Incidence and outcome of myocardial infarction treated with percutaneous coronary intervention during COVID-19 pandemic

Objective

Most reports on the declining incidence of myocardial infarction (MI) during the COVID-19 have either been anecdotal, survey results or geographically limited to areas with lockdowns. We examined the incidence of MI during the COVID-19 pandemic in Sweden, which has remained an open society with a different public health approach fighting COVID-19.

Methods

We assessed the incidence rate (IR) as well as the incidence rate ratios (IRRs) of all MI referred for coronary angiography in Sweden using the nationwide Swedish Coronary Angiography and Angioplasty Registry (SCAAR), during the COVID-19 pandemic in Sweden (1 March 2020–7 May 2020) in relation to the same days 2015–2019.

Results

A total of 2443 MIs were referred for coronary angiography during the COVID-19 pandemic resulting in an IR 36 MIs/day (204 MIs/100 000 per year) compared with 15 213 MIs during the reference period with an IR of 45 MIs/day (254 MIs/100 000 per year) resulting in IRR of 0.80, 95% CI (0.74 to 0.86), p<0.001. Results were consistent in all investigated patient subgroups, indicating no change in patient category seeking cardiac care. Kaplan-Meier event rates for 7-day case fatality were 439 (2.3%) compared with 37 (2.9%) (HR: 0.81, 95% CI (0.58 to 1.13), p=0.21). Time to percutaneous coronary intervention (PCI) was shorter during the pandemic and PCI was equally performed, indicating no change in quality of care during the pandemic.

Conclusion

The COVID-19 pandemic has significantly reduced the incidence of MI referred for invasive treatment strategy. No differences in overall short-term case fatality or quality of care indicators were observed.

Relations between implementation of new treatments and improved outcomes in patients with non-ST-elevation myocardial infarction during the last 20 years: experiences from SWEDEHEART registry 1995 to 2014

Aims

We assessed the changes in short- and long-term outcomes and their relation to implementation of new evidence-based treatments in all patients with non-ST-elevation myocardial infarction (NSTEMI) in Sweden over 20 years.

Methods and results

Cases with NSTEMI (n = 205 693) between 1995 and 2014 were included from the nationwide Swedish Web-System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies (SWEDEHEART) registry. During 20 years in-hospital invasive procedures increased from 1.9% to 73.2%, percutaneous coronary intervention or coronary artery bypass grafting 6.5% to 58.1%, dual antiplatelet medication 0% to 72.7%, statins 13.3% to 85.6%, and angiotensin-converting enzyme inhibitors/angiotensin II receptor blocker 36.8% to 75.5%. The standardized 1-year mortality ratio compared with a control population decreased from 5.53 [95% confidence interval (CI) 5.30-5.75] to 3.03 (95% CI 2.89-3.19). If patients admitted the first 2 years were modelled to receive the same invasive treatments as the last 2 years the expected mortality/myocardial infarction (MI) rate would be reduced from 33.0% to 25.0%. After adjusting for differences in baseline characteristics, the change of 1-year cardiovascular death/MI corresponded to a linearly decreasing odds ratio trend of 0.930 (95% CI 0.926-0.935) per 2-year period. This trend was substantially attenuated [0.970 (95% CI 0.964-0.975)] after adjusting for changes in coronary interventions, and almost eliminated [0.988 (95% CI 0.982-0.994)] after also adjusting for changes in discharge medications.

Conclusion

In NSTEMI patients during the last 20 years, there has been a substantial improvement in long-term survival and reduction in the risk of new cardiovascular events. These improvements seem mainly explained by the gradual uptake and widespread use of in-hospital coronary interventions and evidence-based long-term medications.

Improved outcomes in patients with ST-elevation myocardial infarction during the last 20 years are related to implementation of evidence-based treatments: experiences from the SWEDEHEART registry 1995-2014

Aims

Impact of changes of treatments on outcomes in ST-elevation myocardial infarction (STEMI) patients in real-life health care has not been documented.

