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Lisi M, Luisi GA, Pastore MC, Mandoli GE, Benfari G, Ilardi F, Malagoli A, Sperlongano S, Henein MY, Cameli M, D'Andrea A. New perspectives in the echocardiographic hemodynamics multiparametric assessment of patients with heart failure. Heart Fail Rev 2024; 29:799-809. [PMID: 38507022 PMCID: PMC11189326 DOI: 10.1007/s10741-024-10398-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/10/2024] [Indexed: 03/22/2024]
Abstract
International Guidelines consider left ventricular ejection fraction (LVEF) as an important parameter to categorize patients with heart failure (HF) and to define recommended treatments in clinical practice. However, LVEF has some technical and clinical limitations, being derived from geometric assumptions and is unable to evaluate intrinsic myocardial function and LV filling pressure (LVFP). Moreover, it has been shown to fail to predict clinical outcome in patients with end-stage HF. The analysis of LV antegrade flow derived from pulsed-wave Doppler (stroke volume index, stroke distance, cardiac output, and cardiac index) and non-invasive evaluation of LVFP have demonstrated some advantages and prognostic implications in HF patients. Speckle tracking echocardiography (STE) is able to unmask intrinsic myocardial systolic dysfunction in HF patients, particularly in those with LV preserved EF, hence allowing analysis of LV, right ventricular and left atrial (LA) intrinsic myocardial function (global peak atrial LS, (PALS)). Global PALS has been proven a reliable index of LVFP which could fill the gaps "gray zone" in the previous Guidelines algorithm for the assessment of LV diastolic dysfunction and LVFP, being added to the latest European Association of Cardiovascular Imaging Consensus document for the use of multimodality imaging in evaluating HFpEF. The aim of this review is to highlight the importance of the hemodynamics multiparametric approach of assessing myocardial function (from LVFP to stroke volume) in patients with HF, thus overcoming the limitations of LVEF.
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Affiliation(s)
- Matteo Lisi
- Department of Cardiovascular Disease-AUSL Romagna, Division of Cardiology, Ospedale S. Maria delle Croci, Viale Randi 5, 48121, Ravenna, Italy.
| | - Giovanni Andrea Luisi
- Department of Cardiovascular Disease-AUSL Romagna, Division of Cardiology, Ospedale S. Maria delle Croci, Viale Randi 5, 48121, Ravenna, Italy
| | - Maria Concetta Pastore
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Giulia Elena Mandoli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Giovanni Benfari
- Section of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Federica Ilardi
- Department of Advanced Biomedical Sciences, Division of Cardiology, Federico II University Hospital, Via S. Pansini 5, 80131, Naples, Italy
- Mediterranea Cardiocentro, 80122, Naples, Italy
| | - Alessandro Malagoli
- Division of Cardiology, Nephro-Cardiovascular Department, Baggiovara Hospital, Baggiovara, Italy
| | - Simona Sperlongano
- Division of Cardiology, Department of Translational Medical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Michael Y Henein
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Matteo Cameli
- Department of Cardiovascular Disease-AUSL Romagna, Division of Cardiology, Ospedale S. Maria delle Croci, Viale Randi 5, 48121, Ravenna, Italy
| | - Antonello D'Andrea
- Department of Cardiology, Umberto I Hospital, 84014, Nocera Inferiore, SA, Italy
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Gentile F, Sciarrone P, Panichella G, Bazan L, Chubuchny V, Buoncristiani F, Gasparini S, Taddei C, Poggianti E, Fabiani I, Aimo A, Petersen C, Passino C, Emdin M, Giannoni A. Echocardiography-Derived Forward Left Ventricular Output Improves Risk Prediction in Systolic Heart Failure. J Am Soc Echocardiogr 2024:S0894-7317(24)00321-3. [PMID: 38942218 DOI: 10.1016/j.echo.2024.06.008] [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: 03/16/2024] [Revised: 05/30/2024] [Accepted: 06/05/2024] [Indexed: 06/30/2024]
Abstract
BACKGROUND Although it is widely used to classify patients with heart failure (HF), the prognostic role of left ventricular ejection fraction (LVEF) is debated. The aim of this study was to test the hypothesis that echocardiographic measures of forward left ventricular (LV) output, being more representative of cardiac hemodynamics, might improve risk prediction in a large cohort of patients with HF with systolic dysfunction. METHODS Consecutive stable patients with HF with LVEF <50% on guideline-recommended therapies undergoing echocardiography including the evaluation of forward LV output (i.e., LV outflow tract [LVOT] velocity-time integral [VTI], stroke volume index [SVi], and cardiac index) over a 6-year period were selected and followed for the end point of cardiac and all-cause death. RESULTS Among the 1,509 patients analyzed (mean age, 71 ± 12 years; 75% men; mean LVEF, 35 ± 9%), 328 (22%) died during a median follow-up period of 28 months (interquartile range, 14-40 months), 165 (11%) of cardiac causes. On multivariable regression analysis, LVOT VTI (P < .001), SVi (P < .001), and cardiac index (P < .001), but not LVEF (P > .05), predicted cardiac and all-cause death. The optimal prognostic cutoffs for LVOT VTI, SVi, and cardiac index were 15 cm, 38 mL/m2, and 2 L/min/m2, respectively. Adding each of these measures to a multivariable risk model (including clinical, biohumoral, and echocardiographic markers) improved risk prediction (P < .001). Among the different measures of forward LV output, cardiac index was less accurate than LVOT VTI and SVi. CONCLUSIONS The echocardiographic evaluation of forward LV output improves risk prediction in patients with HF across a wide LVEF spectrum over other well-established clinical, biohumoral, and echocardiographic prognostic markers.
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Affiliation(s)
- Francesco Gentile
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy
| | | | - Giorgia Panichella
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Lorenzo Bazan
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy
| | | | | | - Simone Gasparini
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy
| | | | | | | | - Alberto Aimo
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy; Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | | | - Claudio Passino
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy; Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Michele Emdin
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy; Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Alberto Giannoni
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy; Fondazione Toscana Gabriele Monasterio, Pisa, Italy.
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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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Gentile F, Buoncristiani F, Sciarrone P, Bazan L, Panichella G, Gasparini S, Chubuchny V, Taddei C, Poggianti E, Fabiani I, Petersen C, Lancellotti P, Passino C, Emdin M, Giannoni A. Left ventricular outflow tract velocity-time integral improves outcome prediction in patients with secondary mitral regurgitation. Int J Cardiol 2023; 392:131272. [PMID: 37604287 DOI: 10.1016/j.ijcard.2023.131272] [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: 07/20/2023] [Revised: 08/12/2023] [Accepted: 08/17/2023] [Indexed: 08/23/2023]
Abstract
AIMS Left ventricular outflow velocity-time integral (LVOT-VTI) has been shown to improve outcome prediction in different patients' subsets, with or without heart failure (HF). Nevertheless, the prognostic value of LVOT-VTI in patients with HF and secondary mitral regurgitation (MR) has never been investigated so far. Therefore, in the present study, we aimed to assess the prognostic value different metrics of LV forward output, including LVOT-VTI, in HF patients with secondary MR. METHODS AND RESULTS Consecutive patients with HF and moderate-to-severe/severe secondary MR and systolic dysfunction (i.e., left ventricular ejection fraction [LVEF] <50%) were retrospectively selected and followed-up for the primary endpoint of cardiac death. Out of the 287 patients analyzed (aged 74 ± 11 years, 70% men, 46% ischemic etiology, mean LVEF 30 ± 9%, mean LVOT-VTI 20 ± 5 cm), 71 met the primary endpoint over a 33-month median follow-up (16-47 months). Patients with an LVOT-VTI ≤17 cm (n = 96, 32%) showed the greatest risk of cardiac death (Log Rank 44.3, p < 0.001) and all-cause mortality (Log rank 8.6, p = 0.003). At multivariable regression analysis, all the measures of LV forward volume (namely LVOT-VTI, stroke volume index, cardiac output, and cardiac index) were predictors of poor outcomes. Among these, LVOT-VTI was the most accurate in risk prediction (univariable C-statistics 0.70 [95%CI 0.64-0.77]). CONCLUSION Left ventricular forward output, noninvasively estimated through LVOT-VTI, improves outcome prediction in HF patients with low LVEF and secondary MR.
