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Nebhwani M, Chaibekava K, Achten A, Oerlemans MIFJ, Michels M, van der Meer P, Nienhuis HLA, Weerts J, van Empel V, Rocca HPBL, Wijk SSV, van der Pol J, Knackstedt C. Detection of cardiac amyloidosis on routine bone scintigraphy: an important gatekeeper role for the nuclear medicine physician. Int J Cardiovasc Imaging 2024:10.1007/s10554-024-03085-z. [PMID: 38520623 DOI: 10.1007/s10554-024-03085-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 03/11/2024] [Indexed: 03/25/2024]
Abstract
Cardiac amyloidosis (CA)-mostly transthyretin-related (ATTR-CA)-has recently gained interest in cardiology. Bone scintigraphy (BS) is one of the main screening tools for ATTR-CA but also used for various other reasons. The objective was to evaluate whether all CA cases are detected and what happens during follow-up. All routine BS performed at the Maastricht University Medical Center (May 2012-August 2020) were screened for the presence of CA. Scans performed for suspected CA were excluded. A Perugini stage ≥1 was classified as positive necessitating further examination. The electronic medical record system was evaluated for any contact with cardiology or other specialists until 2021. Of the 2738 BS evaluated, 40 scans (1.46%; median age 73.5 [IQR: 65.8-79.5], 82.5% male) were positive (Perugini grade 1: 31/77.5%, grade 2: 6/15%, grade 3: 3/7.5%); the potential diagnosis ATTR-CA was not seen in 38 patients (95%) by the nuclear medicine specialist. During follow-up, 19 out of those 40 patients (47.5%) underwent cardiac evaluation without diagnosing CA. Available echocardiograms of patients with a positive BS showed left ventricular hypertrophy, a preserved ejection fraction, and diastolic dysfunction ≥2 in 9/47%, 10/53%, and 4/21% of patients, respectively. Additionally, 20 (50%) patients presented to at least one specialty with symptoms indicative of cardiac amyloidosis. The prevalence of a positive BS indicating potential CA in an unselected population is low but substantial. The majority was not detected which asks for better awareness for CA of all involved specialists to ensure appropriate treatment and follow-up.
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Affiliation(s)
- Mohit Nebhwani
- Department of Cardiology and Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+, PO Box 5800, 6202 AZ, Maastricht, The Netherlands
| | - Karina Chaibekava
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Anouk Achten
- Department of Cardiology and Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+, PO Box 5800, 6202 AZ, Maastricht, The Netherlands
| | | | - Michelle Michels
- Department of Cardiology, Erasmus MC, Cardiovascular Institute, Thoraxcenter, Rotterdam, The Netherlands
| | - Peter van der Meer
- Department of Cardiology, University Medical Center, Groningen, The Netherlands
| | - Hans L A Nienhuis
- Department of Rheumatology & Clinical Immunology, University Medical Center Groningen, Groningen, The Netherlands
| | - Jerremy Weerts
- Department of Cardiology and Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+, PO Box 5800, 6202 AZ, Maastricht, The Netherlands
| | - Vanessa van Empel
- Department of Cardiology and Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+, PO Box 5800, 6202 AZ, Maastricht, The Netherlands
| | - Hans-Peter Brunner-La Rocca
- Department of Cardiology and Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+, PO Box 5800, 6202 AZ, Maastricht, The Netherlands
| | | | - Jochem van der Pol
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Christian Knackstedt
- Department of Cardiology and Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+, PO Box 5800, 6202 AZ, Maastricht, The Netherlands.
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Boeckmans J, Sandrin L, Knackstedt C, Schattenberg JM. Liver stiffness as a cornerstone in heart disease risk assessment. Liver Int 2024; 44:344-356. [PMID: 38014628 DOI: 10.1111/liv.15801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 11/05/2023] [Accepted: 11/12/2023] [Indexed: 11/29/2023]
Abstract
Metabolic dysfunction-associated steatotic liver disease (MASLD) typically presents with hepatic fibrosis in advanced disease, resulting in increased liver stiffness. A subset of patients further develops liver cirrhosis and hepatocellular carcinoma. Cardiovascular disease is a common comorbidity in patients with MASLD and its prevalence is increasing in parallel. Recent evidence suggests that especially liver stiffness, whether or not existing against a background of MASLD, is associated with heart diseases. We conducted a narrative review on the role of liver stiffness in the prediction of highly prevalent heart diseases including heart failure, cardiac arrhythmias (in particular atrial fibrillation), coronary heart disease, and aortic valve sclerosis. Research papers were retrieved from major scientific databases (PubMed, Web of Science) until September 2023 using 'liver stiffness' and 'liver fibrosis' as keywords along with the latter cardiac conditions. Increased liver stiffness, determined by vibration-controlled transient elastography or hepatic fibrosis as predicted by biomarker panels, are associated with a variety of cardiovascular diseases, including heart failure, atrial fibrillation, and coronary heart disease. Elevated liver stiffness in patients with metabolic liver disease should lead to considerations of cardiac workup including N-terminal pro-B-type natriuretic peptide/B-type natriuretic peptide determination, electrocardiography, and coronary computed tomography angiography. In addition, patients with MASLD would benefit from heart disease case-finding strategies in which liver stiffness measurements can play a key role. In conclusion, increased liver stiffness should be a trigger to consider a cardiac workup in metabolically compromised patients.
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Affiliation(s)
- Joost Boeckmans
- Metabolic Liver Research Center, I. Department of Medicine, University Medical Center Mainz, Mainz, Germany
- In Vitro Liver Disease Modelling Team, Department of In Vitro Toxicology and Dermato-Cosmetology, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
| | | | - Christian Knackstedt
- Department of Cardiology, Maastricht University Medical Center+, Maastricht, the Netherlands
- Faculty of Health, Medicine, and Life Sciences, CARIM School for Cardiovascular Diseases, Maastricht, the Netherlands
| | - Jörn M Schattenberg
- Metabolic Liver Research Center, I. Department of Medicine, University Medical Center Mainz, Mainz, Germany
- Department of Medicine II, Saarland University Medical Center, Homburg, Germany
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Tingen HSA, Tubben A, Bijzet J, van den Berg MP, van der Meer P, Houwerzijl EJ, Muntinghe FLH, van der Zwaag PA, Glaudemans AWJM, Oerlemans MIFJ, Knackstedt C, Michels M, Hirsch A, Hazenberg BPC, Slart RHJA, Nienhuis HLA. Cardiac [ 99mTc]Tc-hydroxydiphosphonate uptake on bone scintigraphy in patients with hereditary transthyretin amyloidosis: an early follow-up marker? Eur J Nucl Med Mol Imaging 2024; 51:681-690. [PMID: 37843599 PMCID: PMC10796605 DOI: 10.1007/s00259-023-06459-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 09/23/2023] [Indexed: 10/17/2023]
Abstract
PURPOSE There is a need for early quantitative markers of potential treatment response in patients with hereditary transthyretin (ATTRv) amyloidosis to guide therapy. This study aims to evaluate changes in cardiac tracer uptake on bone scintigraphy in ATTRv amyloidosis patients on different treatments. METHODS In this retrospective cohort study, outcomes of 20 patients treated with the transthyretin (TTR) gene silencer patisiran were compared to 12 patients treated with a TTR-stabilizer. Changes in NYHA class, cardiac biomarkers in serum, wall thickness, and diastolic parameters on echocardiography and NYHA class during treatment were evaluated. RESULTS Median heart/whole-body (H/WB) ratio on bone scintigraphy decreased from 4.84 [4.00 to 5.31] to 4.16 [3.66 to 4.81] (p < .001) in patients treated with patisiran for 29 [15-34] months. No changes in the other follow-up parameters were observed. In patients treated with a TTR-stabilizer for 24 [20 to 30] months, H/WB ratio increased from 4.46 [3.24 to 5.13] to 4.96 [ 3.39 to 5.80] (p = .010), and troponin T increased from 19.5 [9.3 to 34.0] ng/L to 20.0 [11.8 to 47.8] ng/L (p = .025). All other parameters did not change during treatment with a TTR-stabilizer. CONCLUSION A change in cardiac tracer uptake on bone scintigraphy may be an early marker of treatment-specific response or disease progression in ATTRv amyloidosis patients.
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Affiliation(s)
- H S A Tingen
- Department of Nuclear Medicine and Molecular Imaging, University Medical Centre Groningen and Amyloidosis Centre of Expertise, Groningen, The Netherlands.
| | - A Tubben
- Department of Cardiology, University Medical Centre Groningen and Amyloidosis Centre of Expertise, Groningen, The Netherlands
| | - J Bijzet
- Department of Rheumatology & Clinical Immunology, University Medical Centre Groningen and Amyloidosis Centre of Expertise, Groningen, The Netherlands
| | - M P van den Berg
- Department of Cardiology, University Medical Centre Groningen and Amyloidosis Centre of Expertise, Groningen, The Netherlands
| | - P van der Meer
- Department of Cardiology, University Medical Centre Groningen and Amyloidosis Centre of Expertise, Groningen, The Netherlands
| | - E J Houwerzijl
- Department of Internal Medicine, University Medical Centre Groningen and Amyloidosis Centre of Expertise, Groningen, The Netherlands
| | - F L H Muntinghe
- Department of Internal Medicine, University Medical Centre Groningen and Amyloidosis Centre of Expertise, Groningen, The Netherlands
| | - P A van der Zwaag
- Department of Clinical Genetics, University Medical Centre Groningen and Amyloidosis Centre of Expertise, Groningen, The Netherlands
| | - A W J M Glaudemans
- Department of Nuclear Medicine and Molecular Imaging, University Medical Centre Groningen and Amyloidosis Centre of Expertise, Groningen, The Netherlands
| | - M I F J Oerlemans
- Department of Cardiology and Member of the European Reference Network for rare, low prevalence and complex diseases of the heart: ERN GUARD-Heart , University Medical Centre Utrecht, Utrecht, The Netherlands
| | - C Knackstedt
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre +, Maastricht, The Netherlands
| | - M Michels
- Department of Cardiology, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - A Hirsch
- Department of Radiology and Nuclear Medicine, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - B P C Hazenberg
- Department of Rheumatology & Clinical Immunology, University Medical Centre Groningen and Amyloidosis Centre of Expertise, Groningen, The Netherlands
| | - R H J A Slart
- Department of Nuclear Medicine and Molecular Imaging, University Medical Centre Groningen and Amyloidosis Centre of Expertise, Groningen, The Netherlands
- Biomedical Photonic Imaging Group, Faculty of Science and Technology, University of Twente, Enschede, The Netherlands
| | - H L A Nienhuis
- Department of Internal Medicine, University Medical Centre Groningen and Amyloidosis Centre of Expertise, Groningen, The Netherlands
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Gingele AJ, Brandts L, Vossen K, Knackstedt C, Boyne J, Brunner-La Rocca HP. Prognostic value of signs and symptoms in heart failure patients using remote telemonitoring. J Telemed Telecare 2024; 30:180-185. [PMID: 34516318 DOI: 10.1177/1357633x211039404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Heart failure is a serious burden on health care systems due to frequent hospital admissions. Early recognition of outpatients at risk for clinical deterioration could prevent hospitalization. Still, the role of signs and symptoms in monitoring heart failure patients is not clear. The heart failure coach is a web-based telemonitoring application consisting of a 9-item questionnaire assessment of heart failure signs and symptoms and developed to identify outpatients at risk for clinical deterioration. If deterioration was suspected, patients were contacted by a heart failure nurse for further evaluation. METHODS Heart failure coach questionnaires completed between 2015 and 2018 were collected from 287 patients, completing 18,176 questionnaires. Adverse events were defined as all-cause mortality, heart failure- or cardiac-related hospital admission or emergency cardiac care visits within 30 days after completion of each questionnaire. Multilevel logistic regression analyses were performed to assess the association between the heart failure coach questionnaire items and the odds of an adverse event. RESULTS No association between dyspnea and adverse events was observed (odds ratio 1.02, 95% confidence interval 0.79-1.30). Peripheral edema (odds ratio 2.21, 95% confidence interval 1.58-3.11), persistent chest pain (odds 2.06, 95% confidence interval 1.19-3.58), anxiety about heart failure (odds ratio 2.12, 95% confidence interval 1.44-3.13), and extensive struggle to perform daily activities (odds ratio 2.23, 95% confidence interval 1.38-3.62) were significantly associated with adverse outcome. DISCUSSION Regular assessment of more than the classical signs and symptoms may be helpful to identify heart failure patients at risk for clinical deterioration and should be an integrated part of heart failure telemonitoring programs.
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Affiliation(s)
| | - Lloyd Brandts
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, the Netherlands
| | - Kjeld Vossen
- Department of Cardiology, Maastricht University Medical Centre, the Netherlands
| | | | - Josiane Boyne
- Department of Cardiology, Maastricht University Medical Centre, the Netherlands
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Henkens MTHM, Raafs AG, Vanloon T, Vos JL, Vandenwijngaard A, Brunner HG, Krapels IPC, Knackstedt C, Gerretsen S, Hazebroek MR, Vernooy K, Nijveldt R, Lumens J, Verdonschot JAJ. Left Atrial Function in Patients with Titin Cardiomyopathy. J Card Fail 2024; 30:51-60. [PMID: 37230314 DOI: 10.1016/j.cardfail.2023.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 05/01/2023] [Accepted: 05/01/2023] [Indexed: 05/27/2023]
Abstract
BACKGROUND Truncating variants in titin (TTNtv) are the most prevalent genetic etiology of dilated cardiomyopathy (DCM). Although TTNtv has been associated with atrial fibrillation, it remains unknown whether and how left atrial (LA) function differs between patients with DCM with and without TTNtv. We aimed to determine and compare LA function in patients with DCM with and without TTNtv and to evaluate whether and how left ventricular (LV) function affects the LA using computational modeling. METHODS AND RESULTS Patients with DCM from the Maastricht DCM registry that underwent genetic testing and cardiovascular magnetic resonance (CMR) were included in the current study. Subsequent computational modeling (CircAdapt model) was performed to identify potential LV and LA myocardial hemodynamic substrates. In total, 377 patients with DCM (n = 42 with TTNtv, n = 335 without a genetic variant) were included (median age 55 years, interquartile range [IQR] 46-62 years, 62% men). Patients with TTNtv had a larger LA volume and decreased LA strain compared with patients without a genetic variant (LA volume index 60 mLm-2 [IQR 49-83] vs 51 mLm-2 [IQR 42-64]; LA reservoir strain 24% [IQR 10-29] vs 28% [IQR 20-34]; LA booster strain 9% [IQR 4-14] vs 14% [IQR 10-17], respectively; all P < .01). Computational modeling suggests that while the observed LV dysfunction partially explains the observed LA dysfunction in the patients with TTNtv, both intrinsic LV and LA dysfunction are present in patients with and without a TTNtv. CONCLUSIONS Patients with DCM with TTNtv have more severe LA dysfunction compared with patients without a genetic variant. Insights from computational modeling suggest that both intrinsic LV and LA dysfunction are present in patients with DCM with and without TTNtv.
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Affiliation(s)
- Michiel T H M Henkens
- Department of Cardiology, Maastricht University Medical Center, Maastricht, the Netherlands; Centre for Heart Failure Research, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, the Netherlands; Netherlands Heart Institute (NLHI), Utrecht, the Netherlands
| | - Anne G Raafs
- Department of Cardiology, Maastricht University Medical Center, Maastricht, the Netherlands; Centre for Heart Failure Research, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, the Netherlands
| | - Tim Vanloon
- Department of Biomedical Engineering, CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, the Netherlands
| | - Jacqueline L Vos
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Arthur Vandenwijngaard
- Department of Clinical Genetics, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Han G Brunner
- Department of Clinical Genetics, Maastricht University Medical Center, Maastricht, the Netherlands; GROW Institute for Developmental Biology and Cancer, Maastricht University, Maastricht, the Netherlands; Department of Human Genetics, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Ingrid P C Krapels
- Department of Clinical Genetics, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Christian Knackstedt
- Department of Cardiology, Maastricht University Medical Center, Maastricht, the Netherlands; Centre for Heart Failure Research, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, the Netherlands
| | - Suzanne Gerretsen
- Department of Radiology and Nuclear Medicine, Cardiovascular research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Mark R Hazebroek
- Department of Cardiology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Kevin Vernooy
- Department of Cardiology, Maastricht University Medical Center, Maastricht, the Netherlands; Centre for Heart Failure Research, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, the Netherlands
| | - Robin Nijveldt
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Joost Lumens
- Department of Biomedical Engineering, CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, the Netherlands
| | - Job A J Verdonschot
- Centre for Heart Failure Research, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, the Netherlands; Department of Clinical Genetics, Maastricht University Medical Center, Maastricht, the Netherlands.
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Knackstedt C, Ramaekers B, Schummers G, Schreckenberg M, Faessen J, Marx N, Becker M, Sanders-van Wijk S, van Empel V, Norra C, Kunert HJ, Brunner-La Rocca HP. Influence of Individual Personality Traits of the Reader on Visual Assessment of Left Ventricular Ejection Fraction: Another Reason to Abandon Visual Assessment. J Am Soc Echocardiogr 2023; 36:1332-1335. [PMID: 37619911 DOI: 10.1016/j.echo.2023.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 08/10/2023] [Accepted: 08/11/2023] [Indexed: 08/26/2023]
Affiliation(s)
- Christian Knackstedt
- Department of Cardiology, Maastricht University Medical Center+, Maastricht, The Netherlands.
| | - Bram Ramaekers
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | | | | | - Jelle Faessen
- Department of Cardiology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Nikolaus Marx
- Department of Cardiology, Angiology, Pneumology and Intensive Care Medicine, RWTH Aachen University Hospital, Aachen, Germany
| | - Michael Becker
- Department of Cardiology, Rhein-Maas Klinikum, Würselen, Germany
| | | | - Vanessa van Empel
- Department of Cardiology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Christine Norra
- Department of Psychiatry and Psychosomatics, LWL Hospital Paderborn, Ruhr University Bochum, Bochum, Germany
| | - Hanns Jürgen Kunert
- Department of Psychiatry and Psychotherapy, Georg-August-University Göttingen, Göttingen, Germany
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Weerts J, Amin H, Barandiarán Aizpurua A, Gevaert AB, Handoko ML, Dauw J, Tun HN, Rommel K, Verbrugge FH, Kresoja K, Sanders‐van Wijk S, Brunner‐La Rocca H, Bayés‐Genís A, Lumens J, Knackstedt C, van Empel VP. Webtool to enhance the accuracy of diagnostic algorithms for HFpEF: a prospective cross-over study. ESC Heart Fail 2023; 10:3493-3503. [PMID: 37724334 PMCID: PMC10682885 DOI: 10.1002/ehf2.14525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 08/22/2023] [Indexed: 09/20/2023] Open
Abstract
AIMS Diagnosis of heart failure with preserved ejection fraction (HFpEF) can be challenging. This study aimed to evaluate the potential of a webtool to enhance the scoring accuracy when applying the complex HFA-PEFF and H2 FPEF algorithms, which are commonly used for diagnosing HFpEF. METHODS AND RESULTS We developed an online tool, the HFpEF calculator, that enables the automatic calculation of current HFpEF algorithms. We assessed the accuracy of manual vs. automatic scoring, defined as the percentage of correct scores, in a cohort of cardiologists with varying clinical experience. Cardiologists scored eight online clinical cases using a triple cross-over design (i.e. two manual-two automatic-two manual-two automatic). Data were analysed in study completers (n = 55, 29% heart failure specialists, 42% general cardiologists, and 29% cardiology residents). Manually calculated scores were correct in 50% (HFA-PEFF: 50% [50-75]; H2 FPEF: 50% [38-50]). Correct scoring improved to 100% using the HFpEF calculator (HFA-PEFF: 100% [88-100], P < 0.001; H2 FPEF: 100% [75-100], P < 0.001). Time spent on clinical cases was similar between scoring methods (±4 min). When corrections for faulty algorithm scores were displayed, cardiologists changed their diagnostic decision in up to 67% of cases. At least 67% of cardiologists preferred using the online tool for future cases in clinical practice. CONCLUSIONS Manual calculation of HFpEF diagnostic algorithms is often inaccurate. Using an automated webtool to calculate HFpEF algorithms significantly improved correct scoring. This new approach may impact the eventual diagnostic decision in up to two-thirds of cases, supporting its routine use in clinical practice.
