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Moons P, Norekvål TM, Arbelo E, Borregaard B, Casadei B, Cosyns B, Cowie MR, Fitzsimons D, Fraser AG, Jaarsma T, Kirchhof P, Mauri J, Mindham R, Sanders J, Schiele F, Torbica A, Zwisler AD. Placing patient-reported outcomes at the centre of cardiovascular clinical practice: implications for quality of care and management. Eur Heart J 2023; 44:3405-3422. [PMID: 37606064 DOI: 10.1093/eurheartj/ehad514] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 05/01/2023] [Accepted: 07/25/2023] [Indexed: 08/23/2023] Open
Abstract
Patient-reported outcomes (PROs) provide important insights into patients' own perspectives about their health and medical condition, and there is evidence that their use can lead to improvements in the quality of care and to better-informed clinical decisions. Their application in cardiovascular populations has grown over the past decades. This statement describes what PROs are, and it provides an inventory of disease-specific and domain-specific PROs that have been developed for cardiovascular populations. International standards and quality indices have been published, which can guide the selection of PROs for clinical practice and in clinical trials and research; patients as well as experts in psychometrics should be involved in choosing which are most appropriate. Collaborations are needed to define criteria for using PROs to guide regulatory decisions, and the utility of PROs for comparing and monitoring the quality of care and for allocating resources should be evaluated. New sources for recording PROs include wearable digital health devices, medical registries, and electronic health record. Advice is given for the optimal use of PROs in shared clinical decision-making in cardiovascular medicine, and concerning future directions for their wider application.
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Affiliation(s)
- Philip Moons
- KU Leuven Department of Public Health and Primary Care, KU Leuven - University of Leuven, Kapucijnenvoer 35 PB7001, 3000 Leuven, Belgium
- Institute of Health and Care Sciences, University of Gothenburg, Arvid Wallgrens backe 1, 413 46 Gothenburg, Sweden
- Department of Paediatrics and Child Health, University of Cape Town, Klipfontein Rd, Rondebosch, 7700 Cape Town, South Africa
| | - Tone M Norekvål
- Department of Heart Disease, Haukeland University Hospital, Haukelandsveien 22, 5009 Bergen, Norway
- Department of Clinical Science, Faculty of Medicine, University of Bergen, Jonas Lies veg, 875021 Bergen, Norway
| | - Elena Arbelo
- Cardiology Department, Hospital Clínic, Universitat de Barcelona, C/Villarroel 170, 08036 Barcelona, Spain
- Institut d'Investigació August Pi i Sunyer (IDIBAPS). Rosselló 149-153, 08036 Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Av. Monforte de Lemos, 3-5. Pabellón 11. Planta 0, 28029 Madrid, Spain
| | - Britt Borregaard
- Department of Cardiology, Odense University Hospital, J.B. Winsløws Vej 4, 5000 Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, J.B. Winsløws Vej 19, 5000 Odense, Denmark
| | - Barbara Casadei
- Division of Cardiovascular Medicine, RDM, University of Oxford; Headley Way, Headington Oxford OX3 9DU, UK
- NIHR Biomedical Research Centre, Headley Way, Headington Oxford OX3 9DU, UK
| | - Bernard Cosyns
- Department of Cardiology, University Hospital Brussels, Laarbeeklaan 101, 1090 Jette, Belgium
| | - Martin R Cowie
- Royal Brompton Hospital & School of Cardiovascular Medicine, Faculty of Medicine & Lifesciences, King's College London, Sydney St, London SW3 6NP, UK
| | - Donna Fitzsimons
- School of Nursing & Midwifery, Queens University Belfast, 97 Lisburn Road, Belfast | BT9 7BL, Northern Ireland
| | - Alan G Fraser
- School of Medicine, Cardiff University, Heath Park, Cardiff CF14 4XW, UK
| | - Tiny Jaarsma
- Department of Medicine, Health and Caring Sciences, Linköping University, Campus Norrköping, 601 74 Norrköping, Sweden
- Nursing Science, Julius Center, University Medical Centre Utrecht, Universiteitsweg 100, 3584 CG Utrecht, The Netherlands
| | - Paulus Kirchhof
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistrasse 52, D-20246 Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Martinistrasse 52, D-20246 Hamburg, Germany
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, Edgbaston Birmingham B15 2TT, UK
| | - Josepa Mauri
- Department of Cardiology, Hospital Universitari Germans Trias i Pujol, Carretera de Canyet, s/n, 08916 Badalona, Barcelona, Spain
| | - Richard Mindham
- European Society of Cardiology (ESC) Patient Forum, 2035 route des colles, CS 80179 Biot, 06903 Sophia Antipolis Cedex, France
| | - Julie Sanders
- St Bartholomew's Hospital, Barts Health NHS Trust, West Smithfield, London EC1A 7BE, UK
- William Harvey Research Institute, Charterhouse Square, Queen Mary University of London, London EC1M 6BQ, UK
| | - Francois Schiele
- Department of Cardiology, University Hospital Besancon, 3 Bd Alexandre Fleming, 25030 Besançon, France
| | - Aleksandra Torbica
- Centre for Research on Health and Social Care Management (CERGAS), Bocconi University, Via Sarfatti, 10 20136 Milan, Italy
| | - Ann Dorthe Zwisler
- Department of Cardiology, Odense University Hospital, J.B. Winsløws Vej 4, 5000 Odense, Denmark
- REHPA, The Danish Knowledge Centre for Rehabilitation and Palliative Care, Odense University Hospital, Vestergade 17, 5800 Nyborg, Denmark
