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Slavich M, Ricchetti G, Demarchi B, Cavalli G, Spoladore R, Federico A, Federico F, Bezzi C, Margonato A, Fragasso G. Clinical and functional effects of beta-blocker therapy discontinuation in patients with biventricular heart failure. J Cardiovasc Med (Hagerstown) 2024; 25:141-148. [PMID: 38149700 DOI: 10.2459/jcm.0000000000001571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2023]
Abstract
BACKGROUND Nearly two-thirds of patients with heart failure with reduced ejection fraction (HFrEF) have right ventricular dysfunction, previously identified as an independent predictor of reduced functional capacity and poor prognosis. Beta-blocker therapy (β-BT) reduces mortality and hospitalizations in patients with HFrEF and is approved as first-line therapy regardless of concomitant right ventricular function. However, the exact role of sympathetic nervous system activation in right ventricular dysfunction and the potential usefulness (or harmfulness) of β-BT in these patients are still unclear. OBJECTIVES The aim of the study is to evaluate the medium-term effect of β-BT discontinuation on functional capacity and right ventricular remodelling based on cardiopulmonary exercise testing (CPET), echocardiography and serum biomarkers in patients with clinically stable biventricular dysfunction. METHODS In this single-centre, open-label, prospective trial, 16 patients were enrolled using the following criteria: patients were clinically stable without signs of peripheral congestion; NYHA II-III while on optimal medical therapy (including β-BT); LVEF 40% or less; echocardiographic criteria of right ventricular dysfunction. Patients were randomized 1 : 1 either to withdraw (group 0) or continue (group 1) β-BT. In group 0, optimal heart rate was obtained with alternative rate-control drugs. Echo and serum biomarkers were performed at baseline, after 3 and 6 months; CPET was performed at baseline and 6 months. Mann--Whitney U test was adopted to determine the relationships between β-BT discontinuation and effects on right ventricular dysfunction. RESULTS At 6 months' follow up, S' DTI improved (ΔS': 1.01 vs. -0.92 cm/s; P = 0.03), while estimated PAPs (ΔPAPs: 0.8 vs. -7.5 mmHg; P = 0.04) and echo left ventricular-remodelling (ΔEDVi: 19.55 vs. -0.96 ml/mq; P = 0.03) worsened in group 0. In absolute terms, the only variables significantly affected by β-BT withdrawal were left ventricular EDV and ESV, appearing worse in group 0 (mean EDVi 115 vs. 84 ml/mq; mean ESVi 79 vs. 53.9 ml/mq, P = 0.03). No significant changes in terms of functional capacity were observed after β-BT withdrawal. CONCLUSION In HFrEF patients with concomitant right ventricular dysfunction, β-BT discontinuation did not produce any beneficial effects. In addition, despite maintenance of optimal heart rate control, β-BT discontinuation induced worsening of left ventricular remodelling. Our study corroborates the hypothesis that improvement in left ventricular function may likewise be a major determinant for improvement in right ventricular function, reducing pulmonary wedge pressure and right ventricular afterload, with only a marginal action of its negative inotropic effect. In conclusion, β-BT appears beneficial also in heart failure patients with biventricular dysfunction.