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Affiliation(s)
- Francesco Gentile
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy
| | | | | | - Lorenzo Bazan
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Giorgia Panichella
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Simone Gasparini
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy
| | | | | | | | | | | | - Patrizio Lancellotti
- University of Liège Hospital, Cardiology Department, GIGA Cardiovascular Sciences, CHU Sart Tilman, Liège, Belgium; Gruppo Villa Maria Care and Research, Maria Cecilia Hospital, Cotignola, and Anthea Hospital, Bari, Italy
| | - Claudio Passino
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy; Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Michele Emdin
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy; Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Alberto Giannoni
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy; Fondazione Toscana Gabriele Monasterio, Pisa, Italy.
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Suleman M, Saqib M, Mumtaz H, Iftikhar M, Raza A, Rauf Butt S, Talha KM. Novel echocardiographic markers for left ventricular filling pressure prediction in heart failure with preserved ejection fraction (ECHO-PREDICT): a prospective cross-sectional study. Ann Med Surg (Lond) 2023; 85:5384-5395. [PMID: 37915674 PMCID: PMC10617904 DOI: 10.1097/ms9.0000000000001287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Accepted: 08/31/2023] [Indexed: 11/03/2023] Open
Abstract
Heart failure with preserved ejection fraction is a complex clinical syndrome associated with a high level of morbidity and mortality, constituting 56% of heart failure cases and showing an increasing prevalence. The E/Ea ratio, used for echocardiographic assessment of left ventricular (LV) filling pressure, has been commonly recommended as a noninvasive measure. However, its validity lacks robust prospective validation in patients with preserved LV ejection fraction, and its accuracy has been questioned in comparison to patients with reduced LV ejection fraction. The objective of this study was to evaluate the accuracy of novel echocardiographic markers incorporating peak E velocity, left atrial volume index (LAVi), and pulmonary artery systolic pressure (PAP) for noninvasive estimation of LV end-diastolic pressure (LVEDP) against invasive measurement. In this cross-sectional study conducted at a tertiary care hospital, a sample size of 122 participants was utilized. Statistical analyses including independent samples t-test, χ2 test, and linear regression analysis were employed to explore correlations and predict outcomes. The results indicated that Group 1 (LVEDP <20 mmHg) had a mean age of 59.25 years, while Group 2 (LVEDP >20 mmHg) had a mean age of 56.93 years. Mitral E velocity positively predicted LVEDP, while Mitral E/A ratio showed a negative association. Notably, (E+PAP)/2, (E+LAVi)/2, and Mitral E exhibited good discriminative ability, with respective area under the curve values of 0.840, 0.900, and 0.854. (E+LAVi)/2 demonstrated the highest discriminatory power, with a threshold of 40.100, yielding high sensitivity (0.971) but relatively low specificity (0.302) in predicting LVEDP greater than 20. These findings emphasize the accuracy and utility of combining diastolic variables and peak E velocity as markers for left ventricular filling pressure in patients with a high burden of cardiac disease. Additionally, the study highlights the importance of these parameters in assessing cardiac abnormalities and supports the potential of novel echocardiographic parameters, particularly (E+LAVi)/2, in predicting LVEDP greater than 20. Further research is warranted to validate and explore the prognostic implications of these parameters in larger patient populations, ultimately improving the diagnosis and management of cardiac disease and enhancing clinical outcomes.
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Affiliation(s)
| | | | | | | | - Ali Raza
- Peshawar Institute of Cardiology
| | - Samia Rauf Butt
- University College of Medicine and Dentistry, Lahore, Pakistan
| | - Kenza Manahal Talha
- Clinical Research Associate, Department of Clinical Investigation, Maroof International Hospital, Islamabad
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Wu H, Huan C, Hu Y, Xiao S, Xu T, Guo M, Wang X, Liu A, Sun J, Wang C, Wang J, Zhu H, Pan D. Development and Validation of a Nomogram for Predicting All-Cause Mortality in Patients with Hemodialysis Having Pulmonary Hypertension. Cardiorenal Med 2023; 13:282-291. [PMID: 37640012 PMCID: PMC10664330 DOI: 10.1159/000533674] [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: 01/29/2023] [Accepted: 08/11/2023] [Indexed: 08/31/2023] Open
Abstract
INTRODUCTION Patients with end-stage renal disease receiving hemodialysis (HD) have a high morbidity and mortality rate associated with pulmonary hypertension (PH). A nomogram was developed to predict all-cause mortality in HD patients with PH. In this study, we aimed to validate the usefulness of this nomogram. METHODS A total of 274 HD patients with PH were hospitalized at the Affiliated Hospital of Xuzhou Medical University between January 2014 and June 2019 and followed up for 3 years. Echocardiography detected PH when the peak tricuspid regurgitation velocity (TRV) was more than 2.8 m/s. To evaluate the all-cause mortality for long-term HD patients with PH, Cox regression analysis was performed to determine the factors of mortality that were included in the prediction model. Next, the area under the receiver-operating characteristic curve (AUC-ROC) was used to assess the predictive power of the model. Calibration plots and decision curve analysis (DCA) were used to assess the accuracy of the prediction results and the clinical utility of the model. RESULTS The all-cause mortality rate was 29.20% throughout the follow-up period. The nomogram comprised six commonly available predictors: age, diabetes mellitus, cardiovascular disease, hemoglobin, left ventricular ejection fraction, and TRV. The 1-year, 2-year, and 3-year AUC-ROC values were 0.842, 0.800, and 0.781, respectively. The calibration curves revealed excellent agreement with the nomogram, while the DCA demonstrated favorable clinical practicability. CONCLUSION The first developed nomogram for predicting all-cause mortality in HD patients with PH could guide clinical decision-making and intervention planning.
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Affiliation(s)
- Huimin Wu
- Department of General Practice, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China,
| | - Chunyan Huan
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Yue Hu
- Department of General Practice, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Shengjue Xiao
- Department of Cardiology, Zhongda Hospital, School of Medicine, Southeast University 87 Dingjiaqiao, Nanjing, China
| | - Tao Xu
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Minjia Guo
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Xiaotong Wang
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Ailin Liu
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Jiayi Sun
- Department of General Practice, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Chunqing Wang
- Department of General Practice, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Jia Wang
- Department of Nephrology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Hong Zhu
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Defeng Pan
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
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Du Y, Yuan N, Yan J, Han G, Hu X, Zhang Y, Tian J. Identification of echocardiographic subgroups in patients with coronary heart disease combined with heart failure based on latent variable stratification. Int J Cardiol 2023; 373:90-98. [PMID: 36442673 DOI: 10.1016/j.ijcard.2022.11.038] [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: 09/01/2022] [Revised: 11/18/2022] [Accepted: 11/22/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND The prognosis of chronic heart failure is poor, and it remains a challenge to classify patients for better personalized intervention. This study aimed to explore potential subgroups in patients with coronary heart disease and chronic heart failure using comprehensive echocardiographic indices. METHODS 5126 patients with coronary heart disease with chronic heart failure were included. Latent class analysis was applied to identify the grouping patterns of patients based on echocardiographic indices. Network maps and radar charts of echocardiographic indices were drawn to visualize the distribution of echocardiographic findings. The incidence of adverse outcomes was presented on the Kaplan-Meier curve and compared using the log-rank test. The Cox regression model was used to analyze the relationship between subgroups and mortality. RESULTS Three groups were identified: eccentric hypertrophy, concentric hypertrophy, and decreased diastolic function. Network plots showed a higher correlation between left atrial diameter, left ventricular mass index, and left ventricle ejection fraction in the eccentric hypertrophy group than in the other groups. The Kaplan-Meier curve showed a significant difference in mortality between the three subgroups (P < 0.001). Multivariate Cox analysis indicated that the eccentric hypertrophy group had the highest risk of death (HR = 1.586, 95% CI: 1.310-1.921, P < 0.001) compared with the other groups. CONCLUSION Patients with coronary heart disease and chronic heart failure can be classified into three subgroups based on echocardiographic indices. This grouping has been shown to be an independent risk factor for mortality in these patients. Accurate subgrouping based on echocardiographic indices is important for identifying high-risk patients.