- Department of Clinical Research, University of Southern Denmark, Campusvej 55, DK-5230 Odense, Denmark
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Savarese G, Lindenfeld J, Stolfo D, Adams K, Ahmad T, Desai NR, Ammirati E, Gottlieb SS, Psotka MA, Rosano GMC, Allen LA. Use of patient-reported outcomes in heart failure: from clinical trials to routine practice. Eur J Heart Fail 2023; 25:139-151. [PMID: 36644876 DOI: 10.1002/ejhf.2778] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 12/06/2022] [Accepted: 01/08/2023] [Indexed: 01/17/2023] Open
Abstract
Heart failure (HF) is a complex syndrome that affects mortality/morbidity and acts at different levels in the patient's life, resulting in a drastic impairment in multiple aspects of daily activities (e.g. physical, mental/emotional, and social) and leading to a reduction in quality of life. The definition of disease status and symptom severity has been traditionally based on the physician assessment, while the patient's experience of disease has been long overlooked. The active participation of patients in their own care is necessary to better understand the perception of disease and the multiple aspects of life affected, and to improve adherence to treatments. Patient-reported outcomes (PROs) aim to switch traditional care to a more patient-centred approach. Although PROs demonstrated precision in the evaluation of disease status and have a good association with prognosis in several randomized controlled trials, their implementation into clinical practice is limited. This review discusses the modalities of use of PROs in HF, summarizes the most largely adopted PROs in HF care, and provides an overview on the application of PROs in trials and the potential for their transition to clinical practice. By discussing the advantages and the disadvantages of their use, the reasons limiting their application in daily clinical routine, and the strategies that may promote their implementation, this review aims to foster the systematic integration of the patient's standpoint in HF care.
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Affiliation(s)
- Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Joann Lindenfeld
- Vanderbilt Heart and Vascular Institute, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Davide Stolfo
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy
| | - Kirkwood Adams
- Division of Cardiology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Tariq Ahmad
- Yale School of Medicine, Section of Cardiovascular Medicine, New Haven, CT, USA
| | - Nihar R Desai
- Yale School of Medicine, Section of Cardiovascular Medicine, New Haven, CT, USA
| | - Enrico Ammirati
- De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Stephen S Gottlieb
- Division of Cardiovascular Medicine, University of Maryland School of Medicine and Baltimore Veterans Administration Medical Center, Baltimore, MD, USA
| | | | - Giuseppe M C Rosano
- Centre for Clinical & Basic Research, IRCCS San Raffaele Pisana, Rome, Italy
| | - Larry A Allen
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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Moshki M, Khajavi A, Vakilian F, Minaee S, Hashemizadeh H. The content comparison of health-related quality of life measures in heart failure based on the international classification of functioning, disability, and health: a systematic review. J Cardiovasc Thorac Res 2019; 11:167-175. [PMID: 31579455 PMCID: PMC6759616 DOI: 10.15171/jcvtr.2019.29] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2018] [Accepted: 08/02/2019] [Indexed: 11/09/2022] Open
Abstract
Introduction: Due to the necessity of assessing the health-related quality of life (HRQOL) in heart failure (HF) and the increased use of the International Classification of Functioning, Disability, and Health (ICF) for making a content comparison of measurement instruments, the present study aimed to evaluate the relationship between the instruments and ICF. To this aim, the disease-specific HRQOL instruments in HF were identified, and then psychometric properties and content comparison of included instruments were conducted by linking to ICF. Methods: Disease-specific HRQOL instruments in HF were identified through a comprehensive and systematic search strategy. Then, the psychometric properties of included instruments were determined, and their contents were analyzed and compared based on the ICF coding system. In addition, each instrument was independently linked to ICF by two researchers based on standardized linking rules, and finally their degree of agreement was assessed by the Cohen's kappa coefficient. Results: Ten instruments including a total of 247 items and 417 concepts were linked to 124 different ICF categories. Further, 39 (31.5%), 65 (52.5%), 13 (10.4%), and 7 (5.6%) categories were linked to body function, activity and participation, environmental factors, and body structure, respectively. According to the content analysis approach and psychometric properties, the appropriate measurement instruments were Kansas City Cardiomyopathy and Minnesota living with HF questionnaires, respectively. Conclusion: Content comparison provides researchers with valuable information on the instrument heterogeneity and overlapping, which results in selecting the most appropriate measurement instrument based on a specific clinical context.