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Affiliation(s)
- Massimo Slavich
- Department of Cardiology, IRCCS San Raffaele Scientific Institute
| | | | - Barbara Demarchi
- Department of Cardiology, IRCCS San Raffaele Scientific Institute
| | - Giulio Cavalli
- Immunology, Rheumatology, Allergology and Rare Diseases Unit, IRCCS Ospedale San Raffaele
| | | | - Anna Federico
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Milan, Italy
| | | | - Carolina Bezzi
- Nuclear Medicine Department, IRCCS San Raffaele Scientific Institute
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Bethlehem C, Bootsma IT, De Lange F, Boerma EC. Identifying risk factors for perioperative decline in right ventricular performance in cardiac surgery patients: a prospective observational study in a tertiary care hospital. BMJ Open 2023; 13:e068598. [PMID: 36828663 PMCID: PMC9972410 DOI: 10.1136/bmjopen-2022-068598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 02/15/2023] [Indexed: 02/26/2023] Open
Abstract
OBJECTIVES Impaired right ventricular (RV) function after cardiac surgery is associated with morbidity and long-term mortality. The purpose of this study was to identify factors that play a role in the development of RV dysfunction in the perioperative cardiac surgery setting. DESIGN We performed a prospective, observational, single centre study. Over a 2-year period, baseline and perioperative characteristics were recorded. For analysis, subjects were divided into three groups: patients with a ≥3% absolute increase in postoperative RV ejection fraction (RVEF) in comparison to baseline (RVEF+), patients with a ≥3% absolute decrease in RVEF (RVEF-) and patients with a <3% absolute change in RVEF (RVEF=). SETTING Tertiary care hospital in the Netherlands. PARTICIPANTS We included all cardiac surgery patients ≥18 years of age equipped with a pulmonary artery catheter and admitted to the ICU in 2015-2016. There were no exclusion criteria. A total number of 267 patients were included (65.5% men). OUTCOME MEASURES Risk factors for a perioperative decline in RV function. RESULTS A reduction in RVEF was observed in 40% of patients. In multivariate analysis, patients with RVEF- were compared with patients with RVEF= (first-mentioned OR) and RVEF+ (second-mentioned OR). Preoperative use of calcium channel blocker (CCB) (OR 3.06, 95% CI 1.24 to 7.54/OR 2.73, 95% CI 1.21 to 6.16 (both p=0.015)), intraoperative fluid balance (FB) (OR 1.45, 95% CI 1.02 to 2.06 (p=0.039)/OR 1.09, 95% CI 0.80 to 1.49 (p=0.575)) and baseline RVEF (OR 1.22; 95% CI 1.14 to 1.30/OR 1.27, 95% CI 1.19 to 1.35 (both p<0.001)) were identified as independent risk factors for a decline in RVEF during surgery. CONCLUSION Apart from the impact of the perioperative FB, preoperative use of a CCB as a risk factor for perioperative reduction in RVEF is the most prominent new finding of this study.
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Affiliation(s)
- Carina Bethlehem
- Department of Intensive Care, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
- Department of Clinical Pharmacy and Pharmacology, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - Inge T Bootsma
- Department of Intensive Care, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
| | - Fellery De Lange
- Department of Intensive Care, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
| | - E Christiaan Boerma
- Department of Intensive Care, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
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Briasoulis A, Stamatelopoulos K, Petropoulos I, Patras R, Theodorakakou F, Gavriatopoulou M, Ntalianis A, Dimopoulos MA, Kastritis E. Utilization and tolerance of beta-blockers among patients with AL amyloidosis. Amyloid 2022; 29:31-37. [PMID: 34549676 DOI: 10.1080/13506129.2021.1981281] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND The utilization and clinical impact of beta-blockers (BBs) in cardiac amyloidosis (CA) is largely unexplored. METHODS We conducted a retrospective, single-center analysis of indications, timing of initiation, types and doses of BB used, reasons to discontinue BB and association between BB tolerance and outcomes in a cohort of patients with immunoglobulin light chain amyloidosis (AL). RESULTS We reviewed 236 patients with AL CA and identified 53 patients taking BB (22.5%). Most patients presented in New York Heart Association Class (NYHA) II or III (74.5%) and 24% presented in Mayo stage IIIB. The most frequent indications for BB initiation were atrial fibrillation (AF) and coronary artery disease (CAD). In most cases (59%) BB was started before the diagnosis of CA. The median duration of BB treatment was 9 months (interquartile range [IQR] 3-24 months). Among patients receiving BB, 28 tolerated BB during follow-up whereas 25 patients discontinued BB. The main causes of BB discontinuation were hypotension and heart failure (HF) exacerbation. Patients intolerant to BB presented with more advanced NYHA class, worse performance status and lower median left ventricular ejection fraction (LVEF) at baseline. At median follow-up duration of 17.7 months, patients who did not tolerate BB had a poor survival. CONCLUSIONS Although some patients with CA may have indications for treatment with BB, their use is uncommon and those with more advanced disease tolerate BB poorly. Intolerance to BB in patients with cardiac AL is an indicator of poorer outcome.
