Multiple Phenotypes of Chronic Coronary Syndromes Identified by ABCDE Stress Echocardiography

BACKGROUND

Regional wall motion abnormality is considered a sensitive and specific marker of ischemia during stress echocardiography (SE). However, ischemia is a multifaceted entity associated with either coronary artery disease (CAD) or angina with normal coronary arteries, a distinction difficult to make using a single sign. The aim of this study was to evaluate the diagnostic potential of the five-step ABCDE SE protocol for CAD detection.

METHODS

From the 2016-2022 Stress Echo 2030 study data bank, 3,229 patients were selected (mean age, 66 ± 12 years; 2,089 men [65%]) with known CAD (n = 1,792) or angina with normal coronary arteries (n = 1,437). All patients were studied using both the ABCDE SE protocol and coronary angiography, within 3 months. In step A, regional wall motion abnormality is assessed; in step B, B-lines and diastolic function; in step C, left ventricular contractile reserve; in step D, coronary flow velocity reserve in the left anterior descending coronary artery; and in step E, heart rate reserve.

RESULTS

SE response ranged from a score of 0 (all steps normal) to a score of 5 (all steps abnormal). For CAD, rates of abnormal results were 347 for step A (19.4%), 547 (30.5%) for step B, 720 (40.2%) for step C, 615 (34.3%) for step D, and 633 (35.3%) for step E. For angina with normal coronary arteries, rates of abnormal results were 81 (5.6%) for step A, 429 (29.9%) for step B, 432 (30.1%) for step C, 354 (24.6%) for step D, and 445 (31.0%) for step E. The dominant "solitary phenotype" was step B in 109 patients (9.1%).

CONCLUSIONS

Stress-induced ischemia presents with a wide range of diagnostic phenotypes, highlighting its complex nature. Using a comprehensive approach such as the advanced ABCDE score, which combines multiple markers, proves to be more valuable than relying on a single marker in isolation.

High Resting Coronary Flow Velocity by Echocardiography Is Associated With Worse Survival in Patients With Chronic Coronary Syndromes

BACKGROUND

Resting coronary flow velocity (CFV) in the mid-distal left anterior descending coronary artery can be easily assessed with transthoracic echocardiography. In this observational study, the authors sought to assess the relationship between resting CFV, CFV reserve (CFVR), and outcome in patients with chronic coronary syndromes.

METHODS AND RESULTS

In a prospective multicenter study design, the authors retrospectively analyzed 7576 patients (age, 66±11 years; 4312 men) with chronic coronary syndromes and left ventricular ejection fraction ≥50% referred for dipyridamole stress echocardiography. Recruitment (years 2003-2021) involved 7 accredited laboratories, with interobserver variability <10% for CFV measurement at study entry. Baseline peak diastolic CFV was obtained by pulsed-wave Doppler in the mid-distal left anterior descending coronary artery. CFVR (abnormal value ≤2.0) was assessed with dipyridamole. All-cause death was the only end point. The mean CFV of the left anterior descending coronary artery was 31±12 cm/s. The mean CFVR was 2.32±0.60. During a median follow-up of 5.9±4.3 years, 1121 (15%) patients died. At multivariable analysis, resting CFV ≥32 cm/s was identified by a receiver operating curve as the best cutoff and was independently associated with mortality (hazard ratio [HR], 1.24 [95% CI, 1.10-1.40]; P<0.0001) together with CFVR ≤2.0 (HR, 1.78 [95% CI, 1.57-2.02]; P<0.0001), age, diabetes, history of coronary surgery, and left ventricular ejection fraction. When both CFV and CFVR were considered, the mortality rate was highest in patients with resting CFV ≥32 cm/s and CFVR ≤2.0 and lowest in patients with resting CFV <32 cm/s and CFVR >2.0.

CONCLUSIONS

High resting CFV is associated with worse survival in patients with chronic coronary syndromes and left ventricular ejection fraction ≥50%. The value is independent and additive to CFVR. The combination of high resting CFV and low CFVR is associated with the worst survival.

Exercise Stress Echocardiography of the Right Ventricle and Pulmonary Circulation

BACKGROUND

Exercise echocardiography is used for assessment of pulmonary circulation and right ventricular function, but limits of normal and disease-specific changes remain insufficiently established.

OBJECTIVES

The objective of this study was to explore the physiological vs pathologic response of the right ventricle and pulmonary circulation to exercise.

