Restrictive left ventricular diastolic filling identifies patients with heart failure after acute myocardial infarction

Artificial intelligence-enabled ECG for left ventricular diastolic function and filling pressure

Assessment of left ventricular diastolic function plays a major role in the diagnosis and prognosis of cardiac diseases, including heart failure with preserved ejection fraction. We aimed to develop an artificial intelligence (AI)-enabled electrocardiogram (ECG) model to identify echocardiographically determined diastolic dysfunction and increased filling pressure. We trained, validated, and tested an AI-enabled ECG in 98,736, 21,963, and 98,763 patients, respectively, who had an ECG and echocardiographic diastolic function assessment within 14 days with no exclusion criteria. It was also tested in 55,248 patients with indeterminate diastolic function by echocardiography. The model was evaluated using the area under the curve (AUC) of the receiver operating characteristic curve, and its prognostic performance was compared to echocardiography. The AUC for detecting increased filling pressure was 0.911. The AUCs to identify diastolic dysfunction grades ≥1, ≥2, and 3 were 0.847, 0.911, and 0.943, respectively. During a median follow-up of 5.9 years, 20,223 (20.5%) died. Patients with increased filling pressure predicted by AI-ECG had higher mortality than those with normal filling pressure, after adjusting for age, sex, and comorbidities in the test group (hazard ratio (HR) 1.7, 95% CI 1.645-1.757) similar to echocardiography and in the indeterminate group (HR 1.34, 95% CI 1.298-1.383). An AI-enabled ECG identifies increased filling pressure and diastolic function grades with a good prognostic value similar to echocardiography. AI-ECG is a simple and promising tool to enhance the detection of diseases associated with diastolic dysfunction and increased diastolic filling pressure.

Incremental value of left atrial function analysis in the assessment of left ventricular filling pressures in patients with ST-elevation myocardial infarction

Background:

Left atrial (LA) reservoir strain provides interesting information about left ventricular (LV) filling pressure. However, the advantages of atrial reservoir strain in comparison with conventional parameters in patients with myocardial infarction are not clear yet.

Methods:

Fifty patients with ST-elevation myocardial infarction (STEMI) prospectively underwent echocardiographic assessment of LV systolic and diastolic function by conventional parameters and two-dimensional speckle tracking longitudinal strain of left atrium. LV filling pressure was estimated by brain natriuretic peptide (BNP) levels.

Results:

Systolic and conventional diastolic parameters did not show significant differences between patients with increased and normal BNP values, whereas LA reservoir strain was reduced (33.1 ± 8% vs. 46.5 ± 9.8%; P = 0.001) in patients with higher BNP levels. LA reservoir strain had higher area under curve value (0.880) than the other parameters in identifying patients with elevated BNP and a cut-off value of 40.5% reached sensitivity and specificity values of 93% and 86% and positive and negative predictive values of 92% and 85%. LA reservoir strain reclassified 23 patients with increased BNP values, which were previously estimated to have normal (16 patients) and undeterminable LA pressure (seven patients) by using the recommended algorithm for diastolic function.

Conclusions:

LA reservoir strain is a useful tool for the evaluation of diastolic function and seems to be more sensitive than conventional parameters in the detection of subtle increase of LV filling pressure in patients with STEMI. It allows physicians to reclassify patients with undeterminable diastolic function according to conventional algorithm.

Impact of right ventricular diastolic dysfunction on clinical outcomes in inferior STEMI

BACKGROUND

The aim of this study was to investigate the prognostic value of restrictive right ventricular filling pattern (RRVFP) in patients with the first acute inferior wall myocardial infarction (IWMI) complicated by right ventricular myocardial infarction (RVMI) undergoing primary percutaneous coronary intervention (p-PCI).

METHOD

A total of 152 patients with acute IWMI complicated by RVMI undergoing p‑PCI were divided into two groups according to the presence of RRVFP. RRVFP was defined as tricuspid diastolic early/late flow velocities (Et/At) > 2 and Et deceleration time (DT) < 120 ms.

RESULTS

There were 23 patients with RRVFP in the study cohort. At, DTt, isovolumetric relaxation time (IVRT), and tissue Doppler tricuspid annular late velocity (A't) were reduced significantly in patients with RRVFP than in those without RRVFP (At 19.6 ± 2.7 vs. 39.1 ± 7.4 cm/s, p < 0.001; DTt 106 ± 13 vs.156 ± 21 ms, p = 0.001; IVRT 59 ± 6.7 vs. 62 ± 7.4 ms, p = 0.01; A't 4.6 ± 1.1 vs. 8.6 ± 1.05, p = 0.001). Et/At ratios were higher in patients with RRVFP than in those without RRVFP (Et/At 2.20 ± 0.2 vs. 1.15 ± 0.37, p < 0.001). Et, tissue Doppler tricuspid annular early velocity (E't), E't/A't ratio, and Et/E't ratio were not significantly different between groups (Et 43.3 ± 5.4 vs. 40.7 ± 9.2 cm/s p = 0.18; E't 8.8 ± 1.4 vs. 9.5 ± 2.3, p = 0.15; E't/A't 1.08 ± 0.24 vs. 1.13 ± 0.30, p = 0.52; Et/E't ratio 5.0 ± 1.1 vs. 4.5 ± 1.5 p = 0.09). Presence of E't/A't > 2, short DTt, RRVFP, unsuccessful p‑PCI, and cardiogenic shock on admission were independent predictors of in-hospital mortality (p < 0.05) in multivariable logistic regression analysis.

