Comparison of Left Ventricular Function and Myocardial Infarct Size Determined by 2-Dimensional Speckle Tracking Echocardiography in Patients With and Without Chronic Obstructive Pulmonary Disease After ST-Segment Elevation Myocardial Infarction

Effects of COPD on Left Ventricular and Left Atrial Deformation in Patients with Acute Myocardial Infarction: Strain Analysis Using Speckle-Tracking Echocardiography

Myocardial strain analysis, which describes myocardial deformation (shortening or lengthening), provides more detailed information about left ventricular (LV) and atrial (LA) functions than conventional echocardiography and delivers prognostic information. To analyze the effects of COPD on left heart function upon acute myocardial infarction (AMI), consecutive AMI patients were retrospectively screened, and patients were included if a post-AMI echocardiography and results of recent pulmonary function tests (PFTs) were available. Strain analysis was performed by a cardiologist who was blinded to clinical information. Overall, 109 AMI patients were included (STEMI: 38%, non-STEMI: 62%). COPD patients (41%) had significantly more impaired LV “global-longitudinal-strain” (LV-GLS) compared to non-COPD patients (−15 ± 4% vs. −18 ± 4%; p < 0.001, respectively), even after adjusting for LV-ejection-fraction (LVEF) and age (mean estimated difference: 1.7%, p = 0.009). Furthermore, COPD patients had more impaired LA strain (LAS) than non-COPD patients in all cardiac cycle phases (estimated mean differences after adjusting for LVEF and age: during reservoir phase: −7.5% (p < 0.001); conduit phase: 5.5% (p < 0.001); contraction phase: 1.9% (p = 0.034)). There were no correlations between PFT variables and strain values. In conclusion, the presence of COPD was associated with more impaired LV and LA functions after AMI, as detected by strain analysis, which was independent of age, LVEF, and PFT variables.

COPD and acute myocardial infarction

COPD is strongly associated with cardiovascular disease, in particular acute myocardial infarction (AMI). Besides shared risk factors, COPD-related factors, such as systemic inflammation and hypoxia, underlie the pathophysiological interaction between COPD and AMI. The prevalence of COPD amongst AMI populations ranges from 7% to 30%, which is possibly even an underestimation due to underdiagnoses of COPD in general. Following the acute event, patients with COPD have an increased risk of mortality, heart failure and arrhythmias during follow-up. Adequate risk stratification can be performed using various imaging techniques, evaluating cardiac size and function after AMI. Conventional imaging techniques such as echocardiography and cardiac magnetic resonance imaging have already indicated impaired cardiac function in patients with COPD without known cardiovascular disease. Advanced imaging techniques such as speckle-tracking echocardiography and T1 mapping could provide more insight into cardiac structure and function after AMI and have proven to be of prognostic value. Future research is required to better understand the impact of AMI on patients with COPD in order to provide effective secondary prevention. The present article summarises the current knowledge on the pathophysiologic factors involved in the interaction between COPD and AMI, the prevalence and outcomes of AMI in patients with COPD and the role of imaging in the acute phase and risk stratification after AMI in patients with COPD.

Right Ventricle Function in Patients with Acute Coronary Syndrome and Concomitant Undiagnosed Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD) is frequently undiagnosed in patients with ischemic heart disease. Nowadays, it is still unknown whether undiagnosed concomitant COPD is related to early structural changes of the heart, as detectable by trans-thoracic echocardiography (TTE). Starting from the study population of the Screening for COPD in ACS Patients (SCAP) trial, we sought to investigate potential differences in echocardiographic parameters in patients with acute coronary syndromes (ACS), with or without undiagnosed concomitant COPD. Overall, 137 patients were included. Undiagnosed COPD was detected by spirometry in 39 (29%) patients. TTE was performed at inclusion (before hospital discharge) and after six months. Several echocardiographic parameters including fractional area change (FAC) and RV strain (RVS), were measured. Patients with undiagnosed COPD, as compared to those without COPD, showed lower FAC and reduced RVS both at inclusion (37 ± 6% vs. 44 ± 9%, p < 0.001; -15 ± -4 vs. -20 ± -5, p < 0.001, respectively) and after six months (38 ± 7% vs. 45 ± 9%, p < 0.001; -16 ± -4 vs. -20 ± -5, p < 0.001, respectively). After multivariate analysis undiagnosed COPD was independently associated with lower FAC and reduced RVS at baseline and at TTE after six months. Early impairment of RV function can be detected in ACS patients with concomitant undiagnosed COPD. If these alterations may be changed by an early diagnosis and an early treatment, should be evaluated in future studies. Clinical trial registration: NCT02324660.