METHODS

A total of 2,228 subjects were enrolled: 375 healthy controls, 40 athletes, 516 patients with cardiovascular risk factors, 17 with pulmonary arterial hypertension, 872 with connective tissue diseases without overt pulmonary hypertension, 113 with left-sided heart disease, 30 with lung disease, and 265 with chronic exposure to high altitude. All subjects underwent resting and exercise echocardiography on a semirecumbent cycle ergometer. All-cause mortality was recorded at follow-up.

RESULTS

The 5th and 95th percentile of the mean pulmonary artery pressure-cardiac output relationships were 0.2 to 3.5 mm Hg.min/L in healthy subjects without cardiovascular risk factors, and were increased in all patient categories and in high altitude residents. The 5th and 95th percentile of the tricuspid annular plane systolic excursion to systolic pulmonary artery pressure ratio at rest were 0.7 to 2.0 mm/mm Hg at rest and 0.5 to 1.5 mm/mm Hg at peak exercise, and were decreased at rest and exercise in all disease categories and in high-altitude residents. An increased all-cause mortality was predicted by a resting tricuspid annular plane systolic excursion to systolic pulmonary artery pressure <0.7 mm/mm Hg and mean pulmonary artery pressure-cardiac output >5 mm Hg.min/L.

CONCLUSIONS

Exercise echocardiography of the pulmonary circulation and the right ventricle discloses prognostically relevant differences between healthy subjects, athletes, high-altitude residents, and patients with various cardio-respiratory conditions. (Right Heart International NETwork During Exercise in Different Clinical Conditions; NCT03041337).

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

Speckle tracking-derived left atrial strain rate – undervalued and useful predictor of adverse events

Background

Strain rate reflects the rate of change of the distance between two points of the myocardium occurring in the cardiac cycle. It is a time-dependent parameter requiring higher temporal resolution than standard strain assessment. Because of this limitation, speckle tracking-derived left atrial (LA) strain rate analysis is of less interest in the literature.

Purpose

To analyze the prognostic value of LA strain rate during 2-years follow-up in patients with atrial fibrillation (AF).

Methods

The prospective study involved 80 patients with nonvalvular AF scheduled for elective electrical cardioversion (mean age 63.5±13 years, 60% male). All patients underwent echo before cardioversion and 24 hours after conversion to sinus rhythm. We analyzed standard echocardiographic parameters. Using the speckle-tracking method, we assessed LA strain rate during ventricular systole LA-SSR, in the early stage of ventricular diastole LA-ESR, and during atrial active pump phase LA-ASR. The last one is possible to measure only in the sinus rhythm. The analysis included 4-chamber and 2-chamber views. The clinical endpoint was predefined as AF recurrence.

Results

Median time of the current AF episode was 2.1 (IQR 0.5–5) months. Standard echo measurements revealed a median left ventricular ejection fraction of 55% (IQR 46–58) and the median of LA volume indexed to body surface area 42 ml/m2 (IQR 33–51). The successful cardioversion rate was 90%. During follow-up, we noticed AF recurrence in 49 (68%) patients. The median time-to-event was 2 (IQR 1 to 6.9) months. Receiver operating characteristic curve analysis revealed that LA-SSR &lt;−0.73 s–1 (AUC=0.745; p=0.0004) and LA-ESR &gt;−1 s–1 (AUC=0.703; p=0.0015) assessed during AF as well as LA-ESR &gt;−0.88 s–1 (AUC=0.644; p=0.04) and LA-ASR &gt;−1 s–1 (AUC=0.837; p&lt;0.0001) measured in sinus rhythm were the optimal cut-off values for predicting AF recurrence. The figure presents Kaplan-Meier survival analysis for AF recurrence.

Conclusions

Speckle tracking-derived LA strain rate predicts the recurrence of AF after successful electrical cardioversion.

Funding Acknowledgement

Type of funding sources: None.

Supra-normal values of resting left ventricular systolic function are associated with decreased survival: to good to be normal?

Background

Hyper-contractile phenotype of the left ventricle (LV) is generally considered prognostically benign, but recent data challenge this intuitive assumption.

Aim

To assess the effects of resting LV function on survival.

Methods

In a prospective, observational, multicenter study, we recruited 5,122 patients (age 65±11.1 years, 2974 males, 58%) with chronic coronary syndromes referred for resting transthoracic echocardiography with technically successful volumetric echocardiography in 14 accredited laboratories. All recruiting centers had a structured follow-up program with &gt;90% follow-up rate. In each patient, we quantitatively assessed (by Simpson's biplane, apical single-plane or parasternal linear method) LV end-diastolic volume (EDV), end-systolic volume (ESV), and ejection fraction (EF). As a load-independent index of LV contractility, LV force was estimated as systolic blood pressure by cuff sphygmomanometer/ESV. All-cause death was the only considered outcome end-point.

