Association of Left Ventricular Ejection Fraction with Mortality and Hospitalizations

Association of left ventricular ejection fraction with risk of cardiovascular diseases: a prospective cohort study

Left ventricular ejection fraction (LVEF) is the most ubiquitous parameter in cardiac imaging examinations, we aimed to investigate the associations between subtle changes of LVEF and risk of common cardiovascular diseases. This is a prospective cohort study based on UK Biobank. LVEF was obtained from cardiac magnetic resonance. Incident cardiovascular disease was the outcome, including heart failure, atrial fibrillation, ischemic heart disease, and myocardial infarction. Cox proportional hazard model was the main method. A U-shaped relationship was observed between quantified LVEF and cardiovascular events risk with the nadir at the LVEF of 55-64%. As compared to moderate LVEF (55-64%), both low (40-54%) and high LVEF ( ≥ 5%) were related to higher risk of cardiovascular diseases after adjusting for confounders (HRlow = 1.15, 95%CI = 1.02-1.30; HRhigh = 1.34, 95%CI = 1.05-1.72). Specifically, low LVEF was associated with increased risk of heart failure while high LVEF predominantly predicted elevated risk of ischemic heart diseases, both low and high LVEF were related to a borderline higher incidence of atrial fibrillation. Besides, associations with specific cardiovascular diseases varied by age, sex or comorbidities. There was a U-shaped relationship between LVEF and cardiovascular events risk with the nadir at the LVEF of 55-64%, while these associations were disease-specific and varied by age, sex or comorbidities.

Segmentation-Free Estimation of Left Ventricular Ejection Fraction Using 3D CNN Is Reliable and Improves as Multiple Cardiac MRI Cine Orientations Are Combined

OBJECTIVES

We aimed to study classical, publicly available convolutional neural networks (3D-CNNs) using a combination of several cine-MR orientation planes for the estimation of left ventricular ejection fraction (LVEF) without contour tracing.

METHODS

Cine-MR examinations carried out on 1082 patients from our institution were analysed by comparing the LVEF provided by the CVI42 software (V5.9.3) with the estimation resulting from different 3D-CNN models and various combinations of long- and short-axis orientation planes.

RESULTS

The 3D-Resnet18 architecture appeared to be the most favourable, and the results gradually and significantly improved as several long-axis and short-axis planes were combined. Simply pasting multiple orientation views into composite frames increased performance. Optimal results were obtained by pasting two long-axis views and six short-axis views. The best configuration provided an R2 = 0.83, a mean absolute error (MAE) = 4.97, and a root mean square error (RMSE) = 6.29; the area under the ROC curve (AUC) for the classification of LVEF < 40% was 0.99, and for the classification of LVEF > 60%, the AUC was 0.97. Internal validation performed on 149 additional patients after model training provided very similar results (MAE 4.98). External validation carried out on 62 patients from another institution showed an MAE of 6.59. Our results in this area are among the most promising obtained to date using CNNs with cardiac magnetic resonance.

CONCLUSION

(1) The use of traditional 3D-CNNs and a combination of multiple orientation planes is capable of estimating LVEF from cine-MRI data without segmenting ventricular contours, with a reliability similar to that of traditional methods. (2) Performance significantly improves as the number of orientation planes increases, providing a more complete view of the left ventricle.

Prognostic impact of prior LVEF in patients with heart failure with mildly reduced ejection fraction

AIMS

As there is limited evidence regarding the prognostic impact of prior left ventricular ejection fraction (LVEF) in patients with heart failure with mildly reduced ejection fraction (HFmrEF), this study investigates the prognostic impact of longitudinal changes in LVEF in patients with HFmrEF.

METHODS

Consecutive patients with HFmrEF (i.e. LVEF 41-49% with signs and/or symptoms of HF) were included retrospectively in a monocentric registry from 2016 to 2022. Based on prior LVEF, patients were categorized into three groups: stable LVEF, improved LVEF, and deteriorated LVEF. The primary endpoint was 30-months all-cause mortality (median follow-up). Secondary endpoints included in-hospital and 12-months all-cause mortality, as well as HF-related rehospitalization at 12 and 30 months. Kaplan-Meier and multivariable Cox proportional regression analyses were applied for statistics.

RESULTS

Six hundred eighty-nine patients with HFmrEF were included. Compared to their prior LVEF, 24%, 12%, and 64% had stable, improved, and deteriorated LVEF, respectively. None of the three LVEF groups was associated with all-cause mortality at 12 (p ≥ 0.583) and 30 months (31% vs. 37% vs. 34%; log rank p ≥ 0.376). In addition, similar rates of 12- (p ≥ 0.533) and 30-months HF-related rehospitalization (21% vs. 23% vs. 21%; log rank p ≥ 0.749) were observed. These findings were confirmed in multivariable regression analyses in the entire study cohort.

CONCLUSION

The transition from HFrEF and HFpEF towards HFmrEF is very common. However, prior LVEF was not associated with prognosis, likely due to the persistently high dynamic nature of LVEF in the follow-up period.

Artificial Intelligence-Based Left Ventricular Ejection Fraction by Medical Students for Mortality and Readmission Prediction

INTRODUCTION

Point-of-care ultrasound has become a universal practice, employed by physicians across various disciplines, contributing to diagnostic processes and decision-making.

AIM

To assess the association of reduced (<50%) left-ventricular ejection fraction (LVEF) based on prospective point-of-care ultrasound operated by medical students using an artificial intelligence (AI) tool and 1-year primary composite outcome, including mortality and readmission for cardiovascular-related causes.

METHODS

Eight trained medical students used a hand-held ultrasound device (HUD) equipped with an AI-based tool for automatic evaluation of the LVEF of non-selected patients hospitalized in a cardiology department from March 2019 through March 2020.

RESULTS

The study included 82 patients (72 males aged 58.5 ± 16.8 years), of whom 34 (41.5%) were diagnosed with AI-based reduced LVEF. The rates of the composite outcome were higher among patients with reduced systolic function compared to those with preserved LVEF (41.2% vs. 16.7%, p = 0.014). Adjusting for pertinent variables, reduced LVEF independently predicted the composite outcome (HR 2.717, 95% CI 1.083-6.817, p = 0.033). As compared to those with LVEF ≥ 50%, patients with reduced LVEF had a longer length of stay and higher rates of the secondary composite outcome, including in-hospital death, advanced ventilatory support, shock, and acute decompensated heart failure.

CONCLUSION

AI-based assessment of reduced systolic function in the hands of medical students, independently predicted 1-year mortality and cardiovascular-related readmission and was associated with unfavorable in-hospital outcomes. AI utilization by novice users may be an important tool for risk stratification for hospitalized patients.