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Affiliation(s)
- Yutao Du
- Department of Health Statistics, School of Public Health, Shanxi Medical University, 56 South XinJian Road, Taiyuan, Shanxi Province 030001, China
| | - Na Yuan
- Department of Health Statistics, School of Public Health, Shanxi Medical University, 56 South XinJian Road, Taiyuan, Shanxi Province 030001, China
| | - Jingjing Yan
- Department of Health Statistics, School of Public Health, Shanxi Medical University, 56 South XinJian Road, Taiyuan, Shanxi Province 030001, China
| | - Gangfei Han
- Department of Cardiology, the 1st Hospital of Shanxi Medical University, 85 South Jiefang Road, Taiyuan, Shanxi Province 030001, China
| | - Xiaojuan Hu
- Department of Cardiology, the 1st Hospital of Shanxi Medical University, 85 South Jiefang Road, Taiyuan, Shanxi Province 030001, China
| | - Yanbo Zhang
- Department of Health Statistics, School of Public Health, Shanxi Medical University, 56 South XinJian Road, Taiyuan, Shanxi Province 030001, China; Shanxi Provincial Key Laboratory of Major Diseases Risk Assessment, 56 South XinJian Road, Taiyuan, Shanxi Province 030001, China; Shanxi University of Chinese Medicine, 121 University Street, Jinzhong, Shanxi Province 030619, China.
| | - Jing Tian
- Department of Cardiology, the 1st Hospital of Shanxi Medical University, 85 South Jiefang Road, Taiyuan, Shanxi Province 030001, China; Shanxi Provincial Key Laboratory of Major Diseases Risk Assessment, 56 South XinJian Road, Taiyuan, Shanxi Province 030001, China.
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Does the Measurement of Ejection Fraction Still Make Sense in the HFpEF Framework? What Recent Trials Suggest. J Clin Med 2023; 12:jcm12020693. [PMID: 36675622 PMCID: PMC9867046 DOI: 10.3390/jcm12020693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 01/06/2023] [Accepted: 01/11/2023] [Indexed: 01/17/2023] Open
Abstract
Left ventricular ejection fraction (LVEF) is universally accepted as a cardiac systolic function index and it provides intuitive interpretation of cardiac performance. Over the last two decades, it has erroneously become the leading feature used by clinicians to characterize the left ventricular function in heart failure (HF). Notably, LVEF sets the basis for structural and functional HF phenotype classification in current guidelines. However, its diagnostic and prognostic role in patients with preserved or mildly reduced contractile function is less clear. This is related to several concerns due to intrinsic technical, methodological and hemodynamic limitations entailed in LVEF measurement that do not describe the chamber's real contractile performance as expressed by pressure volume loop relationship. In patients with HF and preserved ejection fraction (HFpEF), it does not reflect the effective systolic function because it is prone to preload and afterload variability and it does not account for both longitudinal and torsional contraction. Moreover, a repetitive measurement could be assessed over time to better identify HF progression related to natural evolution of disease and to the treatment response. Current gaps may partially explain the causes of negative or neutral effects of traditional medical agents observed in HFpEF. Nevertheless, recent pooled analysis has evidenced the positive effects of new therapies across the LVEF range, suggesting a potential role irrespective of functional status. Additionally, a more detailed analysis of randomized trials suggests that patients with higher LVEF show a risk reduction strictly related to overall cardiovascular (CV) events; on the other hand, patients experiencing lower LVEF values have a decrease in HF-related events. The current paper reports the main limitations and shortcomings in LVEF assessment, with specific focus on patients affected by HFpEF, and it suggests alternative measurements better reflecting the real hemodynamic status. Future investigations may elucidate whether the development of non-invasive stroke volume and longitudinal function measurements could be extensively applied in clinical trials for better phenotyping and screening of HFpEF patients.
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Chen YY, Chung FP, Lin YJ, Chien KL, Chang WT. Exploring the Risk Factors of Sudden Cardiac Death Using an Electrocardiography and Medical Ultrasonography for the General Population Without a History of Coronary Artery Disease or Left Ventricular Ejection Fraction <35% and Aged >35 Years - A Novel Point-Based Prediction Model Based on the Chin-Shan Community Cardiovascular Cohort. Circ J 2022; 87:139-149. [PMID: 36047166 DOI: 10.1253/circj.cj-22-0322] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Most of the factors and prediction models of sudden cardiac death (SCD) have been developed without considering the Asia population. The purpose of this study is to construct a point-based prediction model for the general population in Asia.Methods and Results: Chin-Shan Community Cardiovascular Cohort (CCCC) is a community-based longitudinal cohort initiated between 1990 and 1991, enrolling participants aged ≥35 years and following them up until 2005. Participants with coronary artery disease (CAD) or a left ventricular ejection fraction (LVEF) of 35% were excluded from this study. The Framingham risk score function was used to derive a simple point-based prediction model. Based on bootstrapping, a novel model (CCCC-SCD-Score) was validated. A total of 2,105 participants were analyzed. The incidence rate of SCD was 0.406 per 1,000 person-years. The CCCC-SCD-Score score was calculated using age groups (maximal points=4), left ventricular hypertrophy, hypertension, left ventricular ejection fraction <40%, aortic flow rate >190 cm/s, and carotid plaque scores ≥5 (point=1 for each risk factor). The C-index of the CCCC-SCD-Score in predicting SCD risks was 0.888 (95% confidence interval: 0.807-0.969). CONCLUSIONS For the general Asian population without a history of CAD or a LVEF <35% and who are aged >35 years, the novel model-based scoring system effectively identifies the risk for SCD using the clinical factors, electrocardiographic and echocardiographic data.
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Affiliation(s)
- Yun-Yu Chen
- Institute of Epidemiology and Preventive Medicine College of Public Health, National Taiwan University.,Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital
| | - Fa-Po Chung
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital.,Department of Internal Medicine, Faculty of Medicine, Institute of Clinical Medicine, Cardiovascular Research Center, School of Medicine, National Yang Ming Chiao Tung University
| | - Yenn-Jiang Lin
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital.,Department of Internal Medicine, Faculty of Medicine, Institute of Clinical Medicine, Cardiovascular Research Center, School of Medicine, National Yang Ming Chiao Tung University
| | - Kuo-Liong Chien
- Institute of Epidemiology and Preventive Medicine College of Public Health, National Taiwan University
| | - Wei-Tien Chang
- Department of Emergency Medicine, National Taiwan University Hospital
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10
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Palazzuoli A, Buono MGD, Ruocco G, Caravita S, Abbate A, Lavie CJ. The Conundrum of HFpEF Definition: Non-Invasive Assessment Uncertainties and Alternative Diagnostic Strategies. Curr Probl Cardiol 2022; 48:101433. [PMID: 36170908 DOI: 10.1016/j.cpcardiol.2022.101433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 09/23/2022] [Indexed: 11/26/2022]
Abstract
Heart failure (HF) with preserved ejection fraction (HFpEF) is a heterogeneous syndrome including several morphological phenotypes and varying pathophysiological mechanisms. The conventional classification of HF based on left ventricular ejection fraction (LVEF) has created an oversimplification in diagnostic criteria. Although LVEF is a standardized parameter easy to calculate and broadly applied in the large clinical trials, but it is erroneously considered an index of left ventricular (LV) systolic function. Indeed, it is affected by preload and afterload and it has limitations related to reproducibility, reduced sensitivity and scarce prognostic values especially when above 50%. Notably, additional diagnostic parameters have been recently proposed in order to improve diagnostic accuracy and to homogenise the different HFpEF populations. Unfortunately, these algorithms comprise sophisticated measurements that are difficult to apply in the daily clinical practice. Additionally, the scarce diffusion of these diagnostic criteria may have led to neutral or negative results in interventional phase 3 trials . We propose changes to the current HFpEF diagnostic approach mainly based on LVEF stratification measurement aiming towards a more inclusive model taking into consideration an integrative approach starting from the main diseases responsible for cardiac dysfunction through to cardiac structural and functional alterations. Accordingly, with recent universal HF definitions, a stepwise model could be helpful in recognizing patients with early vs. overt HFpEF by the appraisal of specific Doppler echocardiographic variables. Thus, we would encourage the application of new criteria in order to better identify the different phenotypes and to move towards more personalized medicine.
