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Dini FL, Carluccio E, Ghio S, Pugliese NR, Galeotti G, Correale M, Beltrami M, Tocchetti CG, Mercurio V, Paolillo S, Palazzuoli A. Patient phenotype profiling using echocardiography and natriuretic peptides to personalise heart failure therapy. Heart Fail Rev 2024; 29:367-378. [PMID: 37728750 DOI: 10.1007/s10741-023-10340-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/07/2023] [Indexed: 09/21/2023]
Abstract
Heart failure (HF) is a progressive condition with a clinical picture resulting from reduced cardiac output (CO) and/or elevated left ventricular (LV) filling pressures (LVFP). The original Diamond-Forrester classification, based on haemodynamic data reflecting CO and pulmonary congestion, was introduced to grade severity, manage, and risk stratify advanced HF patients, providing evidence that survival progressively worsened for those classified as warm/dry, cold/dry, warm/wet, and cold/wet. Invasive haemodynamic evaluation in critically ill patients has been replaced by non-invasive haemodynamic phenotype profiling using echocardiography. Decreased CO is not infrequent among ambulatory HF patients with reduced ejection fraction, ranging from 23 to 45%. The Diamond-Forrester classification may be used in combination with the evaluation of natriuretic peptides (NPs) in ambulatory HF patients to pursue the goal of early identification of those at high risk of adverse events and personalise therapy to antagonise neurohormonal systems, reduce congestion, and preserve tissue/renal perfusion. The most benefit of the Guideline-directed medical treatment is to be expected in stable patients with the warm/dry profile, who more often respond with LV reverse remodelling, while more selective individualised treatments guided by echocardiography and NPs are necessary for patients with persisting congestion and/or tissue/renal hypoperfusion (cold/dry, warm/wet, and cold/wet phenotypes) to achieve stabilization and to avoid further neurohormonal activation, as a result of inappropriate use of vasodilating or negative chronotropic drugs, thus pursuing the therapeutic objectives. Therefore, tracking the haemodynamic status over time by clinical, imaging, and laboratory indicators helps implement therapy by individualising drug regimens and interventions according to patients' phenotypes even in an ambulatory setting.
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Affiliation(s)
- Frank L Dini
- Istituto Auxologico IRCCS, Centro Medico Sant'Agostino, Via Temperanza, 6, 20127, Milan, Italy.
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden.
| | - Erberto Carluccio
- Cardiology and Cardiovascular Pathophysiology, Santa Maria della Misericordia, University of Perugia, Perugia, Italy
| | - Stefano Ghio
- Cardiology Division, Fondazione IRCCS, Policlinico San Matteo, Pavia, Italy
| | | | | | - Michele Correale
- Department of Cardiology, University Hospital Policlinico, Riuniti, Foggia, Italy
| | - Matteo Beltrami
- Cardiology Unit, San Giovanni di Dio Hospital, Azienda USL Toscana Centro, Florence, Italy
| | - Carlo Gabriele Tocchetti
- Department of Translational Medical Sciences (DISMET), Center for Basic and Clinical Immunology Research (CISI), Interdepartmental Center of Clinical and Translational Sciences (CIRCET), Interdepartmental Hypertension Research Center (CIRIAPA), Federico II University, Naples, Italy
| | - Valentina Mercurio
- Department of Translational Medical Sciences (DISMET), Interdepartmental Center of Clinical and Translational Sciences (CIRCET), Interdepartmental Hypertension Research Center (CIRIAPA), Federico II University, Naples, Italy
| | - Stefania Paolillo
- Department of Advanced Biomedical Sciences, Section of Cardiology, Federico II University, Naples, Italy
| | - Alberto Palazzuoli
- Cardiovascular Diseases Unit, Cardio-thoracic and vascular Department, S. Maria alle Scotte Hospital, University of Siena, Siena, Italy
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Zhou L, Wiley BM. Current and Future Role of Ultrasonography in the Cardiac Intensive Care Unit. Crit Care Clin 2024; 40:15-35. [PMID: 37973351 DOI: 10.1016/j.ccc.2023.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
The contemporary practice of ultrasonography in the cardiac intensive care unit integrates the principles of echocardiography with whole-body imaging to create a more expansive paradigm of critical care ultrasonography (CCUS). This article will review the use of CCUS for diagnostic assessment, monitoring, therapeutic guidance, and prognosis.
