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Goeddel LA, Grant MC. Preoperative Evaluation and Cardiac Risk Assessment in Vascular Surgery. Anesthesiol Clin 2022; 40:575-585. [PMID: 36328616 DOI: 10.1016/j.anclin.2022.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
We summarize epidemiologic trends, outcomes, and preoperative guidelines for vascular surgery patients from 2010 to 2022. Vascular surgery continues to evolve in technology and engineering to treat a surgical population that suffers from a high prevalence of comorbidities. Preoperative optimization seeks to characterize the burden of disease and to achieve medical control in the timeline available before surgery. Risk assessment, evaluation, optimization, and prediction of major adverse cardiac events is an evolving science where the Vascular Surgery Quality Initiative has made an impact. Ongoing investigation may demonstrate value for preoperative echocardiography, functional capacity, frailty, and mobility assessments.
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Affiliation(s)
- Lee A Goeddel
- Department of Anesthesiology & Critical Care Medicine, Johns Hopkins School of Medicine, Zayed 6208J, 1800 Orleans, Baltimore, MD 21287, USA.
| | - Michael C Grant
- Department of Anesthesiology & Critical Care Medicine, Johns Hopkins School of Medicine, Zayed 6208J, 1800 Orleans, Baltimore, MD 21287, USA
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2
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Goeddel LA, Erlinger S, Murphy Z, Tang O, Bergmann J, Moeller S, Hattab M, Hebbar S, Slowey C, Esfandiary T, Fine D, Faraday N. Association Between Left Ventricular Relative Wall Thickness and Acute Kidney Injury After Noncardiac Surgery. Anesth Analg 2022; 135:605-616. [PMID: 35467553 DOI: 10.1213/ane.0000000000006055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) after major noncardiac surgery is commonly attributed to cardiovascular dysfunction. Identifying novel associations between preoperative cardiovascular markers and kidney injury may guide risk stratification and perioperative intervention. Increased left ventricular relative wall thickness (RWT), routinely measured on echocardiography, is associated with myocardial dysfunction and long-term risk of heart failure in patients with preserved left ventricular ejection fraction (LVEF); however, its relationship to postoperative complications has not been studied. We evaluated the association between preoperative RWT and AKI in high-risk noncardiac surgical patients with preserved LVEF. METHODS Patients ≥18 years of age having major noncardiac surgery (high-risk elective intra-abdominal or noncardiac intrathoracic surgery) between July 1, 2016, and June 30, 2018, who had transthoracic echocardiography in the previous 12 months were eligible. Patients with preoperative creatinine ≥2 mg/dL or reduced LVEF (<50%) were excluded. The association between RWT and AKI, defined as an increase in serum creatinine by 0.3 mg/dL from baseline within 48 hours or by 50% within 7 days after surgery, was assessed using multivariable logistic regression adjusted for preoperative covariates. An additional model adjusted for intraoperative covariates, which are strongly associated with AKI, especially hypotension. RWT was modeled continuously, associating the change in odds of AKI for each 0.1 increase in RWT. RESULTS The study included 1041 patients (mean ± standard deviation [SD] age 62 ± 15 years; 59% female). A total of 145 subjects (13.9%) developed AKI within 7 days. For RWT quartiles 1 through 4, respectively, 20 of 262 (7.6%), 40 of 259 (15.4%), 39 of 263 (14.8%), and 46 of 257 (17.9%) developed AKI. Log-odds and proportion with AKI increased across the observed RWT values. After adjusting for confounders (demographics, American Society of Anesthesiologists [ASA] physical status, comorbidities, baseline creatinine, antihypertensive medications, and left ventricular mass index), each RWT increase of 0.1 was associated with an estimated 26% increased odds of developing AKI (odds ratio [OR]; 95% confidence interval [CI]) of 1.26 (1.09-1.46; P = .002). After adjusting for intraoperative covariates (length of surgery, presence of an arterial line, intraoperative hypotension, crystalloid administration, transfusion, and urine output), RWT remained independently associated with the odds of AKI (OR; 95% CI) of 1.28 (1.13-1.47; P = .001). Increased RWT was also independently associated with hospital length of stay and adjusted hazard ratio (HR [95% CI]) of 0.94 (0.89-0.99; P = .018). CONCLUSIONS Left ventricular RWT is a novel cardiovascular factor associated with AKI within 7 days after high-risk noncardiac surgery among patients with preserved LVEF. Application of this commonly available measurement of risk stratification or perioperative intervention warrants further investigation.
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Affiliation(s)
- Lee A Goeddel
- From the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Samuel Erlinger
- Department of Anesthesiology, Washington University in Saint Louis School of Medicine, St Louis, Missouri
| | - Zachary Murphy
- From the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Olive Tang
- From the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jules Bergmann
- From the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Shaun Moeller
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Mohammad Hattab
- From the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sachinand Hebbar
- From the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Charles Slowey
- From the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Tina Esfandiary
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Derek Fine
- Department of Medicine, Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Nauder Faraday
- From the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Department of Surgery Johns Hopkins University School of Medicine, Baltimore, Maryland.,Department ofMedicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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3
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Sengupta SP, Okwose NC, MacGowan GA, Jakovljevic DG. Peak atrio-ventricular mechanics predicts exercise tolerance in heart failure patients. Int J Cardiol 2022; 359:84-90. [PMID: 35367509 DOI: 10.1016/j.ijcard.2022.03.048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 02/27/2022] [Accepted: 03/23/2022] [Indexed: 12/22/2022]
Abstract
PURPOSE Exercise intolerance is a cardinal symptom of patients with heart failure (HF). We hypothesized that patients with HF with preserved ejection fraction (HFpEF) in comparison with those with reduced ejection fraction (HFrEF) have disproportionate exercise-induced impairment of left atrial (LA) function that may explain the effort intolerance. METHODS Total 40 HFpEF patients, 40 HFrEF patients, and 20 matched healthy controls underwent resting and exercise stress transthoracic echocardiography using modified Bruce protocol with speckle-tracking derived assessments of peak atrial longitudinal strain (PALS) and left ventricular global longitudinal strain (LVGLS). RESULTS In comparison to controls, PALS and LVGLS were reduced in HFpEF and HFrEF patients (P < 0.01); however, the strain magnitudes were significantly lower in HFrEF than in HFpEF (P < 0.01). Both HFpEF and HFrEF showed a 28% and 30% reduction in exercise time in comparison with controls (HFpEF, 363 ± 152, HFrEF 352 ± 91, controls, 505 ± 42 s, P < 0.01) and exercise-related rise in E/E' in HFpEF patients. However, during exercise PALS reduced from resting values by 26% (resting 23.1 ± 4.7 and peak 18.5 ± 3.5, P < 0.01) in HFpEF but only 8% in HFrEF (resting 11.5 ± 1.4 and peak 10.5 ± 1.5, P < 0.01), and remained unchanged in controls (resting 34 ± 1.9 and peak 34.4 ± 1.2, P = 0.4). Regression analysis of the combined data from the HF patients and controls revealed that PALS was independently associated with exercise time such that a 1% reduction in PALS was associated with a 10 s reduction in exercise duration (p < 0.01). PALS at baseline and peak exercise differentiated normal from HF patients. LVGLS at baseline and peak exercise differentiated HFpEF from HFrEF and patients of HFpEF showed abnormality of both PALS and LVGLS. CONCLUSION Although left ventricle and LA strain are lower in HFrEF than HFpEF at rest and exercise compared to healthy controls, patients with HFpEF show more profound deterioration of LA reservoir function with exercise which appears to contribute to exercise intolerance.
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Affiliation(s)
- Shantanu P Sengupta
- Sengupta Hospital and Research Institute, Ravinagar, Nagpur, India; Cardiovascular Research Theme, Translational and Clinical, and Biosciences Research Institutes, Faculty of Medical Sciences, Newcastle University, UK.
| | - Nduka C Okwose
- Cardiovascular Research Theme, Translational and Clinical, and Biosciences Research Institutes, Faculty of Medical Sciences, Newcastle University, UK; Cardiovascular and Lifestyle Medicine, Faculty Research Centre (CSELS), Faculty of Health and Life Sciences, Coventry University, UK
| | - Guy A MacGowan
- Cardiovascular Research Theme, Translational and Clinical, and Biosciences Research Institutes, Faculty of Medical Sciences, Newcastle University, UK
| | - Djordje G Jakovljevic
- Cardiovascular Research Theme, Translational and Clinical, and Biosciences Research Institutes, Faculty of Medical Sciences, Newcastle University, UK; Cardiovascular and Lifestyle Medicine, Faculty Research Centre (CSELS), Faculty of Health and Life Sciences, Coventry University, UK
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Rodrigues JCL, Rooms B, Hyde K, Rohan S, Nightingale AK, Paton J, Manghat N, Bucciarelli-Ducci C, Hamilton M, Zhang H, MacIver DH. The corrected left ventricular ejection fraction: a potential new measure of ventricular function. Int J Cardiovasc Imaging 2021; 37:1987-1997. [PMID: 33616783 DOI: 10.1007/s10554-021-02193-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 02/12/2021] [Indexed: 12/28/2022]
Abstract
Left ventricular ejection fraction (LVEF) has a limited role in predicting outlook in heart diseases including heart failure. We quantified the independent geometric factors that determine LVEF using cardiac MRI and sought to provide an improved measure of ventricular function by adjusting for such independent variables. A mathematical model was used to analyse the independent effects of structural variables and myocardial shortening on LVEF. These results informed analysis of cardiac MRI data from 183 patients (53 idiopathic dilated cardiomyopathy (DCM), 36 amyloidosis, 55 hypertensives and 39 healthy controls). Left ventricular volumes, LVEF, wall thickness, internal dimensions and longitudinal and midwall fractional shortening were measured. The modelling demonstrated LVEF increased in a curvilinear manner with increasing mFS and longitudinal shortening and wall thickness but decreased with increasing internal diameter. Controls in the clinical cohort had a mean LVEF 64 ± 7%, hypertensives 66 ± 8%, amyloid 49 ± 16% and DCM 30 ± 11%. The mean end-diastolic wall thickness in controls was 8 ± 1 mm, DCM 8 ± 1 mm, hypertensives 11 ± 3 mm and amyloid 14 ± 3 mm, P < 0.0001). LVEF correlated with absolute wall thickening relative to ventricular size (R2 = 0.766). A regression equation was derived from raw MRI data (R2 = 0.856) and used to 'correct' LVEF (EFc) by adjusting the wall thickness and ventricular size to the mean of the control group. Improved quantification of the effects of geometric changes and strain significantly enhances understanding the myocardial mechanics. The EFc resulted in reclassification of a 'ventricular function' in some individuals and may provide an improved measure of myocardial performance especially in thick-walled, low-volume ventricles.
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Affiliation(s)
- Jonathan Carl Luis Rodrigues
- NIHR Bristol Cardiovascular Biomedical Research Centre, Cardiac Magnetic Resonance Department, Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust, Bristol, UK.,Department of Radiology, Royal United Hospital Bath NHS Foundation Trust, Bath, UK
| | - Benjamin Rooms
- Medical School, Faculty of Medicine and Dentistry, University of Bristol, Bristol, UK
| | - Katie Hyde
- Medical School, Faculty of Medicine and Dentistry, University of Bristol, Bristol, UK
| | - Stephen Rohan
- Medical School, Faculty of Medicine and Dentistry, University of Bristol, Bristol, UK
| | - Angus K Nightingale
- CardioNomics Research Group, Clinical Research and Imaging Centre, Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Julian Paton
- CardioNomics Research Group, Clinical Research and Imaging Centre, Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust, Bristol, UK.,Faculty of Medicine and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Nathan Manghat
- Department of Radiology, Bristol Royal Infirmary, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Chiara Bucciarelli-Ducci
- NIHR Bristol Cardiovascular Biomedical Research Centre, Cardiac Magnetic Resonance Department, Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Mark Hamilton
- Department of Radiology, Bristol Royal Infirmary, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Henggui Zhang
- Biological Physics Group, School of Physics and Astronomy, University of Manchester, Manchester, UK
| | - David H MacIver
- Biological Physics Group, School of Physics and Astronomy, University of Manchester, Manchester, UK. .,Department of Cardiology, Musgrove Park Hospital, Taunton, TA1 5DA, UK.