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Affiliation(s)
- Alberto Palazzuoli
- Cardiovascular Diseases Unit, Cardio thoracic and vascular Department, Le Scotte Hospital University of Siena, Italy.
| | - Marco Giuseppe Del Buono
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli, Rome, Italy
| | - Gaetano Ruocco
- Cardiovascular Diseases Unit, Cardio thoracic and vascular Department, Le Scotte Hospital University of Siena, Italy
| | - Sergio Caravita
- Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milan, Italy
| | - Antonio Abbate
- Berne Cardiovascular Research Centerand Division of Cardiology and Heart and Vascular Center University of Virginia - School of Medicine Charlottesville, VA
| | - Carl J Lavie
- John Ochsner Heart and Vascular Institute Ochsner Clinical School-The University of Queensland School of Medicine New Orleans, Louisiana, US
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11
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Chen C, Zhao J, Xue R, Liu X, Zhu W, Ye M. Prognostic significance of resting cardiac power to left ventricular mass and E/e’ ratio in heart failure with preserved ejection fraction. Front Cardiovasc Med 2022; 9:961837. [PMID: 36061551 PMCID: PMC9433697 DOI: 10.3389/fcvm.2022.961837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Accepted: 07/12/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundCardiac power-to-left ventricular mass (power/mass) is an index reflecting the muscular hydraulic pump capability of the heart, and the E/e’ ratio is a specific indicator for identifying increased left ventricular filling pressure. Limited data exist regarding the prognostic value of incorporating power/mass and E/e’ ratio in heart failure with preserved ejection fraction (HFpEF).Materials and methodsIn total, 475 patients with HFpEF from the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist (TOPCAT) trial with complete baseline echocardiography data were included in our analysis. Patients were categorized into four groups according to power/mass and E/e’ ratio. The risk of outcomes was examined using Cox proportional hazards models and competing risk models.ResultsPatients with low power/mass and high E/e’ were more likely to be males (60.5%), with higher waist circumference, and had a higher prevalence of diabetes (52.1%), atrial fibrillation (50.4%), and lower estimated glomerular filtration rate (eGFR). Combined resting power/mass and E/e’ have graded correlations with left ventricular (LV) dysfunction and clinical outcomes in patients with HFpEF. After multivariable adjustments, an integrative approach combining power/mass and E/e’ remained to be a powerful prognostic predictor, with the highest HRs of clinical outcomes observed in patients with low power/mass and high E/e’ (all-cause mortality: HR 3.45; 95% CI: 1.69–7.05; P = 0.001; hospitalization for heart failure: HR 3.27; 95% CI: 1.60–6.67; P = 0.001; and primary endpoint: HR 3.07; 95% CI: 1.73–5.42; P < 0.001).ConclusionIn patients with HFpEF, an echo-derived integrated approach incorporating resting power/mass and E/e’ ratio remained to be a powerful prognosis predictor and may be useful to risk-stratify patients with this heterogeneous syndrome.Clinical Trial Registration[https://clinicaltrials.gov], identifier [NCT00094302].
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Affiliation(s)
- Cong Chen
- Department of Cardiology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Jie Zhao
- Department of Cardiovascular Medicine, Wuhan Third Hospital, Tongren Hospital of Wuhan University, Wuhan, China
| | - Ruicong Xue
- Department of Cardiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiao Liu
- Department of Cardiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Wengen Zhu
- Department of Cardiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- *Correspondence: Wengen Zhu,
| | - Min Ye
- Department of Cardiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Min Ye,
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12
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The Effectiveness and Safety of Ropivacaine and Medium-Dose Dexmedetomidine in Cesarean Section. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2022; 2022:4447484. [PMID: 35774754 PMCID: PMC9239787 DOI: 10.1155/2022/4447484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 05/28/2022] [Accepted: 05/31/2022] [Indexed: 11/18/2022]
Abstract
Objective: To study the effects of epidural anesthesia with different doses of dexmedetomidine and ropivacaine on postoperative hemodynamics and neonatal outcome of cesarean section parturients. Methods. A total of 90 parturients who underwent cesarean section admitted to our hospital from January 2019 to January 2020 were selected as the research objects and were divided into groups A, B, and C according to different dosages of dexmedetomidine, with 30 cases in each group. Groups A, B, and C were given dexmedetomidine 0.5 μg/kg, 0.8 μg/kg, 1.0 μg/kg, respectively, combined with 0.2% ropivacaine. The anesthesia effect, traction response, hemodynamic indexes, and neonatal Apgar score of the three groups were compared; the “Numerical Rating Scale (NRS) Score” was used to assess the postoperative pain of the parturients, and the “Ramsay Sedation Scale” was used to assess the sedation state of the parturients. Results. The superior anesthesia effect of group B was obtained compared with groups A and C (P < 0.05). Group B witnessed a lower degree of grade III stretching response, as compared to group A (P < 0.05). In comparison with groups A and C, superior results of the heart rate and mean artery pressure (MAP) of group B at T1 and T2 were obtained (P < 0.05). The neonatal Apgar score in group B was lower than those in groups A and C (P < 0.05), and the NRS score of group B was also lower than that of group A (P < 0.05). Compared with groups A and C, group B yielded a more favorable outcome in terms of the Ramsay score (P < 0.05). Conclusion. The use of medium-dose dexmedetomidine in cesarean section parturients is safer and can effectively reduce the impact on maternal hemodynamics, which is worthy of promotion and application.
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13
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Aronow WS, Lloji A, Sreenivasan J, Novograd J, Pan S, Lanier GM. Heart failure with preserved ejection fraction: key stumbling blocks for experimental drugs in clinical trials. Expert Opin Investig Drugs 2022; 31:463-474. [PMID: 35443138 DOI: 10.1080/13543784.2022.2069009] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Heart failure with preserved ejection fraction (HFpEF) is a disease process with a high prevalence. Accounting for more than 50% of all heart failure cases, it carries a significant mortality. So far, there has been a lack of therapeutic options that truly show improvement in morbidity and mortality. Certain novel therapies have shown a decrease in heart failure hospitalizations, however, this beneficial effect was more pronounced for heart failure patients with mildly reduced ejection fraction (EF). AREAS COVERED This review summarizes the pathophysiology of the disease to help elucidate the differences between heart failure with reduced ejection fraction (HFrEF), and HFpEF, which could explain why therapies are successful in one (rather than the other). At the focus of this review are non-standardized nomenclature across major trials, the challenges of finding a therapeutic agent for such a heterogeneous population, and identification of specific phenotypes that have different outcomes and could be a target for future therapies. EXPERT OPINION Lack of standardized diagnostic criteria, associated with population heterogeneity, might explain why trials have failed to improve outcomes for patients with HFpEF. Standardizing phenotypes and recapitulating these phenotypes in animal models, as well as understanding the mechanisms of the disease at the molecular level could be the first steps in identifying promising therapeutic options.