CONCLUSION

Presence of RRVFP is associated with in-hospital mortality in patients presenting with their first IWMI complicated by RVMI.

Prolonged QRS duration on surface electrocardiogram is associated with left ventricular restrictive filling pattern

Background

Prolonged QRS duration is associated with decreased left ventricular (LV) systolic function. However, the relation between LV restrictive filling pattern (RFP) and QRS duration has not been investigated yet. The purpose of our study was to assess this relationship.

Methods

We analyzed standard 12-lead surface electrocardiogram (ECG) of 155 consecutive patients. Mitral inflow and septal tissue velocities were obtained using the apical 4-chamber view with pulsed Doppler echocardiography. Patients were divided into 2 groups according to measured deceleration time (DT): restrictive (with DT ≤130 ms) or non-restrictive (with DT >130 ms).

Results

QRS duration was significantly longer in the restrictive group than in the non-restrictive group (0.101 vs. 0.090 s, p < 0.0001). QRS duration of >0.10 s was highly specific (82.6%), but modestly sensitive (64.7%), for the prediction of LV RFP. Multivariate analyses demonstrated that E/A ratio, peak E, peak A, septal e’, and a’ velocities were significantly associated with RFP.

Conclusions

Prolonged QRS duration (>0.10 s) obtained from a standard resting 12-lead ECG is associated with LV RFP. However, the relationship of QRS duration with RFP was not independent of echocardiographic parameters.

Early changes of left ventricular filling pattern after reperfused ST-elevation myocardial infarction and doxycycline therapy: Insights from the TIPTOP trial

AIM

Metalloproteinases inhibition by doxycycline reduces cardiac protein degradation at extracellular and intracellular level in the experimental model ischemia/reperfusion injury. Since both extracellular cardiac matrix and titin filaments inside the cardiomyocyte are responsible for the myocardial stiffness, we hypothesized that doxycycline could favorably act on left ventricular (LV) filling pressures in patients after reperfused acute ST-elevation myocardial infarction (STEMI).

METHODS AND RESULTS

Seventy-three of 110 patients of the TIPTOP trial underwent a 2D-Echo-Doppler on admission, and at pre-discharge and at 6-month after a primary PCI for STEMI and LV dysfunction. From admission to pre-discharge, LV filling changed from a high filling pressure (HFP) to a normal filling pressure (NFP) pattern in 91% of the doxycycline-group, and in 67% of the control-group. Conversely, 1% of the doxycycline-group, and 37% of the control-group changed the LV filling from NFP to HFP pattern. Overall, a pre-discharge HFP pattern was present in 4 patients (11%) of the doxycycline-group and in 13 patients (36%) of the control-group (p=0.025). The evaluation of metalloproteinases and their tissue inhibitors plasma concentrations provide possible favorable action of doxycycline. On the multivariate analyses, troponine I peak (p=0.026), doxycycline (p=0.033), and on admission to pre-discharge LVEF changes (p=0.044) were found to be associated with pre-discharge HFP pattern. Independently of their baseline LV filling behavior, the 6-month remodeling was less in patients with pre-discharge NFP pattern than in patients with HFP pattern.

CONCLUSIONS

In patients with STEMI and LV dysfunction doxycycline can favorably modulate the LV filling pattern early after primary PCI.

Impact of Elevated End-Diastolic Pulmonary Regurgitation Gradient on Worse Clinical Outcomes in Hospitalized Patients With Heart Failure

The echo Doppler end-diastolic pulmonary regurgitation (EDPR) gradient correlates well with catheter-derived pulmonary artery diastolic pressure. An elevated EDPR gradient is associated with worse clinical outcomes in patients with stable coronary artery disease. However, the prognostic significance of EDPR gradient in patients with heart failure (HF) is unclear. The aim of the present study was to investigate the prognostic impact of EDPR gradient in HF. We retrospectively examined 751 consecutive hospitalized patients with acute HF. Those with acute coronary syndrome or in-hospital death and those without accessible EDPR gradient data at discharge were excluded. Finally, 265 patients were examined and divided into 2 groups according to EDPR gradient (cutoff 9 mm Hg). Adverse events were defined as worsening HF and death. Patients with elevated EDPR gradient had higher B-type natriuretic peptide, lower age, and lower left ventricular ejection fraction at discharge than those with nonelevated EDPR gradient. During a median follow-up of 429 days, elevated EDPR gradient was independently associated with adverse events (hazard ratio 2.34, 95% CI 1.44 to 3.78, p <0.001) after adjustment for confounders. In conclusion, echo Doppler EDPR gradient might be a noninvasive predictor of clinical outcomes in hospitalized patients with HF.

Heart failure with preserved left ventricular ejection fraction in patients with acute myocardial infarction

Background

The prevalence and clinical outcomes of heart failure with preserved left ventricular ejection fraction after acute myocardial infarction have not been well elucidated.

Objective

To analyze the prevalence of heart failure with preserved left ventricular ejection fraction in acute myocardial infarction and its association with mortality.

Methods

Patients with acute myocardial infarction (n = 1,474) were prospectively included. Patients without heart failure (Killip score = 1), with heart failure with preserved left ventricular ejection fraction (Killip score > 1 and left ventricle ejection fraction ≥ 50%), and with systolic dysfunction (Killip score > 1 and left ventricle ejection fraction < 50%) on admission were compared. The association between systolic dysfunction with preserved left ventricular ejection fraction and in-hospital mortality was tested in adjusted models.

