Noninvasive estimation of left ventricular filling pressure by e/e′ is a powerful predictor of survival after acute myocardial infarction

Prognostic value of E/e' ratio and its change over time in ST-segment elevation myocardial infarction with preserved left ventricular ejection fraction in the reperfusion era

BACKGROUND

The ratio of early diastolic mitral inflow velocity to mitral annular velocity (E/e') is a prognostic factor in patients with ST-segment elevation myocardial infarction (STEMI). However, data are lacking on long-term outcomes and longitudinal changes in E/e' in patients with preserved left ventricular ejection fraction (LVEF) in the reperfusion era.

METHODS

This is a pre-specified echocardiographic substudy of a randomized controlled trial evaluating the efficacy of beta-blockers in STEMI patients with LVEF ≥40 % after primary percutaneous coronary intervention (PCI). Patients were divided into 2 groups according to E/e' at discharge: ≤14 (normal E/e' group) or > 14 (high E/e' group). The primary outcome was a composite of all-cause death, myocardial infarction, stroke, acute coronary syndrome, and heart failure hospitalization. We also assessed longitudinal changes in E/e' and conducted a landmark analysis using E/e' at 1 year after STEMI.

RESULTS

There were 173 and 38 patients in the normal and high E/e' groups, respectively. During a median follow-up of 3.9 years, the primary outcome occurred in 19 patients (11.0 %) and 10 patients (26.3 %) in the normal and high E/e' groups, respectively. The cumulative incidence of the primary outcome was higher in the high E/e' group than in the normal E/e' group (21.9 % vs. 7.1 % at 3 years; log-rank p = 0.013). E/e' in the high E/e' group decreased over time (p < 0.001), but remained higher than in the normal E/e' group at 1 year after STEMI (13.7 ± 5.3 vs. 8.6 ± 2.3, p < 0.001). E/e' > 14 at 1 year was also associated with poor outcomes (log-rank p = 0.008). A sensitivity analysis using multivariate Cox proportional hazards regression models yielded consistent results.

CONCLUSION

High E/e' at discharge is associated with poor long-term outcomes in STEMI patients with preserved LVEF after primary PCI, which may be explained by persistent high E/e' late after STEMI.

Novel combined echocardiographic score comprising prognostically validated measures of left ventricular size and function to predict long-term survival following myocardial infarction: A proposal to improve risk stratification

BACKGROUND

While left ventricular ejection fraction (LVEF) is the primary variable utilized for prognosis following myocardial infarction (MI), it is relatively indiscriminate for survival in patients with mildly reduced (> 40%) or preserved LVEF (> 50%). Improving risk stratification in patients with mildly reduced or preserved LVEF remains an unmet need, and could be achieved by using a combination approach using prognostically validated measures of left-ventricular (LV) size, geometry, and function.

AIMS

The aim of this study was to compare the prognostic utility of a Combined Echo-Score for predicting all-cause (ACM) and cardiac mortality (CM) following MI to LVEF alone, including the sub-groups with LVEF > 40% and LVEF > 50%.

METHODS

Retrospective data on 3094 consecutive patients with MI from 2013 to 2021 who had inpatient echocardiography were included, including both patients with ST-elevation MI (n = 869 [28.1%]) and non-ST-elevation MI (n = 2225 [71.9%]). Echo-Score consisted of LVEF < 40% (2 points) or LVEF < 50% (1 point), and 1 point each for left atrial volume index > 34 mL/m2, septal E/e' > 15, abnormal LV mass-index, tricuspid regurgitation velocity > 2.8 m/s, and abnormal LV end-systolic volume-index. Simple addition was used to derive a score out of 7.

RESULTS

At a median follow-up of 4.5 years there were 445 deaths (130 cardiac deaths). On Cox proportional-hazards multivariable analysis incorporating significant clinical and echocardiographic predictors, Echo-Score was an independent predictor of both ACM (HR 1.34, p < .001) and CM (HR 1.59, p < .001). Inter-model comparisons of model 𝛘2, Harrel's C and Somer's D, and Receiver operating curves confirmed the superior prognostic value of Echo-Score for both endpoints compared to LVEF. In the subgroups with LVEF > 40% and LVEF > 50%, Echo-Score was similarly superior to LVEF for predicting ACM and CM.

CONCLUSIONS

An Echo-Score composed of prognostically validated LV parameters is superior to LVEF alone for predicting survival in patients with MI, including the subgroups with mildly reduced and preserved LVEF. This could lead to improved patient risk stratification, better-targeted therapies, and potentially more efficient use of device therapies. Further studies should be considered to define the benefit of further investigation and treatment in high-risk subgroups.

Tricuspid annular plane systolic excursion over systolic pulmonary artery pressure prognostic value for in-hospital adverse events in patients hospitalized for acute coronary syndrome

AIMS

Although several studies have shown that the right ventricular to pulmonary artery (RV-PA) coupling, assessed by the ratio between tricuspid annular plane systolic excursion and systolic pulmonary artery pressure (TAPSE/sPAP) using echocardiography, is strongly associated with cardiovascular events, its prognostic value is not established in acute coronary syndrome (ACS). We aimed to assess the in-hospital prognostic value of TAPSE/sPAP among patients hospitalized for ACS in a retrospective analysis from the prospective ADDICT-ICCU study.

METHODS AND RESULTS

A total of 481 consecutive patients hospitalized in intensive cardiac care unit [mean age 65 ± 13 years, 73% of male, 46% ST-elevation myocardial infarction (STEMI)] for ACS [either STEMI or non-STEMI (NSTEMI)] with TAPSE/sPAP available were included in this prospective French multicentric study (39 centres). The primary outcome was in-hospital major adverse cardiovascular events (MACEs) defined as all-cause death, resuscitated cardiac arrest, or cardiogenic shock and occurred in 33 (7%) patients. Receiver operating characteristic curve analysis identified 0.55 mm/mmHg as the best TAPSE/sPAP cut-off to predict in-hospital MACEs. TAPSE/sPAP <0.55 was associated with in-hospital MACEs, even after adjustment with comorbidities [odds ratio (OR): 19.1, 95% confidence interval (CI) 7.78-54.8], clinical severity including left ventricular ejection fraction (OR: 14.4, 95% CI 5.70-41.7), and propensity-matched population analysis (OR: 22.8, 95% CI 7.83-97.2, all P < 0.001). After adjustment, TAPSE/sPAP <0.55 showed the best improvement in model discrimination and reclassification above traditional prognosticators (C-statistic improvement: 0.16; global χ2 improvement: 52.8; likelihood ratio test P < 0.001) with similar results for both STEMI and NSTEMI subgroups.

CONCLUSION

A low RV-PA coupling defined as TAPSE/sPAP ratio <0.55 was independently associated with in-hospital MACEs and provided incremental prognostic value over traditional prognosticators in patients hospitalized for ACS.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05063097.

E/e' Ratio as a Predictor of In-Hospital Complications and Clinical Outcomes of Acute Myocardial Infarction

Introduction Acute myocardial infarction (AMI) is the leading cause of death worldwide. E/e' ratio can predict complications and mortality in the long term, but information on its effectiveness in in-hospital settings is limited. Identifying high-risk patients effectively is crucial for early management, which may improve overall clinical outcomes. This study evaluated the predictive value of the E/e' ratio of in-hospital complications and clinical outcomes of AMI. Methods Patients presenting with AMI to Batumi Referral Hospital, Georgia, between December 2023 and May 2024, were examined in this study. During the first 24 hours of hospitalization, all patients underwent two-dimensional echocardiograms. Early diastolic filling velocity (E) was measured by pulsed wave Doppler, and early mitral annulus velocity (e') was measured by tissue Doppler. Based on the ratio of the two measures, patients were divided into three groups: E/e'<8, E/e' 8-14, and E/e'>14. Results A total of 113 patients (92 males and 21 females) were included in the study. The average age of the patients was 62 years (SD = 11.71). Overall, 27 (23.8%) patients were diagnosed with ST-elevation myocardial infarction (STEMI) and 86 (76.2%) patients with non-ST-elevation myocardial infarction (NSTEMI). The E/e' ratio was normal (less than 8) in 39 (34.5%) patients (group A), increased to 8-14 in 46 (40.7%) (group B), and greater than 14 in 28 (24.8%) (group C). The percentage of deaths in group B was higher than that in group A (2.2% vs 0%), and in group C, it was significantly higher than that in group B (17.9% vs 2.2%) (p<0.05). The percentage of heart failure developed during hospitalization was higher in group B compared to group A (54.3% vs 2.6%), and it was significantly higher in group C compared to group B (67.9% vs 54.3%) (p<0.05). The percentage of arrhythmias developed during hospitalization was higher in group B compared to group A (13.0% VS 2.6%), and in group C, was significantly higher compared to group B (35.7% VS 13.0%) (p<0.05). The percentage of cardiogenic shock in group B was higher than that in group A (4.3% VS 0%), and in group C, it was significantly higher than group B (25.0% VS 4.3%) (p<0.05). No significant association was found between E/e' ratio and recurrent angina, nor was there a significant association between all-cause deterioration during hospitalization (p>0.05). Conclusions Both slightly and significantly elevated E/e' ratios are predictors of in-hospital complications and may be used to identify individuals at high risk of negative health outcomes.

Effects of Glucagon-Like Peptide-1 Receptor Agonist (GLP-1RA) on Cardiac Structure and Function: A Systematic Review and Meta-Analysis of Randomized-Controlled Trials

PURPOSE

Recent trials suggest glucagon-like peptide-1 receptor agonists (GLP-1RAs) may have a cardioprotective role by reducing major adverse cardiac events, stroke mortality and heart failure-related hospitalisations. We examined whether and how GLP-1RAs affect cardiac function in cardiovascular and metabolic diseases including type 2 diabetes, heart failure and post-myocardial infarction.

METHODS

In this PRISMA-adherent systematic review and meta-analysis, three databases were searched from inception to July 2021 and registered on PROSPERO (CRD42021259661).