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Affiliation(s)
- Wilbert S Aronow
- Westchester Medical Center, New York Medical College,New York, USA
| | - Amanda Lloji
- Westchester Medical Center, New York Medical College,New York, USA
| | | | - Joel Novograd
- Westchester Medical Center, New York Medical College,New York, USA
| | - Stephen Pan
- Westchester Medical Center, New York Medical College,New York, USA
| | - Gregg M Lanier
- Westchester Medical Center, New York Medical College,New York, USA
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14
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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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15
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Dini FL, Carluccio E, Bitto R, Ciccarelli M, Correale M, D'Agostino A, Dattilo G, Ferretti M, Grelli A, Guida S, Jacoangeli F, Lupi L, Luschi L, Masarone D, Mercurio V, Pacileo G, Pugliese NR, Rispoli A, Scelsi L, Tocchetti CG, Brunetti ND, Palazzuoli A, Piepoli M, Nodari S, Ambrosio G. Echocardiographically defined haemodynamic categorization predicts prognosis in ambulatory heart failure patients treated with sacubitril/valsartan. ESC Heart Fail 2022; 9:1107-1117. [PMID: 35122477 PMCID: PMC8934975 DOI: 10.1002/ehf2.13779] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 11/06/2021] [Accepted: 12/05/2021] [Indexed: 12/11/2022] Open
Abstract
AIM Echo-derived haemodynamic classification, based on forward-flow and left ventricular (LV) filling pressure (LVFP) correlates, has been proposed to phenotype patients with heart failure and reduced ejection fraction (HFrEF). To assess the prognostic relevance of baseline echocardiographically defined haemodynamic profile in ambulatory HFrEF patients before starting sacubitril/valsartan. METHODS AND RESULTS In our multicentre, open-label study, HFrEF outpatients were classified into 4 groups according to the combination of forward flow (cardiac index; CI:< or ≥2.0 L/min/m2 ) and early transmitral Doppler velocity/early diastolic annular velocity ratio (E/e': ≥ or <15): Profile-A: normal-flow, normal-pressure; Profile-B: low-flow, normal-pressure; Profile-C: normal-flow, high-pressure; Profile-D: low-flow, high-pressure. Patients were started on sacubitril/valsartan and followed-up for 12.3 months (median). Rates of the composite of death/HF-hospitalization were assessed by multivariable Cox proportional-hazards models. Twelve sites enrolled 727 patients (64 ± 12 year old; LVEF: 29.8 ± 6.2%). Profile-D had more comorbidities and worse renal and LV function. Target dose of sacubitril/valsartan (97/103 mg BID) was more likely reached in Profile-A (34%) than other profiles (B: 32%, C: 24%, D: 28%, P < 0.001). Event-rate (per 100 patients per year) progressively increased from Profile-A to Profile-D (12.0%, 16.4%, 22.9%, and 35.2%, respectively, P < 0.0001). By covariate-adjusted Cox model, profiles with low forward-flow (B and D) remained associated with poor outcome (P < 0.01). Adding this categorization to MAGGIC-score and natriuretic peptides, provided significant continuous net reclassification improvement (0.329; P < 0.001). Intermediate and high-dose sacubitril/valsartan reduced the event's risk independently of haemodynamic profile. CONCLUSIONS Echocardiographically-derived haemodynamic classification identifies ambulatory HFrEF patients with different risk profiles. In real-world HFrEF outpatients, sacubitril/valsartan is effective in improving outcome across different haemodynamic profiles.
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Affiliation(s)
- Frank L. Dini
- Cardiac, Thoracic and Vascular DepartmentUniversity of PisaPisaItaly
| | - Erberto Carluccio
- Cardiology and Cardiovascular PathophysiologyUniversity of PerugiaPerugiaItaly
| | - Roberto Bitto
- Department of Clinical and Experimental Medicine Section of CardiologyUniversity of MessinaMessinaItaly
| | - Michele Ciccarelli
- Chair of Cardiology, Department of Medicine, Surgery and DentistryUniversity of SalernoSalernoItaly
| | | | | | - Giuseppe Dattilo
- Department of Clinical and Experimental Medicine Section of CardiologyUniversity of MessinaMessinaItaly
| | - Marco Ferretti
- Department of CardiologyUniversity Hospital of ParmaParmaItaly
| | - Arianna Grelli
- Division of CardiologyFondazione I.R.C.C.S. Policlinico San MatteoPaviaItaly
| | - Stefania Guida
- Division of CardiologyFondazione I.R.C.C.S. Policlinico San MatteoPaviaItaly
| | | | - Laura Lupi
- Department of CardiologyUniversity of Brescia and ASST Spedali Civili di BresciaBresciaItaly
| | - Lorenzo Luschi
- Cardiovascular Diseases Unit, Department of Internal MedicineUniversity of SienaSienaItaly
| | | | - Valentina Mercurio
- Department of Translational Medical SciencesFederico II UniversityNaplesItaly
| | | | | | - Antonella Rispoli
- Chair of Cardiology, Department of Medicine, Surgery and DentistryUniversity of SalernoSalernoItaly
| | - Laura Scelsi
- Division of CardiologyFondazione I.R.C.C.S. Policlinico San MatteoPaviaItaly
| | | | | | - Alberto Palazzuoli
- Cardiovascular Diseases Unit, Department of Internal MedicineUniversity of SienaSienaItaly
| | - Massimo Piepoli
- Heart Failure Unit, Cardiology DepartmentGuglielmo da Saliceto Hospital, AUSLPiacenzaItaly
| | - Savina Nodari
- Department of CardiologyUniversity of Brescia and ASST Spedali Civili di BresciaBresciaItaly
| | - Giuseppe Ambrosio
- Cardiology and Cardiovascular PathophysiologyUniversity of PerugiaPerugiaItaly
- CERICLET‐Centro Ricerca Clinica e TraslazionaleUniversity of PerugiaPerugiaItaly
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16
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Results of PRospect trial to Elucidate the utility of EchocarDiography-based Cardiac ouTput in acute heart failure (PREDICT). J Cardiol 2022; 80:218-225. [DOI: 10.1016/j.jjcc.2022.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 02/16/2022] [Accepted: 03/04/2022] [Indexed: 11/23/2022]
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17
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Do the Current Guidelines for Heart Failure Diagnosis and Treatment Fit with Clinical Complexity? J Clin Med 2022; 11:jcm11030857. [PMID: 35160308 PMCID: PMC8836547 DOI: 10.3390/jcm11030857] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 02/01/2022] [Accepted: 02/04/2022] [Indexed: 02/06/2023] Open
Abstract
Heart failure (HF) is a clinical syndrome defined by specific symptoms and signs due to structural and/or functional heart abnormalities, which lead to inadequate cardiac output and/or increased intraventricular filling pressure. Importantly, HF becomes progressively a multisystemic disease. However, in August 2021, the European Society of Cardiology published the new Guidelines for the diagnosis and treatment of acute and chronic HF, according to which the left ventricular ejection fraction (LVEF) continues to represent the pivotal parameter for HF patients’ evaluation, risk stratification and therapeutic management despite its limitations are well known. Indeed, HF has a complex pathophysiology because it first involves the heart, progressively becoming a multisystemic disease, leading to multiorgan failure and death. In these terms, HF is comparable to cancer. As for cancer, surviving, morbidity and hospitalisation are related not only to the primary neoplastic mass but mainly to the metastatic involvement. In HF, multiorgan involvement has a great impact on prognosis, and multiorgan protective therapies are equally important as conventional cardioprotective therapies. In the light of these considerations, a revision of the HF concept is needed, starting from its definition up to its therapy, to overcome the old and simplistic HF perspective.