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Affiliation(s)
- Jerremy Weerts
- Department of CardiologyCardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+ (MUMC+)PO Box 6166200 MDMaastrichtThe Netherlands
| | - Hesam Amin
- Department of CardiologyCardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+ (MUMC+)PO Box 6166200 MDMaastrichtThe Netherlands
- Department of CardiologyThoraxcentrum Twente, Medisch Spectrum TwenteEnschedeThe Netherlands
| | - Arantxa Barandiarán Aizpurua
- Department of CardiologyCardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+ (MUMC+)PO Box 6166200 MDMaastrichtThe Netherlands
| | - Andreas B. Gevaert
- Research Group Cardiovascular Diseases, GENCOR DepartmentUniversity of AntwerpAntwerpBelgium
- Department of CardiologyAntwerp University Hospital (UZA)EdegemBelgium
| | - M. Louis Handoko
- Department of CardiologyAmsterdam University Medical Centers, Vrije UniversiteitAmsterdamThe Netherlands
- Amsterdam Cardiovascular Sciences/Heart Failure and ArrhythmiasAmsterdamThe Netherlands
| | - Jeroen Dauw
- Department of CardiologyAZ Sint‐LucasGhentBelgium
| | - Han Naung Tun
- Larner College of MedicineUniversity of VermontBurlingtonVTUSA
| | - Karl‐Philipp Rommel
- Department of Internal Medicine/CardiologyHeart Center Leipzig, Leipzig UniversityLeipzigGermany
| | - Frederik H. Verbrugge
- Centre for Cardiovascular DiseasesUniversity Hospital BrusselsJetteBelgium
- Faculty of Medicine and PharmacyVrije Universiteit BrusselBrusselsBelgium
| | - Karl‐Patrik Kresoja
- Department of Internal Medicine/CardiologyHeart Center Leipzig, Leipzig UniversityLeipzigGermany
| | | | - Hans‐Peter Brunner‐La Rocca
- Department of CardiologyCardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+ (MUMC+)PO Box 6166200 MDMaastrichtThe Netherlands
| | - Antoni Bayés‐Genís
- Heart Institute, Hospital Universitari Germans Trias I Pujol, CIBERCVBadalonaSpain
| | - Joost Lumens
- Department of Biomedical EngineeringCardiovascular Research Institute Maastricht (CARIM), Maastricht UniversityMaastrichtThe Netherlands
| | - Christian Knackstedt
- Department of CardiologyCardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+ (MUMC+)PO Box 6166200 MDMaastrichtThe Netherlands
| | - Vanessa P.M. van Empel
- Department of CardiologyCardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+ (MUMC+)PO Box 6166200 MDMaastrichtThe Netherlands
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8
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Raafs AG, Adriaans BP, Henkens MTHM, Verdonschot JAJ, Abdul Hamid MA, Díez J, Knackstedt C, van Empel VPM, Brunner-La Rocca HP, González A, Wildberger JE, Heymans SRB, Hazebroek MR. Biomarkers of Collagen Metabolism Are Associated with Left Ventricular Function and Prognosis in Dilated Cardiomyopathy: A Multi-Modal Study. J Clin Med 2023; 12:5695. [PMID: 37685762 PMCID: PMC10488673 DOI: 10.3390/jcm12175695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 08/16/2023] [Accepted: 08/22/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND Collagen cross-linking is a fundamental process in dilated cardiomyopathy (DCM) and occurs when collagen deposition exceeds degradation, leading to impaired prognosis. This study investigated the associations of collagen-metabolism biomarkers with left ventricular function and prognosis in DCM. METHODS DCM patients who underwent endomyocardial biopsy, blood sampling, and cardiac MRI were included. The primary endpoint included death, heart failure hospitalization, or life-threatening arrhythmias, with a follow-up of 6 years (5-8). RESULTS In total, 209 DCM patients were included (aged 54 ± 13 years, 65% male). No associations were observed between collagen volume fraction, circulating carboxy-terminal propeptide of procollagen type-I (PICP), or collagen type I carboxy-terminal telopeptide [CITP] and matrix metalloproteinase [MMP]-1 ratio and cardiac function parameters. However, CITP:MMP-1 was significantly correlated with global longitudinal strain (GLS) in the total study sample (R = -0.40, p < 0.0001; lower CITP:MMP-1 ratio was associated with impaired GLS), with even stronger correlations in patients with LVEF > 40% (R = -0.70, p < 0.0001). Forty-seven (22%) patients reached the primary endpoint. Higher MMP-1 levels were associated with a worse outcome, even after adjustment for clinical and imaging predictors (1.026, 95% CI 1.002-1.051, p = 0.037), but CITP and CITP:MMP-1 were not. Combining MMP-1 and PICP improved the goodness-of-fit (LHR36.67, p = 0.004). CONCLUSION The degree of myocardial cross-linking (CITP:MMP-1) is associated with myocardial longitudinal contraction, and MMP-1 is an independent predictor of outcome in DCM patients.
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Affiliation(s)
- Anne G. Raafs
- Department of Cardiology, Maastricht University Medical Centre, 6229 HX Maastricht, The Netherlands; (B.P.A.); (M.T.H.M.H.); (J.A.J.V.); (C.K.); (V.P.M.v.E.); (H.-P.B.-L.R.); (S.R.B.H.); (M.R.H.)
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, 6229 HX Maastricht, The Netherlands;
| | - Bouke P. Adriaans
- Department of Cardiology, Maastricht University Medical Centre, 6229 HX Maastricht, The Netherlands; (B.P.A.); (M.T.H.M.H.); (J.A.J.V.); (C.K.); (V.P.M.v.E.); (H.-P.B.-L.R.); (S.R.B.H.); (M.R.H.)
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, 6229 HX Maastricht, The Netherlands;
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, 6229 HX Maastricht, The Netherlands
| | - Michiel T. H. M. Henkens
- Department of Cardiology, Maastricht University Medical Centre, 6229 HX Maastricht, The Netherlands; (B.P.A.); (M.T.H.M.H.); (J.A.J.V.); (C.K.); (V.P.M.v.E.); (H.-P.B.-L.R.); (S.R.B.H.); (M.R.H.)
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, 6229 HX Maastricht, The Netherlands;
- Netherlands Heart Institute (NLHI), 3511 EP Utrecht, The Netherlands
- Department of Pathology, Maastricht University Medical Centre, 6229 HX Maastricht, The Netherlands;
| | - Job A. J. Verdonschot
- Department of Cardiology, Maastricht University Medical Centre, 6229 HX Maastricht, The Netherlands; (B.P.A.); (M.T.H.M.H.); (J.A.J.V.); (C.K.); (V.P.M.v.E.); (H.-P.B.-L.R.); (S.R.B.H.); (M.R.H.)
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, 6229 HX Maastricht, The Netherlands;
- Department of Clinical Genetics, Maastricht University Medical Centre, 6229 HX Maastricht, The Netherlands
| | - Myrurgia A. Abdul Hamid
- Department of Pathology, Maastricht University Medical Centre, 6229 HX Maastricht, The Netherlands;
| | - Javier Díez
- Program of Cardiovascular Diseases, CIMA Universidad de Navarra and IdiSNA, 31008 Pamplona, Spain; (J.D.); (A.G.)
- CIBERCV, Carlos III Institute of Health, 28029 Madrid, Spain
| | - Christian Knackstedt
- Department of Cardiology, Maastricht University Medical Centre, 6229 HX Maastricht, The Netherlands; (B.P.A.); (M.T.H.M.H.); (J.A.J.V.); (C.K.); (V.P.M.v.E.); (H.-P.B.-L.R.); (S.R.B.H.); (M.R.H.)
| | - Vanessa P. M. van Empel
- Department of Cardiology, Maastricht University Medical Centre, 6229 HX Maastricht, The Netherlands; (B.P.A.); (M.T.H.M.H.); (J.A.J.V.); (C.K.); (V.P.M.v.E.); (H.-P.B.-L.R.); (S.R.B.H.); (M.R.H.)
| | - Hans-Peter Brunner-La Rocca
- Department of Cardiology, Maastricht University Medical Centre, 6229 HX Maastricht, The Netherlands; (B.P.A.); (M.T.H.M.H.); (J.A.J.V.); (C.K.); (V.P.M.v.E.); (H.-P.B.-L.R.); (S.R.B.H.); (M.R.H.)
| | - Arantxa González
- Program of Cardiovascular Diseases, CIMA Universidad de Navarra and IdiSNA, 31008 Pamplona, Spain; (J.D.); (A.G.)
- CIBERCV, Carlos III Institute of Health, 28029 Madrid, Spain
| | - Joachim E. Wildberger
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, 6229 HX Maastricht, The Netherlands;
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, 6229 HX Maastricht, The Netherlands
| | - Stephane R. B. Heymans
- Department of Cardiology, Maastricht University Medical Centre, 6229 HX Maastricht, The Netherlands; (B.P.A.); (M.T.H.M.H.); (J.A.J.V.); (C.K.); (V.P.M.v.E.); (H.-P.B.-L.R.); (S.R.B.H.); (M.R.H.)
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, 6229 HX Maastricht, The Netherlands;
- Department of Cardiovascular Research, University of Leuven, 3000 Leuven, Belgium
| | - Mark R. Hazebroek
- Department of Cardiology, Maastricht University Medical Centre, 6229 HX Maastricht, The Netherlands; (B.P.A.); (M.T.H.M.H.); (J.A.J.V.); (C.K.); (V.P.M.v.E.); (H.-P.B.-L.R.); (S.R.B.H.); (M.R.H.)
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, 6229 HX Maastricht, The Netherlands;
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9
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Kerstens TP, Weerts J, van Dijk APJ, Weijers G, Knackstedt C, Eijsvogels TMH, Oxborough D, van Empel VPM, Thijssen DHJ. Association of left ventricular strain-volume loop characteristics with adverse events in patients with heart failure with preserved ejection fraction. Eur Heart J Cardiovasc Imaging 2023; 24:1168-1176. [PMID: 37259911 PMCID: PMC10445262 DOI: 10.1093/ehjci/jead117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 04/24/2023] [Accepted: 05/15/2023] [Indexed: 06/02/2023] Open
Abstract
AIMS Patients with heart failure with preserved ejection fraction (HFpEF) are characterized by impaired diastolic function. Left ventricular (LV) strain-volume loops (SVL) represent the relation between strain and volume during the cardiac cycle and provide insight into systolic and diastolic function characteristics. In this study, we examined the association of SVL parameters and adverse events in HFpEF. METHODS AND RESULTS In 235 patients diagnosed with HFpEF, LV-SVL were constructed based on echocardiography images. The endpoint was a composite of all-cause mortality and Heart Failure (HF)-related hospitalization, which was extracted from electronic medical records. Cox-regression analysis was used to assess the association of SVL parameters and the composite endpoint, while adjusting for age, sex, and NYHA class. HFpEF patients (72.3% female) were 75.8 ± 6.9 years old, had a BMI of 29.9 ± 5.4 kg/m2, and a left ventricular ejection fraction of 60.3 ± 7.0%. Across 2.9 years (1.8-4.1) of follow-up, 73 Patients (31%) experienced an event. Early diastolic slope was significantly associated with adverse events [second quartile vs. first quartile: adjusted hazards ratio (HR) 0.42 (95%CI 0.20-0.88)] after adjusting for age, sex, and NYHA class. The association between LV peak strain and adverse events disappeared upon correction for potential confounders [adjusted HR 1.02 (95% CI 0.96-1.08)]. CONCLUSION Early diastolic slope, representing the relationship between changes in LV volume and strain during early diastole, but not other SVL-parameters, was associated with adverse events in patients with HFpEF during 2.9 years of follow-up.
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Affiliation(s)
- Thijs P Kerstens
- Department of Medical BioSciences, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
- Department of Cardiology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Jerremy Weerts
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+ (MUMC+), P. Debyeplein 25, 6200 MD Maastricht, The Netherlands
| | - Arie P J van Dijk
- Department of Cardiology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Gert Weijers
- Medical UltraSound Imaging Center (MUSIC), Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Christian Knackstedt
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+ (MUMC+), P. Debyeplein 25, 6200 MD Maastricht, The Netherlands
| | - Thijs M H Eijsvogels
- Department of Medical BioSciences, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - David Oxborough
- Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool L3 5UX, UK
| | - Vanessa P M van Empel
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+ (MUMC+), P. Debyeplein 25, 6200 MD Maastricht, The Netherlands
| | - Dick H J Thijssen
- Department of Medical BioSciences, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
- Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool L3 5UX, UK
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10
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Kerstens TP, Weerts J, van Dijk APJ, Weijers G, Knackstedt C, Eijsvogels TMH, Oxborough D, van Empel VPM, Thijssen DHJ. Left ventricular strain-volume loops and diastolic dysfunction in suspected heart failure with preserved ejection fraction. Int J Cardiol 2023; 378:144-150. [PMID: 36796492 DOI: 10.1016/j.ijcard.2023.01.084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 01/31/2023] [Indexed: 02/16/2023]
Abstract
BACKGROUND Presence of left ventricular diastolic dysfunction (DD) is key in the pathogenesis of heart failure with preserved ejection fraction (HFpEF). However, non-invasive assessment of diastolic function is complex, cumbersome, and largely based on consensus recommendations. Novel imaging techniques may help detecting DD. Therefore, we compared left ventricular strain-volume loop (SVL) characteristics and diastolic (dys-)function in suspected HFpEF patients. METHOD AND RESULTS 257 suspected HFpEF patients with sinus rhythm during echocardiography were prospectively included. 211 patients with quality-controlled images and strain and volume analysis were classified according to the 2016 ASE/EACVI recommendations. Patients with indeterminate diastolic function were excluded, resulting in two groups: normal diastolic function (control; n = 65) and DD (n = 91). Patients with DD were older (74.8 ± 6.9 vs. 68.5 ± 9.4 years, p < 0.001), more often female (88% vs 72%, p = 0.021), and more often had a history of atrial fibrillation (42% vs. 23%, p = 0.024) and hypertension (91% vs. 71%, p = 0.001) compared to normal diastolic function. SVL analysis showed a larger uncoupling i.e., a different longitudinal strain contribution to volume change, in DD compared to controls (0.556 ± 1.10% vs. -0.051 ± 1.14%, respectively, P < 0.001). This observation suggests different deformational properties during the cardiac cycle. After adjustment for age, sex, history of atrial fibrillation and hypertension, we found an adjusted odds ratio of 1.68 (95% confidence interval 1.19-2.47) for DD per unit increase in uncoupling (range: -2.95-3.20). CONCLUSION Uncoupling of the SVL is independently associated with DD. This might provide novel insights in cardiac mechanics and new opportunities to assess diastolic function non-invasively.
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Affiliation(s)
- Thijs P Kerstens
- Department of Medical BioSciences, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, the Netherlands; Department of Cardiology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, the Netherlands
| | - Jerremy Weerts
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+ (MUMC+), P. Debyeplein 25, 6200 MD Maastricht, the Netherlands
| | - Arie P J van Dijk
- Department of Cardiology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, the Netherlands
| | - Gert Weijers
- Medical UltraSound Imaging Center (MUSIC), Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, the Netherlands
| | - C Knackstedt
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+ (MUMC+), P. Debyeplein 25, 6200 MD Maastricht, the Netherlands
| | - Thijs M H Eijsvogels
- Department of Medical BioSciences, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, the Netherlands
| | - David Oxborough
- Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool L3 5UX, United Kingdom
| | - Vanessa P M van Empel
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+ (MUMC+), P. Debyeplein 25, 6200 MD Maastricht, the Netherlands
| | - Dick H J Thijssen
- Department of Medical BioSciences, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, the Netherlands; Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool L3 5UX, United Kingdom.
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11
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van Mourik MJW, Linz D, Verwijs HJA, Bekkers SCAM, Weerts J, Schotten U, Rocca HBL, Lumens J, Crijns HJGM, Weijs B, Knackstedt C. Evaluating subclinical left ventricular and left atrial dysfunction in idiopathic atrial fibrillation: A speckle-tracking based strain-analysis. Int J Cardiol 2023:S0167-5273(23)00577-6. [PMID: 37088325 DOI: 10.1016/j.ijcard.2023.04.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 03/20/2023] [Accepted: 04/14/2023] [Indexed: 04/25/2023]
Abstract
OBJECTIVE A subset of patients with atrial fibrillation (AF) presents without established AF risk factors and normal left ventricular (LV) systolic function, called idiopathic AF (IAF). Traditionally, echocardiography derived LV dimensions and ejection fraction (EF) are used to exclude LV dysfunction in IAF, but their sensitivity is limited. Our objective is to evaluate the presence of subtle alterations in LV function despite normal LVEF in patients with IAF compared to healthy controls, using speckle-tracking echocardiography (STE) based global longitudinal strain (GLS). METHODS Standard transthoracic echocardiography was performed in 80 patients with IAF and 129 healthy controls. Patients with overt cardiac disease as well as known established AF risk factors were excluded. STE analysis was performed to assess GLS of the LV, and left atrial strain (LAS). RESULTS LVEF was normal and comparable between patients with IAF and healthy controls (63 ± 4% for both groups; p = 0.801). Mean GLS was within normal limits for both groups but statistically significantly more negative in patients with IAF (-20.6 ± 2.5% vs. -19.7 ± 2.5%; p = 0.016), however not when indexed for ventricular cycle length (p = 0.784). No differences in LA volume or non-indexed LAS were seen in patients with IAF compared to healthy controls. CONCLUSIONS In this selected group of IAF patients, STE did not detect any overt LV or LA dysfunction compared to healthy controls. Thus, IAF occurred in these patients not only in the absence of established AF risk factors but also without evidence of ventricular dysfunction.
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Affiliation(s)
- Manouk J W van Mourik
- Department of Cardiology, Maastricht University Medical Center+, the Netherlands; CARIM School for Cardiovascular Diseases, Faculty of Health, Medicine, and Life Sciences, Maastricht University, Maastricht, the Netherlands; Katholische Stiftung Marienhospital, Aachen, Germany
| | - Dominik Linz
- Department of Cardiology, Maastricht University Medical Center+, the Netherlands; CARIM School for Cardiovascular Diseases, Faculty of Health, Medicine, and Life Sciences, Maastricht University, Maastricht, the Netherlands; Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands; Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Harm J A Verwijs
- Department of Cardiology, Maastricht University Medical Center+, the Netherlands
| | - Sebastiaan C A M Bekkers
- Department of Cardiology, Maastricht University Medical Center+, the Netherlands; CARIM School for Cardiovascular Diseases, Faculty of Health, Medicine, and Life Sciences, Maastricht University, Maastricht, the Netherlands
| | - Jerremy Weerts
- Department of Cardiology, Maastricht University Medical Center+, the Netherlands; CARIM School for Cardiovascular Diseases, Faculty of Health, Medicine, and Life Sciences, Maastricht University, Maastricht, the Netherlands
| | - Ulrich Schotten
- CARIM School for Cardiovascular Diseases, Faculty of Health, Medicine, and Life Sciences, Maastricht University, Maastricht, the Netherlands
| | - Hanspeter Brunner-La Rocca
- Department of Cardiology, Maastricht University Medical Center+, the Netherlands; CARIM School for Cardiovascular Diseases, Faculty of Health, Medicine, and Life Sciences, Maastricht University, Maastricht, the Netherlands
| | - Joost Lumens
- CARIM School for Cardiovascular Diseases, Faculty of Health, Medicine, and Life Sciences, Maastricht University, Maastricht, the Netherlands
| | - Harry J G M Crijns
- Department of Cardiology, Maastricht University Medical Center+, the Netherlands; CARIM School for Cardiovascular Diseases, Faculty of Health, Medicine, and Life Sciences, Maastricht University, Maastricht, the Netherlands
| | - Bob Weijs
- Department of Cardiology, Maastricht University Medical Center+, the Netherlands; Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Christian Knackstedt
- Department of Cardiology, Maastricht University Medical Center+, the Netherlands; CARIM School for Cardiovascular Diseases, Faculty of Health, Medicine, and Life Sciences, Maastricht University, Maastricht, the Netherlands.
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12
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Knackstedt C, Schummers G, Schröder J, Marx N, Lumens J, Wijk SSV, Ramaekers B, Becker M, van Empel V, Brunner-La Rocca HP. A graphical analysis of aspects contributing to the spreading of measurements of left ventricular function. Int J Cardiovasc Imaging 2023; 39:915-927. [PMID: 36800058 PMCID: PMC10160217 DOI: 10.1007/s10554-023-02796-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 01/05/2023] [Indexed: 02/18/2023]
Abstract
The Simpson's method is the standard technique to determine left ventricular (LV) ejection fraction (EF) on echocardiography. The large inter-observer variability of measuring LVEF is well documented but not fully understood. A graphical analysis was used to elaborate what contributes to the inter-observer difference. Forty-two cardiologists (32 male, 39 ± 7 years) evaluated the LVEF using the Simpson's method on 15 different echocardiograms (2 and 4 chamber view (2CH/4CH)); the program did not show the result of EF to prevent a bias. End-diastolic (ED) and end-systolic (ES) frames were predefined ensuring measurement at the same time point of the cardiac cycles. After standardization of the LV contour, the differences of the individual contours compared to a reference contour were measured. Also, the spreading of lateral/medial mitral annulus contours and the apex were depicted. A significant spreading of LV-contours was seen with larger contours leading to higher EFs (p < 0.001). Experience did not influence the determination of LVEF. ED-volumes showed more spreading than ES-volumes ((3.6 mm (IQR: 2.6-4.0) vs. 3.4 mm (IQR: 2.8-3.8), p < 0.001). Also, the differences were larger for the 2CH compared to the 4CH (p < 0.001). Variability was significantly larger for lateral than septal wall (p < 0.001) as well as the anterior compared to the inferior wall (p < 0.001). There was a relevant scattering of the apex and medial/ lateral mitral annulus ring. There was a large variability of LV-volumes and LVEF as well as position of mitral valve ring and apex. There were global differences (apical 2CH or 4CH), regional aspects (LV walls) and temporal factors (ED vs. ES). Thus, multiple factors contributed to the large variability.Trial registration: The study was registered at "Netherlands Trial Register" ( www.trialregister.nl ; study number: NL5131).
