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Ramos GV, Santos MM, Gava FN, de Lacerda-Neto JC. Effects of conditioning on the left ventricular function of young purebred Arabian horses. PLoS One 2024; 19:e0304724. [PMID: 38829873 PMCID: PMC11146711 DOI: 10.1371/journal.pone.0304724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Accepted: 05/17/2024] [Indexed: 06/05/2024] Open
Abstract
The effects of conditioning on cardiac function in young horses is still unknown. For this reason, this study evaluated the left ventricular (LV) function of young horses by echocardiography after six weeks of conditioning. Fourteen untrained young purebred Arabian horses were evaluated at rest and after a stress test (ST) before and after a six-week conditioning program. There was an increase in V4 (p < 0.001) after conditioning, as well as a reduction in both heart rate (HR) at rest and peak HR during the ST (p < 0.001). There was also a reduction in internal diameter, along with an increase in interventricular septal, free wall and mean thicknesses and LV mass (p < 0.05). After the ST, the conditioned animals showed higher values of velocity time integral, stroke volume, systolic and cardiac indices, ejection (ET) and deceleration times (DT), end-diastolic volume, time to onset of radial myocardial velocity during early diastole and time to peak of transmitral flow velocity, in addition to reduced pre-ejection period (PEP), PEP/ET ratio and mean velocity of circumferential fiber shortening (p < 0.05). The conditioning protocol promoted physiological adaptations that indicate an improvement in the animals' aerobic capacity associated with an enhanced left ventricular function.
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Affiliation(s)
- Gabriel Vieira Ramos
- Department of Veterinary Clinics and Surgery, School of Agricultural and Veterinary Sciences, São Paulo State University (UNESP), Jaboticabal, São Paulo, Brazil
| | - Maíra Moreira Santos
- Department of Veterinary Clinics and Surgery, School of Agricultural and Veterinary Sciences, São Paulo State University (UNESP), Jaboticabal, São Paulo, Brazil
| | - Fábio Nelson Gava
- Department of Veterinary Clinics, State University of Londrina, Londrina, Paraná, Brazil
| | - José Corrêa de Lacerda-Neto
- Department of Veterinary Clinics and Surgery, School of Agricultural and Veterinary Sciences, São Paulo State University (UNESP), Jaboticabal, São Paulo, Brazil
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2
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Kadoglou NPE, Mouzarou A, Hadjigeorgiou N, Korakianitis I, Myrianthefs MM. Challenges in Echocardiography for the Diagnosis and Prognosis of Non-Ischemic Hypertensive Heart Disease. J Clin Med 2024; 13:2708. [PMID: 38731238 PMCID: PMC11084735 DOI: 10.3390/jcm13092708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 04/26/2024] [Accepted: 04/27/2024] [Indexed: 05/13/2024] Open
Abstract
It has been well established that arterial hypertension is considered as a predominant risk factor for the development of cardiovascular diseases. Despite the link between arterial hypertension and cardiovascular diseases, arterial hypertension may directly affect cardiac function, leading to heart failure, mostly with preserved ejection fraction (HFpEF). There are echocardiographic findings indicating hypertensive heart disease (HHD), defined as altered cardiac morphology (left ventricular concentric hypertrophy, left atrium dilatation) and function (systolic or diastolic dysfunction) in patients with persistent arterial hypertension irrespective of the cardiac pathologies to which it contributes, such as coronary artery disease and kidney function impairment. In addition to the classical echocardiographic parameters, novel indices, like speckle tracking of the left ventricle and left atrium, 3D volume evaluation, and myocardial work in echocardiography, may provide more accurate and reproducible diagnostic and prognostic data in patients with arterial hypertension. However, their use is still underappreciated. Early detection of and prompt therapy for HHD will greatly improve the prognosis. Hence, in the present review, we shed light on the role of echocardiography in the contemporary diagnostic and prognostic approaches to HHD.
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Affiliation(s)
- Nikolaos P. E. Kadoglou
- Medical School, University of Cyprus, 215/6 Old Road Lefkosias-Lemesou, Aglatzia, Nicosia CY 2029, Cyprus
| | - Angeliki Mouzarou
- Department of Cardiology, Pafos General Hospital, Paphos CY 8026, Cyprus
| | | | - Ioannis Korakianitis
- Medical School, University of Cyprus, 215/6 Old Road Lefkosias-Lemesou, Aglatzia, Nicosia CY 2029, Cyprus
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3
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Rahbar Z, Tavoosi A, Bakhshandeh A, Mehrpooya M, Sardari A, Larti F, Sattarzadeh Badkoubeh R. Echocardiographic estimation of left ventricular filling pressures in heart transplant recipients. Egypt Heart J 2024; 76:12. [PMID: 38289542 PMCID: PMC10828230 DOI: 10.1186/s43044-024-00443-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 01/19/2024] [Indexed: 02/02/2024] Open
Abstract
BACKGROUND Echocardiographic estimation of left ventricular filling pressure in heart transplant (HTx) recipients is challenging. The ability of echocardiography to detect elevated left ventricular end-diastolic pressure (LVEDP) in HTx patients was assessed in this study. RESULTS This descriptive cross-sectional study included 39 HTx recipients who were candidates for endomyocardial biopsy as a part of their routine post-transplantation surveillance. Doppler transthoracic echocardiography was done before the procedure, and left heart catheterization was done during the endomyocardial biopsy. Thirty-nine patients (15 female, 24 male), with a mean age of 39.6 years (range 13-70), were enrolled. A strong relation was observed between lateral E/e' and LVEDP (R = 0.64, P value < 0.001) and average E/e' and LVEDP (R = 0.6, P value < 0.001). The best cutoff value for LVEDP prediction was the average E/e' ≥ 6.8 with a sensitivity of 96.15% and specificity of 68.5% for the prediction of LVEDP more than or equal to 20 mmHg. Two predictive models comprising age, gender, and lateral E/e' or average E/e' were also proposed. A significant relationship was also found between LVEDP and left ventricular global longitudinal strain (R = - 0.31, P value < 0.01). CONCLUSIONS Lateral E/e' was the best predictor of LVEDP. The cutoff of average E/e' had the best validity for the estimation of LVEDP. Despite the strong observed association, echocardiographic parameters cannot be considered a surrogate for invasive LVEDP measurements when seeking information about left ventricle filling pressure on heart transplant recipients.
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Affiliation(s)
- Zohreh Rahbar
- Department of Cardiology, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, End of Keshavarz Boulevard, Tehran, 1419733141, Iran
| | - Anahita Tavoosi
- Department of Cardiology, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, End of Keshavarz Boulevard, Tehran, 1419733141, Iran
| | - Alireza Bakhshandeh
- Department of Cardiothoracic Surgery, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Mehrpooya
- Department of Cardiology, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, End of Keshavarz Boulevard, Tehran, 1419733141, Iran
| | - Akram Sardari
- Department of Cardiology, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, End of Keshavarz Boulevard, Tehran, 1419733141, Iran
| | - Farnoosh Larti
- Department of Cardiology, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, End of Keshavarz Boulevard, Tehran, 1419733141, Iran.
| | - Roya Sattarzadeh Badkoubeh
- Department of Cardiology, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, End of Keshavarz Boulevard, Tehran, 1419733141, Iran
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Pellegrini JAS, Mendes CL, Gottardo PC, Feitosa K, John JF, de Oliveira ACT, Negri AJDA, Grumann AB, Barros DDS, Negri FEFDO, de Macedo GL, Neves JLB, Rodrigues MDS, Spagnól MF, Ferez MA, Chalhub RÁ, Cordioli RL. The use of bedside echocardiography in the care of critically ill patients - a joint consensus document of the Associação de Medicina Intensiva Brasileira, Associação Brasileira de Medicina de Emergência and Sociedade Brasileira de Medicina Hospitalar. Part 2 - Technical aspects. CRITICAL CARE SCIENCE 2023; 35:117-146. [PMID: 37712802 PMCID: PMC10406406 DOI: 10.5935/2965-2774.20230310-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 01/12/2023] [Indexed: 09/16/2023]
Abstract
Echocardiography in critically ill patients has become essential in the evaluation of patients in different settings, such as the hospital. However, unlike for other matters related to the care of these patients, there are still no recommendations from national medical societies on the subject. The objective of this document was to organize and make available expert consensus opinions that may help to better incorporate echocardiography in the evaluation of critically ill patients. Thus, the Associação de Medicina Intensiva Brasileira, the Associação Brasileira de Medicina de Emergência, and the Sociedade Brasileira de Medicina Hospitalar formed a group of 17 physicians to formulate questions relevant to the topic and discuss the possibility of consensus for each of them. All questions were prepared using a five-point Likert scale. Consensus was defined a priori as at least 80% of the responses between one and two or between four and five. The consideration of the issues involved two rounds of voting and debate among all participants. The 27 questions prepared make up the present document and are divided into 4 major assessment areas: left ventricular function, right ventricular function, diagnosis of shock, and hemodynamics. At the end of the process, there were 17 positive (agreement) and 3 negative (disagreement) consensuses; another 7 questions remained without consensus. Although areas of uncertainty persist, this document brings together consensus opinions on several issues related to echocardiography in critically ill patients and may enhance its development in the national scenario.
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Affiliation(s)
- José Augusto Santos Pellegrini
- Department of Intensive Care, Hospital de Clínicas de Porto
Alegre, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brazil
| | - Ciro Leite Mendes
- Department of Intensive Care, Hospital Universitário Lauro
Wanderley - João Pessoa (PB), Brazil
| | - Paulo César Gottardo
- Department of Intensive Care, Hospital Nossa Senhora das Neves -
João Pessoa (PB), Brazil
| | - Khalil Feitosa
- Department of Emergency Medicine, Hospital Geral de Fortaleza -
Fortaleza (CE), Brazil
| | - Josiane França John
- Department of Intensive Care, Hospital de Clínicas de Porto
Alegre, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brazil
| | | | | | - Ana Burigo Grumann
- Department of Intensive Care, Hospital Nereu Ramos -
Florianópolis (SC), Brazil
| | - Dalton de Souza Barros
- Cardiovascular Intensive Care Unit, Hospital Cardiopulmonar
Instituto D’Or - Salvador (BA), Brazil
| | | | | | | | - Márcio da Silveira Rodrigues
- Department of Emergency, Hospital de Clínicas de Porto
Alegre, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brazil
| | | | - Marcus Antonio Ferez
- Intensive Care Unit, Hospital Beneficência Portuguesa -
Ribeirão Preto (SP), Brazil
| | - Ricardo Ávila Chalhub
- Department of Echocardiogram, Hospital Santo Antônio, Obras
Sociais Irmã Dulce - Salvador (BA), Brazil
| | - Ricardo Luiz Cordioli
- Department of Intensive Care, Hospital Israelita Albert Einstein -
São Paulo (SP), Brazil
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Diaz-Canestro C, Montero D. Sex-specific improvement in cardiac phenotype in older females combining blood withdrawal and exercise training. J Appl Physiol (1985) 2023; 134:296-304. [PMID: 36519567 DOI: 10.1152/japplphysiol.00328.2022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
This study determined whether an intervention combining hematological and exercise stimuli may overcome the prevailing limitations to improve the cardiac phenotype and orthostatic tolerance (OT) of females with advanced age. Healthy females (n = 15) and males (n = 14) matched by age (63.7 ± 7.0 vs. 63.6 ± 8.7 yr) and moderate physical activity were recruited. OT, transthoracic echocardiography, and central hemodynamics were assessed during incremental lower body negative pressure (LBNP) levels (up to -50 mmHg) for 1 h or until presyncope, prior to and after an intervention comprising standard (10%) blood withdrawal and an 8-wk exercise training program designed to maximize central hemodynamic adaptations. OT time was lower in females compared with males (48.1 ± 10.6 vs. 57.0 ± 4.8 min, P = 0.008) before the intervention. Improved OT time (+11%) in females (48.1 ± 10.6 vs. 53.5 ± 6.1 min, P = 0.021) but not in males (57.0 ± 4.8 vs. 56.7 ± 5.6 min, P = 0.868) was found following the intervention, resulting in similar OT time between females and males (P = 0.156). The intervention induced improvements in left ventricular (LV) diastolic function (+13% for myocardial e') along with increased LV mass (+13%) in females (P ≤ 0.039) but not in males (P ≥ 0.257). During the initial LBNP stages (0 to -20 mmHg), LV stroke volume and cardiac output were exclusively increased in females after the intervention (P ≤ 0.034). In conclusion, the cardiac phenotype of females with advanced age can be structurally and functionally modified in parallel to improved OT via short-term hematological and central hemodynamic stimuli.NEW & NOTEWORTHY Based on previous studies, main features of the cardiac phenotype in females with advanced age are generally unresponsive to lifestyle interventions. The present findings reveals that the cardiac phenotype of middle-age and older females is amenable to large modification in a short-term period when hematological stimuli are combined with those induced by exercise training. The same intervention only induced minor adaptations in males matched by age and potential confounding factors.