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18
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Carluccio E, Dini FL, Bitto R, Ciccarelli M, Correale M, D'Agostino A, Dattilo G, Ferretti M, Grelli A, Guida S, Jacoangeli F, Lupi L, Luschi L, Masarone D, Mercurio V, Pacileo G, Pugliese NR, Rispoli A, Scelsi L, Tocchetti CG, Brunetti ND, Palazzuoli A, Piepoli M, Nodari S, Ambrosio G. Benefit from sacubitril/valsartan is associated with hemodynamic improvement in heart failure with reduced ejection fraction: An echocardiographic study. Int J Cardiol 2022; 350:62-68. [PMID: 34998946 DOI: 10.1016/j.ijcard.2022.01.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 12/15/2021] [Accepted: 01/02/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Sacubitril/valsartan improves outcome in patients with heart failure (HF) with reduced left ventricular (LV) ejection fraction (EF, HFrEF). However, little is known about possible mechanisms underlying this favourable effect. PURPOSE To assess changes in echocardiographically-derived hemodynamic profiles induced by sacubitril/valsartan and their impact on outcome. METHODS In this multicenter, open-label study, 727 HFrEF outpatients underwent comprehensive echocardiography at baseline (before starting sacubitril/valsartan) and after 12 months. Estimated LV filling pressure (E/e') and cardiac index (CI, l/min/m2) were combined to determine 4 hemodynamic profiles: profile-A (normal-flow/normal-pressure); profile-B (low-flow/normal-pressure); profile-C: (normal-flow/high-pressure); profile-D: (low-flow/high-pressure). Changes among categories were recorded, and their associations with rates of the composite of death/HF-hospitalization were assessed by multivariable Cox analysis. RESULTS At baseline, 29% had profile-A, 15% had profile-B, 32% profile-C, and 24% profile-D. After 12 months, the hemodynamic profile improved in 53% of patients (all profile-A achievers, or profile-D patients achieving either C or B profile), while it remained unchanged in 39% patients and worsened in 9%. Prevalence of improved profile progressively increased with increasing dose of sacubitril/valsartan (P < 0.0001). After the second echocardiography, patients were followed up 12.6 ± 7.6 months: event-rate was lower in patients with improved profile (12.3%, 95%CI: 9.4-16.1) compared to patients in whom hemodynamic profile remained unchanged (29.9%, 24.0-37.3) or worsened (31.2%, 20.7-46.9, P < 0.0001). Improved hemodynamic profile was associated with favourable outcome independent of LVEF and other covariates (HR 0.65, 95%CI: 0.45-0.95, P < 0.05). CONCLUSION In HFrEF patients, the beneficial prognostic effects of sacubitril/valsartan are associated with improvement in hemodynamic conditions.
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Affiliation(s)
- Erberto Carluccio
- Cardiology and Cardiovascular Pathophysiology, University of Perugia, Italy.
| | - Frank L Dini
- Cardiac, Thoracic and Vascular Department, University of Pisa, Italy
| | - Roberto Bitto
- Dpt. of Clinical and Experimental Medicine Section of Cardiology, University of Messina, Italy
| | - Michele Ciccarelli
- Chair of Cardiology, Dept. of Medicine, Surgery and Dentistry, University of Salerno, Italy
| | | | | | - Giuseppe Dattilo
- Dpt. of Clinical and Experimental Medicine Section of Cardiology, University of Messina, Italy
| | - Marco Ferretti
- Department of Cardiology, University Hospital of Parma, Parma, Italy
| | - Arianna Grelli
- Division of Cardiology, Fondazione I.R.C.C.S. Policlinico San Matteo, Pavia, Italy
| | - Stefania Guida
- Division of Cardiology, Fondazione I.R.C.C.S. Policlinico San Matteo, Pavia, Italy
| | | | - Laura Lupi
- Department of Cardiology, University of Brescia and ASST Spedali Civili di Brescia, Italy
| | - Lorenzo Luschi
- Cardiovascular Diseases Unit, Department of Internal Medicine, University of Siena, Italy
| | - Daniele Masarone
- Heart Failure Unit, AORN dei Colli, Monaldi Hospital, Naples, Italy
| | - Valentina Mercurio
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Giuseppe Pacileo
- Heart Failure Unit, AORN dei Colli, Monaldi Hospital, Naples, Italy
| | | | - Antonella Rispoli
- Chair of Cardiology, Dept. of Medicine, Surgery and Dentistry, University of Salerno, Italy
| | - Laura Scelsi
- Division of Cardiology, Fondazione I.R.C.C.S. Policlinico San Matteo, Pavia, Italy
| | | | | | - Alberto Palazzuoli
- Cardiovascular Diseases Unit, Department of Internal Medicine, University of Siena, Italy
| | - Massimo Piepoli
- Heart Failure Unit, Cardiology Department, Guglielmo da Saliceto Hospital, AUSL, Piacenza, Italy
| | - Savina Nodari
- Department of Cardiology, University of Brescia and ASST Spedali Civili di Brescia, Italy
| | - Giuseppe Ambrosio
- Cardiology and Cardiovascular Pathophysiology, University of Perugia, Italy; CERICLET-Centro Ricerca Clinica e Traslazionale, University of Perugia, Italy
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19
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Pestelli G, Fiorencis A, Pergola V, Luisi GA, Smarrazzo V, Trevisan F, Mele D. Indirect ultrasound evaluation of left ventricular outflow tract diameter implications for heart failure and aortic stenosis severity assessment. Echocardiography 2021; 38:1104-1114. [PMID: 34037989 DOI: 10.1111/echo.15123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 04/26/2021] [Accepted: 05/07/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Whereas dependency of left ventricular outflow tract diameter (LVOTD) from body surface area (BSA) has been established and a BSA-based LVOTD formula has been derived, the relationship between LVOTD and aortic root and LV dimensions has never been explored. This may have implications for evaluation of LV output in heart failure (HF) and aortic stenosis (AS) severity. METHODS A cohort of 540 HF patients who underwent transthoracic echocardiography was divided in a derivation and validation subgroup. In the derivation subgroup (N = 340), independent determinants of LVOTD were analyzed to derive a regression equation, which was used for predicting LVOTD in the validation subgroup (N = 200) and compared with the BSA-derived formula. RESULTS LVOTD determinants in the derivation subgroup were sinuses of Valsalva diameter (SVD, beta = 0.392, P < .001), BSA (beta = 0.229, P < .001), LV end-diastolic diameter (LVEDD, beta = 0.145, P = .001), and height (beta = 0.125, P = .037). The regression equation for predicting LVOTD with the aforementioned variables (LVOTD = 6.209 + [0.201 × SVD] + [1.802 × BSA] + [0.03 × LVEDD] + [0.025 × Height]) did not differ from (P = .937) and was highly correlated with measured LVOTD (R = 0.739, P < .001) in the validation group. Repeated analysis with LV end-diastolic volume instead of LVEDD and/or accounting for gender showed similar results, whereas BSA-derived LVOTD values were different from measured LVOTD (P < .001). CONCLUSION Aortic root and LV dimensions affect LVOTD independently from anthropometric data and are included in a new comprehensive equation for predicting LVOTD. This should improve evaluation of LV output in HF and severity of AS when direct LVOTD measurement is difficult or impossible.
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Affiliation(s)
- Gabriele Pestelli
- Cardiology Unit, Morgagni-Pierantoni Hospital, Forlì, Italy.,Cardiovascular Research Unit, Fondazione Sacco, Forlì, Italy
| | | | - Valeria Pergola
- Cardiology Unit, University Hospital of Padova, Padova, Italy
| | | | | | | | - Donato Mele
- Cardiology Unit, University Hospital of Ferrara, Ferrara, Italy
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Patel HN, Miyoshi T, Addetia K, Henry MP, Citro R, Daimon M, Gutierrez Fajardo P, Kasliwal RR, Kirkpatrick JN, Monaghan MJ, Muraru D, Ogunyankin KO, Park SW, Ronderos RE, Sadeghpour A, Scalia GM, Takeuchi M, Tsang W, Tucay ES, Tude Rodrigues AC, Vivekanandan A, Zhang Y, Schreckenberg M, Blankenhagen M, Degel M, Rossmanith A, Mor-Avi V, Asch FM, Lang RM. Normal Values of Cardiac Output and Stroke Volume According to Measurement Technique, Age, Sex, and Ethnicity: Results of the World Alliance of Societies of Echocardiography Study. J Am Soc Echocardiogr 2021; 34:1077-1085.e1. [PMID: 34044105 PMCID: PMC9149664 DOI: 10.1016/j.echo.2021.05.012] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 05/16/2021] [Accepted: 05/17/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Assessment of cardiac output (CO) and stroke volume (SV) is essential to understand cardiac function and hemodynamics. These parameters can be examined using three echocardiographic techniques (pulsed-wave Doppler, two-dimensional [2D], and three-dimensional [3D]). Whether these methods can be used interchangeably is unclear. The influence of age, sex, and ethnicity on CO and SV has also not been examined in depth. In this report from the World Alliance of Societies of Echocardiography Normal Values Study, the authors compare CO and SV in healthy adults according to age, sex, ethnicity, and measurement techniques. METHODS A total of 1,450 adult subjects (53% men) free of heart, lung, and kidney disease were prospectively enrolled in 15 countries, with even distributions among age groups and sex. Subjects were divided into three age groups (young, 18-40 years; middle aged, 41-65 years; and old, >65 years) and three main racial groups (whites, blacks, and Asians). CO and SV were indexed (cardiac index [CI] and SV index [SVI], respectively) to body surface area and height and measured using three echocardiographic methods: Doppler, 2D, and 3D. Images were analyzed at two core laboratories (one each for 2D and 3D). RESULTS CI and SVI were significantly lower by 2D compared with both Doppler and 3D methods in both sexes. SVI was significantly lower in women than men by all three methods, while CI differed only by 2D. SVI decreased with aging by all three techniques, whereas CI declined only with 2D and 3D. CO and SV were smallest in Asians and largest in whites, and the differences persisted after normalization for body surface area. CONCLUSIONS The present results provide normal reference values for CO and SV, which differ by age, sex, and race. Furthermore, CI and SVI measurements by the different echocardiographic techniques are not interchangeable. All these factors need to be taken into account when evaluating cardiac function and hemodynamics in individual patients.
