Association of Ischemic Evaluation and Clinical Outcomes Among Patients Admitted With New-Onset Heart Failure

Background

The significant morbidity associated with systolic heart failure makes it imperative to identify patients with a reversible cause. We thus sought to evaluate the proportion of patients who received an ischemic evaluation after a hospitalization for new‐onset systolic heart failure.

Methods and Results

Patients admitted with a new diagnosis of heart failure and a reduction in left ventricular ejection fraction (≤40%) were identified in the VA Healthcare System from January 2006 to August 2017. Among those who survived 90 days without a readmission, we evaluated the proportion of patients who underwent an ischemic evaluation. We identified 9625 patients who were admitted with a new diagnosis of systolic heart failure with a concomitant reduction in ejection fraction. A minority of patients (3859, 40%) underwent an ischemic evaluation, with significant variation across high‐performing (90th percentile) and low‐performing (10th percentile) sites (odds ratio, 3.79; 95% CI, 2.90–4.31). Patients who underwent an evaluation were more likely to be treated with angiotensin‐converting enzyme inhibitors (75% versus 64%, P<0.001) or beta blockers (92% versus 82%, P<0.001) and subsequently undergo percutaneous (8% versus 0%, P<0.001) or surgical (2% versus 0%, P<0.001) revascularization. Patients with an ischemic evaluation also had a significantly lower adjusted hazard of all‐cause mortality (hazard ratio, 0.54; 95% CI, 0.47–0.61) compared with those without an evaluation.

Conclusions

Ischemic evaluations are underutilized in patients admitted with heart failure and a new reduction in left ventricular systolic function. A focused intervention to increase guideline‐concordant care could lead to an improvement in clinical outcomes.

Determinants of outcome in patients with chronic ischemic left ventricular dysfunction undergone percutaneous coronary interventions

Background

Percutaneous coronary interventions (PCI) in patients with ischemic systolic left ventricular dysfunction (SLVD) are routinely performed although their impact on prognosis remains unclear.

Methods

We retrospectively evaluated 385 consecutive patients (76 % male, 66 ± 9 years) with SLVD (left ventricular ejection fraction [LVEF] ≤40 %) due to chronic coronary artery disease, who underwent PCI between 1999 and 2009, and explored clinical factors associated with higher risk of death or of a composite of death and hospitalization for acute decompensated heart failure (ADHF).

Results

The median follow-up was 28 months (inter-quartile range 14–46 months). Death and the composite outcome of death and hospitalization for ADHF occurred in 80 (21 %) and 109 (28 %) patients respectively (8.4 and 11.5 per 100 patient-years of follow-up). Insulin-dependent diabetes mellitus (IDDM), multivessel disease, LVEF < 35 %, symptoms of heart failure (HF) emerged both as independent predictors of death (adjusted hazard ratios [HR] 2.64; 1.92, 1.88 and 1.67 respectively) and composite outcome of death and hospitalization for ADHF (adjusted HR 2.22, 1.92, 1.79 and 1.94 respectively). Furthermore advanced age (HR = 1.03) emerged as independent predictors of death and having performed a stress test before PCI correlated with reduced number of deaths and ADHF hospitalizations (HR = 0.60). Of note, PCI significantly reduced the symptom of angina from 63.2 % at baseline to 16.3 % at the last follow up (p < 0.0001).

Conclusions

IDDM, symptoms of HF, multivessel disease and LVEF < 35 % appear to be associated with worse outcome patients with ischemic SLVD undergoing PCI, and may be taken into account for optimal risk stratification. On the other hand, performing a stress testing before PCI seems to be associated with a more favorable outcome.

Is the prognosis in patients with diabetes and heart failure a matter of unsatisfactory management? An observational study from the Swedish Heart Failure Registry

AIMS

To analyse the long-term outcome, risk factor panorama, and treatment pattern in patients with heart failure (HF) with and without type 2 diabetes (T2DM) from a daily healthcare perspective.