Results

Among the patients included, 1,256 (85.2%) were admitted without heart failure (72% men, 67 ± 15 years), 78 (5.3%) with heart failure with preserved left ventricular ejection fraction (59% men, 76 ± 14 years), and 140 (9.5%) with systolic dysfunction (69% men, 76 ± 14 years), with mortality rates of 4.3%, 17.9%, and 27.1%, respectively (p < 0.001). Logistic regression (adjusted for sex, age, troponin, diabetes, and body mass index) demonstrated that heart failure with preserved left ventricular ejection fraction (OR 2.91; 95% CI 1.35–6.27; p = 0.006) and systolic dysfunction (OR 5.38; 95% CI 3.10 to 9.32; p < 0.001) were associated with in-hospital mortality.

Conclusion

One-third of patients with acute myocardial infarction admitted with heart failure had preserved left ventricular ejection fraction. Although this subgroup exhibited more favorable outcomes than those with systolic dysfunction, this condition presented a three-fold higher risk of death than the group without heart failure. Patients with acute myocardial infarction and heart failure with preserved left ventricular ejection fraction encounter elevated short-term risk and require special attention and monitoring during hospitalization.

Left atrium function in patients with coronary artery disease

PURPOSE OF REVIEW

The left atrial cavity has recently been identified as a potential biomarker for cardiac and cerebrovascular accidents. This review examines the potential of left atrial size and function in predicting cardiovascular disease in the general population and outcomes in coronary artery disease (CAD) patients.

RECENT FINDINGS

The atrium is perfused primarily by branches of the proximal left circumflex coronary artery (LCx), and depression of the cavity mechanical performance has been demonstrated in experimental studies during LCx occlusion. Thus, left atrial volume and function assessment may have prognostic relevance, particularly in CAD patients. Such a line of thinking, however, is challenged by the widespread notion that the contribution by left atrial chamber morphology and functional quantitation to the risk stratification process after a first cardiovascular event is not adequately considered. However, a number of studies have shown that left atrial volume predicts survival and major adverse events after an acute myocardial infarction. Left atrial remodeling also provides an important overall prognostic information and correlates with brain natriuretic peptide after primary percutaneous coronary interventions.

SUMMARY

Evaluation of left atrial size and function is currently of great interest and it will be more so in the very near future, given its potential for insights into the pathophysiology of the ischemic heart, which makes it an important clinical risk identifier in CAD patients.

Early improvement in serial echocardiographic studies in heart failure patients predicts long term survival-a pilot study

BACKGROUND

Several echocardiographic measures have prognostic value in heart failure (HF). However, no definitive data exist on how changes in these parameters with treatment affect survival in this patient population. We hypothesized that early improvement on echocardiography could predict long-term survival.

METHODS AND RESULTS

We conducted a retrospective review of 404 patients seen in the HF clinic from 2002 to 2008 (6.5 years). Patients had one echocardiogram ≤1 year before and another ≥1 month (10 ± 7 months) after treatment onset. We studied changes in standard echocardiographic parameters, including left (LV) and right (RV) ventricular size and/or function (systolic and/or diastolic), valvular (mitral and tricuspid) function, and pulmonary artery pressure. Survival curves and hazard ratios were generated for patients showing improvement on the 2nd echocardiogram versus those who did not. Multivariable analyses were performed adjusting for age, sex, ischemic etiology, and significant baseline echocardiographic parameters. Average follow-up was 2.9 ± 1.5 years. Improvement in LV end-systolic dimension, RV function, and mitral regurgitation were independent predictors of 5-year survival (P < .05) and, importantly, more predictive than baseline values of these parameters alone (higher hazard ratios).

CONCLUSIONS

Early echocardiographic improvement is strongly associated with 5-year survival in patients with HF. Serial echocardiography may aid in stratifying patient care.

Left ventricular diastolic function in hypertension: methodological considerations and clinical implications

The assessment of left ventricular (LV) diastolic function should be an integral part of a routine examination of hypertensive patient; indeed when LV diastolic function is impaired, it is possible to have heart failure even with preserved LV ejection fraction. Left ventricular diastolic dysfunction (LVDD) occurs frequently and is associated to heart disease. Doppler echocardiography is the best tool for early LVDD diagnosis. Hypertension affects LV relaxation and when left ventricular hypertrophy (LVH) occurs, it decreases compliance too, so it is important to calculate Doppler echocardiography parameters, for diastolic function evaluation, in all hypertensive patients. The purpose of our review was to discuss about the strong relationship between LVDD and hypertension, and their relationship with LV systolic function. Furthermore, we aimed to assess the relationship between the arterial stiffness and LV structure and function in hypertensive patients.

Left atrial function assessed by left atrial strain in patients with left circumflex branch culprit acute myocardial infarction

INTRODUCTION

Although left atrium (LA) has played an important role in diastole, ischemic insult of atrium in acute myocardial infarction (AMI) has not been clearly evaluated.

METHODS

We hypothesized that LA function would be further decreased in AMI patients with a culprit lesion in the left circumflex branch (LCX). This was an observational cohort study in a single university hospital. Echocardiography was performed to evaluate left ventricular diastolic function, LA volume, and LA function. Systolic (LAS ) and late diastolic (LAA ) LA strain were measured using speckle tracking echocardiography.

RESULTS

Sixty-eight AMI patients treated with emergent or urgent percutaneous coronary intervention were enrolled. Global LAS strain was significantly lower in patients with a culprit lesion in the LCX than culprit lesions in other vessels (left anterior descending, 27.3 ± 6.8%; left circumflex, 20.1 ± 8.9%; right coronary artery, 23.3 ± 6.5%; P = 0.007). LA volume index did not differ significantly (P = 0.093). Other clinical and conventional echocardiographic parameters, including Doppler measurements, did not differ significantly.