Methods and results

All STEMI cases (n = 105.674) registered in the nation-wide SWEDEHEART registry between 1995 and 2014 were included and followed for fatal and non-fatal outcomes for up to 20 years. Most changes in treatment and outcomes occurred from 1994 to 2008. Evidence-based treatments increased: reperfusion from 66.2 to 81.7%; primary percutaneous coronary intervention: 4.5 to 78.0%; dual antiplatelet therapy from 0 to 89.6%; statin: 14.1 to 93.6%; beta-blocker: 78.2 to 91.0%, and angiotensin-converting-enzyme/angiotensin-2-receptor inhibitors: 40.8 to 85.2% (P-value for-trend <0.001 for all). One-year mortality decreased from 22.1 to 14.1%. Standardized incidence ratio compared with the general population decreased from 5.54 to 3.74 (P < 0.001). Cardiovascular (CV) death decreased from 20.1 to 11.1%, myocardial infarction (MI) from 11.5 to 5.8%; stroke from 2.9 to 2.1%; heart failure from 7.1 to 6.2%. After standardization for differences in demography and baseline characteristics, the change of 1-year CV-death or MI corresponded to a linear trend of 0.915 (95% confidence interval: 0.906–0.923) per 2-year period which no longer was significant, 0.997 (0.984–1.009), after adjustment for changes in treatment. The changes in treatment and outcomes were most pronounced from 1994 to 2008.

Conclusion

Gradual implementation of new and established evidence-based treatments in STEMI patients during the last 20 years has been associated with prolonged survival and lower risk of recurrent ischaemic events, although a plateauing is seen since around 2008.

Adrenergic and cardiac dysfunction in primary hyperparathyroidism

OBJECTIVE

Primary hyperparathyroidism (PHPT) is associated with cardiovascular morbidity and premature death, but the underlying mechanisms are incompletely understood. The aim of this study was to investigate whether adrenergic dysfunction may be a contributing factor.

PATIENTS AND METHODS

Forty-nine patients with mild PHPT (serum calcium 2·7 ± 0·1 mM) and 48 control subjects, matched for age and sex, were examined; patients within 1 month before parathyroidectomy (PTX) and 6 months postoperatively; control subjects at inclusion. Heart rate variability (HRV) was analysed in 24-h electrocardiograms, and plasma concentrations of epinephrine and norepinephrine were measured at rest and immediately after standardized physical tests.

RESULTS

At baseline, the patients showed, compared to the controls, reduced stress-related increase of circulating epinephrine (P < 0·05) and norepinephrine (P < 0·05). No significant change was observed 6 months after PTX. At baseline, there were no significant differences between patients and controls in HRV or heart rate, but 6 months after curative PTX, the patients showed significantly reduced HRV in both frequency and time domain, and their maximum and average heart rate had decreased (P = 0·011 and P = 0·018, respectively). The patients with the highest preoperative levels of circulating parathyroid hormone showed the greatest changes in heart rate and HRV postoperatively.

CONCLUSIONS

This study demonstrates a previously unknown impairment of catecholamine response to physical stress in PHPT along with changes of HRV, also indicating adrenergic dysfunction. These factors should be considered in the ongoing controversy regarding the management of patients with mild 'asymptomatic' PHPT.

Visually estimated left ventricular ejection fraction by echocardiography is closely correlated with formal quantitative methods

BACKGROUND

Simpson ejection fraction, wall motion score index, atrioventricular (AV) plane displacement and fractional shortening are all established formal echocardiographic methods for the assessment of left ventricular systolic function. Visually estimated (eyeballing) ejection fraction may be considered somewhat more subjective, although shown to correlate well with radionuclide ventriculography. We aimed to explore if echocardiographic eyeballing ejection fraction is comparable to formal methods for the evaluation of left ventricular systolic function.

METHODS

We assessed 89 consecutive patients after myocardial infarction or before coronary angiography. Eyeballing ejection fraction and wall motion score index were evaluated in the long-axis, short-axis and apical four- and two-chamber views. Simpson ejection fraction and AV plane displacement were assessed in the apical views. Fractional shortening was measured in the parasternal long-axis view. The respective systolic function measurements were in each patient made at different time points by a single investigator, masked to prior results.

RESULTS

All formal methods correlated significantly with eyeballing ejection fraction (p<0.001): AV plane displacement, R=0.647; FS, R=0.684; four-chamber Simpson ejection fraction, R=0.857; biplane Simpson ejection fraction, R=0.898; and wall motion score index, R=0.919.