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Affiliation(s)
- Alexandros Briasoulis
- Department of Clinical Therapeutics, National Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Kimon Stamatelopoulos
- Department of Clinical Therapeutics, National Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Ioannis Petropoulos
- Department of Clinical Therapeutics, National Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Raphael Patras
- Department of Clinical Therapeutics, National Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Foteini Theodorakakou
- Department of Clinical Therapeutics, National Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Maria Gavriatopoulou
- Department of Clinical Therapeutics, National Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Argyrios Ntalianis
- Department of Clinical Therapeutics, National Kapodistrian University of Athens, Medical School, Athens, Greece
| | | | - Efstathios Kastritis
- Department of Clinical Therapeutics, National Kapodistrian University of Athens, Medical School, Athens, Greece
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Galves R, Da Costa A, Pierrard R, Bayard G, Guichard JB, Isaaz K. Impact of β-blocker therapy on right ventricular function in heart failure patients with reduced ejection fraction. A prospective evaluation. Echocardiography 2020; 37:1392-1398. [PMID: 32815195 DOI: 10.1111/echo.14813] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 06/30/2020] [Accepted: 07/16/2020] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Beta-blocker (β-blocker) therapy has been shown to improve mortality and reduce hospitalizations in patients with heart failure (HF) with reduced ejection fraction (HFrEF). Although the physiological action mechanisms of β-blockers are well described, their effects on right ventricular (RV) function have not been prospectively studied. OBJECTIVE This prospective study aimed to (a) evaluate whether β-blocker therapy impacts RV remodeling based on echo parameters and (b) determine the predictive echo factors of β-blocker therapy response. METHODS From September 2017 to September 2018, HF patients were prospectively enrolled using CIBIS criteria: Class II, III, or IV HF; left ventricular ejection fraction (LVEF) of ≤40%; hospitalized for HF within the previous 12 months. Echo evaluation was performed before initiating β-blocker therapy and 3 months after optimal dose adjustment. Based on previous studies, patients with (absolute) LVEF ≥ 5% improvement were considered significant β-blocker therapy responders. RESULTS Overall, 40 patients (pts) completed the study, characterized as follows by age: 70 ± 10 years; gender: 10 women; cardiomyopathy etiology: idiopathic in 24 and ischemic in 16; NYHA Class: II in 22 and III in 10; LVEF: 32 ± 5%; and NTProBNP: 2665 ± 2400 pg/mL. The final population comprised 32 pts (79%), with eight (21%) excluded: two because of β-blocker therapy intolerance, one lost to follow-up, and five withdrew from the study. Under β-blocker therapy, several echo parameters significantly improved: LVEF from 31.7 ± 9 to 40.5 ± 9 (P < .0001); LV end-diastolic volume (EDV) from 154 ± 54 to 143 ± 45 mL (P = .06); LV end-systolic volume (ESV) from 107 ± 49 to 88 ± 37 mL (P = .0006); LV ES from 46 ± 11 to 64 ± 13 mL (P = .008); LV end-diastolic diameter (EDD) from 57 ± 9 to 54 ± 6 mm (P = .04); LV end-systolic diameter (ESD) from 48 ± 10 to 44 ± 7 mm (P = .007); and right ventricular systolic pressure (RV SP) from 39 ± 10 to 32 ± 8 mm Hg (P = .0001). Significant modifications were observed in terms of RV echo parameters: right ventricular (RV) size decreased from 30 ± 4 to 27 ± 5 mm (P = .03), while RV systolic function significantly improved based on tricuspid annular plane systolic excursion (TAPSE) (16.5 ± 4 vs. 19 ± 4 mm; 0.0006); DTI-derived tricuspid lateral annular systolic velocity wave (S') (10 ± 2 vs. 11.3 ± 3 cm/s; P = .03); and RIMP (Tei index) (0.5 ± 0.1 vs 0.46 ± 0.1; P = .04). RV 2D fractional area change (%) did not significantly differ despite a clear improvement tendency (35 ± 6 vs. 37 ± 4%; P = .1). No significant modifications were observed concerning LV diastolic parameters. Overall, β-blocker echo responders (n = 23/32; 72%) exhibited the same left and right echo parameters. No echo variables predicted the β-blocker response. CONCLUSIONS In HFrEF pts, β-blocker therapy significantly improves LV and RV systolic remodeling. Accordingly, β-blocker therapy could be applied as soon as possible in HFrEF patients with right ventricular dysfunction so as to limit RV remodeling.