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Affiliation(s)
- Leon Zhou
- Department of Cardiology, Keck School of Medicine of University of Southern California, Los Angeles General Medical Center, Clinic Tower A6E108, 2051 Marengo Street, Los Angeles, CA 90033, USA
| | - Brandon M Wiley
- Department of Cardiology, Keck School of Medicine of University of Southern California, Los Angeles General Medical Center, Clinic Tower A6E108, 2051 Marengo Street, Los Angeles, CA 90033, USA.
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Jentzer JC, Burstein B, Ternus B, Bennett CE, Menon V, Oh JK, Anavekar NS. Noninvasive Hemodynamic Characterization of Shock and Preshock Using Echocardiography in Cardiac Intensive Care Unit Patients. J Am Heart Assoc 2023; 12:e031427. [PMID: 37982222 PMCID: PMC10727278 DOI: 10.1161/jaha.123.031427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 09/27/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND Shock and preshock are defined on the basis of the presence of hypotension, hypoperfusion, or both. We sought to determine the hemodynamic underpinnings of shock and preshock noninvasively using transthoracic echocardiography (TTE). METHODS AND RESULTS We included Mayo Clinic cardiac intensive care unit patients from 2007 to 2015 with TTE within 1 day of admission. Hypotension and hypoperfusion at the time of cardiac intensive care unit admission were used to define 4 groups. TTE findings were evaluated across these groups, and in-hospital mortality was evaluated according to TTE findings in each group. We included 5375 patients with a median age of 69.2 years (36.8% women). The median left ventricular ejection fraction was 50%. Groups based on hypotension and hypoperfusion were assigned as follows: no hypotension or hypoperfusion, 59.7%; isolated hypotension, 15.3%; isolated hypoperfusion, 16.4%; and both hypotension and hypoperfusion, 8.7%. Most TTE variables of interest varied across these groups, with worse biventricular function, lower forward flow, and higher filling pressures as the degree of hemodynamic compromise increased. In-hospital mortality occurred in 8.2%, and inpatient deaths had more TTE parameter abnormalities. In-hospital mortality increased with the degree of hemodynamic compromise, and a marked gradient in in-hospital mortality was observed when the clinical classification of shock and preshock was combined with TTE findings reflecting worse biventricular function, lower forward flow, or higher filling pressures. CONCLUSIONS Substantial differences in cardiac function are observed between cardiac intensive care unit patients with preshock and shock using TTE, and the combination of the clinical and TTE hemodynamic assessment provides robust mortality risk stratification.
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Affiliation(s)
| | - Barry Burstein
- Division of Cardiology, Trillium Health PartnersUniversity of TorontoTorontoOntarioCanada
| | - Bradley Ternus
- Department of Cardiovascular MedicineMayo ClinicRochesterMN
| | | | - Venu Menon
- Department of Cardiovascular MedicineCleveland ClinicClevelandOH
| | - Jae K. Oh
- Department of Cardiovascular MedicineMayo ClinicRochesterMN
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Takahashi T, Iwano H, Shibayama K, Kitai T, Tanaka H, Yamada H, Sata M, Kusunose K. The Clinical Utility of Noninvasive Forrester Classification in Acute Heart Failure from PREDICT Study. Am J Cardiol 2023; 207:75-81. [PMID: 37734303 DOI: 10.1016/j.amjcard.2023.08.119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 08/14/2023] [Accepted: 08/20/2023] [Indexed: 09/23/2023]
Abstract
The Forrester classification plays a crucial role in comprehending the underlying pathophysiology of heart failure (HF) and is employed to categorize the severity and predict the outcomes of patients with acute HF. Our objective was to assess the predictive value of the Forrester classification, based on noninvasive hemodynamic measurements obtained through Doppler echocardiography at admission, in forecasting the short-term prognosis posthospitalization of patients with acute HF. Patients were recruited for the Prospect trial to elucidate the utility of EchocarDIography-based Cardiac ouTput in acute heart failure (PREDICT) study, a multicenter, prospective study conducted in Japan. Participants were stratified into 4 profiles using cardiac index (CI) and early mitral