CONCLUSIONS

Global LAS strain was lower in AMI patients with a culprit lesion in the LCX than those with culprit lesions in other vessels, without any significant difference in LA volume index. The lower global LAS strain might suggest decreased LA function resulting from ischemic insult by AMI with culprit lesions in the LCX.

Relationship of left atrial global peak systolic strain with left ventricular diastolic dysfunction and brain natriuretic peptide level in patients presenting with non-ST elevation myocardial infarction

Background

In patients presenting with non-ST elevation myocardial infarction, we investigated the relationship of left atrial deformational parameters evaluated by 2-dimensional speckle tracking imaging (2D-STI) with conventional echocardiographic diastolic dysfunction parameters and brain natriuretic peptide level.

Material/Methods

We enrolled 74 non-ST segment elevation myocardial infarction patients who were treated with percutaneous coronary intervention and 58 healthy control subjects. Non-ST segment elevation myocardial infarction patients had echocardiographic examination 48 h after the percutaneous coronary intervention procedure and venous blood samples were drawn simultaneously. In addition to conventional echocardiographic parameters, left atrial strain curves were obtained for each patient. Average peak left atrial strain values during left ventricular systole were measured.

Results

BNP values were higher in non-ST segment elevation myocardial infarction patients compared to controls. Mean left atrium peak systolic global longitudinal strain in Group 2 (the control group) was higher than in the non-ST segment elevation myocardial infarction group. Left atrium peak systolic global longitudinal strain was significantly correlated with left ventricular ejection fraction. There was a significant inverse correlation between left atrium peak systolic global longitudinal strain and brain natriuretic peptide level, left atrium volume maximum, and left atrium volume minimum.

Conclusions

Our study shows that Left atrium peak systolic global longitudinal strain values decreased consistently with deteriorating systolic and diastolic function in non-ST segment elevation myocardial infarction patients treated with percutaneous coronary intervention. Left atrium peak systolic global longitudinal strain measurements may be helpful as a complimentary method to evaluate diastolic function in this patient population.

Imaging techniques in the evaluation of post-infarction function and scar

Imaging techniques are essential in the clinical evaluation of patients with a myocardial infarction. They are of value for both initial assessment of the ischemic injury and for detection of the subgroup of patients at higher risk of developing cardiovascular events during follow-up. Echocardiography remains the technique of choice for the initial evaluation, owing to its bedside capability to determine strong predictors, such as ventricular volumes, global and regional systolic function, and valvular regurgitation. New techniques for evaluating ventricular mechanics, mainly assessment of ventricular deformation, are revealing important aspects of post-infarction ventricular adaptation. The main alternative to echocardiography is cardiac magnetic resonance imaging. This technique is highly accurate for determining ventricular volumes and ventricular function and has the additional advantage of being able to characterize the myocardium and demonstrate changes associated with the ischemic insult such as necrosis/fibrosis, edema, microvascular obstruction, and intramyocardial hemorrhage. These features not only allow detection and quantification of the infarct size, but also reveal additional characteristics of the scar tissue with prognostic value.

Comparison of left ventricular function following first ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention in men versus women

Previous data reported worse outcomes in female patients after acute ST elevation myocardial infarction (STEMI), related at least in part to less aggressive and nonparallel treatment. We investigated the presence of gender differences in left ventricular (LV) systolic and diastolic function in patients presenting with first STEMI, treated with primary percutaneous coronary intervention (PCI). Study population included 187 consecutive patients (81% men) presenting with STEMI and treated by primary PCI and guideline-based medications. Their mean age was 58 ± 10 years. All patients underwent a comprehensive echocardiographic evaluation within 3 days of admission. Female patients were older (62 ± 11 vs 59 ± 10 years, p = 0.006), with more co-morbidities and longer symptom duration (490 ± 436 vs 365 ± 437 minutes, p = 0.013). Echocardiography demonstrated that female patients had significantly lower LV systolic function (47 ± 8% vs 45 ± 8%, p = 0.03), lower septal and lateral e' velocities, higher average E/e' ratio (all p <0.001), elevated systolic pulmonary artery pressure (p = 0.03), and worse diastolic dysfunction (p = 0.007). No significant changes were present in left atrial volumes. In a logistic multivariate analysis model, female gender emerged as an independent predictor of septal e' <8 cm/s (odds ratio 10.11, 95% confidence interval 1.23 to 82.32, p = 0.002) and E/average e' ratio >15 (odds ratio 6.47, 95% confidence interval 1.63 to 25.61, p = 0.008). In conclusion, female patients undergoing primary PCI for first STEMI demonstrated worse systolic and diastolic LV function, despite receiving similar treatment as male patients.