CONCLUSION

Eyeballing ejection fraction correlated closely with all formal methods and the correlation coefficient improved with the reliability of the formal method. This finding is in concordance with prior studies, indicating that eyeballing ejection fraction may be the most accurate echocardiographic method for the assessment of left ventricular systolic function. Since it is readily and quickly performed, eyeballing ejection fraction could be used for routine echocardiography instead of formal methods.

Primary hyperparathyroidism and heart disease--a review

Primary hyperparathyroidism (pHPT), caused by solitary parathyroid adenomas in 85% of cases and diffuse hyperplasia in most of the remaining cases, overproduces parathyroid hormone (PTH), which mobilizes calcium to the blood stream. Renal stones, osteoporosis and diffuse symptoms of hypercalcaemia, such as constipation, fatigue and weakness are well-known complications. However, in Western Europe and North America, patients with pHPT are nowadays usually discovered during an early, asymptomatic phase of the disease. It has been reported that patients suffering from symptomatic pHPT have increased mortality, mainly due to an overrepresentation of cardiovascular death. pHPT is reported to be associated with hypertension, disturbances in the renin-angiotensin-aldosterone system, and structural and functional alterations in the vascular wall. Recently, studies have indicated an association between pHPT and heart disease, and studies in vitro have produced a number of theoretical approaches. An increased prevalence of cardiac structural abnormalities such as left ventricular hypertrophy (LVH) and valvular and myocardial calcification has been observed. Associations have been found between PTH and LVH, and between LVH and serum calcium. LV systolic function does not seem to be affected in patients with pHPT, whereas any influence on LV diastolic performance needs further evaluation. The aim of this review is to clarify the connection between pHPT and cardiac disease.

Left atrioventricular plane displacement but not left ventricular ejection fraction is influenced by the degree of aortic stenosis

AIMS

To examine how left atrioventricular plane displacement (AVPD), a widely used measure of left ventricular (LV) function, is related to presence and degree of aortic stenosis.

METHODS AND RESULTS

Cardiac dimensions, LV filling, left AVPD, LV ejection fraction (LVEF), and valve function were assessed by echocardiography/Doppler in 182 patients with various cardiac diseases (mean (SD) age 69 (12) years, 36% women), 49 consecutive with and 133 consecutive without aortic stenosis. In an analysis of covariance, neither left AVPD nor LVEF was independently correlated with the presence of aortic stenosis. However, looking separately at patients with aortic stenosis, left AVPD (p = 0.03) but not LVEF correlated independently with degree of aortic stenosis in multiple linear regression analysis. In patients with aortic stenosis, an abnormal left AVPD had 94% sensitivity and 90% negative predictive value with regard to severe aortic stenosis, compared with 56% and 62%, respectively, for LVEF.

CONCLUSION

In patients with cardiac disease, neither left AVPD nor LVEF correlated independently with presence of aortic stenosis. However, in patients with aortic stenosis, left AVPD but not LVEF correlated with the degree of aortic valve obstruction and left AVPD but not LVEF had high sensitivity and negative predictive value with regard to severe aortic stenosis. Compared with LVEF, left AVPD is an earlier and more sensitive marker of LV haemodynamic load in patients with aortic stenosis.

Left atrioventricular plane displacement determined by echocardiography: a clinically useful, independent predictor of mortality in patients with stable coronary artery disease

BACKGROUND

Echocardiographically determined left atrioventricular plane displacement (AVPD) is strongly related to prognosis in patients with chronic heart failure and in postmyocardial infarction patients. We aimed at exploring whether AVPD, unlike ejection fraction, is related to mortality in patients with stable coronary artery disease (CAD).

METHODS AND RESULTS

Atrioventricular plane displacement was assessed by two dimensionally guided M-mode echocardiography in the four and two chamber views, in 333 consecutive patients with stable CAD and an abnormal coronary angiogram. Patients were followed up for an average of 41 months. AVPD was lower in patients who died (n= 30, 9.0 %) compared with survivors (9.0 +/- 2.2 vs. 11.5 +/- 2.1 mm, P<0.0001). Amongst patients with prior myocardial infarction (n=184) AVPD was 8.7 +/- 2.3 mm in those who died (n=17) and 11.2 +/- 2.3 mm in the survivors (P<0.0001). In patients without prior myocardial infarction (n=149), AVPD was 9.4 +/- 2.1 (n=13) and 11.8 +/- 1.8 mm, respectively (P<0.0001). Age, AVPD and four other echocardiographical variables correlated significantly with prognosis in univariate logistic regression analysis. In multiple logistic regression analysis only AVPD (P<0.0001) correlated independently with mortality.