filling velocity (E)/early-diastolic mitral annular velocity (e') ratio obtained from Doppler echocardiography upon admission (profile I: CI >2.2, E/e' ≤15, profile II: CI >2.2, E/e' >15, profile III: CI ≤2.2, E/e' ≤15, profile IV: CI ≤2.2, E/e' >15). The primary composite outcome of the study was all-cause mortality or worsening HF during the 14 days of hospitalization. Cox proportional hazards model analysis was employed to identify prognostic factors during the observation period. A total of 270 subjects, with a mean age of 74 ± 14 years and a male proportion of 60%, were enrolled in the study. During the 14-day period of hospitalization, 58 participants (22%) had a composite outcome. Patients with low CI (i.e., profiles III and IV) demonstrated an elevated risk of composite outcome after adjusting for confounding variables, as evidenced by the adjusted hazard ratios of 5.85 (95% confidence interval 1.17 to 29.09, p <0.01, vs profile III) and 6.50 (95% confidence interval 1.53 to 27.68, p <0.01, vs profile IV) in comparison with profile I, respectively. In conclusion, the Forrester classification, derived from noninvasive Doppler echocardiography at admission, may predict early deterioration in patients hospitalized with acute HF.
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Affiliation(s)
- Tomonori Takahashi
- Department of Cardiovascular Medicine, Tokushima University Hospital, Tokushima, Japan
| | - Hiroyuki Iwano
- Division of Cardiology, Teine Keijinkai Hospital, Sapporo, Japan
| | - Kentaro Shibayama
- Department of Cardiology, Tokyo Cardiovascular and Internal Medicine Clinic, Tokyo, Japan
| | - Takeshi Kitai
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hidekazu Tanaka
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hirotsugu Yamada
- Department of Community Medicine for Cardiology, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Masataka Sata
- Department of Cardiovascular Medicine, Tokushima University Hospital, Tokushima, Japan
| | - Kenya Kusunose
- Department of Cardiovascular Medicine, Tokushima University Hospital, Tokushima, Japan; Department of Cardiovascular Medicine, Nephrology, and Neurology, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan.
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Charles Jain C, Egbe AC, Oh JK, Connolly HM, Miranda WR. Echo-Doppler and strain assessment of filling pressures in adults with congenitally corrected transposition and systemic right ventricles. Eur Heart J Cardiovasc Imaging 2023; 24:454-462. [PMID: 35866302 DOI: 10.1093/ehjci/jeac115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 05/31/2022] [Accepted: 06/06/2022] [Indexed: 11/13/2022] Open
Abstract
AIMS Systolic dysfunction of the systemic right ventricle (sRV) is common in adults with transposition of the great arteries and sRV. In acquired disease, diastology analysis for assessment of filling pressures (FP) is paramount in patient care. METHODS AND RESULTS Retrospective analysis of 47 adults with sRV without prior systemic tricuspid valve surgery undergoing catheterization and echocardiography within 7 days (median -2 [-1, -3]) from January 2000 to February 2021 at our institution. Median age was 48 (31, 55) years, and 16 (34.0%) patients were female. FPs were normal in 21 patients (44.7%). Left atrial size was enlarged in most patients (83.0%) with mean indexed value 58.3 ± 23.4 mL/m2. Tissue Doppler e' was not significantly different between those with high FPs vs. normal (medial 0.07 ± 0.03 vs. 0.08 ± 0.03 m/s, P = 0.63; lateral 0.08 ± 0.04 vs. 0.08 ± 0.04 m/s, P = 0.88). E velocity and subpulmonic mitral regurgitant velocity were higher in those with high FPs (0.9 ± 0.3 vs. 0.6 ± 0.2 m/s, P = 0.005; 3.8 ± 1.1 vs. 2.8 ± 0.9 m/s, P = 0.004). Left atrial reservoir strain, sRV global longitudinal strain, and subpulmonic left ventricular strain were worse in those with high FP (18.0 ± 7.6 vs. 27.9 ± 10.2%, P = 0.0009; -13.0 ± 4.4 vs. -17.9 ± 5.0%, P = 0.002; -16.8 ± 5.7 vs. -23.0 ± 3.8%, P = 0.001). CONCLUSION Despite the complex anatomy, FPs can be assessed non-invasively in adults with sRV without prior systemic tricuspid valve surgery. The current guideline algorithm for diastolic dysfunction in acquired heart disease has limited applicability in this population. Given the limitations of Doppler in this heterogeneous population, strain analysis can be a helpful adjunct for estimation of FPs.