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Affiliation(s)
- Christian Knackstedt
- Department of Cardiology and Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+, 6202 AZ, Maastricht, The Netherlands.
| | | | - Jörg Schröder
- Department of Cardiology, Angiology, Pneumology and Intensive Care Medicine, RWTH Aachen University Hospital, Aachen, Germany
| | - Nikolaus Marx
- Department of Cardiology, Angiology, Pneumology and Intensive Care Medicine, RWTH Aachen University Hospital, Aachen, Germany
| | - Joost Lumens
- Department of Biomedical Engineering, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | | | - Bram Ramaekers
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Michael Becker
- Department of Cardiology, Rhein-Maas Klinikum, Würselen, Germany
| | - Vanessa van Empel
- Department of Cardiology and Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+, 6202 AZ, Maastricht, The Netherlands
| | - Hans-Peter Brunner-La Rocca
- Department of Cardiology and Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+, 6202 AZ, Maastricht, The Netherlands
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13
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Raafs AG, Vos JL, Henkens MTHM, Verdonschot JAJ, Sikking M, Stroeks S, Gerretsen S, Hazebroek MR, Knackstedt C, Nijveldt R, Heymans SRB. Left Atrial Strain Is an Independent Predictor of New-Onset Atrial Fibrillation in Dilated Cardiomyopathy. JACC Cardiovasc Imaging 2023:S1936-878X(23)00040-2. [PMID: 37038873 DOI: 10.1016/j.jcmg.2023.01.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 12/28/2022] [Accepted: 01/18/2023] [Indexed: 04/12/2023]
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14
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Nuzzi V, Raafs A, Manca P, Henkens MTHM, Gregorio C, Boscutti A, Verdonschot J, Hazebroek M, Knackstedt C, Merlo M, Stolfo D, Sinagra G, Heymans SRB. Left Atrial Reverse Remodeling in Dilated Cardiomyopathy. J Am Soc Echocardiogr 2023; 36:154-162. [PMID: 36332803 DOI: 10.1016/j.echo.2022.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 10/23/2022] [Accepted: 10/24/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Left atrial (LA) dilation is associated with a worse prognosis in several cardiovascular settings, but therapies can promote LA reverse remodeling. The aim of this study was to characterize and define the prognostic implications of LA volume index (LAVI) reduction in patients with dilated cardiomyopathy (DCM). METHODS Consecutive patients with DCM from two tertiary care centers, with available echocardiograms at baseline and at 1-year follow-up, were retrospectively analyzed. LA dilation was defined as LAVI > 34 mL/m2, and change in LAVI (ΔLAVI) was defined as the 1-year relative LAVI reduction. The outcome was a composite of death, heart transplantation (HTx), or heart failure hospitalization (HFH). RESULTS Five hundred sixty patients were included (mean age, 54 ± 13 years; mean left ventricular ejection fraction, 31 ± 10%; mean LAVI, 45 ± 18 mL/m2). Baseline LAVI had a non-linear association with the risk for death, HTx, or HFH, independent of age, left ventricular ejection fraction, mitral regurgitation, and medical therapy (P < .01). At 1-year follow-up, LAVI decreased in 374 patients (67%; median ΔLAVI, -24%; interquartile range, -37% to -11%). Factors independently associated with ΔLAVI were higher baseline LAVI and lower baseline left ventricular ejection fraction. After multivariable adjustment, ΔLAVI showed a linear association with the risk for death, HTx, or HFH (hazard ratio, 0.96 per 5% decrease; 95% CI, 0.93-0.99; P = .042). At 1-year follow-up, patients with reductions in LAVI of >10% and LAVI normalization (i.e., follow-up LAVI ≤ 34 mL/m2; 31% of the overall cohort) were at lower risk for death, HTx, or HFH (hazard ratio, 0.37; 95% CI, 0.35-0.97; P = .028). CONCLUSIONS In a large cohort of patients with DCM, 1-year reduction in LAVI was observed in a number of patients. The association between reduction in LAVI and death, HTx, or HFH suggests that LA structural reverse remodeling might be considered an additional parameter useful in the individualized risk stratification of patients with DCM.
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Affiliation(s)
- Vincenzo Nuzzi
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Integrata Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Anne Raafs
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Paolo Manca
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Integrata Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Michiel T H M Henkens
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Caterina Gregorio
- Biostatistics Unit, University of Trieste, Trieste, Italy; MOX - Department of Mathematics, Politecnico di Milano, Milan, Italy
| | - Andrea Boscutti
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Integrata Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy; Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Job Verdonschot
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, the Netherlands; Department of Clinical Genetics, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Mark Hazebroek
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Christian Knackstedt
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Marco Merlo
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Integrata Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Davide Stolfo
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Integrata Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy; Division of Cardiology, Department of Medicine, Karolinska Institute, Stockholm, Sweden.
| | - Gianfranco Sinagra
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Integrata Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Stephane R B Heymans
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, the Netherlands
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15
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Weerts J, Barandiaran Aizpurua MA, Brouwers JHM, Mevenkamp J, Schroen BLM, Knackstedt C, Houben AJHM, Schrauwen-Hinderling VB, Van Empel VPM. Effect of iron deficiency on skeletal muscle metabolism in heart failure with preserved ejection fraction. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Iron deficiency (ID) is suggested to be one of the key comorbidities contributing to heart failure with preserved ejection fraction (HFpEF) and concomitant exercise intolerance, possibly by inducing systemic inflammation and microvascular dysfunction (MVD). ID is associated with poorer prognosis in HFpEF, but its exact impact on exercise capacity in HFpEF patients remains to be further investigated.
Purpose
To evaluate the effect of ID on exercise capacity in HFpEF patients by assessing skeletal muscle metabolism. Additionally, to assess the association between ID and MVD in HFpEF patients.
Methods
This prospective study included patients diagnosed with HFpEF according to the ESC Heart Failure 2016 guidelines between January 2018 and May 2021. Patients were excluded if they were of childbearing potential, had any iron supplementation 6 months or chemotherapy 1 year prior to inclusion, were known with significant peripheral artery disease, or had any contraindication for phosphorus-magnetic resonance spectroscopy (31P-MRS). Iron status was defined as absolute ID (serum ferritin <100μg/L), relative ID (serum ferritin 100–299μg/L and transferrin saturation <20%), and no ID. Skeletal muscle oxidative capacity of the upper leg was evaluated by determining phosphocreatine (PCr) recovery kinetics with 31P-MRS in the vastus lateralis muscle after isometric knee extension exercise. Microvascular function was assessed as heat-induced skin hyperemia using laser-Doppler flowmetry. Clinical data up to 6 months prior to or after inclusion was used.
Results
Twenty-four HFpEF patients without ID and 18 with ID were included, including 14 patients with absolute ID. Clinical characteristics of patients without ID and with ID were comparable: median age 74 [69–79] vs. 77 [69–81] years, 13 (54%) vs. 14 (78%) were females, and 20 (83%) vs. 16 (89%) had a history of hypertension (Table 1). Both groups showed similar halftime of PCr recovery after exercise (29.2 [22.8–33.2] vs. 27.0 [21.1–31.4] seconds, p=0.416), and similar skin hyperaemic flow increase (1142 [576–2247] vs. 1023 [574–1511] %, p=0.554). These measures of skeletal muscle metabolism and microvascular function were not correlated. In a subset of patients (11 without ID and 13 with ID), elevated high-sensitive C-reactive protein (hsCRP) was correlated with PCr recovery halftime in those with ID (R2 0.565, p=0.003). This correlation was not found in patients without ID (R2 0.119, p=0.300) in the original data (Figure 1), but was found after removal of a prominent outlier (R2 0.654, p=0.005).
Conclusion
HFpEF patients without ID showed comparable skeletal muscle oxidative capacity and microvascular skin hyperaemia compared to HFpEF patients with ID. Post-hoc analysis suggests that inflammation affects skeletal muscle metabolism in HFpEF patients, possibly regardless of ID. Future studies on the effects of ID and inflammation on cellular metabolism could suggest therapeutic targets in HFpEF.
Funding Acknowledgement
Type of funding sources: Private company. Main funding source(s): This study was funded by Vifor Pharma. The funder had no influence on the study results.
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Affiliation(s)
- J Weerts
- Cardiovascular Research Institute Maastricht (CARIM), Cardiology , Maastricht , The Netherlands
| | | | - J H M Brouwers
- Maastricht University Medical Centre (MUMC), Radiology and Nuclear Medicine , Maastricht , The Netherlands
| | - J Mevenkamp
- Maastricht University Medical Centre (MUMC), Radiology and Nuclear Medicine , Maastricht , The Netherlands
| | - B L M Schroen
- Cardiovascular Research Institute Maastricht (CARIM), Cardiology , Maastricht , The Netherlands
| | - C Knackstedt
- Cardiovascular Research Institute Maastricht (CARIM), Cardiology , Maastricht , The Netherlands
| | - A J H M Houben
- Cardiovascular Research Institute Maastricht (CARIM), Internal Medicine , Maastricht , The Netherlands
| | - V B Schrauwen-Hinderling
- Maastricht University Medical Centre (MUMC), Radiology and Nuclear Medicine , Maastricht , The Netherlands
| | - V P M Van Empel
- Cardiovascular Research Institute Maastricht (CARIM), Cardiology , Maastricht , The Netherlands
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16
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Raafs AG, Vos JL, Henkens MTHM, Verdonschot JAJ, Gerretsen S, Knackstedt C, Hazebroek MR, Nijveldt R, Heymans SRB. Left atrial strain at CMR is a strong independent prognostic predictor in DCM, superior to LV-GLS, LVEF and LAVI, and incremental to LGE. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
The left atrium (LA) is an early sensor of left ventricular (LV) dysfunction. LA size and new-onset atrial fibrillation (AF) are associated with an increased risk of mortality and heart failure (HF) progression in patients with dilated cardiomyopathy (DCM). Whether abnormal LA strain measured at cardiac magnetic resonance (CMR) – a new technology to study atrial function – may predict overall outcome in DCM – either or not leading to new onset AF – remains completely unknown.
Purpose
To determine the prognostic value of CMR derived LA strain in DCM patients.
Methods
A total of 488 DCM patients (age 54 [46–62] years, 61% male) undergoing CMR were prospectively enrolled in the Maastricht Cardiomyopathy Registry between 2004 and 2018. Outcome consisted of the combination of sudden or cardiac death, HF hospitalization or life-threatening arrhythmias. LA reservoir (passive LA filling), conduit (passive LV filling), and booster strain (active LV filling) were measured using feature tracking strain analysis of the 2- and 4-chamber long-axis cines (Figure 1). Given the non-linearity of continuous variables, cubic spline analysis was performed to dichotomize.
Results
Seventy out of 488 DCM patients (14%) reached the endpoint (follow-up 6 [4–9] years). Age, NYHA class ≥3, late gadolinium enhancement (LGE) presence, LV ejection fraction (EF), LA volume index (LAVI), LV global longitudinal strain (GLS), and LA reservoir and conduit strain were univariably associated with worse outcome (all p-values <0.02). LA conduit strain was superior to reservoir strain to predict outcome. LA conduit strain, NYHA class ≥3 and LGE remained associated in the multivariable model (Figure 2A), while age, NTproBNP, LVEF, LA ejection fraction, LAVI and LV-GLS did not. Adding LA conduit strain to NYHA class and LGE significantly improved the calibration, accuracy, and reclassification of the prediction model (p<0.05). In patients without known AF and sinus rhythm (n=425) during CMR, 10% developed new-onset AF (paroxysmal or persistent) at long-term. Higher age, male sex, NYHA class ≥3, higher LAVI and impaired booster strain were all univariably associated with new-onset AF. Age and impaired booster strain remained as independent predictors of new-onset AF in the multivariable analysis (Figure 2B).
Conclusions
LA conduit strain on CMR is a strong independent prognostic predictor in DCM, superior to LV-GLS, LVEF and LAVI, and incremental to LGE. In addition, LA booster strain is an independent predictor of new-onset AF.
Funding Acknowledgement
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Netherlands Cardiovascular Research Initiative, an initiative with support of the Dutch Heart Foundation
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Affiliation(s)
- A G Raafs
- Maastricht University Medical Centre (MUMC) , Maastricht , The Netherlands
| | - J L Vos
- Radboud University Medical Center, Cardiology , Nijmegen , The Netherlands
| | - M T H M Henkens
- Maastricht University Medical Centre (MUMC) , Maastricht , The Netherlands
| | - J A J Verdonschot
- Maastricht University Medical Centre (MUMC) , Maastricht , The Netherlands
| | - S Gerretsen
- Maastricht University Medical Centre (MUMC) , Maastricht , The Netherlands
| | - C Knackstedt
- Maastricht University Medical Centre (MUMC) , Maastricht , The Netherlands
| | - M R Hazebroek
- Maastricht University Medical Centre (MUMC) , Maastricht , The Netherlands
| | - R Nijveldt
- Radboud University Medical Center, Cardiology , Nijmegen , The Netherlands
| | - S R B Heymans
- Maastricht University Medical Centre (MUMC) , Maastricht , The Netherlands
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17
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Gingele A, Brandts L, Brunner-La Rocca HP, Knackstedt C, Boyne J. Introduction of a new scoring tool to identify clinically stable heart failure patients. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Introduction
Heart failure (HF) poses a burden on specialist care, making referral of clinically stable HF patients to primary care a desirable goal. However, a structured approach to guide patient referral is lacking.
Methods
The Maastricht Instability Score–Heart Failure (MIS-HF) questionnaire was developed to objectively stratify the clinical status of HF patients: patients with a low MIS-HF (0–2 points, indicating a stable clinical condition) were considered for treatment in primary care, whereas high scores (>2 points) indicated the need for specialised care. The MIS-HF was evaluated in 637 consecutive HF patients presenting between 2015 and 2018 at Maastricht University Medical Centre.
Results
Of the 637 patients, 329 (52%) had a low score and 205 of these 329 (62%) patients were referred to primary care. The remaining 124 (38%) patients remained in secondary care. Of the 308 (48%) patients with a high score (>2 points), 265 (86%) remained in secondary care and 41 (14%) were referred to primary care. The primary composite endpoint (mortality, cardiac hospital admissions) occurred more frequently in patients with a high compared to those with a low MIS-HF after 1 year of follow-up [29.2% vs 10.9%; odds ratio (OR) 3.36, 95% confidence interval (CI) 2.20–5.14]. No significant difference in the composite endpoint (9.8% vs 12.9%; OR 0.73, 95% CI 0.36–1.47) was found between patients with a low MIS-HF treated in primary versus secondary care.
Conclusion
The MIS-HF questionnaire may improve referral policies, as it helps to identify HF patients that can safely be referred to primary care.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- A Gingele
- Academic Hospital Maastricht, Department of Cardiology MUMC , Maastricht , The Netherlands
| | - L Brandts
- Academic Hospital Maastricht, Department of Cardiology MUMC , Maastricht , The Netherlands
| | - H P Brunner-La Rocca
- Academic Hospital Maastricht, Department of Cardiology MUMC , Maastricht , The Netherlands
| | - C Knackstedt
- Academic Hospital Maastricht, Department of Cardiology MUMC , Maastricht , The Netherlands
| | - J Boyne
- Academic Hospital Maastricht, Department of Cardiology MUMC , Maastricht , The Netherlands
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18
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Verhaert DVM, Knackstedt C, Lankveld TAR, Den Uijl DW, Habibi Z, Westra SW, Hermans ANL, Betz K, Van Der Velden RMJ, Gawalko MM, Schotten U, Linz DK, Vernooy K. We all know A and B, but what about C? Exploring the management of modifiable risk factors in patients with atrial fibrillation. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
The European Society of Cardiology (ESC) guidelines for the management of atrial fibrillation (AF) advise to treat AF according to the ABC pathway: A, anticoagulation, B, better symptom control, and C, comorbidities and cardiovascular risk factor management. Optimal treatment of comorbidities and risk factors slows AF progression and improves success rates of rhythm interventions for AF. However, several studies report underdiagnosis and therefore possible undertreatment for common cardiovascular comorbidities.
Purpose
This study aims to evaluate how common modifiable cardiovascular risk factors are managed in AF patients referred for catheter ablation.
Methods
This is a substudy of the ISOLATION study, a prospective cohort study including consecutive patients with paroxysmal or persistent AF referred for AF ablation. Screening for common modifiable risk factors for AF is structurally embedded in the work-up for AF ablation in the two participating centres. In the present study the prevalence of the following risk factors at this screening moment was assessed: (1) body mass index (BMI) above the target BMI for ablation (≥27 kg/m2), (2) hypertension, defined as on-site systolic blood pressure >130 mmHg and/or diastolic blood pressure >80 mmHg, (3) decreased glucose tolerance or diabetes mellitus, defined as HbA1c ≥6.5%, (4) dyslipidaemia, defined as low-density lipoprotein (LDL) ≥2.5 mmol/l, (5) regular alcohol consumption, defined as self-reported consumption of >15 standardized units/week, and (6) sleep disordered breathing (SDB), defined as apnoea-hypopnoea index (AHI) ≥15 assessed with home sleep tests (subset of patients).
Results
Among the 981 patients studied (median age 65 [59–71] years old, 64% male, 69% paroxysmal AF), previously diagnosed comorbidities were common (46% hypertension, 7% diabetes, 22% dyslipidaemia, 10% SDB), and a large proportion of patients received targeted treatment (Table 1). However, non-optimally managed risk factors remained significant (Figure 1). BMI ≥27 kg/m2 was present in 56% of patients. High systolic and diastolic blood pressure were present in 62% and 51% of patients, respectively, and any form of high blood pressure (either systolic or diastolic) was seen in 72% of patients. HbA1c was found to be above target ranges in 9% patients and LDL in 56%. A weekly alcohol consumption of ≥15 units was reported by 4% of patients. Screening for SDB was performed in a subset of patients (n=287), for whom AHI was ≥15 in 52%. Overall, 9% of patients had 4 or more non-optimally controlled modifiable risk factors, whereas the median number of modifiable risk factors was 2 [1–3].
Conclusions
Structural screening revealed a high prevalence of non-optimally controlled modifiable cardiovascular risk factors in patients referred for AF catheter ablation. According to recent ESC guidelines, improving treatment of comorbidities may improve AF ablation success rates and even reduce mortality.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- D V M Verhaert
- Maastricht University Medical Center and Radboud University Medical Center, Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM) , Maastricht/Nijmegen , The Netherlands
| | - C Knackstedt
- Maastricht University Medical Centre (MUMC), Department of cardiology, Cardiovascular Research Institute Maastricht (CARIM) , Maastricht , The Netherlands
| | - T A R Lankveld
- Maastricht University Medical Centre (MUMC), Department of cardiology, Cardiovascular Research Institute Maastricht (CARIM) , Maastricht , The Netherlands
| | - D W Den Uijl
- Maastricht University Medical Centre (MUMC), Department of cardiology, Cardiovascular Research Institute Maastricht (CARIM) , Maastricht , The Netherlands
| | - Z Habibi
- Maastricht University Medical Center and Radboud University Medical Center, Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM) , Maastricht/Nijmegen , The Netherlands
| | - S W Westra
- Radboud University Medical Center , Nijmegen , The Netherlands
| | - A N L Hermans
- Maastricht University Medical Centre (MUMC), Department of cardiology, Cardiovascular Research Institute Maastricht (CARIM) , Maastricht , The Netherlands
| | - K Betz
- Maastricht University Medical Centre (MUMC), Department of cardiology, Cardiovascular Research Institute Maastricht (CARIM) , Maastricht , The Netherlands
| | - R M J Van Der Velden
- Maastricht University Medical Centre (MUMC), Department of cardiology, Cardiovascular Research Institute Maastricht (CARIM) , Maastricht , The Netherlands
| | - M M Gawalko
- Maastricht University Medical Centre (MUMC), Department of cardiology, Cardiovascular Research Institute Maastricht (CARIM) , Maastricht , The Netherlands
| | - U Schotten
- Cardiovascular Research Institute Maastricht (CARIM), Department of physiology , Maastricht , The Netherlands
| | - D K Linz
- Maastricht University Medical Center and Radboud University Medical Center, Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM) , Maastricht/Nijmegen , The Netherlands
| | - K Vernooy
- Maastricht University Medical Center and Radboud University Medical Center, Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM) , Maastricht/Nijmegen , The Netherlands
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19
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Henkens MTHM, Stroeks SLVM, Raafs AG, Sikking MA, Tromp J, Ouwerkerk W, Hazebroek MR, Krapels IPC, Knackstedt C, van den Wijngaard A, Brunner HG, Heymans SRB, Verdonschot JAJ. Dynamic Ejection Fraction Trajectory in Patients With Dilated Cardiomyopathy With a Truncating Titin Variant. Circ Heart Fail 2022; 15:e009352. [PMID: 35543125 DOI: 10.1161/circheartfailure.121.009352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Michiel T H M Henkens
- Department of Cardiology, Maastricht University Medical Center+, the Netherlands (M.T.H.M.H., S.L.V.M.S., A.G.R., M.A.S., M.R.H., C.K., S.R.B.H.).,Centre for Heart Failure Research, Cardiovascular Research Institute Maastricht, Maastricht University, the Netherlands (M.T.H.M.H., S.L.V.M.S., A.G.R., M.A.S., M.R.H., C.K., S.R.B.H., J.A.J.V.).,Netherlands Heart Institute, Utrecht (M.T.H.M.H.)
| | - Sophie L V M Stroeks
- Department of Cardiology, Maastricht University Medical Center+, the Netherlands (M.T.H.M.H., S.L.V.M.S., A.G.R., M.A.S., M.R.H., C.K., S.R.B.H.).,Centre for Heart Failure Research, Cardiovascular Research Institute Maastricht, Maastricht University, the Netherlands (M.T.H.M.H., S.L.V.M.S., A.G.R., M.A.S., M.R.H., C.K., S.R.B.H., J.A.J.V.)
| | - Anne G Raafs
- Department of Cardiology, Maastricht University Medical Center+, the Netherlands (M.T.H.M.H., S.L.V.M.S., A.G.R., M.A.S., M.R.H., C.K., S.R.B.H.).,Centre for Heart Failure Research, Cardiovascular Research Institute Maastricht, Maastricht University, the Netherlands (M.T.H.M.H., S.L.V.M.S., A.G.R., M.A.S., M.R.H., C.K., S.R.B.H., J.A.J.V.)