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Støylen A, Dalen H, Molmen HE. Left ventricular longitudinal shortening: relation to stroke volume and ejection fraction in ageing, blood pressure, body size and gender in the HUNT3 study. Open Heart 2020; 7:openhrt-2020-001243. [PMID: 32978265 PMCID: PMC7520903 DOI: 10.1136/openhrt-2020-001243] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 06/04/2020] [Accepted: 08/07/2020] [Indexed: 01/22/2023] Open
Abstract
Background Aims of this cross-sectional study were to assess: the relative contribution of left ventricular (LV) systolic long-axis shortening (mean mitral annular plane systolic excursion, MAPSE) to stroke volume (SV), the mechanisms for preserved ejection fraction (EF) despite reduced MAPSE, the age dependency of myocardial volume and myocardial systolic compression. Methods Linear dimensions and longitudinal and cross-sectional M-modes were acquired in 1266 individuals without history of heart disease, diabetes or known hypertension from the third wave of the Nord-Trøndelag Health Study. Measurements were entered into a half-ellipsoid LV model for volume calculations, and volumes were related to age, body size (body surface area, BSA), sex and blood pressure (BP). Results Mean BP and proportion with hypertensive values increased with increasing age. MAPSE contributed to 75% of SV, with no relation to age or BSA as both MAPSE and SV decreased with increasing age. LV end-diastolic volume (LVEDV) and SV increased with BSA and decreased with higher age; EF was not related to age or BSA. Myocardial volume increased with higher age and BSA, with an additional gender dependency. The association of age with myocardial volume was not significant when corrected for BP, while both systolic and diastolic BP were significant associated with myocardial volume. Myocardial compression was less than 3%. Conclusions MAPSE contributes approximately 75% and short axis shortening 25% to SV. Both decline with age, but their percentage contributions to SV are unchanged. EF is preserved by the simultaneous decrease in LVEDV and SV. Myocardial volume is positively associated with age, but this is only related to higher BP, which may have implications for BP treatment in ageing. The myocardium is near incompressible.
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Affiliation(s)
- Asbjørn Støylen
- Faculty of Medicine, Dept of Circulation and Medical Imaging, NTNU, Norwegian University of Science and Technology, Trondheim, Norway .,Cardiology, St. Olav University Hospital, Trondheim, Norway
| | - Håvard Dalen
- Faculty of Medicine, Dept of Circulation and Medical Imaging, NTNU, Norwegian University of Science and Technology, Trondheim, Norway.,Cardiology, St. Olav University Hospital, Trondheim, Norway.,MI Lab and Department of Circulation and Medical Imaging, NTNU, Trondheim, Norway.,Cardiology, Levanger Hospital, Levanger, Norway
| | - Harald Edvard Molmen
- Asgardstrand General Practice, Horten, Norway.,Division of Medicine, Department of Endocrinology, Morbid Obesity Centre, Vestfold Hospital Trust, Tonsberg, Norway
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Ben-Shoshan J, Overtchook P, Buithieu J, Mousavi N, Martucci G, Spaziano M, de Varennes B, Lachapelle K, Brophy J, Modine T, Baumbach A, Maisano F, Prendergast B, Tamburino C, Windecker S, Piazza N. Predictors of Outcomes Following Transcatheter Edge-to-Edge Mitral Valve Repair. JACC Cardiovasc Interv 2020; 13:1733-1748. [DOI: 10.1016/j.jcin.2020.03.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 03/18/2020] [Accepted: 03/19/2020] [Indexed: 01/20/2023]
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7
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Milani P, Dispenzieri A, Scott CG, Gertz MA, Perlini S, Mussinelli R, Lacy MQ, Buadi FK, Kumar S, Maurer MS, Merlini G, Hayman SR, Leung N, Dingli D, Klarich KW, Lust JA, Lin Y, Kapoor P, Go RS, Pellikka PA, Hwa YL, Zeldenrust SR, Kyle RA, Rajkumar SV, Grogan M. Independent Prognostic Value of Stroke Volume Index in Patients With Immunoglobulin Light Chain Amyloidosis. Circ Cardiovasc Imaging 2019; 11:e006588. [PMID: 29752392 DOI: 10.1161/circimaging.117.006588] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 03/27/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Heart involvement is the most important prognostic determinant in AL amyloidosis patients. Echocardiography is a cornerstone for the diagnosis and provides important prognostic information. METHODS AND RESULTS We studied 754 patients with AL amyloidosis who underwent echocardiographic assessment at the Mayo Clinic, including a Doppler-derived measurement of stroke volume (SV) within 30 days of their diagnosis to explore the prognostic role of echocardiographic variables in the context of a well-established soluble cardiac biomarker staging system. Reproducibility of SV, myocardial contraction fraction, and left ventricular strain was assessed in a separate, yet comparable, study cohort of 150 patients from the Pavia Amyloidosis Center. The echocardiographic measures most predictive for overall survival were SV index <33 mL/min, myocardial contraction fraction <34%, and cardiac index <2.4 L/min/m2 with respective hazard ratios (95% confidence intervals) of 2.95 (2.37-3.66), 2.36 (1.96-2.85), and 2.32 (1.91-2.80). For the subset that had left ventricular strain performed, the prognostic cut point was -14% (hazard ratios, 2.70; 95% confidence intervals, 1.84-3.96). Each parameter was independent of systolic blood pressure, Mayo staging system (NT-proBNP [N-terminal pro-B-type natriuretic peptide] and troponin), and ejection fraction on multivariable analysis. Simple predictive models for survival, including biomarker staging along with SV index or left ventricular strain, were generated. CONCLUSIONS SV index prognostic performance was similar to left ventricular strain in predicting survival in AL amyloidosis, independently of biomarker staging. Because SV index is routinely calculated and widely available, it could serve as the preferred echocardiographic measure to predict outcomes in AL amyloidosis patients.
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Affiliation(s)
- Paolo Milani
- Division of Hematology, Department of Internal Medicine (P.M., A.D., M.A.G., M.Q.L., F.K.B., S.K., S.R.H., N.L., D.D., J.A.L. Y.L., P.K., R.S.G., Y.L.H., S.R.Z., R.A.K., S.V.R.).,Mayo Clinic, Rochester, MN. Amyloidosis Research and Treatment Center, Fondazione IRCCS Policlinico San Matteo, and Department of Molecular Medicine, University of Pavia, Italy (P.M., S.P., R.M., G.M.)
| | - Angela Dispenzieri
- Division of Hematology, Department of Internal Medicine (P.M., A.D., M.A.G., M.Q.L., F.K.B., S.K., S.R.H., N.L., D.D., J.A.L. Y.L., P.K., R.S.G., Y.L.H., S.R.Z., R.A.K., S.V.R.)
| | | | - Morie A Gertz
- Division of Hematology, Department of Internal Medicine (P.M., A.D., M.A.G., M.Q.L., F.K.B., S.K., S.R.H., N.L., D.D., J.A.L. Y.L., P.K., R.S.G., Y.L.H., S.R.Z., R.A.K., S.V.R.)
| | - Stefano Perlini
- Mayo Clinic, Rochester, MN. Amyloidosis Research and Treatment Center, Fondazione IRCCS Policlinico San Matteo, and Department of Molecular Medicine, University of Pavia, Italy (P.M., S.P., R.M., G.M.).,Clinica Medica 2, Fondazione IRCCS Policlinico San Matteo, Department of Internal Medicine, University of Pavia, Italy (S.P., R.M.)
| | - Roberta Mussinelli
- Mayo Clinic, Rochester, MN. Amyloidosis Research and Treatment Center, Fondazione IRCCS Policlinico San Matteo, and Department of Molecular Medicine, University of Pavia, Italy (P.M., S.P., R.M., G.M.).,Clinica Medica 2, Fondazione IRCCS Policlinico San Matteo, Department of Internal Medicine, University of Pavia, Italy (S.P., R.M.)
| | - Martha Q Lacy
- Division of Hematology, Department of Internal Medicine (P.M., A.D., M.A.G., M.Q.L., F.K.B., S.K., S.R.H., N.L., D.D., J.A.L. Y.L., P.K., R.S.G., Y.L.H., S.R.Z., R.A.K., S.V.R.)
| | - Francis K Buadi
- Division of Hematology, Department of Internal Medicine (P.M., A.D., M.A.G., M.Q.L., F.K.B., S.K., S.R.H., N.L., D.D., J.A.L. Y.L., P.K., R.S.G., Y.L.H., S.R.Z., R.A.K., S.V.R.)
| | - Shaji Kumar
- Division of Hematology, Department of Internal Medicine (P.M., A.D., M.A.G., M.Q.L., F.K.B., S.K., S.R.H., N.L., D.D., J.A.L. Y.L., P.K., R.S.G., Y.L.H., S.R.Z., R.A.K., S.V.R.)
| | - Mathew S Maurer
- Clinical Cardiovascular Research Laboratory for the Elderly, Columbia University Medical Center, Allen Hospital of New York Presbyterian Hospital (M.S.M.)
| | - Giampaolo Merlini
- Department of Cardiovascular Medicine (K.W.K., P.A.P., M.G.).,Mayo Clinic, Rochester, MN. Amyloidosis Research and Treatment Center, Fondazione IRCCS Policlinico San Matteo, and Department of Molecular Medicine, University of Pavia, Italy (P.M., S.P., R.M., G.M.)
| | - Suzanne R Hayman
- Division of Hematology, Department of Internal Medicine (P.M., A.D., M.A.G., M.Q.L., F.K.B., S.K., S.R.H., N.L., D.D., J.A.L. Y.L., P.K., R.S.G., Y.L.H., S.R.Z., R.A.K., S.V.R.)
| | - Nelson Leung
- Division of Hematology, Department of Internal Medicine (P.M., A.D., M.A.G., M.Q.L., F.K.B., S.K., S.R.H., N.L., D.D., J.A.L. Y.L., P.K., R.S.G., Y.L.H., S.R.Z., R.A.K., S.V.R.)
| | - David Dingli
- Division of Hematology, Department of Internal Medicine (P.M., A.D., M.A.G., M.Q.L., F.K.B., S.K., S.R.H., N.L., D.D., J.A.L. Y.L., P.K., R.S.G., Y.L.H., S.R.Z., R.A.K., S.V.R.)
| | - Kyle W Klarich
- Department of Cardiovascular Medicine (K.W.K., P.A.P., M.G.)
| | - John A Lust
- Division of Hematology, Department of Internal Medicine (P.M., A.D., M.A.G., M.Q.L., F.K.B., S.K., S.R.H., N.L., D.D., J.A.L. Y.L., P.K., R.S.G., Y.L.H., S.R.Z., R.A.K., S.V.R.)
| | - Yi Lin
- Division of Hematology, Department of Internal Medicine (P.M., A.D., M.A.G., M.Q.L., F.K.B., S.K., S.R.H., N.L., D.D., J.A.L. Y.L., P.K., R.S.G., Y.L.H., S.R.Z., R.A.K., S.V.R.)
| | - Prashant Kapoor
- Division of Hematology, Department of Internal Medicine (P.M., A.D., M.A.G., M.Q.L., F.K.B., S.K., S.R.H., N.L., D.D., J.A.L. Y.L., P.K., R.S.G., Y.L.H., S.R.Z., R.A.K., S.V.R.)
| | - Ronald S Go
- Division of Hematology, Department of Internal Medicine (P.M., A.D., M.A.G., M.Q.L., F.K.B., S.K., S.R.H., N.L., D.D., J.A.L. Y.L., P.K., R.S.G., Y.L.H., S.R.Z., R.A.K., S.V.R.)
| | | | - Yi L Hwa
- Division of Hematology, Department of Internal Medicine (P.M., A.D., M.A.G., M.Q.L., F.K.B., S.K., S.R.H., N.L., D.D., J.A.L. Y.L., P.K., R.S.G., Y.L.H., S.R.Z., R.A.K., S.V.R.)
| | - Stephen R Zeldenrust
- Division of Hematology, Department of Internal Medicine (P.M., A.D., M.A.G., M.Q.L., F.K.B., S.K., S.R.H., N.L., D.D., J.A.L. Y.L., P.K., R.S.G., Y.L.H., S.R.Z., R.A.K., S.V.R.)
| | - Robert A Kyle
- Division of Hematology, Department of Internal Medicine (P.M., A.D., M.A.G., M.Q.L., F.K.B., S.K., S.R.H., N.L., D.D., J.A.L. Y.L., P.K., R.S.G., Y.L.H., S.R.Z., R.A.K., S.V.R.)
| | - S Vincent Rajkumar
- Division of Hematology, Department of Internal Medicine (P.M., A.D., M.A.G., M.Q.L., F.K.B., S.K., S.R.H., N.L., D.D., J.A.L. Y.L., P.K., R.S.G., Y.L.H., S.R.Z., R.A.K., S.V.R.)
| | - Martha Grogan
- Department of Cardiovascular Medicine (K.W.K., P.A.P., M.G.)
