Impaired left ventricular diastolic filling in patients with coronary artery disease: assessment with radionuclide angiography

HER2-Targeted Therapy-From Pathophysiology to Clinical Manifestation: A Narrative Review

Trastuzumab is the primary treatment for all stages of HER2-overexpressing breast cancer in patients. Though discovered over 20 years ago, trastuzumab-induced cardiotoxicity (TIC) remains a research topic in cardio-oncology. This review explores the pathophysiological basis of TIC and its clinical manifestations. Their understanding is paramount for early detection and cardioprotective treatment. Trastuzumab renders cardiomyocytes susceptible by inhibiting the cardioprotective NRG-1/HER2/HER4 signaling pathway. The drug acts on HER2-receptor-expressing cardiomyocytes, endothelium, and cardiac progenitor cells (see the Graphical Abstract). The activation of immune cells, fibroblasts, inflammation, and neurohormonal systems all contribute to the evolution of TIC. A substantial amount of research demonstrates that trastuzumab induces overt and subclinical left ventricular (LV) systolic failure. Data suggest the development of right ventricular damage, LV diastolic dysfunction, and heart failure with preserved ejection fraction. Further research is needed to define a chronological sequence of cardiac impairments to guide the proper timing of cardioprotection implementation.

Nuclear medicine imaging methods of radiation-induced cardiotoxicity

Breast cancer survival is significantly improved over the past decades due to major improvements in anti-tumor therapies and the implementation of regular screening, which leads to early detection of breast cancer. Therefore, it is of utmost importance to prevent patients from long-term side effects, including radiotherapy-induced cardiotoxicity. Radiotherapy may contribute to damage of myocardial structures on the cellular level, which eventually could result in various types of cardiovascular problems, including coronary artery disease and (non-)ischemic cardiomyopathy, leading to heart failure. These cardiac complications of radiotherapy are preceded by alterations in myocardial perfusion and blood flow. Therefore, early detection of these alterations is important to prevent the progression of these pathophysiological processes. Several radionuclide imaging techniques may contribute to the early detection of these changes. Single-Photon Emission Computed Tomography (SPECT) cameras can be used to create Multigated Acquisition scans in order to assess the left ventricular systolic and diastolic function. Furthermore, SPECT cameras are used for myocardial perfusion imaging with radiopharmaceuticals such as ^99mTc-sestamibi and ^99mTc-tetrofosmin. Accurate quantitative measurement of myocardial blood flow (MBF), can be performed by Positron Emission Tomography (PET), as the uptake of some of the tracers used for PET-based MBF measurement almost creates a linear relationship with MBF, resulting in very accurate blood flow quantification. Furthermore, there are PET and SPECT tracers that can assess inflammation and denervation of the cardiac sympathetic nervous system. Research over the past decades has mainly focused on the long-term development of left ventricular impairment and perfusion defects. Considering laterality of the breast cancer, some early studies have shown that women irradiated for left-sided breast cancer are more prone to cardiotoxic side effects than women irradiated for right-sided breast cancer. The left-sided radiation field in these trials, which predominantly used older radiotherapy techniques without heart-sparing techniques, included a larger volume of the heart and left ventricle, leading to increased unavoidable radiation exposure to the heart due to the close proximity of the radiation treatment volume. Although radiotherapy for breast cancer exposes the heart to incidental radiation, several improvements and technical developments over the last decades resulted in continuous reduction of radiation dose and volume exposure to the heart. In addition, radiotherapy reduces loco-regional tumor recurrences and death from breast cancer and improves survival. Therefore, in the majority of patients, the benefits of radiotherapy outweigh the potential very low risk of cardiovascular adverse events after radiotherapy. This review addresses existing nuclear imaging techniques, which can be used to evaluate (long-term) effects of radiotherapy-induced mechanical cardiac dysfunction and discusses the potential use of more novel nuclear imaging techniques, which are promising in the assessment of early signs of cardiac dysfunction in selected irradiated breast cancer patients.

Diastolic dysfunction can precede systolic dysfunction on MUGA in cancer patients receiving trastuzumab-based therapy

Background

Trastuzumab (T) and anthracycline (A)-based chemotherapy is considered the standard of care in human epidermal growth factor receptor-2+ overexpressing breast cancer, but requires monitoring for known cardiotoxicity using left ventricular (LV) ejection fraction (EF) every 3–4 months during treatment. It is not conclusively established whether diastolic dysfunction (DD) precedes LVEF decrease in patients developing trastuzumab-induced cardiotoxicity (TIC).

Objective

The aim was to elucidate whether DD precedes LVEF decrease in trastuzumab-treated patients being monitored with radionuclide multigated acquisition for TIC.

Patients and methods

Patients treated with T±A-based chemotherapy who had undergone multigated acquisition were selected by date range (January 2006–September 2015). Up to four scans were analyzed per patient: (a) pre-A therapy, (b) pre-T therapy, (c) 4 months into T therapy, and (d) at end of T therapy. Baseline referred to the first scan of each patient (i.e. pre-A or pre-T). LV systolic and DD were defined as follows: EF less than 50% or a 10-point decrease from baseline and LV peak filling rate (PFR) less than 2.5 end-diastolic volume/s and time to peak LV filling rates (TPFR) greater than 180 ms, respectively.

Results

A total of 202 patients were screened for this study, of whom 153 had received A therapy (5.1±4.1 months duration) before T, 192 had 4 months of follow-up data, and 146 had 4 months of follow-up data and beyond (10.5±5.0 months). LVEF decreased with A and T therapy (P<0.005), but remained stable between 4 months and the final exam (P=0.26). In patients with normal diastolic function at baseline (45.5%), PFR decreased with A and T, and DD preceded SD by 73 days on average. In the remaining patients, with abnormal diastolic function at baseline (54.5%), PFR did not change over the course of treatment (P>0.1), nor did TPFR (P>0.3).

Conclusion

Patients with normal diastolic function at baseline receiving trastuzumab±anthracycline adjuvant therapy may develop DD before SD, therefore offering an opportunity for early referral to cardiologists to optimize cardiovascular risk factors and manage cardiotoxicity.

Left atrial deformation analysis as a predictor of severity of coronary artery disease

BACKGROUND

Two-dimensional (2D) speckle-tracking strain imaging is a novel method for assessment of regional myocardial deformation that uses tracking of acoustic speckles or kernels rather than Doppler myocardial velocities. It has been suggested that Left atrial (LA) strain as measured by 2D speckle tracking can be used to evaluate dynamic LA function.

OBJECTIVE

To study the relation between left atrial deformation and the severity of coronary artery stenosis in patients with stable coronary artery disease (CAD).