RESULTS

20 reports of 19 randomized placebo-controlled trials including 2062 participants were meta-analyzed. Among type 2 diabetes patients, GLP-1RA resulted in improved systolic function measured by circumferential strain (mean difference [MD]= -5.48; 95% CI: -10.47 to -0.49; P= 0.03; I2= 89%) and diastolic dysfunction measured by E / A (MD= -0.15; 95% CI: -0.25 to -0.05; P= 0.003; I2= 0%). For post-myocardial infarction patients, GLP-1RA reduced infarct size (g) (MD= -5.36; 95% CI: -10.68 to -0.04; P= 0.05; I2= 78%). Liraglutide, but not exenatide, demonstrated improved systolic function, by increasing left ventricular ejection fraction (MD= 4.89; 95% CI: 3.62 to 6.16; P< 0.00001; I2= 0%) and reducing left ventricular end-systolic volume (MD= -4.15; 95% CI: -7.49 to -0.81; P = 0.01; I2= 0%). Among heart failure patients, no significant changes were noted.

CONCLUSION

GLP-1RA drugs may improve systolic and diastolic function in type 2 diabetes and reduce infarct size post-acute myocardial infarction with no demonstrable effect on cardiac function in heart failure. Tailored recommendations for the use of GLP-1RAs for cardioprotection should be considered for each patient's condition.

Ratio of early transmitral inflow velocity to early diastolic strain rate predicts atrial fibrillation following acute myocardial infarction

The ratio of early transmitral filling velocity to early diastolic strain rate (E/SRe) has been proposed as a new non-invasive measurement of left ventricular filling pressure. We aimed to investigate the ability of E/SRe to predict atrial fibrillation (AF) after ST-elevation myocardial infarction (STEMI). This was a prospective cohort study of patients (n = 369) with STEMI. Patients underwent an echocardiographic examination a median of two days after pPCI. By echocardiography, transmitral early filling velocity (E) was measured by pulsed-wave Doppler, and early diastolic strain rate (SRe) was measured by speckle tracking of the left ventricle. E was indexed to SRe and the early myocardial relaxation velocity (e') to obtain the E/SRe and E/e', respectively. The endpoint was new-onset AF. During follow-up (median 5.6 years, IQR: 5.0-6.1 years), 23 (6%) of the 369 patients developed AF. In unadjusted analyses, both E/SRe and E/e' were significantly associated with AF [E/SRe: HR = 1.06; (1.03-1.10); p < 0.001, per 10 increase] and [E/e': HR = 1.11 (1.05-1.17); p < 0.001, per 1 increase] and had equal Harrell's C-statistic of 0.71. However, only E/SRe remained an independent predictor after multivariable adjustments for clinical and echocardiographic parameters [E/SRe: HR = 1.06 (1.00-1.11); p = 0.044, per 10 increase]. E/SRe was further significantly associated with AF in patients with E/e' < 14 HR = 1.09 (1.01-1.17); p = 0.030, per 10 increase), also after multivariable adjustments. E/SRe is an independent predictor of AF in STEMI patients, even in subjects with seemingly normal filling pressure.

Renal and cardiovascular prognostic significance of echocardiographic early diastolic mitral annular velocity in IgA nephropathy

In chronic kidney disease (CKD), as in IgA nephropathy (IgAN), cardiovascular (CV) mortality and morbidity are many times higher than in the general population, and diastolic dysfunction (LVDD) has prognostic significance as well. Tissue Doppler Echocardiography (TDI) is another method for measuring myocardial contractility and determining diastolic dysfunction. 79 IgAN patients (age 46 ± 11 years) with CKD stages 1-3 were investigated and followed for 70 ± 28.7 months. Doppler echocardiography was used to measure the E (early) and A (late) waves, as well as the E wave deceleration time (EDT) during mitral inflow. TDI was used to measure early (Ea) and late (Aa) diastolic velocities (lateral and septal basal wall fragment average). From these, we calculated the E/Ea and Ea/Aa ratios. The primary combined endpoints were total mortality, major CV events, and end-stage renal disease, and the secondary endpoints were cardiovascular or renal (eGFR decreased below 15 ml/min/1.73 m2 or renal replacement therapy was started). Patients with decreased Ea (< 13 cm/s) had significantly more endpoints (20/42 vs. 3/37; p = 0.001) than patients with higher Ea (≥ 13 cm/s). The secondary renal endpoints were also significantly higher (p = 0.004). In a multivariate model, the eGFR showed independent correlation with the E/A ratio (r = 0.466; p < 0.01), EDT (r = - 0.270; p < 0.01), Ea/Aa ratio (r = 0.455; p < 0.01), and decreased Ea (r = 0.544; p < 0.01). Independent factors influencing Ea were only EDT by uni- and multivariate regression but age and albuminuria by logistic regression. Decreased Ea measured by TDI seems to be an eligible factor to predict the prognosis of IgA nephropathy. The decreased Ea may be a helpful parameter to identify high-risk CKD patients.

Incremental prognostic value of speckle tracking echocardiography and early follow-up echo assessment in predicting left ventricular recovery after reperfusion for ST-segment elevation myocardial infarction (STEMI)

PURPOSE

Up to 50% of patients do not achieve significant left ventricular ejection fraction (LVEF) recovery after primary percutaneous intervention (PPCI) for STEMI. We aimed to identify the echocardiographic predictors for LVEF recovery and assess the value of early follow-up echocardiography (Echo) in risk assessment of post-myocardial infarction (MI) patients.

METHODS

One hundred one STEMI patients undergoing PPCI were enrolled provided EF below 50%. Baseline echocardiography assessed LVEF, volumes, wall motion score index (WMSI), global longitudinal strain (GLS), global circumferential strain (GCS), and E/e'. Follow-up echocardiography after 6 weeks reassessed left ventricular volumes, LVEF and GLS.GCS was not assessed at follow up. Patients were classified into recovery and non-recovery groups. Predictors of LVEF recovery and major adverse cardiovascular events (MACE) at 6 months were analysed.

RESULTS

The mean change of EF was 8.04 ± 3.32% in group I versus -.39 ± 5.09 % in group II (p < .001). Recovered patients had better baseline GLS, baseline GCS, E/e', and follow-up GLS. Multivariate regression analysis revealed E/e', GCS, and follow-up GLS after 6 weeks to be strong independent predictors for LVEF recovery. Composite MACE was considerably higher in group II (32.7% vs. 4.1%, p < .001) mainly driven by higher heart failure hospitalisation Multivariate regression analysis revealed baseline GLS, E/e', and ejection fraction (EF) percentage recovery as strong independent predictors for MACE.

CONCLUSIONS

Multiparametric echocardiographic approach incorporating LVEF, strain parameters, and diastolic function could allow early optimal risk stratification after STEMI treated with PPCI. Follow-up GLS and LVEF percentage change are the strongest predictors for early LV recovery and long term clinical outcome, respectively.

Current and Future Role of Ultrasonography in the Cardiac Intensive Care Unit

The contemporary practice of ultrasonography in the cardiac intensive care unit integrates the principles of echocardiography with whole-body imaging to create a more expansive paradigm of critical care ultrasonography (CCUS). This article will review the use of CCUS for diagnostic assessment, monitoring, therapeutic guidance, and prognosis.

Relationship between Preoperative Echocardiographic Parameters and the Incidence of Postoperative Complications in Patients Undergoing Clipping of Unruptured Intracranial Aneurysms: A Retrospective Cohort Study

Background and Objectives: Preoperative echocardiography is widely performed in patients undergoing major surgeries to evaluate cardiac functions and detect structural abnormalities. However, studies on the clinical usefulness of preoperative echocardiography in patients undergoing cerebral aneurysm clipping are limited. Therefore, this study aimed to investigate the correlation between preoperative echocardiographic parameters and the incidence of postoperative complications in patients undergoing clipping of unruptured intracranial aneurysms. Materials and Methods: Electronic medical records of patients who underwent clipping of an unruptured intracranial aneurysm from September 2018 to April 2020 were retrospectively reviewed. Data on baseline characteristics, laboratory variables, echocardiographic parameters, postoperative complications, and hospital stays were obtained. Univariable and multivariable logistic regression analyses were performed to identify independent variables related to the occurrence of postoperative complications and prolonged hospital stay (≥8 d). Results: Among 531 patients included in the final analysis, 27 (5.1%) had postoperative complications. In multivariable logistic regression, the total amount of crystalloids infused (1.002 (1.001-1.003), p = 0.001) and E/e' ratio (1.17 (1.01-1.35), p = 0.031) were significant independent factors associated with the occurrence of a postoperative complication. Additionally, the maximal diameter of a cerebral aneurysm (1.13 (1.02-1.25), p = 0.024), total amount of crystalloids infused (1.001 (1.000-1.002), p = 0.031), E/A ratio (0.22 (0.05-0.95), p = 0.042), and E/e' ratio (1.16 (1.04-1.31), p = 0.011) were independent factors related to prolonged hospitalization. Conclusions: Echocardiographic parameters related to diastolic function might be associated with postoperative complications in patients undergoing clipping of unruptured intracranial aneurysms.

Relationship between arterial stiffness, left ventricular diastolic function, and renal function in chronic kidney disease

AIM

In chronic kidney disease, IgA nephropathy, and left ventricular diastolic dysfunction have prognostic significance as well. However, the relationship between diastolic dysfunction, arterial stiffness, and renal function has not been fully elucidated.

METHODS

79 IgA nephropathy patients (aged 46 ± 11 years) and 50 controls were investigated. Tissue Doppler imaging was used to measure early (Ea) and late (Aa) diastolic velocities. Arterial stiffness was measured by a photoplethysmographic (stiffness index (SI)) and an oscillometric method (aortic pulse wave velocity (PWVao)).

RESULTS

We compared the IgAN patients to a similar cardiovascular risk group with a preserved eGFR. A strong correlation was found between Ea/Aa and SI (p < 0.001), also with PWVao (p < 0.001), just in IgAN, and with eGFR (p < 0.001) in both groups. IgAN patients were divided into groups CKD1-2 vs. CKD3-5. In the CKD 3-5 group, the incidence of diastolic dysfunction increased significantly: 39% vs. 72% (p = 0.003). Left ventricle rigidity (LVR) was calculated, which showed a close correlation with SI (p = 0.009) and eGFR (p = 0.038). By linear regression analysis, the independent predictors of SI were age, E/A, and E/Ea; SI was the predictor of LVR; and E/A and hypertension were the predictors of eGFR.