Left ventricular diastolic function and long-term outcomes in patients with normal exercise echocardiographic findings

The objective of the present study was to determine whether diastolic dysfunction (DD) is associated with outcomes in the absence of myocardial ischemia. We studied 2,835 patients undergoing exercise echocardiography from January 2006 through December 2006 who had normal systolic function (ejection fraction ≥50%) and an absence of exercise-induced wall motion abnormalities. Diastolic function was graded as normal, mild DD, or moderate to severe DD. Medical records review and patient contact were undertaken to determine mortality, cardiovascular events (i.e., death, myocardial infarction, or stroke), incident heart failure (HF), and hospitalization. The mean ± SD age was 58.9 ± 12.8 years, and 54.0% were women. DD was present in 40.0% of the participants, with mild DD in 28.2% and moderate to severe DD in 11.8%. During a median follow-up of 4.4 years, 81 deaths and 114 cardiovascular events occurred, and DD was associated with greater rates of mortality, cardiovascular events, and HF events or hospitalizations (all p <0.001). On multivariate analysis, mild or moderate to severe DD (referent, normal function) was associated with HF or hospitalization (hazard ratio 1.45, 95% confidence interval 1.18 to 1.78, p <0.001 for mild DD; hazard ratio 1.75, 95% confidence interval 1.37 to 2.24, p <0.001 for moderate to severe DD) but was not independently associated with death or cardiovascular events. The diastolic index of filling pressure (E/e') was independently associated with mortality, cardiovascular events, and HF or hospitalization. In conclusion, among patients without demonstrable myocardial ischemia, left ventricular DD was associated with greater event rates during long-term follow up but did not independently predict hard end points other than HF or hospitalization. E/e' was independently associated with the clinical outcomes and might be an important echocardiographically derived parameter to identify in patients undergoing exercise echocardiography.

Relation of left atrial peak systolic strain with left ventricular diastolic dysfunction and brain natriuretic peptide level in patients presenting with ST-elevation myocardial infarction

BACKGROUND

In patients presenting with ST-elevation myocardial infarction (STEMI), we investigated the relation of left atrial (LA) deformational parameters evaluated by two-dimensional speckle tracking imaging (2D-STI) with conventional echocardiographic diastolic dysfunction parameters and B-type natriuretic peptide (BNP) level.

METHODS

Ninety STEMI patients who were treated with primary percutaneous coronary intervention (PCI) and 22 healthy control subjects were enrolled. STEMI patients had echocardiographic examination 48 hours after the PCI procedure and venous blood samples were drawn simultaneously. In addition to conventional echocardiographic parameters, LA strain curves were obtained for each patient. Average peak LA strain values during left ventricular (LV) systole (LAs-strain) were measured.

RESULTS

BNP values were higher in MI patients compared to controls. Mean LAs-strain in control group was higher than MI group (30.6 ± 5.6% vs. 21.6 ± 6.6%; p = 0.001). LAs-strain had significant correlation with LVEF (r = 0.51, p = 0.001), also significant inverse correlations between LAs-strain and BNP level (r = -0.41, p = 0.001), E/Em (r = -0.30, p = 0.001), LA maximal volume (r = -0.41, p = 0.001), LA minimal volume (r = -0.50, p = 0.001) and LV end systolic volume (r = -0.37, p = 0.001) were detected. The cut off value of LAs-strain to predict BNP > 100 pg/ml was determined as 19.9% with 55.3% sensitivity and 77.2% specificity (p < 0.05 AUC:0.7).

CONCLUSION

Our study showed that LAs-strain values decreased consistently with deteriorating systolic and diastolic function in STEMI patients treated with primary PCI. LA-s strain measurements may be helpful as a complimentary method to evaluate diastolic function in this patient population.

Percutaneous Assist Devices for Infarct Size Reduction

Improving myocyte salvage during acute myocardial infarction (AMI) has proved elusive; the keys to success seem to be the ability to lower oxygen demand of ischemic myocardium and also activate salvage enzyme pathways to take advantage of endogenous cardioprotective mechanisms. Pharmacologic approaches have been largely unsuccessful. A percutaneous left ventricular (LV) assist device could improve myocyte salvage during AMI therapy if it were able to reduce myocardial oxygen demand, wall tension, and LV stroke work substantially.

Perioperative assessment of diastolic dysfunction

Assessment of diastolic function should be a component of a comprehensive perioperative transesophageal echocardiographic examination. Abnormal diastolic function exists in >50% of patients presenting for cardiac and high-risk noncardiac surgery, and has been shown to be an independent predictor of adverse postoperative outcome. Normalcy of systolic function in 50% of patients with congestive heart failure implicates diastolic dysfunction as the probable etiology. Comprehensive evaluation of diastolic function requires the use of various, load-dependent Doppler techniques This is further complicated by the additional effects of dehydration and anesthetic drugs on myocardial relaxation and compliance as assessed by these Doppler measures. The availability of more sophisticated Doppler techniques, e.g., Doppler tissue imaging and flow propagation velocity, makes it possible to interrogate left ventricular diastolic function with greater precision, analyze specific stages of diastole, and to differentiate abnormalities of relaxation from compliance. Additionally, various Doppler-derived ratios can be used to estimate left ventricular filling pressures. The varying hemodynamic environment of the operating room mandates modification of the diagnostic algorithms used for ambulatory cardiac patients when left ventricular diastolic function is evaluated with transesophageal echocardiography in anesthetized surgical patients.

The prognostic value of early left ventricular longitudinal systolic dysfunction in asymptomatic subjects with cardiovascular risk factors

BACKGROUND

Early diagnosis of left ventricular (LV) dysfunction represents a major challenge in asymptomatic subjects with cardiovascular (CV) risk factors. Tissue Doppler imaging (TDI) has emerged as an important tool with clinical relevance in several cardiac diseases.

HYPOTHESIS

To evaluate the prognostic ability of TDI in detecting early longitudinal ventricular dysfunction in a large group of asymptomatic subjects with CV risk factors (RsF), normal LV systolic function, and normal diastolic function.

METHODS

A total of 554 subjects (mean age 55 ± 13 years, 39% men) formed our study population: controls, 144 healthy subjects; group 1, 163 subjects with 1 CV RsF; group 2, 147 subjects with 2 CV RsF; group 3, 100 subjects with ≥3 CV RsF. All subjects underwent a comprehensive standard echo-Doppler evaluation, including posterior wall TDI study. Follow-up data were available in all the studied samples (mean 28 ± 16 mo).