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Affiliation(s)
| | - Tatsuya Miyoshi
- MedStar Health Research Institute, Washington, District of Columbia
| | | | | | | | | | | | | | | | | | - Denisa Muraru
- University of Milano-Bicocca and Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | | | - Seung Woo Park
- Samsung Medical Center/Sungkyunkwan University School of Medicine, Seoul, Korea
| | | | - Anita Sadeghpour
- Rajaie Cardiovascular Medical Center, Iran University of Medical Sciences, Tehran, Iran
| | | | - Masaaki Takeuchi
- University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Wendy Tsang
- Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | - Yun Zhang
- Qilu Hospital of Shandong University, Jinan, China
| | | | | | - Markus Degel
- TomTec Imaging Systems, Unterschleissheim, Germany
| | | | | | - Federico M Asch
- MedStar Health Research Institute, Washington, District of Columbia
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Palazzuoli A, Beltrami M. Are HFpEF and HFmrEF So Different? The Need to Understand Distinct Phenotypes. Front Cardiovasc Med 2021; 8:676658. [PMID: 34095263 PMCID: PMC8175976 DOI: 10.3389/fcvm.2021.676658] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 04/12/2021] [Indexed: 12/20/2022] Open
Abstract
Traditionally, patients with heart failure (HF) are divided according to ejection fraction (EF) threshold more or <50%. In 2016, the ESC guidelines introduced a new subgroup of HF patients including those subjects with EF ranging between 40 and 49% called heart failure with midrange EF (HFmrEF). This group is poorly represented in clinical trials, and it includes both patients with previous HFrEF having a good response to therapy and subjects with initial preserved EF appearance in which systolic function has been impaired. The categorization according to EF has recently been questioned because this variable is not really a representative of the myocardial contractile function and it could vary in relation to different hemodynamic conditions. Therefore, EF could significantly change over a short-term period and its measurement depends on the scan time course. Finally, although EF is widely recognized and measured worldwide, it has significant interobserver variability even in the most accredited echo laboratories. These assumptions imply that the same patient evaluated in different periods or by different physicians could be classified as HFmrEF or HFpEF. Thus, the two HF subtypes probably subtend different responses to the underlying pathophysiological mechanisms. Similarly, the adaptation to hemodynamic stimuli and to metabolic alterations could be different for different HF stages and periods. In this review, we analyze similarities and dissimilarities and we hypothesize that clinical and morphological characteristics of the two syndromes are not so discordant.
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Affiliation(s)
- Alberto Palazzuoli
- Cardiovascular Diseases Unit, Department of Medical Sciences, Le Scotte Hospital University of Siena, Siena, Italy
| | - Matteo Beltrami
- Cardiology Unit, San Giovanni di Dio Hospital, Florence, Italy
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22
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Mele D, Pestelli G, Molin DD, Smarrazzo V, Luisi GA, Trevisan F, Fiorencis A, Flamigni F, Ferrari R. Right Atrial Pressure Is Associated with Outcomes in Patients with Heart Failure and Indeterminate Left Ventricular Filling Pressure. J Am Soc Echocardiogr 2020; 33:1345-1356. [DOI: 10.1016/j.echo.2020.05.027] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 05/17/2020] [Accepted: 05/18/2020] [Indexed: 12/20/2022]
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Left ventricular output indices in hospitalized heart failure: when "simpler" may not mean "better". Int J Cardiovasc Imaging 2020; 37:59-68. [PMID: 32734497 DOI: 10.1007/s10554-020-01946-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 07/20/2020] [Indexed: 10/23/2022]
Abstract
Assessment of left ventricular (LV) output in hospitalized patients with heart failure (HF) is important to determine prognosis. Although echocardiographic LV ejection fraction (EF) is generally used to this purpose, its prognostic value is limited. In this investigation LV-EF was compared with other echocardiographic per-beat measures of LV output, including non-indexed stroke volume (SV), SV index (SVI), stroke distance (SD), ejection time (ET), and flow rate (FR), to determine the best predictor of all-cause mortality in patients hospitalized with HF. A final cohort of 350 consecutive patients hospitalized with HF who underwent echocardiography during hospitalization was studied. At a median follow-up of 2.7 years, 163 patients died. Non-survivors at follow-up had lower SD, SVI and SV, but not ET, FR and LV-EF than survivors. At multivariate analysis, only age, systolic blood pressure, chronic kidney disease, chronic obstructive pulmonary disease, use of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers and SVI remained significantly associated with outcome [HR for SVI 1.13 (1.04-1.22), P = 0.003]. In particular, for each 5 ml/m2 decrease in SVI, a 13% increase in risk of mortality for any cause was observed. SVI is a powerful prognosticator in HF patients, better than other per-beat measures, which may be simpler but partial or incomplete descriptors of LV output. SVI, therefore, should be considered for the routine echocardiographic evaluation of patients hospitalized with HF to predict prognosis.
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Chen JS, Pei Y, Li CE, Li NY, Guo T, Yu J. Prognostic value of heart failure echocardiography index in HF patients with preserved, mid-ranged and reduced ejection fraction. BMC Cardiovasc Disord 2020; 20:351. [PMID: 32727406 PMCID: PMC7391637 DOI: 10.1186/s12872-020-01635-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 07/20/2020] [Indexed: 11/28/2022] Open
Abstract
Background To investigate the clinical value of heart failure echocardiography index (HFEI) in evaluating the cardiac function and predicting the prognosis of patients with different types of heart failure (HF). Methods Four hundred eighty-nine consecutively admitted HF patients were divided into three groups: HF with reduced ejection (HFrEF), HF with mid-range ejection fraction (HFmrEF), and HF with preserved ejection fraction (HFpEF). The baseline characteristics and ultrasound indexes were compared between the three groups. The correlation between HFEI and one-year risk of adverse events was compared by multivariate logistic regression. The clinical value of HFEI and plasma level of NT-proBNP in assessing the prognosis of patients with chronic heart failure (CHF) was analyzed by the receiver operating characteristic (ROC) curve. Results HFEI in HFrEF was significantly higher than that in HFmrEF and HFpEF. Multivariate regression analysis indicated that HFEI and plasma level of NT-proBNP were independent risk factors for predicting the short-time prognosis of HF patients. The ROC curve indicated that the HFEI cutoff level of 3.5 and the plasma NT-proBNP level of 3000 pg/ml predicted a poor prognosis of CHF patients with a sensitivity of 64% and a specificity of 75% vs. 68 and 65%. Conclusion HFEI can comprehensively evaluate the overall cardiac function of patients with various types of HF, and may prove to be an important index of assessing the prognosis of HF patients.