Association of number of siblings with preclinical markers of cardiovascular disease. The cardiovascular risk in Young Finns study

To investigate the association of number of siblings with preclinical cardiovascular disease (CVD) markers in adulthood. The sample comprised 2776 participants (54 % female) from the Cardiovascular Risk in Young Finns Study who had CVD risk factor data measured in childhood in 1980 (aged 3-18 years) and markers of preclinical CVD measured in adulthood. Echocardiography was performed in 2011, and carotid intima-media thickness, carotid distensibility, brachial flow-mediated dilatation, and arterial pulse wave velocity were measured in 2001 or 2007. The association between the number of siblings and preclinical CVD was assessed using generalized linear and logistic regression models. Analyses were stratified by sex as associations differed between sexes. Women with 1 sibling had lower E/e'-ratio (4.9, [95%CI 4.8-5.0]) in echocardiography compared with those without siblings (5.1[4.9-5.2]) and those with ≥2 more siblings (5.1[5.0-5.2]) (P for trend 0.01). Men without siblings had the lowest E/A-ratio (1.4[1.3-1.5]) compared with those with 1 sibling (1.5[1.5-1.5]), or ≥2 siblings (1.5[1.5-1.5]) (P for trend 0.01). Women without siblings had highest left ventricular ejection fraction (59.2 %[58.6-59.7 %]) compared with those with 1 sibling (59.1 %[58.8-59.4 %]), or ≥2 siblings (58.4 %[58.1-58.8 %])(P for trend 0.01). In women, brachial flow-mediated dilatation, a measure of endothelial function, was the lowest among participants with ≥2 siblings (9.4 %[9.0-9.8 %]) compared with those with 1 sibling (10.0 %[9.6-10.3 %]) and those without siblings (10.4 %[9.7-11.0 %])(P for trend 0.03). We observed that number of siblings may be associated with increased risk of heart failure in women. As the associations were somewhat inconsistent in males and females, further research is warranted.

Prognostic impact of acute decompensated heart failure in patients with heart failure with mildly reduced ejection fraction

AIMS

This study sought to determine the prognostic impact of acute decompensated heart failure (ADHF) in patients with heart failure with mildly reduced ejection fraction (HFmrEF). ADHF is a major complication in patients with heart failure (HF). However, the prognostic impact of ADHF in patients with HFmrEF has not yet been clarified.

METHODS AND RESULTS

Consecutive patients hospitalized with HFmrEF (i.e. left ventricular ejection fraction 41-49% and signs and/or symptoms of HF) were retrospectively included at one institution from 2016 to 2022. The prognosis of patients with ADHF was compared with those without (i.e. non-ADHF). The primary endpoint was long-term all-cause mortality. Secondary endpoints included in-hospital all-cause mortality and long-term HF-related re-hospitalization. Kaplan-Meier, multivariable Cox proportional regression, and propensity score matched analyses were performed for statistics. Long-term follow-up was set at 30 months. A total of 2184 patients with HFmrEF were included, ADHF was present in 22%. The primary endpoint was higher in ADHF compared to non-ADHF patients with HFmrEF [50% vs. 26%; hazard ratio (HR) = 2.269; 95% confidence interval (CI) 1.939-2.656; P = 0.001]. Accordingly, the secondary endpoint of long-term HF-related re-hospitalization was significantly higher (27% vs. 10%; HR = 3.250; 95% CI 2.565-4.118; P = 0.001). A history of previous ADHF before the index hospitalization was associated with higher rates of long-term HF-related re-hospitalization (42% vs. 23%; HR = 2.073; 95% CI 1.420-3.027; P = 0.001), but not with long-term all-cause mortality (P = 0.264).

CONCLUSION

ADHF is a common finding in patients with HFmrEF associated with an adverse impact on long-term prognosis.

Adverse Events Requiring Hospitalization Following Catheter Ablation for Atrial Fibrillation in Heart Failure with versus without Systolic Dysfunction

BACKGROUND

The safety and efficacy of atrial fibrillation (AF) ablation in individuals with heart failure (HF) with preserved ejection fraction (EF), particularly concerning the occurrence of post-procedural adverse events necessitating hospitalization, including anticoagulant-associated major bleeding, still lack conclusive determination.

METHODS

Data from patients with HF and AF who underwent catheter ablation for AF between 2019 and 2022 at our institution were retrospectively reviewed. All participants were divided into an EF < 50% group or an EF ≥ 50% group according to their baseline left ventricular EF. The composite incidence of the clinical events following catheter ablation was compared between the two groups: (1) all-cause death, (2) HF hospitalization, (3) stroke or systemic embolism, and (4) major bleeding.

RESULTS

A total of 122 patients (75 years old, 68 male) were included. Of them, 62 (50.8%) patients had an EF ≥ 50%. EF ≥ 50% was an independent predictor of the composite endpoint (adjusted odds ratio 6.07, 95% confidence interval 1.37-26.99, p = 0.018). The incidences of each adverse event were not significantly different between the two groups, except for a higher incidence of major bleeding in the EF ≥ 50% group (12.7% vs. 0%, p = 0.026).

CONCLUSIONS

Among patients with HF coupled with AF, the incidence of adverse events following AF ablation proved notably elevated in patients with EF ≥ 50% in contrast to their counterparts with EF < 50%. This disparity primarily stems from a heightened occurrence of major bleeding within the EF ≥ 50% cohort. The strategy to reduce adverse events, especially in patients with EF ≥ 50%, remains the next concern.

Predictors of mortality in heart failure patients with reduced or mildly reduced Ejection Fraction: The CASABLANCA HF Study

BACKGROUND

Heart failure (HF) poses a significant public health challenge throughout the world and Morocco. Our objective was to delineate the epidemiological characteristics of Moroccan patients living with chronic heart failure and to identify prognostic factors correlated with CHF mortality.

RESULTS

A total of 1344 patients participated in this study, with survival rates at 3, 6, and 10 years recorded at 75.2%, 60%, and 34%, respectively. During the follow-up, 886 patients succumbed, representing a mortality rate of 65.9%. A Cox regression model, utilizing baseline candidate variables, was developed to predict cardiovascular (CV) mortality. Predictors all of which had a P value less than 0.05 included age, left ventricular ejection fraction (EF) at commencement (< 35%), hypertension, male sex, anemia, creatinine levels, and the number of hospitalizations due to HF decompensation. Notably, the frequency of hospitalizations emerged as the most potent predictor of mortality, with an HR of 2.5 (95% CI [2-2.9]). Almost 90% of patients with three or more readmissions for HF decompensation experienced mortality by the follow-up's conclusion.

CONCLUSIONS

This study offers valuable insights into risk factors and clinical outcomes in HF patients in Morocco. Factors such as male gender, advanced age, a history of hypertension, lower systolic blood pressure, rehospitalizations for HF decompensation, low left ventricular ejection fraction, anemia, and elevated creatinine levels were associated with increased mortality. Medical and health services managers should be aware of the substantial burden and future challenges posed by HF in Morocco, prompting the adoption of multidisciplinary strategies for its management and care.

Heart failure with improved ejection fraction: Beyond diagnosis to trajectory analysis

Left ventricular (LV) systolic dysfunction represents a highly treatable cause of heart failure (HF). A substantial proportion of patients with HF with reduced ejection fraction (EF;HFrEF) demonstrate improvement in LV systolic function (termed HF with improved EF [HFimpEF]), either spontaneously or when treated with guideline-directed medical therapy (GDMT). Although it is a relatively new HF classification, HFimpEF has emerged in recent years as an important and distinct clinical entity. Improvement in LVEF leads to decreased rates of mortality and adverse HF-related outcomes compared to patients with sustained LV systolic dysfunction (HFrEF). While numerous clinical and imaging factors have been associated with HFimpEF, identification of which patients do and do not improve requires further investigation. In addition, patients improve at different rates, and what determines the trajectory of HFimpEF patients after improvement is incompletely characterized. A proportion of patients maintain improvement in LV systolic function, while others experience a recrudescence of systolic dysfunction, especially with GDMT discontinuation. In this review we discuss the contemporary guideline-recommended classification definition of HFimpEF, the epidemiology of improvement in LV systolic function, and the clinical course of this unique patient population. We also offer evidence-based recommendations for the clinical management of HFimpEF and provide a roadmap for future directions in understanding and improving outcomes in the care of patients with HFimpEF.