METHODS AND RESULTS

Patients with (n=8809) and without (n=27,465) T2DM included in the Swedish Heart Failure Registry (S-HFR) 2003–2011 due to a physician-based HF diagnosis were prospectively followed for long-term mortality (median follow-up time: 1.9 years, range 0–8.7 years). Left ventricular function expressed as EF did not differ between patients with and without T2DM. Survival was significantly shorter in patients with T2DM, who had a median survival time of 3.5 years compared with 4.6 years (P<0.0001). In subjects with T2DM. unadjusted and adjusted odds ratios (ORs) for mortality were 1.37 [95% confidence interval (CI) 1.30–1.44) and 1.60 (95% CI 1.50–1.71), and T2DM predicted mortality in all age groups. Ischaemic heart disease was an important predictor for mortality (OR 1.68, 95% CI 1.47–1.94), more abundant in patients with T2DM (59% vs. 45%) among whom only 35% had been subjected to coronary angiography and 32% to revascularization. Evidence-based pharmacological HF treatment was somewhat more extensive in patients with T2DM.

CONCLUSION

The combination of T2DM and HF seriously compromises long-term prognosis. Ischaemic heart disease was identified as one major contributor; however, underutilization of available diagnostic and therapeutic facilities for ischaemic heart disease was obvious and may be an important area for future improvement in patients with T2DM and HF.

Comparison of off-pump and on-pump coronary endarterectomy for patients with diffusely diseased coronary arteries: early and midterm outcome

BACKGROUND

Coronary endarterectomy (CE) is an alternative for the diffusely diseased left anterior descending (LAD), but its mid and long term results are largely questionable. This study is to compare the early to mid-term results between off-pump and on-pump coronary endarterectomy with coronary artery bypass grafting.

METHODS

212 consecutive patients underwent CE and bypass grafting for diffusely diseased LAD. Ninety-two patients undergoing CE with off-pump (group off-pump) were compared with 120 patients undergoing CE with on-pump (group on-pump). The main preference for selection to an off-pump CE surgery were the preoperative high risk factors, especially previous cerebrovascular accident、chronic obstructive pulmonary disease (COPD)、calcified ascending aorta and right coronary artery (RCA) critical stenosis >90%.

RESULTS

There were three deaths in this group with total operative mortality of 1.4%. The perioperative mortality of group off-pump (1.1%) was similar with that of group on-pump (1.7%). The postoperative myocardial infarctions rate was 2.8%. There was no significant difference as for the morbidity between the group off-pump and group on-pump. Among survivors, the patency rate of the LIMA-LAD anastomosis was 89.4%. There was no difference as for the grafts patency rate between the two groups. Kaplan-Meier survival revealed no significant difference between the two groups. Kaplan-Meier freedom from cardiac events requiring hospital re-admission and angina recurrence were similar in both groups.

CONCLUSIONS

On-pump or off-pump CE is a good technique with the same early and mid-term outcomes. In the series of off-pump CE, we have shown that the effect of OPCABG with CE appears to be durable, and mid-term clinical outcomes are encouraging. Despite the higher risk profile, hospital mortality and major complications in our study are comparable to those for CCE.

Prompt recognition and percutaneous coronary intervention leads to favorable myocardial recovery after ST-segment elevation myocardial infarction secondary to acute promyelocytic leukemia: pediatric case report

Acute myocardial infarction (AMI) is extremely rare in children, and unlike the adult disease, the etiology of the infarction is rarely due to atherosclerotic coronary disease. This unique reported case involved a 15-year-old boy with severe chest pain who presented with an ST-segment-elevation myocardial infarction secondary to in situ thrombus formation in the left anterior descending (LAD) coronary artery. The initial electrocardiogram (ECG) had a Q-wave pattern in V6 and ST depression in the inferior leads with ST-segment elevation in reciprocal leads. The cardiac enzymes and routine labs showed evidence of myocardial damage. The boy was urgently taken to the cardiac catheterization laboratory for percutaneous coronary intervention, where complete occlusion of the LAD was found and successfully stented. Eventually, a peripheral blood smear showed pancytopenia with 38 % hypergranular blast-like cells consistent with acute myeloid leukemia (AML), and chemotherapy with all-transretinoic acid was implemented. This first pediatric case report of an AML-associated AMI emphasizes the benefit resulting from expedient reperfusion of the ischemic myocardium by quick reestablishment of coronary perfusion. It also emphasizes the limitations of existing noninvasive technologies in detecting myocardial viability.