Results

EF was 59±11% (normal reference sextile = 58.0–59.9%). Force was 4.51±2.11 mmHg/ml (normal reference sextile = 3.50–4.27 mmHg/ml). The correlation between EF and force was linear (r=0.585, p&lt;0.001). After a median follow-up of 862 days, there were 265 all-cause deaths. Considering EF values, mortality was lowest in the highest sextile (&gt;67%) and significantly higher in the lowest sextile (EF &lt;52%): see figure, left panel. A U-shaped curve was found with force, with mortality values being lowest in the middle sextile and significantly higher in the lowest sextile (&lt;2.59 mmHg/ml) and in the highest sextile (&gt;6.36 mmHg/ml): see figure, right panel. At multivariable analysis, after adjustment for age, diabetes, EF, and prior myocardial infarction, both the highest sextile of force (HR 1.84, 95%, confidence intervals 1.12–3.03 p=0.015), and the lowest sextile of force (HR 1.77, 95%, confidence intervals 1.08–2.90 p=0.024) were associated with decreased survival.

Conclusion

Sub-normal values of resting ejection fraction and super- and sub-normal values of the force are associated with worse survival in patients with chronic coronary syndromes. This U-shaped curve of mortality is detectable only with the force, a load independent index of LV contractility: too much of a good thing such as LV contractility can be dangerous on the long-run.

Funding Acknowledgement

Type of funding sources: None.

Misconception in patients with cardiovascular implantable electronic device as a factor of anxiety and depression – how to design optimal educational approach?

Purpose

The aim of this study is to assess the level of knowledge of safety and awareness about daily living in patients with cardiac implantable electronic devices (CIED) and potential impact upon anxiety and depression.

Methods

Data were collected in consecutive patients visiting pacemaker clinic for regular CIED follow-up. Demographic, clinical and psychological data were collected: Hospital Anxiety and Depression Scale-Modified (HADS-M) and a custom self-reported questionnaire was used (CIED-SRQ, 18 questions regarding daily activities, medical procedures and the safe use of electronic devices) to assess the knowledge regarding CIED. Dedicated questions referred to the preferences for CIED education channels in various age groups.

Results

We studied 186 patients (36,6% women, mean age 66,7±10,8) with CIED (63,5% pacemaker, 17,7% cardioverter defibrillator, 18,8% cardiac resynchronization therapy) in their first year following the implantation. In the CIED-SRQ the mean score of correct answers related to knowledge of CIED 13,25±2,86 (with 18 as the maximum possible score). The knowledge of CIED was correlated with the patients' level of education (p&lt;0,001) and inversely correlated with age (rho=−0443; p&lt;001). In the anxiety subscale of HADS-M, normal scores were noted in 75,8% patients, 13,5% cases were borderline, and abnormalities were observed in 10,7% patients. In the depression subscale, 70,4% were recognized as normal, 21,5% as borderline, and 8,1% as abnormal. As the knowledge of patients about CIED increased, there was a significant decrease in their depression level (rho=−0,149; p=0,042) and in the anxiety level (rho=−0,193; p=0,008). Anxiety level was higher in patients with CIED experiencing complications from the implantation (15,6% of patients in total experienced complications), both the mild (hematoma, bruising) and the severe (tamponade, lead dislocation, pneumothorax), when compared to the group without complications (p&lt;0,001). Conversely, no statistically significant difference between these groups was found as to their level of depression (p=0,051). The younger patients (≤64 years) were more often in favour of remote education on CIED (p=0,025), while the elder (≥65 years) most often preferred to be personally informed by the attending physician.

Conclusions

Lack of information and misinformation in patients with CIED may result in self-imposed restrictions, which could in turn result in higher levels of anxiety and depression. Patients experiencing CIED complications should be offered increased psychological care as well as more intense education about CIED, due to higher anxiety levels. Age influences the preferences for CIED education channels, thus educational approach must be individualized and age-appropriate. These findings may help health care professionals to provide holistic care to help patients manage to live with CIED and optimize postprocedural quality of life.

Funding Acknowledgement

Type of funding sources: None.

Left atrial volume, function and B-lines at rest and during vasodilator stress echocardiography

Background

Left atrial volume index (LAVi), left atrial reservoir function assessed with global peak amplitude longitudinal strain (PALS), and B-lines at lung ultrasound are supplementary markers of left ventricular filling pressures.

Aim

To assess the relationship between LAVi, PALS and B-lines at rest and peak vasodilator stress.