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Tahir UA, Doros G, Kim JS, Connors LH, Seldin DC, Sam F. Predictors of Mortality in Light Chain Cardiac Amyloidosis with Heart Failure. Sci Rep 2019; 9:8552. [PMID: 31189919 PMCID: PMC6561903 DOI: 10.1038/s41598-019-44912-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 05/28/2019] [Indexed: 01/20/2023] Open
Abstract
Cardiac involvement in systemic amyloidosis (AL) occurs in ~50% of all AL patients. However once symptomatic heart failure develops, therapeutic options are limited thereby conferring a poor overall prognosis. The median survival is <6 months when AL patients are untreated for the underlying plasma cell dyscrasia. We thus sought to identify risk factors of increased mortality in treatment-naïve, AL cardiac amyloidosis with heart failure. Patients with biopsy-proven AL cardiac amyloid, who presented with heart failure and did not received prior AL treatment, were enrolled between 2004–2014, at the initial visit to the Amyloidosis Center at Boston University Medical Center. Routine laboratory tests, physical examination and echocardiography data were collected. There were 165 predominantly white (76.4%), and male (61%) patients, with a mean age of 61.6 ± 9.5 years. Median survival was 10.9 months (95% CI 6.2–14.7). By multivariate analysis increased relative wall thickness (RWT) [HR 6.70; 95% CI 2.45–18.30), older age (HR 1.04; 95% CI 1.01–1.06), higher New York Heart Association (NYHA) functional class (HR 1.50; 95% CI 1.02–2.2), log brain natriuretic peptide (BNP) levels (HR 1.45; 95% CI 1.15–1.81) and C-reactive protein (CRP) levels (HR 1.02; 95% CI 1.00–1.04) were significant predictors for increased mortality. In conclusion, in treatment-naïve, AL cardiac amyloidosis patients with heart failure symptoms who lack these high-risk features may have a better outcome. These findings might allow for better risk stratification although outcomes are still poor.
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Affiliation(s)
- Usman A Tahir
- Evans Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, USA
| | - Gheorghe Doros
- Department of Biostatistics, Boston University School of Public Health, Boston, USA
| | - John S Kim
- Evans Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, USA
| | - Lawreen H Connors
- Alan and Sandra Gerry Amyloid Research Laboratory in the Amyloidosis Center, Boston University School of Medicine, Boston, USA
| | - David C Seldin
- Evans Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, USA.,Alan and Sandra Gerry Amyloid Research Laboratory in the Amyloidosis Center, Boston University School of Medicine, Boston, USA
| | - Flora Sam
- Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, USA. .,Cardiovascular Section, Boston University School of Medicine, Boston, USA. .,Evans Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, USA.
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9
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Cesari M, Frigo AC, Tonon M, Angeli P. Cardiovascular predictors of death in patients with cirrhosis. Hepatology 2018; 68:215-223. [PMID: 28902431 DOI: 10.1002/hep.29520] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 08/25/2017] [Accepted: 09/07/2017] [Indexed: 12/18/2022]
Abstract
UNLABELLED Cirrhotic cardiomyopathy is associated with poor outcomes in patients with cirrhosis. We investigated if subclinical cardiac morphologic and functional modifications can influence survival in patients with cirrhosis during follow-up. A series of patients with cirrhosis without cardiovascular or pulmonary disease underwent standard and tissue Doppler echocardiography to assess left ventricular geometry, systolic/diastolic function, and the main haemodynamic parameters. After baseline evaluation 115 patients with cirrhosis were followed up for at least 6 years. During follow-up 54 patients died (47%). On univariate analysis, age, body surface area (BSA), Model for End-Stage Liver Disease (MELD), mean arterial pressure, heart rate, cardiac index, systemic vascular resistance index, and the ratio of transmitral Doppler early filling velocity to tissue Doppler early diastolic mitral annular velocity (E/è) were associated with increased risk of death. In a Cox hazard regression analysis including these factors and other hypothesized important factors (but not MELD), increased age (P = 0.04) and left atrial dimension (P = 0.005) and lower BSA (P = 0.03) were the strongest predictors of death. When MELD was included in the analysis, the main predictors were MELD, age, and BSA. When multivariate analysis was performed incorporating only cardiovascular parameters, increased E/è (P = 0.003) and heart rate (P = 0.03) and reduced mean blood pressure (P = 0.01) were significantly associated with poor prognosis. CONCLUSION In a large cohort of patients with cirrhosis and after a long follow-up, MELD, age, and BSA were the main predictors of death; among cardiovascular parameters, left atrium enlargement, increased heart rate and E/è, and reduced mean blood pressure were independent predictors of death. (Hepatology 2018).
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Affiliation(s)
- Maurizio Cesari
- Clinica dell'Ipertensione, Department of Medicine, University of Padua, Padua, Italy
| | - Anna Chiara Frigo
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Marta Tonon
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine, University of Padua, Padua, Italy
| | - Paolo Angeli
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine, University of Padua, Padua, Italy
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10
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Hoffmann S, Böhme J, Kube C, Pees M, Haufe J, Abraham G. Breed-related differences in age-dependent down-regulation of the β1-adrenoceptor and adenylate cyclase activity in atrial and ventricular myocardium of Cröllwitzer ("wild-type") turkeys. Poult Sci 2018; 97:1041-1049. [PMID: 29253207 DOI: 10.3382/ps/pex362] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 11/09/2017] [Indexed: 11/20/2022] Open
Abstract
In conventional meat-type (British United Turkey (B.U.T.) Big 6) turkey hearts, it has been shown that all cardiac chambers exhibit down-regulation of the β1-adrenoceptors (β1-AR) and concomitantly cAMP accumulation with increasing age regardless of sex. In this study we proved the hypothesis that breed differences exist in age-dependent alterations in the β1-AR system. Right (RA) and left (LA) atrial as well as right (RV) and left (LV) ventricular tissues were collected from male and female Cröllwitzer "wild-type" turkey poults of increasing age (6 wk, 12 wk, 16 wk, 21 wk). The β1-AR density and function were quantified by (-)-[125I]-iodocyanopindolol (ICYP) radioligand binding analysis in cell membranes from 4 cardiac chambers. Basal and stimulated cAMP production was determined as indicator of the receptor function. Wild-type turkeys showed significantly higher heart to body weight ratio than the meat-type B.U.T. Big 6 turkeys. In both sexes of Cröllwitzer turkey hearts, the β1-AR density decreased with age but significance was reached in male cardiac chambers. The receptor affinity (KD) and subtype distribution were not altered. Sex had no effect on age-related decrease in receptor density but had an effect on adenylate cyclase (AC) activity and subsequently cAMP production. In male Cröllwitzer turkey hearts of all ages, cAMP remained at same level, whereas this was even increased in female cardiac chambers. Thus, breed affected age-related receptor-, G-protein and AC-stimulated cAMP formation in normal ventricles and atria, with females exhibiting pronounced increase with age. This suggests that the receptor signaling in wild-type turkey hearts is not as blunted as in hearts of meat-type turkey poults in which stressful farming conditions and fast growing lead to receptor down-regulation.
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Affiliation(s)
- Sandra Hoffmann
- Institute of Pharmacology, Pharmacy and Toxicology, Faculty of Veterinary Medicine, University of Leipzig, D-04103 Leipzig, Germany
| | - Julia Böhme
- Clinic for Birds and Reptiles, Faculty of Veterinary Medicine, University of Leipzig, D-04103 Leipzig, Germany
| | - Christian Kube
- Clinic for Birds and Reptiles, Faculty of Veterinary Medicine, University of Leipzig, D-04103 Leipzig, Germany
| | - Michael Pees
- Clinic for Birds and Reptiles, Faculty of Veterinary Medicine, University of Leipzig, D-04103 Leipzig, Germany
| | - Jörg Haufe
- GLU mbH, Handwerkerstraße 24d, D-15366 Hoppegarten, Germany
| | - Getu Abraham
- Institute of Pharmacology, Pharmacy and Toxicology, Faculty of Veterinary Medicine, University of Leipzig, D-04103 Leipzig, Germany
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11
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Kresge HA, Khan OA, Wagener MA, Liu D, Terry JG, Nair S, Cambronero FE, Gifford KA, Osborn KE, Hohman TJ, Pechman KR, Bell SP, Wang TJ, Carr JJ, Jefferson AL. Subclinical Compromise in Cardiac Strain Relates to Lower Cognitive Performances in Older Adults. J Am Heart Assoc 2018; 7:JAHA.117.007562. [PMID: 29440034 PMCID: PMC5850190 DOI: 10.1161/jaha.117.007562] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Global longitudinal strain (GLS), reflecting total shortening of the myocardium during the cardiac cycle, has emerged as a more precise myocardial function measure than left ventricular ejection fraction (LVEF). Longitudinal strain may be selectively affected in subclinical heart disease, even in the presence of normal LVEF. This study examines subclinical cardiac dysfunction, assessed by GLS and LVEF, and cognition among older adults. METHODS AND RESULTS Vanderbilt Memory and Aging Project participants who were free of clinical dementia, stroke, and heart failure (n=318, 73±7 years, 58% male) completed neuropsychological assessment and cardiac magnetic resonance to quantify GLS and LVEF. Linear regression models related GLS and LVEF to neuropsychological performances, adjusting for age, sex, race/ethnicity, education, Framingham Stroke Risk Profile, cognitive diagnosis, and APOE*ε4 status. Models were repeated with a cardiac×cognitive diagnosis interaction term. Compromised GLS (reflected by higher values) related to worse naming (β=-0.07, P=0.04), visuospatial immediate recall (β=-0.83, P=0.03), visuospatial delayed recall (β=-0.22, P=0.03), and verbal delayed recall (β=-0.11, P=0.007). LVEF did not relate to worse performance on any measure (P>0.18). No diagnostic interactions were observed. CONCLUSIONS Our study results are among the first to suggest that compromised GLS relates to worse episodic memory and language performance among older adults who are free of clinical dementia, stroke, and heart failure. Subclinical cardiac dysfunction may correlate with cognitive health in late life, even when LVEF remains normal. The results add to growing evidence that GLS may be a more sensitive and preferred method for quantifying subclinical changes in cardiac function.