CONCLUSION

Echocardiographically determined AVPDis a clinically useful, independent prognostic tool in patients with stable CAD. The presence of a documented previous myocardial infarction does not influence this observation.

Left atrioventricular plane displacement predicts cardiac mortality in patients with chronic atrial fibrillation

AIM

The aim of the present study was to investigate if left atrioventricular plane displacement (AVPD) has a prognostic value in patients with atrial fibrillation.

METHODS AND RESULTS

Left AVPD was assessed by two-dimensionally guided M-mode echocardiography in the four- and two-chamber views in 160 consecutive patients with chronic atrial fibrillation, who were followed up with regard to mortality for an average of 45 months. All-cause mortality during follow-up was 49% (n=78). AVPD was lower in patients who died compared to those who survived: 6.6+/-1.7 versus 7.5+/-1.7 mm, P=0.0005. In 49 patients (31%), death was due to chronic heart failure or acute myocardial infarction. Among those who died of cardiac events, AVPD was 6.3+/-1.6 mm, versus 7.1+/-1.8 mm among those who died of other causes, P=0.0001. In multiple logistic regression analysis, AVPD (P=0.005), age (P=0.0005), and a history of chronic heart failure (P=0.004) correlated independently with mortality.

CONCLUSION

Left AVPD was clearly decreased in patients with atrial fibrillation. The decrease was most pronounced in patients who died of cardiac events, whereas it did not differ significantly between those who died of non-cardiac causes and those who survived. The discriminative value of left AVPD was limited.

Safety and efficacy of valsartan versus enalapril in heart failure patients

Although a cornerstone in the treatment of heart failure, angiotensin-converting enzyme inhibitors are under-used, partly due to side effects. If proven at least similarly efficacious to angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers may replace them due to their superior tolerability. We aimed to compare the efficacy and safety of valsartan and enalapril in heart failure patients stabilised on an angiotensin-converting enzyme inhibitor. We randomised 141 patients (mean 68 years, 74% males) with stable mild/moderate heart failure and left ventricular ejection fraction 0.45 or less, to valsartan 160 mg q.d. (n=70) or enalapril 10 mg b.i.d. (n=71) for 12 weeks. Changes in 6-min-walk test (primary efficacy variable), patients' wellbeing and left ventricular size and function did not differ significantly between the treatment groups. Valsartan was significantly non-inferior to enalapril in walk test distance change: least-square means treatment difference +1.12 m (95% confidence interval -21.9 to 24.1), non-inferiority P<0.001. Left ventricular size (P<0.001) and function (P=0.048) improved significantly only in the valsartan group. Fewer patients experienced adverse events in the valsartan group (50%) than in the enalapril group (63%), although statistically non-significant. Valsartan is similarly efficacious and safe to enalapril in patients with stable, mild/moderate heart failure, previously stabilised on an angiotensin-converting enzyme inhibitor and directly switched to study medication.

Echocardiographic assessment of left atrioventricular plane displacement as a complement to left ventricular regional wall motion evaluation in the detection of myocardial dysfunction

AIM

We aimed to find out if abnormal left atrioventricular plane displacement (AVPD) is a sign of myocardial dysfunction, even in patients with normal left ventricular (LV) regional wall motion (RWM).

METHODS

We prospectively performed echocardiography in 1350 consecutive patients referred to our echocardiography laboratory. Left AVPD and LV RWM were evaluated in all patients. We prospectively selected all patients with normal LV RWM but impaired left AVPD for further analysis of clinical parameters.

RESULTS

Eighty-eight of the 1350 patients had completely normal LV RWM but impaired left AVPD (< or = 10 mm) in at least one region (septal, lateral, posterior, anterior). Of these, 60.2% had prior and/ or acute myocardial infarction, predominantly non-Q-wave, whereas 33.0% had angina without infarction and 2.3% had hypertension. In 49 (55.7%) patients coronary angiography was performed. All were abnormal. In 4.5% (n = 4) of the patients no obvious reason for the AVPD decrease was found, but was not precluded.