Methods

A comprehensive dipyridamole stress echo was completed in 266 patients (187 male, 71%, age 65±10 years) with chronic coronary syndromes. LAVi was measured with the biplane disk summation method. PALS was measured from a single vendor with 2-dimensional speckle tracking echocardiography and expressed in % values as the mean of the 12 atrial segments from 4- and 2-chamber values. B-lines were assessed with the simplified 4-site scan in the third intercostal space, with global score from 0 to 40, and considered significant with global score ≥2 units.

Results

During dipyridamole, LAVi decreased (rest= 26±14 ml/m2 vs stress= 24±12 ml/m2, p&lt;0.001), PALS increased (rest= 33±8 vs stress= 38±10%, p&lt;0.001), and B-lines were more frequent (rest= 0.4, median interquartile range 0–30, vs stress= 0.7, median interquartile range 0–30, units, p&lt;0.001). There was a significant, linear, inverse correlation between LAVi and PALS both at rest (r=−0.301, p&lt;0.001) and at peak stress (r=−0.279, p&lt;0.001, see figure). At group analysis, peak B-lines were directly correlated with peak LAVi (r=0.151, p=0.017) and inversely correlated with peak PALS (r=−0.234, p&lt;0.001). At individual patient analysis, 4/93 patients (4.3%) showed stress B-lines (black dots in figure) with normal LAVi (&lt;34 ml/m2) and preserved PALS (&gt;42%).

Conclusion

Vasodilator stress echocardiography with combined assessment of left atrial volume, function and pulmonary congestion is feasible with high success rate in patients with chronic coronary syndromes. Pulmonary congestion is more frequent with dilated left atrium with reduced atrial contractile reserve, but it may occur in a minority of patients with normal LAVi and normal PALS.

Funding Acknowledgement

Type of funding sources: None.

Anxiety and depression among ambulatory and hospitalized patients with cardiovascular long-COVID-19 presentation referred to cardiology consultation after COVID-19 infection

Introduction

COVID-19 is connected with varying degrees of emotional stress. Patients (pts) who are hospitalized with severe COVID-19 (C19) are located in single rooms without a permanent attendant to prevent contamination. All personnel serving these pts come into contact with patients with personal full-body protective garment. Ambulatory C19 pts, usually with less severe presentation, are treated in more comfortable conditions.

Purpose

To evaluate the impact of the psychosocial changing conditions on individuals' psyche and to analyse the differences in terms of experienced anxiety and depression among the ambulatory and hospital patients referred to post-C19 cardiology consultation.

Methods

The study involved 388 pts with persistent cardiovascular symptoms, including 198 ambulatory patients (130 females and 68 males) and 190 hospital patients (128 females and 62 males) referred to the cardiology consultation (mean age 4.9±12.9 and 50.5±14.4 years, respectively). The data were collected using the specially designed questionnaire related to descriptive characteristics of the patients and to standardized questionnaires: the State-Trait Anxiety Inventory (STAI) and Beck's Depression Inventory (BDI).

Results

Abnormal psychological metrics was common in the study pts. Indicators of anxiety were lower in the ambulatory than in hospitalized pts (p<0.001). Depression level was also lower in the ambulatory pts (p<0.001). The same differences were statistically significant in both female and male pts subsets. However, anxiety and depression were more pronounced among female than male pts. Very strong positive correlation was observed between anxiety - state and depression among ambulatory patients, both females and males (p<0.05).

Conclusions

C19 convalescents with persistent symptoms of presumed cardiovascular origin present with abnormal psychological traits including increased anxiety and depression especially in individuals requiring hospital treatment. For this reason, it is necessary to plan the interventions particularly in hospitalized pts to reduce their anxiety and depression levels and to create psychological support programs.

Funding Acknowledgement

Type of funding sources: None.

Impact of COVID-19 pandemics upon nationwide pulmonary hypertension cohort: 18-months analysis of BNP-PL national database

Introduction

Pulmonary hypertension (PH) patients may be vulnerable to SARS-CoV-2 infection, but large analytic studies on morbidity and mortality risks are limited.

Aim

Assessment of the incidence and course of COVID-19 among patients (pts) diagnosed with PH, treated under the NFZ program, registered in the national BNP-PL database with the assessment of the impact of the SARS-CoV-2 pandemic on the care of patients with pulmonary hypertension in Poland.

Methods

We analyzed the records of the complete population of Polish pts treated under the National Drug Program of PH (PAH and CTEPH), registered in the national database of BNP-PL, and updated on an ongoing basis by all PH centers. The frequency of SARS-CoV-2 infections, clinical severity of COVID-19 course and mortality were reviewed. Clinical characteristics of infected and deceased patients were compared to the remaining patients registered in the BNP-PL database. The rate of increase of new diagnoses ended with inclusion in the Drug Program between 01 March 2020 and 31 August 2021, compared to the pre-pandemic year 2019, and the change in the treatment profile were reviewed.