Current indications for heart transplantation and left ventricular assist device: a practical point of view

Heart transplantation (HTx) is considered the "gold standard" therapy of refractory heart failure (HF), but it is accessible only to few patients because of the paucity of suitable heart donors. On the other hand, left ventricular assist devices (LVADs) have proven to be effective in improving survival and quality of life in patients with refractory HF. The challenge encountered by multidisciplinary teams in dealing with advanced HF lies in identifying patients who could benefit more from HTx as compared to LVAD implantation and the appropriate timing. The decision-making is based on clinical parameters, imaging-based data and risk scores. Current outcome of HF patients supported by LVAD (2-year survival around 70%) is rapidly improving and leads the way to a new therapeutic strategy. Patients who have a low likelihood to gain access to the heart graft pool could benefit more from LVAD implantation (defined as bridge to transplantation indication) than from remaining on HTx waiting list with the likely risk of clinical deterioration or removal from the list because patients are no longer suitable for transplantation. LVAD has also demonstrated to be effective in patients who are not considered eligible candidates for HTx with a destination therapy indication. HTx should be reserved to those patients for whom the maximum clinical benefit can be expected, such as young patients with no comorbidities. Here we discuss the current listing criteria for HTx and indications to implant of LVAD for patients with refractory acute and chronic HF based on the guidelines and the practical experience of our center.

Twenty four hour imaging delay improves viability detection by Tl-201 myocardial perfusion scintigraphy

Objective

Since twenty-four-hour imaging by Tl-201 myocardial perfusion scintigraphy has been introduced as an effective additional procedure, the aim of this study was to compare this method's result with only rest redistribution procedure in the diagnosis of myocardial viability.

Methods

Thirty patients (Seven female, 23 male; mean: 59.8 ± 10.7, 55.8-63.8 years old) with diagnosis of coronary artery disease were involved in this study. All patients had anamnesis of previous myocardial infarction and/or total occlusion of any main artery in the coronary angiography. Myocardial perfusion scintigraphy with Tl-201 with rest four hour (early) redistribution and 24 hour delayed redistribution protocol were performed to all of the patients. The images were evaluated according to 17 segment basis by an experienced nuclear medicine physician and improvement of a segment by visual interpretation was considered as viable myocardial tissue.

Results

Viability was found at 52 segments in the early redistribution images and additional 18 segments in the 24 hour delayed redistribution images on segment basis in the evaluation of 510 segments of 30 patients. On per patient basis, among the 26 patients who had viable tissue, 14 (54%) had additional improvement in 24 hour delayed images. Three (12%) patients had viable tissue in only 24 hour delayed images.

Conclusion

Delayed imaging in Tl-201 MPS is a necessary application for the evaluation of viable tissue according to considerable number of patients with additional improvement in 24 hour images in our study, which is restricted to the patients with myocardial infarct.

Coronary artery bypass grafting in patients with left ventricular dysfunction: predictors of long-term survival and impact of surgical strategies

BACKGROUND

In the surgical management of ischemic cardiomyopathy, factors associated with long-term prognosis after coronary artery bypass grafting (CABG) in patients with severe left ventricular (LV) dysfunction are poorly understood. This study aimed to determine predictors of clinical outcomes in patients with severe LV dysfunction undergoing CABG.

METHODS

Out of 6084 patients who underwent CABG between 1997 and 2011, 476 patients (aged 62.6 ± 9.3 years, 100 females) were identified as having severe LV dysfunction (ejection fraction ≤ 35%), preoperatively. All-cause mortality and adverse cardiac events (myocardial infarction, repeat revascularization, stroke and hospitalization due to cardiovascular causes) were evaluated during a median follow-up period of 55.2 months (inter-quartile range: 26.4-94.8 months).

RESULTS

During the follow-up, 187 patients (39.3%) died and 126 cardiac events occurred in 104 patients (21.8%). Five-year survival and event-free survival rates were 72.1 ± 2.2% and 61.3 ± 2.4%, respectively. On Cox-regression analysis, old age (P < 0.001), recent MI (P < 0.001), history of coronary stenting (P = 0.023), decreased glomerular filtration rate (P < 0.001), and presence of mitral regurgitation (≥moderate) (P = 0.012) or LV wall thinning (P = 0.007) emerged as significant and independent predictors of death. After adjustment for important covariates affecting outcomes, none of the pump strategy (off-pump vs. on-pump), concomitant mitral surgery or surgical ventricular reconstruction (SVR) affected survival or event-free survival (P = 0.082 to >0.99).

CONCLUSIONS

Long-term survival following CABG in patients with severe LV dysfunction was affected by age, renal function, recent MI, prior coronary stenting, and presence of mitral regurgitation or LV wall thinning. Neither concomitant mitral surgery nor SVR, however, had significant influence on clinical outcomes.