RESULTS

Upon follow-up, 18 individuals (3.2%) developed a first overt CV event. The presence of a peak systolic velocity <7.5 cm/second showed a significant additional predictive value compared with the presence of CV RsF (P<0.001).

CONCLUSIONS

Tissue Doppler imaging is able to identify early longitudinal LV systolic abnormalities in the presence of apparently normal systolic and diastolic function. It demonstrated a significant additional prognostic value compared with the simple presence of coexisting CV RsF. These findings could be clinically relevant in identifying asymptomatic subjects with CV RsF who need early, tailored preventive treatment.

Echocardiographic predictors of early in-hospital heart failure during first ST-elevation acute myocardial infarction: does myocardial performance index and left atrial volume improve diagnosis over conventional parameters of left ventricular function?

BACKGROUND

Left ventricular ejection fraction (LVEF) has been considered a major determinant of early outcome in acute myocardial infarction (AMI). Myocardial performance index (MPI) has been associated to early evolution in AMI in a heterogeneous population, including non ST-elevation or previous AMI. Left atrial volume has been related with late evolution after AMI. We evaluated the independent role of clinical and echocardiographic variables including LVEF, MPI and left atrial volume in predicting early in-hospital congestive heart failure (CHF) specifically in patients with a first isolated ST-elevation AMI.

METHODS

Echocardiography was performed within 30 hours of chest pain in 95 patients with a first ST-elevation AMI followed during the first week of hospitalization. Several clinical and echocardiographic variables were analyzed. CHF was defined as Killip class ≥ II. Multivariate regression analysis was used to select independent predictor of in-hospital CHF.

RESULTS

Early in-hospital CHF occurred in 29 (31%) of patients. LVEF ≤ 0.45 was the single independent and highly significant predictor of early CHF among other clinical and echocardiographic variables (odds ratio 17.0; [95% CI 4.1 - 70.8]; p < 0.0001). MPI alone could not predict CHF in first ST-elevation AMI patients. Left atrial volume was not associated with early CHF in such patients.

CONCLUSION

For patients with first, isolated ST-elevation AMI, LVEF assessed by echocardiography still constitutes a strong and accurate independent predictor of early in-hospital CHF, superior to isolated MPI and left atrial volume in this particular subset of patients.

Risk factors for development of left ventricular thrombus after first acute anterior myocardial infarction-association with anticardiolipin antibodies

Background

Left ventricular thrombus(LVT] formation is a frequent complication in patients with acute anterior myocardial infarction(MI). LVT is associated with increased risk of embolism and higher mortality rates after acute MI. Anticardiolipin antibodies (ACA) are immunoglobulins that react with phospholipid-binding proteins interfering with the prothrombin activator complex. The effects of phospholipids on pathophysiology of cardiovascular thrombotic events are well known. In this study, we aimed to evaluate the importance of clinical and biochemical parameters including anticardiolipin antibodies on left ventricular thrombus formation after acute anterior MI.

Methods and Results

Seventy patients with a first anterior AMI were prospectively and consecutively enrolled. Patients with previous MI, autoimmune disease, collagen vascular disease and arterial or venous thrombosis history were excluded from this study. At the time of hospitalization, key demographic and clinical characteristics were collected including age, gender, ethanol intake and presence of traditional risk factors for atherosclerosis (hypertension, diabetes, smoking, hyperlipidemia, positive family history). Patients were evaluated for echocardiographic data, blood chemistry and ACA. Two-dimensional and Doppler echocardiographic examinations were performed in all patients within the first week and at 14 days after MI. LV thrombus was detected in 30 (42.8%) patients. ACA IgM levels were significantly higher in the patient group with LV thrombus than in the group without thrombus (12.44 ±4.12 vs. 7.69 ± 4.25 mpl, p = 0,01). ACA IgG levels were also found higher in the group with LV thrombus (24.2 ± 7.5 vs.17.98 ± 6.45 gpl, p = 0.02). Multivariate analyses revealed diabetes mellitus, higher WMSI, lower MDT and higher ACA IgM and higher ACA IgG levels as independent predictors of left ventricular thrombus formation.

Conclusions

Our data demonstrate that beside the low ejection fraction, lower MDT and higher wall motion score index, modestly elevated ACA IgM and ACA IgG levels are associated with LV thrombus formation in patients with anterior MI.

Smoking and atherosclerotic cardiovascular disease: part III: functional biomarkers influenced by smoking

Smoking cigarettes induces rapidly occurring and reversible functional changes in the cardiovascular system, which precede morphologic changes. These functional changes are also related to atherosclerotic disease development and thus may qualify as prognostic parameters in chronic smokers. As opposed to smoking-induced morphologic changes functional alterations occur and revert within minutes, thus, allowing for the detection of smoking-induced effects on the cardiovascular system within minutes following exposure to mainstream smoke. Some alterations represent 'direct' changes (e.g., endothelial function), others reflect changes in a different organ system (e.g., the autonomous nervous system influencing heart rate variability), while some represent the sum of alterations in many organs and systems (e.g., exercise performance influenced by the autonomous nervous and by endothelial and cardiac function). Since a specific functional parameter usually changes with at least one or several others, caution should be exercised when trying to establish a direct cause relationship between the alteration of a single parameter and a clinical outcome.