Results

The analysis included 1923 pts (PAH 1292, CTEPH 631). The incidence of SARS-CoV-2 infections was 7.4% (n=143) and similar to general population (7.6%), with a slight preponderance in PAH 8.1% (n=105) vs. CTEPH 6.0% (n=38) (p=0.099). 47 patients (33%) required hospitalization. Mortality rate was 24% (34/143) vs. 2.6% for general population – including 19/34 outside of hospital. Those who died due to COVID-19 were older (mean age 56±17.6 vs. 70.5±12.8 yrs; p<0.0001) and had more cardiovascular comorbidities (1.35 vs. 1.97; p=0.01). Systemic arterial hypertension was the strongest unique risk factor for mortality, present in 71% decedents vs. 45% of survivors, and the only independent risk factor in multivariate logistic regression analysis (OR 2.94, 95% CI 1.28–6.73). Moreover, there was a trend towards a higher incidence of diabetes and coronary artery disease in the group of non-survivors (Table 1). The number of new diagnoses of PH decreased during the pandemic compared to 2019 (new diagnoses rate in 2019 was 28.2/month vs. 19.2/month during COVID). A significant increase in total mortality was also observed in the PH group (11.1/month in 2019 vs. 13.7/month during COVID). Escalation of specific PH therapy also reduced (rate of specific therapy escalation in 2019 was 30.4/month vs. 20.5/month during COVID).

Conclusions

The COVID-19 pandemic has deeply affected the care of patients with pulmonary hypertension by reducing the number of new diagnoses, escalation of therapy, and increasing overall mortality in this population, and this impact continues into second year of pandemics. Pulmonary hypertension is associated with a more severe course and higher mortality in COVID-19.

Funding Acknowledgement

Type of funding sources: None.

The use of handheld ultrasound device in cardiac examination of patients with history of COVID-19

Background

Clinical usefulness of Handheld Ultrasound Device [HUD] was previously confirmed in numerous clinical scenarios. During the previous two years Covid-19 patients become a focal point of healthcare worldwide. The assessment of long term consequences of this infection is bound to overload already burdened healthcare system.

Purpose

To assess clinical usefulness of HUD as an adjunct to physical cardiac examination of patients with history of COVID-19.

Methods

Study population consisted of randomly selected patients with no symptoms of cardiovascular pathology, who had been hospitalized due to COVID-19 one year prior to examination. Physical examination and clinical assessment was augmented with short examination with the use of HUD, which included: visual evaluation of the global and regional LV function, measurement of RV size, screening for the significant valve defects and the presence of pericardial effusion. Subsequently full echocardiographic examination with the use of high-end workstation was performed, which results were treated as reference.

Results

54 patients (35 men, mean age 63±13 years) were enrolled into the study. In clinical examination no significant cardiovascular abnormalities were discovered. In 30 [56%] of patients cardiac abnormalities in HUD examination were detected. In 18 patients [33%] LV function assessment was not performed, due to insufficient quality of registered view. In the remaining group significant impairment of LV ejection fraction (<50%) was detected in HUD examination in 3 [6%] patients (2 confirmed in full examination, positive predictive value [PPV] 57%, negative predictive value [NPV] 97%, AUC 0,82±0,17, P 0,057). WMA were diagnosed in 6 [11%] patients (4 confirmed in full examination, PPV 84% NPV 78%, AUC 0,69±0,17, P 0,02). RV enlargement was identified in 21 [39%] patients (PPV 57%, NPV 97%, AUC 0,85±0,05, P<0,0001), mild pericardial effusion in 3 [6%] patient (1 confirmed in full echocardiographic examination; 2 false positive, no false negative), at least moderate mitral/tricuspid/aortic valve insufficiency in 7 [13%] patients (3 confirmed, 4 false positive cases, no false negative). A total mean time of the heart and lungs HUD examination was 2,1±0,6 minute.

Conclusion

Cardiac abnormalities exposed in brief assessment with the use HUD are a relatively common finding in asymptomatic patients previously hospitalized due to COVID infection in a 1-year follow-up, despite normal physical examination. Normal HUD examination excludes the presence of significant cardiac abnormalities with high probability. However one should keep in mind a relatively high percentage of false positive results, which may lead to an exceeding number of patients referred for a full echocardiographic examination.

Funding Acknowledgement

Type of funding sources: None.