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Affiliation(s)
- Candela Diaz-Canestro
- Department of Medicine, University of Hong Kong, Hong Kong, People's Republic of China
| | - David Montero
- Faculty of Medicine, School of Public Health, University of Hong Kong, Hong Kong, People's Republic of China.,Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
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Peteiro J, Bouzas-Mosquera A, Barbeito-Caamaño C, Martin-Alvarez E, Souto-Cainzos B, Vazquez-Rodriguez JM. Additive prognostic and diagnostic value of diastolic exercise parameters in patients referred for exercise echocardiography. Eur Heart J Cardiovasc Imaging 2022; 24:108-118. [PMID: 35175338 DOI: 10.1093/ehjci/jeac039] [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] [Received: 11/22/2021] [Accepted: 02/08/2022] [Indexed: 12/24/2022] Open
Abstract
AIMS Exercise echocardiography (ExE) may evaluate left ventricular (LV) systolic and diastolic function. We aimed to assess the value of diastolic parameters at exercise [early LV inflow velocity to early tissue Doppler annulus velocity (E/e')] in patients with normal or abnormal resting diastolic function (DF) referred for a clinically indicated ExE. METHODS AND RESULTS LV systolic and DF according to ASE/EACVI guidelines and mitral regurgitation (MR) were evaluated at rest in 772 patients (age 67 ± 12 years) with preserved LV ejection fraction (LVEF ≥ 50%). We assessed regional/global LV systolic function at peak exercise, while MR and E/e' where evaluated in the immediate post-exercise period. Abnormal ExE was defined as ischaemia or fixed wall motion abnormalities, and raised E/e' values as >15 at rest and at exercise (e' at the septal level). Patients were grouped as complaining or not of dyspnoea. Events were overall mortality, myocardial infarction, admission for unstable angina or cardiac failure, and coronary revascularization. DF was abnormal at rest in 221 patients (29%) and indeterminate in 77 (10%), with similar percentages in patients with and without dyspnoea. Exercise E/e' >15 was found in 37% of patients with abnormal DF, 21% with indeterminate DF, and 6% with normal DF (P < 0.001). Patients with abnormal ExE had more often abnormal resting DF (39% vs. 25%, P = 0.001) and exercise E/e' >15 (25% vs. 13%, P < 0.001) than those with normal ExE. During a median follow-up of 1.68 years, there were 132 events. Independent predictors included peak exercise LVEF [hazard ratio (HR) = 0.93, 95% confidence interval (CI) = 0.91-0.94, P < 0.001], and exercise E/e' (HR= 1.04, 95% CI = 1.01-1.07, P = 0.01). Neither resting E/e' values nor resting abnormal DF by ASE/EACVI guidelines, were independent predictors. Annualized event-rates were 43.2% in patients with (+) ExE plus (+) exercise E/e', 23.8% in those with (+) ExE and (-) exercise E/e', 7.9% in (-) ExE and (+) exercise E/e', and 3.6% with both variables normal. CONCLUSIONS The results of diastolic dysfunction at rest and at exercise were similar between patients with or without dyspnoea referred for ExE, but they were associated with abnormal ExE. Exercise E/e' reclassified 21% of patients with indeterminate DF and further predicted outcome on top of ExE results.
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Affiliation(s)
- Jesús Peteiro
- Department of Cardiology, Complejo Hospitalario Universitario de A Coruña (CHUAC), CIBERCV, Instituto de Investigación Biomédica de A Coruña (INIBIC), Universidad de A Coruña, As Xubias, 84, 15006 A Coruña, Spain
| | - Alberto Bouzas-Mosquera
- Department of Cardiology, Complejo Hospitalario Universitario de A Coruña (CHUAC), CIBERCV, Instituto de Investigación Biomédica de A Coruña (INIBIC), Universidad de A Coruña, As Xubias, 84, 15006 A Coruña, Spain
| | - Cayetana Barbeito-Caamaño
- Department of Cardiology, Complejo Hospitalario Universitario de A Coruña (CHUAC), CIBERCV, Instituto de Investigación Biomédica de A Coruña (INIBIC), Universidad de A Coruña, As Xubias, 84, 15006 A Coruña, Spain
| | - Esteban Martin-Alvarez
- Department of Cardiology, Complejo Hospitalario Universitario de A Coruña (CHUAC), CIBERCV, Instituto de Investigación Biomédica de A Coruña (INIBIC), Universidad de A Coruña, As Xubias, 84, 15006 A Coruña, Spain
| | - Borja Souto-Cainzos
- Department of Cardiology, Complejo Hospitalario Universitario de A Coruña (CHUAC), CIBERCV, Instituto de Investigación Biomédica de A Coruña (INIBIC), Universidad de A Coruña, As Xubias, 84, 15006 A Coruña, Spain
| | - Jose M Vazquez-Rodriguez
- Department of Cardiology, Complejo Hospitalario Universitario de A Coruña (CHUAC), CIBERCV, Instituto de Investigación Biomédica de A Coruña (INIBIC), Universidad de A Coruña, As Xubias, 84, 15006 A Coruña, Spain
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7
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Saura M, Zamorano JL, Zaragoza C. Preclinical models of congestive heart failure, advantages, and limitations for application in clinical practice. Front Physiol 2022; 13:850301. [PMID: 35991184 PMCID: PMC9386157 DOI: 10.3389/fphys.2022.850301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 07/11/2022] [Indexed: 11/13/2022] Open
Abstract
Congestive heart failure (CHF) has increased over the years, in part because of recent progress in the management of chronic diseases, thus contributing to the maintenance of an increasingly aging population. CHF represents an unresolved health problem and therefore the establishment of animal models that recapitulates the complexity of CHF will become a critical element to be addressed, representing a serious challenge given the complexity of the pathogenesis of CHF itself, which is further compounded by methodological biases that depend on the animal species in use. Animal models of CHF have been developed in many different species, with different surgical procedures, all with promising results but, for the moment, unable to fully recapitulate the human disease. Large animal models often provide a more promising reality, with all the difficulties that their use entails, and which limit their performance to fewer laboratories, the costly of animal housing, animal handling, specialized facilities, skilled methodological training, and reproducibility as another important limiting factor when considering a valid animal model versus potentially better performing alternatives. In this review we will discuss the different animal models of CHF, their advantages and, above all, the limitations of each procedure with respect to effectiveness of results in terms of clinical application.
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Affiliation(s)
- Marta Saura
- Departamento de Biología de Sistemas, Facultad de Medicina (IRYCIS), Universidad de Alcalá, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Jose Luis Zamorano
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
- Departamento de Cardiología, Hospital Universitario Ramón y Cajal (IRYCIS), Madrid, Spain
| | - Carlos Zaragoza
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
- Unidad de Investigación Cardiovascular, Departamento de Cardiología, Universidad Francisco de Vitoria, Hospital Ramón y Cajal (IRYCIS), Madrid, Spain
- *Correspondence: Carlos Zaragoza,
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Prognostic value of the MAGGIC score, H2FPEF score and HFA-PEFF algorithm in patients with exertional dyspnea and the incremental value of exercise echocardiography. J Am Soc Echocardiogr 2022; 35:966-975. [DOI: 10.1016/j.echo.2022.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 05/09/2022] [Accepted: 05/10/2022] [Indexed: 11/21/2022]
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Irzmański R, Glowczynska R, Banach M, Szalewska D, Piotrowicz R, Kowalik I, Pencina MJ, Zareba W, Orzechowski P, Pluta S, Kalarus Z, Opolski G, Piotrowicz E. Prognostic Impact of Hybrid Comprehensive Telerehabilitation Regarding Diastolic Dysfunction in Patients with Heart Failure with Reduced Ejection Fraction—Subanalysis of the TELEREH-HF Randomized Clinical Trial. J Clin Med 2022; 11:jcm11071844. [PMID: 35407452 PMCID: PMC8999786 DOI: 10.3390/jcm11071844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 03/21/2022] [Accepted: 03/22/2022] [Indexed: 12/04/2022] Open
Abstract
Aims: The objective of the study was to evaluate the effects of individually prescribed hybrid comprehensive telerehabilitation (HCTR) implemented at patients’ homes on left ventricular (LV) diastolic function in heart failure (HF) patients. Methods and results: The Telerehabilitation in Heart Failure Patients trial (TELEREH-HF) is a multicenter, prospective, randomized (1:1), open-label, parallel-group, controlled trial involving HF patients assigned either to HCTR involving a remotely monitored home training program in conjunction with usual care (HCTR group) or usual care only (UC group). The patient in the HCTR group underwent a 9-week HCTR program consisting of two stages: an initial stage (1 week) conducted in hospital and the subsequent stage (eight weeks) of home-based HCTR five times weekly. Due to difficulties of proper assessment and differences in the evaluation of diastolic function in patients with atrial fibrillation, we included in our subanalysis only patients with sinus rhythm. Depending on the grade of diastolic dysfunction, patients were assigned to subgroups with mild diastolic (MDD) or severe diastolic dysfunction (SDD), both in HCTR (HCTR-MDD and HCTR-SDD) and UC groups (UC-MDD and UC-SDD). Changes from baseline to 9 weeks in echocardiographic parameters were seen only in A velocities in HCTR-MDD vs. UC-MDD; no significant shifts between groups of different diastolic dysfunction grades were observed after HCTR. All-cause mortality was higher in UC-SDD vs. UC-MDD with no difference between HCTR-SDD and HCTR-MDD. Higher probability of HF hospitalization was observed in HCTR-SDD than HCTR-MDD and in UC-SDD than UC-MDD. No differences in the probability of cardiovascular mortality and hospitalization were found. Conclusions: HCTR did not influence diastolic function in HF patients in a significant manner. The grade of diastolic dysfunction had an impact on mortality only in the UC group and HF hospitalization over a 12–24-month follow-up in HCTR and UC groups.
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Affiliation(s)
- Robert Irzmański
- Department of Internal Medicine and Cardiac Rehabilitation, Medical University of Łódź, 90-647 Lodz, Poland;
| | - Renata Glowczynska
- 1st Chair and Department of Cardiology, Medical University of Warsaw, 02-097 Warsaw, Poland;
- Correspondence:
| | - Maciej Banach
- Department of Hypertension, Medical University of Łódź, 90-647 Lodz, Poland;
| | - Dominika Szalewska
- Clinic of Rehabilitation Medicine, Faculty of Health Sciences, Medical University of Gdańsk, 80-210 Gdańsk, Poland;
| | - Ryszard Piotrowicz
- National Institute of Cardiology, 04-628 Warsaw, Poland; (R.P.); (I.K.)
- Warsaw Academy of Medical Rehabilitation, 01-234 Warsaw, Poland
| | - Ilona Kowalik
- National Institute of Cardiology, 04-628 Warsaw, Poland; (R.P.); (I.K.)
| | - Michael J. Pencina
- The Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC 27710, USA;
| | - Wojciech Zareba
- Cardiology Unit of the Department of Medicine, University of Rochester Medical Center, Rochester, NY 14642, USA;
| | - Piotr Orzechowski
- Telecardiology Center, National Institute of Cardiology, 04-628 Warsaw, Poland; (P.O.); (E.P.)
| | - Slawomir Pluta
- Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Silesian Center for Heart Diseases, Silesian Medical University, 41-800 Zabrze, Poland; (S.P.); (Z.K.)
| | - Zbigniew Kalarus
- Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Silesian Center for Heart Diseases, Silesian Medical University, 41-800 Zabrze, Poland; (S.P.); (Z.K.)
| | - Grzegorz Opolski
- 1st Chair and Department of Cardiology, Medical University of Warsaw, 02-097 Warsaw, Poland;
| | - Ewa Piotrowicz
- Telecardiology Center, National Institute of Cardiology, 04-628 Warsaw, Poland; (P.O.); (E.P.)
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van de Bovenkamp AA, Wijkstra N, Oosterveer FPT, Vonk Noordegraaf A, Bogaard HJ, van Rossum AC, de Man FS, Borlaug BA, Handoko ML. The Value of Passive Leg Raise During Right Heart Catheterization in Diagnosing Heart Failure With Preserved Ejection Fraction. Circ Heart Fail 2022; 15:e008935. [PMID: 35311526 PMCID: PMC9009844 DOI: 10.1161/circheartfailure.121.008935] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Because of limited accuracy of noninvasive tests, diastolic stress testing plays an important role in the diagnostic work-up of patients with heart failure with preserved ejection fraction (HFpEF). Exercise right heart catheterization is considered the gold standard and indicated when HFpEF is suspected but left ventricular filling pressures at rest are normal. However, performing exercise during right heart catheterization is not universally available. Here, we examined whether pulmonary capillary wedge pressure (PCWP) during a passive leg raise (PLR) could be used as simple and accurate method to diagnose or rule out occult-HFpEF. METHODS In our tertiary center for pulmonary hypertension and HFpEF, all patients who received a diagnostic right heart catheterization with PCWP-measurements at rest, PLR, and exercise were evaluated (2014-2020). The diagnostic value of PCWPPLR was compared with the gold standard (PCWPEXERCISE). Cut-offs derived from our cohort were subsequently validated in an external cohort (N=74). RESULTS Thirty-nine non-HFpEF, 33 occult-HFpEF, and 37 manifest-HFpEF patients were included (N=109). In patients with normal PCWPREST (<15 mmHg), PCWPPLR significantly improved diagnostic accuracy compared with PCWPREST (AUC=0.82 versus 0.69, P=0.03). PCWPPLR ≥19 mmHg (24% of cases) had a specificity of 100% for diagnosing occult-HFpEF, irrespective of diuretic use. PCWPPLR ≥11 mmHg had a 100% sensitivity and negative predictive value for diagnosing occult-HFpEF. Both cut-offs retained a 100% specificity and 100% sensitivity in the external cohort. Absolute change in PCWPPLR or V-wave derived parameters had no incremental value in diagnosing occult-HFpEF. CONCLUSIONS PCWPPLR is a simple and powerful tool that can help to diagnose or rule out occult-HFpEF.
