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Ciampi Q, Cortigiani L, Gaibazzi N, Rigo F, Zagatina A, Wierzbowska-Drabik K, Kasprzak JD, Djordjevic-Dikic A, Haberka M, Barbieri A, Bartolacelli Y, Pepi M, Carerj S, Villari B, Pellikka PA, Picano E. Echocardiographic functional determinants of survival in heart failure with abnormal ejection fraction. Front Cardiovasc Med 2023; 10:1290366. [PMID: 38075970 PMCID: PMC10699198 DOI: 10.3389/fcvm.2023.1290366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 10/30/2023] [Indexed: 10/16/2024] Open
Abstract
Background and Aims Patients with heart failure (HF) with reduced left ventricular (LV) ejection fraction (EF) have a heterogeneous prognosis, and assessment of coronary physiology with coronary flow velocity (CFV) and coronary flow velocity reserve (CFVR) may complement established predictors based on wall motion and EF. Methods and results In a prospective multicenter study design, we enrolled 1,408 HF patients (age 66 ± 12 years, 1,035 men), with EF <50%, 743 (53%) with coronary artery disease, and 665 (47%) with normal coronary arteries. Recruitment (years 2004-2022) involved 8 accredited laboratories, with inter-observer variability <10% for CFV measurement. Baseline CFV (abnormal value >31 cm/s) was obtained by pulsed-wave Doppler in mid-distal LAD. CFVR (abnormal value ≤2.0) was assessed with exercise (n = 99), dobutamine (n = 100), and vasodilator stress (dipyridamole in 1,149, adenosine in 60). Inducible myocardial ischemia was identified with wall motion score index (WMSI) stress > rest (cut-off Δ ≥ 0.12). LV contractile reserve (CR) was identified with WMSI stress < rest (cutoff Δ ≥ 0.25). Test response ranged from score 0 (EF > 30%, CFV ≥ 32 cm/s, CFVR > 2.0, LVCR present, ischemia absent) to score 5 (all steps abnormal). All-cause death was the only endpoint. Results. During a median follow-up of 990 days, 253 patients died. Independent predictors of death were EF (HR: 0.956, 95% CI: 0.943-0.968, p < 0.0001), CFV (HR: 2.407, 95% CI: 1.871-3.096, p < 0.001), CFVR (HR: 3.908, 95% CI: 2.903-5.260, p < 0.001), stress-induced ischemia (HR: 2.223, 95% CI: 1.642-3.009, p < 0.001), and LVCR (HR: 0.524, 95% CI: 0.324-.647, p = 0.008). The annual mortality rate was lowest (1.2%) in patients with a score of 0 (n = 61) and highest (31.9%) in patients with a score of 5 (n = 15, p < 0.001). Conclusion High resting CFV is associated with worse survival in ischemic and nonischemic HF with reduced EF. The value is independent and additive to resting EF, CFVR, LVCR, and inducible ischemia.