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Affiliation(s)
- Rémi Galves
- Division of Cardiology CHU Saint Etienne, Jean Monnet University, Saint-Etienne, France
| | - Antoine Da Costa
- Division of Cardiology CHU Saint Etienne, Jean Monnet University, Saint-Etienne, France
| | - Romain Pierrard
- Division of Cardiology CHU Saint Etienne, Jean Monnet University, Saint-Etienne, France
| | - Geoffrey Bayard
- Division of Cardiology CHU Saint Etienne, Jean Monnet University, Saint-Etienne, France
| | | | - Karl Isaaz
- Division of Cardiology CHU Saint Etienne, Jean Monnet University, Saint-Etienne, France
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McCutcheon K, Manga P. Left ventricular remodelling in chronic primary mitral regurgitation: implications for medical therapy. Cardiovasc J Afr 2019; 29:51-65. [PMID: 29582880 PMCID: PMC6002796 DOI: 10.5830/cvja-2017-009] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Accepted: 01/12/2017] [Indexed: 01/07/2023] Open
Abstract
Surgical repair or replacement of the mitral valve is currently the only recommended therapy for severe primary mitral regurgitation. The chronic elevation of wall stress caused by the resulting volume overload leads to structural remodelling of the muscular, vascular and extracellular matrix components of the myocardium. These changes are initially compensatory but in the long term have detrimental effects, which ultimately result in heart failure. Understanding the changes that occur in the myocardium due to volume overload at the molecular and cellular level may lead to medical interventions, which potentially could delay or prevent the adverse left ventricular remodelling associated with primary mitral regurgitation. The pathophysiological changes involved in left ventricular remodelling in response to chronic primary mitral regurgitation and the evidence for potential medical therapy, in particular beta-adrenergic blockers, are the focus of this review.
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Affiliation(s)
- Keir McCutcheon
- Division of Cardiology, Department of Internal Medicine, Charlotte Maxeke Johannesburg Academic Hospital and University of the Witwatersrand, Johannesburg, South Africa.
| | - Pravin Manga
- Division of Cardiology, Department of Internal Medicine, Charlotte Maxeke Johannesburg Academic Hospital and University of the Witwatersrand, Johannesburg, South Africa
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Konstam MA, Kiernan MS, Bernstein D, Bozkurt B, Jacob M, Kapur NK, Kociol RD, Lewis EF, Mehra MR, Pagani FD, Raval AN, Ward C. Evaluation and Management of Right-Sided Heart Failure: A Scientific Statement From the American Heart Association. Circulation 2018; 137:e578-e622. [DOI: 10.1161/cir.0000000000000560] [Citation(s) in RCA: 335] [Impact Index Per Article: 55.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background and Purpose:
The diverse causes of right-sided heart failure (RHF) include, among others, primary cardiomyopathies with right ventricular (RV) involvement, RV ischemia and infarction, volume loading caused by cardiac lesions associated with congenital heart disease and valvular pathologies, and pressure loading resulting from pulmonic stenosis or pulmonary hypertension from a variety of causes, including left-sided heart disease. Progressive RV dysfunction in these disease states is associated with increased morbidity and mortality. The purpose of this scientific statement is to provide guidance on the assessment and management of RHF.
Methods:
The writing group used systematic literature reviews, published translational and clinical studies, clinical practice guidelines, and expert opinion/statements to summarize existing evidence and to identify areas of inadequacy requiring future research. The panel reviewed the most relevant adult medical literature excluding routine laboratory tests using MEDLINE, EMBASE, and Web of Science through September 2017. The document is organized and classified according to the American Heart Association to provide specific suggestions, considerations, or reference to contemporary clinical practice recommendations.
Results:
Chronic RHF is associated with decreased exercise tolerance, poor functional capacity, decreased cardiac output and progressive end-organ damage (caused by a combination of end-organ venous congestion and underperfusion), and cachexia resulting from poor absorption of nutrients, as well as a systemic proinflammatory state. It is the principal cause of death in patients with pulmonary arterial hypertension. Similarly, acute RHF is associated with hemodynamic instability and is the primary cause of death in patients presenting with massive pulmonary embolism, RV myocardial infarction, and postcardiotomy shock associated with cardiac surgery. Functional assessment of the right side of the heart can be hindered by its complex geometry. Multiple hemodynamic and biochemical markers are associated with worsening RHF and can serve to guide clinical assessment and therapeutic decision making. Pharmacological and mechanical interventions targeting isolated acute and chronic RHF have not been well investigated. Specific therapies promoting stabilization and recovery of RV function are lacking.
Conclusions:
RHF is a complex syndrome including diverse causes, pathways, and pathological processes. In this scientific statement, we review the causes and epidemiology of RV dysfunction and the pathophysiology of acute and chronic RHF and provide guidance for the management of the associated conditions leading to and caused by RHF.
