <3.0 mmol/L)

• Severe mental illness which significantly impedes cooperation

• Severe linguistic problems that significantly hinder cooperation

• Treatment with ergot alkaloids

*The patient must not be treated with digoxin for the duration of the intervention. For atrial fibrillation/flutter, select according to the Cardiovascular National Treatment Guide (NBV): Calcium antagonist, Beta blocker, direct current (DC) conversion or amiodarone. In case of urgent need for digoxin treatment (contraindication for the aforementioned equal alternatives), the test drug should be paused, and ECG should be taken daily.

Intervention and comparator

Control group:

The control group will receive the standard treatment + placebo for both types of intervention medication at all times. If part or all the intervention therapy being investigated becomes standard treatment during the study, this may also be offered to the control group.

Intervention group:

The patients in the intervention group will also receive standard care. Immediately after randomisation to the intervention group, the patient will begin treatment with:

Azithromycin:

Day 1-3: 500 mg x 1

Day 4-15: 250 mg x 1

If the patient is unable to take the medication orally by themselves, the medication will, if possible, be administered by either stomach-feeding tube, or alternatively, temporary be changed to clarithromycin 500 mg x 2 (this only in agreement with either study coordinator Pradeesh Sivapalan or principal investigator Jens-Ulrik Stæhr Jensen). This will also be done in the control group if necessary. The patient will switch back to azithromycin when possible.

Hydroxychloroquine:

Furthermore, the patient will be treated with hydroxychloroquine as follows:

Day 1-15: 200 mg x 2

Main outcomes

• Number of days alive and discharged from hospital within 14 days (summarises both whether the patient is alive and discharged from hospital) ("Days alive and out of hospital")

Randomisation

The sponsor (Chronic Obstructive Pulmonary Disease Trial Network, COP:TRIN) generates a randomisation sequence. Randomisation will be in blocks of unknown size and the final allocation will be via an encrypted website (REDCap). There will be stratification for age (>70 years vs. <=70 years), site of recruitment and whether the patient has any of the following chronic lung diseases: COPD, asthma, bronchiectasis, interstitial lung disease (Yes vs. No).

Blinding (masking)

Participants and study personnel will both be blinded, i.e. neither will know which group the participant is allocated to.

Numbers to be randomised (sample size)

This study requires 226 patients randomised 1:1 with 113 in each group.

Trial Status

Protocol version 1.8, from April 16, 2020. Recruitment is ongoing (first patient recruited April 6, 2020; final patient expected to be recruited October 31, 2020).

Trial registration

ClinicalTrials.gov Identifier: NCT04322396 (registered March 26, 2020)

Full protocol

The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol.

The study protocol has been reported in accordance with the Standard Protocol Items: Recommendations for Clinical Interventional Trials (SPIRIT) guidelines (Additional file 2).

Myocardial performance index by tissue Doppler echocardiography predicts adverse events in patients with atrial fibrillation

AIMS

The prognostic value of myocardial performance index (MPI) has not yet been assessed in patients with atrial fibrillation (AF). The aim of this study was to evaluate the prognostic value of MPI by tissue Doppler imaging (TDI) M-mode in AF patients.

METHODS AND RESULTS

Echocardiograms from 210 patients with AF during examination were analysed offline. Patients with known heart failure (HF) were excluded. Time intervals were measured using an M-mode line through the mitral valve leaflets to provide a colour diagram of the mitral leaflet movement so all time intervals could be measured from one cardiac cycle. MPI was calculated as the sum of isovolumic relaxation time and isovolumic contraction time divided by the ejection time [(IVRT+IVCT)/ET]. During a median follow-up of 2.4 years, 84 patients (40%) reached the combined endpoint of major adverse cardiovascular events (MACE), being all-cause mortality, HF, myocardial infarction, or stroke. Increasing MPI was significantly associated with an increased risk of MACE, and the risk increased with 20% per 0.1 increase in MPI [hazard ratio (HR) 1.20, 95% confidence interval (CI) 1.10-1.32; P < 0.001]. Increasing MPI was also significantly associated with a lower left ventricular ejection fraction (LVEF) (P < 0.001). Nevertheless, MPI remained an independent predictor even after adjustment for age, sex, diabetes mellitus, left atrial volume, and LVEF (HR 1.12, 95% CI 1.01-1.25; P = 0.038).