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Affiliation(s)
- Arno A van de Bovenkamp
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Cardiology, Amsterdam Cardiovascular Sciences, the Netherlands (A.A.v.d.B., N.W., A.C.v.R., M.L.H.)
| | - Niels Wijkstra
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Cardiology, Amsterdam Cardiovascular Sciences, the Netherlands (A.A.v.d.B., N.W., A.C.v.R., M.L.H.)
| | - Frank P T Oosterveer
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Pulmonology, Amsterdam Cardiovascular Sciences, the Netherlands (F.P.T.O., A.V.N., H.J.B., F.S.d.M.)
| | - Anton Vonk Noordegraaf
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Pulmonology, Amsterdam Cardiovascular Sciences, the Netherlands (F.P.T.O., A.V.N., H.J.B., F.S.d.M.)
| | - Harm Jan Bogaard
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Pulmonology, Amsterdam Cardiovascular Sciences, the Netherlands (F.P.T.O., A.V.N., H.J.B., F.S.d.M.)
| | - Albert C van Rossum
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Cardiology, Amsterdam Cardiovascular Sciences, the Netherlands (A.A.v.d.B., N.W., A.C.v.R., M.L.H.)
| | - Frances S de Man
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Pulmonology, Amsterdam Cardiovascular Sciences, the Netherlands (F.P.T.O., A.V.N., H.J.B., F.S.d.M.)
| | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (B.A.B.)
| | - M Louis Handoko
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Cardiology, Amsterdam Cardiovascular Sciences, the Netherlands (A.A.v.d.B., N.W., A.C.v.R., M.L.H.)
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11
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Systolic and diastolic function during cycling at the respiratory threshold between elderly and young healthy individuals. Sci Rep 2022; 12:3825. [PMID: 35264702 PMCID: PMC8907329 DOI: 10.1038/s41598-022-07933-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 02/28/2022] [Indexed: 11/20/2022] Open
Abstract
The hemodynamic consequences of aging have been extensively investigated during maximal incremental exercise. However, less is known about the effects of aging on hemodynamics during submaximal steady-state exercise. The aim of the present investigation was to compare the hemodynamics of healthy elderly and young subjects during an exercise bout conducted at the gas threshold (GET) intensity. Two groups of healthy, physically active subjects were studied: the elderly group—EG (n = 11; > 60 years old) and the young group—YG (n = 13; < 35 years old). Both groups performed a 5-min rectangular exercise test at the GET intensity. Hemodynamics were measured using echocardiography. The main finding was that stroke volume responses were higher in the YG than the EG (72.5 ± 16.7 vs. 52.4 ± 8.4 ml, respectively). The increased stroke volume capacity in the YG was the consequence of a greater capacity to increase cardiac preload and contractility and, to a lesser extent, to reduce systemic vascular resistance. Importantly, the atrial contribution to ventricular diastolic filling was substantially higher in the YG when compared to the EG.
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12
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Arterial Hypertension and Cardiopulmonary Function: The Value of a Combined Cardiopulmonary and Echocardiography Stress Test. High Blood Press Cardiovasc Prev 2022; 29:145-154. [PMID: 35107808 PMCID: PMC8942964 DOI: 10.1007/s40292-021-00494-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 11/23/2021] [Indexed: 11/27/2022] Open
Abstract
Arterial hypertension (AH) is a global burden and the leading risk factor for mortality worldwide. Haemodynamic abnormalities, longstanding neurohormonal and inflammatory activation, which are commonly observed in patients with AH, promote cardiac structural remodeling ultimately leading to heart failure (HF) if blood pressure values remain uncontrolled. While several epidemiological studies have confirmed the strong link between AH and HF, the pathophysiological processes underlying this transition remain largely unclear. The combined cardiopulmonary-echocardiography stress test (CPET-ESE) represents a precious non-invasive aid to detect alterations in patients at the earliest stages of HF. The opportunity to study the response of the cardiovascular system to exercise, and to differentiate central from peripheral cardiovascular maladaptations, makes the CPET-ESE an ideal technique to gain insights into the mechanisms involved in the transition from AH to HF, by recognizing alterations that might be silent at rest but influence the response to exercise. Identifications of these subclinical alterations might allow for a better risk stratification in hypertensive patients, facilitating the recognition of those at higher risk of evolution towards established HF. This may also lead to the development of novel preventive strategies and help tailor medical treatment. The purpose of this review is to summarise the potential advantages of using CPET-ESE in the characterisation of hypertensive patients in the cardiovascular continuum.
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13
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Vaishnav J, Sharma K. A Stepwise Guide to the Diagnosis and Treatment of Heart Failure with Preserved Ejection Fraction. J Card Fail 2021; 28:1016-1030. [PMID: 34968656 DOI: 10.1016/j.cardfail.2021.12.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 11/19/2021] [Accepted: 12/20/2021] [Indexed: 12/11/2022]
Abstract
Heart failure with a preserved ejection fraction (HFpEF) is a growing epidemic owing to an increasingly obese and aging patient population. Making the diagnosis of HFpEF is often challenging as patients frequently have multiple co-morbidities and alternative reasons for exercise intolerance that is hallmark to the disease. Additionally, a universal diagnostic algorithm and definition of HFpEF is lacking. The treatment of HFpEF is equally challenging as there has been significant difficulty in identifying therapies to improve survival in HFpEF, and management to date requires intensive optimization of HFpEF risk factors. In this review, we highlight a stepwise approach to the diagnosis and management of HFpEF inclusive of 1) how to establish a clinical diagnosis of HFpEF, 2) when to refer for invasive testing, 3) treatment of HFpEF including pharmacologic, non-pharmacologic, and risk factor modification interventions, and 4) when to refer to a dedicated HFpEF center or advanced heart failure specialist. With this systematic stepwise approach to HFpEF management, we aim to improve accurate diagnosis of the disease as well as raise awareness of all available therapeutic options for this challenging patient population. Heart failure with preserved ejection fraction (HFpEF) is becoming increasingly common due to our aging patient population with a higher prevalence of hypertension, diabetes, and obesity. Accurate diagnosis is important, particularly to ensure that an alternative heart failure diagnosis is not missed. We highlight a stepwise approach to the diagnosis of HFpEF, including when to pursue exercise or invasive hemodynamic testing. We also discuss pertinent treatment options by both medication class and co-morbidity status.
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Affiliation(s)
- Joban Vaishnav
- From the Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Kavita Sharma
- From the Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland.
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14
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Kim K, Jentzer JC, Wiley BM, Miranda WR, Bennett C, Barsness GW, Oh JK. Diamond-Forrester classification using echocardiography haemodynamic assessment in cardiac intensive care unit patients. ESC Heart Fail 2021; 8:4933-4943. [PMID: 34535970 PMCID: PMC8712910 DOI: 10.1002/ehf2.13527] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 05/28/2021] [Accepted: 07/08/2021] [Indexed: 11/29/2022] Open
Abstract
AIMS We sought to determine whether the Diamond-Forrester classification using non-invasive haemodynamic measurements by 2-D and Doppler echocardiography would predict hospital mortality in cardiac intensive care unit (CICU) patients. METHODS AND RESULTS We retrospectively analysed unique patients admitted to the CICU at Mayo Clinic Rochester from 2007 to 2018. Doppler-derived cardiac index (CI) and ratio of mitral valve E velocity to medial mitral annulus e' velocity (E/e' ratio) were used to classify patients into four profiles: Profile I (warm/dry), Profile II (warm/wet), Profile III (cold/dry), and Profile IV (cold/wet). Logistic regression was used to determine predictors of hospital mortality, and Cox proportional-hazards analysis was used to determine predictors of mortality during one year of follow-up. We included 4563 patients with a mean age of 68.3 ± 14.3 years, including 36.2% female patients. The distribution of each profile was as follows: I, 47.4%; II, 36.2%; III, 7.9%; IV, 8.5%. A total of 5.8% patients died during hospitalization, and 18.1% died by 1 year. Patients with either low CI or elevated E/e' ratio had higher in-hospital and 1 year mortality. Patients with elevated E/e' ratio (i.e. Profiles II and IV) had an increased risk of death during hospitalization and at 1 year after multivariate adjustment (adjusted hazard ratio 1.72 and 2.17 for 1 year mortality, respectively, compared with Profile I, P < 0.01). CONCLUSIONS Simple Doppler echocardiographic assessment can be used to identify haemodynamic profiles defined by the Diamond-Forester classification in patients admitted in CICU. These profiles predict outcomes and may be used to guide therapy in critically ill patients.
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Affiliation(s)
- Kyung‐Hee Kim
- Department of Cardiovascular Medicine, Echocardiography LaboratoryMayo Clinic200 First St SWRochesterMN55905USA
- Division of Cardiovascular DiseaseIncheon Sejong HospitalIncheonSouth Korea
| | - Jacob C. Jentzer
- Department of Cardiovascular MedicineMayo ClinicRochesterMNUSA
- Division of Pulmonary and Critical Care Medicine, Department of Internal MedicineMayo ClinicRochesterMNUSA
| | - Brandon M. Wiley
- Department of Cardiovascular MedicineMayo ClinicRochesterMNUSA
- Division of Pulmonary and Critical Care Medicine, Department of Internal MedicineMayo ClinicRochesterMNUSA
| | - William R. Miranda
- Department of Cardiovascular Medicine, Echocardiography LaboratoryMayo Clinic200 First St SWRochesterMN55905USA
| | - Courtney Bennett
- Department of Cardiovascular MedicineMayo ClinicRochesterMNUSA
- Division of Pulmonary and Critical Care Medicine, Department of Internal MedicineMayo ClinicRochesterMNUSA
| | - Gregory W. Barsness
- Department of Cardiovascular MedicineMayo ClinicRochesterMNUSA
- Division of Pulmonary and Critical Care Medicine, Department of Internal MedicineMayo ClinicRochesterMNUSA
| | - Jae K. Oh
- Department of Cardiovascular Medicine, Echocardiography LaboratoryMayo Clinic200 First St SWRochesterMN55905USA
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15
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Pradhan A, Scaringi J, Gerard P, Arena R, Myers J, Kaminsky LA, Kung E. Systematic Review and Regression Modeling of the Effects of Age, Body Size, and Exercise on Cardiovascular Parameters in Healthy Adults. Cardiovasc Eng Technol 2021; 13:343-361. [PMID: 34668143 DOI: 10.1007/s13239-021-00582-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 09/24/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE Blood pressure, cardiac output, and ventricular volumes correlate to various subject features such as age, body size, and exercise intensity. The purpose of this study is to quantify this correlation through regression modeling. METHODS We conducted a systematic review to compile reference data of healthy subjects for several cardiovascular parameters and subject features. Regression algorithms used these aggregate data to formulate predictive models for the outputs-systolic and diastolic blood pressure, ventricular volumes, cardiac output, and heart rate-against the features-age, height, weight, and exercise intensity. A simulation-based procedure generated data of virtual subjects to test whether these regression models built using aggregate data can perform well for subject-level predictions and to provide an estimate for the expected error. The blood pressure and heart rate models were also validated using real-world subject-level data. RESULTS The direction of trends between model outputs and the input subject features in our study agree with those in current literature. CONCLUSION Although other studies observe exponential predictor-output relations, the linear regression algorithms performed the best for the data in this study. The use of subject-level data and more predictors may provide regression models with higher fidelity. SIGNIFICANCE Models developed in this study can be useful to clinicians for personalized patient assessment and to researchers for tuning computational models.
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Affiliation(s)
- Aseem Pradhan
- Department of Mechanical Engineering, Clemson University, Clemson, SC, USA
| | - John Scaringi
- Department of Bioengineering, Clemson University, Clemson, SC, USA
| | - Patrick Gerard
- School of Mathematical and Statistical Sciences, Clemson University, Clemson, SC, USA
| | - Ross Arena
- Department of Physical Therapy, College of Applied Science, University of Illinois at Chicago, Chicago, IL, USA
| | - Jonathan Myers
- Division of Cardiology, VA Palo Alto Healthcare System, Palo Alto, CA, USA
| | - Leonard A Kaminsky
- Fisher Institute of Health and Well-Being and Clinical Exercise Physiology Laboratory, Ball State University, Muncie, IN, USA
| | - Ethan Kung
- Department of Mechanical Engineering, Clemson University, Clemson, SC, USA.
- Department of Bioengineering, Clemson University, Clemson, SC, USA.