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Affiliation(s)
- Mahdi Moshki
- Department of Health Education and Promotion, School of Health; Social Development and Health Promotion Research Center, Gonabad University of Medical Sciences, Gonabad, Iran
| | - Abdoljavad Khajavi
- Department of Community Medicine, School of Medicine, Gonabad University of Medical Sciences, Gonabad, Iran
| | - Farveh Vakilian
- Department of Cardiology, Preventive Atherosclerotic Research Center, Imam Reza Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Shima Minaee
- Department of Cardiovascular Diseases, Razavi Hospital, Mashhad, Iran
| | - Haydeh Hashemizadeh
- Social Development and Health Promotion Research Center, Gonabad University of Medical Sciences, Gonabad, Iran
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Utility of Patient-Reported Outcome Instruments in Heart Failure. JACC-HEART FAILURE 2016; 4:165-75. [DOI: 10.1016/j.jchf.2015.10.015] [Citation(s) in RCA: 89] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Revised: 10/21/2015] [Accepted: 10/22/2015] [Indexed: 11/17/2022]
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Tate CW, Robertson AD, Zolty R, Shakar SF, Lindenfeld J, Wolfel EE, Bristow MR, Lowes BD. Quality of Life and Prognosis in Heart Failure: Results of the Beta-Blocker Evaluation of Survival Trial (BEST). J Card Fail 2007; 13:732-7. [DOI: 10.1016/j.cardfail.2007.07.001] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2006] [Revised: 05/24/2007] [Accepted: 07/06/2007] [Indexed: 11/24/2022]
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Vigna C, Russo A, De Rito V, Perna GP, Testa M, Lombardo A, Lanna P, Langialonga T, Salvatori MP, Fanelli R, Loperfido F. Regional wall motion analysis by dobutamine stess echocardiography to distinguish between ischemic and nonischemic dilated cardiomyopathy. Am Heart J 1996; 131:537-43. [PMID: 8604635 DOI: 10.1016/s0002-8703(96)90534-7] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
To distinguish between ischemic and nonischemic dilated cardiomyopathy (DCM), we studied 43 patients with left ventricular dysfunction (15 ischemic and 28 nonischemic detected by coronary angiography) by dobutamine stress echocardiography. At rest, there were more normal segments (p<0.001) and a trend toward more akinetic segments (p, not significant) per ischemic than per nonischemic DCM patient. However, either at rest or with low-dose dobutamine, individual data largely overlapped. At peak dose, in ischemic DCM, regional contraction worsened in many normal or dys-synergic regions at rest (in the latter case after improvement with low-dose dobutamine); in contrast, in nonischemic DCM, further mild improvement was observed in a variable number of left ventricular areas. Thus with peak-dose dobutamine, more akinetic and less normal segments were present per ischemic than per nonischemic DCM patient (both, p<0.001). A value of six or more akinetic segments was 80% sensitive and 96% specific for ischemic DCM. Our data show that analysis of regional contraction by dobutamine stress echocardiography can distinguish between ischemic and nonischemic DCM.
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Affiliation(s)
- C Vigna
- Department of Cardiology, Casa Sollievo della Sofferenza Hospital, Instituto Ricovero Cura Carattere Scientifico, San Giovanni Rotondo, Italy
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Lewis JF, Webber JD, Sutton LL, Chesoni S, Curry CL. Discordance in degree of right and left ventricular dilation in patients with dilated cardiomyopathy: recognition and clinical implications. J Am Coll Cardiol 1993; 21:649-54. [PMID: 8436746 DOI: 10.1016/0735-1097(93)90097-k] [Citation(s) in RCA: 66] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVES The purpose of the present study was to assess the influence of variations in the relative degree of dilation of left and right ventricular chambers on the clinical outcome of patients with dilated cardiomyopathy. BACKGROUND Dilated cardiomyopathy, a primary myocardial disease characterized by ventricular dilation and systolic dysfunction, is generally associated with a poor prognosis. However, considerable variability has been observed in the clinical course and the morphologic and hemodynamic features in individual patients. METHODS We evaluated 67 consecutive patients with dilated cardiomyopathy and without evidence of ischemic or primary valvular heart disease. On the basis of diastolic ventricular chamber area measurements obtained by echocardiography, patients were classified into two groups: 38 patients with a relatively equal degree of left and right ventricular dilation (LV congruent to RV) and 29 patients with predominant and disproportionate dilation of the left ventricle (LV > RV). RESULTS The 67 patients ranged in age from 19 to 81 years (mean 56); 49 (73%) were male. The two subsets of patients with dilated cardiomyopathy did not differ with regard to age, left ventricular diastolic dimension, wall thickness and mass or ejection fraction. However, patients in the LV congruent to RV group showed more severe mitral and tricuspid regurgitation by Doppler echocardiography than did those in the LV > RV group (p = 0.01 for mitral and 0.004 for tricuspid regurgitation). Over the follow-up period of 2 to 60 months (mean 28), there were 19 deaths. Survival in the LV > RV group was significantly better than in the LV congruent to RV group (p = 0.03). CONCLUSIONS Patients with dilated cardiomyopathy represent a heterogeneous group with regard to both clinical outcome and the relative degree of left and right ventricular chamber dilation. Patients in the LV > RV subset appear to have better overall survival and less severe mitral and tricuspid regurgitation than do patients in the LV congruent to RV subset. Longitudinal studies are needed to determine whether these morphologic subsets in fact represent a continuum within the disease spectrum of dilated cardiomyopathy.