CONCLUSION

Increasing MPI was significantly associated with increased risk of MACE and remained an independent predictor after multivariable adjustment. This demonstrates that the MPI obtained by TDI M-mode might be useful in assessing cardiac function in AF patients with ongoing arrhythmia during examination.

Level of Physical Activity, Left Ventricular Mass, Hypertension, and Prognosis

Left ventricular hypertrophy is a strong predictor of prognosis in hypertension. Physical activity is associated with higher left ventricular mass but also reduced risk of cardiovascular outcomes. The aims were to explore whether (1) presence of hypertension modifies the association between physical activity and left ventricular mass; (2) the beneficial association between physical activity and prognostic outcome is modified by left ventricular hypertrophy. Randomly selected number of 3078 persons from the general population underwent echocardiogram. Left ventricular mass was indexed to body surface area. Level of physical activity was self-reported: inactivity, light activity, and moderate/high activity. Blood pressure was measured in rest: normal BP (<140/90 mm Hg) and hypertension (≥140/90 mm Hg or in pharmacological treatment for hypertension). Presence of hypertension modified the association between physical activity and left ventricular mass index significantly (test for interaction: P =0.01): in normal BP, higher levels of physical activity were associated with significantly higher left ventricular mass index ( P <0.001), but this was not present in hypertension ( P =0.90). Level of physical activity was associated with reduction in mortality and cardiovascular outcome independent of the presence of LVH (Persons with LVH: light activity HR, 0.77 [0.52–1.15], moderate/high activity HR, 0.61 [0.38–0.97]; test for interaction between LVH and level of physical activity P =0.71). In conclusion, persons with normal BP had higher left ventricular mass index at increased levels of physical activity, whereas this association was not present among persons with hypertension. Level of physical activity was associated with better prognosis independent of whether left ventricular hypertrophy was present or not.

Body mass index and B-lines on lung ultrasonography in chronic and acute heart failure

AIMS

Increased body mass index (BMI) is common in heart failure (HF) patients and is associated with lower levels of N-terminal pro-brain natriuretic peptide (NT-proBNP). We evaluated the influence of BMI on lung ultrasonography (LUS) findings indicative of pulmonary congestion (i.e. B-lines) in patients with chronic and acute HF (AHF).

METHODS AND RESULTS

We analysed ambulatory chronic HF (n = 118) and hospitalized AHF (n = 177) patients (mean age 70 years, 64% men, mean BMI 29 kg/m² , mean ejection fraction 42%) undergoing echocardiography and LUS in eight chest zones. B-lines and chest wall thickness (skin to pleura) on ultrasound were quantified offline and blinded to clinical findings. NT-proBNP was available in AHF patients (n = 167). In chronic HF, B-line number decreased by 18% per 5 unit increase in BMI [95% confidence interval (CI) -35% to +5%, P = 0.11]. In AHF, the number of B-lines decreased by 12% per 5 unit increase in BMI (95% CI -19% to -5%, P = 0.001), whereas NT-proBNP concentration decreased by 28% per 5 unit increase in BMI (95% CI -40% to -16%, P < 0.001). For AHF, B-line number declined to a lesser degree than NT-proBNP concentration with increasing BMI (P = 0.020), and >6 B-lines were observed in half of AHF patients with severe obesity. There was an inverse relationship between B-line number and chest wall thickness, and this association varied by chest region.

CONCLUSIONS

Despite an inverse relationship between B-lines and BMI, B-lines declined to a lesser degree than NT-proBNP with increasing BMI. These data suggest that LUS may be useful in patients with HF despite obesity.

Early Systolic Lengthening in Patients With ST-Segment-Elevation Myocardial Infarction: A Novel Predictor of Cardiovascular Events

Background

Early systolic lengthening (ESL) may occur in ischemic myocardial segments with reduced contractile force. We sought to evaluate the prognostic potential of ESL in patients with ST‐segment–elevation myocardial infarction treated with primary percutaneous coronary intervention.