| | - Maurits A Sikking
- Department of Cardiology, Maastricht University Medical Center+, the Netherlands (M.T.H.M.H., S.L.V.M.S., A.G.R., M.A.S., M.R.H., C.K., S.R.B.H.).,Centre for Heart Failure Research, Cardiovascular Research Institute Maastricht, Maastricht University, the Netherlands (M.T.H.M.H., S.L.V.M.S., A.G.R., M.A.S., M.R.H., C.K., S.R.B.H., J.A.J.V.)
| | - Jasper Tromp
- Saw Swee Hock School of Public Health, National University of Singapore (NUS) (J.T.).,National Heart Centre Singapore, Singapore (J.T., W.O.).,Duke-NUS Medical School, Singapore (J.T., W.O.).,Yong Loo Lin School of Medicine, National University of Singapore (J.T.).,Duke-NUS School of Medicine, Singapore (J.T.)
| | - Wouter Ouwerkerk
- National Heart Centre Singapore, Singapore (J.T., W.O.).,Duke-NUS Medical School, Singapore (J.T., W.O.).,Department of Dermatology, Amsterdam UMC, Amsterdam Infection & Immunity Institute, University of Amsterdam, the Netherlands (W.O.)
| | - Mark R Hazebroek
- Department of Cardiology, Maastricht University Medical Center+, the Netherlands (M.T.H.M.H., S.L.V.M.S., A.G.R., M.A.S., M.R.H., C.K., S.R.B.H.).,Centre for Heart Failure Research, Cardiovascular Research Institute Maastricht, Maastricht University, the Netherlands (M.T.H.M.H., S.L.V.M.S., A.G.R., M.A.S., M.R.H., C.K., S.R.B.H., J.A.J.V.)
| | - Ingrid P C Krapels
- Department of Clinical Genetics, Maastricht University Medical Center+, the Netherlands (I.P.C.K., A.v.d.W., H.G.B., J.A.J.V.)
| | - Christian Knackstedt
- Department of Cardiology, Maastricht University Medical Center+, the Netherlands (M.T.H.M.H., S.L.V.M.S., A.G.R., M.A.S., M.R.H., C.K., S.R.B.H.).,Centre for Heart Failure Research, Cardiovascular Research Institute Maastricht, Maastricht University, the Netherlands (M.T.H.M.H., S.L.V.M.S., A.G.R., M.A.S., M.R.H., C.K., S.R.B.H., J.A.J.V.)
| | - Arthur van den Wijngaard
- Department of Clinical Genetics, Maastricht University Medical Center+, the Netherlands (I.P.C.K., A.v.d.W., H.G.B., J.A.J.V.)
| | - Han G Brunner
- Department of Clinical Genetics, Maastricht University Medical Center+, the Netherlands (I.P.C.K., A.v.d.W., H.G.B., J.A.J.V.).,GROW Institute for Developmental Biology and Cancer, Maastricht University, the Netherlands (H.G.B.).,Department of Human Genetics, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands (H.G.B.)
| | - Stephane R B Heymans
- Department of Cardiology, Maastricht University Medical Center+, the Netherlands (M.T.H.M.H., S.L.V.M.S., A.G.R., M.A.S., M.R.H., C.K., S.R.B.H.).,Centre for Heart Failure Research, Cardiovascular Research Institute Maastricht, Maastricht University, the Netherlands (M.T.H.M.H., S.L.V.M.S., A.G.R., M.A.S., M.R.H., C.K., S.R.B.H., J.A.J.V.).,Centre for Molecular and Vascular Biology, Department of Cardiovascular Sciences, KU Leuven, Belgium (S.R.B.H.)
| | - Job A J Verdonschot
- Department of Cardiology, Maastricht University Medical Center+, the Netherlands (M.T.H.M.H., S.L.V.M.S., A.G.R., M.A.S., M.R.H., C.K., S.R.B.H.).,Centre for Heart Failure Research, Cardiovascular Research Institute Maastricht, Maastricht University, the Netherlands (M.T.H.M.H., S.L.V.M.S., A.G.R., M.A.S., M.R.H., C.K., S.R.B.H., J.A.J.V.).,Department of Clinical Genetics, Maastricht University Medical Center+, the Netherlands (I.P.C.K., A.v.d.W., H.G.B., J.A.J.V.)
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20
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Verhaert DVM, Linz D, Chaldoupi SM, Westra SW, den Uijl DW, Philippens S, Kerperien M, Habibi Z, Vorstermans B, ter Bekke RMA, Beukema RJ, Evertz R, Hemels MEW, Luermans JGLM, Manusama R, Lankveld TAR, van der Heijden CAJ, Bidar E, Hermans BJM, Zeemering S, Bijvoet GP, Habets J, Holtackers RJ, Mihl C, Nijveldt R, van Empel VPM, Knackstedt C, Simons SO, Buhre WFFA, Tijssen JGP, Isaacs A, Crijns HJGM, Maesen B, Vernooy K, Schotten U. Rationale and Design of the ISOLATION Study: A Multicenter Prospective Cohort Study Identifying Predictors for Successful Atrial Fibrillation Ablation in an Integrated Clinical Care and Research Pathway. Front Cardiovasc Med 2022; 9:879139. [PMID: 35879962 PMCID: PMC9307503 DOI: 10.3389/fcvm.2022.879139] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 06/08/2022] [Indexed: 11/28/2022] Open
Abstract
Introduction Continuous progress in atrial fibrillation (AF) ablation techniques has led to an increasing number of procedures with improved outcome. However, about 30-50% of patients still experience recurrences within 1 year after their ablation. Comprehensive translational research approaches integrated in clinical care pathways may improve our understanding of the complex pathophysiology of AF and improve patient selection for AF ablation. Objectives Within the "IntenSive mOlecular and eLectropathological chAracterization of patienTs undergoIng atrial fibrillatiOn ablatioN" (ISOLATION) study, we aim to identify predictors of successful AF ablation in the following domains: (1) clinical factors, (2) AF patterns, (3) anatomical characteristics, (4) electrophysiological characteristics, (5) circulating biomarkers, and (6) genetic background. Herein, the design of the ISOLATION study and the integration of all study procedures into a standardized pathway for patients undergoing AF ablation are described. Methods ISOLATION (NCT04342312) is a two-center prospective cohort study including 650 patients undergoing AF ablation. Clinical characteristics and routine clinical test results will be collected, as well as results from the following additional diagnostics: determination of body composition, pre-procedural rhythm monitoring, extended surface electrocardiogram, biomarker testing, genetic analysis, and questionnaires. A multimodality model including a combination of established predictors and novel techniques will be developed to predict ablation success. Discussion In this study, several domains will be examined to identify predictors of successful AF ablation. The results may be used to improve patient selection for invasive AF management and to tailor treatment decisions to individual patients.
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Affiliation(s)
- Dominique V. M. Verhaert
- Department of Cardiology, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, Netherlands
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Dominik Linz
- Department of Cardiology, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, Netherlands
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, Netherlands
- Centre for Heart Rhythm Disorders, Royal Adelaide Hospital, The University of Adelaide, Adelaide, SA, Australia
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Sevasti Maria Chaldoupi
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Sjoerd W. Westra
- Department of Cardiology, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Dennis W. den Uijl
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Suzanne Philippens
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Mijke Kerperien
- Department of Cardiology, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Zarina Habibi
- Department of Cardiology, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, Netherlands
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Bianca Vorstermans
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Rachel M. A. ter Bekke
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Rypko J. Beukema
- Department of Cardiology, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Reinder Evertz
- Department of Cardiology, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Martin E. W. Hemels
- Department of Cardiology, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Justin G. L. M. Luermans
- Department of Cardiology, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, Netherlands
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Randolph Manusama
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Theo A. R. Lankveld
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Claudia A. J. van der Heijden
- Department of Cardiothoracic Surgery, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, Netherlands
| | - Elham Bidar
- Department of Cardiothoracic Surgery, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, Netherlands
| | - Ben J. M. Hermans
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, Netherlands
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
| | - Stef Zeemering
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
| | - Geertruida P. Bijvoet
- Department of Cardiology, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, Netherlands
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Jesse Habets
- Department of Medical Imaging, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Robert J. Holtackers
- Department of Radiology and Nuclear Medicine, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, Netherlands
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
| | - Casper Mihl
- Department of Radiology and Nuclear Medicine, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, Netherlands
| | - Robin Nijveldt
- Department of Cardiology, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Vanessa P. M. van Empel
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Christian Knackstedt
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Sami O. Simons
- Department of Respiratory Medicine, Maastricht University Medical Center, Maastricht, Netherlands
| | | | - Jan G. P. Tijssen
- Department of Cardiology, Amsterdam University Medical Center (UMC), Amsterdam, Netherlands
| | - Aaron Isaacs
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
| | - Harry J. G. M. Crijns
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Bart Maesen
- Department of Cardiothoracic Surgery, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, Netherlands
| | - Kevin Vernooy
- Department of Cardiology, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, Netherlands
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Ulrich Schotten
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
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21
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Raafs AG, Vos JL, Henkens MTHM, Slurink BO, Verdonschot JAJ, Bossers D, Roes K, Gerretsen S, Knackstedt C, Hazebroek MR, Nijveldt R, Heymans SRB. Left Atrial Strain Has Superior Prognostic Value to Ventricular Function and Delayed-Enhancement in Dilated Cardiomyopathy. JACC Cardiovasc Imaging 2022; 15:1015-1026. [PMID: 35680209 DOI: 10.1016/j.jcmg.2022.01.016] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 01/01/2022] [Accepted: 01/24/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND The left atrium is an early sensor of left ventricular (LV) dysfunction. Still, the prognostic value of left atrial (LA) function (strain) on cardiac magnetic resonance (CMR) in dilated cardiomyopathy (DCM) remains unknown. OBJECTIVES The goal of this study was to evaluate the prognostic value of CMR-derived LA strain in DCM. METHODS Patients with DCM from the Maastricht Cardiomyopathy Registry with available CMR imaging were included. The primary endpoint was the combination of sudden or cardiac death, heart failure (HF) hospitalization, or life-threatening arrhythmias. Given the nonlinearity of continuous variables, cubic spline analysis was performed to dichotomize. RESULTS A total of 488 patients with DCM were included (median age: 54 [IQR: 46-62] years; 61% male). Seventy patients (14%) reached the primary endpoint (median follow-up: 6 [IQR: 4-9] years). Age, New York Heart Association (NYHA) functional class >II, presence of late gadolinium enhancement (LGE), LV ejection fraction (LVEF), LA volume index (LAVI), LV global longitudinal strain (GLS), and LA reservoir and conduit strain were univariably associated with the outcome (all P < 0.02). LA conduit strain was a stronger predictor of outcome compared with reservoir strain. LA conduit strain, NYHA functional class >II, and LGE remained associated in the multivariable model (LA conduit strain HR: 3.65 [95% CI: 2.01-6.64; P < 0.001]; NYHA functional class >II HR: 1.81 [95% CI: 1.05-3.12; P = 0.033]; and LGE HR: 2.33 [95% CI: 1.42-3.85; P < 0.001]), whereas age, N-terminal pro-B-type natriuretic peptide, LVEF, left atrial ejection fraction, LAVI, and LV GLS were not. Adding LA conduit strain to other independent predictors (NYHA functional class and LGE) significantly improved the calibration, accuracy, and reclassification of the prediction model (P < 0.05). CONCLUSIONS LA conduit strain on CMR is a strong independent prognostic predictor in DCM, superior to LV GLS, LVEF, and LAVI and incremental to LGE. Including LA conduit strain in DCM patient management should be considered to improve risk stratification.
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Affiliation(s)
- Anne G Raafs
- Department of Cardiology, Cardiovascular Research Institute (CARIM), Maastricht University Medical Center, Maastricht, the Netherlands.
| | - Jacqueline L Vos
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Michiel T H M Henkens
- Department of Cardiology, Cardiovascular Research Institute (CARIM), Maastricht University Medical Center, Maastricht, the Netherlands; Netherlands Heart Institute (NLHI), Utrecht, the Netherlands
| | - Bram O Slurink
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Job A J Verdonschot
- Department of Cardiology, Cardiovascular Research Institute (CARIM), Maastricht University Medical Center, Maastricht, the Netherlands; Department of Clinical Genetics, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Daan Bossers
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Kit Roes
- Department of Health Evidence, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Suzanne Gerretsen
- Department of Radiology and Nuclear Medicine, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Christian Knackstedt
- Department of Cardiology, Cardiovascular Research Institute (CARIM), Maastricht University Medical Center, Maastricht, the Netherlands
| | - Mark R Hazebroek
- Department of Cardiology, Cardiovascular Research Institute (CARIM), Maastricht University Medical Center, Maastricht, the Netherlands
| | - Robin Nijveldt
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Stephane R B Heymans
- Department of Cardiology, Cardiovascular Research Institute (CARIM), Maastricht University Medical Center, Maastricht, the Netherlands; Department of Cardiovascular Research, University of Leuven, Leuven, Belgium
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22
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van Stipdonk AMW, Schretlen S, Dohmen W, Knackstedt C, Beckers-Wesche F, Debie L, Brunner-La Rocca HP, Vernooy K. Better outcome at lower costs after implementing a CRT-care pathway: comprehensive evaluation of real-world data. ESC Heart Fail 2022; 9:2518-2527. [PMID: 35638466 PMCID: PMC9288799 DOI: 10.1002/ehf2.13958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 04/11/2022] [Accepted: 04/19/2022] [Indexed: 11/11/2022] Open
Abstract
AIMS Cardiac resynchronization therapy (CRT) requires intensive, complex, and multidisciplinary care for heart failure (HF) patients. Due to limitations in time, resources, and coordination of care, in current practice, this is often incomplete. We evaluated the effect of the introduction of a CRT-care pathway (CRT-CPW) on clinical outcome and costs. METHODS AND RESULTS The CRT-CPW focused on structuring CRT patient selection, implantation, and follow-up management. To facilitate and guarantee quality, checklists were introduced. The CRT-CPW was implemented in the Maastricht University Medical Centre in 2014. Physician-led usual care was restructured to a nurse-led care pathway. A retrospective comparison of data from CRT patients receiving usual care (2012-2014, 222 patients) and patients receiving care according to CRT-CPW (2015-2018, 241 patients) was performed. The primary outcome was the composite of all-cause mortality and HF hospitalization. Hospital-related costs of cardiovascular care after CRT implantation were analysed to address cost-effectiveness of the CRT-CPW. Demographics were comparable in the usual care and CRT-CPW groups. Kaplan-Meier estimates of the occurrence of the primary endpoint showed a significant improvement in the CRT-CPW group (25.7% vs. 34.7%, hazard ratio 0.56; confidence interval 0.40-0.78; P < 0.005), at 36 months of follow-up. The total costs for cardiology-related hospitalizations were significantly reduced in the CRT-CPW group [€17 698 (14 192-21 195) vs. 19 933 (16 980-22 991), P < 0.001]. Bootstrap cost-effectiveness analyses showed that implementation of CRT-CPW would be an economically dominant strategy in 90.7% of bootstrap samples. CONCLUSIONS The introduction of a novel multidisciplinary, nurse-led care pathway for CRT patients resulted in significant reduction of the combination of all-cause mortality and HF hospitalizations, at reduced cardiovascular-related hospital costs.
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Affiliation(s)
- Antonius M W van Stipdonk
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Stijn Schretlen
- Medtronic Integrated Health Solutions, Eindhoven, The Netherlands
| | - Wim Dohmen
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Christian Knackstedt
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Fabienne Beckers-Wesche
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Luuk Debie
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Hans-Peter Brunner-La Rocca
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Kevin Vernooy
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, The Netherlands.,Cardiology Department, Radboud University Medical Center, Nijmegen, The Netherlands
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23
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Raafs AG, Boscutti A, Henkens MTHM, van den Broek WWA, Verdonschot JAJ, Weerts J, Stolfo D, Nuzzi V, Manca P, Hazebroek MR, Knackstedt C, Merlo M, Heymans SRB, Sinagra G. Global Longitudinal Strain is Incremental to Left Ventricular Ejection Fraction for the Prediction of Outcome in Optimally Treated Dilated Cardiomyopathy Patients. J Am Heart Assoc 2022; 11:e024505. [PMID: 35253464 PMCID: PMC9075270 DOI: 10.1161/jaha.121.024505] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Background
Speckle tracking echocardiographic global longitudinal strain (GLS) predicts outcome in patients with new onset heart failure. Still, its incremental value on top of left ventricular ejection fraction (LVEF) in patients with nonischemic, nonvalvular dilated cardiomyopathy (DCM) after optimal heart failure treatment remains unknown.
Methods and Results
Patients with DCM were included at the outpatient clinics of 2 centers in the Netherlands and Italy. The prognostic value of 2‐dimensional speckle tracking echocardiographic global longitudinal strain was evaluated when being on optimal heart failure medication for at least 6 months. Outcome was defined as the combination of sudden or cardiac death, life‐threatening arrhythmias, and heart failure hospitalization. A total of 323 patients with DCM (66% men, age 55±14 years) were included. The mean LVEF was 42%±11% and mean GLS after optimal heart failure treatment was −15%±4%. Twenty percent (64/323) of all patients reached the primary outcome after optimal heart failure treatment (median follow‐up of 6[4–9] years). New York Heart Association class ≥3, LVEF, and GLS remained associated with the outcome in the multivariable‐adjusted model (New York Heart Association class: hazard ratio [HR], 3.43; 95% CI, 1.49–7.90,
P
=0.004; LVEF: HR, 2.13; 95% CI, 1.11–4.10,
P
=0.024; GLS: HR, 2.24; 95% CI, 1.18–4.29,
P
=0.015), whereas left ventricular end‐diastolic diameter index, left atrial volume index, and delta GLS were not. The addition of GLS to New York Heart Association class and LVEF improved the goodness of fit (log likelihood ratio test
P
<0.001) and discrimination (Harrell’s C 0.703).
Conclusions
Within this bicenter study, GLS emerged as an independent and incremental predictor of adverse outcome, which exceeded LVEF in patients with optimally treated DCM. This presses the need to routinely include GLS in the echocardiographic follow‐up of DCM.
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Affiliation(s)
- Anne G. Raafs
- Department of Cardiology and Cardiovascular Research Institute Maastricht (CARIM) Maastricht University Medical Center+ Maastricht The Netherlands
| | - Andrea Boscutti
- Cardiothoracovascular Department Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI)University of Trieste Trieste Italy
| | - Michiel T. H. M. Henkens
- Department of Cardiology and Cardiovascular Research Institute Maastricht (CARIM) Maastricht University Medical Center+ Maastricht The Netherlands
- Netherlands Heart Institute (Nl‐HI) Utrecht The Netherlands
| | - Wout W. A. van den Broek
- Department of Cardiology and Cardiovascular Research Institute Maastricht (CARIM) Maastricht University Medical Center+ Maastricht The Netherlands
| | - Job A. J. Verdonschot
- Department of Cardiology and Cardiovascular Research Institute Maastricht (CARIM) Maastricht University Medical Center+ Maastricht The Netherlands
- Department of Clinical Genetics Maastricht University Medical Center Maastricht The Netherlands
| | - Jerremy Weerts
- Department of Cardiology and Cardiovascular Research Institute Maastricht (CARIM) Maastricht University Medical Center+ Maastricht The Netherlands
| | - Davide Stolfo
- Cardiothoracovascular Department Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI)University of Trieste Trieste Italy
| | - Vincenzo Nuzzi
- Cardiothoracovascular Department Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI)University of Trieste Trieste Italy
| | - Paolo Manca
- Cardiothoracovascular Department Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI)University of Trieste Trieste Italy
| | - Mark R. Hazebroek
- Department of Cardiology and Cardiovascular Research Institute Maastricht (CARIM) Maastricht University Medical Center+ Maastricht The Netherlands
| | - Christian Knackstedt
- Department of Cardiology and Cardiovascular Research Institute Maastricht (CARIM) Maastricht University Medical Center+ Maastricht The Netherlands
| | - Marco Merlo
- Cardiothoracovascular Department Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI)University of Trieste Trieste Italy
| | - Stephane R. B. Heymans
- Department of Cardiology and Cardiovascular Research Institute Maastricht (CARIM) Maastricht University Medical Center+ Maastricht The Netherlands
- Netherlands Heart Institute (Nl‐HI) Utrecht The Netherlands
- Department of Cardiovascular Research University of Leuven Leuven Belgium
| | - Gianfranco Sinagra
- Cardiothoracovascular Department Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI)University of Trieste Trieste Italy
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24
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Weerts J, Mourmans SGJ, Barandiarán Aizpurua A, Schroen BLM, Knackstedt C, Eringa E, Houben AJHM, van Empel VPM. The Role of Systemic Microvascular Dysfunction in Heart Failure with Preserved Ejection Fraction. Biomolecules 2022; 12:biom12020278. [PMID: 35204779 PMCID: PMC8961612 DOI: 10.3390/biom12020278] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 02/01/2022] [Accepted: 02/05/2022] [Indexed: 02/06/2023] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) is a condition with increasing incidence, leading to a health care problem of epidemic proportions for which no curative treatments exist. Consequently, an urge exists to better understand the pathophysiology of HFpEF. Accumulating evidence suggests a key pathophysiological role for coronary microvascular dysfunction (MVD), with an underlying mechanism of low-grade pro-inflammatory state caused by systemic comorbidities. The systemic entity of comorbidities and inflammation in HFpEF imply that patients develop HFpEF due to systemic mechanisms causing coronary MVD, or systemic MVD. The absence or presence of peripheral MVD in HFpEF would reflect HFpEF being predominantly a cardiac or a systemic disease. Here, we will review the current state of the art of cardiac and systemic microvascular dysfunction in HFpEF (Graphical Abstract), resulting in future perspectives on new diagnostic modalities and therapeutic strategies.