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Affiliation(s)
- C Charles Jain
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Alexander C Egbe
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Jae K Oh
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Heidi M Connolly
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - William R Miranda
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
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Jentzer JC, Tabi M, Wiley BM, Lanspa MJ, Anavekar NS, Oh JK. Doppler-derived haemodynamics performed during admission echocardiography predict in-hospital mortality in cardiac intensive care unit patients. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2022; 11:640-650. [PMID: 35851395 DOI: 10.1093/ehjacc/zuac084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 06/20/2022] [Accepted: 06/28/2022] [Indexed: 06/15/2023]
Abstract
AIMS Cardiac point-of-care ultrasound (CV-POCUS) has become a fundamental part for the assessment of patients admitted to cardiac intensive care units (CICU). We sought to refine the practice of CV-POCUS by identifying 2D and Doppler-derived measurements from bedside transthoracic echocardiograms (TTEs) performed in the CICU that are associated with mortality. METHODS AND RESULTS We retrospectively included Mayo Clinic CICU patients admitted from 2007 to 2018 and assessed the TTEs performed within 1 day of CICU admission, including Doppler and 2D measurements of left and right ventricular function. Logistic regression and classification and regression tree (CART) analysis were used to determine the association between TTE variables with in-hospital mortality. A total of 6957 patients were included with a mean age of 68.0 ± 14.9 years (37.0% females). A total of 609 (8.8%) patients died in the hospital. Inpatient deaths group had worse biventricular systolic function [left ventricular ejection fraction (LVEF) 48.2 ± 16.0% vs. 38.7 ± 18.2%, P < 0.0001], higher filling pressures, and lower forward flow. The strongest TTE predictors of hospital mortality were left ventricular outflow tract velocity-time integral [LVOT VTI, adjusted OR 0.912 per 1 cm higher, 95% confidence interval (CI) 0.883-0.942, P < 0.0001] followed by medial mitral E/e' ratio (adjusted OR 1.024 per 1 unit higher, 95% CI 1.010-1.039, P = 0.0011). Classification and regression tree analysis identified LVOT VTI <16 cm as the most important TTE predictor of mortality. CONCLUSIONS Doppler-derived haemodynamic TTE parameters have a strong association with mortality in the CICU, particularly LVOT VTI <16 cm or mitral E/e' ratio >15. The incorporation of these simplified Doppler-derived haemodynamics into admission CV-POCUS facilitates early risk stratification and strengthens the clinical yield of the ultrasound exam.