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16
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Pugliese NR, DE Biase N, Balletti A, Filidei F, Pieroni A, D'Angelo G, Armenia S, Mazzola M, Gargani L, Del Punta L, Asomov M, Cerri E, Franzoni F, Nesti L, Mengozzi A, Paneni F, Masi S. Characterisation of haemodynamic and metabolic abnormalities in the heart failure spectrum: the role of combined cardiopulmonary and exercise echocardiography stress test. Minerva Cardiol Angiol 2021; 70:370-384. [PMID: 34137244 DOI: 10.23736/s2724-5683.21.05743-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Heart failure (HF) is a complex clinical syndrome characterised by different etiologies and a broad spectrum of cardiac structural and functional abnormalities. Current guidelines suggest a classification based on left ventricular ejection fraction (LVEF), distinguishing HF with reduced (HFrEF) from preserved (HFpEF) LVEF. HF should also be thought of as a continuous range of conditions, from asymptomatic stages to clinically manifest syndrome. The transition from one stage to the next is associated with a worse prognosis. While the rate of HF-related hospitalisation is similar in HFrEF and HFpEF once clinical manifestations occur, accurate knowledge of the steps and risk factors leading to HF progression is still lacking, especially in HFpEF. Precise hemodynamic and metabolic characterisation of patients with or at risk of HF may help identify different disease trajectories and risk factors, with the potential to identify specific treatment targets that might offset the slippery slope towards overt clinical manifestations. Exercise can unravel early metabolic and haemodynamic alterations that might be silent at rest, potentially leading to improved risk stratification and more effective treatment strategies. Cardiopulmonary exercise testing (CPET) offers valuable aid to investigate functional alterations in subjects with or at risk of HF, while echocardiography can assess cardiac structure and function objectively, both at rest and during exercise (exercise stress echocardiography, ESE). The purpose of this narrative review is to summarise the potential advantages of using an integrated CPET-ESE evaluation in the characterisation of both subjects at risk of developing HF and patients with stable HF.
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Affiliation(s)
- Nicola R Pugliese
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy -
| | - Nicolò DE Biase
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Alessio Balletti
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Francesco Filidei
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Alessandra Pieroni
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Silvia Armenia
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Matteo Mazzola
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy.,Institute of Clinical Physiology, C.N.R., Pisa, Italy
| | - Luna Gargani
- Institute of Clinical Physiology, C.N.R., Pisa, Italy
| | - Lavinia Del Punta
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Muzaffar Asomov
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Eugenio Cerri
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Ferdinando Franzoni
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Lorenzo Nesti
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Alessandro Mengozzi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Francesco Paneni
- Center for Molecular Cardiology, University of Zürich, Zürich, Switzerland
| | - Stefano Masi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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17
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Jain V, Ghosh R, Gupta M, Saijo Y, Bansal A, Farwati M, Marcus R, Klein A, Xu B. Contemporary narrative review on left atrial strain mechanics in echocardiography: cardiomyopathy, valvular heart disease and beyond. Cardiovasc Diagn Ther 2021; 11:924-938. [PMID: 34295714 DOI: 10.21037/cdt-20-461] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 08/19/2020] [Indexed: 12/14/2022]
Abstract
Left atrial (LA) strain mechanics refer to the measurement of LA myocardial deformation expressed as a percentage, and have been gathering interest over the last decade with expanding research supporting their utility in multiple cardiovascular disorders. Measured through advanced dynamic imaging techniques which include tissue Doppler imaging (TDI) and two-dimensional (2D) speckle tracking echocardiography (STE), LA strain mechanics are affected by left ventricular diastolic dysfunction prior to the onset of functional and structural changes in the left ventricle (LV). There is a need for practising cardiologists to become more familiar with the clinical utility of LA strain mechanics. In this article, we begin by reviewing the physiologic function of the LA, using this as a basis for understanding LA strain mechanics. The focus of this review article is to provide a contemporary update on the utility of LA strain mechanics in a range of cardiovascular disorders, including atrial fibrillation (AF), hypertrophic cardiomyopathy (HCM), valvular pathologies, coronary artery disease (CAD) as well as systemic diseases, such as hypertension (HTN), obesity and diabetes mellitus (DM). This article also highlights the current limitations in more widespread clinical applications of LA strain mechanics, as well as outlining the future perspectives on the clinical applications of LA strain mechanics.
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Affiliation(s)
- Vardhmaan Jain
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Raktim Ghosh
- MedStar Heart and Vascular Institute at MedStar Union Memorial Hospital and MedStar Good Samaritan Hospital, Baltimore, MD, USA
| | - Manasvi Gupta
- Department of Internal Medicine, UConn Health, University of Connecticut, Farmington, CT, USA
| | - Yoshihito Saijo
- Section of Cardiovascular Imaging, Robert and Suzanne Tomsich, Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Agam Bansal
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Medhat Farwati
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Rachel Marcus
- MedStar Heart and Vascular Institute at MedStar Union Memorial Hospital and MedStar Good Samaritan Hospital, Baltimore, MD, USA
| | - Allan Klein
- Section of Cardiovascular Imaging, Robert and Suzanne Tomsich, Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Bo Xu
- Section of Cardiovascular Imaging, Robert and Suzanne Tomsich, Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
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18
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Estimation of Pulmonary Artery Occlusion Pressure Using Doppler Echocardiography in Mechanically Ventilated Patients. Crit Care Med 2021; 48:e943-e950. [PMID: 32885942 DOI: 10.1097/ccm.0000000000004512] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Evaluation of left atrial pressure is frequently required for mechanically ventilated critically ill patients. The objective of the present study was to evaluate the 2016 American Society of Echocardiography and the European Association of Cardiovascular Imaging guidelines for assessment of the pulmonary artery occlusion pressure (a frequent surrogate of left atrial pressure) in this population. DESIGN A pooled analysis of three prospective cohorts of patients simultaneously assessed with a pulmonary artery catheter and echocardiography. SETTINGS Medical-surgical intensive care department of two university hospitals in France. PATIENTS Mechanically ventilated critically ill patients. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 98 included patients (males: 67%; mean ± SD age: 59 ± 16; and mean Simplified Acute Physiology Score 2: 54 ± 20), 53 (54%) experienced septic shock. Using the 2016 American Society of Echocardiography and the European Association of Cardiovascular Imaging guidelines, the predicted pulmonary artery occlusion pressure was indeterminate in 48 of the 98 patients (49%). Of the 24 patients with an elevated predicted left atrial pressure (grade II/III diastolic dysfunction), only 17 (71%) had a pulmonary artery occlusion pressure greater than or equal to 18 mm Hg. Similarly, 20 of the 26 patients (77%) with a normal predicted left atrial pressure (grade I diastolic dysfunction) had a measured pulmonary artery occlusion pressure less than 18 mm Hg. The sensitivity and specificity of American Society of Echocardiography and the European Association of Cardiovascular Imaging guidelines for predicting elevated pulmonary artery occlusion pressure were both 74%. The agreement between echocardiography and the pulmonary artery catheter was moderate (Cohen's Kappa, 0.48; 95% CI, 0.39-0.70). In a proposed alternative algorithm, the best echocardiographic predictors of a normal pulmonary artery occlusion pressure were a lateral e'-wave greater than 8 (for a left ventricular ejection fraction ≥ 45%) or an E/A ratio less than or equal to 1.5 (for a left ventricular ejection fraction < 45%). CONCLUSIONS The American Society of Echocardiography and the European Association of Cardiovascular Imaging guidelines do not accurately assess pulmonary artery occlusion pressure in ventilated critically ill patients. Simple Doppler measurements gave a similar level of diagnostic performance with less uncertainly.
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19
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Yagi K, Imamura T, Tada H, Chujo D, Liu J, Shima Y, Ohbatake A, Miyamoto Y, Okazaki S, Ito N, Nakano K, Shikata M, Enkaku A, Takikawa A, Honoki H, Fujisaka S, Origasa H, Tobe K. Diastolic Cardiac Function Improvement by Liraglutide Is Mainly Body Weight Reduction Dependent but Independently Contributes to B-Type Natriuretic Peptide Reduction in Patients with Type 2 Diabetes with Preserved Ejection Fraction. J Diabetes Res 2021; 2021:8838026. [PMID: 33855087 PMCID: PMC8019623 DOI: 10.1155/2021/8838026] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Revised: 02/15/2021] [Accepted: 03/06/2021] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES A single-arm prospective study was conducted among Japanese patients with type 2 diabetes having preserved ejection fraction. The aim was to investigate (1) whether liraglutide therapy could improve B-type natriuretic peptide (BNP) levels and diastolic cardiac function assessed by the E-wave to E' ratio (E/E') using transthoracic echocardiography (TTE), and (2) whether E/E' contributed to BNP improvement independent of bodyweight reduction (UMIN000005565). METHODS Patients with type 2 diabetes and left ventricular ejection fraction (LVEF) ≥ 40% without heart failure symptoms were enrolled, and daily injection with liraglutide (0.9 mg) was introduced. Cardiac functions were assessed by TTE before and after 26 weeks of liraglutide treatment. Diastolic cardiac function was defined as septal E/E' ≥ 13.0. RESULTS Thirty-one patients were analyzed. BNP and E/E' improved, with BNP levels declining from 36.8 ± 30.5 pg/mL to 26.3 ± 25.9 pg/mL (p = 0.0014) and E/E' dropping from 12.7 ± 4.7 to 11.0 ± 3.3 (p = 0.0376). The LVEF showed no significant changes. E/E' improved only in patients with E/E' ≥ 13.0. Favorable changes in E/E' were canceled when adjusted for body mass index (BMI). Multivariate linear regression analysis revealed that the left ventricular diastolic diameter and ∆E/E'/∆BMI contributed to ∆BNP/baseline BNP (p = 0.0075, R 2 = 0.49264). CONCLUSIONS Liraglutide had favorable effects on BNP and E/E' but not on LVEF. E/E' improvement was only seen in patients with diastolic cardiac function. Body weight reduction affected the change of E/E'. The BMI-adjusted E/E' significantly contributed to the relative change of BNP. GLP-1 analog treatment could be considered a therapeutic option against diabetic diastolic cardiac dysfunction regardless of body weight. This trial is registered with the University Hospital Medical Information Network in Japan, with clinical trial registration number: UMIN000005565.
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Affiliation(s)
- Kunimasa Yagi
- 1st Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama 934-0194, Japan
- 2nd Department of Internal Medicine, Kanazawa University Graduate School of Medical Science, 13-1 Takaramachi, Kanazawa 920-0934, Japan
| | - Teruhiko Imamura
- 2nd Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama 934-0194, Japan
| | - Hayato Tada
- 2nd Department of Internal Medicine, Kanazawa University Graduate School of Medical Science, 13-1 Takaramachi, Kanazawa 920-0934, Japan
| | - Daisuke Chujo
- 1st Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama 934-0194, Japan
- 2nd Department of Internal Medicine, Kanazawa University Graduate School of Medical Science, 13-1 Takaramachi, Kanazawa 920-0934, Japan
| | - Jianhui Liu
- 1st Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama 934-0194, Japan
- 2nd Department of Internal Medicine, Kanazawa University Graduate School of Medical Science, 13-1 Takaramachi, Kanazawa 920-0934, Japan
| | - Yuuki Shima
- 2nd Department of Internal Medicine, Kanazawa University Graduate School of Medical Science, 13-1 Takaramachi, Kanazawa 920-0934, Japan
| | - Azusa Ohbatake
- 2nd Department of Internal Medicine, Kanazawa University Graduate School of Medical Science, 13-1 Takaramachi, Kanazawa 920-0934, Japan
| | - Yukiko Miyamoto
- 2nd Department of Internal Medicine, Kanazawa University Graduate School of Medical Science, 13-1 Takaramachi, Kanazawa 920-0934, Japan
| | - Satoko Okazaki
- 2nd Department of Internal Medicine, Kanazawa University Graduate School of Medical Science, 13-1 Takaramachi, Kanazawa 920-0934, Japan
| | - Naoko Ito
- 2nd Department of Internal Medicine, Kanazawa University Graduate School of Medical Science, 13-1 Takaramachi, Kanazawa 920-0934, Japan
| | - Kaoru Nakano
- 2nd Department of Internal Medicine, Kanazawa University Graduate School of Medical Science, 13-1 Takaramachi, Kanazawa 920-0934, Japan
| | - Masataka Shikata
- 1st Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama 934-0194, Japan
| | - Asako Enkaku
- 1st Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama 934-0194, Japan
| | - Akiko Takikawa
- 1st Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama 934-0194, Japan
| | - Hisae Honoki
- 1st Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama 934-0194, Japan
| | - Shiho Fujisaka
- 1st Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama 934-0194, Japan
| | - Hideki Origasa
- Biostatistics and Clinical Epidemiology, University of Toyama Graduate School of Medicine and Pharmaceutical Sciences, 2630 Sugitani, Toyama 934-0194, Japan
| | - Kazuyuki Tobe
- 1st Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama 934-0194, Japan
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20
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Sozzi FB, Maganti K, Malanchini G, Gherbesi E, Tondi L, Ciulla M, Canetta C, Lombardi F. Diastolic stress test in heart failure with preserved ejection fraction. Eur J Prev Cardiol 2020; 27:2089-2091. [DOI: 10.1177/2047487319858796] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Fabiola B Sozzi
- Ospedale Maggiore Policlinico Cà Granda, IRCCS, Milan, Italy
| | | | | | - Elisa Gherbesi
- Ospedale Maggiore Policlinico Cà Granda, IRCCS, Milan, Italy
| | - Lara Tondi
- Ospedale Maggiore Policlinico Cà Granda, IRCCS, Milan, Italy
| | - Michele Ciulla
- Ospedale Maggiore Policlinico Cà Granda, IRCCS, Milan, Italy
| | - Ciro Canetta
- Ospedale Maggiore Policlinico Cà Granda, IRCCS, Milan, Italy
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21
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Pieske B, Tschöpe C, de Boer RA, Fraser AG, Anker SD, Donal E, Edelmann F, Fu M, Guazzi M, Lam CSP, Lancellotti P, Melenovsky V, Morris DA, Nagel E, Pieske-Kraigher E, Ponikowski P, Solomon SD, Vasan RS, Rutten FH, Voors AA, Ruschitzka F, Paulus WJ, Seferovic P, Filippatos G. How to diagnose heart failure with preserved ejection fraction: the HFA-PEFF diagnostic algorithm: a consensus recommendation from the Heart Failure Association (HFA) of the European Society of Cardiology (ESC). Eur Heart J 2020; 40:3297-3317. [PMID: 31504452 DOI: 10.1093/eurheartj/ehz641] [Citation(s) in RCA: 776] [Impact Index Per Article: 194.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 10/30/2018] [Accepted: 08/26/2019] [Indexed: 02/07/2023] Open
Abstract
Making a firm diagnosis of chronic heart failure with preserved ejection fraction (HFpEF) remains a challenge. We recommend a new stepwise diagnostic process, the 'HFA-PEFF diagnostic algorithm'. Step 1 (P=Pre-test assessment) is typically performed in the ambulatory setting and includes assessment for HF symptoms and signs, typical clinical demographics (obesity, hypertension, diabetes mellitus, elderly, atrial fibrillation), and diagnostic laboratory tests, electrocardiogram, and echocardiography. In the absence of overt non-cardiac causes of breathlessness, HFpEF can be suspected if there is a normal left ventricular ejection fraction, no significant heart valve disease or cardiac ischaemia, and at least one typical risk factor. Elevated natriuretic peptides support, but normal levels do not exclude a diagnosis of HFpEF. The second step (E: Echocardiography and Natriuretic Peptide Score) requires comprehensive echocardiography and is typically performed by a cardiologist. Measures include mitral annular early diastolic velocity (e'), left ventricular (LV) filling pressure estimated using E/e', left atrial volume index, LV mass index, LV relative wall thickness, tricuspid regurgitation velocity, LV global longitudinal systolic strain, and serum natriuretic peptide levels. Major (2 points) and Minor (1 point) criteria were defined from these measures. A score ≥5 points implies definite HFpEF; ≤1 point makes HFpEF unlikely. An intermediate score (2-4 points) implies diagnostic uncertainty, in which case Step 3 (F1: Functional testing) is recommended with echocardiographic or invasive haemodynamic exercise stress tests. Step 4 (F2: Final aetiology) is recommended to establish a possible specific cause of HFpEF or alternative explanations. Further research is needed for a better classification of HFpEF.