Sleep apnea in patients with exacerbated heart failure and overweight

Sleep disorders are a common concomitant comorbidity in patients with heart failure. The aims of our study are to determine the incidence and phenotypic characteristics of sleep apnea in overweight patients with exacerbated heart failure and to assess the degree of involvement of systolic and diastolic function impairment in the individual group. From 100 screened patients with heart failure in our department from 2015 to 2017, 61 met the inclusion criteria and participated in the study. 82% (n = 50) of the patients had obstructive sleep apnea (OSA), and 18% (n = 11) had central sleep apnea (CSA). The CSA group had a significantly lower left ventricular ejection fraction (LVEF) than the OSA group (EF% 49.6 ± 8.5 vs 41.8 ± 11.4; p = 0.013). A negative correlation was found between LVEF and the number of central apnea events (r = -0.52; p < 0.001). More frequent hospitalizations for heart failure (HF) and higher mortality rate were found in the CSA group. Screening for sleep apnea in patients with exacerbated heart failure and obesity is necessary for the complex treatment of these patients.

Association of neighbourhood-level material deprivation with adverse outcomes and processes of care among patients with heart failure in a single-payer healthcare system: A population-based cohort study

AIM

We studied the association between neighbourhood material deprivation, a metric estimating inability to attain basic material needs, with outcomes and processes of care among incident heart failure patients in a universal healthcare system.

METHODS AND RESULTS

In a population-based retrospective study (2007-2019), we examined the association of material deprivation with 1-year all-cause mortality, cause-specific hospitalization, and 90-day processes of care. Using cause-specific hazards regression, we quantified the relative rate of events after multiple covariate adjustment, stratifying by age ≤65 or ≥66 years. Among 395 763 patients (median age 76 [interquartile range 66-84] years, 47% women), there was significant interaction between age and deprivation quintile for mortality/hospitalization outcomes (p ≤ 0.001). Younger residents (age ≤65 years) of the most versus least deprived neighbourhoods had higher hazards of all-cause death (hazard ratio [HR] 1.19, 95% confidence interval [CI] 1.10-1.29]) and cardiovascular hospitalization (HR 1.29 [95% CI 1.19-1.39]). Older individuals (≥66 years) in the most deprived neighbourhoods had significantly higher hazard of death (HR 1.11 [95% CI 1.08-1.14]) and cardiovascular hospitalization (HR 1.13 [95% CI 1.09-1.18]) compared to the least deprived. The magnitude of the association between deprivation and outcomes was amplified in the younger compared to the older age group. More deprived individuals in both age groups had a lower hazard of cardiology visits and advanced cardiac imaging (all p < 0.001), while the most deprived of younger ages were less likely to undergo implantable cardioverter-defibrillator/cardiac resynchronization therapy-pacemaker implantation (p = 0.023), compared to the least deprived.

CONCLUSION

Patients with newly-diagnosed heart failure residing in the most deprived neighbourhoods had worse outcomes and reduced access to care than those less deprived.

Exploring Patterns of COPD Exacerbations and Comorbid Flare-Ups

Background

Comorbidities are known to complicate disease management in patients with Chronic Obstructive Pulmonary Disease (COPD). This is partly due to lack of insight into the interplay of acute exacerbations of COPD (AECOPD) and comorbid flare-ups. This study aimed to explore patterns of AECOPDs and comorbid flare-ups.

Methods

Data of increased symptoms were extracted from a 12-month daily symptom follow-up database including patients with COPD and comorbidities (chronic heart failure (CHF), anxiety, depression) and transformed to visualizations of AECOPDs and comorbid flare-up patterns over time. Patterns were subsequently categorized using an inductive approach, based on both predominance (ie, which occurs most often) of AECOPDs or comorbid flare-ups, and their simultaneous (ie, simultaneous start in ≥ 50%) occurrence.

Results

We included 48 COPD patients (68 ± 9 years; comorbid CHF: 52%, anxiety: 40%, depression: 38%). In 25 patients with AECOPDs and CHF flare-ups, the following patterns were identified: AECOPDs predominant (n = 14), CHF flare-ups predominant (n = 5), AECOPDs nor CHF flare-ups predominant (n = 6). Of the 24 patients with AECOPDs and anxiety and/or depression flare-ups, anxiety and depression flare-ups occurred simultaneously in 15 patients. In 9 of these 24 patients, anxiety or depression flare-ups were observed independently from each other. In 31 of the included 48 patients, AECOPDs and comorbid flare-ups occurred mostly simultaneously.

Conclusion

Patients with COPD and common comorbidities show a variety of patterns of AECOPDs and comorbid flare-ups. Some patients, however, show repetitive patterns that could potentially be used to improve personalized disease management, if recognized.

The effect of myocardial dysfunction on mortality in children with septic shock: a prospective observational study

Pediatric septic shock is defined as progressive multi-organ dysfunction and cardiovascular dysfunction accompanying sepsis. Studies showing myocardial dysfunction associated with pediatric septic shock are very limited. The aim of this study was to evaluate the relationship between myocardial functions calculated by echocardiography, disease severity, and clinical outcomes in children with septic shock. This observational prospective study was conducted in a pediatric intensive care at a university-affiliated tertiary hospital. The patients diagnosed with septic shock between January 2021 and February 2022 were included in the study. The study was conducted with 56 patients. The rate of myocardial dysfunction (systolic and/or diastolic dysfunction) was 50%. Of these, 39.3% (n = 22) had systolic dysfunction, 17.9% (n = 10) had diastolic dysfunction, and 8.9% (n = 5) had both systolic and diastolic dysfunction. PRISM III score (p = 0.004), VIS (p < 0.001), lactate (p = 0.002), CK-MB (p = 0.023), troponin (p = 0.038), EF (p = 0.004) EF z-score (p = 0.003), MAPSE z-score (p = 0.049), TAPSE (p = 0.010), TAPSE z-score (p = 0.003), and mitral valve E/e ´z-score (p = 0.028) were statistically significant difference with mortality. No significant difference was found for mortality with MAPSE (p = 0.090), mitral valve E/A (p = 0.624), and mitral valve E/A z-score (p = 0.327). EF z-score was found to be associated with 30-day mortality (OR = 0,681, 95% CI 0,480 to 0.991, p = 0,045). We found the TAPSE z-score to be the most significant parameter with 30-day mortality (OR = 0,690, 95% CI 0,489 to 0.998, p = 0,032).  Conclusion: We found left ventricular dysfunction associated factor with mortality. TAPSE showing right ventricular dysfunction was found to be the independent risk factor most associated with mortality. What is Known: • Studies showing myocardial dysfunction associated with pediatric septic shock are limited. • Little is known about the use of echocardiography in pediatric septic shock, and there are no specific guidelines for treatment and follow-up in pediatric patients. What is New: • Characteristics, echocardiographic measurements, and outcomes were comprehensively assessed in children with septic shock. • As a result of our analysis, we found that TAPSE, which is easily measured at the bedside, is the most critical parameter in relation to mortality. • We offer recommendations for its use in the follow-up of children with septic shock.