Usefulness of a combination of systolic function by left ventricular ejection fraction and diastolic function by E/E' to predict prognosis in patients with heart failure

Left ventricular (LV) ejection fraction (EF) was known as a conventional predictor of heart failure (HF). However, early transmitral flow velocity (E)/early diastolic velocity of mitral annulus (E') correlated well with LV end-diastolic pressure, and E/E' ratio >15 was an excellent predictor of adverse outcomes in patients with HF. This study was designed to determine the prognostic value of a new combined index, E/E' ratio and LVEF, in patients with HF. One hundred twenty-six consecutive patients hospitalized with HF underwent comprehensive echocardiographic-Doppler study when ready for discharge. Patients were divided into the 4 groups of group I (LVEF >40% and E/E' ratio <15), group II (EF >40% and E/E' ratio >or=15), group III (EF <or=40% and E/E' ratio <15), and group IV (EF <or=40% and E/E' ratio >or=15). The ability of this index to determine the primary end point (rehospitalization for HF or cardiac death) was assessed. Patients with significant valvular disease were excluded. Of 126 patients, 110 met the inclusion criteria. Follow-up was complete for 108 of 110 patients at 351 +/- 252 days after discharge. There were 27, 30, 21, and 30 patients in groups I, II, III, and IV, respectively. There were 52 patients with the primary end point. On univariate analysis, E/E' ratio, group IV, E', and age were significant predictors. In multivariable analysis, the most powerful independent prognostic indicator of events was group IV (hazard ratio 12.6, 95% confidence interval 2.2 to 74.2, p = 0.005). In conclusion, a new index, a combination of LVEF and E/E' ratio, allowed the identification of patients at higher risk of readmission and cardiac death in patients with HF.

Early predictors of late dilation and remodeling after thrombolized anterior transmural myocardial infarction

BACKGROUND AND HYPOTHESIS

Dilation of the left ventricle after myocardial infarction is associated with an adverse prognosis. There are no clinical studies on the role viable myocardium in the infarcted area assumes in relation to the development of late ventricular remodeling. The hypothesis of this study was to define the relation between remodeling and the presence of viable but akinetic myocardium in the infarct area and to identify early predictors of left ventricular (LV) dilation at 1 year.

METHODS

In all, 92 consecutive patients with myocardial infarction were divided into two groups according to their ventricular volumes. Group I included 57 patients with normal volumes at discharge (9 +/- 3 days after acute infarction) and after 12 months or with LV dilation at discharge who had a normalization of their volumes over a 12-month period. Group II included 35 patients who, independent of their initial volumes, developed LV dilation during follow-up. Low-dose dobutamine infusion was utilized at discharge for echocardiographic evaluation of contractile recovery of viable myocardial segments.

RESULTS

At the first control, patients in Group I presented an end-diastolic volume index (EDVI) of 100 +/- 7 ml/m2 which decreased to 68.8 +/- 6.5 ml/m2 12 months later (p < 0.0001), and an end-systolic volume index (ESVI) of 47.6 +/- 6.7 ml/m2 at the first control and 30.5 +/- 8.8 ml/m2 after 12 months (p < 0.001). Patients in Group II presented a mean EDVI of 116.2 +/- 8.1 ml/m2 at the first control and 138.8 +/- 8 ml/m2 12 months later (p < 0.001), and a mean ESVI of 68.8 +/- 6.5 ml/m2 at the first control and 79.5 +/- 5.4 after 12 months (p < 0.01). Ventricular mass index (VMI) in Group I increased from 106.4 +/- 11 to 122.3 +/- 15 g/m2 (p < 0.01), while in Group II it decreased from 101.1 +/- 10 to 98.7 +/- 8 g/m2 (p = NS). In Group I, mass-to-volume ratio was 1.15 +/- 0.1 g/ml at the first control and 1.67 +/- 0.1 g/ml 12 months later (p < 0.001), while in Group II it declined from 0.88 +/- 0.1 to 0.69 +/- 0.1 g/ml (p < 0.01). The multivariate analysis revealed that ejection fraction < or = 40%, restrictive filling pattern, wall motion score index > 2.5 in response to dobutamine infusion, and mass-to-volume ratio < or = 1 g/ml, all at discharge, as well as an occluded left anterior descending artery discriminate in favor of late LV dilation and remodeling.

CONCLUSIONS

Correct use of noninvasive strategies should result in early identification of postinfarct patients who are at risk of developing LV remodeling.

Tissue Doppler imaging a new prognosticator for cardiovascular diseases

Tissue Doppler imaging (TDI) is evolving as a useful echocardiographic tool for quantitative assessment of left ventricular (LV) systolic and diastolic function. Recent studies have explored the prognostic role of TDI-derived parameters in major cardiac diseases, such as heart failure, acute myocardial infarction, and hypertension. In these conditions, myocardial mitral annular or basal segmental (Sm) systolic and early diastolic (Ea or Em) velocities have been shown to predict mortality or cardiovascular events. In particular, those with reduced Sm or Em values of <3 cm/s have a very poor prognosis. In heart failure and after myocardial infarction, noninvasive assessment of LV diastolic pressure by transmitral to mitral annular early diastolic velocity ratio (E/Ea or E/Em) is a strong prognosticator, especially when E/Ea is > or =15. In addition, systolic intraventricular dyssynchrony measured by segmental analysis of myocardial velocities is another independent predictor of adverse clinical outcome in heart failure subjects, even when the QRS duration is normal. In heart failure patients who received cardiac resynchronization therapy, the presence of systolic dyssynchrony at baseline is associated with favorable LV remodeling, which in turn predicts a favorable long-term clinical outcome. Finally, TDI and derived deformation parameters improve prognostic assessment during dobutamine stress echocardiography. A high mean Sm value in the basal segments of patients with suspected coronary artery disease is associated with lower mortality rate or myocardial infarction and is superior to the wall motion score.