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Affiliation(s)
- Hailey A Kresge
- Department of Neurology, Vanderbilt Memory & Alzheimer's Center Vanderbilt University Medical Center, Nashville, TN
| | - Omair A Khan
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Madison A Wagener
- Department of Neurology, Vanderbilt Memory & Alzheimer's Center Vanderbilt University Medical Center, Nashville, TN
- Department of Psychology, Vanderbilt University, Nashville, TN
| | - Dandan Liu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - James G Terry
- Radiology& Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN
| | - Sangeeta Nair
- Radiology& Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN
| | - Francis E Cambronero
- Department of Neurology, Vanderbilt Memory & Alzheimer's Center Vanderbilt University Medical Center, Nashville, TN
| | - Katherine A Gifford
- Department of Neurology, Vanderbilt Memory & Alzheimer's Center Vanderbilt University Medical Center, Nashville, TN
| | - Katie E Osborn
- Department of Neurology, Vanderbilt Memory & Alzheimer's Center Vanderbilt University Medical Center, Nashville, TN
| | - Timothy J Hohman
- Department of Neurology, Vanderbilt Memory & Alzheimer's Center Vanderbilt University Medical Center, Nashville, TN
| | - Kimberly R Pechman
- Department of Neurology, Vanderbilt Memory & Alzheimer's Center Vanderbilt University Medical Center, Nashville, TN
| | - Susan P Bell
- Department of Neurology, Vanderbilt Memory & Alzheimer's Center Vanderbilt University Medical Center, Nashville, TN
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Division of General Internal Medicine, Department of Medicine, Center for Quality Aging, Vanderbilt University Medical Center, Nashville, TN
| | - Thomas J Wang
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - John Jeffrey Carr
- Radiology& Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Angela L Jefferson
- Department of Neurology, Vanderbilt Memory & Alzheimer's Center Vanderbilt University Medical Center, Nashville, TN
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
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12
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Rodrigues JCL, Rohan S, Dastidar AG, Trickey A, Szantho G, Ratcliffe LEK, Burchell AE, Hart EC, Bucciarelli-Ducci C, Hamilton MCK, Nightingale AK, Paton JFR, Manghat NE, MacIver DH. The Relationship Between Left Ventricular Wall Thickness, Myocardial Shortening, and Ejection Fraction in Hypertensive Heart Disease: Insights From Cardiac Magnetic Resonance Imaging. J Clin Hypertens (Greenwich) 2016; 18:1119-1127. [PMID: 27316563 DOI: 10.1111/jch.12849] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 04/11/2016] [Accepted: 04/13/2016] [Indexed: 12/13/2022]
Abstract
Hypertensive heart disease is often associated with a preserved left ventricular ejection fraction despite impaired myocardial shortening. The authors investigated this paradox in 55 hypertensive patients (52±13 years, 58% male) and 32 age- and sex-matched normotensive control patients (49±11 years, 56% male) who underwent cardiac magnetic resonance imaging at 1.5T. Long-axis shortening (R=0.62), midwall fractional shortening (R=0.68), and radial strain (R=0.48) all decreased (P<.001) as end-diastolic wall thickness increased. However, absolute wall thickening (defined as end-systolic minus end-diastolic wall thickness) was maintained, despite the reduced myocardial shortening. Absolute wall thickening correlated with ejection fraction (R=0.70, P<.0001). In multiple linear regression analysis, increasing wall thickness by 1 mm independently increased ejection fraction by 3.43 percentage points (adjusted β-coefficient: 3.43 [2.60-4.26], P<.0001). Increasing end-diastolic wall thickness augments ejection fraction through preservation of absolute wall thickening. Left ventricular ejection fraction should not be used in patients with hypertensive heart disease without correction for degree of hypertrophy.
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Affiliation(s)
- Jonathan C L Rodrigues
- NIHR Bristol Cardiovascular Biomedical Research Unit, Cardiac Magnetic Resonance Department Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust, Bristol, UK.,School of Physiology, Pharmacology and Neuroscience, Faculty of Biomedical Sciences, University of Bristol, Bristol, UK
| | - Stephen Rohan
- Medical School, Faculty of Medicine and Dentistry, University of Bristol, Bristol, UK
| | - Amardeep Ghosh Dastidar
- NIHR Bristol Cardiovascular Biomedical Research Unit, Cardiac Magnetic Resonance Department Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Adam Trickey
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Gergely Szantho
- NIHR Bristol Cardiovascular Biomedical Research Unit, Cardiac Magnetic Resonance Department Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Laura E K Ratcliffe
- CardioNomics Research Group, Clinical Research and Imaging Centre, Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Amy E Burchell
- CardioNomics Research Group, Clinical Research and Imaging Centre, Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Emma C Hart
- School of Physiology, Pharmacology and Neuroscience, Faculty of Biomedical Sciences, University of Bristol, Bristol, UK.,CardioNomics Research Group, Clinical Research and Imaging Centre, Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Chiara Bucciarelli-Ducci
- NIHR Bristol Cardiovascular Biomedical Research Unit, Cardiac Magnetic Resonance Department Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Mark C K Hamilton
- NIHR Bristol Cardiovascular Biomedical Research Unit, Cardiac Magnetic Resonance Department Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Angus K Nightingale
- CardioNomics Research Group, Clinical Research and Imaging Centre, Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Julian F R Paton
- School of Physiology, Pharmacology and Neuroscience, Faculty of Biomedical Sciences, University of Bristol, Bristol, UK.,CardioNomics Research Group, Clinical Research and Imaging Centre, Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Nathan E Manghat
- NIHR Bristol Cardiovascular Biomedical Research Unit, Cardiac Magnetic Resonance Department Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - David H MacIver
- Medical School, Faculty of Medicine and Dentistry, University of Bristol, Bristol, UK. .,Department of Cardiology, Musgrove Park Hospital, Taunton, UK. .,Biological Physics Group School of Physics & Astronomy, University of Manchester, Manchester, UK.
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13
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Marwick TH, Gillebert TC, Aurigemma G, Chirinos J, Derumeaux G, Galderisi M, Gottdiener J, Haluska B, Ofili E, Segers P, Senior R, Tapp RJ, Zamorano JL. Recommendations on the Use of Echocardiography in Adult Hypertension: A Report from the European Association of Cardiovascular Imaging (EACVI) and the American Society of Echocardiography (ASE). J Am Soc Echocardiogr 2016; 28:727-54. [PMID: 26140936 DOI: 10.1016/j.echo.2015.05.002] [Citation(s) in RCA: 235] [Impact Index Per Article: 29.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Hypertension remains a major contributor to the global burden of disease. The measurement of blood pressure continues to have pitfalls related to both physiological aspects and acute variation. As the left ventricle (LV) remains one of the main target organs of hypertension, and echocardiographic measures of structure and function carry prognostic information in this setting, the development of a consensus position on the use of echocardiography in this setting is important. Recent developments in the assessment of LV hypertrophy and LV systolic and diastolic function have prompted the preparation of this document. The focus of this work is on the cardiovascular responses to hypertension rather than the diagnosis of secondary hypertension. Sections address the pathophysiology of the cardiac and vascular responses to hypertension, measurement of LV mass, geometry, and function, as well as effects of treatment.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Roxy Senior
- Biomedical Research Unit, Imperial College, London, UK; Royal Brompton Hospital, London, UK
| | | | - Jose L Zamorano
- University Hospital Ramón y Cajal, Carretera de Colmenar Km 9.100, Madrid 28034, Spain
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14
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Abstract
OBJECTIVE To investigate the subclinical cardiac morphological and functional modifications in cirrhotic patients according to the stage of liver disease. PATIENTS AND METHODS One hundred and thirteen cirrhotic patients underwent standard Doppler echocardiography and were compared with healthy individuals. Left ventricular (LV) geometry, systolic/diastolic function, and the main hemodynamic parameters were assessed according to current guidelines. RESULTS Cirrhotic patients showed a reduction in the peripheral vascular resistance (PVR), a compensatory hyperdynamic syndrome, and a significant increase in cardiac index (CI), cardiac output (CO), and cardiac work, with a consequent increase in the prevalence of LV hypertrophy and associated diastolic dysfunction (DD). Age (P=0.005) and LV mass index (P=0.03) were the strongest predictors of DD. Even though all the systolic parameters assessed were similar between patients and controls, in patients with refractory ascites, the reduction of the PVR and mean blood pressure was not balanced by a further increase in cardiac work and therefore the CI and CO were supported only by the increase in heart rate. CONCLUSION In cirrhotic patients, DD is strongly related to the increase in LV mass, not related to the stage of the liver disease, and can be correctly detectable only by the use of tissue Doppler imaging. For systolic dysfunction, along with the development and worsening of ascites, CO and CI do not increase further to compensate the continuous reduction of PVR and mean blood pressure, and their maintenance becomes critically dependent on the heart rate, thus suggesting a possible detrimental effect of β-blockers in these patients.
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15
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Prognostic value of depressed midwall systolic function in cardiac light-chain amyloidosis. J Hypertens 2014; 32:1121-31; discussion 1131. [PMID: 24509117 DOI: 10.1097/hjh.0000000000000120] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Cardiac amyloidosis represents an archetypal form of restrictive heart disease, characterized by profound diastolic dysfunction. As ejection fraction is preserved until the late stage of the disease, the majority of patients do fulfill the definition of diastolic heart failure, that is, heart failure with preserved ejection fraction (HFpEF). In another clinical model of HFpEF, that is, pressure-overload hypertrophy, depressed midwall fractional shortening (mFS) has been shown to be a powerful prognostic factor. OBJECTIVE AND METHODS To assess the potential prognostic role of mFS in cardiac light-chain amyloidosis with preserved ejection fraction, we enrolled 221 consecutive untreated patients, in whom a first diagnosis of cardiac light-chain amyloidosis was concluded between 2008 and 2010. HFpEF was present in 181 patients. Patients in whom cardiac involvement was excluded served as controls (n = 121). Prognosis was assessed after a median follow-up of 561 days. RESULTS When compared with light-chain amyloidosis patients without myocardial involvement, cardiac light-chain amyloidosis was characterized by increased wall thickness (P <0.001), reduced end-diastolic left ventricular volumes (P <0.001), and diastolic dysfunction (P <0.001). In patients with preserved ejection fraction, mFS was markedly depressed [10.6% (8.7-13.5) vs. 17.8% (15.9-19.5) P <0.001]. At multivariable analysis, mFS, troponin I, and NT-pro-brain natriuretic peptide were the only significant prognostic determinants (P <0.001), whereas other indices of diastolic (E/E' ratio, transmitral and pulmonary vein flow velocities) and systolic function (tissue Doppler systolic indices, ejection fraction), or the presence/absence of congestive heart failure did not enter the model. CONCLUSION In cardiac light-chain amyloidosis with normal ejection fraction, depressed circumferential mFS, a marker of myocardial contractile dysfunction, is a powerful predictor of survival.
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16
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Abstract
Heart failure with preserved ejection fraction (HFpEF) is common, increasing in prevalence, and causes substantial morbidity and mortality. HFpEF has commonly been viewed as an expression of advanced hypertensive heart disease, with a cardiac phenotype characterized by an increase in wall thickness-to-chamber radius ratio (concentric hypertrophy). However, marked clinical heterogeneity within this syndrome is now well appreciated, and is mirrored in the variability in left ventricular (LV) structure. A review of larger imaging studies from epidemiology and clinical trial cohorts demonstrate that while concentric LV remodeling is common, it is by no means universal and many patients demonstrate normal LV geometry or even an eccentric pattern. More detailed assessment of cardiac structure and function in broader HFpEF populations will be necessary to better define the prevalence, determinants, and prognostic relevance of these measures, which may in turn serve as a foundation to identify pathophysiologically relevant sub-phenotypes within this diverse syndrome.