CONCLUSION

In chronic kidney disease, increased cardiac rigidity and vascular stiffness coexist with decreased renal function, which is directly connected to diastolic dysfunction and vascular stiffness. On the basis of comparing the CKD group to the control group, vascular alterations in very early CKD can be identified.

Trajectory and correlates of pulmonary congestion by lung ultrasound in patients with acute myocardial infarction: insights from PARADISE-MI

AIM

PARADISE-MI examined the efficacy of sacubitril/valsartan in acute myocardial infarction (AMI) complicated by reduced left ventricular ejection fraction (LVEF), pulmonary congestion, or both. We sought to assess the trajectory of pulmonary congestion using lung ultrasound (LUS) and its association with cardiac structure and function in a pre-specified substudy.

METHODS AND RESULTS

Patients without prior heart failure (HF) underwent eight-zone LUS and echocardiography at baseline (±2 days of randomization) and after 8 months. B-lines were quantified offline, blinded to treatment, clinical findings, time point, and outcomes. Among 152 patients (median age 65, 32% women, mean LVEF 41%), B-lines were detectable in 87% at baseline [median B-line count: 4 (interquartile range 2-8)]. Among 115 patients with LUS data at baseline and follow-up, B-lines decreased significantly from baseline (mean ± standard deviation: -1.6 ± 7.3; P = 0.018). The proportion of patients without pulmonary congestion at follow-up was significantly higher in those with fewer B-lines at baseline. Adjusted for baseline, B-lines at follow-up were on average 6 (95% confidence interval: 3-9) higher in patients who experienced an intercurrent HF event vs. those who did not (P = 0.001). A greater number of B-lines at baseline was associated with larger left atrial size, higher E/e' and E/A ratios, greater degree of mitral regurgitation, worse right ventricular systolic function, and higher tricuspid regurgitation velocity (P-trend <0.05 for all).

CONCLUSION

In this AMI cohort, B-lines, indicating pulmonary congestion, were common at baseline and, on average, decreased significantly from baseline to follow-up. Worse pulmonary congestion was associated with prognostically important echocardiographic markers.

Diastolic Dysfunction Criteria and Heart failure Readmission in Patients with Heart Failure and Reduced Ejection Fraction

Background:

Advanced diastolic dysfunction (DDys) correlates with elevated LV filling pressures and predicts heart failure readmission (HF-R). As grade 2-3 DDys has predictive value for HF-R, and requires 2 of 3 criteria (left atrial volume index >34 ml/m2, E/e’>14, or tricuspid regurgitation velocity >2.8 m/s), we hypothesized that all 3 criteria would predict greater HF risk than any 2 criteria.

Methods:

In this single-center retrospective study that included 380 patients in sinus rhythm with HF and reduced ejection, we recorded patient characteristics, Doppler-echo, and HF-R with follow-up to 2167 days (median=1423 days; interquartile range=992-1821 days).

Results:

For grade 1 DDys (223 patients), any single criteria resulted in greater HF-R as compared to 0 criteria (HR=2.52, (1.56-3.88) p<0.0001) with an AUC (area under curve)=0.637, p<0.001. For grade 2 DDys (94 patients), there was greater HF-R for all 3 (vs. 0 criteria: HR=4.0 (2.90-8.36), p<0.0001). There was greater HF-R for 3 vs any 2 criteria (HR=1.81, (1.10-3.39), p=0.0222). For all 3 criteria, there was moderate predictability for HF-R (AUC=0.706, p<0.0001) which was more predictive than any 2 criteria (AUC difference 0.057, (0.011-0.10), p=0.009). For grade 3 DDys (63 patients), E/A>2+2-3 criteria identified a subgroup with the greatest risk of HF-R (HR=5.03 (4.62-22.72), p<0.0001) compared with 0 DDys criteria with moderate predictability for 2-3 criteria (AUC=0.726, p<0.0001) exceeding E/A>2+0-1 criteria (AUC difference=0.120, (0.061-0.182), p<0.001).

Conclusion:

Increasing the number of abnormal criteria increased the risk and predictive value of HF-R for grade 1-3 DDys in patients with HF with reduced ejection fraction.

Serum Pro-N-Cadherin Is a Marker of Subclinical Heart Failure in the General Population

Background We recently reported aberrant processing and localization of the precursor PNC (pro-N-cadherin) protein in failing heart tissues and detected elevated PNC products in the plasma of patients with heart failure. We hypothesize that PNC mislocalization and subsequent circulation is an early event in the pathogenesis of heart failure, and therefore circulating PNC is an early biomarker of heart failure. Methods and Results In collaboration with the Duke University Clinical and Translational Science Institute's MURDOCK (Measurement to Understand Reclassification of Disease of Cabarrus and Kannapolis) study, we queried enrolled individuals and sampled 2 matched cohorts: a cohort of individuals with no known heart failure at the time of serum collection and no heart failure development in the following 13 years (n=289, cohort A) and a matching cohort of enrolled individuals who had no known heart failure at the time of serum collection but subsequently developed heart failure within the following 13 years (n=307, cohort B). Serum PNC and NT-proBNP (N-terminal pro B-type natriuretic peptide) concentrations in each population were quantified by ELISA. We detected no significant difference in NT-proBNP rule-in or rule-out statistics between the 2 cohorts at baseline. In participants who developed heart failure, serum PNC is significantly elevated relative to those who did not report development of heart failure (P<0.0001). Receiver operating characteristic analyses of PNC demonstrate diagnostic value for subclinical heart failure. Additionally, PNC has diagnostic potential when comparing participants with no reported heart failure risk factors from cohort A to at-risk participants from cohort B over the 13-year follow-up. Participants whose PNC levels measure >6 ng/mL have a 41% increased risk of all-cause mortality independent of age, body mass index, sex, NT-proBNP, blood pressure, previous heart attack, and coronary artery disease (P=0.044, n=596). Conclusions These data suggest that PNC is an early marker of heart failure and has the potential to identify patients who would benefit from early therapeutic intervention.

Heart failure as a complication of myocardial infarction: rational therapy. Case report

Heart failure (HF) is still a frequent complication of myocardial infarction. Timely identification of subjects at risk for HF development and early initiation of guideline-directed HF therapy in these patients, can decrease the HF burden. This article aims at summarizing clinical data on established pharmacological therapies in treating post-MI patients with left ventricular systolic dysfunction and signs and symptoms of HF.

Diagnostic Accuracy of the 2016 Guideline-Based Echocardiographic Algorithm to Estimate Invasively-Measured Left Atrial Pressure by Direct Atrial Cannulation

BACKGROUND

Although estimation of left ventricular filling pressure (LVFP) using an integrated echocardiographic algorithm is recommended, the usefulness of this algorithm has not been fully validated.

OBJECTIVES

The purpose of this study was to investigate the reliability of an algorithmic classification system using invasively measured left atrial pressure (LAP) in a large-scale cohort.

METHODS

The authors enrolled 1,967 patients (age 68 ± 10 years) whose LAP was directly measured within the left atrium during catheter ablation for atrial fibrillation. Patients were classified into 3 groups based on the echocardiographic algorithm: normal (group N, n = 1,282), undetermined (group U, n = 160), and elevated (group E, n = 346) LAP groups. Invasively measured LAP and echocardiographic parameters estimating LVFP were compared among the groups.

RESULTS

The median LAP was 12.6 ± 5.7 mm Hg in the entire cohort. LAP was significantly higher in group E than that in the other groups (groups E vs U vs N, 14.2 ± 6.3 mm Hg vs 13.5 ± 5.9 mm Hg vs 12.0 ± 5.5 mm Hg; P < 0.001). Among group E patients, 43.1% had elevated LAP (≥15 mm Hg), whereas 56.9% had normal LAP (<15 mm Hg). Of the patients in group N, 69.0% had normal LAP, whereas 31% had elevated LAP. Although the correlation between invasively measured LAP and E/e', peak tricuspid regurgitant velocity, and left atrial volume index was modest, the number of abnormal values correlated significantly with elevated LAP (P < 0.001).

CONCLUSIONS

The classification using combined echocardiographic parameters in the recommendations may be useful for detecting patients with normal LVFP but may be limited for detecting elevated LVFP.

The long-term prognostic value of E/e' in patients with ST segment elevation myocardial infarction

Objectives

This study aimed to evaluate the long-term prognostic value of E/e’ ratio in patients with ST-segment elevation myocardial infarction (STEMI).

Methods

We retrospectively assessed 314 patients who underwent primary coronary interventions between January 2010 and December 2015. The included patients were classified into two groups according to the E/e’ ratios: E/e’<15 (n = 245) and E/e’≥15 (n = 69). We investigated the incidence of major adverse cardiac events (MACEs) from the event to the final follow-up period of at least three years.

Results

A total of 55 cases of MACEs occurred during the follow-up. The E/e’≥15 group showed a significantly higher rate of MACEs than the E/e’<15 group (34.8% vs. 12.7%, p < 0.001). Among the MACE, the percentage of cardiac deaths (17.4% vs. 0.4%, p < 0.001) was higher in the E/e’≥15 group than in the E/e’<15 group. In the multivariable model, E/e’≥15 was demonstrated as the strongest prognostic factor for MACEs (hazard ratio [HR], 2.597; 95% confidence interval [CI], 1.294–5.211; p = 0.007) and cardiac death (HR, 27.537; 95% CI, 3.287–230.689; p = 0.002), while left ventricular ejection fraction (LVEF) was not. Neither the discrepancy of systolic nor diastolic function between initial and follow-up echocardiography affected the overall prevalence of MACEs. A disparity was observed between the two groups, with a significant increase in the rate of MACEs in the E/e’≥15 group (log-rank test, p < 0.001).

Conclusion

The baseline E/e’≥15 in patients with STEMI after successful reperfusion is the strongest predictor of poor long-term clinical outcomes among those analyzed.

Doppler-derived haemodynamics performed during admission echocardiography predict in-hospital mortality in cardiac intensive care unit patients

AIMS

Cardiac point-of-care ultrasound (CV-POCUS) has become a fundamental part for the assessment of patients admitted to cardiac intensive care units (CICU). We sought to refine the practice of CV-POCUS by identifying 2D and Doppler-derived measurements from bedside transthoracic echocardiograms (TTEs) performed in the CICU that are associated with mortality.