Evaluation of Wearable Acoustic Sensors and Machine Learning Algorithms for Automated Measurement of Left Ventricular Ejection Fraction

Left ventricular ejection fraction (EF) is a predictor of mortality and guides clinical decisions. Although transthoracic echocardiography (TTE) is commonly used for measuring EF, it has limitations, such as subjectivity and requires expert personnel. Advancements in biosensor technology and artificial intelligence are allowing systems capable of determining left ventricular function and providing automated measurement of EF. In this study, we tested new wearable automated real-time biosensors (Cardiac Performance System [CPS]) that compute EF using waveform machine learning on cardiac acoustic signals. The primary aim was to compare the accuracy of CPS EF with TTE EF. Adult patients presenting to cardiology, presurgical, and diagnostic radiology clinical settings in an academic center were enrolled. TTE examination was performed by a sonographer, followed immediately by a 3-minute recording of acoustic signals from CPS biosensors placed on the chest by nonexpert personnel. TTE EF was calculated offline using the Simpson biplane method. A total of 81 patients (aged 19 to 88 years, 27 women, 20% to 80% EF) were included. Deming regression and Bland-Altman analysis were performed to assess the accuracy of CPS EF against TTE EF. Both Deming regression (slope 0.9981; intercept 0.03415%) and Bland-Altman analysis (bias -0.0247%; limits of agreement [-11.65, 11.60]%) demonstrated equivalency between CPS EF and TTE EF. The receiver operating characteristic for measuring sensitivity and specificity of CPS in identifying subjects with abnormal EF showed an area under the curve value of 0.974 for identifying EF <35% and 0.916 for detecting EF <50% CPS EF intraoperator and interoperator assessments demonstrated low variability. In conclusion, this technology measuring cardiac function from noninvasive biosensors and machine learning on acoustic signals provides an accurate EF measurement that is automated, real-time, and acquired rapidly by personnel with minimal training.

Association of outcome with left ventricular volumes and ejection fraction measured with two- and three-dimensional echocardiography in patients referred for routine, clinically indicated studies

Objectives

We sought to analyze if left ventricular (LV) volumes and ejection fraction (EF) measured by three-dimensional echocardiography (3DE) have incremental prognostic value over measurements obtained from two-dimensional echocardiography (2DE) in patients referred to a high-volume echocardiography laboratory for routine, clinically-indicated studies.

Methods

We measured LV volumes and EF using both 2DE and 3DE in 725 consecutive patients (67% men; 59 ± 18 years) with various clinical indications referred for a routine clinical study.

Results

LV volumes were significantly larger, and EF was lower when measured by 3DE than 2DE. During follow-up (3.6 ± 1.2 years), 111 (15.3%) all-cause deaths and 248 (34.2%) cardiac hospitalizations occurred. Larger LV volumes and lower EF were associated with worse outcome independent of age, creatinine, hemoglobin, atrial fibrillation, and ischemic heart diseases). In stepwise Cox regression analyses, the associations of both death and cardiac hospitalization with clinical data (CD: age, creatinine, hemoglobin, atrial fibrillation, and ischemic heart disease) whose Harrel's C-index (HC) was 0.775, were augmented more by the LV volumes and EF obtained by 3DE than by 2DE parameters. The association of CD with death was not affected by LV end-diastolic volume (EDV) either measured by 2DE or 3DE. Conversely, it was incremented by 3DE LVEF (HC = 0.84, p < 0.001) more than 2DE LVEF (HC = 0.814, p < 0.001). The association of CD with the composite endpoint (HC = 0.64, p = 0.002) was augmented more by 3DE LV EDV (HC = 0.786, p < 0.001), end-systolic volume (HC = 0.801, p < 0.001), and EF (HC = 0.84, p < 0.001) than by the correspondent 2DE parameters (HC = 0.786, HC = 0.796, and 0.84, all p < 0.001) In addition, partition values for mild, moderate and severe reduction of the LVEF measured by 3DE showed a higher discriminative power than those measured by 2DE for cardiac death (Log-Rank: χ² = 98.3 vs. χ² = 77.1; p < 0.001). Finally, LV dilation defined according to the 3DE threshold values showed higher discriminatory power and prognostic value for death than when using 2DE reference values (3DE LVEDV: χ² = 15.9, p < 0.001 vs. χ² = 10.8, p = 0.001; 3DE LVESV: χ² = 24.4, p < 0.001 vs. χ² = 17.4, p = 0.001).

Conclusion

In patients who underwent routine, clinically-indicated echocardiography, 3DE LVEF and ESV showed stronger association with outcome than the corresponding 2DE parameters.

Population study of sex-based outcomes after surgical aortic valve replacement

Background

Surgical aortic valve replacement (SAVR) is a key strategy for the treatment of aortic valve disease. However, studies have involved primarily male patients, and whether the benefits of this approach can be extrapolated to female patients is unclear.

Methods

Clinical and administrative datasets for 12,207 patients undergoing isolated SAVR in Ontario from 2008 to 2019 were linked. Male and female patients were balanced using inverse probability treatment weighting. Mortality, endocarditis, and major hemorrhagic and thrombotic events, as well as 2 composite outcomes-major adverse cerebral and cardiovascular events (MACCE) and patient-derived adverse cardiovascular and noncardiovascular events (PACE)-and their component events, were compared in the weighted groups with a stratified log-rank test.

Results

A total of 7485 male patients and 4722 female patients were included in the study. Median follow-up was 5.2 years in both sexes. All-cause mortality did not differ between sexes (hazard ratio [HR] 0.949 [95% confidence interval {CI} 0.851-1.059]). Male sex was associated with an increased risk of new-onset dialysis (HR 0.689 [95% CI 0.488-0.974]). Female sex was associated with a significantly increased risk of both new-onset heart failure (HR 1.211 [95% CI 1.051-1.394], P = 0.0081) and heart failure hospitalization (HR 1.200 [95% CI 1.036-1.390], P = 0.015). No statistically significant differences were seen in any of the other secondary outcomes between sexes.

Conclusions

This population health study demonstrated that survival did not differ between male and female patients undergoing SAVR. Significant sex-related differences were found in the risk of heart failure and new-onset dialysis, but these findings should be considered exploratory and require further study.

Predictors of in-hospital mortality in critically ill patients with COVID-19: a large dual tertiary centre study

OBJECTIVES

The aim of this study was to investigate the relationship of echocardiographic parameters, laboratory findings and clinical characteristics with in-hospital mortality in adult patients with COVID-19 admitted to the intensive care units (ICU) in two large collaborating tertiary UK centres.

DESIGN

Observational retrospective study.

SETTING

The study was conducted in patients admitted to the ICU in two large tertiary centres in London, UK.

PARTICIPANTS

Inclusion criteria were: (1) patients admitted to the ICU with a COVID-19 diagnosis over a period of 16 weeks. and (2) underwent a transthoracic echocardiogram on the first day of ICU admission as clinically indicated.No exclusion criteria applied.Three hundred patients were enrolled and completed the follow-up.

PRIMARY AND SECONDARY OUTCOME MEASURES

The outcome measure in this study was in-hospital mortality in patients admitted to the ICU with COVID-19 infection.

RESULTS

Older age (HR: 1.027, 95% CI 1.007 to 1.047; p=0.008), left ventricular (LV) ejection fraction<35% (HR: 5.908, 95% CI 2.609 to 13.376; p<0.001), and peak C reactive protein (CRP) (HR: 1.002, 95% CI 1.001 to 1.004, p=0.001) were independently correlated with mortality in a multivariable Cox regression model. Following multiple imputation of variables with more than 5% missing values, random forest analysis was applied to the imputed data. Right ventricular (RV) basal diameter (RVD1), RV mid-cavity diameter (RVD2), tricuspid annular plane systolic excursion, RV systolic pressure, hypertension, RV dysfunction, troponin level on admission, peak CRP, creatinine level on ICU admission, body mass index and age were found to have a high relative importance (> 0.7).