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Affiliation(s)
- Amil M Shah
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA,
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17
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López-Candales A. Automated Functional Imaging for Assessment of Left Ventricular Mechanics in the Presence of Left Ventricular Hypertrophy. Echocardiography 2013; 31:605-14. [DOI: 10.1111/echo.12441] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Affiliation(s)
- Angel López-Candales
- Division of Cardiovascular Diseases; University of Cincinnati College of Medicine; Cincinnati Ohio
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18
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Novelli GP, Vasapollo B, Gagliardi G, Tiralongo GM, Pisani I, Manfellotto D, Giannini L, Valensise H. Left ventricular midwall mechanics at 24 weeks' gestation in high-risk normotensive pregnant women: relationship to placenta-related complications of pregnancy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2012; 39:430-437. [PMID: 22411543 DOI: 10.1002/uog.10089] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/15/2011] [Indexed: 05/31/2023]
Abstract
OBJECTIVES Most studies during pregnancy have assessed maternal left ventricular (LV) function by load-dependent indices, assessing only chamber function. The aim of this study was to assess afterload-adjusted LV myocardial and chamber systolic function at 24 weeks' gestation and 6 months postpartum in high-risk normotensive pregnant women. METHODS A group of 118 high-risk women with bilateral notching of the uterine arteries underwent an echocardiographic examination to evaluate midwall mechanics (midwall shortening (mFS%) and stress-corrected midwall shortening (SCmFS%)) of the LV at 24 weeks' gestation and 6 months postpartum. Patients were followed until delivery and pregnancies were classified retrospectively as uneventful (uncomplicated outcome) or complicated. A control group of 54 low-risk women with uneventful pregnancies without bilateral notching was also enrolled. RESULTS The pregnancy was uneventful in 74 (62.7%) women, whereas 44 (37.3%) developed complications. At 24 weeks' gestation, mFS% and SCmFS% were greater in the uncomplicated-outcome compared with the complicated-outcome group (25.9 ± 4.8 vs 18.8 ± 5.0%, P < 0.001 and 107.9 ± 18.4 vs 77.9 ± 20.7%, P < 0.001, respectively). At 6 months postpartum, SCmFS% remained greater in the uncomplicated-outcome compared with the complicated-outcome group (100.4 ± 21.6 vs 87.8 ± 19.1, P < 0.05). In the uncomplicated-outcome group, SCmFS% was higher during pregnancy than it was postpartum, whereas in the complicated-outcome group, it was lower during pregnancy than it was postpartum (P < 0.05). CONCLUSIONS Maternal cardiac midwall mechanics appear to be enhanced (SCmFS% increased compared with controls) during pregnancy compared with postpartum in high-risk patients with uncomplicated pregnancy, whereas midwall mechanics are depressed both during pregnancy and postpartum in patients with pregnancy complications.
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Affiliation(s)
- G P Novelli
- Department of Cardiology, San Sebastiano Martire Hospital Frascati, Rome, Italy.
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19
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Park K, Chang SA, Kim HK, Park HE, Na SH, Kim YJ, Sohn DW, Oh BH, Park YB. Normal ranges and physiological changes of midwall fractional shortening in healthy korean population. Korean Circ J 2010; 40:587-92. [PMID: 21217936 PMCID: PMC3008830 DOI: 10.4070/kcj.2010.40.11.587] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2010] [Revised: 05/24/2010] [Accepted: 06/01/2010] [Indexed: 01/19/2023] Open
Abstract
Background and Objectives Left ventricular (LV) midwall fractional shortening (FSmw) reflects systolic function more accurately than LV endocardial fractional shortening (eFS) in patients with increased LV wall thickness. Although the normal reference ranges of LV-FSmw have been suggested in Western population studies, its reference values and age-related physiological changes in Eastern populations remain unknown. Subjects and Methods Conventional echocardiographic parameters, LV-FSmw, and stress-corrected LV-FSmw were assessed in 160 healthy and clinically normal subjects with a mean age of 45 (range, 11-72 years; 104 males, 56 women), all of whom were confirmed to be free of disease, based on laboratory investigations, clinical and physical examination findings and computed tomographic coronary angiographic examinations. Results LV-FSmw was higher in women compared to men. However, the differences were without statistical significance (18.2±1.5% for male gender and 19.4±2.5% for female gender, p=0.07). In contrast to LV-eFS that progressively increased with age (p=0.001), LV-FSmw and stress-corrected LV-FSmw was not influenced by changes in age (p=0.88 and 0.29, respectively). The results remained unchanged when analyses were performed adjusting for gender. Conclusion The results of this study provide normal reference values for LV-FSmw and stress-corrected LV-FSmw and their natural physiological changes with advancing age. These measures can be used as reference standards for research on LV systolic function in the setting of pressure or volume overload.
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Affiliation(s)
- Kyungil Park
- Division of Cardiology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
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20
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van Bemmel T, Holman ER, Gussekloo J, Blauw GJ, Bax JJ, Westendorp RGJ. Low blood pressure in the very old, a consequence of imminent heart failure: the Leiden 85-plus Study. J Hum Hypertens 2008; 23:27-32. [DOI: 10.1038/jhh.2008.79] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Palmiero P, Maiello M, Nanda NC. Is echo-determined left ventricular geometry associated with ventricular filling and midwall shortening in hypertensive ventricular hypertrophy? Echocardiography 2008; 25:20-6. [PMID: 18186776 DOI: 10.1111/j.1540-8175.2007.00564.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND The correlation between left ventricular (LV) geometry, mass, diastolic function, and midwall fractional shortening (MFS) in hypertensive patients with left ventricular hypertrophy (LVH) is not well established owing to limited diffusion of MFS evaluation. The aim of the study was to evaluate this correlation in 1887 consecutive hypertensive patients, all affected by LVH (mean age 66 years, 924 males), with LV ejection fraction (LVEF) >45% for early detection of ventricular dysfunction rather than LVEF and diastolic function impairment. METHODS AND RESULTS All patients underwent M-B mode echocardiography and PW-Doppler evaluation. LV geometry and mass were compared with Doppler-determined mitral flow and tissue velocities. LV geometry was eccentric (E) for 1018 subjects (53.9%) and concentric (C) for 869 (46.1%). There was no difference concerning LV diastolic dysfunction (P: n.s.) between 576 (30.6%) of the ELVH and 368 (19.4%) of the CLVH patients. The following parameters showed significant statistical differences: LV MFS impairment (P < 0.01) between 86 (4.6%) of the ELVH and 177 (9.4%) of the CLVH patients. LV MFS impairment rate was higher in 171 patients without LV diastolic dysfunction (9.1%), than in 92 patients affected (4.9%, P < 0.02). In CLVH patients, a higher prevalence of LV MFS impairment was observed in 143 without LV diastolic dysfunction (7.6%), than in 34 patients affected (1.8%, P < 0.01). In ELVH patients, a lower prevalence of LV MFS impairment was observed in 28 without diastolic dysfunction (1.5%), than in 58 patients affected (3.1%, P < 0,03). CONCLUSION Midwall LV impairment, an independent predictor of cardiac death and morbidity in hypertensive patients, can allow early identification of patients with LV dysfunction even when LVEF or assessment of diastolic function are normal. LV MFS impairment rate is higher in CLVH patients, and even higher when considering only those CLVH patients with no diastolic dysfunction. These results suggest that the ventricular dysfunction with normal LVEF is not always due to diastolic dysfunction, but often to systolic dysfunction as assessed by MFS impairment, an important early sign of ventricular dysfunction in hypertensive patients, even when diastolic function is normal.
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22
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De Marco M, Chinali M, Romano C, Benincasa M, D'Addeo G, D'Agostino L, de Simone G. Increased left ventricular mass in pre-liver transplantation cirrhotic patients. J Cardiovasc Med (Hagerstown) 2008; 9:142-6. [PMID: 18192806 DOI: 10.2459/jcm.0b013e3280c7c29c] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Severe liver disease is associated with abnormalities in cardiac geometry and function. We aimed to assess the prevalence of these abnormalities and to determine if they represent an adaptation of the heart to the haemodynamic overload associated with liver dysfunction. METHODS Seventy cirrhotic patients underwent standard Doppler echocardiography, as a screening evaluation for liver transplantation, and were compared with 70 normal subjects matched for age and sex. The values of echocardiographically measured left ventricular mass (LVM) were compared with those predicted from individual haemodynamic load, sex and height, which represent the compensatory values. LVM was considered inappropriately high when the observed/predicted LVM ratio was >128%. RESULTS Cirrhotic patients had higher LVM index (40.6 +/- 11.2 vs. 36.3 +/- 7.7 g/m; P = 0.009)), similar values of ejection fraction, but lower intrinsic wall mechanics (P < 0.01) compared to controls. The observed/predicted LVM ratio was also significantly increased (117.7 +/- 30.2 vs. 106.5 +/- 16.8%; P < 0.01) and prevalence of inappropriate LVM was almost three-fold higher in cirrhotic patients (27.7 vs. 10.0%; P < 0.05) than in controls. Cirrhotic patients also presented mild impairment of left ventricular systolic function, documented by lower values of midwall shortening. CONCLUSIONS Patients with severe liver disease have LVM values exceeding the compensatory needs to sustain haemodynamic overload, associated with subclinical systolic dysfunction.
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Affiliation(s)
- Marina De Marco
- Echocardiography Laboratory, Department of Clinical and Experimental Medicine, Federico II University Hospital, Naples, Italy
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Abstract
Most elderly patients, particularly women, who have heart failure have a normal ejection fraction. Patients who have this syndrome have severe symptoms of exercise intolerance, frequent hospitalizations, and increased mortality. The pathophysiology and treatment are not well defined. Control of systemic hypertension may be a key to prevention and treatment. Several large trials of specific agents are currently underway.
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Affiliation(s)
- Dalane W Kitzman
- Wake Forest University Health Sciences Center, Winston-Salem, NC, USA.
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Abstract
Most elderly patients, particularly women, who have heart failure have a normal ejection fraction. Patients who have this syndrome have severe symptoms of exercise intolerance, frequent hospitalizations, and increased mortality. The pathophysiology and treatment are not well defined. Control of systemic hypertension may be a key to prevention and treatment. Several large trials of specific agents are currently underway.
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Affiliation(s)
- Dalane W Kitzman
- Department of Internal Medicine, Wake Forest University Health Sciences Center, Medical Center Boulevard, Winston-Salem, NC 27157, USA.
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25
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Abstract
Studies have demonstrated that diastolic dysfunction is frequently present in asymptomatic community-based individuals, especially in the elderly with hypertension, coronary artery disease, and diabetes. The presence of diastolic dysfunction is a predictor for the development of heart failure (HF) and confers a higher risk of mortality. These findings have raised the question of whether treating preclinical diastolic dysfunction will be helpful in preventing or delaying the onset of clinical HF and mortality, as has been proven with treatment of asymptomatic left ventricular systolic dysfunction. In addition, in some individuals, diastolic dysfunction in the presence of a normal ejection fraction is associated with exercise intolerance as well as symptomatic clinical HF, referred to as diastolic HF. Patients with diastolic HF, who are more often elderly women, have a significant mortality and morbidity burden compared with age-matched controls. Studies that further our understanding of mechanisms underlying diastolic dysfunction and diastolic HF will provide potential new targets for development of effective therapies for these conditions.
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Affiliation(s)
- Anita Deswal
- Michael E. DeBakey VA Medical Center (152), 2002 Holcombe Boulevard, Houston, TX 77030, USA.