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Affiliation(s)
- J F Lewis
- Department of Medicine, Howard University College of Medicine, Washington, D.C
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Woodley SL, Gilbert EM, Anderson JL, O'Connell JB, Deitchman D, Yanowitz FG, Mealey PC, Volkman K, Renlund DG, Menlove R. Beta-blockade with bucindolol in heart failure caused by ischemic versus idiopathic dilated cardiomyopathy. Circulation 1991; 84:2426-41. [PMID: 1683602 DOI: 10.1161/01.cir.84.6.2426] [Citation(s) in RCA: 167] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND We investigated the effects of bucindolol, a nonselective, non-ISA beta-blocker with mild-vasodilatory properties, in patients with congestive heart failure from ischemic dilated cardiomyopathy (ISCDC, n = 27) and compared the results with those in subjects with heart failure from idiopathic dilated cardiomyopathy (IDC, n = 22). METHODS AND RESULTS Patients were randomized in a double-blind fashion to receive 12 weeks' treatment with either bucindolol or placebo, with randomization stratified for IDC or ISCDC: Invasive (right heart catheterization) and noninvasive (echo, MUGA, central venous norepinephrine, exercise treadmill studies, and symptom scores) tests of heart failure severity were determined at baseline and end of the study. For all subjects (ISCDC plus IDC), relative to placebo treatment, bucindolol-treated patients had significant improvement in ejection fraction, left ventricular size and filling pressure, stroke work index, symptom score, and central venous norepinephrine. However, most of these differences could be attributed to improvement in the IDC subgroup, as the only parameter with a statistically significant degree of improvement in the bucindolol-treated ISCDC subgroup was left ventricular size. CONCLUSIONS We conclude that beta-blockade may produce quantitatively different degrees of response in different kinds of heart muscle disease.
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Affiliation(s)
- S L Woodley
- Heart Failure Treatment Program, University of Utah School of Medicine, Salt Lake City
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Gilbert EM, Anderson JL, Deitchman D, Yanowitz FG, O'Connell JB, Renlund DG, Bartholomew M, Mealey PC, Larrabee P, Bristow MR. Long-term beta-blocker vasodilator therapy improves cardiac function in idiopathic dilated cardiomyopathy: a double-blind, randomized study of bucindolol versus placebo. Am J Med 1990; 88:223-9. [PMID: 1968710 DOI: 10.1016/0002-9343(90)90146-5] [Citation(s) in RCA: 199] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
PURPOSE Bucindolol is a potent nonselective beta-blocking agent with vasodilatory properties. In this study, we evaluated the effects of long-term bucindolol therapy in the treatment of heart failure from idiopathic dilated cardiomyopathy. PATIENTS AND METHODS Patients were eligible for enrollment if they had symptomatic heart failure, idiopathic dilated cardiomyopathy, and left ventricular ejection fraction less than 0.40. All patients received an initial test dose of 12.5 mg bucindolol orally every 12 hours for two or three doses. Patients tolerating the test dose were randomly assigned (double-blind) to receive bucindolol or placebo in a 3:2 ratio. Study medication was begun at a dose of 12.5 mg orally every 12 hours and gradually increased over a 1-month period until either a maximum tolerated dose or a target dose of 100 mg every 12 hours was reached. Study medication was then continued for an additional 2 months. RESULTS A total of 24 patients were enrolled into the study. Twenty-three patients tolerated bucindolol test challenge; 14 were randomized to receive bucindolol, and nine were randomly assigned to receive placebo. The placebo group (age 56 +/- 2 years) was significantly older than the bucindolol group (46 +/- 3 years), but by all other clinical and hemodynamic parameters the two groups were comparable. Twenty-two of 23 patients completed the study. Patients treated with bucindolol had significant improvements in clinical heart failure symptoms and in resting hemodynamic function, including an increase of left ventricular ejection fraction (0.26 +/- 0.02 to 0.35 +/- 0.09, p = 0.003), cardiac index (2.2 +/- 0.1 to 2.5 +/- 0.4 L/minute/m2, p = 0.014), and left ventricular stroke work index (25 +/- 3 to 35 +/- 7 g.m/m2, p = 0.002) and a decrease in pulmonary artery wedge pressure (17 +/- 3 to 10 +/- 5 mm Hg, p = 0.005) and heart rate (86 +/- 3 to 75 +/- 9 beats/minute, p = 0.012). Patients treated with bucindolol also had a significant increase in exercise left ventricular ejection fraction (0.26 +/- 0.03 to 0.32 +/- 0.14, p = 0.015) and reduction in questionnaire-measured symptoms (p = 0.007) and New York Heart Association functional class (p less than 0.001). However, total treadmill exercise duration and maximal oxygen consumption with exercise did not change. No changes in rest or exercise parameters were observed in the placebo-treated group. Central venous plasma norepinephrine concentration decreased significantly in the bucindolol-treated group (423 +/- 79 to 212 +/- 101 pg/mL, p = 0.010), but was unchanged in the placebo-treated group. CONCLUSION Bucindolol is well tolerated in patients with idiopathic dilated cardiomyopathy and congestive heart failure, and therapy for 3 months is associated with improved resting cardiac function, improved heart failure symptoms, and a reduction in venous norepinephrine concentration.