METHODS AND RESULTS

We retrospectively included Mayo Clinic CICU patients admitted from 2007 to 2018 and assessed the TTEs performed within 1 day of CICU admission, including Doppler and 2D measurements of left and right ventricular function. Logistic regression and classification and regression tree (CART) analysis were used to determine the association between TTE variables with in-hospital mortality. A total of 6957 patients were included with a mean age of 68.0 ± 14.9 years (37.0% females). A total of 609 (8.8%) patients died in the hospital. Inpatient deaths group had worse biventricular systolic function [left ventricular ejection fraction (LVEF) 48.2 ± 16.0% vs. 38.7 ± 18.2%, P < 0.0001], higher filling pressures, and lower forward flow. The strongest TTE predictors of hospital mortality were left ventricular outflow tract velocity-time integral [LVOT VTI, adjusted OR 0.912 per 1 cm higher, 95% confidence interval (CI) 0.883-0.942, P < 0.0001] followed by medial mitral E/e' ratio (adjusted OR 1.024 per 1 unit higher, 95% CI 1.010-1.039, P = 0.0011). Classification and regression tree analysis identified LVOT VTI <16 cm as the most important TTE predictor of mortality.

CONCLUSIONS

Doppler-derived haemodynamic TTE parameters have a strong association with mortality in the CICU, particularly LVOT VTI <16 cm or mitral E/e' ratio >15. The incorporation of these simplified Doppler-derived haemodynamics into admission CV-POCUS facilitates early risk stratification and strengthens the clinical yield of the ultrasound exam.

Composite Echocardiographic Score to Predict Long-Term Survival Following Myocardial Infarction

BACKGROUND

Whilst the left ventricular ejection fraction (LVEF) remains the primary echocardiographic measure widely utilised for risk stratification following myocardial infarction (MI), it has a number of well recognised limitations. The aim of this study was to compare the prognostic utility of a composite echocardiographic score (EchoScore) composed of prognostically validated measures of left-ventricular (LV) size, geometry and function, to the utility of LVEF alone, for predicting survival following MI.

METHODS

Retrospective data on 394 consecutive patients with a first-ever MI were included. Comprehensive echocardiography was performed within 24 hours of admission for all patients. EchoScore consisted of LVEF<50%, left atrial volume index>34 mL/m², average E/e >14, E/A ratio>2, abnormal LV mass index, and abnormal LV end-systolic volume index. A single point was allocated for each measure to derive a score out of 6. The primary outcome measure was all-cause mortality.

RESULTS

At a median follow-up of 24 months there were 33 deaths. On Kaplan-Meier analysis, a high EchoScore (>3) displayed significant association with all-cause mortality (log-rank χ²=74.48 p<0.001), and was a better predictor than LVEF<35% (log-rank χ²=17.01 p<0.001). On Cox proportional-hazards multivariate analysis incorporating significant clinical and echocardiographic predictors, a high EchoScore was the strongest independent predictor of all-cause mortality (HR 6.44 95%CI 2.94-14.01 p<0.001), and the addition of EchoScore resulted in greater increment in model power compared to addition of LVEF (model χ² 56.29 vs 44.71 p<0.001, Harrell's C values 0.83 vs 0.79).

CONCLUSIONS

A composite echocardiographic score composed of prognostically validated measures of LV size, geometry, and function is superior to LVEF alone for predicting survival following MI.

A Phenotyping of Diastolic Function by Machine Learning Improves Prediction of Clinical Outcomes in Heart Failure

Background: Discriminating between different patterns of diastolic dysfunction in heart failure (HF) is still challenging. We tested the hypothesis that an unsupervised machine learning algorithm would detect heterogeneity in diastolic function and improve risk stratification compared with recommended consensus criteria.

Methods: This study included 279 consecutive patients aged 24–97 years old with clinically stable HF referred for echocardiographic assessment, in whom diastolic variables were measured according to the current guidelines. Cluster analysis was undertaken to identify homogeneous groups of patients with similar profiles of the variables. Sequential Cox models were used to compare cluster-based classification with guidelines-based classification for predicting clinical outcomes. The primary endpoint was hospitalization for worsening HF.

Results: The analysis identified three clusters with distinct properties of diastolic function that shared similarities with guidelines-based classification. The clusters were associated with brain natriuretic peptide level (p < 0.001), hemoglobin concentration (p = 0.017) and estimated glomerular filtration rate (p = 0.001). During a mean follow-up period of 2.6 ± 2.0 years, 62 patients (22%) experienced the primary endpoint. Cluster-based classification predicted events with a hazard ratio 1.68 (p = 0.019) that was independent from and incremental to the Meta-analysis Global Group in Chronic Heart Failure (MAGGIC) risk score for HF, and from left ventricular end-diastolic volume and global longitudinal strain, whereas guidelines-based classification did not retain its independent prognostic value (hazard ratio = 1.25, p = 0.202).

Conclusion: Machine learning can identify patterns of diastolic function that better stratify the risk for decompensation than the current consensus recommendations in HF. Integrating this data-driven phenotyping may help in refining prognostication and optimizing treatment.

Peri-operative changes in diastolic function and outcomes in congenital aortic valve surgery

Background

The ratio of early diastolic mitral inflow velocity (E) to early diastolic mitral annular tissue velocity (e’), or E/e’, is an echocardiographic measure of left ventricular filling pressure. Peri‐operative changes in E/e’ and association with outcomes have been demonstrated in adults undergoing surgery for aortic stenosis (AS). We sought to explore changes in E/e’ and other diastolic indices in the setting of congenital AS surgery and to assess for association with post‐operative outcomes among children and young adults.

Methods

A retrospective, single‐center study was performed among patients 6 months to 30 years of age who underwent congenital AS surgery from 2006 to 2018. Tissue Doppler indices were collected from pre‐ and post‐operative echocardiograms. Post‐operative outcomes were reviewed.

Results

Sixty‐six subjects with subvalvar (45%), valvar (47%), and supravalvar (8%) AS underwent surgery at a median age of 9.5 years (IQR: 4.0–14.8). Pre‐operatively, the lateral E/e’ ratio was 8.6 (6.7–11.0); 33% had E/e’≥10. Post‐operatively, the lateral e’ decreased to 9.9 cm/s (8.0–11.4), the E/e’ ratio increased to 10.4 (8.3–13.1); and 53% had E/e’≥10 (p‐values < 0.0001, 0.0072, and < 0.001, respectively). Pre‐operative lateral e’ correlated modestly with duration of intubation (ρ = −0.24, p‐value 0.048) and post‐operative lateral e’ correlated modestly with duration of intubation and length of hospital stay (ρ = −0.28 and −0.26, p‐values = 0.02 and 0.04, respectively).

Conclusions

Children and young adults who underwent congenital AS surgery had echocardiographic evidence of diastolic dysfunction pre‐operatively that worsened post‐operatively. Lateral e’ may be a sensitive indicator of impaired ventricular relaxation in these patients and may impact duration of intubation and hospital stay.

Moderate aortic stenosis: importance of symptoms and left ventricular ejection fraction

AIMS

The aim of this study is to investigate the independent determinants of survival in patients with moderate aortic stenosis (AS), stratified by severity of symptoms and left ventricular ejection fraction (LVEF).

METHODS AND RESULTS

Patients with a first diagnosis of moderate AS (aortic valve area >1.0 and ≤1.5 cm2) were identified. Patients were stratified by New York Heart Association (NYHA) functional class (NYHA I, NYHA II, or NYHA III-IV) and LVEF (LVEF ≥60%, LVEF 50-59%, or LVEF <50%) at the time of moderate AS diagnosis. The primary endpoint was all-cause mortality, while the secondary endpoint included all-cause mortality and aortic valve replacement. Of 1961 patients with moderate AS (mean age 73 ± 10 years, 51% men), 1108 (57%) patients were in NYHA class I, while 527 (27%) and 326 (17%) patients had symptoms of NYHA class II and III-IV, respectively. Regarding LVEF, 1032 (53%) had LVEF ≥60%, 544 (28%) LVEF 50-59%, and 385 (20%) LVEF <50%. During a median follow-up of 50 (23-82) months, 868 (44%) patients died. On multivariable analysis, NYHA class II [hazard ratio (HR): 1.633; 95% confidence interval (CI): 1.431-1.864; P < 0.001], NYHA class III-IV (HR: 2.084; 95% CI: 1.797-2.417; P < 0.001), LVEF 50-59% (HR: 1.194; 95% CI: 1.013-1.406; P = 0.034), and LVEF <50% (HR: 1.694; 95% CI: 1.417-2.026; P < 0.001) were independently associated with increased mortality.

CONCLUSION

Moderate AS is associated with poor long-term survival. Baseline symptom severity and LVEF are associated with worse outcomes in these patients. Patients with low-normal LVEF (<60%) and mild symptoms (NYHA II) already have an increased risk of adverse events.

Diamond-Forrester classification using echocardiography haemodynamic assessment in cardiac intensive care unit patients

AIMS

We sought to determine whether the Diamond-Forrester classification using non-invasive haemodynamic measurements by 2-D and Doppler echocardiography would predict hospital mortality in cardiac intensive care unit (CICU) patients.

METHODS AND RESULTS

We retrospectively analysed unique patients admitted to the CICU at Mayo Clinic Rochester from 2007 to 2018. Doppler-derived cardiac index (CI) and ratio of mitral valve E velocity to medial mitral annulus e' velocity (E/e' ratio) were used to classify patients into four profiles: Profile I (warm/dry), Profile II (warm/wet), Profile III (cold/dry), and Profile IV (cold/wet). Logistic regression was used to determine predictors of hospital mortality, and Cox proportional-hazards analysis was used to determine predictors of mortality during one year of follow-up. We included 4563 patients with a mean age of 68.3 ± 14.3 years, including 36.2% female patients. The distribution of each profile was as follows: I, 47.4%; II, 36.2%; III, 7.9%; IV, 8.5%. A total of 5.8% patients died during hospitalization, and 18.1% died by 1 year. Patients with either low CI or elevated E/e' ratio had higher in-hospital and 1 year mortality. Patients with elevated E/e' ratio (i.e. Profiles II and IV) had an increased risk of death during hospitalization and at 1 year after multivariate adjustment (adjusted hazard ratio 1.72 and 2.17 for 1 year mortality, respectively, compared with Profile I, P < 0.01).