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Affiliation(s)
- Quirino Ciampi
- Cardiology Department, Fatebenefratelli Hospital of Benevento, Benevento, Italy
| | | | - Nicola Gaibazzi
- Cardiology Department, Villa Salus Foundation/IRCCS San Camillo Hospital, Venice, Italy
| | - Fausto Rigo
- Cardiology Department, University of Parma, Parma, Italy
| | - Angela Zagatina
- Cardiology Department, Research Cardiology Center “Medika”, Saint Petersburg, Russian Federation
| | | | - Jaroslaw D. Kasprzak
- Department of Cardiology, Medical University of Lodz, BieganskiSpecialty Hospital, Lodz, Poland
| | - Ana Djordjevic-Dikic
- Clinical Center of Serbia and School of Medicine, University of Belgrade, Cardiology Clinic, Belgrade, Serbia
| | - Maciej Haberka
- Cardiology Department, University of Silesia, Katowice, Poland
| | - Andrea Barbieri
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Ylenia Bartolacelli
- Paediatric Cardiology and Adult Congenital Heart Disease Unit, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Mauro Pepi
- Cardiology Division, Centro Cardiologico Monzino, IRCCS, Milano, Italy
| | - Scipione Carerj
- Cardiology Division, University Hospital Polyclinic G.Martino, University of Messina, Messina, Italy
| | - Bruno Villari
- Cardiology Department, Fatebenefratelli Hospital of Benevento, Benevento, Italy
| | - Patricia A. Pellikka
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Eugenio Picano
- Biomedicine Department, CNR, Institute of Clinical Physiology, Pisa, Italy
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Ciampi Q, Cortigiani L, Rivadeneira Ruiz M, Barbieri A, Manganelli F, Mori F, D’Alfonso MG, Bursi F, Villari B. ABCDEG Stress Echocardiography in Aortic Stenosis. Diagnostics (Basel) 2023; 13:1727. [PMID: 37238211 PMCID: PMC10217228 DOI: 10.3390/diagnostics13101727] [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: 04/19/2023] [Revised: 05/06/2023] [Accepted: 05/10/2023] [Indexed: 05/28/2023] Open
Abstract
Rest and stress echocardiography (SE) plays a pivotal role in the evaluation of valvular heart disease. The use of SE is recommended in valvular heart disease when there is a mismatch between resting transthoracic echocardiography findings and symptoms. In aortic stenosis (AS), rest echocardiographic analysis is a stepwise approach that begins with the evaluation of aortic valve morphology and proceeds to the measurement of the transvalvular aortic gradient and aortic valve area (AVA) using continuity equations or planimetry. The presence of the following three criteria suggests severe AS: AVA < 1.0 cm2, a peak velocity > 4.0 m/s, or a mean gradient > 40 mmHg. However, in approximately one in three cases, we can observe a discordant AVA < 1 cm2 with a peak velocity < 4.0 m/s or a mean gradient <40 mmHg. This is due to reduced transvalvular flow associated with LV systolic dysfunction (LVEF < 50%) defined as "classical" low-flow low-gradient (LFLG) AS or normal LVEF "paradoxical" LFLG AS. SE has an established role in evaluating LV contractile reserve (CR) patients with reduced LVEF. In classical LFLG AS, LV CR distinguished pseudo-severe AS from truly severe AS. Some observational data suggest that long-term prognosis in asymptomatic severe AS may not be as favorable as previously thought, offering a window of opportunity for intervention prior to the onset of symptoms. Therefore, guidelines recommend evaluating asymptomatic AS with exercise stress in physically active patients, particularly those younger than 70 years, and symptomatic classical LFLG severe AS with low-dose dobutamine SE. A comprehensive SE assessment includes evaluating valve function (gradients), the global systolic function of the LV, and pulmonary congestion. This assessment integrates considerations of blood pressure response, chronotropic reserve, and symptoms. StressEcho 2030 is a prospective, large-scale study that employs a comprehensive protocol (ABCDEG) to analyze the clinical and echocardiographic phenotypes of AS, capturing various vulnerability sources which support stress echo-driven treatment strategies.
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Affiliation(s)
- Quirino Ciampi
- Cardiology Division, Fatebenefratelli Hospital, 82100 Benevento, Italy;
| | | | | | - Andrea Barbieri
- Department of Biomedical, Cardiology Division, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, 41121 Modena, Italy;
| | - Fiore Manganelli
- Cardiology Division, San Giuseppe Moscati Hospital, 83100 Avellino, Italy;
| | - Fabio Mori
- Cardiology Division, Careggi Hospital, 50134 Florence, Italy; (F.M.); (M.G.D.)