Predictors and clinical consequences of heart damage in CMR in patients after COVID-19

Methods

Out-hospital clinic patients (pts) recovered from COVID-19 were prospectively recruited and underwent cardiac magnetic resonance (CMR) examination with a protocol including: edema, hyperemia, and necrosis or scar-derived from signal intensity assessment in T2-weighted, early gadolinium enhancement (EGE) and late gadolinium enhancement (LGE) CMR images.

Results

A total of 702 patients (mean age 50±12 years, 62% female) were included. The median (IQR) time interval between COVID-19 diagnosis and CMR was 13 (8–22) weeks. In none pts signs of edema, hyperemia and necrosis derived from signal intensity assessment in T2-weighted and early gadolinium enhancement was found. LGE was found in 152 (22%). LGE+ patients had significantly lower left ventricular (LV) ejection fraction (58.5±7.7 vs 61.1±7.9%, p&lt;0.001) and greater LV end-diastolic (117.0±52.2 vs 103,0±36.3 ml, p=0.023) and end-systolic (50.3±28.0 vs 41.0±17.5 ml, p=0.010) volumes when compared with LGE− patients. In the resting electrocardiogram (ECG) fragmented QRS was observed significantly more frequently (46% vs 25%, p&lt;0.001) in LGE+ group, whereas in 24h Holter ECG neither single premature, nor complex ventricular extrasystole burden did not differ between groups (p&gt;0.05). There were observed no differences between symptoms of COVD-19 and comorbidities between LGE+ and LGE− pts. In the multivariable logistic regression analysis: fragmented QRS [OR and 95% CI: 2.85 (1.93–4.21)] and any ST-T segment deviation in resting ECG [OR: 1.93 (1.15–3.25)] were identified as independent predictors of LGE, even after adjustment for comorbidities and COVID-19 symptoms.

Conclusions

1. In patients with fibrosis after COVID-19 reduced left ventricular ejection fraction and greater volume of the heart was found.

2. Fragmented QRS and ST-T abnormalities were independent predictors for LGE in patients after COVID-19.

Funding Acknowledgement

Type of funding sources: None.

The prognostic value of speckle tracking echocardiography in patients hospitalized with COVID-19

Introduction

In COVID-19 patients, both preexisting cardiovascular disease as well as cardiac injury resulting from SARS-CoV-2 infection are associated with increased mortality. We hypothesized that novel parameters of myocardial function may be useful in the assessment of in-hospital and long-term prognosis.

Aim

The aim of study was to determine the prevalence of myocardial dysfunction revealed by speckle tracking echocardiography and its association with in-hospital and one-year mortality.

Methods

The study group comprised 192 patients hospitalized in the cardiology department due to COVID-19. All patients underwent transthoracic echocardiographic examination with off-line analysis. Using speckle tracking technique, we measured the following parameters: left ventricular global longitudinal strain (GLS), right ventricular global longitudinal strain (RV-GLS), right ventricular free wall strain (RV-FWS) and myocardial work parameters – global work index (GWI), global wasted work (GWW), global constructive work (GCW) and global work efficiency (GWE). The primary outcome was in-hospital and one-year mortality.

Results

112 patients (mean age 68±14 years, 76 (68%) male) had adequate image quality to evaluate strain-derived parameters. 27 patients died during hospitalization and 44 patients died within one-year after discharge. In-hospital non-survivors were older, had lower baseline oxygen saturation (SpO2) and had higher NTproBNP (Table 1). In non-survivors speckle-tracking echocardiography revealed significant impairment of left and right ventricular function compared to the group of survivors (Table 1). The independent predictors of in-hospital death were GWE (OR 0.85; 95% CI 0.78–0.93) and SpO2 on admission (OR 0.91; 95% CI 0.86–0.96). Based on the ROC curve analysis, the optimal cut-off points for predicting in-hospital death were identified: GWE ≤87% (sensitivity 63%, specificity 89%) and baseline SpO2 value ≤88% (sensitivity 81%, specificity 71%).

The independent predictors of one-year mortality were: age (OR 1.28 [1.13–1.46]), NTproBNP (OR 1.002 [1.001–1.003]), baseline SpO2 (OR 0.71 [0.59–0.86]) and RV-GLS (OR 1.32 [1.12–1.55]). Based on the ROC curve analysis, the cut-off points optimal for predicting death within 12 months after COVID-19 were also identified: baseline SpO2 value ≤88% (sensitivity 69.8%, specificity 77.3%), age >60 years (sensitivity 90%, specificity 43%), NTproBNP >500 pg/ml (sensitivity 95%, specificity 41.8%), RV-GLS >−18.5 (sensitivity 93%, specificity 64.2%).