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Ezekowitz JA, O'Meara E, McDonald MA, Abrams H, Chan M, Ducharme A, Giannetti N, Grzeslo A, Hamilton PG, Heckman GA, Howlett JG, Koshman SL, Lepage S, McKelvie RS, Moe GW, Rajda M, Swiggum E, Virani SA, Zieroth S, Al-Hesayen A, Cohen-Solal A, D'Astous M, De S, Estrella-Holder E, Fremes S, Green L, Haddad H, Harkness K, Hernandez AF, Kouz S, LeBlanc MH, Masoudi FA, Ross HJ, Roussin A, Sussex B. 2017 Comprehensive Update of the Canadian Cardiovascular Society Guidelines for the Management of Heart Failure. Can J Cardiol 2017; 33:1342-1433. [PMID: 29111106 DOI: 10.1016/j.cjca.2017.08.022] [Citation(s) in RCA: 443] [Impact Index Per Article: 63.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 08/28/2017] [Accepted: 08/28/2017] [Indexed: 02/06/2023] Open
Abstract
Since the inception of the Canadian Cardiovascular Society heart failure (HF) guidelines in 2006, much has changed in the care for patients with HF. Over the past decade, the HF Guidelines Committee has published regular updates. However, because of the major changes that have occurred, the Guidelines Committee believes that a comprehensive reassessment of the HF management recommendations is presently needed, with a view to producing a full and complete set of updated guidelines. The primary and secondary Canadian Cardiovascular Society HF panel members as well as external experts have reviewed clinically relevant literature to provide guidance for the practicing clinician. The 2017 HF guidelines provide updated guidance on the diagnosis and management (self-care, pharmacologic, nonpharmacologic, device, and referral) that should aid in day-to-day decisions for caring for patients with HF. Among specific issues covered are risk scores, the differences in management for HF with preserved vs reduced ejection fraction, exercise and rehabilitation, implantable devices, revascularization, right ventricular dysfunction, anemia, and iron deficiency, cardiorenal syndrome, sleep apnea, cardiomyopathies, HF in pregnancy, cardio-oncology, and myocarditis. We devoted attention to strategies and treatments to prevent HF, to the organization of HF care, comorbidity management, as well as practical issues around the timing of referral and follow-up care. Recognition and treatment of advanced HF is another important aspect of this update, including how to select advanced therapies as well as end of life considerations. Finally, we acknowledge the remaining gaps in evidence that need to be filled by future research.
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Affiliation(s)
| | - Eileen O'Meara
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | | | - Michael Chan
- Edmonton Cardiology Consultants, Edmonton, Alberta, Canada
| | - Anique Ducharme
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | - Adam Grzeslo
- Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | | | | | | | | | - Serge Lepage
- Université de Sherbrooke, Sherbrooke, Québec, Canada
| | | | | | - Miroslaw Rajda
- QEII Health Sciences Centre, Halifax, Nova Scotia, Canada
| | | | - Sean A Virani
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | | | | | - Sabe De
- London Health Sciences, Western University, London, Ontario, Canada
| | | | - Stephen Fremes
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Lee Green
- University of Alberta, Edmonton, Alberta, Canada
| | - Haissam Haddad
- University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Karen Harkness
- Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | | | - Simon Kouz
- Centre Hospitalier Régional de Lanaudière, Joliette, Québec, Canada
| | | | | | | | - Andre Roussin
- Centre hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Bruce Sussex
- Memorial University, St John's, Newfoundland, Canada
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Yang Y, Yam Y, Chen L, Aljizeeri A, Aliyary Ghraboghly S, Al-Harbi I, Pen A, Ruddy TD, Chow BJW. Assessment of left ventricular ejection fraction using low radiation dose computed tomography. J Nucl Cardiol 2016; 23:414-21. [PMID: 26002814 DOI: 10.1007/s12350-015-0123-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Accepted: 03/09/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND Cardiac CT is a non-invasive modality with the ability to estimate LVEF. However, given its limited temporal resolution and radiation, there has been initial resistance to use CT to measure LVEF. Developing an accurate, fast, low radiation dose protocol is desirable. OBJECTIVE The objective of this study is to demonstrate that a 'low radiation dose' 64 slice cardiac computed tomography (CT) protocol is feasible and can accurately measure left ventricular ejection fraction (LVEF) while delivering a radiation dose lower than radionuclide angiography (RNA). METHODS Patients undergoing RNA were prospectively screened and enrolled to undergo a 'low-dose' 64 slice CT LVEF protocol. LVEF measures, duration of each study and radiation dose between CT and RNA were compared. RESULTS A total of 77 patients (mean age = 61.8 ± 12.2 years and 58 men) were analyzed. The mean LVEF measured by CT and RNA were 41.9 ± 15.2% and 39.4 ± 13.9%, respectively, (P = 0.154) with a good correlation (r = 0.863). Bland-Altman plot revealed a good agreement between the CT and RNA LVEF (mean difference of -2.4). There was good agreement between CT LVEF and RNA for identifying patients with LVEF ≤30% (kappa = 0.693) and LVEF ≥50% (kappa = 0.749). The mean dose estimated effective dose for CT and RNA were 4.7 ± 1.6 and 9.5 ± 1.0 mSv, respectively. The mean CT LVEF imaging duration (4:32 ± 3:05 minutes) was significantly shorter than the RNA image acquisition time (9:05 ± 2:36 minutes; p < 0.001). CONCLUSION The results of our study suggest that low-dose CT LVEF protocol is feasible, accurate, and fast while delivering a lower radiation dose than traditional RNA.