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Affiliation(s)
- Jian-Shu Chen
- Lanzhou University Second College of Clinical Medicine, Number 199 Donggang West Road, Chengguan District, Lanzhou, 730030, China
| | - Ying Pei
- Lanzhou University Second College of Clinical Medicine, Number 199 Donggang West Road, Chengguan District, Lanzhou, 730030, China
| | - Cai-E Li
- Lanzhou University Second College of Clinical Medicine, Number 199 Donggang West Road, Chengguan District, Lanzhou, 730030, China
| | - Ning-Yin Li
- Lanzhou University Second College of Clinical Medicine, Number 199 Donggang West Road, Chengguan District, Lanzhou, 730030, China
| | - Tao Guo
- Lanzhou University Second College of Clinical Medicine, Number 199 Donggang West Road, Chengguan District, Lanzhou, 730030, China
| | - Jing Yu
- Lanzhou University Second College of Clinical Medicine, Number 199 Donggang West Road, Chengguan District, Lanzhou, 730030, China. .,Department of Cardiology, Second Hospital of Lanzhou University, No.82 Cui Ying Men, Cheng Guan District, Lanzhou, 730030, China.
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25
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Mele D, Pestelli G, Dal Molin D, Fiorencis A, Flamigni F, Luisi GA, Smarrazzo V, Trevisan F, Ferrari R. Paradoxical low-flow phenotype in hospitalized heart failure with preserved ejection fraction. IJC HEART & VASCULATURE 2020; 28:100539. [PMID: 32490146 PMCID: PMC7262439 DOI: 10.1016/j.ijcha.2020.100539] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 05/15/2020] [Indexed: 12/31/2022]
Abstract
Patients with HFpEF and paradoxical low forward flow have a worse outcome. Stroke volume index identifies HFpEF patients with paradoxical low flow. Small LV cavity, atrial fibrillation and RV dysfunction affect paradoxical low flow.
Background Low flow (LF) in heart failure with preserved ejection fraction (HFpEF) is a paradox but is associated with worse prognosis. Determinants of LF in HFpEF have not been clarified but their assessment could corroborate recognition and definition of such a paradoxical condition. Methods A cohort of 193 patients hospitalized with HFpEF was retrospectively studied and divided in a group with LF (N = 45), defined by a left ventricular (LV) stroke volume index (SVI) < 30 ml/m2, and a group with normal flow (N = 148). A small LV cavity was pre-defined as LV end diastolic diameter index (EDDI) below median values (<25 mm/m2 for males and <26 mm/m2 for females). Right ventricular dysfunction (RVD) was defined as the ratio between tricuspid annular plane systolic excursion and systolic pulmonary artery pressure < 0.36 mm/mmHg. An endpoint of all-cause mortality was evaluated after a median follow-up of 2.4 years. Results RVD (OR = 7.4; P < 0.001), atrial fibrillation (AF) during echocardiography (OR = 3.26; P = 0.008), and small LV cavity (OR = 3.81; P = 0.003) were independently associated with LF. After adjusting for age, body mass index, systolic blood pressure, renal function, chronic obstructed pulmonary disease, use of ACE inhibitors/angiotensin receptor blockers, moderate tricuspid regurgitation, RVD), LF was associated with mortality (HR = 3.69; P < 0.001) whereas the combination of the determinants of LF was not. Conclusion Paradoxical LF in HFpEF is associated with small LV cavity, AF and RVD. None of the combination of different factors associated with LF could substitute direct assessment of LF status in predicting prognosis in this cohort.
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Affiliation(s)
- Donato Mele
- Cardiology Unit and LTTA Centre, University of Ferrara, Italy
| | - Gabriele Pestelli
- Cardiology Unit, Morgagni-Pierantoni Hospital, Forlì, Italy.,Unità di Ricerca Cardiovascolare, Fondazione Sacco, Forlì, Italy
| | | | | | | | | | | | | | - Roberto Ferrari
- Cardiology Unit and LTTA Centre, University of Ferrara, Italy.,Maria Cecilia Hospital, GVM Care & Research, E.S. Health Science Foundation, Cotignola (RA), Italy
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Mele D, Pestelli G, Dini FL, Dal Molin D, Smarrazzo V, Trevisan F, Luisi GA, Ferrari R. Novel Echocardiographic Approach to Hemodynamic Phenotypes Predicts Outcome of Patients Hospitalized With Heart Failure. Circ Cardiovasc Imaging 2020; 13:e009939. [PMID: 32312116 DOI: 10.1161/circimaging.119.009939] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Although in clinical practice heart failure (HF) patients are classified using left ventricular ejection fraction (LVEF), this categorization is insufficient for prognosis, especially when LVEF is preserved or there is a concomitant right ventricular (RV) dysfunction. We hypothesized that a combined noninvasive evaluation of LV forward flow, filling pressure, and RV function would be better than LVEF in predicting all-cause mortality of hospitalized patients with HF. METHODS Transthoracic echocardiographic examinations of 603 patients hospitalized with HF were analyzed. In a subsample of 200 patients with HF, LV stroke volume index, LV filling pressure estimation, tricuspid annular plane systolic excursion, and systolic pulmonary artery pressure were combined to determine 4 hemodynamic profiles: normal flow-normal pressure, normal flow-high pressure, low flow without RV dysfunction, and low flow with RV dysfunction profile. This model was then applied in a validation cohort (n=403). RESULTS Prognosis worsened from the normal flow-normal pressure profile to the low flow with right ventricular dysfunction profile. At the multivariate survival analysis, the model showed independent high risk-stratification capability (P<0.001), even in subgroups of patients with LVEF < or ≥50% (P=0.011 and P<0.001, respectively) and < or ≥40% (P=0.044 and P<0.001, respectively). LVEF and HF classification based on LVEF did not predict outcome. CONCLUSIONS Echocardiographic-derived profiling of LV forward flow, filling pressure, and RV function allowed categorization of patients hospitalized with HF and predicted all-cause mortality independently of LVEF. This model is based on conventional echocardiography, is easy to apply, and is, therefore, suggested for clinical practice.
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Affiliation(s)
- Donato Mele
- Cardiology Unit and LTTA Centre, University of Ferrara, Italy (D.M., G.P., D.D.M., V.S., F.T., G.A.L., R.F.)
| | - Gabriele Pestelli
- Cardiology Unit and LTTA Centre, University of Ferrara, Italy (D.M., G.P., D.D.M., V.S., F.T., G.A.L., R.F.)
| | - Frank Lloyd Dini
- Cardiovascular Diseases Unit 1, Cardiovascular and Thoracic Department, University of Pisa, Italy (F.L.D.)
| | - Davide Dal Molin
- Cardiology Unit and LTTA Centre, University of Ferrara, Italy (D.M., G.P., D.D.M., V.S., F.T., G.A.L., R.F.)
| | - Vittorio Smarrazzo
- Cardiology Unit and LTTA Centre, University of Ferrara, Italy (D.M., G.P., D.D.M., V.S., F.T., G.A.L., R.F.)
| | - Filippo Trevisan
- Cardiology Unit and LTTA Centre, University of Ferrara, Italy (D.M., G.P., D.D.M., V.S., F.T., G.A.L., R.F.)
| | - Giovanni Andrea Luisi
- Cardiology Unit and LTTA Centre, University of Ferrara, Italy (D.M., G.P., D.D.M., V.S., F.T., G.A.L., R.F.)
| | - Roberto Ferrari
- Cardiology Unit and LTTA Centre, University of Ferrara, Italy (D.M., G.P., D.D.M., V.S., F.T., G.A.L., R.F.).,Maria Cecilia Hospital, GVM Care & Research, E.S. Health Science Foundation, Cotignola (RA), Italy (R.F.)
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Mele D, Pestelli G, Molin DD, Trevisan F, Smarrazzo V, Luisi GA, Fucili A, Ferrari R. Echocardiographic Evaluation of Left Ventricular Output in Patients with Heart Failure: A Per-Beat or Per-Minute Approach? J Am Soc Echocardiogr 2020; 33:135-147.e3. [DOI: 10.1016/j.echo.2019.09.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 07/03/2019] [Accepted: 09/09/2019] [Indexed: 12/28/2022]
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