CONCLUSIONS

Simple Doppler echocardiographic assessment can be used to identify haemodynamic profiles defined by the Diamond-Forester classification in patients admitted in CICU. These profiles predict outcomes and may be used to guide therapy in critically ill patients.

Echocardiographic Killip Classification

BACKGROUND

Although routine echocardiographic parameters such as ejection fraction are used to risk-stratify for death in patients referred for echocardiography, they have limited predictive value. The authors speculated that noninvasive hemodynamic echocardiographic data, assessing left ventricular filling pressure and output, stratified on the basis of the clinical Killip score, might have additive prognostic value on top of routine echocardiographic parameters. The authors created an echocardiographic correlate of this classification, using diastolic grade and stroke volume index (SVI) as indicators of pulmonary congestion and systemic perfusion, respectively, and evaluated the prognostic value of this correlate.

METHODS

A retrospective study of consecutive patients (hospitalized or not) referred for echocardiography for a range of cardiac diagnoses in a tertiary medical center. A total of 556 patients in sinus rhythm who were evaluated by two sonographers, and reviewed by a single cardiologist, were included. Normal filling pressure and normal SVI (>35 mL/m²) defined echocardiographic Killip (eKillip) class 1. Patients with pseudonormal or restrictive diastolic patterns and normal SVI were ascribed to eKillip class 2 or 3, respectively. A pseudonormal or restrictive diastolic pattern and a subnormal SVI defined eKillip class 4.

RESULTS

eKillip class 1 was present in 382 patients (68%); 115 (20%), 26 (5%), and 42 (7%) patients were in eKillip classes 2 to 4, respectively. Median follow-up time was 1,056 days (interquartile range, 729-1,390 days). A total of 105 deaths occurred. Univariate Cox regression analysis showed that eKillip class was associated with all-cause mortality; hazard ratios (HR) -2.73 (95% CI, 1.67-4.48), 3.19 (95% CI, 1.42-7.17), and 4.79 (95% CI, 2.58-8.89) for each eKillip class above 1 (P < .001). In a multivariate analysis adjusted for the Charlson comorbidity index, eKillip class remained independently associated with all-cause mortality (P = .04).

CONCLUSIONS

eKillip class was associated with all-cause mortality among all patients undergoing echocardiography at a tertiary hospital.

Effect of systolic dysfunction and elevated left ventricular end diastolic pressure on 3-year clinical outcomes in patients with atrial fibrillation

OBJECTIVES

Systolic and diastolic dysfunctions are related to adverse clinical outcomes in patients with sinus rhythm. The aim of this study was to clarify the prognostic significance of systolic and diastolic dysfunctions in patients with persistent atrial fibrillation (AF).

METHODS

We evaluated the data of 114 consecutive patients with persistent AF who underwent measurement of LVEDP at our hospital between March 1, 2011 and December 31, 2014. The patients were divided into two groups according to the left ventricular ejection fraction (LVEF): LVEF < 50 (reduced ejection fraction, REF group) and LVEF ≥50 (preserved EF, PEF group). The PEF group was further divided into two subgroups according to the left ventricular end-diastolic filling pressure (LVEDP): LVEDP > 15 mm Hg and LVEDP ≤ 15 mm Hg subgroups. The 3-year clinical outcomes were compared between the PEF and REF groups and the LVEDP ≥15 mm Hg and LVEDP < 15 mm Hg groups.

RESULTS

During the 3-year follow-up period, the rate of heart failure (HF) hospitalization and incidence of AF with rapid ventricular rhythm (RVR) were higher in the REF group than in the PEF group. Multivariate analysis revealed that REF was the only significant predictor of HF hospitalization (hazard ratio, 4.71; 95% confidence interval, 1.48-15.02; p = 0.009).

CONCLUSIONS

Our mid-term follow-up data demonstrated that systolic dysfunction was an important predictor of HF hospitalization in patients with AF. However, elevated LVEDP may not be associated with adverse mid-term clinical outcomes in patients without systolic dysfunction.

Usefulness of Diastolic Function Score as a Predictor of Long-Term Prognosis in Patients With Acute Myocardial Infarction

Background: Left ventricular diastolic function (LVDF) evaluation using a combination of several echocardiographic parameters is an important predictor of adverse events in patients with acute myocardial infarction (AMI). To date, the clinical impact of each individual LVDF marker is well-known, but the clinical significance of the sum of the abnormal diastolic function markers and the long-term clinical outcome are not well-known. This study aimed to investigate the usefulness of LVDF score in predicting clinical outcomes of patients with AMI. Methods: LVDF scores were measured in a 2,030 patients with AMI who underwent successful percutaneous coronary intervention from 2012 to 2015. Four LVDF parameters (septal e' ≥ 7 cm/s, septal E/e' ≤ 15, TR velocity ≤ 2.8 m/s, and LAVI ≤ 34 ml/m²) were used for LVDF scoring. The presence of each abnormal LVDF parameter was scored as 1, and the total LVDF score ranged from 0 to 4. Mortality and hospitalization due to heart failure (HHF) in relation to LVDF score were evaluated. To compare the predictive ability of LVDF scores and left ventricular ejection fraction (LVEF) for mortality and HHF, receiver operating characteristic (ROC) curve and landmark analyses were performed. Results: Over the 3-year clinical follow-up, all-cause mortality occurred in 278 patients (13.7%), while 91 patients (4.5%) developed HHF. All-cause mortality and HHF significantly increased as LVDF scores increased (all-cause mortality-LVDF score 0: 2.3%, score 1: 8.8%, score 2: 16.7%, score 3: 31.8%, and score 4: 44.5%, p < 0.001; HHF-LVDF score 0: 0.6%, score 1: 1.8%, score 2: 6.3%, score 3: 10.3%, and score 4: 18.2%, p < 0.001). In multivariate analysis, a higher LVDF score was associated with significantly higher adjusted hazard ratios for all-cause mortality and HHF. In landmark analysis, LVDF score was a better predictor of long-term mortality than LVEF (area under the ROC curve: 0.739 vs. 0.640, p < 0.001). Conclusion: The present study demonstrated that LVDF score was a significant predictor of mortality and HHF in patients with AMI. LVDF scores are useful for risk stratification of patients with AMI; therefore, careful monitoring and management should be performed for patients with AMI with higher LVDF scores.

Diastolic function grading by American Society of Echocardiography guidelines and prediction of heart failure readmission and all-cause mortality in a community-based cohort

BACKGROUND

Diastolic function (DF) guidelines have been simplified but lack extensive outcome data. Using a rural university heart failure (HF) database, we assessed whether DF grading could predict HF, HF readmission, and all-cause mortality (ACM).

METHODS

In this single-center retrospective study that included 613 patients in sinus rhythm hospitalized for HF (HF with preserved-254 patients, with mid-range-216 patients, and reduced ejection fraction-143 patients), we recorded demographics, Doppler-echo, Framingham HF score, laboratories, HF readmission, and ACM with follow-up to 2167 days.

RESULTS

Diastolic dysfunction (Ddys) parameters (left atrial volume index [LAVI] > 34 ml/m² , tricuspid regurgitation [TR] velocity > 2.8 m/sec, and E/e' > 14) had moderate sensitivity (46.2%-65.0%) for predicting HF among all phenotypes combined with DF grading having moderate predictability and additive to a clinical composite for HF prediction (AUC = .677, P < 0.0001; difference = .043, P < 0.001) for combined phenotypes. Ddys parameters and Ddys severity (2016 ASE criteria: grade II and III) were significantly associated with HF readmission for decompensated HF within 60-2167 days of follow-up (LAVI > 34 ml/m² : HR 1.56 [1.26-2.19]; E/e' > 14: HR 1.44 [1.21-1.99]; TR > 2.8 m/sec: H1.43 [1.19-1.88]; LV Dys grade II: HR 2.12 [1.42-2.96]; LV Ddys grade III: HR 2.39 [1.57-4.82]).

CONCLUSION

The findings of this study highlight the clinical and prognostic relevance of determining the severity of LV Ddys in patients with HF with regard to HF verification and HF readmission.

The Incremental Prognostic Value of E/(e'×s') Ratio in Non-ST-Segment Elevated Acute Coronary Syndrome

It has been shown that the E/(e’×s’) index, which associates a marker of diastolic function (E/e’, early transmitral/diastolic mitral annulus velocity ratio) and a parameter that explores LV systolic performance (s’, systolic mitral annulus velocity), is a good predictor of outcome in acute anterior myocardial infarction. There are no studies that have investigated the prognostic value of E/(e’×s’) in a non-ST-segment elevated acute coronary syndrome (NSTE-ACS) population. Echocardiography was performed in 307 consecutive hospitalized patients with NSTE-ACS and succesful percutaneous coronary intervention, before discharge and six weeks after. The primary endpoint consisted of cardiac death or readmission due to re-infarction or heart failure. During the follow-up period (25.4 ± 3 months), cardiac events occurred in 106 patients (34.5%). Receiver operating characteristic (ROC) analysis identified E/(e’×s’) at discharge as the best independent predictor of composite outcome. The optimal cut-off value was 1.63 (74% sensitivity, 67% specificity). By multivariate Cox regression analysis, E/(e’×s’) was the only independent predictor of cardiac events. Kaplan–Meier analysis identified that patients with an initial E/(e’×s’) > 1.63 that worsened after six weeks presented the worst prognosis regarding composite outcome, readmission, and cardiac death (all p < 0.001). In conclusion, in NSTE-ACS, E/(e’×s’) is a powerful predictor of clinical outcome, particularly if it is accompanied by worsening after 6-weeks.

Prognostic implications of echocardiographic measures of left and right atrial pressures on survival in patients with end stage renal disease

BACKGROUND

Volume excess is common in patients with end stage renal disease (ESRD). We examined the prognostic value of clinical and echocardiographic measures of left (LA) and right atrial (RA) hypertension in this population.

METHOD

We prospectively collected demographic, clinical, pharmacological, echocardiographic data on 575 consecutive ESRD patients on hemodialysis undergoing cardiac evaluation before renal transplantation in a dedicated cardiac clinic. Survival was analyzed as a function of clinical and echocardiographic measures of LA and (RA) hypertension.