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Affiliation(s)
- YiQi Yang
- Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada
| | - Yeung Yam
- Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada
| | - Li Chen
- Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, Canada
| | - Ahmed Aljizeeri
- Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada
| | - Siamak Aliyary Ghraboghly
- Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada
| | - Ibraheem Al-Harbi
- Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada
| | - Ally Pen
- Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada
| | - Terrence D Ruddy
- Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada
- Department of Radiology, University of Ottawa, Ottawa, Canada
| | - Benjamin J W Chow
- Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada.
- Department of Radiology, University of Ottawa, Ottawa, Canada.
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Yang Y, Yam Y, Chen L, Aljizeeri A, Aliyary Ghraboghly S, Al-Harbi I, Pen A, Ruddy TD, Chow BJW. Erratum to: Assessment of left ventricular ejection fraction using low radiation dose computed tomography. J Nucl Cardiol 2016; 23:422. [PMID: 26092631 DOI: 10.1007/s12350-015-0211-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- YiQi Yang
- Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada
| | - Yeung Yam
- Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada
| | - Li Chen
- Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, Canada
| | - Ahmed Aljizeeri
- Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada
| | - Siamak Aliyary Ghraboghly
- Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada
| | - Ibraheem Al-Harbi
- Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada
- Department of Medicine (Cardiology), King Fahad Hospital, Medina, Saudi Arabia
| | - Ally Pen
- Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada
| | - Terrence D Ruddy
- Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada
- Department of Radiology, University of Ottawa, Ottawa, Canada
| | - Benjamin J W Chow
- Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada.
- Department of Radiology, University of Ottawa, Ottawa, Canada.
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Andersen S, Andersen A, de Man FS, Nielsen-Kudsk JE. Sympathetic nervous system activation and β-adrenoceptor blockade in right heart failure. Eur J Heart Fail 2015; 17:358-66. [PMID: 25704592 DOI: 10.1002/ejhf.253] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Revised: 01/22/2015] [Accepted: 01/23/2015] [Indexed: 11/07/2022] Open
Abstract
Right heart failure may develop from pulmonary arterial hypertension or various forms of congenital heart disease. Right ventricular adaptation to the increased afterload is the most important prognostic factor in pulmonary hypertension and congenital heart disease, which share important pathophysiological mechanisms, despite having different aetiologies. There is substantial evidence of increased sympathetic nervous system activation in right heart failure related to both pulmonary hypertension and congenital heart disease. It is unknown to which degree this activation is an adaptive response, a maladaptive response, or if it mainly reflects disease progression. Several experimental studies and clinical trials have been conducted to answer these questions. Here, we review the existing knowledge on sympathetic nervous system activation and the effects of β-adrenoceptor blockade in experimental and clinical right heart failure. This review identifies important gaps in our understanding of the right ventricle and discusses the potential of β-blockers in the treatment of right heart failure.
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Affiliation(s)
- Stine Andersen
- Department of Cardiology - Research, Institute of Clinical Medicine, Aarhus University Hospital, Brendstrupgaardsvej 100, 8200, Aarhus N, Denmark
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Abstract
The function of the right ventricle (RV) in heart failure (HF) has been mostly ignored until recently. A 2006 report of the National Heart, Lung, and Blood Institute identified a gap between RV research efforts and its clinical importance compared with that of the left ventricle. This recent shift in paradigm is fueled by the prognostic value ascribed to RV failure in HF and morbidity/mortality after myocardial infarction and surgery. In this review, we examine the significance of RV failure in the HF setting, its clinical presentation and pathophysiology, and ways to evaluate RV function using echocardiographic measurements. Furthermore, we discuss the medical management of RV failure including traditional therapies like beta-blockers and newer options like nitric oxide, phosphodiesterase inhibitors, and calcium sensitizers. Mechanical support is also examined. Finally, this review places an emphasis on RV failure in the setting of left ventricular assist devices and heart transplantation.