Conclusions

Two-dimensional speckle tracking echocardiography is a useful technique to evaluate myocardial function in COVID-19 patients and provides good prognostic value for identifying patients at risk of death during hospitalization and in long term follow-up.

Funding Acknowledgement

Type of funding sources: None.

Long-term clinical outcome in patients with isolated chronic total occlusion treated percutaneously or pharmacologically

Purpose

Chronic Total Coronary Occlusion (CTO) is defined as the total obstruction of coronary blood flow for at least 3 months duration. The aim of this study was to compare the long-term clinical outcome in patients with stable angina (CCS I-III) and isolated CTO treated with successful percutaneous coronary intervention (PCI) or conservative management (a priori pharmacologically or after failed PCI) and to detect potential risk factors of unsuccessful PCI.

Methods

The inclusion criteria were: isolated CTO of one CA, previously confirmed viability of myocardium in the area of occluded CA, stable coronary disease, absence of significant valve disease resulting in predicted survival below 1 year. Choice of management was based on individualized risk/benefit analysis encompassing ischemia assessment and angiographic considerations. Clinical follow-up of 24 months duration was conducted with regard to occurrence of major adverse cardiac events (MACE) including death, acute myocardial infarction (MI), need for repeat revascularization (surgical or PCI), major bleeding and hospitalization for angina.

Results

The study group consisted of 119 pts with isolated CTO (88 males, mean age 60.7±9.6 years)– 75 (63%) in the right CA, 28 (23,5%) in the left anterior descending CA, 16 (13,5%) in the circumflex CA. The history of MI was revealed in 37 pts in medically treated group, 10 pts in PCI group and 7 pts after failed PCI. Successful PCI was performed in 39 (33%) pts while 80 (67%) pts were treated pharmacologically (16 after failed PCI). Over a mean 24-months follow-up there were 58 MACE in all groups, including: 2 cardiac deaths (1 in medically treated group and 1 in PCI group), hospitalization due to angina in 17 pts (10 in medically treated group, 6 in PCI group, 1 after failed PCI), 4 repeated revascularizations (1 in PCI group, 3 after failed PCI), 33 pts developed unstable angina (25 medically treated, 6 in PCI group, 2 after failed PCI), major bleeding occurred in 2 pts in medically treated group. The risk of MACE was lower in pts after successful PCI comparing both with patients treated medically as well as those with failed PCI (p=0.05 for both). Univariate analysis showed that left ventricular endsystolic (p=0.001) and enddiastolic diameter (p=0.01), left ventricular ejection fraction (p=0.03), higher NYHA class (p=0.002) and duration of angina (p=0.05) were significant predictors of MACE. Multivariate analysis identified two independent predictors of MACE: absence of effective PCI (as an intention-to-treat and per protocol) (OR 3.6, 95% CI 1.6–8.3) and larger left ventricular systolic diameter (OR=1.16, 95% CI 1.04–1.29). The independent negative predictors of procedural success were severity of calcification (p=0.001) and length of occlusion (p=0.02).

Conclusions

Successful PCI of CTO leads to a significant reduction in MACE in 24 months follow-up. Failed PCI is predicted by the occlusion length and extent of calcification.

Funding Acknowledgement

Type of funding sources: None.

Impact of the COVID-19 Pandemic on Pulmonary Hypertension Patients: Insights from the BNP-PL National Database

We aimed to evaluate the clinical course and impact of the SARS-CoV-2 pandemic on the rate of diagnosis and therapy in the complete Polish population of patients (pts) with pulmonary arterial hypertension (PAH-1134) and CTEPH (570 pts) treated within the National Health Fund program and reported in the national BNP-PL database. Updated records of 1704 BNP-PL pts collected between March and December 2020 were analyzed with regard to incidence, clinical course and mortality associated with COVID-19. Clinical characteristics of the infected pts and COVID-19 decedents were analyzed. The rates of new diagnoses and treatment intensification in this period were studied and collated to the proper intervals of the previous year. The incidence of COVID-19 was 3.8% (n = 65) (PAH, 4.1%; CTEPH, 3.2%). COVID-19-related mortality was 28% (18/65 pts). Those who died were substantially older and had a more advanced functional WHO class and more cardiovascular comorbidities (comorbidity score, 4.0 ± 2.1 vs. 2.7 ± 1.8; p = 0.01). During the pandemic, annualized new diagnoses of PH diminished by 25–30% as compared to 2019. A relevant increase in total mortality was also observed among the PH pts (9.7% vs. 5.9% pre-pandemic, p = 0.006), whereas escalation of specific PAH/CTEPH therapies occurred less frequently (14.7% vs. 21.6% pre-pandemic). The COVID-19 pandemic has affected the diagnosis and treatment of PH by decreasing the number of new diagnoses, escalating therapy and enhancing overall mortality. Pulmonary hypertension is a risk factor for worsened course of COVID-19 and elevated mortality.