CONCLUSION

Almost all patients with abnormal left AVPD and completely normal LV RWM had clinical cardiac disease. Thus, decreased AVPD despite normal LV RWM seems to be a true sign of myocardial dysfunction, predominantly indicating subendocardial dysfunction. In screening for patients with myocardial dysfunction assessment of left AVPD may be useful as a complement to LV RWM evaluation. The prognosis in such patients is currently being evaluated.

Prognostication and risk stratification by assessment of left atrioventricular plane displacement in patients with myocardial infarction

BACKGROUND

Mean left atrioventricular plane displacement is strongly related to prognosis in patients with heart failure. We aimed to examine its value for prognostication and risk stratification in patients hospitalised for acute myocardial infarction.

METHODS AND RESULTS

Left atrioventricular plane displacement was assessed by echocardiography in 271 consecutive patients with acute myocardial infarction. Mean prospective follow-up was 628 days. Atrioventricular plane displacement was readily assessed in all patients and was significantly lower in patients who died (n=41, 15.1%) compared to the survivors: 8.2(5.6) v. 10.0(5.5) mm, P<0.0001. Overall mortality was 31.3% in the lowest quartile with regard to atrioventricular plane displacement (<8.00 mm) and 10.1% in the combined upper three quartiles. Thus, the hazard ratio for an atrioventricular plane displacement <8.0 mm compared to 8 mm or more was 3.1, P=0.0001. The combined mortality/heart failure hospitalisation incidence was 43.8% in the lowest and 14.6% in the combined upper three quartiles: Risk ratio 3.0, P<0.0001. In multivariate analysis, including age and history of atrial fibrillation, left atrioventricular plane displacement was an independent prognostic marker.

CONCLUSION

In post-myocardial infarction patients, echocardiographic assessment of atrioventricular plane displacement showed a strong, independent prognostic value. Determination of left atrioventricular plane displacement can be readily performed in virtually all patients, and may in clinical practice facilitate identification of high-risk patients.

The prevalence of impaired left ventricular diastolic filling is related to the extent of coronary atherosclerosis in patients with stable coronary artery disease

AIMS

The relation between abnormal left ventricular (LV) diastolic filling and the extent of coronary atherosclerosis per se has not been described. We aimed to investigate the prevalence of impaired LV diastolic filling in patients with stable coronary artery disease (CAD) and its relationship to the number and location of coronary lesions visualized at coronary angiography.

METHODS AND RESULTS

In 170 consecutive patients with stable CAD and an abnormal coronary angiogram we assessed LV diastolic filling by Doppler evaluation of the transmitral early to atrial peak flow velocity (E/A) and the systolic to diastolic ratio of the pulmonary venous peak inflow to the left atrium (S/D). Abnormal diastolic filling was defined as E/A < or =0.75, or E/A >1.0 combined with S/D < or =1.0, and was present in 41% of the patients. In patients with one-, two- and three-vessel disease the prevalence of impaired diastolic filling was 27, 30 and 49%, respectively (P = 0.026). In multiple logistic regression analysis diastolic filling was independently correlated with the number of stenotic coronary vessel areas.

CONCLUSION

In patients with stable angiographically verified CAD, the prevalence of impaired diastolic filling was 41%. The prevalence increased with an increasing number of stenotic coronary artery areas independent of other variables tested, including prior myocardial infarction, LV systolic function and mitral regurgitation.

Left ventricular diastolic filling is related to the atrioventricular plane displacement in patients with coronary artery disease

OBJECTIVE

Left atrioventricular plane displacement (AVPD) is often decreased and abnormalities in left ventricular diastolic filling are common in patients with coronary artery disease (CAD). This study was designed to assess the relationship between AVPD and diastolic filling in patients with CAD.

DESIGN

AVPD was assessed by echocardiography and diastolic filling by transmitral and pulmonary venous pulsed Doppler in 170 consecutive patients (66 +/- 11 years) with proven CAD at coronary angiography. Diastolic filling was grouped as normal, mildly impaired and moderately to severely impaired.