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Meuwese CL, Kirkels JH, de Jonge N, Nathoe HM, Doevendans PA, Klöpping C. Beta-blocker therapy in unstable severe heart failure, evidence or experience? Neth Heart J 2012; 21:3-5. [PMID: 23239450 DOI: 10.1007/s12471-012-0366-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Currently, no evidence exists on the effects of beta-receptor blocker (BRB) treatment in patients with unstable severe heart failure. When confronted with this specific patient category, clinical experience in our centre has consistently guided us to lower the dose or stop BRB therapy. To share this experience, we present three clinical case scenarios and discuss background literature motivating our approach in these patients.
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Affiliation(s)
- C L Meuwese
- Department of Cardiology, Utrecht Medical Centre, Utrecht, the Netherlands
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14
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Desai RV, Meyer P, Ahmed MI, Mujib M, Adamopoulos C, White M, Aban IB, Iskandrian AE, Ahmed A. Relationship between left and right ventricular ejection fractions in chronic advanced systolic heart failure: insights from the BEST trial. Eur J Heart Fail 2010; 13:392-7. [PMID: 21097899 DOI: 10.1093/eurjhf/hfq206] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
AIMS Abnormally low right ventricular ejection fraction (RVEF) is a predictor of poor outcomes in chronic heart failure (HF) patients with low left ventricular ejection fraction (LVEF). However, little is known about the relationship between LVEF and RVEF in these patients. METHODS AND RESULTS Of the 2707 Beta-blocker Evaluation of Survival Trial (BEST) participants with ambulatory chronic HF, New York Heart Association class III-IV symptoms, and LVEF ≤ 35%, 2008 patients had gated-equilibrium radionuclide angiographic data on baseline LVEF and RVEF. Patients were categorized into quartiles by LVEF ≥ 29% (n = 507), 23-28% (n = 513), 17-22% (n = 538), and < 17% (n = 450). Logistic regression models were used to determine the association of LVEF quartiles (reference, ≥ 29%) with abnormally low RVEF (<20%). The prevalence of RVEF < 20% for patients with LVEF quartiles ≥ 29, 23-28, 17-22, and < 17% were 3, 6, 15, and 32%, respectively. Unadjusted odds ratios [95% confidence intervals (CIs)] for RVEF < 20% (vs. ≥ 20%) associated with LVEF quartiles 23-28, 17-22, and < 17% (reference, ≥ 29%) were 2.18 (1.14-4.17; P = 0.018), 6.32 (3.54-11.30; P < 0.001), and 16.67 (9.46-29.39; P < 0.001), respectively. Respective multivariable-adjusted odds ratios (95% CIs) were 1.82 (0.94-3.54; P = 0.076), 4.55 (2.48-8.35; P < 0.001), and 10.53 (5.70-19.44; P< 0.001), respectively. Heart failure symptoms and signs had unadjusted associations with low RVEF, but lacked intrinsic associations. CONCLUSION In patients with advanced systolic HF, LVEF has a strong dose-dependent relationship with RVEF which is independent of other characteristics, and low LVEF is useful as a surrogate marker of abnormally low RVEF in these patients.