Prognosis in myocardial infarction patients with heart failure and normal or mildly impaired systolic function

PURPOSE

To assess factors of importance for long term prognosis in patients with acute myocardial infarction (AMI) and heart failure and normal or mildly reduced left ventricular systolic function.

SUBJECTS AND METHODS

Seventy-one consecutive AMI-survivors with clinical or radiological signs of heart failure and an echocardiographically determined wall motion score >1.2 (EF >35-40%) were followed during 11 years for mortality, heart failure readmissions and new ischemic events.

RESULTS

Seventeen patients died (24%) while the combined endpoint of death or a new ischemic event (MI or hospitalisation for angina pectoris) occurred in 40 (56%) and fatal or non-fatal heart failure in 20 (28%) patients, respectively. A pre-discharge echocardiographic assessment of diastolic function was obtained in 67 patients out of whom 56 (84%) had diastolic dysfunction, most frequently relaxation abnormalities (43%). Wall motion score did not differ between survivors and non-survivors (1.48+/-0.20 vs. 1.44+/-0.18; p=0.46). Adjusting for age, sex and wall motion score N-terminal pro-ANP, prolongation of the isovolumic relaxation time and exercise induced ST-depressions at discharge (global chi2=26.2; p<0.0001) remained as independent mortality predictors while re-admission for heart failure was predicted by wall motion score, N-terminal pro-ANP and previous heart failure (global chi2=23.7; p<0.001). Death or new ischemic events were associated with low Doppler A-wave flow velocity and male sex (global chi2=14.0; p<0.01).

CONCLUSIONS

Evaluation of diastolic function and a natriuretic peptide adds prognostically important information in AMI-patients with clinical heart failure and normal or mildly reduced left ventricular systolic function. Isovolumic relaxation time is an independent predictor of long term mortality and N-terminal pro-ANP of mortality and heart failure.

Diastolic dysfunction is an independent risk factor for death in patients with sickle cell disease

OBJECTIVES

The goal of this study was to characterize left ventricular diastolic function in the sickle cell disease (SCD) population and to relate echocardiographic measures of dysfunction with pulmonary hypertension and mortality.

BACKGROUND

Pulmonary hypertension has been identified as a predictor of death in the adult SCD population. Although diastolic dysfunction is also observed in this population, its prevalence, association with high pulmonary artery systolic pressure, and attributable mortality remain unknown.

METHODS

Diastolic function assessment using tissue Doppler imaging was performed in a group of 141 SCD patients. Conventional echocardiographic parameters of diastolic function were performed in a total of 235 SCD patients.

RESULTS

Diastolic dysfunction was present in 18% of patients. A combination of diastolic dysfunction and pulmonary hypertension was present in 11% of patients, and diastolic dysfunction accounted for only 10% to 20% of the variability in tricuspid regurgitation (TR) jet velocity. Diastolic dysfunction, as reflected by a low E/A ratio, was associated with mortality with a risk ratio of 3.5 (95% confidence interval 1.5 to 8.4, p < 0.001), even after adjustment for tricuspid regurgitation (TR) jet velocity. The presence of both diastolic dysfunction and pulmonary hypertension conferred a risk ratio for death of 12.0 (95% confidence interval 3.8 to 38.1, p < 0.001).

CONCLUSIONS

Diastolic dysfunction and pulmonary hypertension each contribute independently to prospective mortality in patients with SCD. Patients with both risk factors have an extremely poor prognosis. These data support the implementation of echocardiographic screening of adult patients with SCD to identify high-risk individuals for further evaluation.

The prognostic value of the mitral diastolic filling velocity ratio for all-cause mortality and cardiovascular morbidity in African Americans: the Atherosclerotic Risks in Communities (ARIC) study

BACKGROUND

Although recent data suggest that the mitral diastolic early-to-late (E/A) ratio may be prognostic in selected population-based cohorts, its predictive value for morbidity and mortality in African Americans has not yet been well studied.

METHODS

The study population consisted of African American participants from the Jackson cohort of the Atherosclerotic Risks in Community Study. Three subgroups of E/A ratios were defined: E/A <0.7, E/A 0.7-1.5, and E/A >1.5, using the middle group as reference. Cox proportional hazard models were used to assess the association between the E/A ratio and both all-cause mortality and incident cardiovascular disease (CVD). The mean follow-up period was 6.8 +/- 1.3 years.

RESULTS

Of the 2211 participants in the study population (mean age 62 years, 65.1% women), 8.2% had an E/A ratio <0.7, 84.7% had an E/A 0.7-1.5, and 7.1% had an E/A >1.5. An E/A >1.5 was independently associated with all-cause mortality (hazard ratio [HR] 2.18, 95% confidence interval [CI] 1.20-4.03) in the multivariable model. An E/A <0.7 was associated with higher all-cause mortality (HR 1.79, 95% CI 1.17-2.73) and incident CVD (HR 1.91, 95% CI 1.29-2.83) compared with a normal E/A in the age and sex adjusted model but was not independently predictive in the multivariable model (P > .05).

CONCLUSIONS

In a population-based cohort of middle-aged African Americans, an E/A >1.5 independently predicts all-cause mortality. An E/A >1.5 and an E/A <0.7 were both associated with incident CVD when adjusted for age and sex alone but were not independently predictive in the multivariable analysis.