STUDY DESIGN

30 patients with stable coronary artery disease (SCAD) with coronary artery stenosis (>50%) who were admitted for elective coronary angiography at Ain Shams University hospitals and AlAzhar University hospitals were included in the study. Measurements of conventional echocardiographic parameters as well as LA strain and strain rate parameters were obtained, Syntax (SX) score was calculated for all patients.

RESULTS

Patients were categorized into 3 groups: low Syntax score of <23 (Group I), moderate syntax score 23-32 (Group II) and high syntax score of ≥33 (Group III). Peak atrial longitudinal strain (PALS) (Group I: 29.80 ± 4.48, Group II: 22.44 ± 1.42, Group III: 19.53 ± 4.46; p < 0.001) and Peak atrial contraction strain (PACS) (Group I: 13.43 ± 4.05, Group II: 10.84 ± 2.47, Group III: 7.19 ± 0.71; p < 0.022) were significantly lower in high syntax group. Significant negative correlation was found between SX score level and LA strain parameters (PALS and PACS) (r = 0.861; p < 0.001).

CONCLUSION

Left atrial deformation analysis by 2D Speckle tracking Doppler Echocardiography can predict the severity of coronary affection in patients with stable CAD.

Assessment of left and right atrial geometrical changes in patients with stable coronary artery disease: Left and right atrial strain and strain rate imaging study

Objective

In patients with coronary artery disease (CAD), there are several studies that assessed the left ventricular (LV) function by strain (S) and strain rate (SR) imaging. The aim of this study is to evaluate the function of both atria in patients with CAD using strain and strain rate imaging, and to correlate this with the severity of CAD.

Methods

We conducted a prospective, single center case control study for 40 consecutive patients who presented to our department with chronic stable angina and were candidates for invasive coronary angiography. We enrolled patients from December 2013 to May 2014 and each patient was subjected to echocardiographic assessment of E/e' of mitral valve, left atrial volume index (LAVI), right atrial volume index (RAVI), and peak atrial longitudinal strain (es) and strain rate (SR) during LV systole. This was followed by invasive coronary angiography for assessment of the severity of CAD using Gensini score. Patients were classified according to angiographic results into 3 groups: Group I (Gensini score = zero), Group II (Gensini score > 0 and < 20) and Group III (Gensini score ≥ 20).

Results

There was no statistically significant difference between the three groups in either LA volumes (V_min, V_max) and distensibility with p value of 0.272, 0.126, and 0.243 respectively or RA volumes and distensibility with a p value of 0.671, 0.183, and 0.259 respectively. On the other hand, LA & RA systolic S and SR were significantly lower among CAD patients in comparison with the group of normal coronaries. Mean LA S and SR was decreased in group III than group II (15.97 ± 3.73, 21.8 ± 6.75 % and 1.11 ± 0.30, 1.81 ± 1.23 s^-1) with p value of 0.005&0.041 respectively. RA systolic S and SR were significantly lower in the 2 groups with CAD than the group with normal coronaries with a p value of 0.001 and 0.002 respectively.

Conclusion

In patients with CAD and normal EF, borderline E/e' ratio and normal atrial size, there are decreased LA and RA systolic S and SR parameters with no effect on atrial volumes or distensibility. Accordingly, this could prove that atrial wall deformation occurs early in CAD even before any changes in atrial volumes or dimensions.

A New Potential Predictor of Coronary Artery Disease: The Ratio of Mitral Peak Filling Velocity to Mitral Annular Velocity in Early Diastole

Background

The aim of this study was to explore the value of the ratio of mitral peak filling velocity (E) to mitral annular velocity (e’) in early diastole as a predictor of coronary artery disease (CAD).

Material/Methods

The study population consisted of 83 consecutive patients (aged 38–77 years, 22 women and 61 men) who received coronary angiography. The E/e’ ratio was estimated by echocardiographic examination. Statistical significance was determined by receiver operating characteristic (ROC) curve and multiple logistic regression analyses.

Results

ROC curve analysis showed that the optimal E/e’ ratio cut-off for predicting CAD was 8.153 with a specificity of 72.4% and sensitivity of 57.4%. The area under the ROC curve was 0.635 with a 95% confidence interval (CI) for normal distribution of 0.515–0.755 (p=0.043). Multivariate logistic regression analysis demonstrated that the E/e’ ratio was closely associated with CAD (odds ratio [OR], 1.350; 95% CI, 1.087–1.676, p=0.007).

Conclusions

The E/e’ ratio is a simple and practical predictor of CAD and may be an independent risk factor for CAD. Large-cohort and multi-center studies are required to confirm these observations.

Detection of left atrial dysfunction with speckle tracking echocardiography

BACKGROUND

The aim of this study was to evaluate the relationship between the SYNTAX (Synergy Between PCI With Taxus and Cardiac Surgery) score and left ventricular end-diastolic pressure (LVEDP) measured with an invasive method and with speckle-tracking echocardiography (STE).

METHODS

The study included 124 patients who underwent cardiac catheterization. LVEDP values and coronary images were obtained for all patients. SYNTAX scores were calculated and separated into three tertiles (SYNTAX = 0, SYNTAX < 22, and SYNTAX > 22). Standard echocardiography and STE were performed on all the patients. Peak LA strain (LAs strain) in ventricular end-systole and LA strain during LA contraction (LAa strain) values were obtained with STE.

RESULTS

In univariate analysis, a strong correlation was observed between the SYNTAX score and LAs strain and a moderate correlation with LAa strain. A moderate correlation was also found between both LAs strain and LAa strain and LVEDP. In multiple regression analysis, LAs strain and LVEDP were observed to be independent predictors of SYNTAX score.

CONCLUSION

LAs strain and LVEDP were observed to be independent predictors of SYNTAX scores. The relationship between LAs strain, LVEDP, and SYNTAX score could be useful in clinical practice.

Diastolic Dyssynchrony in Acute ST Segment Elevation Myocardial Infarction and Relationship with Functional Recovery of Left Ventricle

Background

Incidence of diastolic dyssynchrony (DD) and its impact on functional recovery of left ventricle (LV) after ST segment elevation myocardial infarction (STEMI) is not known.

Methods

Consecutive patients with STEMI who underwent successful revascularization were prospectively enrolled. Echocardiography with tissue Doppler imaging was performed within 48 hours of admission and at 6 months. LV end-diastolic volume index (EDVI), end-systolic volume index (ESVI), ejection fraction (EF), and left atrial volume index (LAVI) were calculated. Diastolic delay was calculated from onset of QRS complex to peak of E wave in tissue Doppler image and presented as maximal temporal difference between peak early diastolic velocity of 6 basal segments of LV (TeDiff). Study patients were compared with demographically matched control group.