RESULT

Elevated LA pressure was seen in 48% of the patients based on E/e' velocity ratio of ≥ 15, and 28% had elevated RA pressure based on inferior vena caval size. Physical examination grossly underestimated the prevalence of both LA and RA hypertension. Atrial pressures were normal in 46% and both atrial pressures were elevated in 20% of the patients. Elevated LA pressure in the presence of normal RA pressure was found in 30%. Over a period of 20 ± 8 months, there were 43 deaths. There was a graded increase in mortality with increases in LA and bi-atrial hypertension (p = .009). The 2-year mortality rate was 6% in those with normal atrial pressures, 13% in those with isolated LA hypertension and 28% in those with bi-atrial hypertension.

CONCLUSION

Mitral E/e' ratio and inferior vena caval size are vastly more sensitive than physical examination for recognition of elevated atrial pressures and are strong predictors of survival in ESRD patients. Limited echocardiographic examination may have a role in ESRD patients undergoing dialysis to help achieve euvolemic status.

Basic and advanced echocardiography in advanced heart failure: an overview

Advanced chronic heart failure (ACHF) is the last phase in the evolution of heart failure and is characterized by high hospitalization and mortality rates and is refractory to medical therapy, therefore requiring more aggressive therapies, such as mechanical circulatory support or heart transplantation. Over the last years, the incidence of ACHF was continuously growing, together with the increase in population survival rates. Therefore, the early recognition of the transition to ACHF is of crucial importance in HF patients, which also helps in prognostication of such patients, since advanced therapeutic options are limited to selected patients and they also have some important risk implications. Echocardiography is the gold standard tool for the evaluation of patients with HF; moreover, the recent technological advances provided new structural and functional indices of the four cardiac chambers that showed to be comparable to advanced imaging or invasive hemodynamic parameters. This allows us to operate an accurate study of ACHF with first- and second-level echocardiographic techniques, which are now being integrated in daily clinical practice. The present review presents an overview of the currently available tools for the echocardiographic examination of patients with ACHF, with its advantages and limitations, based on the latest supporting evidences.

Initial diastolic dysfunction is a powerful predictor of 5-year mortality in peripheral arterial disease patients undergoing percutaneous transluminal angioplasty

Peripheral arterial disease (PAD) and heart failure share common risks and are associated with increased morbidity and mortality. However, it is unknown whether cardiac function can be an independent predictor of long-term mortality in patients with PAD. In total, 902 patients who underwent percutaneous transluminal angioplasty for PAD were enrolled. The patients were categorized into three groups according to the left ventricular ejection fraction (LVEF): reduced EF (< 40%, n = 62); mid-range EF (40-49%, n = 76); and preserved EF (≥ 50%, n = 764). Echocardiographic (EF, ratio of mitral inflow velocity to annular velocity E/e' ≥ 15, and others) and clinical parameters were tested using stepwise logistic regression analysis to determine independent predictors of 5-year mortality. A higher proportion of patients with reduced EF had ischemic heart disease than those with preserved EF (77.4% vs. 56.8%, p < 0.001). Up to 5 years, patients with reduced EF and mid-range EF showed a higher incidence of total death than those with normal EF. However, there was no difference in the incidence of myocardial infarction, stroke, and revascularization among the three groups. After multivariable adjustment, the ratio of E/e' ≥ 15 was the only strong predictor of total mortality (hazard ratio 6.14; 95% confidence interval 3.7-10.1; p < 0.01). Patients with PAD and reduced EF undergoing PTA had a higher incidence of total death during the 5-year follow-up. Initial tissue Doppler E/e' ≥ 15, a non-invasive estimate of left atrial filling pressure, was the only independent predictor of long-term mortality. The relationship between PAD and HF.

Prognostic value of left atrial volume index in acute coronary syndrome: A systematic review and meta-analysis

BACKGROUND

In the absence of mitral valve disease, increased left atrial volume (LAV) is a marker of diastolic dysfunction and long-standing elevated left ventricle (LV) pressure. The aim of this study was to assess the role of increased baseline LAV in predicting clinical outcome of patients presenting with acute coronary syndrome (ACS).

METHODS

We systematically searched all electronic databases up to September 2020 in order to select clinical trials and observational studies, which assessed the predictive role of LAV indexed (LAVI) on clinical outcome in patients with ACS. Primary clinical endpoints were as follows: major adverse cardiac events (MACE), all-cause mortality and hospitalization. Secondary endpoints were in-hospital complications.

RESULTS

A total of 2,705 patients from 11 cohort studies with a mean follow-up 18.7 ± 9.8 months were included in the meta-analysis. Patients with low LAVI had low risk for MACE (15.9% vs. 33.7%; p < .01), long-term all-cause mortality (9.14% vs. 18.1%; p < .01), short-term mortality (3.31% vs. 9.38%; p = .02) and lower hospitalization rate (11.6% vs. 25.5%; p < .01) compared to patients with increased LAVI. Atrial fibrillation and cardiogenic shock as in-hospital events were lower (p < .05 for all) in patients with low LAVI but ventricular fibrillation/tachycardia was not different between groups (p = .14).

CONCLUSION

Increased LAVI is an independent predictor of outcome in patients with ACS. Thus, assessment of LA index in these patients is important for better risk stratification and guidance towards optimum clinical management.

Soluble Epoxide Hydrolase in Aged Female Mice and Human Explanted Hearts Following Ischemic Injury

Myocardial infarction (MI) accounts for a significant proportion of death and morbidity in aged individuals. The risk for MI in females increases as they enter the peri-menopausal period, generally occurring in middle-age. Cytochrome (CYP) 450 metabolizes N-3 and N-6 polyunsaturated fatty acids (PUFA) into numerous lipid mediators, oxylipids, which are further metabolised by soluble epoxide hydrolase (sEH), reducing their activity. The objective of this study was to characterize oxylipid metabolism in the left ventricle (LV) following ischemic injury in females. Human LV specimens were procured from female patients with ischemic cardiomyopathy (ICM) or non-failing controls (NFC). Female C57BL6 (WT) and sEH null mice averaging 13–16 months old underwent permanent occlusion of the left anterior descending coronary artery (LAD) to induce myocardial infarction. WT (wild type) mice received vehicle or sEH inhibitor, trans-4-[4-(3-adamantan-1-yl-ureido)-cyclohexyloxy]-benzoic acid (tAUCB), in their drinking water ad libitum for 28 days. Cardiac function was assessed using echocardiography and electrocardiogram. Protein expression was determined using immunoblotting, mitochondrial activity by spectrophotometry, and cardiac fibre respiration was measured using a Clark-type electrode. A full metabolite profile was determined by LC–MS/MS. sEH was significantly elevated in ischemic LV specimens from patients, associated with fundamental changes in oxylipid metabolite formation and significant decreases in mitochondrial enzymatic function. In mice, pre-treatment with tAUCB or genetic deletion of sEH significantly improved survival, preserved cardiac function, and maintained mitochondrial quality following MI in female mice. These data indicate that sEH may be a relevant pharmacologic target for women with MI. Although future studies are needed to determine the mechanisms, in this pilot study we suggest targeting sEH may be an effective strategy for reducing ischemic injury and mortality in middle-aged females.

Markers of Elevated Left Ventricular Filling Pressure Are Associated with Increased Mortality in Nonsevere Aortic Stenosis

BACKGROUND

Echocardiographic measures of elevated left ventricular filling pressures are associated with an adverse prognosis. The aim of this study was to determine the relationship between acute (ratio of early transmitral flow to mitral annular velocity [E/e']) and chronic (indexed left atrial volume) markers of left ventricular filling pressure and mortality in patients with nonsevere aortic stenosis (AS), within the National Echo Database Australia cohort, testing the hypothesis that they would reflect the early hemodynamic consequences of AS and be associated with increased mortality in this setting.

METHODS

The first record for patients ≥18 years of age showing hemodynamically significant but nonsevere (mild or moderate) AS (mean pressure gradient ≥ 10 to <40 mm Hg and aortic valve area > 1 cm²) was analyzed. Baseline demographics and echocardiographic variables were compared with those among patients without AS (mean pressure gradient < 10 mm Hg). Mortality linkage data were available for all patients.

RESULTS

Of 78,886 patients with aortic valve mean pressure gradients < 40 mm Hg and aortic valve areas > 1 cm², 13,768 (17%) were identified with nonsevere AS (aortic valve mean pressure gradient 10-40 mm Hg), of whom 57% were men (mean age, 73 ± 13.4 years) with a median follow-up of 3.4 years (interquartile range, 1.7-6.1 years). In unadjusted time-varying coefficient models, nonsevere AS and indexed left atrial volume > 34 mL/m² (hazard ratio [HR], 2.29; 95% CI, 2.03-2.58), E/e' ratio > 14 (HR, 2.27; 95% CI, 2.08-2.49), left ventricular ejection fraction < 50% (HR, 2.82; 95% CI, 2.50-3.19), and tricuspid regurgitation peak velocity > 280 cm/sec (HR, 2.54; 95% CI, 2.30-2.80) were associated with increased mortality hazard at the time of echocardiography. All markers were significant when combined in a multivariate model.

CONCLUSIONS

Indices of elevated left ventricular filling pressure are independently associated with death in patients with nonsevere AS. Risk stratification models incorporating these variables may identify patients at risk for complications, warranting closer surveillance and possibly earlier intervention.

Clinical and echocardiographic predictors of left ventricular remodeling following anterior acute myocardial infarction

OBJECTIVES

Coronary artery disease is the primary cause of death and is responsible for a high number of hospitalizations worldwide. Ventricular remodeling is associated with worse prognosis following ST-segment elevation myocardial infarction (STEMI) and is a risk factor for ventricular dysfunction and heart failure. This study aimed to identify the predictors of ventricular remodeling following STEMI. Additionally, we evaluated the clinical, laboratory, and echocardiographic characteristics of patients with anterior wall STEMI who underwent primary percutaneous intervention in the acute phase and at 6 months after the infarction.

METHODS

This prospective, observational, and longitudinal study included 50 patients with anterior wall STEMI who were admitted to the coronary care unit (CCU) of a tertiary hospital in Brazil between July 2017 and August 2018. During the CCU stay, patients were evaluated daily and underwent echocardiogram within the first three days following STEMI. After six months, the patients underwent clinical evaluation and echocardiogram according to the local protocol.