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26
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Jung HO, Sheehan FH, Bolson EL, Waiss MP, Otto CM. Evaluation of Midwall Systolic Function in Left Ventricular Hypertrophy: A Comparison of 3-Dimensional Versus 2-Dimensional Echocardiographic Indices. J Am Soc Echocardiogr 2006; 19:802-10. [PMID: 16762760 DOI: 10.1016/j.echo.2006.01.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2005] [Indexed: 11/21/2022]
Abstract
OBJECTIVE This study investigated the sensitivity of 3-dimensional (3D) midwall ejection fraction (EF) (3DEF(mw)) to the presence of left ventricular (LV) hypertrophy (LVH) in comparison with conventional echocardiographic indices for systolic function. BACKGROUND EF and fractional shortening (FS) do not reflect the prognosis of patients with LVH. Midwall mechanics better represent the true function in LVH. However, midwall FS (FS(mw)) interrogates a limited region of LV. We developed a method for determining 3DEF(mw). METHODS This study compared 3DEF(mw) with 2-dimensional (endocardial EF [EF(endo)], endocardial FS, FS(mw), and systolic tissue velocity) and 3D (3D EF(endo) and mitral annular motion [MAM]) echocardiographic indices in 28 patients with essential hypertension and LV mass index by M-mode greater than 125 g/m(2) versus 21 healthy individuals. RESULTS Systolic function assessed by EF(endo), endocardial FS, 3D EF(endo), and systolic tissue velocity did not differ between the two groups, but MAM (11.6 vs 14.0 mm), FS(mw) (14.7 vs 18.2%), and 3DEF(mw) (36.6 vs 44.1%) were significantly decreased in LVH compared with normal. Only 3 parameters correlated significantly with both the M-mode and 3D measurements of LV mass index: FS(mw) (r = -0.74 [M-mode]; r = -0.48 [3D]), 3DEF(mw) (r = -0.63 [M-mode]; r = -0.68 [3D]), and MAM (r = -0.43 [M-mode]; r = -0.36 [3D]). Midwall indices FS(mw) (F = 40.4) and 3DEF(mw) (F = 26.5) better discriminated LVH and normal groups than MAM or endocardial indices. CONCLUSIONS The 3DEF(mw) method discriminates the systolic function of LVH and normal groups, and correlates with the degree of hypertrophy. By avoiding the limitations of FS(mw) or MAM, 3DEF(mw) provides a more comprehensive metric of systolic function in patients with LVH.
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Affiliation(s)
- Hae Ok Jung
- Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
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27
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Aurigemma GP, Zile MR, Gaasch WH. Contractile behavior of the left ventricle in diastolic heart failure: with emphasis on regional systolic function. Circulation 2006; 113:296-304. [PMID: 16418449 DOI: 10.1161/circulationaha.104.481465] [Citation(s) in RCA: 179] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Gerard P Aurigemma
- Division of Cardiology, Department of Medicine, University of Massachusetts Medical School, Worcester, MA 01655, USA.
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28
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Vinch CS, Aurigemma GP, Simon HU, Hill JC, Tighe DA, Meyer TE. Analysis of left ventricular systolic function using midwall mechanics in patients >60 years of age with hypertensive heart disease and heart failure. Am J Cardiol 2005; 96:1299-303. [PMID: 16253602 DOI: 10.1016/j.amjcard.2005.06.076] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2005] [Revised: 06/24/2005] [Accepted: 06/24/2005] [Indexed: 11/26/2022]
Abstract
Normal ejection fraction (EFs) is often equated with normal systolic function. However, midwall mechanics reveal systolic dysfunction in hypertensive heart disease accompanied by hypertrophic remodeling. Midwall mechanics are unstudied in patients with acute diastolic heart failure (HF). This study analyzed left ventricular (LV) midwall stress-shortening relations in 61 patients aged >60 years with hypertensive heart disease, HF, and normal EF. Sixty-one hypertensive patients (mean age 78 +/- 10 years) who presented with HF, each with an EF >50%, underwent echocardiography. Midwall mechanics were compared with those of 79 controls (mean age 75 +/- 8 years) without structural heart disease. Relative wall thickness (0.63 +/- 0.11 vs 0.46 +/- 0.10 mm) and LV mass (237 +/- 67 vs 177 +/- 57 g) were significantly greater in patients with HF compared with controls. Mean EFs were similar in patients with HF and controls (64 +/- 9% vs 67 +/- 9%). Although mean endocardial fractional shortening (35 +/- 7% vs 37 +/- 7%) was not significantly different, midwall shortening in patients with HF was significantly less compared with controls (16 +/- 2% vs 19 +/- 3%, p <0.05). Eighteen of the 61 patients with HF (30%) had midwall shortening that was <95% confidence intervals of the normal midwall stress-shortening relations. By this criterion, these patients had systolic dysfunction despite normal EF; they had smaller LV chambers (in dimension and volume), greater relative wall thickness, and smaller stroke volumes. In conclusion, almost 1/3 of patients hospitalized with diastolic HF had systolic dysfunction, characterized by abnormal midwall stress-shortening relations.
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Affiliation(s)
- Craig S Vinch
- Department of Medicine, Division of Cardiovascular Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA
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29
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Curiel R, Perez-Gonzalez J, Torres E, Landaeta R, Cerrolaza M. Operative contractility: A functional concept of the inotropic state. Clin Exp Pharmacol Physiol 2005; 32:871-81. [PMID: 16173950 DOI: 10.1111/j.1440-1681.2010.04282.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
1. Initial unsuccessful attempts to evaluate ventricular function in terms of the 'heart as a pump' led to focusing on the 'heart as a muscle' and to the concept of myocardial contractility. However, no clinically ideal index exists to assess the contractile state. The aim of the present study was to develop a mathematical model to assess cardiac contractility. 2. A tri-axial system was conceived for preload (PL), afterload (AL) and contractility, where stroke volume (SV) was represented as the volume of the tetrahedron. Based on this model, 'operative' contractility ('OperCon') was calculated from the readily measured values of PL, AL and SV. The model was tested retrospectively under a variety of different experimental and clinical conditions, in 71 studies in humans and 29 studies in dogs. A prospective echocardiographic study was performed in 143 consecutive subjects to evaluate the ability of the model to assess contractility when SV and PL were measured volumetrically (mL) or dimensionally (cm). 3. With inotropic interventions, OperCon changes were comparable to those of ejection fraction (EF), velocity of shortening (Vcf) and dP/dt-max. Only with positive inotropic interventions did elastance (Ees) show significantly larger changes. With load manipulations, OperCon showed significantly smaller changes than EF and Ees and comparable changes to Vcf and dP/dt-max. Values of OperCon were similar when AL was represented by systolic blood pressure or wall stress and when volumetric or dimensional values were used. 4. Operative contractility is a reliable, simple and versatile method to assess cardiac contractility.
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Affiliation(s)
- Roberto Curiel
- Centro Medico Docente La Trinidad, Facultad de Medicina, Universidad Central de Venezuela, Caracas, Venezuela.
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30
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Skaluba SJ, Bray BE, Litwin SE. Close Coupling of Systolic and Diastolic Function: Combined Assessment Provides Superior Prediction of Exercise Capacity. J Card Fail 2005; 11:516-22. [PMID: 16198247 DOI: 10.1016/j.cardfail.2005.04.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2004] [Revised: 02/23/2005] [Accepted: 04/14/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND Isolated diastolic dysfunction is thought to account for approximately 50% of cases of heart failure. We tested the hypotheses that (1) the use of different methods for assessing systolic and diastolic function may contribute to the apparent frequency with which they are dissociated and (2) that combined assessment of systolic and diastolic function is superior to either one alone. METHODS AND RESULTS A total of 110 patients underwent echocardiography with tissue Doppler imaging (TDI) of the mitral annulus before maximal exercise testing. The correlation between left ventricular (LV) ejection fraction (EF) and exercise capacity was weak (r = 0.199). Among patients with EF greater than 55%, those with normal exercise capacity (>7 METs) had a higher systolic velocity of the mitral annulus than those achieving less than 7 METs (9.6 +/- 0.3 versus 7.5 +/- 0.4 cm/s, P = .001). The mitral annular systolic (Sa) and early diastolic (Ea) velocities each correlated moderately with exercise tolerance (r = 0.40 and 0.49, respectively). Sa and Ea correlated highly with each other (r = 0.79, P < .001). The sum of isovolumic contraction and relaxation times measured from TDI correlated moderately with exercise duration (r = -0.59). A combined index of systolic and diastolic function that includes isovolumic contraction and relaxation times and ejection time had the best correlation with achieved METs (r = -0.73, P < .001). A TDI index of cardiac performance higher than 0.52 had excellent sensitivity (86%) and specificity (100%) for predicting reduced exercise tolerance lower than 7 METs. CONCLUSION When assessed with the same technique, LV systolic and diastolic function are tightly linked. A TDI-derived combined index of myocardial performance is the best predictor of exercise capacity.
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Affiliation(s)
- Stanislaw J Skaluba
- Division of Cardiology, University of Utah Health Sciences Center, Salt Lake City, Utah 84132-2401, USA
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31
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Baicu CF, Zile MR, Aurigemma GP, Gaasch WH. Left ventricular systolic performance, function, and contractility in patients with diastolic heart failure. Circulation 2005; 111:2306-12. [PMID: 15851588 DOI: 10.1161/01.cir.0000164273.57823.26] [Citation(s) in RCA: 191] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Patients with diastolic heart failure (DHF) have significant abnormalities in left ventricular (LV) diastolic function, including slow and delayed relaxation and increased chamber stiffness. Whether and to what extent these abnormalities in diastolic function occur in association with abnormalities in LV systolic performance, function, and contractility has not been investigated thoroughly. METHODS AND RESULTS The systolic properties of the LV were examined in 75 patients with heart failure and a normal ejection fraction (ie, DHF) and 75 normal control subjects with no evidence of cardiovascular disease. LV systolic properties were assessed with echocardiographic and cardiac catheterization data. Stroke work (an index of LV systolic performance), preload recruitable stroke work and ejection fraction (indices of LV systolic function), systolic stress-shortening relationship, end-systolic pressure-volume relationship, and peak (+)dP/dt (indices of LV contractility) were examined. The systolic properties of the LV were normal in patients with DHF. Stroke work was 8.4+/-2.3 in DHF versus 8.8+/-2.5 kg . cm in controls (P=0.26). Preload recruitable stroke work was 99+/-22 in DHF versus 109+/-18 g/cm2 in controls (P=0.13). The relationship between stroke work and end-diastolic volume was similar in DHF and controls. Peak (+) dP/dt was 1596+/-362 in DHF versus 1664+/-305 mm Hg/s in controls (P=0.54). The end-systolic pressure-volume relationship was increased in DHF. The systolic stress versus endocardial fractional shortening relationship was similar in DHF and controls. CONCLUSIONS Patients with DHF had normal LV systolic performance, function, and contractility. The pathophysiology of DHF does not appear to be related to significant abnormalities in these systolic properties of the LV.
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Affiliation(s)
- Catalin F Baicu
- Division of Cardiology, Department of Medicine, Medical University of South Carolina and RHJ Department of Veterans Affairs Medical Center, Charleston, SC 29425, USA
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Bendjelid K, Schütz N, Suter PM, Fournier G, Jacques D, Fareh S, Romand JA. Does continuous positive airway pressure by face mask improve patients with acute cardiogenic pulmonary edema due to left ventricular diastolic dysfunction? Chest 2005; 127:1053-8. [PMID: 15764794 DOI: 10.1378/chest.127.3.1053] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
OBJECTIVE Continuous positive airway pressure (CPAP) by face mask is an effective method of treating severe cardiogenic pulmonary edema (CPE). However, to our knowledge, no study has provided a precise evaluation of the effects of CPAP on cardiac function in patients presenting with CPE and preserved left ventricular (LV) function. DESIGN Prospective observational clinical study. SETTING A 14-bed, medical ICU at a university hospital. PATIENTS Nine consecutive patients presenting with hypoxemic acute CPE. INTERVENTIONS All patients were selected for 30 min of CPAP with 10 cm H(2)O by mask with fraction of inspired oxygen adjusted for a cutaneous saturation > 90%. Doppler echocardiography was performed before CPAP application and during the last 10 min of breathing with CPAP. Two-tailed, paired t-tests were used to compare data recorded at baseline (oxygen alone) and after CPAP. MEASUREMENTS AND RESULTS Four patients presented CPE with preserved left ventricular (LV) function (a preserved LV ejection fraction [LVEF] > 45%, and/or aortic velocity time integral > 17 cm in the absence of aortic stenosis or hypertrophic cardiomyopathy). Oxygenation and ventilatory parameters were improved by CPAP in all patients. Hemodynamic monitoring and Doppler echocardiographic analysis demonstrated that in patients with preserved LV systolic function, mean arterial pressure and LV end-diastolic volume were decreased significantly by CPAP (p < 0.04). In patients with LV systolic dysfunction, CPAP improved LVEF (p < 0.05) and decreased LV end-diastolic volume (p = 0.001) significantly. CONCLUSION CPAP improves oxygenation and ventilatory parameters in all kinds of CPE. In patients with preserved LV contractility, the hemodynamic benefit of CPAP results from a decrease in LV end-diastolic volume (preload).