Left ventricular dysfunction due to diffuse multiple vessel coronary artery spasm can be concealed in dilated cardiomyopathy

AIMS

Many patients with idiopathic dilated cardiomyopathy (DCM) have been diagnosed on the basis of the exclusion of significant coronary stenosis and the presence of left ventricular (LV) dysfunction. In the present study, we investigated the possibility that coronary multispasm is one of the mechanisms leading to diffuse idiopathic DCM-like LV dysfunction.

METHODS AND RESULTS

Forty-two patients with severely depressed LV function but without significant coronary stenosis were enrolled (baseline LV ejection fraction, 33 ± 11%). An acetylcholine (ACh) provocation test was performed at the time of coronary angiography. In patients with a positive ACh provocation test (n = 20), coronary angiography revealed multivessel diffuse coronary spasm with marked electrocardiogram changes. In patients with a negative ACh provocation test (n = 22), significant findings compatible with idiopathic DCM were more frequently observed on magnetic resonance imaging (MRI) or in LV biopsies compared with the ACh-positive group (MRI, 73% vs. 12%; and LV biopsy, 71% vs. 0%, respectively; P < 0.01). In the ACh-positive group, LV function significantly improved after the administration of calcium channel blockers (LV ejection fraction, 34 ± 12% vs. 54 ± 10%; and brain natriuretic peptide, 803 ± 482 pg/mL vs. 69 ± 84 pg/mL, at baseline and 1 year, respectively; P < 0.01).

CONCLUSIONS

Our results raise the possibility that patients with LV dysfunction due to repeated coronary multispasm are being diagnosed as idiopathic DCM, and that calcium channel blockers may prove to be a promising therapeutic strategy in those patients.

A Turkish perspective on coronary artery bypass surgery and percutaneous coronary artery intervention in chronic heart failure patients

The impact of coronary revascularization methods (coronary artery bypass graft [CABG] surgery and stent implantation) on clinical outcome has not been determined yet in patients with systolic heart failure (SHF). We examined outcomes in patients discharged from our hospital after hospitalization for decompensated SHF. Of 637 patients with SHF (mean age, 64 ± 13 years; mean ejection fraction, 26.5% ± 9%), 402 patients (63%) had coronary artery disease (CAD) and 235 patients (37%) had no CAD; 223 patients (35%) died because of cardiovascular reasons during follow-up. Patients who had stenting alone and patients who had CABG surgery and stenting had better prognosis than patients with CAD but no revascularization procedure (P < .001 and P = .013, respectively). In the patients with SHF having CAD who had stenting and CABG surgery + stenting may have better prognosis compared with patients with CAD who had no revascularization procedure in their past.

Is cardiac magnetic resonance imaging assessment of myocardial viability useful for predicting which patients with impaired ventricles might benefit from revascularization?

A best evidence topic in cardiac magnetic resonance imaging (MRI) was written according to a structured protocol. The question addressed was: what is the role of cardiac magnetic resonance (CMR) imaging in viability assessment of ischaemic cardiomyopathy? Altogether more than 164 papers were found using the reported search; of which, 6 represented the best available evidence to answer the clinical question and an additional 4 were found by crosschecking the reference lists for further 'best available evidence' papers. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Using late-gadolinium enhancement-cardiac magnetic resonance (LGE-CMR) imaging, infarcted myocardium can be identified by the presence of hyperenhanced signal. The extent of myocardial hyperenhancement correlates inversely with improved myocardial contractility following surgical or percutaneous revascularization. Furthermore, CMR is able to assess not only viability, but also make gold-standard assessment of ventricular function and volume as well as identify stress perfusion deficits, each of which is relevant to estimating patient prognosis. National bodies have also begun to formally recommend CMR imaging for cardiac viability assessment. For example, the Canadian Cardiovascular Society (CCS) has stated that 'assessment of myocardial viability in patients with left ventricle dysfunction or akinetic segments for predicting recovery of ventricular function following revascularization is a class I indication for the use of LGE-CMR'. We conclude that cardiac MRI is an excellent tool for predicting myocardial viability, in the context of acute and chronic ischaemic heart disease whether subsequent revascularization is achieved by surgical or percutaneous means. In addition, the versatility of CMR imaging makes it an increasingly attractive tool for the complete assessment of the patient with ischaemic cardiomyopathy.