| | | | - Francesca Bursi
- Department of Health Science, University of Milan, Cardiology Division, San Paolo Hospital, ASST Santi Paolo e Carlo, 20142 Milano, Italy;
| | - Bruno Villari
- Cardiology Division, Fatebenefratelli Hospital, 82100 Benevento, Italy;
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Liu Q, Li Q, Wan X, Xu M, Pan J, Zhang Y, Li M, Zhang M. The value of myocardial work in the estimation of left ventricular systolic function in patients with coronary microvascular disease: A study based on adenosine stress echocardiography. Front Cardiovasc Med 2023; 10:1119785. [PMID: 37113699 PMCID: PMC10126338 DOI: 10.3389/fcvm.2023.1119785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 03/20/2023] [Indexed: 04/29/2023] Open
Abstract
Background Coronary microvascular dysfunction (CMD) is associated with increased cardiovascular events in patients with angina with non-obstructive coronary (ANOCA), especially heart failure. Conventional echocardiography is difficult to identify early alterations in cardiac function due to CMD. Methods We recruited 78 ANOCA patients. All patients underwent conventional echocardiography examination, adenosine stress echocardiography and examination of coronary flow reserve (CFR) by transthoracic echocardiography. Based on the CFR results, patients were divided into the CMD group (CFR < 2.5) and the non-CMD group (CFVR ≥ 2.5). Demographic data, conventional echocardiographic parameters, two-dimensional speckle-tracking echocardiography (2D-STE) parameters and myocardial work (MW) were compared between the two groups at rest and at stress. Logistic regression was used to analyze the factors associated with CMD. Results There was no significant difference in conventional echocardiography parameters, 2D-STE related indices or MW at rest between the two groups. Global work index (GWI), global contractive work (GCW), and global work efficiency (GWE) were lower in the CMD group than in the non-CMD group at stress (p = 0.040, 0.044, <0.001, respectively), but global waste work (GWW) and peak strain dispersion (PSD) were higher (both p < 0.001). GWI and GCW were associated with systolic blood pressure, diastolic blood pressure, product of heart rate and blood pressure, GLS and coronary flow velocity. While GWW was mainly correlated with PSD, GWE was correlated with PSD and GLS. In the non-CMD group, the responses to adenosine was mainly manifested as an increase in GWI, GCW and GWE (p = 0.001, 0.001, 0.009, respectively) and a decrease in PSD and GWW (p = 0.001, 0.015, respectively). In the CMD group, the response to adenosine was mainly manifested as an increase in GWW and a decrease in GWE (p = 0.002, and 0.006, respectively). In the multivariate regression analysis, we found that ΔGWW (difference in GWW before vs. after adenosine stress) and ΔPSD (difference in PSD before vs. after adenosine stress) were independent factors associated with CMD. The ROC curves showed that the composite prediction model consisting of ΔGWW and ΔPSD had excellent diagnostic value for CMD (area under the curve = 0.913). Conclusion In the present study, we found that CMD caused deterioration of myocardial work in ANOCA patients under adenosine stress, and that increased cardiac contraction asynchrony and wasted work may be the main changes caused by CMD.
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Affiliation(s)
| | | | | | | | | | - Yu Zhang
- Correspondence: Yu Zhang Mengmeng Li Mei Zhang
| | - Mengmeng Li
- Correspondence: Yu Zhang Mengmeng Li Mei Zhang
| | - Mei Zhang
- Correspondence: Yu Zhang Mengmeng Li Mei Zhang
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Cortigiani L, Vecchi A, Bovenzi F, Picano E. Reduced coronary flow velocity reserve and blunted heart rate reserve identify a higher risk group in patients with chest pain and negative emergency department evaluation. Intern Emerg Med 2022; 17:2103-2111. [PMID: 35864372 DOI: 10.1007/s11739-022-03018-5] [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: 03/17/2022] [Accepted: 05/25/2022] [Indexed: 11/30/2022]
Abstract