Results

Forty eight consecutive patients (55 ± 10 years, 88% male) and 24 controls (56 ± 6 years, 88% male) were included. TeDiff was higher in STEMI than in controls (35.9 ± 19.9 ms vs. 26.3 ± 6.8 ms, p = 0.025). Presence of DD was higher in STEMI than controls (58% vs. 33%, p = 0.046) according to calculated cut-off value (≥ 29 ms). There was no correlation between TeDiff and change in EDVI, ESVI, and LAVI at 6 months, however TeDiff and change in EF at 6 months was positively correlated (r = 0.328, p = 0.023). Patients with baseline DD experienced remodeling less frequently compared to patients without baseline DD (11% vs. 38%, p = 0.040) during follow-up.

Conclusion

STEMI disrupts diastolic synchronicity of LV. However, DD during acute phase of STEMI is associated with better recovery of LV thereafter. This suggests that DD is associated with peri-infarct stunned myocardium that is salvaged with primary intervention as well as infarct size.

Early diastolic dyssynchrony in relation to left ventricular remodeling and function in hypertension

BACKGROUND

Cardiac synchronization is important in maintaining myocardial performance, but the mechanism of diastolic dyssynchrony leading to failing myocardium is unclear. We aim to study the relation of left ventricular (LV) diastolic dyssynchrony with diastolic dysfunction in patients with hypertension.

METHODS

Two-D, three-D and Doppler echocardiography were performed using the GE Vivid E9 system on 230 subjects. Among them, 154 patients with hypertension were divided into group 1 (86 patients with mild to moderate hypertension, BP 152 ± 8/91 ± 11 mm Hg) and group 2 (68 patients with severe hypertension, BP 188 ± 12/105 ± 24 mm Hg), age 76, gender matched normotensive subjects (119 ± 6/76 ± 9 mm Hg) as control. The routine 2D and Doppler parameters were measured and LV systolic and diastolic dyssynchrony indices were determined as the standard deviation of the time interval from the peak R of the QRS complex to peak myocardial systolic strain rate (Ts-SD), and to early diastolic strain rate (Te-SD) of 12 LV segments.

RESULTS

LV relative wall thickness, mass index, and Te-SD were significantly higher in patients with hypertension than in control group (p<0.0001), but Ts-SD showed no significant differences. Te-SD and diastolic dysfunction worsened progressively with increasing severity of hypertension (p<0.05). Te-SD was significantly and independently associated with parameters of LV remodeling and diastolic function.

CONCLUSION

Our study demonstrated that LV diastolic dyssynchrony was associated with LV remodeling, which seems to contribute to diastolic dysfunction in hypertension. This diastolic dyssynchrony index derived from speckle tracking echocardiography can be used as a marker for studying the LV function and effects of therapy in hypertensive heart disease.

Left ventricular diastolic parameters in dilated cardiomypoathy: are we missing out on something?

Equilibrium radionuclide ventriculography is an established modality to assess the left ventricular (LV) systolic function in several clinical situations. Diastolic parameters can also be extracted from this investigation. The aim of our study is to assess the diastolic function of the left ventricle in cases of idiopathic dilated cardiomyopathy (IDCM) and ischemic cardiomyopathy, where systolic dysfunction has been considered of prime pathologic significance. We conducted a retrospective analysis of 89 patients who had undergone radionuclide ventriculography at our department with established diagnosis of IDCM in 59 patients and ischemic cardiomyopathy in remaining 30 patients. Peak filling rate (PFR) was assessed. The PFR was significantly lower in both patients with IDCM (median = 1.61 end diastolic volumes [EDV]/s) and ischemic cardiomyopathy (median = 2.005 EDV/s). 33% of the patients with ischemic cardiomyopathy and ejection fraction (EF) >45% had diastolic dysfunction while 25% of patients with IDCM and EF >45% had low PFR. Diastolic dysfunction can coexist in patients with dilated cardiomyopathy and even in patients with preserved LV EF. Routine evaluation of diastolic function in patients with heart failure can help in elucidation of pathogenesis and management of patients.

Left atrial and right atrial deformation in patients with coronary artery disease: a velocity vector imaging-based study

Background

Impaired left ventricular (LV) function has been shown by strain rate (SR) imaging in patients with coronary artery disease (CAD). Our aim was to investigate global and regional, systolic and diastolic left atrial (LA) and right atrial (RA) longitudinal deformation in CAD using velocity vector imaging.

Methods

Echocardiographic and velocity vector imaging studies were performed in 20 patients with mild CAD, 40 patients with severe CAD and 25 controls. Maximal atrial volume, peak atrial longitudinal strain (ε_s) and SR during LV systole (SRs), SR during early LV filling (SRe) and late LV filling (SRa) were measured. Longitudinal strain during atrial contraction (ε_a) was obtained at the onset of P-wave on electrocardiography, and ε_a/ε_s was calculated.

Results

Longitudinal peak ε_s and SRs of LA showed decreased trend among CAD patients. The global and lateral LA SRe were prominently lower, while RA ε_a, SRa and ε_a/ε_s were prominently higher in 2 CAD groups than control group (P value <0.05). As compared with controls and patients with other single-vessel disease, LA SRa and ε_a/ε_s ratio were significantly increased among patients with exclusively left anterior descending coronary artery (LAD) stenosis (SRa 1.14±0.38 s⁻¹, 1.10±0.41 s⁻¹, 1.45±0.46 s⁻¹, P value<0.05; ε_a/ε_s 0.44±0.11, 0.44±0.20, 0.57±0.12, P value<0.01).

Conclusions

Apparently decreased SRe of LA and increased ε_a, SRa and ε_a/ε_s of RA were found in CAD patients with preserved LVEF and E/E' in gray zone. SRa and ε_a/ε_s of LA were found to significantly increase in those with LAD stenosis.

Equilibrium radionuclide angiocardiography: Its usefulness in current practice and potential future applications

The routine and potential future applications of equilibrium radionuclide angiocardiography/multigated acquisition (MUGA) in clinical decision making are explored in this review. The non-invasive nature of the test, less operator dependence, lower radiation dose and ease of performing, even in ill patients, are important considerations in clinical cardiology practice. Two important routine uses of this modality in day-to-day clinical practice include the following: serial assessment of left ventricular ejection fraction (LVEF) in patients receiving cardiotoxic chemotherapy, and determination of accurate LVEF in patients with intractable heart failure. Other potential utilities of MUGA that could be translated into clinical practice include determination of regional LVEF, obtaining information about both right and left ventricle in suitable patients as a part of first pass angiocardiography, identification of diastolic dysfunction in patients with heart failure with preserved LVEF, and demonstration of dyssynchrony prior to cardiac resynchronisation, specifically by MUGA single photon emission tomography.The last two indications are particularly important and evolving at this point.