CONCLUSIONS

In patients with COVID-19 in the ICU, both severely impaired LV function and impaired RV function may have adverse prognostic implications, but older age and inflammatory markers appear to have a greater impact. A combination of echocardiographic and laboratory investigations as well as demographic and clinical characteristics appears appropriate for risk stratification in patients with COVID-19 who are admitted to the ICU.

The State of Heart Failure Care in Canada: Minimal Improvement in Readmissions Over Time Despite an Increased Number of Evidence-Based Therapies

Background

Methods

Results

Conclusions

Cardiac Function after Modern Radiation Therapy with Volumetric Modulated Arc Therapy or Helical Tomotherapy for Advanced Left-Breast Cancer Receiving Regional Nodal Irradiation

Background: Protecting cardiac function in patients with advanced left-breast cancer receiving radiation therapy (RT) with regional nodal irradiation (RNI) is an important issue. Modern RT techniques can limit cardiac exposure. The aim of this study was to explore the association be-tween cardiac dose and cardiac function. Methods: Between 2017 and 2020, we retrospectively reviewed left-breast cancer patients who received adjuvant RT, including RNI with either volumetric-modulated arc therapy (VMAT) or helical tomotherapy (HT). Left ventricular ejection fraction (LVEF) was assessed by echocardiography before RT and 1 year after RT to detect any early deterioration in cardiac systolic function. Results: A total of 30 eligible patients were enrolled. The median follow-up time from the initiation of RT was 3.9 years (range 0.6–5 years). Seventeen patients received VMAT, and the other 13 patients received HT. The median RT dose was 55 Gray (Gy), and the mean heart dose was 3.73 Gy (range 1.95–9.36 Gy). The median LVEF before and after RT was 68% and 68.5%, respectively. No obvious deterioration was found. There was no association between cardiac dose (mean heart dose, V5–V30) and LVEF (change in values or post-RT). Conclusions: For left-breast cancer patients undergoing RT with RNI, VMAT, or HT can be used to limit cardiac exposure. Cardiac function as evaluated by LVEF revealed no obvious deterioration after RT in our patients, and no association was found between cardiac dose and LVEF in those treated with either VMAT or HT in early cardiac surveillance.

Hyperdynamic left ventricular ejection fraction is associated with higher mortality in COVID-19 patients

Study objective

To compare the characteristics and outcomes of COVID-19 patients with a hyperdynamic LVEF (HDLVEF) to those with a normal or reduced LVEF.

Design

Retrospective study.

Setting

Rush University Medical Center.

Participants

Of the 1682 adult patients hospitalized with COVID-19, 419 had a transthoracic echocardiogram (TTE) during admission and met study inclusion criteria.

Interventions

Participants were divided into reduced (LVEF < 50%), normal (≥50% and <70%), and hyperdynamic (≥70%) LVEF groups.

Main outcome measures

LVEF was assessed as a predictor of 60-day mortality. Logistic regression was used to adjust for age and BMI.

Results

There was no difference in 60-day mortality between patients in the reduced LVEF and normal LVEF groups (adjusted odds ratio [aOR] 0.87, p = 0.68). However, patients with an HDLVEF were more likely to die by 60 days compared to patients in the normal LVEF group (aOR 2.63 [CI: 1.36–5.05]; p < 0.01). The HDLVEF group was also at higher risk for 60-day mortality than the reduced LVEF group (aOR 3.34 [CI: 1.39–8.42]; p < 0.01).

Conclusion

The presence of hyperdynamic LVEF during a COVID-19 hospitalization was associated with an increased risk of 60-day mortality, the requirement for mechanical ventilation, vasopressors, and intensive care unit.

Prognostic Impact of Left Ventricular Ejection Fraction in Patients With Moderate Aortic Regurgitation: Potential Implications for Treatment Decision-Making

BACKGROUND

The prognostic impact and optimal treatment of left ventricular systolic dysfunction in patients with moderate aortic regurgitation (AR) remain unknown. We aimed to assess the prognostic value of left ventricular ejection fraction (LVEF) in patients with moderate AR and explore the potential benefits of aortic valve intervention (AVI).

METHODS

In total, 1,211 consecutive patients with moderate AR (jet width, 25-64% of LV outflow tract; vena contracta, 0.3-0.6 cm; regurgitant volume, 30-59 mL/beat; regurgitant fraction, 30-49%; effective regurgitation orifice, 0.10-0.29 cm2) prospectively registered between April and June 2018 at 46 academic hospitals were included. The primary outcome was a composite of death or hospitalization for heart failure (HHF). The optimal LVEF threshold for predicting the primary outcome was determined through the penalized spline shape and maximally selected rank statistics.

RESULTS

During the 2-year follow-up, 125 deaths or HHF occurred. In the penalized splines, the relative hazard of death or HHF monotonically increased with decreasing LVEF. In the multivariate analysis, LVEF ≤55% was identified as the best threshold for independently predicting death or HHF under medical treatment (adjusted hazard ratio [HR]: 2.18; 95% confidence interval [CI] 1.38-3.42; P = 0.001), with substantial incremental values (integrated discrimination improvement index = 0.018, P = 0.030; net reclassification improvement index = 0.225, P = 0.006; likelihood ratio test P < 0.001). Among patients with LVEF 35-55%, AVI within 6 months of diagnosis was associated with a reduced risk of death or HHF compared with medical treatment alone (adjusted HR: 0.15; 95% CI: 0.04-0.50; P = 0.002), whereas this benefit was markedly attenuated when LVEF was ≤35% (adjusted HR: 0.65; 95% CI: 0.21-1.97; P = 0.441, P-interaction = 0.010) or >55% (adjusted HR: 0.40; 95% CI: 0.14-1.15; P = 0.089, P-interaction = 0.723).

CONCLUSIONS

LVEF is an independent and incremental prognostic factor in patients with moderate AR, with LVEF ≤55% being a robust marker of poor prognosis. Patients with LVEF 35-55% may benefit from early surgical correction of moderate AR. Further studies are warranted to validate our findings in a randomized setting.

REGISTRATION

China Valvular Heart Disease Study (China-VHD study, NCT03484806); clinicaltrials.gov/ct2/show/NCT03484806.

Patient Selection for Adult Ambulatory Surgery: A Narrative Review

With migration of medically complex patients undergoing more extensive surgical procedures to the ambulatory setting, selecting the appropriate patient is vital. Patient selection can impact patient safety, efficiency, and reportable outcomes at ambulatory surgery centers (ASCs). Identifying suitability for ambulatory surgery is a dynamic process that depends on a complex interplay between the surgical procedure, patient characteristics, and the expected anesthetic technique (eg, sedation/analgesia, local/regional anesthesia, or general anesthesia). In addition, the type of ambulatory setting (ie, short-stay facilities, hospital-based ambulatory center, freestanding ambulatory center, and office-based surgery) and social factors, such as availability of a responsible individual to take care of the patient at home, can also influence patient selection. The purpose of this review is to present current best evidence that would provide guidance to the ambulatory anesthesiologist in making an informed decision regarding patient selection for surgical procedures in freestanding ambulatory facilities.

Obesity surgery in patients with end-stage organ failure: Is it worth it?

BACKGROUND

Little is known about the long-term outcomes of patients with end-stage organ failure (ESOF) undergoing obesity surgery.