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Affiliation(s)
- Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, 200 First Street SW, Rochester, MN 55905, USA
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic Rochester, 200 First Street SW, Rochester, MN 55905, USA
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN 55905, USA
| | - Meir Tabi
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, 200 First Street SW, Rochester, MN 55905, USA
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic Rochester, 200 First Street SW, Rochester, MN 55905, USA
| | - Brandon M Wiley
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, 200 First Street SW, Rochester, MN 55905, USA
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic Rochester, 200 First Street SW, Rochester, MN 55905, USA
| | - Michael J Lanspa
- Division of Respiratory, Critical Care and Occupational Pulmonary Medicine, University of Utah, Murray, UT 84132, USA
| | - Nandan S Anavekar
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, 200 First Street SW, Rochester, MN 55905, USA
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic Rochester, 200 First Street SW, Rochester, MN 55905, USA
| | - Jae K Oh
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, 200 First Street SW, Rochester, MN 55905, USA
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic Rochester, 200 First Street SW, Rochester, MN 55905, USA
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Kataoka Y, Fukuda Y, Peterson J, Shelly I, Alexander J, Sunagawa K. System Design for Optimizing Drug Infusions Using Cardiovascular Space Mapping for Acute Heart Failure. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2022; 2022:1388-1393. [PMID: 36086004 DOI: 10.1109/embc48229.2022.9871694] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Acute heart failure is caused by various factors and requires multiple drug therapies to remedy underlying causes. Due to the complexity of pharmacologic effects of cardiovascular agents, few studies have theoretically addressed the multidrug optimization problem. This paper proposes a drug infusion system for acute heart failure that controls cardiovascular performance metrics (cardiac output, left atrial pressure, and mean arterial pressure) within desired ranges as dictated by the cardiovascular parameters (systemic vascular resistance, cardiac contractility, heart rate, and stressed blood volume). The key to our system design is modeling and controlling cardiovascular parameters to yield the desired cardiovascular metrics. A 'tailored drug infusion' technique controls parameters by solving the optimization problem in order to conquer the complexity of multi-dependencies and the different dosage limits among multiple drugs. A 'cardiovascular space mapping' technique identifies the desired parameters from the desired metrics by deriving the analytical solutions of the metrics as functions of the parameters. To facilitate clinical discussions, parameters were set to realistic values in 5,600 simulated patients. Our results showed not only that the optimized drug combinations and dosages controlled the cardiovascular metrics to within the desired ranges, but also that they mostly corresponded to the recommended clinical use guidelines. An additional value of our system is that it proactively predicts the limitations of the tailored drug therapy, which supports the clinical decision of pivoting to alternative treatment strategies such as mechanical circulatory support.
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Dini FL, Ballo P, Pugliese NR, Bytyçi I, D'Agostino A, Bajraktari G, Pedrinelli R, Henein MY. Improved diastolic dysfunction is associated with higher forward flow and better prognosis in chronic heart failure. THE INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING 2022; 38:727-737. [PMID: 34727251 DOI: 10.1007/s10554-021-02457-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 10/25/2021] [Indexed: 02/05/2023]
Abstract
The benefit of repeat assessment of left ventricular (LV) systolic and diastolic function in heart failure (HF) remains uncertain. We assessed the prognostic value of repeat echocardiographic assessment of LV filling pressure (LVFP) and its interaction with cardiac index (CI) in ambulatory patients with chronic HF and reduced ejection fraction (HFrEF). We enrolled 357 patients (age 68 ± 11 years; 22% female) with chronic HFrEF. Patients underwent a clinical and echocardiographic examination at baseline. LVFP as assessed by the 2016 Guidelines and Doppler-derived CI were estimated. After the second echocardiographic examination, patients were followed for a median time of 30 months. The study endpoint included all-cause death and hospitalization for worsening HF. Patients who normalized LVFP or showed persistently normal LVFP at the follow-up examination had a significantly lower mortality rate than those with worsening or persistently raised LVFP (p < 0.0001). After stratification by CI, patients with elevated LVFP and CI < 2.0 l/min/m2 had a further worse outcome than those with elevated LVFP and CI ≥ 2.0 l/min/m2 (p < 0.0001). Multivariate survival analysis confirmed an independent prognostic impact of changes in LVFP, incremental to that of established clinical, laboratory and echocardiographic predictors. Repeat assessment of LVFP and CI significantly improved risk stratification of chronic HFrEF outpatients compared to baseline evaluation.
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Affiliation(s)
- Frank Lloyd Dini
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma, 67, 56126, Pisa, Italy
| | - Piercarlo Ballo
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma, 67, 56126, Pisa, Italy
| | - Nicola Riccardo Pugliese
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma, 67, 56126, Pisa, Italy.
| | - Ibadete Bytyçi
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma, 67, 56126, Pisa, Italy
| | - Andreina D'Agostino
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma, 67, 56126, Pisa, Italy
| | - Gani Bajraktari
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma, 67, 56126, Pisa, Italy
| | - Roberto Pedrinelli
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma, 67, 56126, Pisa, Italy
| | - Michael Y Henein
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma, 67, 56126, Pisa, Italy
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