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Affiliation(s)
- Ravi V Desai
- University of Alabama at Birmingham, 1530 3rd Ave South, CH19, Ste-219, Birmingham, AL 35294-2041, USA
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15
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Banerjee D, Haddad F, Zamanian RT, Nagendran J. Right Ventricular Failure: A Novel Era of Targeted Therapy. Curr Heart Fail Rep 2010; 7:202-11. [DOI: 10.1007/s11897-010-0031-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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16
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Tratamiento basado en la evidencia de la insuficiencia cardiaca derecha: una revisión sistemática de un campo empírico. Rev Esp Cardiol 2010. [DOI: 10.1016/s0300-8932(10)70066-x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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17
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Right ventricular stunning in inferior myocardial infarction. Int J Cardiol 2009; 136:294-9. [DOI: 10.1016/j.ijcard.2008.05.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2007] [Revised: 05/09/2008] [Accepted: 05/10/2008] [Indexed: 11/20/2022]
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18
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Manrique A, Bernard M, Hitzel A, Bauer F, Ménard JF, Sabatier R, Jacobson A, Véra P, Agostini D. Prognostic value of sympathetic innervation and cardiac asynchrony in dilated cardiomyopathy. Eur J Nucl Med Mol Imaging 2008; 35:2074-81. [DOI: 10.1007/s00259-008-0889-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2008] [Accepted: 06/23/2008] [Indexed: 01/08/2023]
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19
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Norozi K, Buchhorn R, Wessel A, Bahlmann J, Raab B, Geyer S, Kuehne T, Beibei L, Werdan K, Loppnow H. Beta-Blockade Does Not Alter Plasma Cytokine Concentrations and Ventricular Function in Young Adults With Right Ventricular Dysfunction Secondary to Operated Congenital Heart Disease. Circ J 2008; 72:747-52. [DOI: 10.1253/circj.72.747] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Kambiz Norozi
- Department of Paediatric Cardiology and Intensive Care, Medical School Hannover
| | - Reiner Buchhorn
- Department of Paediatrics, Caritas Krankenhaus Bad Mergentheim
- Department of Paediatric Cardiology and Intensive Care, Georg-August-University
| | - Armin Wessel
- Department of Paediatric Cardiology and Intensive Care, Medical School Hannover
| | - Jens Bahlmann
- Department of Paediatric Cardiology and Intensive Care, Georg-August-University
| | - Björn Raab
- Department of Radiology, Georg-August-University
| | | | - Titus Kuehne
- Department of Congenital Heart Disease and Paediatric Cardiology, German Heart Institute
| | - Li Beibei
- Universitätsklinik und Poliklinik für Innere Medizin III, Martin-Luther-Universität Halle-Wittenberg
| | - Karl Werdan
- Universitätsklinik und Poliklinik für Innere Medizin III, Martin-Luther-Universität Halle-Wittenberg
| | - Harald Loppnow
- Universitätsklinik und Poliklinik für Innere Medizin III, Martin-Luther-Universität Halle-Wittenberg
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Kim TH, Ryu YH, Hur J, Kim SJ, Kim HS, Choi BW, Kim Y, Kim HJ. Evaluation of right ventricular volume and mass using retrospective ECG-gated cardiac multidetector computed tomography: comparison with first-pass radionuclide angiography. Eur Radiol 2005; 15:1987-93. [PMID: 15776241 DOI: 10.1007/s00330-005-2716-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2004] [Revised: 01/03/2005] [Accepted: 01/21/2005] [Indexed: 10/25/2022]
Abstract
The purposes of this study were to evaluate the right ventricular (RV) volume and mass using cardiac multidetector computed tomography (MDCT) and to compare the cardiac MDCT results with those from first-pass radionuclide angiography (FPRA). Twenty patients were evaluated for the RV end-diastolic volume (RVEDV), the RV end-systolic volume (RVESV), the RV ejection fraction (RVEF), and RV mass using cardiac MDCT with a two-phase reconstruction method based on ECG. The end-diastolic phase was reconstructed at the starting point of the QRS complex on ECG, and the end-systolic phase was reconstructed at the halfway point of the ascending T-wave on ECG. The RV mass was measured for the end-systole. The RVEF was also obtained by FPRA. The mean RVEF (47+/-7%) measured by cardiac MDCT was well correlated with that (44+/-6%) measured by FPRA (r=0.854). A significant difference in the mean RVEF was found between cardiac MDCT and FPRA (p=0.001), with an overestimation of 2.9+/-5.3% by cardiac MDCT versus FPRA. The interobserver variability was 4.4% for the RVEDV, 6.8% for the RVESV, and 7.9% for the RV mass, respectively. Cardiac MDCT is relatively simple and allows the RV volume and mass to be assessed, and the RVEF obtained by cardiac MDCT correlates well with that measured by FPRA.
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Affiliation(s)
- Tae Hoon Kim
- Department of Radiology, Yonsei University College of Medicine, Seoul, 135-720, South Korea.
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21
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Hess M, Hurst D. Right ventricular function: a stepchild in the management of congestive heart failure. CONGESTIVE HEART FAILURE (GREENWICH, CONN.) 2004; 10:152-3. [PMID: 15184730 DOI: 10.1111/j.1527-5299.2004.03573.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Affiliation(s)
- Michael Hess
- Virginia Commonwealth University Health Center, Richmond, VA, USA.
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