OBJECTIVE

To investigate the perioperative and mid-term outcomes of patients with ESOF undergoing obesity surgery.

SETTING

University hospital, Germany.

METHODS

A total of 1 094 patients undergoing obesity surgery from 2006 to 2019 were screened. Inclusion criteria were ejection fraction <30%, continuous oxygen/noninvasive ventilation therapy, liver cirrhosis, or kidney failure stage 4/5. ESOF patients were compared with matched standard (MS) patients without advanced organ failure and matched for age, gender, body mass index (BMI), operation type, diabetes, arterial hypertension, and sleep apnea.

RESULTS

Twenty-seven ESOF patients (56% female, age 50.3 ± 8.6, BMI 53.8 ± 8.7 kg/m²) were identified. Eighty-five percent had a sleeve gastrectomy. Mid-term total weight loss was 26.6% ± 9.0% in the ESOF patients versus 17.8% ± 11.1% in MS patients (P = .181). Long-term improvement of type 2 diabetes was comparable (ESOF: HbA1C 8.79 ± 2.06% to 6.25±1.17%, P = .047; MS: HbA1C 7.94 ± 2.02% to 7.2 ± 1.28%; P = .343). Depression scores (Patient Health Questionnaire 9) among ESOF patients improved from 13.0 ± 6.3 to 6.1 ± 5.8 (P = .004) but without significant change in MS patients (9.4 ± 7.3 to 4.3 ± 5.7; P = .082). Lung function improved in all patients although only 15% were off oxygen therapy. Treatment goals were achieved in >50% of the other groups. Major complications occurred in 11% (ESOF) versus 4% (MS) of patients (P = .299) with one death in the ESOF group (4%).

CONCLUSION

Both groups had similar outcomes regarding weight loss and co-morbidity improvement. Depression only improved significantly in the ESOF group. Patients with ESOF should not be precluded from obesity surgery. Further investigation is needed to define optimized selection criteria.

Utility of Functional and Volumetric Left Atrial Parameters Derived From Preprocedural Cardiac CTA in Predicting Mortality After Transcatheter Aortic Valve Replacement

Background: Cardiac CTA is required for preprocedural workup before transcatheter aortic valve replacement (TAVR) and can be used to assess functional parameters of the left atrium (LA). Objective: We aimed to evaluate the utility of functional and volumetric LA parameters derived from cardiac CTA to predict mortality in patients with severe aortic stenosis (AS) undergoing TAVR. Methods: This retrospective study included 175 patients with severe AS (median age 79 years; 92 male, 83 female) who underwent cardiac CTA for clinical pre-TAVR assessment. A postdoctoral research fellow calculated maximum and minimum LA volumes using biplane area-length measurements; the values were indexed to body surface area (LAVImax and LAVImin, respectively). LA emptying fraction (LAEF) was automatically calculated. All-cause mortality within a 24-month follow-up period post-TAVR was recorded. To identify parameters predictive of mortality, Cox regression was performed, and results were summarized by hazard ratio (HR) and 95% CI. Harrell's c-index was used to assess model performance. A radiology resident repeated the measurements in a random sample of 20% (n=35) of cases, and interobserver agreement was computed using the intraclass correlation coefficient (ICC). Results: Thirty-eight deaths (22%) were recorded within a median follow-up of 21 months. LAVImax (HR 1.02 [1.01-1.04]; p=.005), LAVImin (HR 1.02 [1.01-1.04]; p<.001), and LAEF (HR 0.97 [0.95-0.99]; p=.002) were predictive of mortality in univariable analysis. After adjusting for clinical parameters, only LAEF (HR 0.97 [0.94-0.99]; p=.02) independently predicted mortality. The c-index of the Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) significantly increased from 0.64 to 0.68, 0.69, and 0.70 when incorporating into the model LAVImax, LAVImin, and LAEF, respectively. ICC for maximum and minimum LA volumes and LAEF ranged from 0.94 to 0.99. Conclusion: LAEF derived from preprocedural cardiac CTA independently predicts mortality in patients with severe AS undergoing TAVR. Clinical impact: Cardiac CTA-derived LA function, evaluated during pre-TAVR workup, can be used to assess preprocedural risk and may improve risk stratification in post-TAVR surveillance.

Rationale and design of the comparison of outcomes and access to care for heart failure (COACH) trial: A stepped wedge cluster randomized trial

BACKGROUND

Heart failure (HF) is an ambulatory care sensitive condition and a leading reason for emergency department (ED) visits and hospitalizations. Improved decision-making and care may enhance safety and efficiency for patients presenting to the ED with acute HF.

OBJECTIVES

We will evaluate an intervention comprised of 2 complementary components: (1) the Emergency Heart Failure Mortality Risk Grade simultaneous 7- and 30-day (EHMRG30-ST) risk scores, which will inform admission-discharge decisions, and (2) a rapid outpatient follow-up (RAPID-HF) clinic for low-to-intermediate risk patients on cardiovascular readmissions or death.

STUDY DESIGN

Stepped wedge cluster randomized trial with cross-sectional measurement at 10 acute care hospitals in Ontario, Canada. Patients presenting during control and intervention periods are eligible if they have a primary ED diagnosis of HF. In the intervention periods, access to the EHMRG30-ST web calculator will become available to hospitals' internet protocol (IP) addresses, and referral to the RAPID-HF clinic will be facilitated by a study nurse navigator. Patients with a high risk EHMRG30-ST score will be admitted to hospital. The RAPID-HF clinic will accept referrals for patients: (1) with low risk 7- and 30-day EHMRG30-ST scores who are discharged directly from the ED, or (2) intermediate risk patients with hospital length of stay < 72 hours. The RAPID-HF clinic, staffed by a nurse-clinician and cardiologist, will provide care during the 30-day transition after hospital separation.

CONCLUSION

This trial will determine whether novel risk stratification coupled with rapid ambulatory care achieves better outcomes than conventional decision-making and care for patients with HF.

Outcomes and healthcare resource utilization in adult congenital heart disease patients with heart failure

AIMS

While heart failure (HF) is a leading cause of death in adults with congenital heart disease (ACHD), few studies report contemporary outcomes after the first HF hospitalization. We examined outcomes of ACHD patients newly admitted for HF compared with ACHD patients without HF and the general HF population without ACHD.

METHODS AND RESULTS

Using population databases from a single-payer health system from 1994 to 2018, ACHD patients newly admitted for HF were matched 1:1 to ACHD patients without HF (n = 4030 matched pairs). Similarly, ACHD patients newly admitted for HF were matched 1:1 to HF patients without ACHD (n = 4336 matched pairs). Patients with ACHD and HF (median age 68 years, 45% women) experienced higher mortality in short-term [30 day adjusted hazard ratio (HR) 4.68, 95% confidence interval (CI) 4.06, 5.43, P < 0.001], near-term (1 year HR 3.87, 95% CI 3.77, 4.92, P < 0.001), and long-term (24 year HR 1.59, 95% CI 1.13, 2.36, P = 0.008) follow-up. Patients with ACHD and HF had fewer baseline cardiovascular comorbidities than non-ACHD HF but demonstrated higher 30 day (HR 1.56, 95% CI 1.41, 1.73, P < 0.001), 1 year (HR 1.30, 95% CI 1.20, 1.40, P < 0.001), and 24 year (HR 2.40, 95% CI 1.73, 3.38, P < 0.001) mortality. Those with ACHD and HF also exhibited higher cardiovascular readmission rates at 30 days with HRs 9.15 (95% CI; 8.00, 10.48, P < 0.001) vs. ACHD without HF, and 1.71 (95% CI; 1.54, 1.85, P < 0.001) vs. HF without ACHD, and the higher readmission risk extended to 10 year follow-up.