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Affiliation(s)
- Jerremy Weerts
- Department of Cardiology, CARIM School for Cardiovascular Diseases, Maastricht University Medical Centre (MUMC+), 6229 HX Maastricht, The Netherlands; (S.G.J.M.); (A.B.A.); (B.L.M.S.); (C.K.); (V.P.M.v.E.)
- Correspondence: ; Tel.: +31-43-387-7097
| | - Sanne G. J. Mourmans
- Department of Cardiology, CARIM School for Cardiovascular Diseases, Maastricht University Medical Centre (MUMC+), 6229 HX Maastricht, The Netherlands; (S.G.J.M.); (A.B.A.); (B.L.M.S.); (C.K.); (V.P.M.v.E.)
| | - Arantxa Barandiarán Aizpurua
- Department of Cardiology, CARIM School for Cardiovascular Diseases, Maastricht University Medical Centre (MUMC+), 6229 HX Maastricht, The Netherlands; (S.G.J.M.); (A.B.A.); (B.L.M.S.); (C.K.); (V.P.M.v.E.)
| | - Blanche L. M. Schroen
- Department of Cardiology, CARIM School for Cardiovascular Diseases, Maastricht University Medical Centre (MUMC+), 6229 HX Maastricht, The Netherlands; (S.G.J.M.); (A.B.A.); (B.L.M.S.); (C.K.); (V.P.M.v.E.)
| | - Christian Knackstedt
- Department of Cardiology, CARIM School for Cardiovascular Diseases, Maastricht University Medical Centre (MUMC+), 6229 HX Maastricht, The Netherlands; (S.G.J.M.); (A.B.A.); (B.L.M.S.); (C.K.); (V.P.M.v.E.)
| | - Etto Eringa
- Department of Physiology, CARIM School for Cardiovascular Diseases, Maastricht University, 6211 LK Maastricht, The Netherlands;
- Department of Physiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Center, 1105 AZ Amsterdam, The Netherlands
| | - Alfons J. H. M. Houben
- Department of Internal Medicine, CARIM School for Cardiovascular Diseases, Maastricht University Medical Centre (MUMC+), 6229 HX Maastricht, The Netherlands;
| | - Vanessa P. M. van Empel
- Department of Cardiology, CARIM School for Cardiovascular Diseases, Maastricht University Medical Centre (MUMC+), 6229 HX Maastricht, The Netherlands; (S.G.J.M.); (A.B.A.); (B.L.M.S.); (C.K.); (V.P.M.v.E.)
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25
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Henkens MTHM, Weerts J, Verdonschot JAJ, Raafs AG, Stroeks S, Sikking MA, Amin H, Mourmans SGJ, Geraeds CBG, Sanders-van Wijk S, Barandiarán Aizpurua A, Uszko-Lencer NHMK, Krapels IPC, Wolffs PFG, Brunner HG, van Leeuwen REW, Verhesen W, Schalla SM, van Stipdonk AWM, Knackstedt C, Li X, Abdul Hamid MA, van Paassen P, Hazebroek MR, Vernooy K, Brunner-La Rocca HP, van Empel VPM, Heymans SRB. Improving diagnosis and risk stratification across the ejection fraction spectrum: the Maastricht Cardiomyopathy registry. ESC Heart Fail 2022; 9:1463-1470. [PMID: 35118823 PMCID: PMC8934928 DOI: 10.1002/ehf2.13833] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 01/05/2022] [Accepted: 01/18/2022] [Indexed: 12/14/2022] Open
Abstract
AIMS Heart failure (HF) represents a clinical syndrome resulting from different aetiologies and degrees of heart diseases. Among these, a key role is played by primary heart muscle disease (cardiomyopathies), which are the combination of multifactorial environmental insults in the presence or absence of a known genetic predisposition. The aim of the Maastricht Cardiomyopathy registry (mCMP-registry; NCT04976348) is to improve (early) diagnosis, risk stratification, and management of cardiomyopathy phenotypes beyond the limits of left ventricular ejection fraction (LVEF). METHODS AND RESULTS The mCMP-registry is an investigator-initiated prospective registry including patient characteristics, diagnostic measurements performed as part of routine clinical care, treatment information, sequential biobanking, quality of life and economic impact assessment, and regular follow-up. All subjects aged ≥16 years referred to the cardiology department of the Maastricht University Medical Center (MUMC+) for HF-like symptoms or cardiac screening for cardiomyopathies are eligible for inclusion, irrespective of phenotype or underlying causes. Informed consented subjects will be followed up for 15 years. Two central approaches will be used to answer the research questions related to the aims of this registry: (i) a data-driven approach to predict clinical outcome and response to therapy and to identify clusters of patients who share underlying pathophysiological processes; and (ii) a hypothesis-driven approach in which clinical parameters are tested for their (incremental) diagnostic, prognostic, or therapeutic value. The study allows other centres to easily join this initiative, which will further boost research within this field. CONCLUSIONS The broad inclusion criteria, systematic routine clinical care data-collection, extensive study-related data-collection, sequential biobanking, and multi-disciplinary approach gives the mCMP-registry a unique opportunity to improve diagnosis, risk stratification, and management of HF and (early) cardiomyopathy phenotypes beyond the LVEF limits.
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Affiliation(s)
- Michiel T H M Henkens
- Department of Cardiology, CARIM, Maastricht University Medical Centre, Maastricht, The Netherlands.,Netherlands Heart Institute (NLHI), Utrecht, The Netherlands.,Department of Pathology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Jerremy Weerts
- Department of Cardiology, CARIM, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Job A J Verdonschot
- Department of Cardiology, CARIM, Maastricht University Medical Centre, Maastricht, The Netherlands.,Department of Clinical Genetics, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Anne G Raafs
- Department of Cardiology, CARIM, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Sophia Stroeks
- Department of Cardiology, CARIM, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Maurits A Sikking
- Department of Cardiology, CARIM, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Hesam Amin
- Department of Cardiology, CARIM, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Sanne G J Mourmans
- Department of Cardiology, CARIM, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Chrit B G Geraeds
- Department of Cardiology, CARIM, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Sandra Sanders-van Wijk
- Department of Cardiology, CARIM, Maastricht University Medical Centre, Maastricht, The Netherlands.,Department of Cardiology, Zuyderland Medical Centre, Heerlen, The Netherlands
| | | | | | - Ingrid P C Krapels
- Department of Clinical Genetics, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Petra F G Wolffs
- Department of Medical Microbiology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Han G Brunner
- Department of Clinical Genetics, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Rick E W van Leeuwen
- Department of Cardiology, CARIM, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Wouter Verhesen
- Department of Cardiology, CARIM, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Simon M Schalla
- Department of Cardiology, CARIM, Maastricht University Medical Centre, Maastricht, The Netherlands
| | | | - Christian Knackstedt
- Department of Cardiology, CARIM, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Xiaofei Li
- Department of Pathology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Myrurgia A Abdul Hamid
- Department of Pathology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Pieter van Paassen
- Department of Nephrology and Clinical Immunology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Mark R Hazebroek
- Department of Cardiology, CARIM, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Kevin Vernooy
- Department of Cardiology, CARIM, Maastricht University Medical Centre, Maastricht, The Netherlands
| | | | - Vanessa P M van Empel
- Department of Cardiology, CARIM, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Stephane R B Heymans
- Department of Cardiology, CARIM, Maastricht University Medical Centre, Maastricht, The Netherlands.,Department of Cardiovascular Research, University of Leuven, Leuven, Belgium
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26
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Gingele AJ, Brandts L, Brunner-La Rocca HP, Cleuren G, Knackstedt C, Boyne JJJ. Introduction of a new scoring tool to identify clinically stable heart failure patients. Neth Heart J 2022; 30:402-410. [PMID: 34988879 PMCID: PMC9402836 DOI: 10.1007/s12471-021-01654-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/24/2021] [Indexed: 12/03/2022] Open
Abstract
Introduction Heart failure (HF) poses a burden on specialist care, making referral of clinically stable HF patients to primary care a desirable goal. However, a structured approach to guide patient referral is lacking. Methods The Maastricht Instability Score—Heart Failure (MIS-HF) questionnaire was developed to objectively stratify the clinical status of HF patients: patients with a low MIS-HF (0–2 points, indicating a stable clinical condition) were considered for treatment in primary care, whereas high scores (> 2 points) indicated the need for specialised care. The MIS-HF was evaluated in 637 consecutive HF patients presenting between 2015 and 2018 at Maastricht University Medical Centre. Results Of the 637 patients, 329 (52%) had a low score and 205 of these 329 (62%) patients were referred to primary care. The remaining 124 (38%) patients remained in secondary care. Of the 308 (48%) patients with a high score (> 2 points), 265 (86%) remained in secondary care and 41 (14%) were referred to primary care. The primary composite endpoint (mortality, cardiac hospital admissions) occurred more frequently in patients with a high compared to those with a low MIS-HF after 1 year of follow-up (29.2% vs 10.9%; odds ratio (OR) 3.36, 95% confidence interval (CI) 2.20–5.14). No significant difference in the composite endpoint (9.8% vs 12.9%; OR 0.73, 95% CI 0.36–1.47) was found between patients with a low MIS-HF treated in primary versus secondary care. Conclusion The MIS-HF questionnaire may improve referral policies, as it helps to identify HF patients that can safely be referred to primary care. Supplementary Information The online version of this article (10.1007/s12471-021-01654-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- A J Gingele
- Department of Cardiology, Maastricht University Medical Centre+, Maastricht, The Netherlands.
| | - L Brandts
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - H P Brunner-La Rocca
- Department of Cardiology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - G Cleuren
- Department of Patient and Care, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - C Knackstedt
- Department of Cardiology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - J J J Boyne
- Department of Patient and Care, Maastricht University Medical Centre+, Maastricht, The Netherlands.,Department of Health Services Research, CAPHRI, Maastricht University, Maastricht, The Netherlands
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27
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Weerts J, Barandiarán Aizpurua A, Henkens MTHM, Lyon A, van Mourik MJW, van Gemert MRAA, Raafs A, Sanders-van Wijk S, Bayés-Genís A, Heymans SRB, Crijns HJGM, Brunner-La Rocca HP, Lumens J, van Empel VPM, Knackstedt C. The prognostic impact of mechanical atrial dysfunction and atrial fibrillation in heart failure with preserved ejection fraction. Eur Heart J Cardiovasc Imaging 2021; 23:74-84. [PMID: 34718457 PMCID: PMC8685598 DOI: 10.1093/ehjci/jeab222] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 10/08/2021] [Indexed: 12/18/2022] Open
Abstract
AIMS This study assessed the prognostic implications of mechanical atrial dysfunction in heart failure with preserved ejection fraction (HFpEF) patients with different stages of atrial fibrillation (AF) in detail. METHODS AND RESULTS HFpEF patients (n = 258) systemically underwent an extensive clinical characterization, including 24-h Holter monitoring and speckle-tracking echocardiography. Patients were categorized according to rhythm and stages of AF: 112 with no history of AF (no AF), 56 with paroxysmal AF (PAF), and 90 with sustained (persistent/permanent) AF (SAF). A progressive decrease in mechanical atrial function was seen: left atrial reservoir strain (LASr) 30.5 ± 10.5% (no AF), 22.3 ± 10.5% (PAF), and 13.9 ± 7.8% (SAF), P < 0.001. Independent predictors for lower LASr values were AF, absence of chronic obstructive pulmonary disease, higher N-terminal-pro hormone B-type natriuretic peptide, left atrial volume index, and relative wall thickness, lower left ventricular global longitudinal strain, and echocardiographic signs of elevated left ventricular filling pressure. LASr was an independent predictor of adverse outcome (hazard ratio per 1% decrease =1.049, 95% confidence interval 1.014-1.085, P = 0.006), whereas AF was not when the multivariable model included LASr. Moreover, LASr mediated the adverse outcome associated with AF in HFpEF (P = 0.008). CONCLUSION Mechanical atrial dysfunction has a possible greater prognostic role in HFpEF compared to AF status alone. Mechanical atrial dysfunction is a predictor of adverse outcome independently of AF presence or stage, and may be an underlying mechanism (mediator) for the worse outcome associated with AF in HFpEF. This may suggest mechanical atrial dysfunction plays a crucial role in disease progression in HFpEF patients with AF, and possibly also in HFpEF patients without AF.
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Affiliation(s)
- Jerremy Weerts
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+ (MUMC+), PO Box 616, 6200 MD Maastricht, the Netherlands
| | - Arantxa Barandiarán Aizpurua
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+ (MUMC+), PO Box 616, 6200 MD Maastricht, the Netherlands
| | - Michiel T H M Henkens
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+ (MUMC+), PO Box 616, 6200 MD Maastricht, the Netherlands
| | - Aurore Lyon
- Department of Biomedical Engineering, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Universiteitssingel 50, 6229 ER Maastricht, the Netherlands
| | - Manouk J W van Mourik
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+ (MUMC+), PO Box 616, 6200 MD Maastricht, the Netherlands
| | - Mathijs R A A van Gemert
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+ (MUMC+), PO Box 616, 6200 MD Maastricht, the Netherlands
| | - Anne Raafs
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+ (MUMC+), PO Box 616, 6200 MD Maastricht, the Netherlands
| | - Sandra Sanders-van Wijk
- Department of Cardiology, Zuyderland Medical Center, Henri Dunantstraat 5, 6419 PC Heerlen, the Netherlands
| | - Antoni Bayés-Genís
- Cardiology Department and Heart Failure Unit, Hospital Universitari Germans Trias i Pujol, CIBERCV, 08916 Badalona, Barcelona, Spain
| | - Stephane R B Heymans
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+ (MUMC+), PO Box 616, 6200 MD Maastricht, the Netherlands
- Centre for Molecular and Vascular Biology, Department of Cardiovascular Sciences, KU Leuven, Herestraat 49, bus 911, 3000 Leuven, Belgium
| | - Harry J G M Crijns
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+ (MUMC+), PO Box 616, 6200 MD Maastricht, the Netherlands
| | - Hans-Peter Brunner-La Rocca
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+ (MUMC+), PO Box 616, 6200 MD Maastricht, the Netherlands
| | - Joost Lumens
- Department of Biomedical Engineering, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Universiteitssingel 50, 6229 ER Maastricht, the Netherlands
| | - Vanessa P M van Empel
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+ (MUMC+), PO Box 616, 6200 MD Maastricht, the Netherlands
| | - Christian Knackstedt
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+ (MUMC+), PO Box 616, 6200 MD Maastricht, the Netherlands
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Nuzzi V, Raafs A, Manca P, Henkens MT, Gregorio C, Boscutti A, Verdonschot J, Hazebroek M, Knackstedt C, Merlo M, Stolfo D, Sinagra G, Heymans SR. 84 Left atrial reverse remodelling in dilated cardiomyopathy. Eur Heart J Suppl 2021. [DOI: 10.1093/eurheartj/suab142.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Abstract
Aims
Left atrial (LA) dilation is associated a with worse prognosis in several cardiovascular settings but therapies can promote LA reverse remodelling. Characterizing and defining the prognostic implications of LA volume (LAVI) reduction in dilated cardiomyopathy (DCM).
Methods and results
Consecutive DCM patients from two tertiary care centres, with available echocardiography at baseline and at 1 year follow-up, were analysed. LA dilation was defined as LAVI >34 ml/m2, Delta (Δ)LAVI was defined as the 1 year relative LAVI reduction. The outcome was a composite of death/heart transplantation/heart failure hospitalization (D/HTx/HFH). Five hundred sixty patients were included [age 52 ± 13 years; left ventricular ejection fraction (LVEF) 31 ± 10%, LAVI 45 ± 18 ml/m2]. Baseline LAVI had a non-linear association with the risk of D/HTx/HFH, independently from LVEF (P < 0.001). At 1 year follow-up, LAVI decreased in 374 patients (67%, median ΔLAVI 24%, interquartile range 37% 11%). Factors independently associated with ΔLAVI were higher baseline LAVI and lower baseline LVEF. After adjustment for confounders, ΔLAVI showed a linear association with the risk of D/HTx/HHF (HR: 0.92, 95% CI: 0.86 0.99 per 5% decrease, P < 0.001). At 1 year Follow-up, patients with a ≥ 15% reduction in ΔLAVI or LAVI normalization (i.e. Follow-up LAVI ≤34ml/m2) (42% of the cohort) were at lower risk of D/HTx/HFH (HR: 0.49, 95% CI: 0.33 0.74, P < 0.001).
Conclusions
In a large cohort of DCM, 1 year reduction in LAVI is observed in the majority of patients. The association between reduction in LAVI and D/HTx/HHF candidates LA reverse remodelling as complementary early therapeutic goal in DCM.
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Affiliation(s)
- Vincenzo Nuzzi
- Azienda Sanitaria Giuliano-Isontina (ASUGI), Università degli Studi di Trieste, Trieste, Italy
| | - Anne Raafs
- Department of Cardiology, Cardiovascular Research Institute (CARIM), University Medical Centre, Maastricht, The Netherlands
| | - Paolo Manca
- Azienda Sanitaria Giuliano-Isontina (ASUGI), Università degli Studi di Trieste, Trieste, Italy
| | - Michiel T.h.M. Henkens
- Department of Cardiology, Cardiovascular Research Institute (CARIM), University Medical Centre, Maastricht, The Netherlands
| | | | - Andrea Boscutti
- Azienda Sanitaria Giuliano-Isontina (ASUGI), Università degli Studi di Trieste, Trieste, Italy
| | - Job Verdonschot
- Department of Cardiology, Cardiovascular Research Institute (CARIM), University Medical Centre, Maastricht, The Netherlands
| | - Mark Hazebroek
- Department of Cardiology, Cardiovascular Research Institute (CARIM), University Medical Centre, Maastricht, The Netherlands
| | - Christian Knackstedt
- Department of Cardiology, Cardiovascular Research Institute (CARIM), University Medical Centre, Maastricht, The Netherlands
| | - Marco Merlo
- Azienda Sanitaria Giuliano-Isontina (ASUGI), Università degli Studi di Trieste, Trieste, Italy
| | - Davide Stolfo
- Azienda Sanitaria Giuliano-Isontina (ASUGI), Università degli Studi di Trieste, Trieste, Italy
| | - Gianfranco Sinagra
- Azienda Sanitaria Giuliano-Isontina (ASUGI), Università degli Studi di Trieste, Trieste, Italy
| | - Stephane R.B. Heymans
- Department of Cardiology, Cardiovascular Research Institute (CARIM), University Medical Centre, Maastricht, The Netherlands
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29
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Moura B, Aimo A, Al-Mohammad A, Flammer A, Barberis V, Bayes-Genis A, Brunner-La Rocca HP, Fontes-Carvalho R, Grapsa J, Hülsmann M, Ibrahim N, Knackstedt C, Januzzi JL, Lapinskas T, Sarrias A, Matskeplishvili S, Meijers WC, Messroghli D, Mueller C, Pavo N, Simonavičius J, Teske AJ, van Kimmenade R, Seferovic P, Coats AJS, Emdin M, Richards AM. Integration of imaging and circulating biomarkers in heart failure: a consensus document by the Biomarkers and Imaging Study Groups of the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail 2021; 23:1577-1596. [PMID: 34482622 DOI: 10.1002/ejhf.2339] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 07/28/2021] [Accepted: 08/29/2021] [Indexed: 12/28/2022] Open
Abstract
Circulating biomarkers and imaging techniques provide independent and complementary information to guide management of heart failure (HF). This consensus document by the Heart Failure Association (HFA) of the European Society of Cardiology (ESC) presents current evidence-based indications relevant to integration of imaging techniques and biomarkers in HF. The document first focuses on application of circulating biomarkers together with imaging findings, in the broad domains of screening, diagnosis, risk stratification, guidance of treatment and monitoring, and then discusses specific challenging settings. In each section we crystallize clinically relevant recommendations and identify directions for future research. The target readership of this document includes cardiologists, internal medicine specialists and other clinicians dealing with HF patients.