B-lines by lung ultrasound predict heart failure in hospitalized patients with acute anterior wall STEMI

OBJECTIVE

B-line imaging by lung ultrasound (LUS) is a new tool for evaluating subclinical pulmonary congestion. The aim of this study was to explore the prognostic value of B-line number at admission in predicting symptomatic heart failure (HF) during hospitalization in acute anterior wall STEMI patients.

METHODS

This was a prospective cohort study which consecutively enrolled 96 anterior wall STEMI patients without dyspnea at admission. Pulmonary auscultation, NT-proBNP test, LUS, and echocardiography were performed within 5 hours after primary PCI. Rale occurrence, plasma NT-proBNP levels, B-line number, LVEF, E/e' were recorded, and their predictive value for HF in-hospital was analyzed.

RESULTS

A total of 19 patients developed symptomatic HF. Median B-line number, NT-proBNP levels, and E/e' in the HF group were higher than those of the nonheart-failure (NHF) group (P < 0.001) while LVEF was lower (P = 0.002). There was no statistical difference in rale occurrence between the two groups. Multivariate logistic regression demonstrated that B-lines, E/e', and NT-proBNP independently predicted HF during hospitalization. According to the area under the ROC curve, the strongest predictor is B-lines (0.972), followed by NT-proBNP (0.936) and E/e' (0.928), and combining the three indicators was better than any single parameter (P = 0.048). B-line cutoff ≥18 could well predict HF event with specificity and sensitivity of 94.7% and 94.8%, respectively.

CONCLUSION

Subclinical pulmonary congestion reflected by B-lines can independently predict symptomatic HF during hospitalization in patients with anterior wall STEMI, LUS will act as a complementary tool for evaluating cardiac function.

Left ventricular hypertrophy as protective factor after bypass grafting

Left ventricular hypertrophy (LVH) is a well established cardiovascular risk factor, accounting for an increase in cardiovascular morbid-mortality, although how much the magnitude and the kind of LVH could affect cardiovascular outcomes is in large part unknown. We speculate that mild LVH in absence of left ventricular (LV) chamber dilation, could play a protective role towards functional capacity, clinical outcome, cardiovascular and total morbi-mortality in conditions in which LV systolic function is generally reduced. Accordingly to many epidemiological observations, the availability of extra-quote of systolic function could lead to a significative improvement in the final outcome of some kinds of heart patients, as those undergoing bypass-grafting, where the stress for heart and cardiovascular system is always high. We suppose that the functional reserve available for patients with LVH could make the difference with respect to other patients undergoing myocardial revascularization. Similarly, the availability of a contractile reserve warranted by LVH could ensure a little gain in the outcome for patients after other major cardiovascular events (such as myocardial infarction or other heart surgery as surgical valve replacement). However, our hypothesis only involves mild LVH without LV chamber dilation, that is the initial stage of "non-dilated concentric" LVH and "non-dilated eccentric" LVH according to the new four-tiered classification of LVH based on relative wall thickness and LV dilation. Support for our hypothesis derives from the well-known protective role of systolic function that is a major factor in almost all cardiovascular diseases, where LV ejection fraction (LVEF) has shown to significantly improve quality of life, as well as morbidity and mortality. The knowledge that mild LVH in absence of LV chamber dilation is not as harmful in such conditions as believed at present could make avoidable some drugs prescription in some stages of the disease. Furthermore, it may allow a better evaluation of the risk profile of patients with LVH undergoing some cardiovascular major events like bypass grafting, myocardial infarction or surgical heart valve replacement.