CONCLUSIONS

Adults with congenital heart disease patients with new HF have high risks of death and cardiovascular hospitalization, and preventative strategies to improve outcomes are urgently needed.

Usefulness of velocity ratio in patients with moderate aortic stenosis and reduced left ventricular ejection fraction

Background. Moderate aortic stenosis (AS) increases left ventricular afterload and results in unfavorable outcomes in patients with reduced left ventricular ejection fraction (LVEF). Velocity ratio (VR) may be appropriate for the evaluation of aortic valve (AV) hemodynamics because of the low dependence on flow. Therefore, this study investigated the usefulness of VR on the clinical outcomes of such patients. Method. Clinical data of patients with moderate AS (AV area, 0.60-0.85 cm²/m²; peak AV velocity, 2.0-4.0 m/s) and reduced LVEF (LVEF 20-50%) were analyzed during 2010-2018. VR was calculated as peak left ventricular outflow tract velocity/peak AV velocity. The primary endpoint included all-cause death, heart failure hospitalization, and AV replacement. Results. In total, 104 patients (mean age, 75.9 ± 7.0 years; 62.5% men) were included. LVEF was 39.5% ± 7.8%. The AV area was 0.72 ± 0.08 cm²/m², peak AV velocity was 2.59 ± 0.40 m/s, and VR was 0.30 ± 0.07. The follow-up period was 1.7 (0.5-3.5) years. Kaplan-Meier estimates for the endpoint were 59.9% at 3 years. Multivariable analysis revealed that VR (hazard ratio, 0.947; 95% confidence interval, 0.905-0.990; p = .018) was significantly related to this endpoint. Patients with a VR <0.25 had significantly higher incidence rates of the endpoint than those with a VR ≥0.25 (85.6% versus 47.8% at 3 years; p < .001). Conclusions. Patients with moderate AS and reduced LVEF have unfavorable clinical outcomes, particularly those with low VR.

Change in ejection fraction and long-term mortality in adults referred for echocardiography

AIMS

We investigated long-term mortality associated with changes in left ventricular ejection fraction (LVEF) in a large, real-world patient cohort.

METHODS AND RESULTS

A total of 117 275 adults (63 ± 16 years, 46% women) had LVEF quantified by the same method ≥6 months apart. This included 17 343 cases (66 ± 15 years, 48% women) being initially investigated for heart failure (HF). During 3.3 [interquartile range (IQR) 1.7-6.0] years from first to last echocardiogram, median change in LVEF was -1 (IQR -8 to +5) units from a baseline of 62% (IQR 54-69%). During subsequent 7.6 (IQR 4.3-10.1) years of follow-up, 11 397 (9.7%) and 34 101 (29.1%) cases died from cardiovascular disease and all causes, respectively. Actual 5-year, all-cause mortality increased from 12% to 29% among those with the smallest to the largest decrease in LVEF (from <5 units to >30 units); the adjusted risk of cardiovascular-related mortality increased two- to eightfold beyond a >10-unit decline in LVEF (vs. minimal change; P < 0.001 for all comparisons). Among those initially investigated for HF (32% with initial LVEF <50%), the adjusted hazard ratio for cardiovascular-related mortality ranged from 0.35 [95% confidence interval (CI) 0.28-0.49] to 4.21 (95% CI 3.30-5.22) for a >30-unit increase to >30-unit decline in LVEF (vs. minimal change; P < 0.001 for both comparisons). A distinctive, bi-directional plateau of improved vs. worsening mortality was evident around a final LVEF of 50% to 55%.

CONCLUSIONS

These data, derived from a large, heterogeneous cohort of adults being followed up with echocardiography, suggest that modest LVEF changes (particularly around an LVEF of 50-55%) may be of clinical significance.

Plasma microrna expression profile for reduced ejection fraction in dilated cardiomyopathy

The left ventricular (LV) ejection fraction (EF) is key to prognosis in dilated cardiomyopathy (DCM). Circulating microRNAs have emerged as reliable biomarkers for heart diseases, included DCM. Clinicians need improved tools for greater clarification of DCM EF categorization, to identify high-risk patients. Thus, we investigated whether microRNA profiles can categorize DCM patients based on their EF. 179-differentially expressed circulating microRNAs were screened in two groups: (1) non-idiopathic DCM; (2) idiopathic DCM. Then, 26 microRNAs were identified and validated in the plasma of ischemic-DCM (n = 60), idiopathic-DCM (n = 55) and healthy individuals (n = 44). We identified fourteen microRNAs associated with echocardiographic variables that differentiated idiopathic DCM according to the EF degree. A predictive model of a three-microRNA (miR-130b-3p, miR-150-5p and miR-210-3p) combined with clinical variables (left bundle branch block, left ventricle end-systolic dimension, lower systolic blood pressure and smoking habit) was obtained for idiopathic DCM with a severely reduced-EF. The receiver operating characteristic curve analysis supported the discriminative potential of the diagnosis. Bioinformatics analysis revealed that miR-150-5p and miR-210-3p target genes might interact with each other with a high connectivity degree. In conclusion, our results revealed a three-microRNA signature combined with clinical variables that highly discriminate idiopathic DCM categorization. This is a potential novel prognostic biomarker with high clinical value.

Effects of clinical depression on left ventricular dysfunction in patients with acute coronary syndrome

Depression is associated with heart failure independent of traditional cardiovascular disease risk factors. Enhanced platelet activation has been suggested as a potential mechanism and has been associated with negative inotropic effects that can affect left ventricular ejection fraction (LVEF). We examined 131 consecutive acute coronary syndrome (ACS) patients to assess whether depression increased the risk for developing LV dysfunction, and to determine the effects of platelet serotonin signaling in this relationship. Major depression was assessed using the Structured Clinical Interview and depressive symptoms were measured using the Beck Depression Inventory (BDI), with BDI ≥ 10 defined as abnormal. LV dysfunction was defined as LVEF ≤ 45%. Platelet serotonin response was measured by serotonin augmented platelet aggregation and platelet serotonin receptor density. Mean age of ACS participants was 59 years, 78.6% male and 74.0% Caucasian. 34.4% of patients had a reduced LVEF ≤ 45% on presentation. Almost half (47.0%) of patients had BDI ≥ 10 and 18.0% had major depressive disorder. Platelet serotonin response was found to be augmented in depressed patients with low LVEF compared to depressed patients with normal LVEF (p < 0.020). However, the presence of LV dysfunction was found to be similar in both depressed (32.3%) and non-depressed (36.2%) patients (p = 0.714). This suggests alternative factors contribute to poor cardiovascular outcomes in depressed patients that are independent of LV function in post ACS patients.