To estimate the prognostic value of stress echo (SE) with the assessment of coronary flow velocity reserve (CFVR) and heart rate reserve (HRR) in patients admitted for chest pain with non-diagnostic EKG, negative troponin, and without inducible regional wall motion abnormalities (RWMA). 658 patients (age 67 ± 12 years) admitted to our Emergency Department with chest pain, non-diagnostic EKG, and negative serial troponin underwent dipyridamole (0.84 mg/kg in 6') SE with simultaneous assessment of RWMA, CFVR in the left anterior descending artery, and HRR as peak/rest heart rate. The outcome measure was all-cause mortality. Of the 658 patients initially enrolled, 20 (3%) showed RWMA during SE and were referred to ischemia-driven revascularization. In the remaining 638, CFVR was abnormal (≤ 2.0) in 148 patients (23%). HRR was abnormal (≤ 1.22 in patients in sinus rhythm, or ≤ 1.17 in patients with permanent atrial fibrillation) in 196 patients (31%). During a follow-up of 7.3 ± 4.3 years, 151 (24%) patients died. Survival at 8 years was 93% in patients with normal CFVR and HRR, 76% in patients with abnormal CFVR only, 73% in patients with abnormal HRR only, and 38% in those with abnormal CFVR and HRR (p < 0.0001). At multivariable analysis, abnormal CFVR (HR 1.49, 95% CI 1.05-2.10, p = 0.02) and abnormal HRR (HR 2.01, 95% CI 1.43-2.84, p < 0.0001) were independent predictors of survival. In admitted patients with non-ischemic EKG, negative serial troponin, and without RWMA during dipyridamole SE, a reduced CFVR and blunted HRR independently identify a subset with worse survival in the long term. Upper panel: Color and pulsed-wave Doppler with the electrocardiographic lead tracing of Four different response patterns (from left to right): normal CFVR and HRR; normal CFVR, abnormal HRR; abnormal CFVR, normal HRR; abnormal CFVR and HRR. Lower panel: The annualized death rate for each of the four groups with negative SE for RWMA and stratified according to the presence of CFVR and HRR: none, one, or two abnormalities.
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Affiliation(s)
- Lauro Cortigiani
- Ospedale San Luca, Via Guglielmo Lippi Francesconi, 55100, Lucca, Italy.
| | - Andrea Vecchi
- Ospedale San Luca, Via Guglielmo Lippi Francesconi, 55100, Lucca, Italy
| | - Francesco Bovenzi
- Ospedale San Luca, Via Guglielmo Lippi Francesconi, 55100, Lucca, Italy
| | - Eugenio Picano
- Biomedicine Department, CNR, Institute of Clinical Physiology, Pisa, Italy
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Yamazaki T, Saito Y, Kobayashi T, Kitahara H, Kobayashi Y. Relation of hyperemic response during fractional flow reserve measurement to coronary flow reserve. J Cardiol 2022; 80:532-536. [PMID: 35882611 DOI: 10.1016/j.jjcc.2022.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 06/27/2022] [Accepted: 07/01/2022] [Indexed: 10/16/2022]
Abstract
BACKGROUND Coronary flow reserve (CFR) represents entire coronary compensatory capacity, while fractional flow reserve (FFR) is a standard to evaluate functional severity of epicardial coronary artery disease (CAD). ΔFFR, a decrease in a ratio of mean distal coronary pressure to aortic pressure (Pd/Pa) at rest to FFR, is conceptually associated with coronary microvascular function. This study aimed to evaluate the relation of ΔFFR to CFR in patients with stable CAD. METHODS We performed resting Pd/Pa and FFR measurements in a total of 309 vessels with intermediate coronary artery stenosis in 242 patients. ΔFFR was defined as (resting Pd/Pa - FFR), and pressure bounded-CFR was calculated to estimate low CFR. Vessels were divided as the low CFR and non-low CFR groups. RESULTS Of 309 vessels, low CFR was observed in 101 (32.7 %). While FFR values were similar (0.78 ± 0.11 vs. 0.78 ± 0.09, p = 0.84), resting Pd/Pa (0.85 ± 0.08 vs. 0.93 ± 0.04, p < 0.001) and ΔFFR (0.07 ± 0.06 vs. 0.15 ± 0.06, p < 0.001) were significantly lower in the low CFR group than in the non-low CFR group. The receiver operating characteristic curve analysis indicated that ΔFFR was predictive for low CFR (area under the curve 0.84, best cut-off value 0.08, p < 0.001). Multivariable analysis identified lower ΔFFR, the left anterior descending coronary artery, and lower hemoglobin and higher brain natriuretic peptide levels as factors associated with low CFR. CONCLUSIONS In patients with stable CAD, lower ΔFFR was significantly associated with low CFR in intermediate coronary stenosis in patients with stable CAD. ΔFFR may be a simple, practical, and useful surrogate to identify patients with impaired CFR.