Methods and Results

We prospectively enrolled 373 patients with ST‐segment–elevation myocardial infarction treated with primary percutaneous coronary intervention. All patients underwent a speckle tracking echocardiographic examination a median of 2 days (interquartile range, 1–3 days) after the percutaneous coronary intervention. We assessed a novel viability index, the ESL index, defined as follows: [−100×(peak positive systolic strain/peak negative strain in cardiac cycle)]. We also calculated ESL duration, defined as time from onset of QRS complex on the ECG to time of peak positive systolic strain. Both parameters were averaged from 18 myocardial segments. During a median follow‐up of 5.3 years (interquartile range, 2.5–6.0 years), 145 (39%) experienced major adverse cardiovascular events, a composite of incident heart failure, new myocardial infarction, and all‐cause mortality. The ESL index and ESL duration were significantly increased in culprit lesion areas (6.7±6.2% versus 5.0±4.1% and 43±33 ms versus 33±24 ms, respectively; P<0.001 for both). In Cox proportional hazard models, the ESL index (hazard ratio, 1.27 per 1% increase; 95% CI, 1.13–1.43; P<0.001) and ESL duration (hazard ratio, 1.49 per 1‐ms increase; 95% CI, 1.15–1.92; P=0.002) yielded prognostic information on major adverse cardiovascular events. Both associations remained significant after adjusting for clinical, echocardiographic, and invasive confounders.

Conclusions

Assessment of ESL after primary percutaneous coronary intervention in patients with ST‐segment–elevation myocardial infarction yields independent and significant prognostic information on the future risk of cardiovascular events.

Prognostic utility of diastolic dysfunction and speckle tracking echocardiography in heart failure with reduced ejection fraction

Aims

We hypothesized that grading of diastolic dysfunction (DDF) according to two DDF grading algorithms and strain imaging yields prognostic information on all‐cause mortality in patients with heart failure with reduced ejection fraction (HFrEF).

Methods and results

We enrolled ambulatory HFrEF (left ventricular ejection fraction < 45%; N = 1 065) patients who underwent echocardiography and speckle tracking assessment of global longitudinal strain (GLS). Patients were stratified according to DDF grades (Grades I–III) according to two contemporary DDF grading algorithms. Prognostic performance was assessed by C‐statistics. Of the originally 1 065 enrolled patients, a total of 645 (61%) patients (age: 67 ± 11 years, male: 72%, ejection fraction: 27 ± 9%) were classified according to both DDF grading algorithms. Concordance between the algorithms was moderate (kappa = 0.48) and the reclassification rate was 33%. During a median follow‐up of 3.3 years (1.9, 4.7 years), 101 (16%) died from all causes. When comparing DDF Grade I vs. Grade III, both algorithms provided prognostic information [Nagueh: (hazard ratio) HR 2.09, 95% confidence interval (CI),1.32–3.31, P = 0.002; Johansen: HR 2.47, 95% CI, 1.57–3.87, P < 0.001]. However, when comparing DDF Grade II vs. Grade III, only the Johansen algorithm yielded prognostic information (Nagueh: HR 1.04, 95% CI, 0.60–1.77, P = 0.90; Johansen: HR 2.26, 95% CI, 1.35–3.77, P = 0.002). We found no difference in prognostic performance between the two algorithms (C‐statistics: 0.604 vs. 0.623, P = 0.24). Assessed by C‐statistics, the most powerful predictors of the endpoint from the two algorithms were E/e'‐ratio (C‐statistics: 0.644), tricuspid regurgitation velocity (C‐statistics: 0.625) and E/A‐ratio (C‐statistics: 0.602). When adding GLS to a combination of these predictors, the prognostic performance increased significantly (C‐statistics: 0.705 vs. C‐statistics: 0.634, P = 0.028).

Conclusions

Evaluation of DDF in patients with HFrEF yields prognostic information on all‐cause mortality. Furthermore, adding GLS to contemporary algorithms of DDF adds novel prognostic information.