RESULTS

Differences were noted between those who developed ventricular remodeling and those who did not in the mean±standard deviation levels of creatine phosphokinase MB isoenzyme (CKMB) peak (no remodeling group: 323.7±228.2 U/L; remodeling group: 522.4±201.6 U/L; p=0.008) and the median and interquartile range of E/E' ratio (no remodeling group: 9.20 [8.50-11.25] and remodeling group: 12.60 [10.74-14.40]; p=0.004). This difference was also observed in multivariate logistic regression.

CONCLUSIONS

Diastolic dysfunction and CKMB peak in the acute phase of STEMI can be predictors of ventricular remodeling following STEMI.

Heart failure after myocardial infarction: incidence and predictors

Aims

The aim of the present paper was to provide an up‐to‐date view on epidemiology and risk factors of heart failure (HF) development after myocardial infarction.

Methods and results

Based on literature review, several clinical risk factors and biochemical, genetic, and imaging biomarkers were identified to predict the risk of HF development after myocardial infarction.

Conclusions

Heart failure is still a frequent complication of myocardial infarction. Timely identification of subjects at risk for HF development using a multimodality approach, and early initiation of guideline‐directed HF therapy in these patients, can decrease the HF burden.

Impaired left ventricular global longitudinal strain is associated with elevated left ventricular filling pressure after myocardial infarction

Left ventricular (LV) global longitudinal strain (GLS) has emerged as a significant prognostic marker in patients after myocardial infarction (MI). Although elevated LV filling pressure after MI might alter GLS, direct evidence for this is lacking. This study aimed to clarify the association between GLS and LV filling pressure in a large animal MI model. A total of 104 Yorkshire pigs underwent both echocardiographic and hemodynamic assessments 1-4 wk after induction of large anterior MI. GLS was measured in the apical four-chamber view using a semiautomated speckle-tracking software. LV pressure-volume relationship was invasively measured using a high-fidelity pressure-volume catheter. GLS >-14% was considered impaired. Compared with pigs with LV ejection fraction (LVEF) >40% and preserved GLS (n = 29), those with LVEF >40% and impaired GLS (n = 37) and those with LVEF ≤40% (n = 38) had significantly higher LV end-diastolic pressure (15.5 ± 5.5 vs. 19.7 ± 5.8 and 19.6 ± 6.6 mmHg; P = 0.008 and P = 0.026, respectively) and higher LV mean diastolic pressure (7.1 ± 2.9 vs. 10.4 ± 4.5 and 11.1 ± 5.4 mmHg; P = 0.013 and P = 0.002, respectively). GLS was modestly correlated with τ (r = 0.21, P = 0.039) and slope of LV end-diastolic pressure-volume relationship (r = 0.43, P < 0.001). Impaired GLS was associated with higher LV end-diastolic and mean-diastolic pressures after adjusting for LVEF and baseline characteristics (P = 0.026 and P = 0.001, respectively). Impaired GLS assessed by speckle-tracking echocardiography was associated with elevated LV filling pressure after MI. GLS has an incremental diagnostic value for detecting elevated LV filling pressure and may be particularly useful for evaluating post-MI patients with preserved LVEF.NEW & NOTEWORTHY Strain analysis was performed in 104 pigs after MI, and its relationship to invasive hemodynamic measurements was studied. Impaired longitudinal strain was associated with high ventricular filling pressure independent of LVEF in post-MI setting. Global longitudinal strain is a potential prognostic marker after MI.

Prognostic value of ratio of transmitral early filling velocity to early diastolic strain rate in patients with Type 2 diabetes

AIMS

The ratio of early mitral inflow velocity to global diastolic strain rate (E/e'sr) has recently emerged as a novel measure of left ventricular filling pressure. E/e'sr has in previous studies demonstrated to have good prognostic value in various patient populations. The aim of this study is to investigate the prognostic value of E/e'sr in a large cohort of patients with Type 2 diabetes in relation to cardiovascular morbidity and mortality.

METHODS AND RESULTS

In this prospective study, 848 Type 2 diabetic patients (mean age 63.6 ± 10.3 years, 64.7% male) underwent comprehensive echocardiographic examination including 2D speckle tracking in which E/e'sr along with novel and conventional echocardiographic variables were obtained. During follow-up (median: 4.8 years, interquartile range: 4.0-5.3), 122 (14.1%) met the composite outcome of cardiovascular disease, hospitalization, and mortality. Both E/e'sr and E/e' were significantly associated with the outcome [E/e'sr: hazard ratio (HR) 1.07, 95% confidence interval (CI): 1.05-1.10; P < 0.001, per 0.10 m increase] and (E/e': HR 1.07, 95% CI: 1.05-1.10; P = 0.001, per 1 unit increase). E/e'sr remained an independent predictor after multivariable adjustment for demographical, clinical, and echocardiographic parameters (HR 1.06, 95% CI: 1.01-1.12; P = 0.032, per 10 cm increase). The same was true for E/e' (HR 1.09, 95% CI: 1.04-1.14; P < 0.001, per 1 unit increase). Additionally, E/e'sr provided incremental prognostic information beyond the UK 'Prospective Diabetes Study risk engine' 0.72 (0.68-0.77) vs. 0.74 (0.70-79), P = 0.040.

CONCLUSION

In patients with Type 2 diabetes, E/e'sr provides independent and incremental prognostic information regarding cardiovascular morbidity and mortality.

Noninvasive Echocardiographic Left Ventricular Stroke Work Index Predicts Mortality in Cardiac Intensive Care Unit Patients

BACKGROUND

Reduced left ventricular stroke work index (LVSWI) has been associated with adverse outcomes in several populations of patients with chronic heart disease, but no prior studies have examined this metric in cardiac intensive care unit (CICU) patients. We sought to determine whether a low LVSWI, as measured noninvasively using transthoracic echocardiography, is associated with higher mortality in CICU patients.

METHODS

Using a database of unique Mayo Clinic CICU admissions from 2007 to 2018, we identified patients with LVSWI measured by transthoracic echocardiography within 1 day of CICU admission. Hospital mortality was analyzed using multivariable logistic regression, and 1-year mortality was analyzed using multivariable Cox proportional-hazards analysis, adjusted for left ventricular ejection fraction and known predictors of hospital mortality.

RESULTS

We included 4536 patients with a mean age of 68±14 years (36% women). Admission diagnoses (not mutually exclusive) included acute coronary syndrome in 62%, heart failure in 46%, and cardiogenic shock in 11%. The mean LVSWI was 38±14 g×min/m², and in-hospital mortality occurred in 6% of patients. LVSWI had better discrimination for hospital mortality than left ventricular ejection fraction (P<0.001 by De Long test). Higher LVSWI was associated with lower in-hospital mortality (adjusted odds ratio, 0.72 per 10 g×min/m² higher [95% CI, 0.61-0.84]; P<0.001) and lower 1-year mortality (adjusted hazard ratio, 0.812 per 1 g×min/m² higher [95% CI, 0.759-0.868]; P<0.001). Stepwise decreases in hospital and 1-year mortality were observed with higher LVSWI.

CONCLUSIONS

Low LVSWI, reflecting poor left ventricular systolic and diastolic performance, is associated with increased short-term and long-term mortality among CICU patients. This emphasizes the importance of Doppler transthoracic echocardiography as a predictor of outcomes among critically ill patients. Further study is required to determine whether early interventions to optimize LVSWI can improve outcomes in the CICU setting.

The systolic pulmonary artery pressure and the E/e' ratio decrease after septoplasty in patients with grade 2 and 3 pure nasal septal deviation

INTRODUCTION

Nasal septal deviation may contribute to a wide range of symptoms including nasal obstruction, headache, increased secretion, crusting, mucosal damage, and loss of taste and smell. Excessive increase in the respiratory resistance, as seen in nasal septal deviation, results in reduced lung ventilation, thereby potentially leading to hypoxia, hypercapnia, pulmonary vasoconstriction. The deformities in the nasal cavity can be associated with major respiratory and circulatory system diseases.

OBJECTIVE

To investigate cardiovascular effects of septoplasty by comparing pre- and postoperative transthoracic echocardiography findings in nasal septal deviation patients undergoing septoplasty.

METHODS

The prospective study included 35 patients with moderate and severe nasal septal deviation (mean age, 23.91±7.01) who underwent septoplasty. The Turkish version of the nasal obstruction symptom evaluation, NOSE questionnaire, was administered to each participant both pre- and postoperatively in order to assess their views on the severity of nasal septal deviation, the effect of nasal obstruction, and the effectiveness of surgical outcomes. A comprehensive transthoracic echocardiography examination was performed both preoperatively and at three months postoperatively for each patient and the findings were compared among patients.

RESULTS

Mean preoperative NOSE score was 17.34±1.62 and the mean postoperative score was 2.62±1.68 (p=0.00). Mean preoperative systolic pulmonary artery pressure value was 22.34±4.31mmHg and postoperative value was 18.90±3.77mmHg (p=0.00). Mean E/e' ratio was 5.33±1.00 preoperatively and was 5.01±0.90 postoperatively (p=0.01). The NOSE scores, systolic pulmonary artery pressure values, and the E/e' ratios decreased significantly after septoplasty (p<0.05 for all), whereas no significant difference was found in other transthoracic echocardiography parameters (p>0.05).

CONCLUSION

The decrease in NOSE scores following septoplasty indicated that the satisfaction levels of the patients were increased. Upper airway obstruction secondary to nasal septal deviation may be a cardiovascular risk factor and may affect transthoracic echocardiography measurements. Moreover, the significant decrease in the systolic pulmonary artery pressure value and E/e's ratio following septoplasty indicated that negative echocardiographic findings may be prevented by this surgery.

Additional roles of diastolic parameters in the diagnosis of obstructive coronary artery disease

BACKGROUND

A recent guideline emphasizes the role of four indicators, including annular e´ velocity, E/e´, left atrial (LA) size, and peak tricuspid regurgitation (TR) velocity, in the assessment of left ventricular (LV) diastolic dysfunction. This study was performed to determine the relationships among these four parameters and obstructive coronary artery disease (CAD).