Assessment of cardiovascular function by combining clinical data with a computational model of the cardiovascular system

OBJECTIVE

A sufficient understanding of patients' cardiovascular status is necessary for doctors to make the best decisions with regard to the treatment of cardiovascular disease; however, it is often not available because of the limitation of clinical measurements. The objective of this study was to examine whether cardiovascular function can be assessed quantitatively and for specific patients by combining clinical data with a computational model of the cardiovascular system.

METHODS

Seven consecutive patients undergoing off-pump coronary artery bypass grafting were enrolled in this study. The clinical data were collected both during the preoperative diagnosis and during the operation. Sensitivity analysis was performed to select the major model parameters most relevant to the measured data. The major model parameters were then estimated through a data-fitting procedure, enabling a patient-specific quantitative assessment of various aspects of cardiovascular function.

RESULTS

The results revealed the prevalence of left ventricular diastolic dysfunction in the patients, although the severity of dysfunction exhibits significant interpatient variability (the estimated left ventricular passive elastance varies from 194% to 540% of its reference value). Moreover, 4 of the 7 patients studied had impaired left ventricular systolic function.

CONCLUSIONS

The current study demonstrates the feasibility of assessing cardiovascular function quantitatively by combining clinical data with a cardiovascular model. In particular, the assessment utilizes the measurements already in use or available in clinical settings, enhancing the clinical potential of the proposed method.

Ventricular dyssynchrony of idiopathic versus pacing-induced left bundle branch block and its prognostic effect in patients with preserved left ventricular systolic function

The extent of left ventricular (LV) dyssynchrony might not be comparable between right ventricular pacing-induced left bundle branch block (RV-LBBB) and idiopathic LBBB (iLBBB), despite the morphologic analogy on the electrocardiogram. The objectives of the present study were to elucidate the differences in the LV dyssynchrony index (LVdys) between RV-LBBB and iLBBB, and to assess the prognostic implication of LV dyssynchrony. The conventional echocardiographic parameters, LVdys, and LV end-systolic wall stress were evaluated in 20 healthy volunteers and 21 patients with iLBBB and 20 with RV-LBBB with preserved LV systolic function. Three types of LVdys were evaluated: LVdys-6, LVdys-2, and LVdys-standard deviation. The patients were clinically followed up for about 3 years. The prevalence of LV dyssynchrony was not rare in those with either iLBBB or RV-LBBB, but it was more prevalent in the patients with iLBBB than in those with RV-LBBB. The patients with iLBBB had greater LVdys than those with RV-LBBB (84 ± 55 vs 55 ± 50 for LVdys-6, 51 ± 49 vs 31 ± 40 for LVdys-2, 37 ± 24 vs 24 ± 22 for LVdys-standard deviation in iLBBB vs RV-LBBB). LVdys displayed significant correlations with QRS duration, LV volumes, LV ejection fraction, LV end-systolic wall stress, and mitral inflow E/mitral annular E' velocity ratio. Multivariate logistic regression analysis showed that the LV end-diastolic volume and LV end-systolic wall stress were independent determinants of the presence of LV dyssynchrony. During follow-up, no cardiovascular death or hospitalization for heart failure was reported in either group. In conclusion, despite similarities in electrocardiographic morphology, the extent of LV dyssynchrony were greater in patients with iLBBB, with LV preload and afterload the main determinants. No association was found between the presence of LV dyssynchrony and prognosis.

Baseline diastolic dysfunction as a predictive factor of trastuzumab-mediated cardiotoxicity after adjuvant anthracycline therapy in breast cancer

To evaluate the interest in assessing left ventricular diastolic function at baseline for prediction of trastuzumab-mediated cardiotoxicity (TMC) in the setting of adjuvant treatment for breast cancer. The study included 118 women presenting with HER2-positive early-stage invasive breast cancer. Patients received trastuzumab therapy over 1 year, concurrent with six cycles of docetaxel (n = 53), or following anthracycline-based chemotherapy with a cumulative dose of 300 mg/m(2) (n = 45) or 600 mg/m(2) (n = 20) of epirubicine. RNA was performed before anthracycline-based chemotherapy, before trastuzumab treatment (baseline), and every 3 months during treatment. Left ventricular ejection fraction (LVEF) and peak ejection rate (PER) were calculated to evaluate LV systolic function; peak filling rate (PFR), and time to peak filling rate (TPFR) were also calculated to evaluate LV diastolic function. Eighteen patients (15%) developed grade 1 or 2 TMC during follow-up. No significant difference was observed for age, cardiovascular risk factors, fasting blood glucose level, heart rate, systolic blood pressure, baseline LVEF, PER, and PFR between patients with and without TMC. In contrast, patients with TMC showed a longer TPFR at baseline (median [Q1-Q3]: 165 ms [149-190] vs. 142 ms [130-162]; P < 0.001). Furthermore, by logistic regression analysis, baseline TPFR >180 ms and the cumulative dose of epirubicin remained independent predictors of TMC. Patients receiving 600 mg/m(2) of epirubicin before trastuzumab showed a higher incidence of TMC (35%) than did both patients who previously received 300 mg/m(2) of epirubicin (13%) and those who received only docetaxel associated with trastuzumab (9%). Impaired left ventricular diastolic function before treatment is an independent predictor of trastuzumab-mediated cardiotoxicity. The evaluation of diastolic function could allow optimal risk stratification before the introduction of trastuzumab.

LV mechanical dyssynchrony in heart failure with preserved ejection fraction complicating acute coronary syndrome

OBJECTIVES

The aim of this study was to evaluate the role of left ventricular (LV) mechanical dyssynchrony in heart failure with preserved ejection fraction (HFPEF) complicating acute coronary syndrome (ACS).

BACKGROUND

In systolic heart failure, LV mechanical dyssynchrony worsens cardiac function and cardiac resynchronization therapy improves clinical outcome. The role of LV mechanical dyssynchrony in HFPEF complicating ACS is unknown.

METHODS

One hundred two patients presenting with ACS (ejection fraction ≥50%) and 104 healthy controls were studied using tissue Doppler imaging: group 1 (n = 55) had HFPEF on presentation and group 2 (n = 47) had no clinical HFPEF. The SD of time to peak systolic myocardial velocity and the SD of early diastolic (Te-SD) myocardial velocity of 12 LV segments were obtained for evaluation of dyssynchrony. Longitudinal mean myocardial ejection systolic velocity (mean Sm) and mean early diastolic velocity (mean Em) were measured.