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Affiliation(s)
- E M Gilbert
- Heart Failure Treatment Program, University of Utah School of Medicine, Salt Lake City
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Ciaccheri M, Castelli G, Cecchi F, Nannini M, Santoro G, Troiani V, Zuppiroli A, Dolara A. Lack of correlation between intracavitary thrombosis detected by cross sectional echocardiography and systemic emboli in patients with dilated cardiomyopathy. Heart 1989; 62:26-9. [PMID: 2757871 PMCID: PMC1216726 DOI: 10.1136/hrt.62.1.26] [Citation(s) in RCA: 59] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
The correlation between intracavitary thrombosis detected by cross sectional echocardiography and systemic embolism was studied in 126 consecutive patients with idiopathic dilated cardiomyopathy who were examined from January 1980 to September 1987. A total of 1041 serial echocardiograms were obtained with 3.5 and 5 MHz transducers. The mean follow up period was 41.2 months. The survival rate was 88% at two years and 56% at five years. Echocardiography showed intracavitary thrombi in 14 (11.1%) patients; 13 were mural and 11 were localised at the apex of the left ventricle. Twelve patients (8.4%) had systemic emboli; this corresponded to an incidence of new embolic events of 1.4 for 100 patient-years. Patients with intracavitary thrombi or systemic emboli were treated with oral anticoagulants, as were nine in functional class IV of the New York Heart Association, for 61 patient-years. The cumulative observation period for the whole population study was 418 patient-years. None of the patients with intracavitary thrombosis had embolic complications and none of those with embolism had intracavitary thrombi. Rates of intracavitary thrombosis and systemic embolism in this series were low and there was no overlap between the two events. This may have been because the patients did not have severe dilated cardiomyopathy, because echocardiography did not detect all the thrombi, or because patients were treated with oral anticoagulants. The presence of intracardiac thrombosis detected by cross sectional echocardiography is not predictive of systemic embolism in patients with idiopathic dilated cardiomyopathy. Criteria for the use of the anticoagulant treatment remain largely empirical in these cases.
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Affiliation(s)
- M Ciaccheri
- Servizio di Cardiologia, Unità Sanitaria Locale 10/D, San Luca-Careggi, Florence, Italy
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Stewart WJ, Schiavone WA, Salcedo EE, Lever HM, Cosgrove DM, Gill CC. Intraoperative Doppler echocardiography in hypertrophic cardiomyopathy: correlations with the obstructive gradient. J Am Coll Cardiol 1987; 10:327-35. [PMID: 3598004 DOI: 10.1016/s0735-1097(87)80015-3] [Citation(s) in RCA: 65] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Although significant pressure gradients can be recorded across the left ventricular outflow tract in patients with hypertrophic cardiomyopathy, controversy exists regarding the presence or absence of true obstruction. Ten patients with hypertrophic cardiomyopathy were studied at the time of septal myectomy. A sterile continuous wave Doppler transducer was placed on the ascending aorta and directed toward the left ventricular outflow tract to measure velocity simultaneously with invasive gradient measured using solid-state hub transducers by direct puncture of the left ventricle and aorta. Simultaneous Doppler velocity and invasive gradient measurements (n = 33) were made at rest, before and after myectomy and during interventions with isoproterenol, volume loading and phenylephrine. High velocity flow with a characteristic contour was recorded in patients with a significant gradient. Using the modified Bernoulli equation (gradient = 4 X velocity), a good correlation was found between the Doppler-derived gradient and the peak instantaneous gradient measured invasively (r = 0.93, y = 0.89X + 12, p = 0.0001). Changes in gradient and velocity due to interventions also correlated well (r = 0.96, y = 0.91X - 3, p = 0.0001). Continuous wave Doppler echocardiography can accurately estimate the outflow tract gradient. The magnitude, timing and contour of these high velocity flow signals support the hypothesis that true obstruction is present in patients with hypertrophic cardiomyopathy who have a significant gradient.