RESULTS

A simple linear regression analysis showed that AVPD decreased in relation to increased severity of diastolic filling impairment (r = -0.36, p < 0.0001). In a multiple regression analysis, ejection fraction, diastolic filling, age and body surface were independently correlated with AVPD. Each millimetre of decrease in AVPD increased the probability of impaired diastolic filling by 28%.

CONCLUSION

AVPD was independently correlated with both left ventricular systolic function and diastolic filling in patients with CAD. Thus, given the same degree of ejection fraction, it was found that the greater the impairment in diastolic filling, the lower the AVPD.

Effects on quality of life, symptoms and daily activity 6 months after termination of an exercise training programme in heart failure patients

BACKGROUND

Exercise training in heart failure patients improves exercise capacity, physical function, and quality-of-life. Prior studies indicate a rapid loss of these effects following termination of the training. We wanted to assess any sustained post-training effects on patients global assessment of change in quality-of-life (PGACQoL) and physical function.

METHODS

Fifty-four stable heart failure patients were randomised to exercise or control. The 4-month exercise programme consisted of bicycle training at 80% of maximal intensity three times/week, and 49 patients completed the active study period. At 10 months (6 months post training) 37 patients were assessed regarding PGACQoL, habitual physical activity, and dyspnea-fatigue-index.

RESULTS

Both post-training patients (n=17) and controls (n=20) deteriorated PGACQoL during the 6-month extended follow-up, although insignificantly. However, post-training patients improved PGACQoL slightly but significantly from baseline to 10 months (P=0.006), differing significantly (P=0.023) from controls who were unchanged. Regarding dyspnea-fatigue-index, post-training patients were largely unchanged and controls deteriorated insignificantly, during the extended follow-up as well as from baseline to 10 months. Both groups decreased physical activity insignificantly during the extended follow-up, and from baseline to 10 months post-training patients tended to decrease whereas controls significantly (P=0.007) decreased physical activity.

CONCLUSION

There was no important sustained benefit 6 months after termination of an exercise training programme in heart failure patients. A small, probably clinically insignificant sustained improvement in PGACQoL was seen in post-training patients. Controls significantly decreased the habitual physical activity over 10 months and post-training patients showed a similar trend. Exercise training obviously has to be continuing to result in sustained benefit.

ACE inhibition with ramipril improves left ventricular function at rest and post exercise in patients with stable ischaemic heart disease and preserved left ventricular systolic function

AIMS

To assess the effects of 6 months intervention with +ramipril on resting and post exercise left ventricular function in patients with stable ischaemic heart disease and preserved left ventricular systolic function.

METHODS AND RESULTS

Patients (n=98, age 65+/-9 years, 37% women) were randomized to double-blind treatment with ramipril 5 mg. day(-1)(n=32), ramipril 1.25 mg. day(-1)(n=34), or placebo (n=32). Resting and post maximum exercise echocardiography/Doppler examinations were performed at baseline and after 6 months. Changes over 6 months in resting transmitral E-wave deceleration time (Edt) and Edt adjusted for heart rate (Edt/RR) differed between the ramipril 5 mg, ramipril 1.25 mg, and placebo groups: Edt 24+/-82, -1+/-69, and -29+/-64 ms, respectively, P=0. 012; Edt/RR 30+/-105, 2+/-61, and -28+/-69 ms, respectively, P=0.015. Changes in the difference between resting and post exercise Edt/RR also varied between groups: -53+/-137, -28+/-118, and 35+/-101 ms, respectively, P=0.029. No differences in E/A indices were noted. Resting atrioventricular plane displacement improved in the combined ramipril groups vs the placebo group: 0.2+/-0.8 vs -0.2+/-1.3 mm, P<0.05.Conclusion Six months ramipril treatment in patients with stable ischaemic heart disease and preserved left ventricular systolic function improved resting left ventricular function and reduced the exercise induced diastolic filling abnormalities usually seen in these patients.

Left atrioventricular plane displacement at rest is reduced in relation to severity of coronary artery disease irrespective of prior myocardial infarction

OBJECTIVE

To examine whether left atrioventricular plane displacement (AVPD) at rest was related to severity of coronary atherosclerosis.