RESULTS

Te-SD was greater in group 1 (33 ± 13 ms) than group 2 (21 ± 9 ms) (p < 0.001), and diastolic mechanical dyssynchrony was evident in 35% of patients in group 1 but in only 9% in group 2 (p < 0.001). Conversely, the SD of time to peak systolic myocardial velocity was similar in the 2 ACS groups (34 ± 16 ms vs. 32 ± 18 ms; p = NS), showing a similar prevalence of systolic mechanical dyssynchrony (47% vs. 43%; p = NS). Worsening of the diastolic dysfunction grade was associated with a parallel increase in Te-SD (grades 0, 1, 2, and 3: 16 ± 3 ms, 21 ± 5 ms, 28 ± 9 ms, and 41 ± 17 ms, respectively; p < 0.001). Te-SD correlated negatively with mean Em (r = -0.56, p < 0.001) and positively with peak mitral inflow velocity of the early rapid-filling wave/Em (r = 0.69, p < 0.001); mean myocardial ejection systolic velocity correlated significantly with mean Em (r = 0.56, p < 0.001), SD of time to peak systolic myocardial velocity (r = -0.42, p < 0.001) and Te-SD (r = -0.23, p = 0.001). Multivariate analysis identified peak mitral inflow velocity of the early rapid-filling wave/Em as the only variable independently associated with HFPEF (odds ratio: 1.48, p = 0.001). When peak mitral inflow velocity of the early rapid-filling wave/Em was excluded from the model, Te-SD (odds ratio: 1.13, p < 0.001) and mean Em (odds ratio: 0.37, p < 0.001) became independently associated with HFPEF.

CONCLUSIONS

LV diastolic mechanical dyssynchrony may impair diastolic function and contribute to the pathophysiology of HFPEF, complicating ACS.

Evolving approaches to the management of heart failure with preserved ejection fraction in patients with coronary artery disease

OPINION STATEMENT

Coronary artery disease (CAD) is a major cause of heart failure with preserved ejection fraction (HFpEF). In studies of HFpEF, the reported prevalence of CAD varies widely, which may be the result of inconsistent definitions of CAD, geographic and ethnic differences in CAD burden, varying definitions of HFpEF (including different cutoffs for "preserved ejection fraction"), and differences in study design. Despite these limitations, pooled analysis of prospective HFpEF studies demonstrates that CAD is common in HFpEF, with an estimated prevalence of approximately 50%. Based on available data, patients with signs and symptoms of heart failure who have preserved left ventricular ejection fraction and evidence of CAD (HFpEF-CAD) most likely comprise a distinct etiologic and pathophysiologic subset of HFpEF. Therefore, future clinical trials in HFpEF should a priori stratify by CAD or specifically target patients with CAD, strategies that may improve the disappointing track record of therapies tested in HFpEF. The combination of systematic evaluation and management of CAD in HFpEF, along with promising future therapies for HFpEF-CAD, may lead to improved outcomes for this challenging clinical syndrome.

Myocardial ischemia in patients with diastolic dysfunction and heart failure

Coronary artery disease is present in 40-55% of patients with diastolic heart failure, and myocardial ischemia is both a cause and a precipitant of diastolic heart failure. Failure to recognize and treat acute and chronic ischemia in patients with this disorder results in rapid disease progression and poor outcomes. In diastolic heart failure patients without obstructive coronary artery disease, ischemia can be induced by other diseases that diminish perfusion gradient, cause myocardium to outgrow blood supply, or decrease diastolic filling time. In this article, we review the role of ischemia and development of fibrosis in the epidemiology, pathophysiology, and evaluation of patients with diastolic dysfunction and diastolic heart failure.

Effect of biventricular pacing on diastolic dyssynchrony

OBJECTIVES

This study sought to examine the changes in diastolic dyssynchrony with cardiac resynchronization therapy (CRT).

BACKGROUND

Little is known about the effect of CRT on diastolic dyssynchrony.

METHODS

Consecutive heart failure patients (n = 266, age 65.7 ± 10.0 years) underwent color-coded tissue Doppler imaging at baseline, 48 h, and 6 months after CRT. Systolic and diastolic dyssynchrony were defined as maximal time delay in peak systolic and early diastolic velocities, respectively, in 4 basal LV segments. CRT responders were defined as those with ≥15% decrease in LV end-systolic volume at 6 months.

RESULTS

Baseline LVEF was 25.2 ± 8.1%; 63.5% patients were CRT responders. Baseline incidence of systolic and diastolic dyssynchrony, and a combination of both was 46.2%, 51.9%, and 28.6%, respectively. Compared to nonresponders, responders had longer baseline systolic (79.2 ± 43.4 ms vs. 45.4 ± 30.4 ms; p < 0.001) and diastolic (78.5 ± 52.0 ms vs. 50.1 ± 38.2 ms; p < 0.001) delays. In follow-up, systolic delays (45.4 ± 31.6 ms at 48 h; 38.9 ± 26.2 ms at 6 months; p < 0.001) and diastolic delays (49.4 ± 36.3 ms at 48 h; 37.7 ± 26.0 ms at 6 months; p < 0.001) improved only in responders.

CONCLUSIONS

At baseline: 1) diastolic dyssynchrony was more common than systolic dyssynchrony in HF patients; 2) nonresponders had less baseline diastolic dyssynchrony compared to responders. After CRT: 1) diastolic dyssynchrony improved only in responders. Further insight into the pathophysiology of diastolic dyssynchrony and its changes with CRT may provide incremental information on patient-specific treatments.

High temporal resolution SSFP cine MRI for estimation of left ventricular diastolic parameters

PURPOSE

To obtain high temporal resolution (HTR) magnetic resonance (MR) steady-state free-precession (SSFP) cine cardiac images by using multichannel radiofrequency (RF) hardware and parallel imaging techniques; to study the effect of temporal resolution; and to compare the derived left ventricular (LV) diastolic filling parameters with echocardiographic results.

MATERIALS AND METHODS

HTR images were acquired in 13 healthy volunteers using a 1.5 T scanner with 32 RF channels and sensitivity encoding (SENSE) and k-t broad-use linear-acquisition speedup technique (k-t BLAST) imaging techniques. LV diastolic parameters were calculated and compared to conventional echocardiographic indices such as the isovolumic relaxation time (IVRT) and E/A ratio. The need for HTR was assessed and the MR results were compared with echocardiographic results.

RESULTS

The HTR (approximately 6-ms) images yielded higher peak filling rates, peak ejection rates, and peak atrial filling rates. A progressive decline in filling and ejection rates was observed with worsening temporal resolution. The IVRTs and E/A ratios measured with MR versus echocardiography were in broad agreement. Also, SENSE and k-t BLAST yielded similar diastolic functional parameters.

CONCLUSION

With SENSE or k-t BLAST and modern hardware, HTR cine images can be obtained. The lower temporal resolutions (30-50 ms) used in clinical practice reduce LV filling rates by <or=30% and may hinder characterization of transient phenomena such as the IVRT.