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Affiliation(s)
- Burkert Pieske
- Department of Internal Medicine and Cardiology, Charité - Universitätsmedizin Berlin, Campus Virchow Klinikum.,German Center for Cardiovascular Research (DZHK), Berlin, Partner Site, Germany.,Department of Internal Medicine and Cardiology, German Heart Institute, Berlin, Germany.,Berlin Institute of Health (BIH), Germany
| | - Carsten Tschöpe
- Department of Internal Medicine and Cardiology, Charité - Universitätsmedizin Berlin, Campus Virchow Klinikum.,German Center for Cardiovascular Research (DZHK), Berlin, Partner Site, Germany.,Berlin Institute of Health (BIH) Center for Regenerative Therapies (BCRT), Charite, Berlin, Germany
| | - Rudolf A de Boer
- University Medical Centre Groningen, University of Groningen, Department of Cardiology, Groningen, the Netherlands
| | | | - Stefan D Anker
- Department of Internal Medicine and Cardiology, Charité - Universitätsmedizin Berlin, Campus Virchow Klinikum.,German Center for Cardiovascular Research (DZHK), Berlin, Partner Site, Germany.,Berlin Institute of Health (BIH) Center for Regenerative Therapies (BCRT), Charite, Berlin, Germany.,Department of Cardiology and Pneumology, University Medicine Göttingen (UMG), Germany
| | - Erwan Donal
- Cardiology and CIC, IT1414, CHU de Rennes LTSI, Université Rennes-1, INSERM 1099, Rennes, France
| | - Frank Edelmann
- Department of Internal Medicine and Cardiology, Charité - Universitätsmedizin Berlin, Campus Virchow Klinikum.,German Center for Cardiovascular Research (DZHK), Berlin, Partner Site, Germany
| | - Michael Fu
- Section of Cardiology, Department of Medicine, Sahlgrenska University Hosptal/Ostra, Göteborg, Sweden
| | - Marco Guazzi
- Department of Biomedical Sciences for Health, University of Milan, IRCCS, Milan, Italy.,Department of Cardiology, IRCCS Policlinico, San Donato Milanese, Milan, Italy
| | - Carolyn S P Lam
- National Heart Centre, Singapore & Duke-National University of Singapore.,University Medical Centre Groningen, The Netherlands
| | - Patrizio Lancellotti
- Department of Cardiology, Heart Valve Clinic, University of Liège Hospital, GIGA Cardiovascular Sciences, CHU Sart Tilman, Liège, Belgium
| | - Vojtech Melenovsky
- Institute for Clinical and Experimental Medicine - IKEM, Prague, Czech Republic
| | - Daniel A Morris
- Department of Internal Medicine and Cardiology, Charité - Universitätsmedizin Berlin, Campus Virchow Klinikum
| | - Eike Nagel
- Institute for Experimental and Translational Cardiovascular Imaging, University Hospital Frankfurt.,German Centre for Cardiovascular Research (DZHK), Partner Site Frankfurt, Germany
| | - Elisabeth Pieske-Kraigher
- Department of Internal Medicine and Cardiology, Charité - Universitätsmedizin Berlin, Campus Virchow Klinikum
| | | | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ramachandran S Vasan
- Section of Preventive Medicine and Epidemiology and Cardiovascular Medicine, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Frans H Rutten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Adriaan A Voors
- University Medical Centre Groningen, University of Groningen, Department of Cardiology, Groningen, the Netherlands
| | - Frank Ruschitzka
- University Heart Centre, University Hospital Zurich, Switzerland
| | - Walter J Paulus
- Department of Physiology and Amsterdam Cardiovascular Sciences, Amsterdam University Medical Center, The Netherlands
| | - Petar Seferovic
- University of Belgrade School of Medicine, Belgrade University Medical Center, Serbia
| | - Gerasimos Filippatos
- Department of Cardiology, National and Kapodistrian University of Athens Medical School; University Hospital "Attikon", Athens, Greece.,University of Cyprus, School of Medicine, Nicosia, Cyprus
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22
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Pugliese NR, De Biase N, Conte L, Gargani L, Mazzola M, Fabiani I, Natali A, Dini FL, Frumento P, Rosada J, Taddei S, Borlaug BA, Masi S. Cardiac Reserve and Exercise Capacity: Insights from Combined Cardiopulmonary and Exercise Echocardiography Stress Testing. J Am Soc Echocardiogr 2020; 34:38-50. [PMID: 33036818 DOI: 10.1016/j.echo.2020.08.015] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 08/13/2020] [Accepted: 08/13/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Cardiopulmonary exercise testing (CPET) represents the gold standard to estimate peak oxygen consumption (VO2) noninvasively. To improve the analysis of the mechanisms behind effort intolerance, we examined whether exercise stress echocardiography measurements relate to directly measured peak VO2 during exercise in a large cohort of patients within the heart failure (HF) spectrum. METHODS We performed a symptom-limited graded ramp bicycle CPET exercise stress echocardiography in 30 healthy controls and 357 patients: 113 at risk of developing HF (American College of Cardiology/American Heart Association stage A-B) and 244 in HF stage C with preserved (HFpEF, n = 101) or reduced ejection fraction (HFrEF, n = 143). RESULTS Peak VO2 significantly decreased from controls (23, 21.7-29.7 mL/kg/minute; median, interquartile range) to stage A-B (18, 15.4-20.7 mL/kg/minute) and stage C (HFpEF: 13.6, 11.8-16.8 mL/kg/minute; HFrEF: 14.2, 10.7-17.5 mL/kg/minute). A regression model to predict peak VO2 revealed that peak left ventricular (LV) systolic annulus tissue velocity (S'), peak tricuspid annular plane systolic excursion/systolic pulmonary artery pressure (right ventricle-pulmonary artery coupling), and low-load left atrial (LA) reservoir strain/E/e' (LA compliance) were independent predictors, in addition to peak heart rate, stroke volume, and workload (adjusted R2 = 0.76, P < .0001). The model was successfully tested in subjects with atrial fibrillation (n = 49) and with (n = 224) and without (n = 163) beta-blockers (all P < .01). Peak S' showed the highest accuracy in predicting peak VO2 < 10 mL/kg/minute (cut point ≤ 7.5 cm/sec, area under the curve = 0.92, P < .0001) and peak VO2 > 20 mL/kg/minute (cut point > 12.5 cm/sec, area under the curve = 0.84, P < .0001) in comparison with the other cardiac variables of the model (P < .05). CONCLUSIONS Peak VO2 is directly related to measures of LV systolic function, LA compliance, and right ventricle-pulmonary artery coupling, in addition to heart rate and stroke volume and independently of workload, age, and sex. The evaluation of cardiac mechanics may provide more insights into the causes of effort intolerance in subjects from HF stages A-C.
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Affiliation(s)
| | - Nicolò De Biase
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Lorenzo Conte
- Cardiology Unit, Ospedale Castelnuovo Garfagnana, Pisa, Italy
| | - Luna Gargani
- Institute of Clinical Physiology, C.N.R., Pisa, Italy
| | - Matteo Mazzola
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Andrea Natali
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Frank L Dini
- Area Cardiologica, Casa di Cura Villa Esperia, Salice Terme, Pavia, Italy
| | - Paolo Frumento
- Department of Political Sciences, University of Pisa, Pisa, Italy
| | - Javier Rosada
- Fourth Unit of Internal Medicine, University Hospital of Pisa, Pisa, Italy
| | - Stefano Taddei
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Barry A Borlaug
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Stefano Masi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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23
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Kapłon-Cieślicka A, Kupczyńska K, Dobrowolski P, Michalski B, Jaguszewski MJ, Banasiak W, Burchardt P, Chrzanowski Ł, Darocha S, Domienik-Karłowicz J, Drożdż J, Fijałkowski M, Filipiak KJ, Gruchała M, Jankowska EA, Jankowski P, Kasprzak JD, Kosmala W, Lipiec P, Mitkowski P, Mizia-Stec K, Szymański P, Tycińska A, Wańha W, Wybraniec M, Witkowski A, Ponikowski P, "Club 30" Of The Polish Cardiac Society OBO. On the search for the right definition of heart failure with preserved ejection fraction. Cardiol J 2020; 27:449-468. [PMID: 32986238 PMCID: PMC8078979 DOI: 10.5603/cj.a2020.0124] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 09/21/2020] [Accepted: 09/10/2020] [Indexed: 12/22/2022] Open
Abstract
The definition of heart failure with preserved ejection fraction (HFpEF) has evolved from a clinically based "diagnosis of exclusion" to definitions focused on objective evidence of diastolic dysfunction and/or elevated left ventricular filling pressures. Despite advances in our understanding of HFpEF pathophysiology and the development of more sophisticated imaging modalities, the diagnosis of HFpEF remains challenging, especially in the chronic setting, given that symptoms are provoked by exertion and diagnostic evaluation is largely conducted at rest. Invasive hemodynamic study, and in particular - invasive exercise testing, is considered the reference method for HFpEF diagnosis. However, its use is limited as opposed to the high number of patients with suspected HFpEF. Thus, diagnostic criteria for HFpEF should be principally based on non-invasive measurements. As no single non-invasive variable can adequately corroborate or refute the diagnosis, different combinations of clinical, echocardiographic, and/or biochemical parameters have been introduced. Recent years have brought an abundance of HFpEF definitions. Here, we present and compare four of them: 1) the 2016 European Society of Cardiology criteria for HFpEF; 2) the 2016 echocardiographic algorithm for diagnosing diastolic dysfunction; 3) the 2018 evidence-based H2FPEF score; and 4) the most recent, 2019 Heart Failure Association HFA-PEFF algorithm. These definitions vary in their approach to diagnosis, as well as sensitivity and specificity. Further studies to validate and compare the diagnostic accuracy of HFpEF definitions are warranted. Nevertheless, it seems that the best HFpEF definition would originate from a randomized clinical trial showing a favorable effect of an intervention on prognosis in HFpEF.
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Affiliation(s)
- Agnieszka Kapłon-Cieślicka
- "Club 30", Polish Cardiac Society, Poland.