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Damiano RJ, Tripp HF, Asano T, Small KW, Jones RH, Lowe JE. Left ventricular dysfunction and dilatation resulting from chronic supraventricular tachycardia. J Thorac Cardiovasc Surg 1987. [DOI: 10.1016/s0022-5223(19)36329-9] [Citation(s) in RCA: 71] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Maron BJ, Epstein SE. Clinical significance and therapeutic implications of the left ventricular outflow tract pressure gradient in hypertrophic cardiomyopathy. Am J Cardiol 1986; 58:1093-6. [PMID: 3776861 DOI: 10.1016/0002-9149(86)90118-9] [Citation(s) in RCA: 54] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Criley JM, Siegel RJ. Obstruction is unimportant in the pathophysiology of hypertrophic cardiomyopathy. Postgrad Med J 1986; 62:515-29. [PMID: 3534838 PMCID: PMC2418802 DOI: 10.1136/pgmj.62.728.515] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
There has been a longstanding controversy about the significance of intracavitary pressure gradients in hypertrophic cardiomyopathy (HCM). It has been generally assumed that the gradient is the result of an 'obstruction' that impedes left ventricular outflow and which can be relieved by operative intervention. In the first decade after the discovery of HCM (1957-66), the site of 'obstruction' was thought to be a muscular sphincter or contraction ring in the submitral region of the left ventricle, and operations designed to emulate pyloromyectomy (for hypertrophic pyloric stenosis) were developed. Following a challenge to the existence of the 'contraction ring' and an alternative non-obstructive explanation of the pressure gradient, the site of 'obstruction' was translocated to a point of apposition between the anterior mitral leaflet and the interventricular septum, a result of systolic anterior motion (SAM) of the mitral valve. Despite the translocation of the site and mechanism of 'obstruction', the operation for 'relief of obstruction' has not changed significantly. The newer site of 'obstruction' has been challenged on the grounds that the ventricle is not demonstrably impeded in its emptying; when a gradient is provoked, the ventricle empties more rapidly and more completely than it does without a gradient. In addition to a non-obstructive explanation of the gradient, other phenomena thought to be indicative of 'obstruction' can be explained by rapid and complete emptying of the ventricle (cavitary obliteration). Since the morbidity and mortality of symptomatic HCM patients without pressure gradients may exceed that of patients with pressure gradients, it is suggested that 'obstruction' may be unimportant in the pathophysiology of HCM and attention should be focused on abnormal diastolic function and life threatening arrhythmias.
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Abstract
The functional classification of the three types of cardiomyopathy has been helpful in organizing practitioners' thinking. The past three decades have witnessed tremendous advances in understanding of the pathophysiology, clinical and laboratory diagnosis, and treatment of these disorders. New doors of exploration are opening to answer such nagging questions as whether medical therapy alters long-term survival rates in dilated (congestive) cardiomyopathy, whether immunologic therapy will alter the course of dilated or restrictive/obliterative cardiomyopathy, and whether genetic manipulation or in utero therapy will prevent hypertrophic cardiomyopathy. The goals of effective treatment in all these disorders remain the same: amelioration of symptoms, prevention of sudden death, and constraint or resolution of the basic disease process. Achieving these goals requires a multidisciplinary approach, involving cardiologists, surgeons, immunologists, geneticists, cell biologists, virologists, and pathologists. Prospects are that one day treatment will no longer be an imprecise, palliative art but a definitive, curative science.