Impact of diastolic dysfunction severity on global left ventricular volumetric filling - assessment by automated segmentation of routine cine cardiovascular magnetic resonance

OBJECTIVES

To examine relationships between severity of echocardiography (echo) -evidenced diastolic dysfunction (DD) and volumetric filling by automated processing of routine cine cardiovascular magnetic resonance (CMR).

BACKGROUND

Cine-CMR provides high-resolution assessment of left ventricular (LV) chamber volumes. Automated segmentation (LV-METRIC) yields LV filling curves by segmenting all short-axis images across all temporal phases. This study used cine-CMR to assess filling changes that occur with progressive DD.

METHODS

115 post-MI patients underwent CMR and echo within 1 day. LV-METRIC yielded multiple diastolic indices - E:A ratio, peak filling rate (PFR), time to peak filling rate (TPFR), and diastolic volume recovery (DVR80 - proportion of diastole required to recover 80% stroke volume). Echo was the reference for DD.

RESULTS

LV-METRIC successfully generated LV filling curves in all patients. CMR indices were reproducible (< or = 1% inter-reader differences) and required minimal processing time (175 +/- 34 images/exam, 2:09 +/- 0:51 minutes). CMR E:A ratio decreased with grade 1 and increased with grades 2-3 DD. Diastolic filling intervals, measured by DVR80 or TPFR, prolonged with grade 1 and shortened with grade 3 DD, paralleling echo deceleration time (p < 0.001). PFR by CMR increased with DD grade, similar to E/e' (p < 0.001). Prolonged DVR80 identified 71% of patients with echo-evidenced grade 1 but no patients with grade 3 DD, and stroke-volume adjusted PFR identified 67% with grade 3 but none with grade 1 DD (matched specificity = 83%). The combination of DVR80 and PFR identified 53% of patients with grade 2 DD. Prolonged DVR80 was associated with grade 1 (OR 2.79, CI 1.65-4.05, p = 0.001) with a similar trend for grade 2 (OR 1.35, CI 0.98-1.74, p = 0.06), whereas high PFR was associated with grade 3 (OR 1.14, CI 1.02-1.25, p = 0.02) DD.

CONCLUSIONS

Automated cine-CMR segmentation can discern LV filling changes that occur with increasing severity of echo-evidenced DD. Impaired relaxation is associated with prolonged filling intervals whereas restrictive filling is characterized by increased filling rates.

Multi-modality imaging of diastolic function

Non-invasive evaluation of diastolic function continues to play a critical role in furthering our understanding of diastole, improving the diagnosis of diastolic dysfunction, evaluating left ventricular filling pressures, and providing important prognostic information for patients with heart failure. Echocardiography, cardiovascular magnetic resonance, and nuclear cardiology each provide important tools for evaluating diastolic performance. This review will focus on the techniques from multiple cardiovascular imaging modalities which have been used for the clinical assessment of diastolic function.

Expanding role of cardiovascular magnetic resonance in left and right ventricular diastolic function

This article focuses on the role of cardiovascular magnetic resonance (CMR) in understanding the physiology of diastolic function and on the future applications of CMR as they relate to diastolic function evaluation. CMR has a demonstrated potential to define diastolic function and quantify its properties, in terms of active and passive stages, and its relaxation and compliance characteristics. CMR is also useful for assessing inflow and myocardial velocities, and untwisting properties of the chamber and myocardium, thus providing insights not fully available in other invasive and noninvasive strategies. CMR, which offers the necessary capabilities to evaluate the complex structure of the right ventricle, can serve in the future as the standard for evaluating diastolic function as it currently does for systolic function.

A dual propagation contours technique for semi-automated assessment of systolic and diastolic cardiac function by CMR

BACKGROUND

Although cardiovascular magnetic resonance (CMR) is frequently performed to measure accurate LV volumes and ejection fractions, LV volume-time curves (VTC) derived ejection and filling rates are not routinely calculated due to lack of robust LV segmentation techniques. VTC derived peak filling rates can be used to accurately assess LV diastolic function, an important clinical parameter. We developed a novel geometry-independent dual-contour propagation technique, making use of LV endocardial contours manually drawn at end systole and end diastole, to compute VTC and measured LV ejection and filling rates in hypertensive patients and normal volunteers.

METHODS

39 normal volunteers and 49 hypertensive patients underwent CMR. LV contours were manually drawn on all time frames in 18 normal volunteers. The dual-contour propagation algorithm was used to propagate contours throughout the cardiac cycle. The results were compared to those obtained with single-contour propagation (using either end-diastolic or end-systolic contours) and commercially available software. We then used the dual-contour propagation technique to measure peak ejection rate (PER) and peak early diastolic and late diastolic filling rates (ePFR and aPFR) in all normal volunteers and hypertensive patients.

RESULTS

Compared to single-contour propagation methods and the commercial method, VTC by dual-contour propagation showed significantly better agreement with manually-derived VTC. Ejection and filling rates by dual-contour propagation agreed with manual (dual-contour - manual PER: -0.12 +/- 0.08; ePFR: -0.07 +/- 0.07; aPFR: 0.06 +/- 0.03 EDV/s, all P = NS). However, the time for the manual method was approximately 4 hours per study versus approximately 7 minutes for dual-contour propagation. LV systolic function measured by LVEF and PER did not differ between normal volunteers and hypertensive patients. However, ePFR was lower in hypertensive patients vs. normal volunteers, while aPFR was higher, indicative of altered diastolic filling rates in hypertensive patients.

CONCLUSION

Dual-propagated contours can accurately measure both systolic and diastolic volumetric indices that can be applied in a routine clinical CMR environment. With dual-contour propagation, the user interaction that is routinely performed to measure LVEF is leveraged to obtain additional clinically relevant parameters.

Increased atrial contribution to left ventricular filling compensates for impaired early filling during exercise in heart failure with preserved ejection fraction

BACKGROUND

The role of left atrial (LA) function on exercise remains poorly understood in heart failure with preserved ejection fraction (HfpEF) despite its key role in optimizing left ventricular (LV) diastolic function. We used resting and exercise radionuclide ventriculography to investigate the role of LA function in the pathophysiology of HfpEF.

METHODS AND RESULTS

A total of 25 patients with HfpEF and 15 age- and gender-matched controls were recruited. All subjects underwent resting echocardiogram, metabolic exercise testing to peak effort, and radionuclide ventriculography (at rest and exercise [to 35% of heart rate reserve]). At rest LA and LV function were similar in patients and controls. During exercise, HfpEF patients had lower left ventricular ejection fraction (69 +/- 9% vs. 73 +/- 10%, P < .05) and lower peak early filling rate (387 +/- 109 end-diastolic count/sec vs. 561 +/- 156 end-diastolic count/sec, P < .001). During exercise, the atrial contribution to LV filling was significantly higher in patients than controls (46 +/- 11% vs. 30 +/- 9%, P < .001). Atrial contribution to LV filling correlated negatively with peak early filling rate during exercise (r = -0.6, P < .001). Peak early filling rate correlated positively with peak oxygen consumption (r = 0.485, P = .004) and negatively with minute/carbon dioxide production (r = -0.423, P = .013).