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland.
| | - Karolina Kupczyńska
- "Club 30", Polish Cardiac Society, Poland
- I Department and Chair of Cardiology, Medical University of Lodz, Łódź, Poland
| | - Piotr Dobrowolski
- "Club 30", Polish Cardiac Society, Poland
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland
| | - Błażej Michalski
- "Club 30", Polish Cardiac Society, Poland
- I Department and Chair of Cardiology, Medical University of Lodz, Łódź, Poland
| | - Miłosz J Jaguszewski
- "Club 30", Polish Cardiac Society, Poland
- 1st Department of Cardiology, Medical University of Gdansk, Gdańsk, Poland
| | - Waldemar Banasiak
- "Club 30", Polish Cardiac Society, Poland
- Department of Cardiology, 4th Military Hospital, Wrocław, Poland
| | - Paweł Burchardt
- "Club 30", Polish Cardiac Society, Poland
- Department of Hypertension, Angiology, and Internal Medicine, Poznan University of Medical Sciences, Poznań, Poland, and Department of Cardiology, J. Strus Hospital, Poznań, Poland
| | - Łukasz Chrzanowski
- "Club 30", Polish Cardiac Society, Poland
- I Department and Chair of Cardiology, Medical University of Lodz, Łódź, Poland
| | - Szymon Darocha
- "Club 30", Polish Cardiac Society, Poland
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Centre of Postgraduate Medical Education, Otwock, Poland
| | - Justyna Domienik-Karłowicz
- "Club 30", Polish Cardiac Society, Poland
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Jarosław Drożdż
- "Club 30", Polish Cardiac Society, Poland
- Department of Cardiology, Medical University of Lodz, Łódź, Poland
| | - Marcin Fijałkowski
- "Club 30", Polish Cardiac Society, Poland
- 1st Department of Cardiology, Medical University of Gdansk, Gdańsk, Poland
| | - Krzysztof J Filipiak
- "Club 30", Polish Cardiac Society, Poland
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Marcin Gruchała
- "Club 30", Polish Cardiac Society, Poland
- 1st Department of Cardiology, Medical University of Gdansk, Gdańsk, Poland
| | - Ewa A Jankowska
- "Club 30", Polish Cardiac Society, Poland
- Department of Heart Diseases, Wroclaw Medical University, Wrocław, Poland, and Center for Heart Diseases, University Hospital, Wrocław, Poland
| | - Piotr Jankowski
- "Club 30", Polish Cardiac Society, Poland
- 1st Department of Cardiology, Interventional Electrocardiology and Hypertension, Institute of Cardiology, Jagiellonian University Medical College, Kraków, Poland
| | - Jarosław D Kasprzak
- "Club 30", Polish Cardiac Society, Poland
- I Department and Chair of Cardiology, Medical University of Lodz, Łódź, Poland
| | - Wojciech Kosmala
- "Club 30", Polish Cardiac Society, Poland
- Chair and Department of Cardiology, Wroclaw Medical University, Wrocław, Poland, and Center for Heart Diseases, University Hospital, Wrocław, Poland
| | - Piotr Lipiec
- "Club 30", Polish Cardiac Society, Poland
- Department of Rapid Cardiac Diagnostics, Chair of Cardiology, Medical University of Lodz, Łódź, Poland
| | - Przemysław Mitkowski
- "Club 30", Polish Cardiac Society, Poland
- 1st Department of Cardiology, Chair of Cardiology, Karol Marcinkowski University of Medical Sciences, Poznań, Poland
| | - Katarzyna Mizia-Stec
- "Club 30", Polish Cardiac Society, Poland
- 1st Department of Cardiology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Piotr Szymański
- "Club 30", Polish Cardiac Society, Poland
- Centre of Postgraduate Medical Education, Central Clinical Hospital of the Ministry of the Interior in Warsaw, Warsaw, Poland
| | - Agnieszka Tycińska
- "Club 30", Polish Cardiac Society, Poland
- Department of Cardiology, Medical University of Bialystok, Białystok, Poland
| | - Wojciech Wańha
- "Club 30", Polish Cardiac Society, Poland
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | - Maciej Wybraniec
- "Club 30", Polish Cardiac Society, Poland
- 1st Department of Cardiology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Adam Witkowski
- "Club 30", Polish Cardiac Society, Poland
- Department of Interventional Cardiology and Angiology, National Institute of Cardiology, Warsaw, Poland
| | - Piotr Ponikowski
- "Club 30", Polish Cardiac Society, Poland
- Department of Heart Diseases, Wroclaw Medical University, Wrocław, Poland, and Center for Heart Diseases, University Hospital, Wrocław, Poland
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24
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Sunderji I, Singh V, Fraser AG. When does the E/e’ index not work? The pitfalls of oversimplifying diastolic function. Echocardiography 2020; 37:1897-1907. [DOI: 10.1111/echo.14697] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 04/27/2020] [Accepted: 04/28/2020] [Indexed: 12/13/2022] Open
Affiliation(s)
| | - Vickram Singh
- Department of Cardiology University Hospital of Wales Cardiff UK
| | - Alan G. Fraser
- Department of Cardiology University Hospital of Wales Cardiff UK
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25
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Nanayakkara S, Byrne M, Mak V, Carter K, Dean E, Kaye DM. Extended-Release Oral Milrinone for the Treatment of Heart Failure With Preserved Ejection Fraction. J Am Heart Assoc 2020; 9:e015026. [PMID: 32552264 PMCID: PMC7670502 DOI: 10.1161/jaha.119.015026] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Background Heart failure with preserved ejection fraction (HFpEF) is an increasingly prevalent form of heart failure, representing half of the total burden of heart failure. We hypothesised that modulation of the phosphodiesterase type 3/cyclic AMP using a novel oral formulation of milrinone might exert favorable effects HFpEF via pulmonary and systemic vasodilation and enhancement of ventricular relaxation. We assessed the safety and efficacy of oral milrinone on quality of life and functional outcomes in patients with HFpEF. Methods and Results The MilHFPEF (Extended Release Oral Milrinone for the Treatment of Heart Failure With Preserved Ejection Fraction) study was a randomized, double‐blind, placebo‐controlled pilot study in 23 patients with symptomatic HFpEF. Efficacy end points included changes from baseline in Kansas City Cardiomyopathy Questionnaire summary score and 6‐minute walk distance. The primary safety end point was the development of clinically significant arrhythmia. The Kansas City Cardiomyopathy Questionnaire score improved significantly in milrinone‐treated patients compared with placebo (+10±13 versus −3±15; P=0.046). Six‐minute walk distance also tended to improve in the treatment group compared with placebo (+22 [−8 to 49] versus −47 [−97 to 12]; P=0.092). Heart rate (−1±5 versus −2±9 bpm; P=0.9) and systolic blood pressure (−3±18 versus +1±12 mm Hg; P=0.57) were unchanged. Early filling velocity/early mitral annular velocity (−0.3±3.0 versus −1.9±4.8; P=0.38) was unchanged. One patient in the placebo arm was hospitalized for heart failure. Holter monitoring did not demonstrate evidence of a proarrhythmic effect of milrinone. Conclusions In this novel pilot study, extended release oral milrinone was well tolerated and associated with improved quality of life in patients with HFpEF. Further longer‐term studies are warranted to establish the role of this therapeutic approach in HFpEF. Registration URL: https://www.anzctr.org.au/; Unique identifier: ACTRN12616000619448.
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Affiliation(s)
- Shane Nanayakkara
- Department of Cardiology Alfred Hospital Melbourne Australia.,Heart Failure Research Group Baker Heart and Diabetes Institute Melbourne Australia.,Faculty of Medicine, Nursing and Health Sciences Monash University Melbourne Australia
| | - Melissa Byrne
- Heart Failure Research Group Baker Heart and Diabetes Institute Melbourne Australia
| | - Vivian Mak
- Department of Cardiology Alfred Hospital Melbourne Australia
| | - Kaye Carter
- Department of Cardiology Alfred Hospital Melbourne Australia
| | - Eliza Dean
- Department of Cardiology Alfred Hospital Melbourne Australia
| | - David M Kaye
- Department of Cardiology Alfred Hospital Melbourne Australia.,Heart Failure Research Group Baker Heart and Diabetes Institute Melbourne Australia.,Faculty of Medicine, Nursing and Health Sciences Monash University Melbourne Australia
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26
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Tadic M, Cuspidi C, Calicchio F, Grassi G, Mancia G. Diagnostic algorithm for HFpEF: how much is the recent consensus applicable in clinical practice? Heart Fail Rev 2020; 26:1485-1493. [PMID: 32346825 DOI: 10.1007/s10741-020-09966-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Heart failure with preserved ejection fraction (HFpEF) represents an important cardiovascular entity with increasing prevalence and relatively high mortality. The agreement about diagnostic algorithm for HFpEF is still missing. Echocardiographic approach remains the cornerstone in HFpEF diagnosis. Echocardiographic diastolic stress test provides numerous useful parameters that correlated well with indexes obtained by cardiac catheterization. Recently published consensus recommended new scoring system that included functional and structural echocardiographic parameters, as well as biomarkers. The new score for evaluation of HFpEF introduces a new set of parameters and proposed novel cutoff values for some of them. There are several important points that need to be resolved before full acceptance and clinical usage. First, some cutoff values are new and represent the result of expert consensus, without previous validation. Second, many patients with hypertension, obesity, and diabetes would be referred for further investigations as the result of this scoring, which is difficult to achieve in clinical circumstances. Third, the consensus equalized non-invasive and invasive diastolic stress tests in diagnosing of HFpEF, which is not a small issue. Namely, even though cardiac catheterization provides the final confirmation of elevated left ventricular filling pressures, it is still an invasive method, associated with procedural risk and other limitations. The aim of this review was to summarize the current knowledge diagnosis of HFpEF, as well as the recent consensus about diagnostic algorithm in patients with suspected HFpEF with its advantages and disadvantages.
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Affiliation(s)
- Marijana Tadic
- Department of Cardiology, University Hospital "Dr. Dragisa Misovic - Dedinje", Heroja Milana Tepica 1, Belgrade, 11000, Serbia.
| | - Cesare Cuspidi
- University of Milan-Bicocca, Milan, Italy.,Clinical Research Unit, Istituto Auxologico Italiano, Viale della Resistenza 23, 20036, Meda, Italy
| | | | | | - Giuseppe Mancia
- University of Milan-Bicocca, Milan, Italy.,Policlinico di Monza, Monza, Italy
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27
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Borlaug BA. Evaluation and management of heart failure with preserved ejection fraction. Nat Rev Cardiol 2020; 17:559-573. [DOI: 10.1038/s41569-020-0363-2] [Citation(s) in RCA: 168] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/02/2020] [Indexed: 01/19/2023]
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28
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Echocardiographic assessment of left ventricular diastolic pressure. Curr Opin Crit Care 2020; 25:252-258. [PMID: 30865612 DOI: 10.1097/mcc.0000000000000601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Knowledge of the left ventricular pressures throughout the cardiac cycle is of considerable assistance in managing a haemodynamically unstable patient. Invasive pressure measurement is the only accurate way to analyze ventricular diastolic pressures but this is not feasible outside the catheterization laboratory, whereas the use of a pulmonary artery catheter or Doppler echocardiography, using surrogate measurements, is available at the bedside. The ever-increasing trend toward noninvasive monitoring puts echocardiography at the forefront and considerable effort has been made to define its role in this setting. RECENT FINDINGS Ongoing refinement of guidelines used to evaluate left ventricular diastolic function have provided a pathway for critical care physicians to better understand how to evaluate left ventricular end-diastolic pressure and/or left atrial pressures. A number of recent studies have investigated the accuracy of combined or single echocardiographic parameters in determining left ventricular diastolic pressures as compared to those obtained invasively. Specifically selected combined parameters have moderate accuracy. SUMMARY The recent literature on the clinical application of echocardiography on the accuracy in determining left ventricular noninvasively demonstrates that although far from perfect, it can be a very useful tool.
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29
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Pieske B, Tschöpe C, de Boer RA, Fraser AG, Anker SD, Donal E, Edelmann F, Fu M, Guazzi M, Lam CSP, Lancellotti P, Melenovsky V, Morris DA, Nagel E, Pieske-Kraigher E, Ponikowski P, Solomon SD, Vasan RS, Rutten FH, Voors AA, Ruschitzka F, Paulus WJ, Seferovic P, Filippatos G. How to diagnose heart failure with preserved ejection fraction: the HFA-PEFF diagnostic algorithm: a consensus recommendation from the Heart Failure Association (HFA) of the European Society of Cardiology (ESC). Eur J Heart Fail 2020; 22:391-412. [PMID: 32133741 DOI: 10.1002/ejhf.1741] [Citation(s) in RCA: 178] [Impact Index Per Article: 44.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 10/30/2018] [Accepted: 08/26/2019] [Indexed: 12/11/2022] Open
Abstract
Making a firm diagnosis of chronic heart failure with preserved ejection fraction (HFpEF) remains a challenge. We recommend a new stepwise diagnostic process, the 'HFA-PEFF diagnostic algorithm'. Step 1 (P=Pre-test assessment) is typically performed in the ambulatory setting and includes assessment for heart failure symptoms and signs, typical clinical demographics (obesity, hypertension, diabetes mellitus, elderly, atrial fibrillation), and diagnostic laboratory tests, electrocardiogram, and echocardiography. In the absence of overt non-cardiac causes of breathlessness, HFpEF can be suspected if there is a normal left ventricular (LV) ejection fraction, no significant heart valve disease or cardiac ischaemia, and at least one typical risk factor. Elevated natriuretic peptides support, but normal levels do not exclude a diagnosis of HFpEF. The second step (E: Echocardiography and Natriuretic Peptide Score) requires comprehensive echocardiography and is typically performed by a cardiologist. Measures include mitral annular early diastolic velocity (e'), LV filling pressure estimated using E/e', left atrial volume index, LV mass index, LV relative wall thickness, tricuspid regurgitation velocity, LV global longitudinal systolic strain, and serum natriuretic peptide levels. Major (2 points) and Minor (1 point) criteria were defined from these measures. A score ≥5 points implies definite HFpEF; ≤1 point makes HFpEF unlikely. An intermediate score (2-4 points) implies diagnostic uncertainty, in which case Step 3 (F1 : Functional testing) is recommended with echocardiographic or invasive haemodynamic exercise stress tests. Step 4 (F2 : Final aetiology) is recommended to establish a possible specific cause of HFpEF or alternative explanations. Further research is needed for a better classification of HFpEF.