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Affiliation(s)
- Tatsuro Yamazaki
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Yuichi Saito
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan.
| | - Takahiro Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Hideki Kitahara
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
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Yamazaki T, Saito Y, Kobayashi T, Kitahara H, Kobayashi Y. Factors associated with discordance between fractional flow reserve and resting full-cycle ratio. J Cardiol 2022; 80:9-13. [DOI: 10.1016/j.jjcc.2022.02.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 02/01/2022] [Accepted: 02/14/2022] [Indexed: 01/01/2023]
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Wang Y, Li W, Zhang H, Zhang Q, Ding G, Guo Z, Deng Y, Li C, Yin L. Echocardiographic Normal Reference of Left Ventricular Contractile Reserve During Treadmill Exercise Stress Echocardiography in Healthy Chinese Adults - New Non-Sex-Specific Parameter for Left Ventricular Contractile Reserve Evaluation. Int J Gen Med 2021; 14:7089-7098. [PMID: 34720598 PMCID: PMC8549965 DOI: 10.2147/ijgm.s334400] [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: 08/15/2021] [Accepted: 10/12/2021] [Indexed: 12/01/2022] Open
Abstract
Purpose Left ventricular (LV) contractile reserve is commonly used for LV systolic function assessment, while data on normal LV contractile reserve to exercise and the effect of gender on it are contradictory and limited, especially in Chinese adults. The aims of the present study are to clarify echocardiographic normal reference of LV contractile reserve during treadmill exercise stress echocardiography in healthy Chinese adults and to evaluate the sex-specific impact on it. Patients and Methods The study population consisted of 157 healthy Chinese adults. All subjects underwent comprehensive echocardiographic assessment at rest and immediately after a symptom-limited treadmill stress test. The impact of gender on LV contractile reserve was analyzed. Results The study population consisted of 157 healthy Chinese adults. All subjects underwent comprehensive echocardiographic assessment at rest and immediately after a symptom-limited treadmill stress test. The impact of gender on LV contractile reserve was analyzed. Conclusion Traditional LV contractile reserve of men was much higher than that of women in a healthy Chinese population. The difference might be because of higher BSA in men. ΔGLS was less influenced by METs and CI at rest compared to ΔEF. ΔGLS, and especially the ΔGLS index, might be considered as a more preferable contractile reserve parameter for clinical cardiac function evaluation.
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Affiliation(s)
- Yi Wang
- Key Laboratory of Ultrasound in Cardiac Electrophysiology and Biomechanics of Sichuan Province, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, People's Republic of China
| | - Wenhua Li
- Key Laboratory of Ultrasound in Cardiac Electrophysiology and Biomechanics of Sichuan Province, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, People's Republic of China
| | - Hongmei Zhang
- Key Laboratory of Ultrasound in Cardiac Electrophysiology and Biomechanics of Sichuan Province, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, People's Republic of China
| | - Qingfeng Zhang
- Key Laboratory of Ultrasound in Cardiac Electrophysiology and Biomechanics of Sichuan Province, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, People's Republic of China
| | - Geqi Ding
- Key Laboratory of Ultrasound in Cardiac Electrophysiology and Biomechanics of Sichuan Province, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, People's Republic of China
| | - Zhiyu Guo
- GE Cardiovascular Ultrasound Clinical & Research Department, Chengdu, People's Republic of China
| | - Yan Deng
- Key Laboratory of Ultrasound in Cardiac Electrophysiology and Biomechanics of Sichuan Province, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, People's Republic of China
| | - Chunmei Li
- Key Laboratory of Ultrasound in Cardiac Electrophysiology and Biomechanics of Sichuan Province, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, People's Republic of China
| | - Lixue Yin
- Key Laboratory of Ultrasound in Cardiac Electrophysiology and Biomechanics of Sichuan Province, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, People's Republic of China
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