CONCLUSION

Patients with HfpEF have increased atrial contribution to LV filling as a compensatory response to impaired early LV filling during cycle exercise.

Congestive heart failure and ejection fraction in acute myocardial infarction

Left ventricular ejection fraction (EF) was determined by means of radionuclide ventriculography (RNV) in 477 patients 8-12 days after an acute myocardial infarction (AMI). EF was correlated to infarct size and clinical and radiological parameters of congestive heart failure (CHF). The 138 patients (29%) who had signs of CHF had a mean (+/- SD) EF of 35 +/- 14% and a relative heart volume of 597 +/- 112 ml/m2 compared to 51 +/- 14% and 487 +/- 88 ml/m2 among those without CHF. The 52 patients who also had radiological signs of CHF had a mean EF of 27 +/- 12% versus 35 +/- 14% among those with clinical signs and symptoms of CHF. Presence of CHF was positively correlated to the size of AMI and to the reduction of EF. CHF was seen with increasing frequency from 16% in small to 46% in large first infarctions. Patients with reinfarctions showed the same correlation between these parameters, however, with subsequently more depressed EF values and more frequent presence of CHF due to previous myocardial damage. CHF was seldom (8%) observed in patients with EF greater than 50%. In contrast, 67% of the patients with EF less than 35% had CHF. Thus patients with an EF less than 35% represent a high risk group with regard to development of CHF and should be followed closely. It is suggested that radionuclide measurement of EF adds important clinical information in patients with diagnostic uncertainty of CHF.

Assessment of atrial contribution to left ventricular filling during cold pressor test by M-mode echocardiography in patients with coronary artery disease

To determine whether temporarily increased afterload causes changes in left ventricular (LV) diastolic properties, we examined 19 patients with coronary artery disease (CAD) and 14 healthy subjects by M-mode echocardiography during immersion of the left hand in ice water. The M-mode echocardiograms were digitized to assess the percentage of atrial contribution (%AC) to LV filling as a marker of diastolic properties. Six patients and 5 controls had to be excluded owing to inability to clearly define the endocardium in the left ventricle throughout the entire heart cycle. In the control situation, the %AC did not differ significantly between the two groups. During the cold pressor test, the mean %AC at peak systolic and peak diastolic pressures was significantly higher in the CAD group than in the control group (p less than 0.05). Thus, by using M-mode echocardiography during the cold pressor test it is possible to document an increased atrial contribution to LV filling in patients with CAD. It is suggested that the mechanism is increased myocardial stiffness evoked by ischaemia with a resultant increased role of atrial contraction.

Left ventricular systolic and diastolic dyssynchrony in asymptomatic hypertensive patients

BACKGROUND

Diastolic and systolic dyssynchrony are common in patients with heart failure. However, the presence of dyssynchrony in asymptomatic patients with hypertension who are susceptible to the development of heart failure is not well understood. The aims of this study were (1) to evaluate the prevalence of systolic and diastolic dyssynchrony and (2) to identify the main determinants of left ventricular (LV) dyssynchrony in asymptomatic patients with hypertension.

METHODS

One hundred ten patients with hypertension consecutively enrolled were compared with 55 age-matched and gender-matched normal control subjects. Comprehensive echocardiography was performed, including conventional and Doppler tissue imaging parameters. LV end-systolic wall stress was calculated using a hemodynamic and echocardiographic M-mode data set. For the assessment of LV dyssynchrony, both the standard deviation of the time from QRS onset to peak systolic velocity and the maximal difference of the time from QRS onset to peak systolic velocity from 6 basal segments at the apical views were used and were compared between the two groups.

RESULTS

Both systolic and diastolic dyssynchrony indexes were significantly higher in patients with hypertension than in the normal controls (P < .001), with no significant correlation between the systolic and diastolic dyssynchrony indexes. The proportions of patients with hypertension who had LV systolic and diastolic dyssynchrony were 24% and 21%, respectively. Multivariate analysis showed that the E/E' ratio (P < .001) was independently associated with LV systolic dyssynchrony, whereas LV mass index (P = .001) and E/E' (P < .001) were major determinants of LV diastolic dyssynchrony.

CONCLUSIONS

LV systolic and diastolic dyssynchrony are not uncommon in asymptomatic patients with hypertension and are significantly associated with LV filling pressure. The determinants of LV systolic dyssynchrony are not the same as those of diastolic dyssynchrony, implying that different mechanisms are involved in the development of LV systolic and diastolic dyssynchrony in asymptomatic patients with hypertension.

Different prognostic significance of right and left ventricular diastolic dysfunction in heart failure

BACKGROUND

Left (LV) and right (RV) ventricular diastolic dysfunction is common in heart failure but the prognostic value of RV diastolic dysfunction is not known.

HYPOTHESIS

As a follow-up to a previously undertaken study, this study was carried out to investigate whether LV and RV diastolic dysfunction affect prognosis differently and, in addition, whether changes in diastolic filling patterns over time correlate with clinical outcome.

METHODS

We studied a cohort of 105 patients (mean age 62.7 +/- 1.3 years, 66% male) with heart failure (ejection fraction < 50%) by Doppler echocardiography in both RV and LV.

RESULTS

An LV restrictive filling pattern (RFP) was present in 48% of the patients and, when compared with non-RFP subgroups, it was associated with poorer systolic function, higher New York Heart Association functional class, and higher cardiac mortality at 1 year (all p < 0.001). The coexistence of an LV-RFP and poor LV systolic function (ejection fraction < 25%) markedly decreased the 1-year survival that was significant when compared with other subgroups (p = 0.001). In contrast, RV diastolic dysfunction that occurred in 21% of patients was not a prognostic factor for mortality either alone or in combination with LV diastolic dysfunction, but predicted nonfatal hospital admissions for heart failure or unstable angina (p = 0.016).

CONCLUSION

An LV restrictive filling pattern is a powerful predictor of a poor prognosis, especially when combined with low ejection fraction, but in this study RV diastolic dysfunction did not appear to be an independent predictor of subsequent mortality.