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Affiliation(s)
- Burkert Pieske
- Department of Internal Medicine and Cardiology, Charité - Universitätsmedizin Berlin, Campus Virchow Klinikum.,German Center for Cardiovascular Research (DZHK), Berlin, Partner Site, Germany.,Department of Internal Medicine and Cardiology, German Heart Institute, Berlin, Germany.,Berlin Institute of Health (BIH), Germany
| | - Carsten Tschöpe
- Department of Internal Medicine and Cardiology, Charité - Universitätsmedizin Berlin, Campus Virchow Klinikum.,German Center for Cardiovascular Research (DZHK), Berlin, Partner Site, Germany.,Berlin Institute of Health (BIH) Center for Regenerative Therapies (BCRT), Charite, Berlin, Germany
| | - Rudolf A de Boer
- University Medical Centre Groningen, University of Groningen, Department of Cardiology, Groningen, the Netherlands
| | | | - Stefan D Anker
- Department of Internal Medicine and Cardiology, Charité - Universitätsmedizin Berlin, Campus Virchow Klinikum.,German Center for Cardiovascular Research (DZHK), Berlin, Partner Site, Germany.,Berlin Institute of Health (BIH) Center for Regenerative Therapies (BCRT), Charite, Berlin, Germany.,Department of Cardiology and Pneumology, University Medicine Göttingen (UMG), Germany
| | - Erwan Donal
- Cardiology and CIC, IT1414, CHU de Rennes LTSI, Université Rennes-1, INSERM 1099, Rennes, France
| | - Frank Edelmann
- Department of Internal Medicine and Cardiology, Charité - Universitätsmedizin Berlin, Campus Virchow Klinikum.,German Center for Cardiovascular Research (DZHK), Berlin, Partner Site, Germany
| | - Michael Fu
- Section of Cardiology, Department of Medicine, Sahlgrenska University Hosptal/Ostra, Göteborg, Sweden
| | - Marco Guazzi
- Department of Biomedical Sciences for Health, University of Milan, IRCCS, Milan, Italy.,Department of Cardiology, IRCCS Policlinico, San Donato Milanese, Milan, Italy
| | - Carolyn S P Lam
- National Heart Centre, Singapore & Duke-National University of Singapore.,University Medical Centre Groningen, The Netherlands
| | - Patrizio Lancellotti
- Department of Cardiology, Heart Valve Clinic, University of Liège Hospital, GIGA Cardiovascular Sciences, CHU Sart Tilman, Liège, Belgium
| | - Vojtech Melenovsky
- Institute for Clinical and Experimental Medicine - IKEM, Prague, Czech Republic
| | - Daniel A Morris
- Department of Internal Medicine and Cardiology, Charité - Universitätsmedizin Berlin, Campus Virchow Klinikum
| | - Eike Nagel
- Institute for Experimental and Translational Cardiovascular Imaging, University Hospital Frankfurt.,German Centre for Cardiovascular Research (DZHK), Partner Site Frankfurt, Germany
| | - Elisabeth Pieske-Kraigher
- Department of Internal Medicine and Cardiology, Charité - Universitätsmedizin Berlin, Campus Virchow Klinikum
| | | | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ramachandran S Vasan
- Section of Preventive Medicine and Epidemiology and Cardiovascular Medicine, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Frans H Rutten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Adriaan A Voors
- University Medical Centre Groningen, University of Groningen, Department of Cardiology, Groningen, the Netherlands
| | - Frank Ruschitzka
- University Heart Centre, University Hospital Zurich, Switzerland
| | - Walter J Paulus
- Department of Physiology and Amsterdam Cardiovascular Sciences, Amsterdam University Medical Center, The Netherlands
| | - Petar Seferovic
- University of Belgrade School of Medicine, Belgrade University Medical Center, Serbia
| | - Gerasimos Filippatos
- Department of Cardiology, National and Kapodistrian University of Athens Medical School; University Hospital "Attikon", Athens, Greece.,University of Cyprus, School of Medicine, Nicosia, Cyprus
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Hsiao CS, Hsiao SH. Relationship of left atrial expansion index to exercise tolerance, pretest probability of restenosis, and positive predictive value of treadmill test in coronary artery disease. Echocardiography 2020; 37:388-398. [PMID: 32077515 DOI: 10.1111/echo.14620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 01/18/2020] [Accepted: 01/31/2020] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Whether left atrial (LA) expansion index is associated with coronary restenosis, and exercise capacity (EC) reduction in coronary artery disease has not been established. METHODS This study analyzed 342 consecutive patients who had received a coronary stent implant. A treadmill exercise test (TET) was administered in all participants. The LA expansion indices were measured immediately before and after TET. Maximal EC measured on a breath-by-breath basis by a metabolic cart with gas analyzers and recorded as metabolic equivalent task. All patients with positive TET results received angiography, and those with restenosis received complete revascularization by either percutaneous coronary intervention (PCI) or bypass surgery. The LA expansion index and EC before and 1 month after PCI were then compared. RESULTS Out of 342 patients, 74 had positive TET results, and 54 had restenosis in angiography. Low LA expansion index was associated with poor EC. In patients with LA expansion index > 200%, only 5% had restenosis with 38.5% positive predictive value (PPV) of TET. In patients with LA expansion index < 100%, however, 64.3% had restenosis with 94.7% PPV of TET. Restenosis induced low pre-TET LA expansion index and further decline during TET. The LA expansion index significantly (P .001) improved from 133 ± 64% before PCI to184 ± 86% after PCI, and the improvement corresponded with EC recovery. A 10% reduction in LA expansion index was associated with a 15% increase in pretest probability of restenosis. CONCLUSION The LA expansion index is associated with EC, pretest probability of restenosis, and PPV of TET. Revascularization improves both EC and LA expansion index.
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Affiliation(s)
- Chao-Sheng Hsiao
- Department of Internal Medicine, College of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Shih-Hung Hsiao
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.,Division of Cardiology, Department of Internal Medicine, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan
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31
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Chen ZW, Huang CY, Cheng JF, Chen SY, Lin LY, Wu CK. Stress Echocardiography-Derived E/e' Predicts Abnormal Exercise Hemodynamics in Heart Failure With Preserved Ejection Fraction. Front Physiol 2019; 10:1470. [PMID: 31849715 PMCID: PMC6901703 DOI: 10.3389/fphys.2019.01470] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 11/14/2019] [Indexed: 12/18/2022] Open
Abstract
Background The correlation between echocardiographic parameters and hemodynamics data in patients with heart failure with preserved ejection fraction (HFpEF) is unclear. It is important to find a non-invasive echocardiographic parameter for predicting exercise pulmonary capillary wedge pressure (PCWP). Aim This study sought to determine the correlation between echocardiographic parameters and hemodynamics data at rest and during exercise in HFpEF patients. Methods and Results This study was a cross-sectional cohort exploratory analysis of baseline data from the ILO-HOPE trial. A total of 34 HFpEF patients were enrolled. The average age was 70 ± 12 years, and most (74%) were women. The patients underwent invasive cardiac catheterization and expired gas analysis at rest and during exercise. Echocardiography including tissue Doppler imaging was performed, and global longitudinal strain and other novel diastolic function indexes were analyzed at rest and during exercise. At rest, no significant correlation was noted between resting PCWP and echocardiographic parameters. However, a significant correlation was observed between post-exercise PCWP and stress E/e′ (septal, lateral, and mean) ratio (p = 0.003, 0.031, 0.012). Moreover, post-exercise ΔPCWP showed a good correlation with stress E/e′ (septal, lateral, and mean; all p ≤ 0.001) and global longitudinal strain (GLS) during exercise (p = 0.03). After multivariate regression analysis with adjustment for possible confounding factors including age and sex, there was still a significant correlation between post-exercise ΔPCWP and E/e′ (r = 0.62, p < 0.001 for E/e′mean). Conclusion Only stress echocardiography derived tissue Doppler E/e′ ratio is closely correlated with abnormal exercise hemodynamics (PCWP and post-exercise ΔPCWP) in HFpEF. This echocardiographic marker is substantially more sensitive than other novel echocardiographic parameters during exercise, and may have significant diagnostic utility for ambulatory HFpEF patients with dyspnea. Clinical Trial Registration https://www.clinicaltrials.gov, identifier NCT03620526.
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Affiliation(s)
- Zheng-Wei Chen
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan.,Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Yun-Lin Branch, Yun-Lin, Taiwan
| | - Chen-Yu Huang
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan.,Division of Cardiology, Department of Internal Medicine, Kinmen Hospital, Ministry of Health and Welfare, Kinmen, Taiwan
| | - Jen-Fang Cheng
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan.,Division of Cardiology, Department of Internal Medicine, Pingtung Hospital, Pingtung, Taiwan
| | - Ssu-Yuan Chen
- Department of Physical Medicine and Rehabilitation, Fu Jen Catholic University Hospital and Fu Jen Catholic University School of Medicine, New Taipei City, Taiwan.,Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Lian-Yu Lin
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan
| | - Cho-Kai Wu
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan.,Cardiovascular Institute, Stanford University, Stanford, CA, United States
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32
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Jentzer JC, Anavekar NS, Mankad SV, Khasawneh M, White RD, Barsness GW, Rabinstein AA, Kashani KB, Pislaru SV. Challenges in the assessment of diastolic function after cardiac arrest. J Crit Care 2019; 54:284-285. [PMID: 31326134 DOI: 10.1016/j.jcrc.2019.07.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 07/09/2019] [Indexed: 11/24/2022]
Affiliation(s)
- Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States of America; Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN, United States of America.
| | - Nandan S Anavekar
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States of America
| | - Sunil V Mankad
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States of America
| | - Majd Khasawneh
- Department of Internal Medicine, William Beaumont Hospital, Royal Oak, MI, United States of America
| | - Roger D White
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, United States of America
| | - Gregory W Barsness
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States of America
| | | | - Kianoush B Kashani
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN, United States of America; Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, MN, United States of America
| | - Sorin V Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States of America
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33
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Reddy YN, Obokata M, Egbe A, Yang JH, Pislaru S, Lin G, Carter R, Borlaug BA. Left atrial strain and compliance in the diagnostic evaluation of heart failure with preserved ejection fraction. Eur J Heart Fail 2019; 21:891-900. [DOI: 10.1002/ejhf.1464] [Citation(s) in RCA: 104] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 02/07/2019] [Accepted: 03/03/2019] [Indexed: 12/28/2022] Open
Affiliation(s)
| | - Masaru Obokata
- Department of Cardiovascular MedicineMayo Clinic Rochester MN USA
| | - Alexander Egbe
- Department of Cardiovascular MedicineMayo Clinic Rochester MN USA
| | - Jeong Hoon Yang
- Department of Cardiovascular MedicineMayo Clinic Rochester MN USA
| | - Sorin Pislaru
- Department of Cardiovascular MedicineMayo Clinic Rochester MN USA
| | - Grace Lin
- Department of Cardiovascular MedicineMayo Clinic Rochester MN USA
| | - Rickey Carter
- Department of Cardiovascular MedicineMayo Clinic Rochester MN USA
| | - Barry A. Borlaug
- Department of Cardiovascular MedicineMayo Clinic Rochester MN USA
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34
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Obokata M, Reddy YNV, Borlaug BA. The Role of Echocardiography in Heart Failure with Preserved Ejection Fraction: What Do We Want from Imaging? Heart Fail Clin 2019; 15:241-256. [PMID: 30832815 DOI: 10.1016/j.hfc.2018.12.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Noninvasive imaging, particularly echocardiography, plays a central role in the evaluation for heart failure with preserved ejection fraction (HFpEF). Echocardiography helps to rule in HFpEF among patients with unexplained dyspnea when the diagnosis is uncertain. In established HFpEF, echocardiography provides important insights into pathophysiology and phenotyping, such as isolated left ventricular diastolic dysfunction, left atrial dysfunction, abnormal right ventricular-pulmonary artery coupling, ischemia, or obesity phenotypes. In addition, imaging enables risk stratification for HFpEF. This article provides a critical appraisal of the role of echocardiography in the diagnosis and evaluation of HFpEF.