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Affiliation(s)
- Brenda Moura
- Faculty of Medicine, University of Porto, Porto, Portugal.,Cardiology Department, Porto Armed Forces Hospital, Porto, Portugal
| | - Alberto Aimo
- Scuola Superiore Sant'Anna, and Fondazione G. Monasterio, Pisa, Italy
| | - Abdallah Al-Mohammad
- Medical School, University of Sheffield and Sheffield Teaching Hospitals, Sheffield, UK
| | | | | | - Antoni Bayes-Genis
- Heart Institute, Hospital Universitari Germans Trias i Pujol, Badalona, Spain.,CIBERCV, Instituto de Salud Carlos III, Madrid, Spain
| | - Hans-Peter Brunner-La Rocca
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Ricardo Fontes-Carvalho
- Cardiovascular Research and Development Unit (UnIC), Faculty of Medicine University of Porto, Porto, Portugal.,Cardiology Department, Centro Hospitalar de Vila Nova Gaia/Espinho, Espinho, Portugal
| | - Julia Grapsa
- Department of Cardiology, Guys and St Thomas NHS Hospitals Trust, London, UK
| | - Martin Hülsmann
- Department of Internal Medicine, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Nasrien Ibrahim
- Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Christian Knackstedt
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - James L Januzzi
- Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Tomas Lapinskas
- Department of Cardiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Axel Sarrias
- Heart Institute, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | | | | | - Daniel Messroghli
- Department of Internal Medicine-Cardiology, Deutsches Herzzentrum Berlin and Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Christian Mueller
- Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Noemi Pavo
- Department of Internal Medicine, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Justas Simonavičius
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, The Netherlands.,Vilnius University Hospital Santaros klinikos, Vilnius, Lithuania
| | - Arco J Teske
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Roland van Kimmenade
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Petar Seferovic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Serbian Academy of Sciences and Arts, Belgrade, Serbia
| | | | - Michele Emdin
- Scuola Superiore Sant'Anna, and Fondazione G. Monasterio, Pisa, Italy
| | - A Mark Richards
- Christchurch Heart Institute, University of Otago, Dunedin, New Zealand.,Cardiovascular Research Institute, National University of Singapore, Singapore
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30
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Verdonschot JAJ, Henkens MTHM, Wang P, Schummers G, Raafs AG, Krapels IPC, van Empel V, Heymans SRB, Brunner-La Rocca HP, Knackstedt C. A global longitudinal strain cut-off value to predict adverse outcomes in individuals with a normal ejection fraction. ESC Heart Fail 2021; 8:4343-4345. [PMID: 34272829 PMCID: PMC8497344 DOI: 10.1002/ehf2.13465] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 05/14/2021] [Accepted: 05/23/2021] [Indexed: 11/30/2022] Open
Abstract
Aims Global longitudinal strain (GLS) has become an alternative to left ventricular ejection fraction (LVEF) to determine systolic function of the heart. The absence of cut‐off values is one of the limitations preventing full clinical implementation. The aim of this study is to determine a cut‐off value of GLS for an increased risk of adverse events in individuals with a normal LVEF. Methods and results Echocardiographic images of 502 subjects (52% female, mean age 48 ± 15) with an LVEF ≥ 55% were analysed using speckle tracking‐based GLS. The primary endpoint was cardiovascular death or cardiac hospitalization. The analysis of Cox models with splines was performed to visualize the effect of GLS on outcome. A cut‐off value was suggested by determining the optimal specificity and sensitivity. The median GLS was −22.2% (inter‐quartile range −20.0 to −24.9%). In total, 35 subjects (7%) had a cardiac hospitalization and/or died because of cardiovascular disease during a follow‐up of 40 (5–80) months. There was a linear correlation between the risk for adverse events and GLS value. Subjects with a normal LVEF and a GLS between −22.9% and −20.9% had a mildly increased risk (hazard ratio 1.01–2.0) for cardiac hospitalization or cardiovascular mortality, and the risk was doubled for subjects with a GLS of −20.9% and higher. The optimal specificity and sensitivity were determined at a GLS value of −20.0% (hazard ratio 2.49; 95% confidence interval: 1.71–3.61). Conclusions There is a strong correlation between cardiac adverse events and GLS values in subjects with a normal LVEF. In our single‐centre study, −20.0% was determined as a cut‐off value to identify subjects at risk. A next step should be to integrate GLS values in a multi‐parametric model.
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Affiliation(s)
- Job A J Verdonschot
- Department of Clinical Genetics, Maastricht University Medical Centre, Maastricht, The Netherlands.,Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, PO Box 5800, Maastricht, 6202 AZ, The Netherlands
| | - Michiel T H M Henkens
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, PO Box 5800, Maastricht, 6202 AZ, The Netherlands
| | - Ping Wang
- Department of Clinical Genetics, Maastricht University Medical Centre, Maastricht, The Netherlands
| | | | - Anne G Raafs
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, PO Box 5800, Maastricht, 6202 AZ, The Netherlands
| | - Ingrid P C Krapels
- Department of Clinical Genetics, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Vanessa van Empel
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, PO Box 5800, Maastricht, 6202 AZ, The Netherlands
| | - Stephane R B Heymans
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, PO Box 5800, Maastricht, 6202 AZ, The Netherlands.,Centre for Molecular and Vascular Biology, Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Hans-Peter Brunner-La Rocca
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, PO Box 5800, Maastricht, 6202 AZ, The Netherlands
| | - Christian Knackstedt
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, PO Box 5800, Maastricht, 6202 AZ, The Netherlands
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31
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Raafs AG, Verdonschot JAJ, Henkens MTHM, Adriaans BP, Wang P, Derks K, Abdul Hamid MA, Knackstedt C, van Empel VPM, Díez J, Brunner-La Rocca HP, Brunner HG, González A, Bekkers SCAM, Heymans SRB, Hazebroek MR. The combination of carboxy-terminal propeptide of procollagen type I blood levels and late gadolinium enhancement at cardiac magnetic resonance provides additional prognostic information in idiopathic dilated cardiomyopathy - A multilevel assessment of myocardial fibrosis in dilated cardiomyopathy. Eur J Heart Fail 2021; 23:933-944. [PMID: 33928704 PMCID: PMC8362085 DOI: 10.1002/ejhf.2201] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 04/22/2021] [Accepted: 04/25/2021] [Indexed: 12/16/2022] Open
Abstract
Aims To determine the prognostic value of multilevel assessment of fibrosis in dilated cardiomyopathy (DCM) patients. Methods and results We quantified fibrosis in 209 DCM patients at three levels: (i) non‐invasive late gadolinium enhancement (LGE) at cardiac magnetic resonance (CMR); (ii) blood biomarkers [amino‐terminal propeptide of procollagen type III (PIIINP) and carboxy‐terminal propeptide of procollagen type I (PICP)], (iii) invasive endomyocardial biopsy (EMB) (collagen volume fraction, CVF). Both LGE and elevated blood PICP levels, but neither PIIINP nor CVF predicted a worse outcome defined as death, heart transplantation, heart failure hospitalization, or life‐threatening arrhythmias, after adjusting for known clinical predictors [adjusted hazard ratios: LGE 3.54, 95% confidence interval (CI) 1.90–6.60; P < 0.001 and PICP 1.02, 95% CI 1.01–1.03; P = 0.001]. The combination of LGE and PICP provided the highest prognostic benefit in prediction (likelihood ratio test P = 0.007) and reclassification (net reclassification index: 0.28, P = 0.02; and integrated discrimination improvement index: 0.139, P = 0.01) when added to the clinical prediction model. Moreover, patients with a combination of LGE and elevated PICP (LGE+/PICP+) had the worst prognosis (log‐rank P < 0.001). RNA‐sequencing and gene enrichment analysis of EMB showed an increased expression of pro‐fibrotic and pro‐inflammatory pathways in patients with high levels of fibrosis (LGE+/PICP+) compared to patients with low levels of fibrosis (LGE‐/PICP‐). This would suggest the validity of myocardial fibrosis detection by LGE and PICP, as the subsequent generated fibrotic risk profiles are associated with distinct cardiac transcriptomic profiles. Conclusion The combination of myocardial fibrosis at CMR and circulating PICP levels provides additive prognostic value accompanied by a pro‐fibrotic and pro‐inflammatory transcriptomic profile in DCM patients with LGE and elevated PICP.
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Affiliation(s)
- Anne G Raafs
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Job A J Verdonschot
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, The Netherlands.,Department of Clinical Genetics, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Michiel T H M Henkens
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Bouke P Adriaans
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, The Netherlands.,Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Ping Wang
- Department of Clinical Genetics, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Kasper Derks
- Department of Clinical Genetics, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Myrurgia A Abdul Hamid
- Department of Pathology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Christian Knackstedt
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Vanessa P M van Empel
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Javier Díez
- Program of Cardiovascular Diseases, CIMA Universidad de Navarra and IdiSNA, Pamplona, Spain.,CIBERCV, Carlos III Institute of Health, Madrid, Spain.,Departments of Nephrology and of Cardiology and Cardiac Surgery, University of Navarra Clinic, Pamplona, Spain
| | - Hans-Peter Brunner-La Rocca
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Han G Brunner
- Department of Clinical Genetics, Maastricht University Medical Centre, Maastricht, The Netherlands.,Department of Human Genetics, and Donders Centre for Neuroscience, Radboud UMC, Nijmegen, The Netherlands
| | - Arantxa González
- Program of Cardiovascular Diseases, CIMA Universidad de Navarra and IdiSNA, Pamplona, Spain.,CIBERCV, Carlos III Institute of Health, Madrid, Spain
| | - Sebastiaan C A M Bekkers
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Stephane R B Heymans
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, The Netherlands.,Department of Cardiovascular Research, University of Leuven, Leuven, Belgium.,Netherlands Heart Institute (Nl-HI), Utrecht, The Netherlands
| | - Mark R Hazebroek
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, The Netherlands
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Van Stipdonk AMW, Schretlen S, Dohmen W, Knackstedt C, Brunner-Larocca HP, Vernooy K. Better outcome at lower costs after implementing a CRT-care pathway: a comprehensive evaluation of real-world data. Europace 2021. [DOI: 10.1093/europace/euab116.445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Medtronic plc.
Background
Cardiac resynchronization therapy (CRT) requires intensive, complex and multi-disciplinary care to maximize clinical benefit in heart failure patients. In current practice, this is often incomplete due to limitations in time, resources and coordination of care.
Purpose
We evaluated the effect of the introduction of a novel multidisciplinary, standardized CRT care pathway (CRT-CPW) compared with usual care, on clinical outcome and costs.
Methods
The CRT care pathway (CRT-CPW) design, based on an expert consensus of experienced European CRT specialists; focussed on structuring patient selection, implantation and follow-up heart failure treatment and device management. To facilitate and guarantee quality, checklists fitted to each moment in the care pathway were designed, to aid contributors. The CRT-CPW was implemented in the Maastricht University Medical Centre in 2014. Data from patients receiving usual care (2012-2014, 222 patients) and patients receiving care under the CRT-CPW (2015-2018, 241 patients) were compared. Data was extracted from the hospital information system. The primary outcome was the composite of all-cause mortality and heart failure (HF) hospitalization. Hospital-related costs of cardiovascular care after CRT implantation was analysed to address cost-effectiveness.
Results
Patient demographics were comparable in both groups, except that the CRT-CPW group showed more AF and previous myocardial infarction at baseline. The combined endpoint of death from any cause and admission for HF occurred in 127 patients (57.2%) in the usual care group and 64 patients (26.6%) in the CRT- CPW group (adjusted HR 0.68 (95% CI, 0.49 to 0.93), p = 0.015) (Figure 1A). Total costs for cardiology related hospitalizations reduced significantly in the CRT care pathway group (€ 19.177 ± 9.692 vs 20.613 ± 7.066, p< 0.001, Table 4). Bootstrap analyses revealed that 90.7% of samples would show improved outcomes as well as reduction in costs in the CRT-CPW treatment group (Figure 1B).
Conclusion
The introduction of a novel CRT-CPW resulted in improved clinical outcome and reduced costs. Abstract Figure 1 Clinical outcome and costs
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Affiliation(s)
- AMW Van Stipdonk
- Maastricht University Medical Centre (MUMC), Cardiology, Maastricht, Netherlands (The)
| | - S Schretlen
- Medtronic Integrated Healthcare Solutions, Eindhoven, Netherlands (The)
| | - W Dohmen
- Maastricht University Medical Centre (MUMC), Cardiology, Maastricht, Netherlands (The)
| | - C Knackstedt
- Maastricht University Medical Centre (MUMC), Cardiology, Maastricht, Netherlands (The)
| | - HP Brunner-Larocca
- Maastricht University Medical Centre (MUMC), Cardiology, Maastricht, Netherlands (The)
| | - K Vernooy
- Maastricht University Medical Centre (MUMC), Cardiology, Maastricht, Netherlands (The)
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33
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van Stipdonk AMW, Schretlen S, Dohmen W, Brunner-LaRocca HP, Knackstedt C, Vernooy K. Development and implementation of a cardiac resynchronisation therapy care pathway: improved process and reduced resource use. BMJ Open Qual 2021; 10:bmjoq-2020-001072. [PMID: 33627342 PMCID: PMC7908295 DOI: 10.1136/bmjoq-2020-001072] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 12/07/2020] [Accepted: 02/07/2021] [Indexed: 11/27/2022] Open
Abstract
Background Cardiac resynchronisation therapy (CRT) requires intensive, complex and multidisciplinary care to maximize the clinical benefit. In current practice this is typically a task for highly specialised physicians. We report on a novel multidisciplinary, standardised CRT care pathway (CRT-CPW). Experienced clinicians developed a CPW with simple and broadly applicable aids based on clinical evidence and identified shortcomings in the current CRT care. The resulting CPW was implemented at the Maastricht University Medical Center, aiming at a transfer from heterogeneous physician-led care to standardized nurse-led care. Methods Two CRT patient cohorts were compared in this analysis. The benchmarked usual care cohort (2012–2014, 122 patients) was compared with the CRT-CPW cohort (2015–2017, 115 patients). The primary outcomes were process-related: number of physician consultations, nurse consultations, length of stay (LOS) at implantation and total hospitalisation days during 1-year follow-up, and referral-to-treatment time. Clinical outcomes were assessed to adress non-inferiority of quality of care. Results Patients in the CRT-CPW cohort consulted nurses and technicians significantly more often than patients in the usual care cohort (2.4±1.5 vs 1.7±2.0, p<0.0001 and 4.3±2.5 vs 3.7±1.5, p=0.063, respectively). Patients with CRT-CPW consulted physicians significantly less often (1.7±1.4 vs 2.6±2.1, p<0.001). Referral to treatment time was significantly reduced in the CRT-CPW group (23.6±18.4 vs 37.0±26.3 days, p=0.002). LOS at implantation and total hospitalisation days were significantly reduced in the CRT-CPW group (1.1±1.2 vs 1.5±0.7 days, p<0.0001 and 2.4±4.8 vs 4.8±9.3, p<0.0001, respectively). Clinical outcome analyses showed no significant difference in 12-month all-cause mortality and heart failure hospitalisations. Conclusion The introduction of a novel CRT-CPW resulted in a successful transition of physician-led to nurse-led care, with a significantly reduced resource use and equal clinical outcomes. Future evaluations will focus on impact on outcomes versus costs, to evaluate cost-effectiveness of the CRT-CPW.
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Affiliation(s)
| | - Stijn Schretlen
- Integrated Health Solutions, Medtronic Inc, Eindhoven, Netherlands
| | - Wim Dohmen
- Cardiology, Maastricht Universitair Medisch Centrum+, Maastricht, Netherlands
| | | | | | - Kevin Vernooy
- Cardiology, Maastricht Universitair Medisch Centrum+, Maastricht, Netherlands.,Cardiology, Radboudumc, Nijmegen, Gelderland, Netherlands
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Amin H, Weerts J, Brunner-La Rocca HP, Knackstedt C, Sanders-van Wijk S. Future perspective of heart failure care: benefits and bottlenecks of artificial intelligence and eHealth. Future Cardiol 2021; 17:917-921. [PMID: 33576271 DOI: 10.2217/fca-2021-0008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Tweetable abstract #eHealth and #ArtificialIntelligence (AI) bring new possibilities for #HeartFailure (HF) care. We elaborate on potential benefits of #AI in #HF and highlight important bottlenecks for its implementation. #Editorial #Cardiology.
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Affiliation(s)
- Hesam Amin
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+ (MUMC+), Maastricht, The Netherlands
| | - Jerremy Weerts
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+ (MUMC+), Maastricht, The Netherlands
| | - Hans-Peter Brunner-La Rocca
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+ (MUMC+), Maastricht, The Netherlands
| | - Christian Knackstedt
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+ (MUMC+), Maastricht, The Netherlands
| | - Sandra Sanders-van Wijk
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+ (MUMC+), Maastricht, The Netherlands.,Department of Cardiology, Zuyderland Medical Center, Heerlen/Sittard-Geleen, The Netherlands
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35
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Van Loon T, Knackstedt C, Cornelussen R, Reesink KD, Brunner-La-Rocca HP, Delhaas T, Van Empel VPM, Lumens J. Linking diastolic function to cardiac exercise performance in heart failure with preserved ejection fraction: a virtual patient study. Eur Heart J Cardiovasc Imaging 2021. [DOI: 10.1093/ehjci/jeaa356.429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): NWO-ZonMw
Background
The relative impact of left ventricular (LV) diastolic dysfunction (LVDD) and impaired left atrial (LA) function on cardiac exercise performance (CEP) in heart failure with preserved ejection fraction (HFpEF) remains largely unknown
Purpose
To elucidate the relative effects of LVDD and impaired LA function on hemodynamics at rest and on cardiac performance during exercise by performing virtual HFpEF patient simulations.
Methods
Using a well-validated cardiovascular system model (CircAdapt), impaired LV relaxation was simulated by increasing the rate of myocardial relaxation (tau) from 35 to 65 ms. To study the effect of moderate and sever LV myocardial stiffness increase, LV end-diastolic elastance was increased from 0.15 mmHg/ml to 0.60 mmHg/ml and 2.00 mmHg/ml, respectively. In each simulation, LV diastolic function at rest (cardiac output (CO) and heart rate (HR) of 5.1 l/min and 70 bpm, respectively) was assessed using LV ejection fraction (LVEF), mitral E/A ratio, maximum LA volume (LAV), and mean left atrial (LA) pressure (mLAP). To investigate the relative effect of these cardiac abnormalities on exercise capacity, CO and HR were gradually increased using a fixed CO-HR relationship until mLAP exceeded a threshold pressure of 35 mmHg, which was assumed to be a physiological limit of exercise intensity.
Results
Simulations showed that regardless of the modelled LV and LA function, LVEF was preserved (>50%). Impaired LV relaxation function was associated with decreased E/A-ratio and a small increase in mLAP at rest, regardless of LA function. Increased LV passive stiffness resulted in increased E/A-ratio, LA dilation and markedly elevated mLAP at rest, regardless of LA function (Figure: top-left). Impaired LA function resulted in reduced A-peak velocity, and increased E/A–ratio, LAV and mLAP at rest regardless of LV function (Figure: top-right) Exercise simulations showed that increased LV passive stiffness exerts a stronger exercise-limiting effect than impaired LV relaxation function, in particular when LA function is impaired (Figure: bottom).
Conclusions
Through simple and well-controlled variations in LV and LA function, we were able to simulate virtual HFpEF patients with a wide range of LVDD severities at rest, preserved LVEF, and reduced cardiac exercise performance. In general, our simulations suggest that increased LV passive stiffness, rather than impaired LV relaxation function, reduces exercise tolerance, especially in the presence of LA dysfunction.
Abstract Figure. Simulating rest & exercise hemodynamics
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Affiliation(s)
- T Van Loon
- Cardiovascular Research Institute Maastricht (CARIM), Biomedical Engineering, Maastricht, Netherlands (The)
| | - C Knackstedt
- Maastricht University Medical Centre (MUMC+), Cardiology, Maastricht, Netherlands (The)
| | - R Cornelussen
- Cardiovascular Research Institute Maastricht (CARIM), Physiology, Maastricht, Netherlands (The)
| | - KD Reesink
- Cardiovascular Research Institute Maastricht (CARIM), Biomedical Engineering, Maastricht, Netherlands (The)
| | - HP Brunner-La-Rocca
- Maastricht University Medical Centre (MUMC+), Cardiology, Maastricht, Netherlands (The)
| | - T Delhaas
- Cardiovascular Research Institute Maastricht (CARIM), Biomedical Engineering, Maastricht, Netherlands (The)
| | - VPM Van Empel
- Maastricht University Medical Centre (MUMC+), Cardiology, Maastricht, Netherlands (The)
| | - J Lumens
- Cardiovascular Research Institute Maastricht (CARIM), Biomedical Engineering, Maastricht, Netherlands (The)
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Barandiarán Aizpurua A, Sanders-van Wijk S, Brunner-La Rocca HP, Henkens MTHM, Weerts J, Spanjers MHA, Knackstedt C, van Empel VPM. Iron deficiency impacts prognosis but less exercise capacity in heart failure with preserved ejection fraction. ESC Heart Fail 2021; 8:1304-1313. [PMID: 33522131 PMCID: PMC8006701 DOI: 10.1002/ehf2.13204] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 10/12/2020] [Accepted: 01/02/2021] [Indexed: 12/11/2022] Open
Abstract
Aims Whether and how iron deficiency (ID) impacts patients with heart failure (HF) with preserved ejection fraction (HFpEF) remain unclear. The aim of our study was to investigate the impact of ID on functional status, exercise capacity, and prognosis in HFpEF. Methods and results The study population consisted of 300 HFpEF patients. ID was defined as serum ferritin <100 μg/L or 100–300 μg/L and transferrin‐saturation <20%. Baseline functional status, quality of life (HADS score and EQ 5D index), 6 min walking test, echocardiography, and outcome (all‐cause mortality and combined all cause‐mortality and HF hospitalization) were evaluated. ID was found in 159 (53%) patients. Patients with ID had a worse prognosis with a higher combined endpoint of all‐cause mortality and HF hospitalization after 4 years of follow‐up (log rank = 0.008). Pulmonary hypertension, depression, and thyroid disease were more prevalent in the ID group. Multivariable analysis showed that ID was independently associated with body mass index (P = 0.003), pulmonary hypertension (P = 0.008), and thyroid disease (P = 0.01). Although patients with ID had a lower exercise capacity compared with patients without ID (393 m [294–455] vs. 344 m [260–441], P = 0.008), there was no significant correlation after multivariable correction for age, BMI, NT‐proBNP, DM, and depression. Conclusions Heart failure with preserved ejection fraction patients with ID have a worse prognosis and impaired exercise capacity compared with those without ID. However, although a trend was observed, after multivariable correction ID was no longer significantly associated with a reduced exercise capacity. This reflects that impaired exercise capacity in HFpEF is complex and seems multifactorial. Interestingly, pulmonary hypertension was an independent predictor of both ID and exercise capacity.