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Affiliation(s)
- Karim Bendjelid
- Surgical Intensive Care Unit, Department of Anesthesiology, Pharmacology and Surgical Intensive Care, Geneva University Hospitals, CH-1211 Genève 14, Switzerland. Karim.
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Munagala VK, Hart CYT, Burnett JC, Meyer DM, Redfield MM. Ventricular structure and function in aged dogs with renal hypertension: a model of experimental diastolic heart failure. Circulation 2005; 111:1128-35. [PMID: 15723971 PMCID: PMC1805473 DOI: 10.1161/01.cir.0000157183.21404.63] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Heart failure (HF) with normal ejection fraction (diastolic HF [DHF]) usually occurs in elderly patients with hypertension. The presence and significance of altered systolic and diastolic ventricular function in DHF is increasingly controversial. Our objective was to develop a clinically relevant large-animal model to better understand the pathophysiology of DHF. METHODS AND RESULTS Ventricular structure and function were characterized in young control (YC group; n=6), old control (OC group; n=7), and old dogs made hypertensive by renal wrapping (experimental DHF [ExDHF] group; n=8). The ExDHF group was associated with normal left ventricular (LV) volume, increased LV mass, and myocardial fibrosis. LV relaxation was impaired in ExDHF (tau=53+/-6 ms) compared with OC (tau=35+/-3 ms; P<0.05) and YC (tau=33+/-6 ms; P<0.05) dogs. The percent diastole at which relaxation is complete was increased in ExDHF (116+/-30%) compared with OC (69+/-8%; P<0.05) and YC (35+/-5%; P<0.05) dogs. The coefficient of LV diastolic stiffness was similar in OC, YC, and ExDHF dogs. Diastolic pressures increased dramatically in response to increases in blood pressure. End-systolic LV stiffness was enhanced in ExDHF dogs and after load enhancement of myocardial performance was maintained. Arterial stiffness was increased in ExDHF dogs. CONCLUSIONS Aged dogs with chronic hypertension exhibit LV hypertrophy and fibrosis with impaired LV relaxation but no increase in the coefficient of LV diastolic stiffness. LV systolic and arterial stiffness are increased, which may exacerbate load-dependent impairment of relaxation and contribute to increased filling pressures with hypertensive episodes. This model mimics many of the structural and functional characteristics described in the limited studies of human DHF and provides insight into the pathogenesis of DHF.
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Affiliation(s)
- Vijaya K Munagala
- Cardiorenal Research Laboratory, Mayo Clinic and Foundation, Rochester, Minn 55905, USA
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Affiliation(s)
- Gerard P Aurigemma
- Division of Cardiology, Department of Medicine, University of Massachusetts Medical School, Worcester, MA 01655, USA.
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35
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Agricola E, Oppizzi M, Pisani M, Margonato A. Stress echocardiography in heart failure. Cardiovasc Ultrasound 2004; 2:11. [PMID: 15285780 PMCID: PMC514499 DOI: 10.1186/1476-7120-2-11] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2004] [Accepted: 07/30/2004] [Indexed: 02/06/2023] Open
Abstract
Echocardiography has the ability to noninvasively explore hemodynamic variables during pharmacologic or exercise stress test in patients with heart failure. In this review, we detail some important potential applications of stress echocardiography in patients with heart failure. In patients with coronary artery disease and chronic LV dysfunction, dobutamine stress echocardiography is able to distinguish between viable and fibrotic tissue to make adequate clinical decisions. Exercise testing, in combination with echocardiographic monitoring, is a method of obtaining accurate information in the assessment of functional capacity and prognosis. Functional mitral regurgitation is a common finding in patients with dilated and ischaemic cardiomyopathy and stress echocardiography in the form of exercise or pharmacologic protocols can be useful to evaluate the behaviour of mitral regurgitation. It is clinical useful to search the presence of contractile reserve in non ischemic dilated cardiomyopathy such as to screen or monitor the presence of latent myocardial dysfunction in patients who had exposure to cardiotoxic agents. Moreover, in patients with suspected diastolic heart failure and normal systolic function, exercise echocardiography could be able to demonstrate the existence of such dysfunction and determine that it is sufficient to limit exercise tolerance. Finally, in the aortic stenosis dobutamine echocardiography can distinguish severe from non-severe stenosis in patients with low transvalvular gradients and depressed left ventricular function.
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Affiliation(s)
- Eustachio Agricola
- Division of Non-Invasive Cardiology, Cardiothoracic Department, San Raffaele Hospital, IRCCS, Milano, Italy
| | - Michele Oppizzi
- Division of Non-Invasive Cardiology, Cardiothoracic Department, San Raffaele Hospital, IRCCS, Milano, Italy
| | - Matteo Pisani
- Division of Non-Invasive Cardiology, Cardiothoracic Department, San Raffaele Hospital, IRCCS, Milano, Italy
| | - Alberto Margonato
- Division of Non-Invasive Cardiology, Cardiothoracic Department, San Raffaele Hospital, IRCCS, Milano, Italy
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Abstract
Thirty to fifty percent of patients presenting with signs and symptoms of heart failure have a normal left ventricular (LV) systolic ejection fraction. The clinical examination cannot distinguish these patients (diastolic heart failure) from those with a depressed ejection fraction (systolic heart failure), but echocardiography can. The management of diastolic heart failure has two major objectives. The first is to reverse the consequences of diastolic dysfunction (e.g., venous congestion), and the second is to eliminate or reduce the factors responsible for diastolic dysfunction (e.g., myocardial hypertrophy, fibrosis, and ischemia).
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Affiliation(s)
- William H Gaasch
- Department of Cardiovascular Medicine, Lahey Clinic, Burlington, Massachusetts 01805, USA.
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Mayet J, Ariff B, Wasan B, Chapman N, Shahi M, Senior R, Foale RA, Thom SAM. Midwall myocardial shortening in athletic left ventricular hypertrophy. Int J Cardiol 2002; 86:233-8. [PMID: 12419561 DOI: 10.1016/s0167-5273(02)00299-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Patients with pathological left ventricular hypertrophy have depressed midwall systolic shortening in spite of normal indices of left ventricular chamber function and a reduced midwall function has been observed to be an independent predictor of cardiovascular risk. Whether midwall shortening is depressed in physiological hypertrophy is unknown. METHODS Forty-two subjects, 27 athletes and 15 age- and sex-matched normal control subjects (group 1) were studied. The athletes were divided into those with eccentric hypertrophy (group 2) and those with concentric hypertrophy (group 3). Systolic left ventricular function was assessed at the midwall and endocardium using two-dimensional echocardiography in all subjects. RESULTS Left ventricular mass index was significantly greater in both athletic groups than in controls (group 1, 101+/-5.8 g/m(2), group 2, 141+/-11.1*, group 3, 155+/-5.8*; *P<0.01 compared with group 1). Left ventricular systolic function assessed at the endocardium was similar among all three groups (ejection fraction: group 1, 66.2+/-2.38, group 2, 66.8+/-1.44, group 3, 63.7+/-1.66%; endocardial fractional shortening: group 1, 37.1+/-1.71, group 2, 37.6+/-1.13, group 3, 35.1+/-1.25%). However, fractional shortening at the midwall was reduced in the concentric hypertrophy athletes compared with the other two groups (midwall fractional shortening: group 1, 21.9+/-1.1, group 2, 21.9+/-0.86, group 3, 18.4+/-0.96*%; P<0.05 compared with groups 1 and 2). CONCLUSION Subjects with physiological concentric hypertrophy have depressed midwall fractional shortening. This suggests that the observed discrepancy between midwall and endocardial shortening in patients with left ventricular hypertrophy is likely to be a function of the geometry and not necessarily a reflection of pathology within the myocardium.
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Affiliation(s)
- Jamil Mayet
- Department of Cardiology, St Mary's Hospital, Praed Street, Paddington, London W2 1NY, UK.
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Carlhäll CJ, Lindström L, Wranne B, Nylander E. Atrioventricular plane displacement correlates closely to circulatory dimensions but not to ejection fraction in normal young subjects. CLINICAL PHYSIOLOGY (OXFORD, ENGLAND) 2001; 21:621-8. [PMID: 11576164 DOI: 10.1046/j.1365-2281.2001.00356.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
AIMS Mitral atrioventricular plane displacement (AVPD) provides information about left ventricular systolic function. M-mode of systolic annulus amplitude or tissue Doppler imaging of systolic annulus velocity are the current methods of evaluating AVPD. A correlation to ejection fraction (EF) has been demonstrated in patients with coronary artery disease and left ventricular dysfunction. Our aim was (i) to investigate the mitral AVPD of normal subjects with different physical work capacities and (ii) to further evaluate AVPD as an index of left ventricular systolic function. METHODS AND RESULTS Twenty-eight healthy men mean age 28 years (20-39) were included: endurance trained (ET) (n=10), strength trained (ST) (n=9) and untrained (UT) (n=9). The systolic AVPD was recorded at four sites, septal, lateral, anterior and posterior, using M-mode. Left ventricular volumes were calculated according to Simpson's rule. Systolic AVPD was higher in endurance trained, 16.9 +/- 1.5 mm, as compared with both strength trained, 13 +/- 1.6 (P<0.001) and untrained, 14 +/- 1.6 (P<0.001). Left ventricular systolic AVPD correlated strongly with end-diastolic volume (r=0.82), stroke volume (r=0.80) and maximal oxygen consumption per body weight (r=0.72). The correlation between AVPD and EF was poor (r=0.22). CONCLUSION In the subjects studied, with a range of normal cardiac dimensions, AVPD correlated to stroke volume, end-diastolic volume and maximal oxygen consumption per body weight, but not to EF. On theoretical grounds, it also seems reasonable that a dimension like AVPD is related to other cardiac dimensions and volumes, rather than to a fraction, like EF. AVPD is one parameter that is useful for evaluation of left ventricular systolic function but is not interchangeable with other measurements such as EF.
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Affiliation(s)
- C J Carlhäll
- Department of Clinical Physiology, Linköping Heart Center, Linköping University Hospital, SE-581 85 Linköping, Sweden
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Palmieri V, Wachtell K, Gerdts E, Bella JN, Papademetriou V, Tuxen C, Nieminen MS, Dahlöf B, de Simone G, Devereux RB. Left ventricular function and hemodynamic features of inappropriate left ventricular hypertrophy in patients with systemic hypertension: the LIFE study. Am Heart J 2001; 141:784-91. [PMID: 11320367 DOI: 10.1067/mhj.2001.114803] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Predicted left ventricular (LV) mass for sex, height (2.7), and hemodynamic load can be used as an intrapatient reference for the observed LV mass. The ratio of observed/predicted LV mass may allow more physiologically correct comparisons of LV geometry, systolic and diastolic functions, and hemodynamics among hypertensive patients. METHODS We studied 659 participants in the LIFE (Losartan Intervention for Endpoint Reduction in Hypertension) study with both electrocardiographic and echocardiographic LV hypertrophy (68% of the echocardiographic cohort) without previous myocardial infarction. LV mass was predicted by an equation including sex, stroke work, and height (2.7). Observed/predicted LV mass > 128% defined inappropriate LV hypertrophy (iLVH). Relative wall thickness > or = 0.43 defined concentric LV geometry. Systolic myocardial dysfunction was assessed by midwall mechanics and abnormal LV relaxation by isovolumic relaxation time (IVRT). RESULTS Compared with patients with appropriate LV hypertrophy (aLVH), those with iLVH had higher body mass index, LV mass index, relative wall thickness, prevalences of systolic myocardial dysfunction and prolonged IVRT and lower end-systolic stress and cardiac index. Patients with eccentric iLVH had the highest wall stress and lowest ejection fraction; 43% had systolic myocardial dysfunction. Of patients with concentric iLVH, 79% had systolic myocardial dysfunction but normal ejection fraction and the lowest wall stress. Systolic myocardial dysfunction was present in 12% with concentric aLVH and none with eccentric aLVH. Prevalence of prolonged IVRT was high in all 4 groups (65% to 77%). Cardiac index was similarly lower with concentric or eccentric iLVH than with aLVH. CONCLUSIONS Among hypertensives with LV hypertrophy, iLVH identified cardiac phenotypes with a high prevalence of myocardial systolic dysfunction.