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Maron BJ, Gottdiener JS, Arce J, Rosing DR, Wesley YE, Epstein SE. Dynamic subaortic obstruction in hypertrophic cardiomyopathy: analysis by pulsed Doppler echocardiography. J Am Coll Cardiol 1985; 6:1-18. [PMID: 4040139 DOI: 10.1016/s0735-1097(85)80244-8] [Citation(s) in RCA: 130] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
To determine whether true obstruction to left ventricular ejection exists in patients with hypertrophic cardiomyopathy and a subaortic gradient, pulsed Doppler echocardiography was used to analyze the patterns of left ventricular emptying in 50 patients with hypertrophic cardiomyopathy (20 with and 30 without evidence of obstruction) and in 20 normal subjects. In obstructive hypertrophic cardiomyopathy, left ventricular ejection was characterized by early and rapid emptying (76 +/- 14% of aortic flow velocity in the initial one-third of systole). The proportion of forward flow velocity occurring before initial mitral-septal contact (and hence, by inference before the onset of the subaortic gradient) was variable, but averaged 58%. In contrast, the proportion of forward flow velocity occurring after mitral-septal contact (and, therefore, concomitant with the gradient and increased intraventricular pressure) was considerable, averaging over 40%. Mid-systolic impedance to left ventricular outflow was suggested by the rapid deceleration in aortic flow velocity concomitant with mitral-septal contact and premature partial aortic valve closure. Furthermore, left ventricular ejection was prolonged (384 +/- 40 ms) and the ventricle continued to empty and shorten during the period when both the pressure gradient and markedly increased intraventricular pressures were present. In 16 of 20 patients, a relatively small second peak in flow velocity appeared in late systole. Since marked systolic anterior motion of the mitral valve was still present, the late systolic portion of forward flow velocity also appeared to be largely ejected during imposition of a mechanical impediment to outflow. In contrast, patients with nonobstructive hypertrophic cardiomyopathy showed no evidence of impedance to left ventricular ejection. Aortic flow velocity waveforms were similar to those of normal subjects, with flow persisting to aortic valve closure; significant mitral systolic anterior motion and partial mid-systolic aortic valve closure were absent, and the systolic ejection period was normal (303 +/- 27 ms).(ABSTRACT TRUNCATED AT 400 WORDS)
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Medina R, Panidis IP, Morganroth J, Kotler MN, Mintz GS. The value of echocardiographic regional wall motion abnormalities in detecting coronary artery disease in patients with or without a dilated left ventricle. Am Heart J 1985; 109:799-803. [PMID: 3157304 DOI: 10.1016/0002-8703(85)90641-6] [Citation(s) in RCA: 47] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
To evaluate the usefulness of echocardiographic regional wall motion abnormalities (RWMA) in detecting coronary artery disease (CAD) in patients with left ventricular (LV) dysfunction and a normal-sized or dilated left ventricle, 103 patients were studied by two-dimensional echocardiography (2DE) and cardiac catheterization. In 60 patients (group I) who had LV dysfunction and a dilated left ventricle by echo (patients with dilated cardiomyopathy), RWMA were detected in 44 patients and 38 (86%) of them had significant CAD, usually two- or three-vessel obstruction; of the 16 patients with dilated cardiomyopathy (DCM) and diffuse LV hypokinesis, eight (50%) had evidence of CAD. Thus the presence of RWMA by 2DE had an 83% sensitivity, a 57% specificity, and a 77% predictive accuracy in detecting CAD in patients with DCM and thus in distinguishing ischemic from idiopathic DCM. In 43 patients with LV dysfunction but normal LV size (group II), the sensitivity, specificity, and predictive accuracy of RWMA in detecting significant CAD was 95%, 100%, and 95%, respectively. We conclude that the detection of RWMA by 2DE is highly suggestive of significant CAD in patients with LV dysfunction and normal-sized or dilated left ventricle; the finding, however, of diffuse LV hypokinesis does not exclude CAD in these patients, especially when the left ventricle is dilated.
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Chakko CS, Gheorghiade M. Ventricular arrhythmias in severe heart failure: incidence, significance, and effectiveness of antiarrhythmic therapy. Am Heart J 1985; 109:497-504. [PMID: 3976476 DOI: 10.1016/0002-8703(85)90554-x] [Citation(s) in RCA: 159] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Forty-three patients receiving maximal medical therapy for severe chronic heart failure from dilated cardiomyopathies (28 ischemic, 15 idiopathic) and ventricular premature beats (VPBs) on the 12-lead ECG had baseline 24-hour ambulatory ECG monitoring. Complex VPBs (multiform, repetitive--couplets, R on T phenomenon) and asymptomatic, nonsustained ventricular tachycardia were present in 38 patients (88%) and 22 patients (51%), respectively. Twenty-three patients (group I) were placed on long-term antiarrhythmic therapy (20 patients received procainamide and the remaining quinidine). Twenty patients (group II) did not receive antiarrhythmic therapy. At baseline, no significant differences between the two groups were noted for age, functional class, type of cardiomyopathy, medical therapy for heart failure, cardiothoracic ratio, radionuclide ejection fraction, or rate and complexity of the ventricular arrhythmias on the 24-hour ambulatory ECG tracings. At a mean follow-up period of 16 months (range 1 to 37), there were 16 deaths, 10 (62%) of which were sudden and unexpected. No significant differences in the incidence of sudden death and overall mortality were noted between the two groups. Among patients with nonsustained ventricular tachycardia, those who died suddenly had a lower mean left ventricular ejection fraction (0.15 +/- 0.01) when compared to the survivors (0.23 +/- 0.02; p less than 0.01). It is concluded that patients with severe heart failure have a high mortality from both sudden and nonsudden cardiac death, incidence of complex VPBs is very high, sudden death is more common when the left ventricular function is severely compromised, and apparently, therapeutic plasma levels of conventional antiarrhythmic drugs do not protect this group of patients from dying.