EANM/ESC guidelines for radionuclide imaging of cardiac function

Radionuclide imaging of cardiac function represents a number of well-validated techniques for accurate determination of right (RV) and left ventricular (LV) ejection fraction (EF) and LV volumes. These first European guidelines give recommendations for how and when to use first-pass and equilibrium radionuclide ventriculography, gated myocardial perfusion scintigraphy, gated PET, and studies with non-imaging devices for the evaluation of cardiac function. The items covered are presented in 11 sections: clinical indications, radiopharmaceuticals and dosimetry, study acquisition, RV EF, LV EF, LV volumes, LV regional function, LV diastolic function, reports and image display and reference values from the literature of RVEF, LVEF and LV volumes. If specific recommendations given cannot be based on evidence from original, scientific studies, referral is given to "prevailing or general consensus". The guidelines are designed to assist in the practice of referral to, performance, interpretation and reporting of nuclear cardiology studies for the evaluation of cardiac performance.

Assessment of diastolic function using 16-frame 201Tl gated myocardial perfusion SPECT: a comparative study of QGS2 and pFAST2

OBJECTIVE

The objective of the present study is to investigate the correlations across various types of interface software for (201)Tl gated myocardial perfusion SPECT (MPS) in calculating two common diastolic function parameters (DFx), peak-filling rates (PFR), and time-to-peak filling (TTPF).

METHODS

A total of 109 patients (66 men and 43 women; age 35-78 years) were studied. All patients were classified into three groups (i.e., ND, no-defect group; SD, small-defect group; LD, large-defect group) to clarify the influence of perfusion defects possibly affecting the analysis. Two kinds of available software, namely, quantitative gated SPECT (QGS2) and perfusion and functional analysis for gated SPECT (pFAST2) with cardioGRAF were used to obtain PFR and TTPF. Finally, we analyzed the correlation between DFx obtained with the two different kinds of software.

RESULTS

The values of LVEF, PFR, and TTPF were assessed in all patients. In both the ND (correlation coefficients were 0.92, 0.79, and 0.99, respectively) and SD groups (correlation coefficients were 0.74, 0.88, and 0.98, respectively), a strong correlation was observed. In contrast, PFR did not show a significant correlation in the LD group.

CONCLUSIONS

With the two different kinds of software, QGS2 and pFAST2, the calculated PFR was almost equal and showed good correlations in both ND and SD groups. In contrast, the numerical value varied between the two methods, and its correlation was poor in the LD group. However, TTPF showed a good correlation regardless of the presence of perfusion defects, and the values were equal. TTPF was confirmed to be a stable diastolic index across the two kinds of software, QGS2 and pFAST2, in (201)Tl gated MPS.

SPECT versus planar gated blood pool imaging for left ventricular evaluation

BACKGROUND

We developed a new segmentation algorithm based on the invariance of the Laplacian (IL) to compute volumes and ejection fractions and compared these results with planar analysis and gradients by use of a standard algorithm (QBS).

METHODS AND RESULTS

Planar and single photon emission computed tomography blood pool acquisition was performed in 202 patients. Planar left ventricular ejection fraction (LVEF) was used as the gold standard, and single photon emission computed tomography images were processed by both 3-dimensional (3D) methods. Correlations between each 3D algorithm and planar methodology were as follows: r = 0.77 for QBS and r = 0.84 for IL. Mean LVEFs were 32.72% +/- 13.05% for the planar method, 32.32% +/- 15.98% for QBS, and 31.93% +/- 13.44% for IL (P = .16). Bland-Altman analysis closely demonstrated negligible systematic bias for both 3D methods. Standard errors of bias were comparable between methods (9.36% for QBS and 7.44% for IL, P = .48). Linear regression of the Bland-Altman bias revealed a slope significantly different from 0 for the QBS method (0.22 +/- 0.048, P < .0001) but not for IL (-0.032 +/- 0.0044, P = .47).

CONCLUSION

The new segmentation algorithm provides comparable results to QBS and planar analysis. However, with QBS, the difference in LVEF was correlated with the magnitude of LVEF, which was not found with the new algorithm.

Left Ventricular Geometry and Renal Function in Hypertensive Patients With Diastolic Heart Failure

BACKGROUND

The objective is to define the relationship between cardiac geometry and renal function in hypertensive subjects with and without diastolic heart failure (DHF).

METHODS

This is a prospective observational study in a tertiary-care teaching institute in a 15-month period of consecutive hospitalized hypertensive patients. Patients on dialysis therapy or with atrial fibrillation, systolic heart failure, gross proteinuria, and glomerular diseases were excluded. Two-dimensional echocardiography was performed and stable glomerular filtration rate (GFR) was calculated by using the Modification of Diet in Renal Disease formula. Patients were classified into stage 1 to 5 chronic kidney disease (CKD).

RESULTS

Five hundred forty hypertensive patients were separated into 2 groups: 286 patients with DHF and 254 patients without DHF. Mean age was 69.1 +/- 13.7 (SD) years in general. In patients with DHF, from stages 1 to 5 CKD, there was a significant graded increase in left ventricular mass index (from 117.3 to 162.4 g/m(2)) and relative wall thickness (from 0.42 to 0.52) and a significant graded decrease in aortic cusp separation (from 1.85 to 1.55 cm). Among echocardiographic variables, left ventricular mass index and relative wall thickness were associated inversely and aortic cusp separation was associated directly with GFR. In the absence of DHF, only left ventricular mass index was associated inversely with GFR, suggesting a prominent role of aortic cusp separation and relative wall thickness in the variability in GFR in patients with DHF through a hemodynamic disturbance.

CONCLUSION

Hemodynamic alterations have a prominent role in the variability of GFR in patients with CKD with DHF. Adverse cardiac geometry is linked to the severity of CKD in hypertensive patients, raising the possibility of preserving both cardiac and renal function by means of hypertension control.

Accurate estimation of regional and global cardiac function in old myocardial infarction patients by multidetector-row computed tomography

Recently we can evaluate cardiac function by multidetector-row computed tomography (MDCT) and quantitative gated SPECT(QGS) as well as left ventriculography (LVG). We evaluated regional and global cardiac function using MDCT and QGS, compared to LVG, and also evaluated parameters of left ventricular (LV) diastolic function using MDCT. Regional cardiac function was evaluated using shortening fraction(SF). Global cardiac function was evaluated using ejection fraction(EF). The peak filling rate(PFR) and the ratio of time to peak filling rate to RR interval(tPFR/RR) on MDCT were measured as parameters of LV diastolic function. The SFs by MDCT and LVG were correlated in almost each segment, but those by QGS and LVG were not correlated in some each segment. The SFs by QGS and LVG were not correlated in the myocardial infarcted segments, but those by QGS and LVG were correlated in the non-infarcted segments. Except for patients who had wall motion abnormalities at the ventricular septum or posterolateral wall, the EFs by MDCT and LVG were correlated, but those by QGS and LVG were not correlated. MDCT was more useful in detecting regional and global cardiac function compared to QGS, and parameters of LV diastolic function could be also measured by MDCT.