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Affiliation(s)
- Arantxa Barandiarán Aizpurua
- Department of Cardiology, Maastricht University Medical Centre (MUMC+), PO 5800, Maastricht, 6202AZ, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Sandra Sanders-van Wijk
- Department of Cardiology, Maastricht University Medical Centre (MUMC+), PO 5800, Maastricht, 6202AZ, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Hans-Peter Brunner-La Rocca
- Department of Cardiology, Maastricht University Medical Centre (MUMC+), PO 5800, Maastricht, 6202AZ, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Michiel T H M Henkens
- Department of Cardiology, Maastricht University Medical Centre (MUMC+), PO 5800, Maastricht, 6202AZ, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Jerremy Weerts
- Department of Cardiology, Maastricht University Medical Centre (MUMC+), PO 5800, Maastricht, 6202AZ, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Mireille H A Spanjers
- Department of Cardiology, Maastricht University Medical Centre (MUMC+), PO 5800, Maastricht, 6202AZ, The Netherlands
| | - Christian Knackstedt
- Department of Cardiology, Maastricht University Medical Centre (MUMC+), PO 5800, Maastricht, 6202AZ, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Vanessa P M van Empel
- Department of Cardiology, Maastricht University Medical Centre (MUMC+), PO 5800, Maastricht, 6202AZ, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
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Hazebroek MR, Henkens MTHM, Raafs AG, Verdonschot JAJ, Merken JJ, Dennert RM, Eurlings C, Abdul Hamid MA, Wolffs PFG, Winkens B, Brunner-La Rocca HP, Knackstedt C, van Paassen P, van Empel VPM, Heymans SRB. Intravenous immunoglobulin therapy in adult patients with idiopathic chronic cardiomyopathy and cardiac parvovirus B19 persistence: a prospective, double-blind, randomized, placebo-controlled clinical trial. Eur J Heart Fail 2021; 23:302-309. [PMID: 33347677 PMCID: PMC8048650 DOI: 10.1002/ejhf.2082] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 11/16/2020] [Accepted: 12/17/2020] [Indexed: 12/19/2022] Open
Abstract
AIMS Previous uncontrolled studies suggested a possible benefit of intravenous immunoglobulin (IVIg) in parvovirus B19 (B19V)-related dilated cardiomyopathy (DCM). This randomized, double-blind, placebo-controlled, single-centre trial investigated the benefits of IVIg beyond conventional therapy in idiopathic chronic DCM patients with B19V persistence. METHODS AND RESULTS Fifty patients (39 men; mean age 54 ± 11 years) with idiopathic chronic (>6 months) DCM on optimal medical therapy, left ventricular ejection fraction (LVEF) <45%, and endomyocardial biopsy (EMB) B19V load of >200 copies/µg DNA were blindly randomized to either IVIg (n = 26, 2 g/kg over 4 days) or placebo (n = 24). The primary outcome was change in LVEF at 6 months after randomization. Secondary outcomes were change in functional capacity assessed by 6-min walk test (6MWT), quality of life [Minnesota Living with Heart Failure Questionnaire (MLHFQ)], left ventricular end-diastolic volume (LVEDV), and EMB B19V load at 6 months after randomization. LVEF significantly improved in both IVIg and placebo groups (absolute mean increase 5 ± 9%, P = 0.011 and 6 ± 10%, P = 0.008, respectively), without a significant difference between groups (P = 0.609). Additionally, change in 6MWT [median (interquartile range) IVIg 36 (13;82) vs. placebo 32 (5;80) m; P = 0.573], MLHFQ [IVIg 0 (-7;5) vs. placebo -2 (-6;6), P = 0.904] and LVEDV (IVIg -16 ± 49 mL/m2 vs. placebo -29 ± 40 mL/m2 ; P = 0.334) did not significantly differ between groups. Moreover, despite increased circulating B19V antibodies upon IVIg administration, reduction in cardiac B19V did not significantly differ between groups. CONCLUSION Intravenous immunoglobulin therapy does not significantly improve cardiac systolic function or functional capacity beyond standard medical therapy in patients with idiopathic chronic DCM and cardiac B19V persistence. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov ID NCT00892112.
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Affiliation(s)
- Mark R Hazebroek
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Michiel T H M Henkens
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Anne G Raafs
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Job A J Verdonschot
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands.,Department of Clinical Genetics, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Jort J Merken
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Robert M Dennert
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Casper Eurlings
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Myrurgia A Abdul Hamid
- Department of Pathology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Petra F G Wolffs
- Department of Medical Microbiology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Bjorn Winkens
- Department of Methodology and Statistics, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Hans-Peter Brunner-La Rocca
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Christian Knackstedt
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Pieter van Paassen
- Department of Nephrology and Clinical Immunology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Vanessa P M van Empel
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Stephane R B Heymans
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands.,Department of Cardiovascular Research, University of Leuven, Leuven, Belgium.,Netherlands Heart Institute (Nl-HI), Utrecht, The Netherlands
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Sanders-van Wijk S, Barandiarán Aizpurua A, Brunner-La Rocca HP, Henkens MTHM, Weerts J, Knackstedt C, Uszko-Lencer N, Heymans S, van Empel V. The HFA-PEFF and H 2 FPEF scores largely disagree in classifying patients with suspected heart failure with preserved ejection fraction. Eur J Heart Fail 2020; 23:838-840. [PMID: 33012125 PMCID: PMC8359393 DOI: 10.1002/ejhf.2019] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 09/26/2020] [Accepted: 09/26/2020] [Indexed: 01/14/2023] Open
Affiliation(s)
- Sandra Sanders-van Wijk
- Department of Cardiology, Maastricht University Medical Centre (MUMC+), Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Arantxa Barandiarán Aizpurua
- Department of Cardiology, Maastricht University Medical Centre (MUMC+), Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Hans-Peter Brunner-La Rocca
- Department of Cardiology, Maastricht University Medical Centre (MUMC+), Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Michiel T H M Henkens
- Department of Cardiology, Maastricht University Medical Centre (MUMC+), Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Jerremy Weerts
- Department of Cardiology, Maastricht University Medical Centre (MUMC+), Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Christian Knackstedt
- Department of Cardiology, Maastricht University Medical Centre (MUMC+), Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Nicole Uszko-Lencer
- Department of Cardiology, Maastricht University Medical Centre (MUMC+), Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Stephane Heymans
- Department of Cardiology, Maastricht University Medical Centre (MUMC+), Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands.,Department of Cardiovascular Research, University of Leuven, Leuven, Belgium.,Netherlands Heart Institute (ICIN), Utrecht, The Netherlands
| | - Vanessa van Empel
- Department of Cardiology, Maastricht University Medical Centre (MUMC+), Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
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van Loon T, Knackstedt C, Cornelussen R, Reesink KD, Brunner La Rocca HP, Delhaas T, van Empel V, Lumens J. Increased myocardial stiffness more than impaired relaxation function limits cardiac performance during exercise in heart failure with preserved ejection fraction: a virtual patient study. Eur Heart J Digit Health 2020; 1:40-50. [PMID: 36713963 PMCID: PMC9707905 DOI: 10.1093/ehjdh/ztaa009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 10/08/2020] [Indexed: 05/30/2023]
Abstract
AIMS The relative impact of left ventricular (LV) diastolic dysfunction (LVDD) and impaired left atrial (LA) function on cardiovascular haemodynamics in heart failure with preserved ejection fraction (HFpEF) is largely unknown. We performed virtual patient simulations to elucidate the relative effects of these factors on haemodynamics at rest and during exercise. METHODS AND RESULTS The CircAdapt cardiovascular system model was used to simulate cardiac haemodynamics in wide ranges of impaired LV relaxation function, increased LV passive stiffness, and impaired LA function. Simulations showed that LV ejection fraction (LVEF) was preserved (>50%), despite these changes in LV and LA function. Impairment of LV relaxation function decreased E/A ratio and mildly increased LV filling pressure at rest. Increased LV passive stiffness resulted in increased E/A ratio, LA dilation and markedly elevated LV filling pressure. Impairment of LA function increased E/A ratio and LV filling pressure, explaining inconsistent grading of LVDD using echocardiographic indices. Exercise simulations showed that increased LV passive stiffness exerts a stronger exercise-limiting effect than impaired LV relaxation function does, especially with impaired LA function. CONCLUSION The CircAdapt model enabled realistic simulation of virtual HFpEF patients, covering a wide spectrum of LVDD and related limitations of cardiac exercise performance, all with preserved resting LVEF. Simulations suggest that increased LV passive stiffness, more than impaired relaxation function, reduces exercise tolerance, especially when LA function is impaired. In future studies, the CircAdapt model can serve as a valuable platform for patient-specific simulations to identify the disease substrate(s) underlying the individual HFpEF patient's cardiovascular phenotype.
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Affiliation(s)
- Tim van Loon
- Department of Biomedical Engineering, CARIM School for Cardiovascular Diseases, Maastricht University, PO Box 616, 6200 MD, Maastricht, the Netherlands
| | - Christian Knackstedt
- Department of Cardiology, Maastricht University Medical Center, PO Box 616, 6200 MD, Maastricht, the Netherlands
| | - Richard Cornelussen
- Department of Physiology, CARIM School for Cardiovascular Diseases, Maastricht University, PO Box 616, 6200 MD, Maastricht, the Netherlands
- Bakken Research Center, Medtronic, Maastricht, the Netherlands
| | - Koen D Reesink
- Department of Biomedical Engineering, CARIM School for Cardiovascular Diseases, Maastricht University, PO Box 616, 6200 MD, Maastricht, the Netherlands
| | - Hans-Peter Brunner La Rocca
- Department of Cardiology, Maastricht University Medical Center, PO Box 616, 6200 MD, Maastricht, the Netherlands
| | - Tammo Delhaas
- Department of Biomedical Engineering, CARIM School for Cardiovascular Diseases, Maastricht University, PO Box 616, 6200 MD, Maastricht, the Netherlands
| | - Vanessa van Empel
- Department of Cardiology, Maastricht University Medical Center, PO Box 616, 6200 MD, Maastricht, the Netherlands
| | - Joost Lumens
- Department of Biomedical Engineering, CARIM School for Cardiovascular Diseases, Maastricht University, PO Box 616, 6200 MD, Maastricht, the Netherlands
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Van Loon T, Knackstedt C, Delhaas T, Reesink K, Brunner-La Rocca H, Van Empel V, Lumens J. From diastolic dysfunction to exercise intolerance: an in silico simulation study on the phenotypic markers of heart failure with preserved ejection fraction. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.0868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Left ventricular (LV) diastolic dysfunction, i.e. impaired LV relaxation function and/or increased LV stiffness, has been hypothesized to be responsible for at least part of the exercise intolerance in heart failure with preserved ejection fraction (HFpEF). Yet the mechanisms remain largely unknown.
Purpose
To determine in silico if and how abnormal LV diastolic function causes reduction in maximum cardiac output (COmax), i.e. exercise intolerance.
Methods
We used a cardiovascular model (CircAdapt) to simulate the effects of impaired LV relaxation and increased LV myocardial stiffness on cardiac hemodynamics. The model was initialized using a reference simulation with hypertension (systolic blood pressure: 150 mmHg) and concentric LV hypertrophy (LV wall mass: +25%). Impaired LV relaxation was introduced by increasing tau from 35 ms to 65 ms. LV stiffness was increased by increasing LV end-diastolic elastance from 0.15 mmHg/ml to 0.60 mmHg/ml and 2.00 mmHg/ml (moderate and severe LV stiffness, respectively). In each simulation, LV ejection fraction (LVEF), E/A ratio and mean left atrial (LA) pressure (mLAP) was assessed. To evaluate the effect on exercise tolerance, COmax was determined by gradually increasing cardiac output and heart rate in a predefined manner until mLAP exceeded 35 mmHg.
Results
In all simulations, LVEF remained unchanged and preserved (i.e. 60%). In rest, impaired LV relaxation decreased E/A ratio from 1.1 to 0.8 (impaired filling pattern) and increased mLAP from 7.2 mmHg to 8.0 mmHg (Figure top: gray vs. orange). Total LV filling time was reduced at rest, reducing diastolic reserve capacity and thereby of COmax, by 15% compared to the reference (Figure bottom: gray vs. orange). Moderate LV stiffness increased E/A ratio to 1.1 (pseudo-normal filling pattern) and mLAP to 15.0 mmHg (Figure top: gray vs. red). COmax was reduced by 40% due to a steep increase of mLAP with exercise intensity. Severe LV stiffness increased E/A ratio to 2.2 (i.e. restrictive filling pattern), but resulted in a non-physiological mLAP of 40 mmHg at rest. However, when combining moderate LV stiffness with LA dysfunction (i.e. reduced LA contractility and increased LA stiffness) also led to restrictive filling pattern (E/A ratio >2.0) with mLAP 19 mmHg (Figure top: red vs. dashed blue). COmax reduced most severely by 53%, emphasizing the importance of LA function in LV diastolic dysfunction (Figure bottom: gray vs. dashed blue).
Conclusions
Through variations in LV and LA function, we linked the progression of LV diastolic dysfunction to LV and LA properties. Increased LV stiffness, more than impaired LV relaxation, is associated with substantially reduced exercise tolerance. The combination of LV and LA dysfunction led to the most severe exercise intolerance. Our unique in silico framework enables future studies to investigate other potential cardiac and vascular mechanisms underlying exercise intolerance in HFpEF.
Figure 1
Funding Acknowledgement
Type of funding source: Public grant(s) – National budget only. Main funding source(s): This work was funded by the Netherlands Organisation for Scientific Research and the Dutch Heart Foundation.
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Affiliation(s)
- T Van Loon
- Cardiovascular Research Institute Maastricht (CARIM), Biomedical Engineering, Maastricht, Netherlands (The)
| | - C Knackstedt
- Maastricht University Medical Centre (MUMC+), Cardiology, Maastricht, Netherlands (The)
| | - T Delhaas
- Cardiovascular Research Institute Maastricht (CARIM), Biomedical Engineering, Maastricht, Netherlands (The)
| | - K.D Reesink
- Cardiovascular Research Institute Maastricht (CARIM), Biomedical Engineering, Maastricht, Netherlands (The)
| | - H.P Brunner-La Rocca
- Maastricht University Medical Centre (MUMC+), Cardiology, Maastricht, Netherlands (The)
| | - V.P.M Van Empel
- Maastricht University Medical Centre (MUMC+), Cardiology, Maastricht, Netherlands (The)
| | - J Lumens
- Cardiovascular Research Institute Maastricht (CARIM), Biomedical Engineering, Maastricht, Netherlands (The)
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Verdonschot JAJ, Merken JJ, van Stipdonk AMW, Pliger P, Derks KWJ, Wang P, Henkens MTHM, van Paassen P, Abdul Hamid MA, van Empel VPM, Knackstedt C, Luermans JGLM, Crijns HJGM, Brunner-La Rocca HP, Brunner HG, Poelzl G, Vernooy K, Heymans SRB, Hazebroek MR. Cardiac Inflammation Impedes Response to Cardiac Resynchronization Therapy in Patients With Idiopathic Dilated Cardiomyopathy. Circ Arrhythm Electrophysiol 2020; 13:e008727. [PMID: 32997547 DOI: 10.1161/circep.120.008727] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Cardiac resynchronization therapy (CRT) is an established therapy in patients with dilated cardiomyopathy (DCM) and conduction disorders. Still, one-third of the patients with DCM do not respond to CRT. This study aims to depict the underlying cardiac pathophysiological processes of nonresponse to CRT in patients with DCM using endomyocardial biopsies. METHODS Within the Maastricht and Innsbruck registries of patients with DCM, 99 patients underwent endomyocardial biopsies before CRT implantation, with histological quantification of fibrosis and inflammation, where inflammation was defined as >14 infiltrating cells/mm2. Echocardiographic left ventricular end-systolic volume reduction ≥15% after 6 months was defined as response to CRT. RNA was isolated from cardiac biopsies of a representative subset of responders and nonresponders. RESULTS Sixty-seven patients responded (68%), whereas 32 (32%) did not respond to CRT. Cardiac inflammation before implantation was negatively associated with response to CRT (25% of responders, 47% of nonresponders; odds ratio 0.3 [0.12-0.76]; P=0.01). Endomyocardial biopsies fibrosis did not relate to CRT response. Cardiac inflammation improved the robustness of prediction beyond well-known clinical predictors of CRT response (likelihood ratio test P<0.001). Cardiac transcriptomic profiling of endomyocardial biopsies reveals a strong proinflammatory and profibrotic signature in the hearts of nonresponders compared with responders. In particular, COL1A1, COL1A2, COL3A1, COL5A1, POSTN, CTGF, LOX, TGFβ1, PDGFRA, TNC, BGN, and TSP2 were significantly higher expressed in the hearts of nonresponders. CONCLUSIONS Cardiac inflammation along with a transcriptomic profile of high expression of combined proinflammatory and profibrotic genes are associated with a poor response to CRT in patients with DCM.
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Affiliation(s)
- Job A J Verdonschot
- Cardiovascular Research Institute (CARIM), Departments of Cardiology (J.A.J.V., J.J.M., A.M.W.v.S., M.T.H.M.H., V.P.M.v.E., C.K., J.G.L.M.L., H.J.G.M.C., H.-P.B.-L.R., K.V., S.R.B.H., M.R.H.), Maastricht University Medical Center, the Netherlands.,Clinical Genetics (J.A.J.V., K.W.J.D., P.W., H.G.B.), Maastricht University Medical Center, the Netherlands
| | - Jort J Merken
- Cardiovascular Research Institute (CARIM), Departments of Cardiology (J.A.J.V., J.J.M., A.M.W.v.S., M.T.H.M.H., V.P.M.v.E., C.K., J.G.L.M.L., H.J.G.M.C., H.-P.B.-L.R., K.V., S.R.B.H., M.R.H.), Maastricht University Medical Center, the Netherlands
| | - Antonius M W van Stipdonk
- Cardiovascular Research Institute (CARIM), Departments of Cardiology (J.A.J.V., J.J.M., A.M.W.v.S., M.T.H.M.H., V.P.M.v.E., C.K., J.G.L.M.L., H.J.G.M.C., H.-P.B.-L.R., K.V., S.R.B.H., M.R.H.), Maastricht University Medical Center, the Netherlands
| | - Philipp Pliger
- Clinical Division of Cardiology and Angiology, Innsbruck Medical University, Austria (P.P., G.P.)
| | - Kasper W J Derks
- Clinical Genetics (J.A.J.V., K.W.J.D., P.W., H.G.B.), Maastricht University Medical Center, the Netherlands
| | - Ping Wang
- Clinical Genetics (J.A.J.V., K.W.J.D., P.W., H.G.B.), Maastricht University Medical Center, the Netherlands
| | - Michiel T H M Henkens
- Cardiovascular Research Institute (CARIM), Departments of Cardiology (J.A.J.V., J.J.M., A.M.W.v.S., M.T.H.M.H., V.P.M.v.E., C.K., J.G.L.M.L., H.J.G.M.C., H.-P.B.-L.R., K.V., S.R.B.H., M.R.H.), Maastricht University Medical Center, the Netherlands
| | - Pieter van Paassen
- Immunology (P.v.P.), Maastricht University Medical Center, the Netherlands
| | | | - Vanessa P M van Empel
- Cardiovascular Research Institute (CARIM), Departments of Cardiology (J.A.J.V., J.J.M., A.M.W.v.S., M.T.H.M.H., V.P.M.v.E., C.K., J.G.L.M.L., H.J.G.M.C., H.-P.B.-L.R., K.V., S.R.B.H., M.R.H.), Maastricht University Medical Center, the Netherlands
| | - Christian Knackstedt
- Cardiovascular Research Institute (CARIM), Departments of Cardiology (J.A.J.V., J.J.M., A.M.W.v.S., M.T.H.M.H., V.P.M.v.E., C.K., J.G.L.M.L., H.J.G.M.C., H.-P.B.-L.R., K.V., S.R.B.H., M.R.H.), Maastricht University Medical Center, the Netherlands
| | - Justin G L M Luermans
- Cardiovascular Research Institute (CARIM), Departments of Cardiology (J.A.J.V., J.J.M., A.M.W.v.S., M.T.H.M.H., V.P.M.v.E., C.K., J.G.L.M.L., H.J.G.M.C., H.-P.B.-L.R., K.V., S.R.B.H., M.R.H.), Maastricht University Medical Center, the Netherlands
| | - Harry J G M Crijns
- Cardiovascular Research Institute (CARIM), Departments of Cardiology (J.A.J.V., J.J.M., A.M.W.v.S., M.T.H.M.H., V.P.M.v.E., C.K., J.G.L.M.L., H.J.G.M.C., H.-P.B.-L.R., K.V., S.R.B.H., M.R.H.), Maastricht University Medical Center, the Netherlands
| | - Hans-Peter Brunner-La Rocca
- Cardiovascular Research Institute (CARIM), Departments of Cardiology (J.A.J.V., J.J.M., A.M.W.v.S., M.T.H.M.H., V.P.M.v.E., C.K., J.G.L.M.L., H.J.G.M.C., H.-P.B.-L.R., K.V., S.R.B.H., M.R.H.), Maastricht University Medical Center, the Netherlands
| | - Han G Brunner
- Clinical Genetics (J.A.J.V., K.W.J.D., P.W., H.G.B.), Maastricht University Medical Center, the Netherlands.,GROW Institute for Developmental Biology and Cancer (H.G.B.), Maastricht University Medical Center, the Netherlands.,Department of Human Genetics, Donders Institute for Brain, Cognition and Behaviour (H.G.B.), Radboud University Medical Center, Nijmegen, the Netherlands
| | - Gerhard Poelzl
- Clinical Division of Cardiology and Angiology, Innsbruck Medical University, Austria (P.P., G.P.)