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Anderson JL, Lutz JR, Gilbert EM, Sorensen SG, Yanowitz FG, Menlove RL, Bartholomew M. A randomized trial of low-dose beta-blockade therapy for idiopathic dilated cardiomyopathy. Am J Cardiol 1985; 55:471-5. [PMID: 2857523 DOI: 10.1016/0002-9149(85)90396-0] [Citation(s) in RCA: 210] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Beta-blockade therapy to improve survival in idiopathic dilated cardiomyopathy (IDC) has been both advocated and criticized. However, randomized studies have not been performed. Thus, 50 patients with IDC were randomized in pairs to standard therapy (C) alone or with beta blockade (BB). Beta-blockade therapy with metoprolol was titrated from 12.5 to 50 mg twice daily as tolerated (final average dose, 61 mg/day). Groups were comparable in age (C, 50 +/- 15 years; BB, 51 +/- 13 years), gender (C, 76% male; BB, 56% male), entry functional class (C, 2.8 +/- 0.8; BB, 2.7 +/- 0.7), and left ventricular ejection fraction (C, 27 +/- 12%; BB, 29 +/- 10%). Follow-up averaged 19 months (range 1 to 38). One subject in each group was lost to follow-up. There were 3 early BB dropouts (within 2 days) due to low-output syndrome (2 patients) or fatigue (1 patient). Eleven patients died. By intention to treat, 5 BB and 6 C patients died (difference not significant). By actual treatment, 3 BB patients died, including 2 late dropouts (at 0.2, 10 and 17 months), and 8 C patients died (at 2, 9, 9, 15, 18, 24, 29 and 32 months, p = 0.12). In additional, functional evaluation on follow-up (functional class, San Diego questionnaire and exercise time) all tended to favor those receiving BB. Low-dose BB is tolerated in 80% of IDC patients on a long-term basis. Those continuing to take BB have a good prognosis. Mortality in C patients, however, is less than in some retrospective studies.(ABSTRACT TRUNCATED AT 250 WORDS)
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Kugler JD, Baisch SD, Cheatham JP, Latson LA, Pinsky WW, Norberg W, Hofschire PJ. Improvement of left ventricular dysfunction after control of persistent tachycardia. J Pediatr 1984; 105:543-8. [PMID: 6481531 DOI: 10.1016/s0022-3476(84)80417-5] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Five children are described who had persistent, chronic tachycardia and left ventricular dysfunction manifested by decreased left ventricular percent fractional shortening on echocardiogram (five patients) cardiomegaly on chest roentgenogram (three), ventricular or atrial hypertrophy on ECG (three), and symptoms of congestive heart failure (three). After antidysrhythmia therapy and control of the tachycardia, signs and symptoms of congestive heart failure resolved in two infants. Moreover, in each patient signs of cardiomegaly resolved on chest roentgenogram, hypertrophy resolved on ECG, and the fractional shortening improved to normal (mean 20.2% +/- 2.4% SEM before vs 36.2% +/- 2.4%, P = 0.02, after treatment). Evaluation in the child who has dilated cardiomyopathy should include assessment of heart rate and rhythm. Moreover, when persistent tachycardia is found in an asymptomatic child, evaluation of left ventricular function is indicated.
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Abstract
The term "ischemic cardiomyopathy" was used initially to describe a clinical syndrome that was indistinguishable from primary congestive cardiomyopathy but due to severe, diffuse coronary artery disease. The term has been expanded to include the larger category of myocardial disease secondary to coronary artery disease. Using this expanded definition, we have discussed the varied clinical presentations of congestive ischemic cardiomyopathy and restrictive ischemic cardiomyopathy (stiff heart syndrome and right ventricular infarction), and how the effects of ischemia on left ventricular systolic and diastolic performance may cause these varied presentations. The prognosis of any ischemic cardiomyopathy is related primarily to the degree of ventricular dysfunction and the extent of coronary artery disease. Therapy is aimed at preventing or ameliorating myocardial ischemia and halting the progression of, or even reversing, the deterioration in myocardial function.
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Tobin R, Slutsky RA, Higgins CB. Serial echocardiograms in patients with congestive cardiomyopathies: lack of evidence for thrombus formation. Clin Cardiol 1984; 7:99-101. [PMID: 6705298 DOI: 10.1002/clc.4960070205] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
We studied 90 patients with congestive myocardial disease documented at cardiac catheterization (46 idiopathic, 39 ischemic, and 5 hypertensive) who underwent M-mode and two-dimensional echocardiograms every 2-3 months for up to 7 years (mean 3.4 +/- 1.6 years, +/- 1 S.D.). All had angiographic evidence of severe left ventricular dysfunction (left ventricular ejection fraction less than 40%), and were on a variety of inotropic, diuretic, and vasodilating drugs. Only 9 were ingesting anticoagulants (5 warfarin and 4 aspirin), those on warfarin had documented pulmonary emboli or deep venous thrombosis. All but 4 patients were in normal sinus rhythm. Only one subject in this group was found to have a myocardial (left ventricular) thrombus. Postmortem examinations of 27 patients confirmed the ultrasound data. Thus, we conclude that cardiac thrombi are unusual in patients with congestive cardiomyopathies and rarely develop over the course of the illness even in the absence of chronic anticoagulation.
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