DESIGN AND PATIENTS

Global and regional left AVPD was evaluated by echocardiography in 159 consecutive patients with significant stenoses at coronary angiography and in 15 age-matched healthy controls. The setting was the University hospital with a primary catchment area of 250,000 inhabitants.

RESULTS

Mean AVPD in controls, patients with one-, two-, and three-vessel disease was 13.5+/-1.1, 12.4+/-1.5, 11.3+/-2.2 and 10.9+/-2.1 mm, respectively (P<0.0001). Similar significant differences were found both in those with (n=69) and without (n=90) a diagnosis of prior myocardial infarction. Regional AVPD did not correspond to the localization of infarction or coronary atherosclerosis.

CONCLUSION

Irrespective of a diagnosis of prior myocardial infarction, left AVPD was related to the degree and extent of coronary artery disease. It was significantly decreased compared to controls in patients with one-vessel disease, and was further decreased with increasing extent of coronary atherosclerosis. Determination of regional left AVPD could not be used to identify regions perfused by stenotic coronary arteries or regions affected by prior myocardial infarction.

Left atrioventricular plane displacement is related to both systolic and diastolic left ventricular performance in patients with chronic heart failure

AIMS

Left atrioventricular plane displacement is proposed to reflect left ventricular systolic function and is strongly related to prognosis in patients with heart failure. Left atrioventricular plane displacement is a different measure of left ventricular function compared to ejection fraction, and the factors influencing left atrioventricular plane displacement are insufficiently characterized. We wanted to assess any relationship between left atrioventricular plane displacement and left ventricular diastolic performance.

METHODS AND RESULTS

Left ventricular diastolic filling, left atrioventricular plane displacement, and fractional shortening were assessed by echocardiography/Doppler in 54 patients with chronic heart failure (age 64 +/- 7 years). Left atrioventricular plane displacement correlated significantly with Doppler variables of left ventricular filling, in particular the inverse logarithm of early transmitral flow deceleration time; log-1 Edt (r = -0.61, P < 0.0001, n = 54). Left atrioventricular plane displacement also correlated with fractional shortening (r = 0.49, P < 0.001, n = 50). However, fractional shortening did not correlate with any Doppler variable. Log-1 Edt, fractional shortening, age, heart rate, left ventricular and atrial size, and degree of mitral regurgitation were included in a multiple regression analysis. Only log-1 Edt (P = 0.001) and fractional shortening (P = 0.03) correlated independently with left atrioventricular plane displacement. Among patients with similar fractional shortening, those with more compromised diastolic performance had lower left atrioventricular plane displacement.

CONCLUSION

Left atrioventricular plane displacement was related to both systolic and diastolic left ventricular performance, which may explain some of the discrepancies between left atrioventricular plane displacement and ejection fraction.

Exercise training in heart failure improves quality of life and exercise capacity

AIMS

Benefit from exercise training in heart failure has mainly been shown in men with ischaemic disease. We aimed to examine the effects of exercise training in heart failure patients < or = 75 years old of both sexes and with various aetiology.

METHODS AND RESULTS

Fifty-four patients with stable mild-to-moderate heart failure were randomized to exercise or control, and 49 completed the study (49% > or = 65 years; 29% women; 24% non-ischaemic aetiology; training, n = 22; controls, n = 27). The exercise programme consisted of bicycle training at 80% of maximal intensity over a period of 4 months. Improvements vs controls were found regarding maximal exercise capacity (6 +/- 12 vs -4 +/- 12% [mean +/- SD], P < 0.01) and global quality-of-life (2 [1] vs 0 [1] units [median ¿inter-quartile range¿], P < 0.01), but not regarding maximal oxygen consumption or the dyspnoea-fatigue index. All of these four variables significantly improved in men with ischaemic aetiology compared with controls (n = 11). However, none of these variables improved in women with ischaemic aetiology (n = 5), or in patients with non-ischaemic aetiology (n = 6). The training response was independent of age, left ventricular systolic function, and maximal oxygen consumption. No training-related adverse effects were reported.

CONCLUSION

Supervised exercise training was safe and beneficial in heart failure patients < or = 75 years, especially in men with ischaemic aetiology. The effects of exercise training in women and patients with non-ischaemic aetiology should be further examined.