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Affiliation(s)
- V Palmieri
- Weill Medical College of Cornell University, New York, NY, USA.
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Mayet J, Ariff B, Wasan B, Chapman N, Shahi M, Poulter NR, Sever PS, Foale RA, Thom SA. Improvement in midwall myocardial shortening with regression of left ventricular hypertrophy. Hypertension 2000; 36:755-9. [PMID: 11082139 DOI: 10.1161/01.hyp.36.5.755] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Despite normal indices of left ventricular (LV) chamber function, patients with LV hypertrophy (LVH) due to hypertension are thought to have depressed midwall systolic shortening compared with normotensives. The aims of the present study were (1) to confirm this observation and (2) to assess the effects of antihypertensive therapy that cause regression of LVH on LV systolic function assessed at both the midwall and endocardium. Thirty-eight previously untreated hypertensive subjects with LVH underwent echocardiography and were compared with 38 normotensive control subjects. Comparisons between the group with LVH and the control group revealed no significant differences in cardiac output (4. 32+/-0.23 versus 4.55+/-0.21 L/min), ejection fraction (62.5+/-2% versus 66.4+/-1.07%), or endocardial fractional shortening (34.5+/-1.45% versus 37.0+/-0.82%), but shortening assessed at the midwall was significantly less in the group with LVH (17.9+/-1.11% versus 21.6+/-0.63%, P<0.01). Subsequently, 32 patients with uncontrolled hypertension (24 previously untreated and 8 on existing antihypertensive therapy) underwent treatment with ramipril, with the addition of felodipine and bendrofluazide if required, to reduce blood pressure to <140/90 mm Hg. These 32 patients underwent echocardiography at baseline, after blood pressure control, and after an additional 6 months of tight blood pressure control. Good blood pressure control was achieved after 6 months compared with baseline (143/86+/-2.8/1.4 versus 174/103+/-4.1/1.9 mm Hg; P<0.01) with significant regression of LV mass index (124+/-3.4 versus 145+/-3.8 g/m(2), P<0.01). LV fractional shortening assessed at the midwall improved with regression of LVH (21.9+/-0.84 and 18.7+/-1. 19%, P<0.05), with posttreatment midwall shortening being similar to that of the normal control subjects evaluated in the first study. Hypertensive patients with LVH have depressed midwall systolic shortening despite normal indices of LV chamber function. Regression of LVH after good blood pressure control improved midwall shortening to normal levels.
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Affiliation(s)
- J Mayet
- Department of Cardiology, St. Mary's Hospital Praed Street, London W2 1NY, UK.
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de Simone G, Devereux RB, Celentano A, Roman MJ. Left ventricular chamber and wall mechanics in the presence of concentric geometry. J Hypertens 1999; 17:1001-6. [PMID: 10419074 DOI: 10.1097/00004872-199917070-00017] [Citation(s) in RCA: 70] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND To test the hypothesis that in the presence of left ventricular concentric geometry the definition of 'normal' ejection fraction should be reconsidered, and normality should rather be considered to have a higher than usual lower limit METHODS M-mode echocardiographic endocardial shortening (eS) was studied in 148 hypertensive patients with left ventricular concentric geometry (relative wall thickness > or = 0.42), 78 with normal (54 +/- 10 years, 27 women) and 70 with depressed midwall shortening (mS) (53 +/- 10 years, 26 women), based on normal distribution of stress-corrected mS, and compared to a reference adult population of 297 age-matched normal subjects (54 +/- 8 years, 121 women) with eS > or = 28%. RESULTS Patients with low mS exhibited higher heart rates and body mass indices than control individuals (both P < 0.01); blood pressure, left ventricular mass, relative wall thickness and peripheral resistance were higher than in patients with normal mS, whereas cardiac index was reduced (all P< 0.01). Adjustment for body mass index and race attenuated but did not eliminate the differences between the two groups of patients (0.05 < P < 0.0001). In contrast, eS was higher than normal in patients with normal midwall shortening, whereas was 'normal' in patients with low left ventricular midwall function. More than 80% of patients in the lowest quartile of apparently normal eS exhibited clear-cut low left ventricular midwall function. CONCLUSIONS 'Normal' left ventricular chamber function in the presence of concentric geometry is associated with depressed midwall performance, more severe left ventricular hypertrophy, lower cardiac output and higher peripheral resistance. 'Normal' eS is the hallmark of normal myocardial function when left ventricular geometry is normal, but should be considered as a marker of systolic dysfunction when associated with concentric left ventricular geometry. Normal limits for eS should be therefore reset to upper values.
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Affiliation(s)
- G de Simone
- Division of Cardiology, The New York Presbyterian Hospital, Weill Medical College of Cornell University, NY, USA.
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Vasan RS, Larson MG, Benjamin EJ, Evans JC, Reiss CK, Levy D. Congestive heart failure in subjects with normal versus reduced left ventricular ejection fraction: prevalence and mortality in a population-based cohort. J Am Coll Cardiol 1999; 33:1948-55. [PMID: 10362198 DOI: 10.1016/s0735-1097(99)00118-7] [Citation(s) in RCA: 955] [Impact Index Per Article: 38.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES The purpose of this study was to assess the relative proportions of normal versus impaired left ventricular (LV) systolic function among persons with congestive heart failure (CHF) in the community and to compare their long-term mortality during follow-up. BACKGROUND Several hospital-based investigations have reported that a high proportion of subjects with CHF have normal LV systolic function. The prevalence and prognosis of CHF with normal LV systolic function in the community are not known. METHODS We evaluated the echocardiograms of 73 Framingham Heart Study subjects with CHF (33 women, 40 men, mean age 73 years) and 146 age- and gender-matched control subjects (nested case-control study). Impaired LV systolic function was defined as an LV ejection fraction (LVEF) <0.50. RESULTS Thirty-seven CHF cases (51%) had a normal LVEF; 36 (49%) had a reduced LVEF. Women predominated in the former group (65%), whereas men constituted 75% of the latter group. During a median follow-up of 6.2 years, CHF cases with normal LVEF experienced an annual mortality of 8.7% versus 3.0% for matched control subjects (adjusted hazards ratio = 4.06, 95% confidence interval 1.61 to 10.26). Congestive heart failure cases with reduced LVEF had an annual mortality of 18.9% versus 4.1% for matched control subjects (adjusted hazards ratio = 4.31, 95% confidence interval 1.98 to 9.36). CONCLUSIONS Normal LV systolic function is often found in persons with CHF in the community and is more common in women than in men. Although CHF cases with normal LVEF have a lower mortality risk than cases with reduced LVEF, they have a fourfold mortality risk compared with control subjects who are free of CHF.
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Affiliation(s)
- R S Vasan
- National Heart, Lung, and Blood Institute's Framingham Heart Study, Massachusetts 01702, USA
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Palatini P, Visentin P, Mormino P, Pietra M, Piccolo D, Cozzutti E, Mione V, Bocca P, Perissinotto F, Pessina AC. Left ventricular performance in the early stages of systemic hypertension. HARVEST Study Group. Hypertension and Ambulatory Recording Venetia Study. Am J Cardiol 1998; 81:418-23. [PMID: 9485130 DOI: 10.1016/s0002-9149(97)00948-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
To investigate whether and how frequently left ventricular (LV) systolic performance assessed with endocardial and midwall measurement is depressed in young subjects with mild systemic hypertension, we studied 722 borderline to mild hypertensive patients (mean age +/- SEM 33 +/- 0.3 years, mean office blood pressure (BP) 146 +/- 0.4/94 +/- 0.2 mm Hg) enrolled in the Hypertension and Ambulatory Recording Venetia Study and 50 normotensive controls with similar age and sex distribution. BP was measured with 24-hour ambulatory monitoring. LV dimensional and functional indexes were assessed by M-mode echocardiography and sympathetic activity from 24-hour urinary catecholamines. In 64 hypertensive subjects (8.9%) the LV midwall shortening-stress relation was < 95% of the confidence interval in 50 normotensive controls. Subjects with depressed LV myocardial function had age, duration of hypertension, and LV mass similar to those of hypertensives with normal performance, and greater relative wall thickness (0.42 vs 0.37, p < 0.001). Stroke volume and cardiac output were lower (p < 0.001) in the former group. Among these 64 subjects, endocardial performance was depressed in 35 (group 1) and normal in 29 (group 2). Group 2 subjects had greater posterior wall (10.0 vs 9.5 mm, p = 0.03), ventricular septum (10.6 vs 10.1 mm, p = 0.05), and relative wall (0.44 vs 0.40, p < 0.001) thicknesses than group 1 subjects. Urinary norepinephrine was 50% higher in group 2 subjects (106 vs 70 g/24 hours, p = 0.03). Stroke volume and cardiac output were similar in both groups. In conclusion, these results show that LV contractility may be depressed in young subjects with borderline to mild hypertension.
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Sadler DB, Aurigemma GP, Williams DW, Reda DJ, Materson BJ, Gottdiener JS. Systolic function in hypertensive men with concentric remodeling. Hypertension 1997; 30:777-81. [PMID: 9336372 DOI: 10.1161/01.hyp.30.4.777] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Hypertensive patients with concentric remodeling (relative wall thickness > or = 0.45 and normal left ventricular [LV] mass index) may have poor outcomes. It is unclear whether systolic function abnormalities, shown to be present in some patients with concentric LV hypertrophy (increased LV mass index and relative wall thickness > or = 0.45), are also present in patients with concentric remodeling. To assess LV pump, chamber, and myocardial function in hypertensive men with concentric remodeling, clinical and echocardiographic data of 118 hypertensive men with concentric remodeling were compared with data from 104 hypertensive men with normal relative wall thickness and normal LV mass index. Chamber function was assessed by relating endocardial fractional shortening to end-systolic circumferential stress, myocardial function was assessed by relating midwall fractional shortening to circumferential stress, and pump performance was assessed by stroke volume (Teichholz method). Compared with hypertensive men with normal relative wall thickness, concentric-remodeling patients had lower stroke volume (84 +/- 20 versus 111 +/- 20 mL, P < .001). Endocardial shortening was no different between the two groups (38 +/- 7% versus 40 +/- 7%, P=NS), but midwall shortening was lower in patients with concentric remodeling (20 +/- 3% versus 22 +/- 3%, P < .001), despite lower end-systolic stress (81 +/- 25 versus 117 +/- 37 g/cm2, P < .001). Endocardial and midwall stress-shortening regression plots classified 28% and 42%, respectively, of the concentric remodeling patients below the fifth percentile of hypertensive patients with normal geometry. These data indicate that indexes of chamber and myocardial function are lower than those observed in hypertensive patients with normal geometry. Thus, indices of chamber, myocardial, and pump performance indicate potential abnormalities in systolic function in men with concentric remodeling.
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Affiliation(s)
- D B Sadler
- Division of Cardiology of the University of Massachusetts Medical Center, Worcester 01655, USA
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