METHODS

The study data were obtained from a nation-wide registry, composed of 1307 patients (age, 60.4 ± 10.8 years; 964 women) with normal LV ejection fraction (LVEF) who underwent invasive coronary angiography in the suspicion of CAD. Septal e´, E/e´, LA dimension (LAd), and TR velocity were assessed by transthoracic echocardiography.

RESULTS

Compared with patients without obstructive CAD, those with obstructive CAD showed changes in diastolic parameters indicating more progressed LV diastolic dysfunction in univariate analyses. In multiple logistic regression analysis, low septal e´ velocity (<7 cm/s) was identified as an independent risk factor associated with obstructive CAD (odd ratio, 1.91; 95% confidence interval, 1.08-3.36; P = 0.026). Receiver-operating characteristic curve analysis showed that septal e´ velocity had the most powerful value in the detection of obstructive CAD than the other three diastolic parameters (P < 0.01 for each comparison). Septal e´ velocity significantly increased diagnostic value of treadmill exercise test (TET) in the detection of obstructive CAD (P < 0.001 for integrated discrimination improvement index).

CONCLUSIONS

Among the four diastolic parameters, septal e´ velocity had the most powerful relationship with obstructive CAD in stable patients with normal LVEF. The addition of septal e´ velocity could improve the diagnostic value of TET.

Prognostic Significance of a Combination of QRS Score and E/e' Obtained 2 Weeks After the Onset of ST-Elevation Myocardial Infarction

BACKGROUND

The early mitral inflow velocity to mitral early diastolic velocity ratio (E/e') and electrocardiogram (ECG) determination of QRS score are useful for risk stratification in patients with ST-elevation myocardial infarction (STEMI).Methods and Results:In this study, 420 consecutive patients (357 male; mean [±SD] age 63.6±12.2 years) with first-time STEMI who successfully underwent primary percutaneous coronary intervention within 12 h of symptom onset were followed-up for 5 years (median follow-up 67 months). Echocardiography, ECG, and blood samples were obtained 2 weeks after onset. Infarct size was estimated by the QRS score after 2 weeks (QRS-2wks) and creatine phosphokinase-MB concentrations (peak and area under the curve). The primary endpoint was death from cardiac causes or rehospitalization for heart failure (HF). During follow-up, 21 patients died of cardiac causes and 62 had HF. Multivariate Cox proportional hazard analysis showed that mean E/e' (hazard ratio [HR] 1.152; 95% confidence interval [CI] 1.088-1.215; P<0.0001), QRS-2wks (HR 1.153; 95% CI 1.057-1.254; P<0.0001), and hypertension (HR 1.702; 95% CI 1.040-2.888; P=0.03) were independent predictors of the primary endpoint. Kaplan-Meier curve analysis showed that patients with QRS-2wks >4 and mean E/e' >14 were at an extremely high risk of cardiac death or HF (log rank, χ²=116.3, P<0.0001).

CONCLUSIONS

In patients with STEMI, a combination of QRS-2wks and mean E/e' was a simple but useful predictor of cardiac death and HF.

“Takotsubo effect” in patients with ST segment elevation myocardial infarction

Background

Myocardial infarction can be a trigger of Takotsubo syndrome. We recently characterized imaging features of acute myocardial infarction-induced Takotsubo syndrome (“Takotsubo effect”). In this study, we investigate diagnostic and prognostic implications of Takotsubo effect in patients with anterior wall ST-segment elevation myocardial infarction.

Methods

We enrolled 111 consecutive patients who developed anterior wall ST-segment elevation myocardial infarction and received percutaneous coronary intervention, and studied systolic/diastolic function, hemodynamic consequences, adverse cardiac events, as well as 30-day and five-year outcomes in patients with and without Takotsubo effect.

Results

Patients with Takotsubo effect showed significantly worse average peak systolic longitudinal strain (–9.5 ± 2.6% vs –11.1 ± 3.6%, p = 0.038), left ventricular ejection fraction (38.5 ± 6.8% vs 47.7 ± 8.7%, p = 0.000) and myocardial performance index (0.54 ± 0.17 vs 0.37 ± 0.15, p = 0.000) within 48 h of myocardial infarction. There was no significant difference between the two groups in diastolic ventricular filling pressures, hemodynamic consequences, and 30-day rehospitalization and mortality (Gehan-Breslow-Wilcoxon test: p = 0.157). However, patients with Takotsubo effect developed more major adverse cardiac events (log-rank test: p = 0.019) when tested at the five-year follow-up. Cox regression analysis revealed that age, hypotension, tricuspid annular plane systolic excursion, and Takotsubo effect were independent prediction factors for five-year major adverse cardiac events. The Doppler/tissue Doppler parameter E/e’ correlated with MACE only in patients without Takotsubo effect.

Conclusion

Takotsubo effect secondary to anterior ST-segment elevation myocardial infarction predicts a worse long-term prognosis.

Noninvasive Hemodynamic Assessment of Shock Severity and Mortality Risk Prediction in the Cardiac Intensive Care Unit

OBJECTIVES

This study sought to define the 2-dimensional and Doppler echocardiographic hemodynamics associated with each Society for Cardiovascular Angiography and Interventions (SCAI) stage, and to determine their association with mortality.

BACKGROUND

The SCAI shock stages classification stratifies mortality risk in cardiac intensive care unit (CICU) patients, but the echocardiographic and hemodynamic parameters that define these SCAI shock stages are unknown.

METHODS

Unique CICU patients admitted from 2007 to 2015 who had a transthoracic echocardiogram within 1 day of CICU admission were included. Echocardiographic variables were evaluated as a function of SCAI shock stage. Multivariable logistic regression determined the association between echocardiographic parameters with adjusted hospital mortality.

RESULTS

We included 5,453 patients with a median age of 69.3 years (interquartile range: 58.2 to 79.0 years) (37% women), and a median left ventricular ejection fraction (LVEF) of 50% (interquartile range: 35% to 61%). Higher SCAI shock stages were associated with lower LVEF and worse systemic hemodynamics. Hospital mortality was higher in patients with LVEF <40%, cardiac index <1.8 l/min/m², stroke volume index <35 ml/m², cardiac power output <0.6 W, or medial early mitral valve inflow velocity to early diastolic annular velocity (E/e') ratio >15 (particularly in SCAI shock Stages A to C). After multivariable adjustment, only stroke volume index <35 ml/m² (adjusted odds ratio: 2.0; 95% confidence interval: 1.4 to 3.0; p < 0.001) and E/e' ratio >15 (adjusted odds ratio: 1.52; 95% confidence interval: 1.04 to 2.23; p = 0.03) remained associated with higher hospital mortality.

CONCLUSIONS

Noninvasive 2-dimensional and Doppler echocardiographic parameters correlate with the SCAI shock stages and improve risk stratification for hospital mortality in CICU patients. Low stroke volume index and high E/e' ratio demonstrated the strongest association with hospital mortality.

Contrasting Effects of Inhibition of Phosphodiesterase 3 and 5 on Cardiac Function and Interstitial Fibrosis in Rats With Isoproterenol-Induced Cardiac Dysfunction

Myocardial relaxation and stiffness are influenced by fibrillar collagen content. Cyclic nucleotide signaling regulators have been investigated targeting more effective modulation of collagen deposition during myocardial healing process. To assess the effects of phosphodiesterase type 3 and phosphodiesterase type 5 inhibitors on cardiac function and left ventricular myocardial fibrosis in catecholamine-induced myocardial injury, sildenafil and pimobendan were administered to male Wistar rats 24 hours after isoproterenol injection. Echocardiography and electrocardiogram were performed to assess kinetic and rhythm changes during 45 days of drug administration. At the end of study, type I and type III collagen were measured through immunohistochemistry analysis, and left ventricular pressure was assessed through invasive method. Echocardiography assessment showed increased relative wall thickness at 45 days in pimobendan group with significant diastolic dysfunction and increased collagen I deposition compared with nontreated positive group (3.03 ± 0.31 vs. 2.73 ± 0.28%, P < 0.05). Diastolic pressure correlated positively with type I collagen (r = 0.54, P < 0.05). Type III collagen analysis did not demonstrate difference among the groups. Sildenafil administration attenuated type I collagen deposition (2.15 ± 0.51 vs. positive group, P < 0.05) and suggested to be related to arrhythmic events. Arrhythmic events were not related to the quantity of fibrillar collagen deposition. Although negative modulation of collagen synthesis through cyclic nucleotides signaling have shown promising results, in this study, pimobendan postconditioning resulted in increased collagen type I formation and severe diastolic dysfunction while sildenafil postconditioning reduced collagen type I deposition and attenuated diastolic dysfunction.

E/e' in relation to outcomes in ST-elevation myocardial infarction

BACKGROUND

Myocardial infarction (MI) is a high-risk condition especially when filling pressure is raised, and earlier reports have suggested that E/e' is associated with poor outcome. However, whether E/e' predicts risk better than LVEF, which is the current standard of practice, is not known. We investigated this question in the largest and most rigorous study of MI patients so far.

METHODS AND RESULTS

We studied 660 patients with ST-elevation MI (STEMI) treated with primary percutaneous coronary intervention and related E/e' to short-term mortality (in-hospital death), as well as long-term events at 2 years comprising (a) a composite of MI, stroke, heart failure, and death, and (b) death alone. Short-term models were adjusted for age, sex, and LVEF. Long-term models were adjusted for age, sex, diabetes, revascularization procedure, history of MI, hypertension, renal function, drugs on discharge, and LVEF. Elevated E/e'> 15 indicated higher risk of short-term events (n = 19:7.0% (95% confidence interval 3.4-10.8%) vs. 1.0% (0.3 - 2.3%); adjusted odds ratio 3.7 (1.3-10.5)). While elevated E/e' was also associated with long-term outcomes (n = 103 composite events: 15.9% (11.9% - 21.4%) vs 6.8% (5.2% - 8.7%), P < .001; n = 38 death events: 6.0% (3.9% - 9.5%) vs 2.0% (1.3% - 3.2%), P = .001), E/e' was rendered nonsignificant for long-term outcomes by multivariable adjustment (p = ns for both). LVEF, on the contrary, was a highly significant predictor in the adjusted long-term model.

CONCLUSION

E/e' is associated with poor outcome in STEMI, but LVEF is a stronger predictor of long-term risk.