| | - Kevin Vernooy
- Cardiovascular Research Institute (CARIM), Departments of Cardiology (J.A.J.V., J.J.M., A.M.W.v.S., M.T.H.M.H., V.P.M.v.E., C.K., J.G.L.M.L., H.J.G.M.C., H.-P.B.-L.R., K.V., S.R.B.H., M.R.H.), Maastricht University Medical Center, the Netherlands.,Department of Cardiology (K.V.), Radboud University Medical Center, Nijmegen, the Netherlands
| | - Stephane R B Heymans
- Cardiovascular Research Institute (CARIM), Departments of Cardiology (J.A.J.V., J.J.M., A.M.W.v.S., M.T.H.M.H., V.P.M.v.E., C.K., J.G.L.M.L., H.J.G.M.C., H.-P.B.-L.R., K.V., S.R.B.H., M.R.H.), Maastricht University Medical Center, the Netherlands.,Department of Cardiovascular Sciences, Centre for Molecular and Vascular Biology, KU Leuven, Belgium (S.R.B.H.).,The Netherlands Heart Institute, Nl-HI, Utrecht (S.R.B.H.)
| | - Mark R Hazebroek
- Cardiovascular Research Institute (CARIM), Departments of Cardiology (J.A.J.V., J.J.M., A.M.W.v.S., M.T.H.M.H., V.P.M.v.E., C.K., J.G.L.M.L., H.J.G.M.C., H.-P.B.-L.R., K.V., S.R.B.H., M.R.H.), Maastricht University Medical Center, the Netherlands
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Verdonschot JA, Merken JJ, Brunner-La Rocca HP, Hazebroek MR, Eurlings CG, Thijssen E, Wang P, Weerts J, van Empel V, Schummers G, Schreckenberg M, van den Wijngaard A, Lumens J, Brunner HG, Heymans SR, Krapels IP, Knackstedt C. Value of Speckle Tracking–Based Deformation Analysis in Screening Relatives of Patients With Asymptomatic Dilated Cardiomyopathy. JACC Cardiovasc Imaging 2020; 13:549-558. [DOI: 10.1016/j.jcmg.2019.02.032] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 02/23/2019] [Accepted: 02/28/2019] [Indexed: 01/04/2023]
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Simonavičius J, Sanders van-Wijk S, Rickenbacher P, Maeder MT, Pfister O, Kaufmann BA, Pfisterer M, Čelutkienė J, Puronaitė R, Knackstedt C, van Empel V, Brunner-La Rocca HP. Prognostic Significance of Longitudinal Clinical Congestion Pattern in Chronic Heart Failure: Insights From TIME-CHF Trial. Am J Med 2019; 132:e679-e692. [PMID: 31051151 DOI: 10.1016/j.amjmed.2019.04.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 04/06/2019] [Accepted: 04/08/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND The relationship between longitudinal clinical congestion pattern and heart failure outcome is uncertain. This study was designed to assess the prevalence of congestion over time and to investigate its impact on outcome in chronic heart failure. METHODS A total of 588 patients with chronic heart failure older than 60 years of age with New York Heart Association (NYHA) functional class ≥II from the TIME-CHF study were included. The endpoints for this study were survival and hospitalization-free heart failure survival. Orthopnea, NYHA ≥III, paroxysmal nocturnal dyspnea, hepatomegaly, peripheral pitting edema, jugular venous distension, and rales were repeatedly investigated and related to outcomes. These congestion-related signs and symptoms were used to design a 7-item Clinical Congestion Index. RESULTS Sixty-one percent of patients had a Clinical Congestion Index ≥3 at baseline, which decreased to 18% at month 18. During the median [interquartile range] follow-up of 27.2 [14.3-39.8] months, 17%, 27%, and 47% of patients with baseline Clinical Congestion Index of 0, 1-2, and ≥3 at inclusion, respectively, died (P <.001). Clinical Congestion Index was identified as an independent predictor of mortality at all visits (P <.05) except month 6 and reduced hospitalization-free heart failure survival (P <.05). Successful decongestion was related to better outcome as compared to persistent congestion or partial decongestion (log-rank P <0.001). CONCLUSIONS The extent of congestion as assessed by means of clinical signs and symptoms decreased over time with intensified treatment, but it remained present or relapsed in a substantial number of patients with heart failure and was associated with poor outcome. This highlights the importance of appropriate decongestion in chronic heart failure.
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Affiliation(s)
- Justas Simonavičius
- Centre of Cardiology and Angiology, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania; Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands.
| | | | - Peter Rickenbacher
- Department of Cardiology, University Hospital Bruderholz, Bruderholz, Switzerland
| | - Micha T Maeder
- Department of Cardiology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Otmar Pfister
- Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Beat A Kaufmann
- Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | | | - Jelena Čelutkienė
- Institute of Clinical Medicine, Medical Faculty of Vilnius University, Vilnius, Lithuania
| | - Roma Puronaitė
- Department of Information Systems, Centre of Informatics and Development, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania; Clinic of Cardiac and Vascular diseases, Faculty of Medicine, Vilnius University, Vilnius, Lithuania; Institute of Data Science and Digital Technologies, Faculty of Mathematics and Informatics, Vilnius University, Vilnius, Lithuania
| | - Christian Knackstedt
- Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Vanessa van Empel
- Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Hans-Peter Brunner-La Rocca
- Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands; Department of Cardiology, University Hospital Basel, Basel, Switzerland
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Gingele AJ, Ramaekers B, Brunner-La Rocca HP, De Weerd G, Kragten J, van Empel V, van der Weg K, Vrijhoef HJM, Gorgels A, Cleuren G, Boyne JJJ, Knackstedt C. Effects of tailored telemonitoring on functional status and health-related quality of life in patients with heart failure. Neth Heart J 2019; 27:565-574. [PMID: 31414308 PMCID: PMC6823399 DOI: 10.1007/s12471-019-01323-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Background Functional status and health-related quality of life (HRQoL) are important in patients with heart failure (HF). Little is known about the effect of telemonitoring on functional status and HRQoL in that population. Methods and results A total of 382 patients with HF (New York Heart Association class 2–4) were included in a randomised controlled trial to investigate the effect of tailored telemonitoring on improving HRQoL and functional status in HF patients. Randomisation was computer-generated with stratification per centre. At baseline and after 12 months, patients’ functional status was determined by metabolic equivalent scores (METS). HRQoL was measured with the EuroQol five dimensions questionnaire (EQ-5D), visual analogue scale (VAS) and Borg rating of perceived exertion scale (Borg). Additional outcome data included number of HF-related outpatient clinic visits and mortality. Telemonitoring was statistically significantly related to an increase in METS after 1 year (regression coefficient 0.318; p = 0.01). Telemonitoring did not improve Borg, EQ-5D or VAS scores after 1 year. EQ-5D [hazard ratio (HR) 0.20, 95% confidence interval (CI) 0.07–0.54], VAS (HR 0.98, 95% CI 0.96–0.99), Borg (HR 1.21, 95% CI 1.11–1.31) and METS (HR 0.73, 95% CI 0.58–0.93) at baseline were significantly associated with survival after 12 months. Conclusions Tailored telemonitoring stabilised the functional status of HF patients but did not improve HRQoL. Therefore, telemonitoring may help to prevent deterioration of exercise capacity in patients with HF. However, because our study is a reanalysis of a randomised controlled trial (RCT), this is considered hypothesis-generating and should be confirmed by adequately powered RCTs. Electronic supplementary material The online version of this article (10.1007/s12471-019-01323-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- A J Gingele
- Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - B Ramaekers
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - H P Brunner-La Rocca
- Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - G De Weerd
- Department of Cardiology, Zuyderland Hospital, Sittard, The Netherlands
| | - J Kragten
- Department of Cardiology, Zuyderland Hospital, Heerlen, The Netherlands
| | - V van Empel
- Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - K van der Weg
- Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - H J M Vrijhoef
- Department of Patient and Care, Maastricht University Medical Centre, Maastricht, The Netherlands
- Panaxea b.v., Amsterdam, The Netherlands
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel, Brussels, Belgium
| | - A Gorgels
- Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - G Cleuren
- Department of Patient and Care, Maastricht University Medical Centre, Maastricht, The Netherlands
- CAPHRI, Department of Health Services Research, Maastricht University, Maastricht, The Netherlands
| | - J J J Boyne
- Department of Patient and Care, Maastricht University Medical Centre, Maastricht, The Netherlands
- CAPHRI, Department of Health Services Research, Maastricht University, Maastricht, The Netherlands
| | - C Knackstedt
- Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands.
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Merken J, Hazebroek M, Van Paassen P, Verdonschot J, Van Empel V, Knackstedt C, Abdul Hamid M, Seiler M, Kolb J, Hoermann P, Ensinger C, Brunner-La Rocca HP, Poelzl G, Heymans S. Immunosuppressive Therapy Improves Both Short- and Long-Term Prognosis in Patients With Virus-Negative Nonfulminant Inflammatory Cardiomyopathy. Circ Heart Fail 2019; 11:e004228. [PMID: 29449368 DOI: 10.1161/circheartfailure.117.004228] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 01/19/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Inflammatory cardiomyopathy (infl-CMP) is characterized by increased cardiac inflammation in the absence of viruses, ischemia, valvular disease, or other apparent causes. Studies addressing the efficacy of immunosuppressive therapy in patients with infl-CMP are sparse. This study retrospectively investigates whether immunosuppressive agents on top of heart failure therapy according to current guidelines improves cardiac function and long-term outcome in patients with infl-CMP. METHODS AND RESULTS Within the Innsbruck and Maastricht Cardiomyopathy Registry, a total of 209 patients fulfilled the criteria for infl-CMP using endomyocardial biopsy (≥14 infiltrating inflammatory cells/mm2). A total of 110 (53%) patients received immunosuppressive therapy and 99 (47%) did not. To correct for potential selection bias, 1:1 propensity score matching was used on all significant baseline parameters, resulting in a total of 90 patients per group. Baseline characteristics did not significantly differ between both patient groups, reflecting optimal propensity score matching. After a median follow-up of 31 (15-47) months, immunosuppressive therapy resulted in an improved long-term outcome (eg, heart transplantation-free survival) as compared with standard heart failure therapy alone (Log-rank P=0.043; hazard ratio, 0.34 [95% CI, 0.17-0.92]) and in a significant larger increase of left ventricular ejection fraction after a mean of 12 months follow-up, as compared with patients receiving standard heart failure treatment only (12.2% versus 7.3%, respectively; P=0.036). CONCLUSIONS To conclude, this study suggests that immunosuppressive therapy in infl-CMP patients results in an improved heart transplantation-free survival as compared with standard heart failure therapy alone, underscoring the urgent need for a large prospective multicenter trial.
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Affiliation(s)
- Jort Merken
- From the Cardiology Department (J.M., M.H., J.V., V.V.E., C.K., H.-P.B.-L.R., S.H.), Immunology Department (P.V.P.), and Pathology Department (M.A.H.), Maastricht University Medical Center, The Netherlands; and Clinical Division of Cardiology and Angiology (M.S., J.K., P.H., G.P.) and Institute of Pathology (C.E.), Innsbruck Medical University, Austria.
| | - Mark Hazebroek
- From the Cardiology Department (J.M., M.H., J.V., V.V.E., C.K., H.-P.B.-L.R., S.H.), Immunology Department (P.V.P.), and Pathology Department (M.A.H.), Maastricht University Medical Center, The Netherlands; and Clinical Division of Cardiology and Angiology (M.S., J.K., P.H., G.P.) and Institute of Pathology (C.E.), Innsbruck Medical University, Austria
| | - Pieter Van Paassen
- From the Cardiology Department (J.M., M.H., J.V., V.V.E., C.K., H.-P.B.-L.R., S.H.), Immunology Department (P.V.P.), and Pathology Department (M.A.H.), Maastricht University Medical Center, The Netherlands; and Clinical Division of Cardiology and Angiology (M.S., J.K., P.H., G.P.) and Institute of Pathology (C.E.), Innsbruck Medical University, Austria
| | - Job Verdonschot
- From the Cardiology Department (J.M., M.H., J.V., V.V.E., C.K., H.-P.B.-L.R., S.H.), Immunology Department (P.V.P.), and Pathology Department (M.A.H.), Maastricht University Medical Center, The Netherlands; and Clinical Division of Cardiology and Angiology (M.S., J.K., P.H., G.P.) and Institute of Pathology (C.E.), Innsbruck Medical University, Austria
| | - Vanessa Van Empel
- From the Cardiology Department (J.M., M.H., J.V., V.V.E., C.K., H.-P.B.-L.R., S.H.), Immunology Department (P.V.P.), and Pathology Department (M.A.H.), Maastricht University Medical Center, The Netherlands; and Clinical Division of Cardiology and Angiology (M.S., J.K., P.H., G.P.) and Institute of Pathology (C.E.), Innsbruck Medical University, Austria
| | - Christian Knackstedt
- From the Cardiology Department (J.M., M.H., J.V., V.V.E., C.K., H.-P.B.-L.R., S.H.), Immunology Department (P.V.P.), and Pathology Department (M.A.H.), Maastricht University Medical Center, The Netherlands; and Clinical Division of Cardiology and Angiology (M.S., J.K., P.H., G.P.) and Institute of Pathology (C.E.), Innsbruck Medical University, Austria
| | - Myrurgia Abdul Hamid
- From the Cardiology Department (J.M., M.H., J.V., V.V.E., C.K., H.-P.B.-L.R., S.H.), Immunology Department (P.V.P.), and Pathology Department (M.A.H.), Maastricht University Medical Center, The Netherlands; and Clinical Division of Cardiology and Angiology (M.S., J.K., P.H., G.P.) and Institute of Pathology (C.E.), Innsbruck Medical University, Austria
| | - Michael Seiler
- From the Cardiology Department (J.M., M.H., J.V., V.V.E., C.K., H.-P.B.-L.R., S.H.), Immunology Department (P.V.P.), and Pathology Department (M.A.H.), Maastricht University Medical Center, The Netherlands; and Clinical Division of Cardiology and Angiology (M.S., J.K., P.H., G.P.) and Institute of Pathology (C.E.), Innsbruck Medical University, Austria
| | - Julian Kolb
- From the Cardiology Department (J.M., M.H., J.V., V.V.E., C.K., H.-P.B.-L.R., S.H.), Immunology Department (P.V.P.), and Pathology Department (M.A.H.), Maastricht University Medical Center, The Netherlands; and Clinical Division of Cardiology and Angiology (M.S., J.K., P.H., G.P.) and Institute of Pathology (C.E.), Innsbruck Medical University, Austria
| | - Philipp Hoermann
- From the Cardiology Department (J.M., M.H., J.V., V.V.E., C.K., H.-P.B.-L.R., S.H.), Immunology Department (P.V.P.), and Pathology Department (M.A.H.), Maastricht University Medical Center, The Netherlands; and Clinical Division of Cardiology and Angiology (M.S., J.K., P.H., G.P.) and Institute of Pathology (C.E.), Innsbruck Medical University, Austria
| | - Christian Ensinger
- From the Cardiology Department (J.M., M.H., J.V., V.V.E., C.K., H.-P.B.-L.R., S.H.), Immunology Department (P.V.P.), and Pathology Department (M.A.H.), Maastricht University Medical Center, The Netherlands; and Clinical Division of Cardiology and Angiology (M.S., J.K., P.H., G.P.) and Institute of Pathology (C.E.), Innsbruck Medical University, Austria
| | - Hans-Peter Brunner-La Rocca
- From the Cardiology Department (J.M., M.H., J.V., V.V.E., C.K., H.-P.B.-L.R., S.H.), Immunology Department (P.V.P.), and Pathology Department (M.A.H.), Maastricht University Medical Center, The Netherlands; and Clinical Division of Cardiology and Angiology (M.S., J.K., P.H., G.P.) and Institute of Pathology (C.E.), Innsbruck Medical University, Austria
| | - Gerhard Poelzl
- From the Cardiology Department (J.M., M.H., J.V., V.V.E., C.K., H.-P.B.-L.R., S.H.), Immunology Department (P.V.P.), and Pathology Department (M.A.H.), Maastricht University Medical Center, The Netherlands; and Clinical Division of Cardiology and Angiology (M.S., J.K., P.H., G.P.) and Institute of Pathology (C.E.), Innsbruck Medical University, Austria
| | - Stephane Heymans
- From the Cardiology Department (J.M., M.H., J.V., V.V.E., C.K., H.-P.B.-L.R., S.H.), Immunology Department (P.V.P.), and Pathology Department (M.A.H.), Maastricht University Medical Center, The Netherlands; and Clinical Division of Cardiology and Angiology (M.S., J.K., P.H., G.P.) and Institute of Pathology (C.E.), Innsbruck Medical University, Austria
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van Mourik MJ, Zaar DV, Smulders MW, Heijman J, Lumens J, Dokter JE, Lima Passos V, Schalla S, Knackstedt C, Schummers G, Gjesdal O, Edvardsen T, Bekkers SC. Adding Speckle-Tracking Echocardiography to Visual Assessment of Systolic Wall Motion Abnormalities Improves the Detection of Myocardial Infarction. J Am Soc Echocardiogr 2019; 32:65-73. [DOI: 10.1016/j.echo.2018.09.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Indexed: 12/17/2022]
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Merken J, Brunner-La Rocca HP, Weerts J, Verdonschot J, Hazebroek M, Schummers G, Schreckenberg M, Lumens J, Heymans S, Knackstedt C. Heart Failure With Recovered Ejection Fraction. J Am Coll Cardiol 2018; 72:1557-1558. [DOI: 10.1016/j.jacc.2018.06.070] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 06/14/2018] [Accepted: 06/20/2018] [Indexed: 11/29/2022]
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Leicht L, Skobel E, Knackstedt C, Mathissen M, Sitter A, Wartzek T, Mohler W, Reith S, Leonhardt S, Teichmann D. Capacitive ECG Monitoring in Cardiac Patients During Simulated Driving. IEEE Trans Biomed Eng 2018; 66:749-758. [PMID: 30004869 DOI: 10.1109/tbme.2018.2855661] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVE This study aims to compare the informative value of a capacitively coupled electrocardiogram (cECG) to a conventional galvanic reference ECG (rECG) in patients after a major cardiac event under simulated driving conditions. Addressed research questions are the comparison and coherence of cECG and rECG by means of the signal quality, the artifact rate, the rate of assessable data for differential diagnosis, the visibility of characteristic ECG structures in cECG, the precision of ECG time intervals, and heart rate (in particular, despite possible waveform deformations due to the cardiac preconditions). METHODS In a clinical trial, cECG and rECG data were recorded from ten patients after a major cardiac event. The cECG and rECG data were blindly evaluated by two cardiologists with regard to signal quality, artifacts, assessable data for differential diagnosis, visibility of ECG structures, and ECG time intervals. The results were statistically compared. RESULTS The cECG presented with more artifacts, an inferior signal quality, and less assessable data. However, when the data were assessable, determination of the ECG interval lengths was coherent to the one obtained from the rECG. CONCLUSION When the signal quality is sufficient, the cECG yields the same informative value as the rECG. SIGNIFICANCE For certain scenarios, cECG might replace rECG systems. Hence, it is an important research question whether a similar amount of information can be obtained using a cECG system.
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Baldewijns K, Bektas S, Boyne J, Rohde C, De Maesschalck L, De Bleser L, Brandenburg V, Knackstedt C, Devillé A, Sanders-Van Wijk S, Brunner La Rocca HP. Improving kNowledge Transfer to Efficaciously RAise the level of Contemporary Treatment in Heart Failure (INTERACT-in-HF): Study protocol of a mixed methods study. Int J Care Coord 2018; 20:171-182. [PMID: 29472989 PMCID: PMC5808819 DOI: 10.1177/2053434517726318] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Heart failure is a complex disease with poor outcome. This complexity may prevent care providers from covering all aspects of care. This could not only be relevant for individual patient care, but also for care organisation. Disease management programmes applying a multidisciplinary approach are recommended to improve heart failure care. However, there is a scarcity of research considering how disease management programme perform, in what form they should be offered, and what care and support patients and care providers would benefit most. Therefore, the Improving kNowledge Transfer to Efficaciously Raise the level of Contemporary Treatment in Heart Failure (INTERACT-in-HF) study aims to explore the current processes of heart failure care and to identify factors that may facilitate and factors that may hamper heart failure care and guideline adherence. Within a cross-sectional mixed method design in three regions of the North-West part of Europe, patients (n = 88) and their care providers (n = 59) were interviewed. Prior to the in-depth interviews, patients were asked to complete three questionnaires: The Dutch Heart Failure Knowledge scale, The European Heart Failure Self-care Behaviour Scale and The global health status and social economic status. In parallel, retrospective data based on records from these (n = 88) and additional patients (n = 82) are reviewed. All interviews were audiotaped and transcribed verbatim for analysis.
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Affiliation(s)
| | - Sema Bektas
- Department of Cardiology, Maastricht University Medical Center, the Netherlands
| | - Josiane Boyne
- Department of Cardiology, Maastricht University Medical Center, the Netherlands
| | - Carla Rohde
- Department of Cardiology, Maastricht University Medical Center, the Netherlands
| | | | - Leentje De Bleser
- Health Care Department, Thomas More University College Mechelen-Antwerpen, Belgium
| | | | | | - Aleidis Devillé
- Social Work Department, Thomas More University College Kempen, Belgium
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