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Affiliation(s)
- Masaru Obokata
- Department of Cardiovascular Medicine, Mayo Clinic and Foundation, 200 First Street Southwest, Rochester, MN 55906, USA
| | - Yogesh N V Reddy
- Department of Cardiovascular Medicine, Mayo Clinic and Foundation, 200 First Street Southwest, Rochester, MN 55906, USA
| | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic and Foundation, 200 First Street Southwest, Rochester, MN 55906, USA.
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35
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Diagnosis of Heart Failure With Preserved Ejection Fraction: Machine Learning of Spatiotemporal Variations in Left Ventricular Deformation. J Am Soc Echocardiogr 2018; 31:1272-1284.e9. [DOI: 10.1016/j.echo.2018.07.013] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Indexed: 11/20/2022]
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36
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Henein MY, Tossavainen E, A'roch R, Söderberg S, Lindqvist P. Can Doppler echocardiography estimate raised pulmonary capillary wedge pressure provoked by passive leg lifting in suspected heart failure? Clin Physiol Funct Imaging 2018; 39:128-134. [PMID: 30298591 DOI: 10.1111/cpf.12547] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 09/12/2018] [Indexed: 11/30/2022]
Abstract
AIMS Non-invasive estimation of left ventricular filling pressure (LVFP) during stress is important for explaining exertional symptoms in patients with heart failure (HF). The aim of this study was to evaluate ability of Doppler echocardiographic measures of elevated LVFP with passive leg lifting (PLL) in patients with suspected HF. METHODS Twenty-nine patients with clinical signs of HF who underwent simultaneous Doppler echocardiography and right heart catheterization (RHC) at rest and during PLL were consecutively investigated. Seventeen patients had normal PCWP (≤15 mmHg) at rest and during PLL and 12 with normal PCWP at rest but >15 mmHg with PLL. Conventional echo and 2D strain were used to assess early diastolic blood flow velocity (E), LV strain rate during early diastole (LVSRe), left atrial SR during atrial contraction (LASRa) and myocardial tissue Doppler velocities to assess lateral e' and further calculate E/e' and E/LVSRe and their relationship with PCWP, at rest and during PLL. RESULTS Resting LAVI (β = 0·45, P = 0·009) and LASRa (β = -0·51, P = 0·004) were independently related to PCWP during PLL. Also, LASRa (β = -0·77, P<0·001), E/e' (β = 0·40, P = 0·04) and E/LVSRe (β = 0·47, P = 0·021) during PLL correlated with PCWP during PLL. Multiple regression analysis identified E/LVSRe (β = 0·46, P = 0·001) and LASRa (β = -0·58, P = 0·002) during PLL as being independently associated with PCWP during PLL. CONCLUSION Left atrial volume and myocardial contraction (LASRa) at rest both predict unstable LV filling pressures measured as raised PCWP when provoked by PLL. Furthermore, LASRa at PLL seems to have the strongest association to PCWP during PLL.
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Affiliation(s)
- Michael Y Henein
- Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Erik Tossavainen
- Public Health and Clinical Medicine, Umeå University, Umeå, Sweden.,Surgery and Perioperative Sciences, Umeå University, Umeå, Sweden
| | - Roman A'roch
- Surgery and Perioperative Sciences, Umeå University, Umeå, Sweden
| | - Stefan Söderberg
- Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Per Lindqvist
- Surgery and Perioperative Sciences, Umeå University, Umeå, Sweden
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37
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Simon MA, Schnatz RG, Romeo JD, Pacella JJ. Bedside Ultrasound Assessment of Jugular Venous Compliance as a Potential Point-of-Care Method to Predict Acute Decompensated Heart Failure 30-Day Readmission. J Am Heart Assoc 2018; 7:e008184. [PMID: 30371245 PMCID: PMC6201476 DOI: 10.1161/jaha.117.008184] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Accepted: 06/19/2018] [Indexed: 12/25/2022]
Abstract
Background Heart failure is one of the most costly diagnosis-related groups, largely because of hospital readmissions. Objective assessment of volume status to ensure optimization before hospital discharge could significantly reduce readmissions. We previously demonstrated an ultrasound method of quantifying percentage of cross-sectional area ( CSA ) change of the right internal jugular vein with Valsalva that reliably estimates central venous pressure. Methods and Results Patients admitted with acute decompensated heart failure ( ADHF ) underwent ultrasound measurements of the right internal jugular vein at end-expiration and during the strain phase of Valsalva to determine a percentage of CSA change. An initial subgroup of patients with right heart catheterization and accompanying ultrasound measurements of the right internal jugular vein identified a percentage of CSA change predictive of right atrial pressure ( RAP ) ≥12 mm Hg. Images of admitted ADHF patients were obtained at admission and discharge for final analysis. Simultaneous right heart catheterization and right internal jugular vein ultrasound measurements demonstrated that a <66% CSA change predicted RAP ≥12 mm Hg (positive predictive value: 87%; P<0.05, receiver operating characteristic curve). Elevated admission RAP by percentage of CSA change normalized by discharge ( P<0.05), indicating that this test is significantly responsive to therapeutic interventions. Using the cutoff value of 66% CSA change, normal RAP at discharge had 91% predictive value for patients avoiding 30-day readmission ( P<0.05). Conclusions This bedside ultrasound technique strongly correlates to invasive RAP measurement in ADHF patients, identifies restoration of euvolemia, and is predictive of 30-day ADHF readmission. This tool could help guide inpatient ADHF treatment and may lead to reduced readmissions.
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Affiliation(s)
- Marc A. Simon
- Pittsburgh Heart, Lung, Blood and Vascular Medicine InstitutePittsburghPA
- UPMC Heart and Vascular InstitutePittsburghPA
- Department of BioengineeringUniversity of PittsburghPittsburghPA
- Division of CardiologyUniversity of PittsburghPittsburghPA
- Department of MedicineUniversity of PittsburghPittsburghPA
| | | | | | - John J. Pacella
- Pittsburgh Heart, Lung, Blood and Vascular Medicine InstitutePittsburghPA
- UPMC Heart and Vascular InstitutePittsburghPA
- Department of BioengineeringUniversity of PittsburghPittsburghPA
- Division of CardiologyUniversity of PittsburghPittsburghPA
- Department of MedicineUniversity of PittsburghPittsburghPA
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38
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Obokata M, Borlaug BA. The strengths and limitations of E/e' in heart failure with preserved ejection fraction. Eur J Heart Fail 2018; 20:1312-1314. [PMID: 29932475 DOI: 10.1002/ejhf.1250] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Affiliation(s)
- Masaru Obokata
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN, USA
| | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN, USA
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39
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Jentzer JC, Anavekar NS, Mankad SV, Khasawneh M, White RD, Barsness GW, Rabinstein AA, Kashani KB, Pislaru SV. Echocardiographic left ventricular diastolic dysfunction predicts hospital mortality after out-of-hospital cardiac arrest. J Crit Care 2018; 47:114-120. [PMID: 29945067 DOI: 10.1016/j.jcrc.2018.06.016] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 05/31/2018] [Accepted: 06/16/2018] [Indexed: 02/06/2023]
Abstract
PURPOSE To determine whether systolic or diastolic dysfunction on transthoracic echocardiogram (TTE) predicts mortality after out-of-hospital cardiac arrest (OHCA). METHODS Retrospective cohort study of 173 OHCA subjects undergoing targeted temperature management who underwent TTE during hospitalization. Univariate analysis and multivariate logistic regression were used to determine associations between TTE measurements of systolic and diastolic function and systemic hemodynamics with all-cause mortality. RESULTS Mean age was 61.6 ± 12.4 years (72.7% male) and initial rhythm was shockable in 89%. Hospital mortality was 30.6%. Mean LVEF was 40% and was not different in hospital survivors (p = 0.81). TTE parameters reflecting systolic function and systemic hemodynamics did not predict hospital mortality. Medial mitral E/e' ratio was associated with hospital mortality, with an optimal cut-off > 13 (p = 0.002). After multivariate adjustment, medial mitral E/e' ratio remained predictive of hospital mortality (OR 1.11, 95% CI 1.03-1.20, p = 0.004). Subjects with a medial mitral E/e' ratio > 13 had higher mortality during long-term follow-up (p < 0.001 by log-rank). CONCLUSIONS Diastolic dysfunction (higher medial mitral E/e' ratio) on TTE independently predicted mortality after OHCA; systolic dysfunction and TTE hemodynamic parameters did not. This reflects a novel use of Doppler TTE to predict outcomes after OHCA.
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Affiliation(s)
- Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States of America; Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN, United States of America.
| | - Nandan S Anavekar
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States of America.
| | - Sunil V Mankad
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States of America.
| | - Majd Khasawneh
- Department of Internal Medicine, William Beaumont Hospital, Royal Oak, MI, United States of America
| | - Roger D White
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, United States of America.
| | - Gregory W Barsness
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States of America.
| | | | - Kianoush B Kashani
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN, United States of America; Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, MN, United States of America.
| | - Sorin V Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States of America.
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40
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Calabrese V, Menna P, Annibali O, Armento G, Carpino A, Cerchiara E, Greco C, Marchesi F, Spallarossa P, Toglia G, Reggiardo G, Minotti G. Early Diastolic Dysfunction after Cancer Chemotherapy: Primary Endpoint Results of a Multicenter Cardio-Oncology Study. Chemotherapy 2018; 63:55-63. [PMID: 29428939 DOI: 10.1159/000486761] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 01/11/2018] [Indexed: 01/14/2023]
Abstract
Asymptomatic diastolic dysfunction (DD) with preserved left ventricular ejection fraction (LVEF) is suspected to precede late cardiac events in cancer survivors treated by chemotherapy. We conducted the first multicenter study of early DD induced by chemotherapy. Patients who were candidates for standard dose chemotherapy were screened for the absence of cardiovascular risk factors, LVEF ≥50%, normal-for-age diastolic function at echocardiography (E/A ratio, E wave deceleration time; DT), normal levels of potential DD biomarkers like Nt-proBNP (≤125 pg/mL), and cardiac troponin I (cTnI, ≤0.05 ng/mL). Mitral Doppler (E/E') was left at the investigator's discretion. Chemotherapy-induced DD with preserved LVEF was diagnosed for patients showing LVEF ≥50% and any of the following: Nt-proBNP > 125 pg/mL, cTnI > 0.05 ng/mL, and out-of-range E/A and DT. Eighty patients (68 females, 12 males, median age 49 years) were evaluated at 1 week after chemotherapy (T1) [corrected]. Thirty-three protocol-defined diastolic events were observed (15 Nt-proBNP > 125 pg/mL, 14 grade I DD by E/A and DT, 4 cTnI > 0.05 ng/mL). The events occurred in 29 asymptomatic patients with LVEF ≥50% (36% incidence of DD with preserved LVEF). Interactions occurred between biomarkers and grade I DD. E/E' abnormalities were not observed. Both anthracycline-based and nonanthracycline regimens induced DD. These findings show that biomarkers and echocardiography intercept early DD in otherwise asymptomatic low-risk cancer patients treated by standard dose chemotherapy. These findings therefore call for the adequate cardiac management of cancer patients.
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Affiliation(s)
- Vito Calabrese
- Units of Cardiology, Hematology, Oncology, Radiation Therapy and Clinical Pharmacology, Department of Medicine, University Campus Bio-Medico, Rome, Italy
| | - Pierantonio Menna
- Units of Cardiology, Hematology, Oncology, Radiation Therapy and Clinical Pharmacology, Department of Medicine, University Campus Bio-Medico, Rome, Italy
| | - Ombretta Annibali
- Units of Cardiology, Hematology, Oncology, Radiation Therapy and Clinical Pharmacology, Department of Medicine, University Campus Bio-Medico, Rome, Italy
| | - Grazia Armento
- Units of Cardiology, Hematology, Oncology, Radiation Therapy and Clinical Pharmacology, Department of Medicine, University Campus Bio-Medico, Rome, Italy
| | - Armando Carpino
- Department of Cardiology, National Cancer Institute "Regina Elena", Rome, Italy
| | - Elisabetta Cerchiara
- Units of Cardiology, Hematology, Oncology, Radiation Therapy and Clinical Pharmacology, Department of Medicine, University Campus Bio-Medico, Rome, Italy
| | - Carlo Greco
- Units of Cardiology, Hematology, Oncology, Radiation Therapy and Clinical Pharmacology, Department of Medicine, University Campus Bio-Medico, Rome, Italy
| | - Francesco Marchesi
- Department of Cardiology, National Cancer Institute "Regina Elena", Rome, Italy
| | - Paolo Spallarossa
- Department of Cardiology, San Martino Hospital and IRCCS, Genoa, Italy
| | - Giuseppe Toglia
- Department of Cardiology, National Cancer Institute "Regina Elena", Rome, Italy
| | | | - Giorgio Minotti
- Units of Cardiology, Hematology, Oncology, Radiation Therapy and Clinical Pharmacology, Department of Medicine, University Campus Bio-Medico, Rome, Italy
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Fraser AG. What Limits Functional Capacity in Heart Failure With Preserved Ejection Fraction? JACC-HEART FAILURE 2018; 6:127-129. [DOI: 10.1016/j.jchf.2017.11.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 11/27/2017] [Indexed: 11/28/2022]
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