Echocardiography 2020: Toward deciphering the "Rosetta stone" of left ventricular diastolic function

In the year 1997, nearly a quarter-century ago, Nishimura and Tajik (J Am Coll Cardiol. 1997;30:8) suggested that Doppler echocardiography was the "Rosetta stone" (a metaphor for decrypting secrets of diastole) of left ventricular diastole, based solely on transmitral E/A ratio and its progression from grade I through IV, supported by cardiac catheterization, as the filling pressure started to increase to over 15 mm Hg. Ten years later, in 2007, the same Mayo group (Nagueh et al, J Am Coll Cardiology. 2008;51:679) was searching to decipher the secrets of diastole using multiple measures such as left atrial (LA) volume, E/E' ratio, pulmonary venous flow, and mitral inflow propagation velocity. This substantial leap from E/A ratio led to the more formal recommendation proposed by the American Society of Echocardiography in 2009 (Nagueh et al, J Am Soc Echocardiogr. 2009;22:107) and, as an update, in the year 2016 (Nagueh et al, J Am Soc Echocardiogr. 2016;29:277): the later version gained popularity for the simplified approach to identify diastolic dysfunction in healthy subjects as well as in those with poorly contracting left ventricle. Despite 30 years of continuous search, we are not sure if we have been able to decipher the hidden secrets of diastolic function. With this background, the Echocardiography Journal under the leadership of Dr Navin Nanda as the Editor-in-Chief has taken this initiative to publish a theme issue on left ventricular diastolic function and when this becomes dysfunctional to diminish life.

Ejection fraction and mortality: a nationwide register-based cohort study of 499 153 women and men

AIMS

We investigated the sex-based risk of mortality across the spectrum of left ventricular ejection fraction (LVEF) in a large cohort of patients in Australia.

METHODS AND RESULTS

Quantified levels of LVEF from 237 046 women (48.1%) and 256 109 men undergoing first-time, routine echocardiography (2000-2019) were linked to 119 232 deaths (median 5.6 years of follow-up). Overall, 17.6% of men vs. 8.3% of women had an LVEF <50%. An LVEF <40% was associated with the highest crude cardiovascular-related and all-cause mortality at 5 years (∼20-30% and ∼ 40-50%, respectively). Thereafter, actual cardiovascular-related and all-cause mortality at 5 years in both sexes steeply improved to a nadir LVEF of 65.0-69.9% (reference group). Below this LVEF level, the adjusted hazard ratio (HR) for cardiovascular-related mortality for a LVEF of 55.0-59.9% was 1.36 [95% confidence interval (CI) 1.16-1.59; P < 0.001] in women and 1.21 (95% CI 1.05-1.39; P = 0.008) in men. In women, an LVEF of 60.0-64.9% was also associated with a HR 1.33 (95% CI 1.16-1.52; P < 0.001) for cardiovascular-related mortality. These associations were most striking in women and men aged <65 years and were replicated in those with suspected heart failure (32 403 cases aged 65.2 ± 16.1 years, 57.0% women). For pre-existing heart failure (33 738 cases aged 67.6 ± 16.9 years, 46.5% women), the specific threshold of increased mortality was at and below 50.0-54.9%.

CONCLUSIONS

Among patients investigated for suspected or established cardiovascular disease, we found clinically relevant sex-based differences in the distribution and mortality associated with an LVEF <65.0-69.9%. Specifically, they suggest a greater risk of mortality at higher LVEF levels among women.

Incremental value of Late Gadolinium Enhancement by Cardiac MRI in risk stratification of heart failure patients with moderate and severe LV dysfunction

Objective

This is a prospective study of patients with LVEF ≤40%, with the objective of correlating CV events to LGE detected and quantified by CMRI.

Methods

Heart Failure (HF) patients with LVEF <40% who underwent CMRI were included. LGE volume of ≥6% of the myocardial volume was considered significant. Data of appropriate ICD shocks, CV hospitalizations and mortality were recorded.

Results

There were 133 HF (72 ICM & 62 NIDCM) patients with a mean age of 54 ± 12 years, mean LVEF of 34 ± 6% and a follow up of 24 ± 3 months. Totally 46 CV events were recorded in 30 patients, 44 in LGE +ve & 2 in LGE -ve groups (HR 17.8, 95% CI-8.03-39.3, P = 0.000095). All the 7 deaths were in LGE +ve group. CV events were 22 (30.5%) in ICM group and 8 (13.1%) in NIDCM group (p = 0.03). All the 22 ICM patients and 6 of the 8 NIDCM with CV events were LGE +ve. The distribution of CV events amongst LGE +ve and LGE -ve were 35 vs 0 (ICM) and 9 vs 2 (NIDCM); p < 0.005.CV events in LVEF ≤ 30% group, were seen in 19 (47.5%) vs 1 (5.8%) in LGE +ve vs LGE -ve and no of events were 29 vs 1 (p = 0.003). In those with LVEF >30% the corresponding figures were 9 (22.5%) vs 1 (2.8%) and 15 vs 1 respectively (p = 0.02).

Conclusion

Demonstration of significant LGE by CMRI indicates high risk occurrence of CV events (CV hospitalization, appropriate shocks and total mortality) in NIDCM & ICM patients with LVEF < 40%.

Prognostic value of D-dimer/fibrinogen ratio in the adverse outcomes of patients hospitalized for heart failure

Aim: To evaluate the clinical value of plasma D-dimer/fibrinogen ratio (DFR) in patients hospitalized for heart failure (HF). Methods: Clinical data of 235 patients were retrospectively analyzed. Kaplan-Meier method and Cox regression analysis were used to identify significant prognosticators. Results: The Kaplan-Meier analysis showed that a higher DFR level was significantly associated with an increase in the end point outcomes, including HF readmission, thrombotic events and death (log-rank test: p < 0.001). The multivariate Cox regression analysis showed that the high tertile of DFR was significantly associated with the study end points (HR: 2.18; 95% CI: 1.31-3.62; p = 0.003), compared with the low tertile. Conclusion: DFR is a reliable prognostic indicator for patients hospitalized for HF.

Comparison of Troponin Elevation, Prior Myocardial Infarction, and Chest Pain in Acute Ischemic Heart Failure

BACKGROUND

Patients with heart failure (HF) with concomitant ischemic heart disease (IHD) have not been well characterized. We examined survival of patients with ischemic HF syndrome (IHFS), defined as presentation with acute HF and concomitant features suggestive of IHD.

METHODS

Patients were included if they presented with acute HF to hospitals in Ontario, Canada. IHD was defined by any of the following criteria: angina/chest pain, prior myocardial infarction (MI), or troponin elevation that was above the upper limit of normal (mild) or suggestive of cardiac injury. Deaths were determined after hospital presentation.

RESULTS

Of 5353 patients presenting with acute HF, 4088 (76.4%) exhibited features of IHFS. Patients with IHFS demonstrated a higher rate of 30-day (hazard ratio [HR], 1.89; 95% confidence interval [CI], 1.33-2.68) and 1-year death (HR, 1.16, 95% CI, 1.00-1.35) compared with those with nonischemic HF. Troponin elevation demonstrated the strongest association with mortality. Mildly elevated troponin was associated with increased hazard over 30-day (HR, 1.77; 95% CI, 1.12-2.81) and 1-year (HR, 1.63; 95% CI, 1.38-1.93) mortality. Troponins indicative of cardiac injury were associated with increased hazard of death over 30 days (HR, 2.33; 95% CI, 1.63-3.33) and 1 year (HR, 1.40; 95% CI, 1.21-1.61). The association between elevated troponin and higher mortality at 30 days was similar in left ventricular ejection fraction subcategories of HF with reduced ejection fraction, HF with mildly reduced ejection fraction, or HF with preserved ejection fraction (P interaction = 0.588). After multivariable adjustment, prior MI and angina were not associated with higher mortality risk.

CONCLUSIONS

In acute HF, elevated troponin, but not prior MI or angina, was associated with a higher risk of 30-day and 1-year mortality irrespective of left ventricular ejection fraction.