Echocardiography improves prediction of major adverse cardiovascular events in a population with type 1 diabetes and without known heart disease: the Thousand & 1 Study

AIMS/HYPOTHESIS

Cardiovascular disease is the most common comorbidity in type 1 diabetes. However, current guidelines do not include routine assessment of myocardial function. We investigated whether echocardiography provides incremental prognostic information in individuals with type 1 diabetes without known heart disease.

METHODS

A prospective cohort of individuals with type 1 diabetes without known heart disease was recruited from the outpatient clinic. Follow-up was performed through Danish national registers. The association of echocardiography with major adverse cardiovascular events (MACE) and the incremental prognostic value when added to the clinical Steno T1D Risk Engine were examined.

RESULTS

A total of 1093 individuals were included: median (interquartile range) age 50.2 (39.2-60.3) years and HbA_1c 65 (56-74) mmol/mol; 53% men; and mean (SD) BMI 25.5 (3.9) kg/m² and diabetes duration 25.8 (14.6) years. During 7.5 years of follow-up, 145 (13.3%) experienced MACE. Echocardiography significantly and independently predicted MACE: left ventricular ejection fraction (LVEF) <45% (n = 18) vs ≥45% (n = 1075), HR (95% CI) 3.93 (1.91, 8.08), p < 0.001; impaired global longitudinal strain (GLS), 1.65 (1.17, 2.34) (n = 263), p = 0.005; diastolic mitral early velocity (E)/early diastolic tissue Doppler velocity (e') <8 (n = 723) vs E/e' 8-12 (n = 285), 1.59 (1.04, 2.42), p = 0.031; and E/e' <8 vs E/e' ≥12 (n = 85), 2.30 (1.33, 3.97), p = 0.003. In individuals with preserved LVEF (n = 1075), estimates for impaired GLS were 1.49 (1.04, 2.15), p = 0.032; E/e' <8 vs E/e' 8-12, 1.61 (1.04, 2.49), p = 0.033; and E/e' <8 vs E/e' ≥12, 2.49 (1.41, 4.37), p = 0.001. Adding echocardiographic variables to the Steno T1D Risk Engine significantly improved risk prediction: Harrell's C statistic, 0.791 (0.757, 0.824) vs 0.780 (0.746, 0.815), p = 0.027; and net reclassification index, 52%, p < 0.001.

CONCLUSIONS/INTERPRETATION

In individuals with type 1 diabetes without known heart disease, echocardiography significantly improves risk prediction over and above guideline-recommended clinical risk factors alone and could have a role in clinical care.

Dose-Response Association Between Level of Physical Activity and Mortality in Normal, Elevated, and High Blood Pressure

It has been a challenge to verify the dose of exercise that will produce the maximum health benefits in hypertension. This study aimed to explore the association between level of daily physical activity, all-cause mortality and cardiovascular outcome at different blood pressure levels. A random sample of 18 974 white men and women aged 20 to 98 years were examined in a prospective cardiovascular population study. Self-reported activity level in leisure-time was drawn from the Physical Activity Questionnaire (level I: inactivity; II: light activity; and III: moderate/high-level activity). Blood pressure was defined as normal blood pressure: <120/<80 mm Hg; Prehypertension: 120–139/80–89 mm Hg; Stage I hypertension: 140–159/90–99 mm Hg; Stage II hypertension ≥160/≥100 mm Hg. The mean follow-up time was 23.4±11.7 years. At all levels of blood pressure, higher levels of physical activity were associated with lower all-cause mortality in a dose-response pattern. The pattern remained unchanged after adjustment for following confounders: sex, age, smoking status, education, diabetes mellitus, previous cardiovascular disease, body mass index, and calendar time. Compared with inactivity, following hazard ratios were found for stage I hypertension: light activity, hazard ratio 0.78 (0.72–0.84; P <0.001), moderate/high-level activity, hazard ratio 0.69 (0.63–0.75; P <0.001). At all levels of blood pressure, the risk of cardiovascular events was significantly reduced independent of the level of physical activity. In conclusion, the association between physical activity and all-cause mortality was present in an inverse dose-response pattern at all levels of blood pressure. Physical activity was associated with reduction in cardiovascular events independent of the level of physical activity.