Pulmonary Congestion During Exercise Stress Echocardiography in Ischemic and Heart Failure Patients

BACKGROUND

Lung ultrasound detects pulmonary congestion as B-lines at rest, and more frequently, during exercise stress echocardiography (ESE).

METHODS

We performed ESE plus lung ultrasound (4-site simplified scan) in 4392 subjects referred for semi-supine bike ESE in 24 certified centers in 9 countries. B-line score ranged from 0 (normal) to 40 (severely abnormal). Five different populations were evaluated: control subjects (n=103); chronic coronary syndromes (n=3701); heart failure with reduced ejection fraction (n=395); heart failure with preserved ejection fraction (n=70); ischemic mitral regurgitation ≥ moderate at rest (n=123). In a subset of 2478 patients, follow-up information was available.

RESULTS

During ESE, B-lines increased in all study groups except controls. Age, hypertension, abnormal ejection fraction, peak wall motion score index, and abnormal heart rate reserve were associated with B-lines in multivariable regression analysis. Stress B lines (hazard ratio, 2.179 [95% CI, 1.015-4.680]; P=0.046) and ejection fraction <50% (hazard ratio, 2.942 [95% CI, 1.268-6.822]; P=0.012) were independent predictors of all-cause death (n=29 after a median follow-up of 29 months).

CONCLUSIONS

B-lines identify the pulmonary congestion phenotype at rest, and more frequently, during ESE in ischemic and heart failure patients. Stress B-lines may help to refine risk stratification in these patients.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT03049995.

Echocardiographic assessment of pulse wave velocity in psoriatic patients with and without psoriatic arthritis

Funding Acknowledgements

Type of funding sources: None.

Background

Psoriasis (PSO) is an inflammatory disorder which in its more severe form affects cardiovascular system (CVS) leading to more rapid atherosclerosis progression. Moreover, some data suggested that the presence of psoriatic arthritis (PSA) may further increase CVS deterioration.

Purpose

Our aim was to compare the pulse wave velocity (PWV) between psoriatic patients without and with psoriatic arthritis (PSA 0 and 1 group, respectively).

Methods

We examined 31 consecutive patients (20 males and 11 females) with moderate to severe PSO taking systemic anti-inflammatory medications (TNF-alpha inhibitor, IL-17 inhibitor, IL-23 inhibitor or IL12/23 inhibitor) with transthoracic echocardiography with the evaluation of PWV

The group was divided into two

17 patients without PSA (PSA 0) and 14 with concomitant PSA (PSA 1). To achieve PWV value the time from R wave in ECG to the onset of arterial flow was measured respectively in carotid (T1) and femoral artery (T2) with further calculation of time difference (delta T). The distance between supraclavicular area and groin was measured during physical examination of patient. PVW was expressed as the ratio between assessed distance (in meters) and time difference (in seconds).

Results

Patients with psoriatic arthritis (PSA 1) had more frequently hypertension and higher BMI but did not differ significantly from the group without joints involvement regarding other demographics, risk factors and basic echocardiographic data. They also showed similar PSO severity as assessed with PASI score, see Table. The PWV assessment was feasible in all patients and the respective mean values achieved 9.2 ± 3.7 m/s in PSA 0 vs 10 ± 2.8 m/s in PSA 1 group, p = ns.

Both T1 and T2 correlated significantly with duration of PSO, see Figure, and even better with patient’s age r = -0.61, p = 0.0003 for T1 and r = -0.77, p &lt; 0.0001 for T2, whereas PWV correlated significantly only with patient’s age.

In the model of 12 variables only older age was the independent predictor of PWV &gt;10 m/s in multivariate logistic analysis, OR 1.08 95% CI 1.003- 1.165.

Conclusions

Patients with PSA showed tendency to the higher prevalence of obesity and hypertension when compared with patients with skin PSO only. Measurement of PWV during echocardiography or even more simple times to flow spectrum onset in carotid or femoral arteries provided quantitative parameters reflecting cardiovascular impairment in PSO and PSA. Abstract Table. Group comparison.  Abstract Figure. PSO duration, T1, T2 and PVW.

Predicting maintenance of sinus rhythm after cardioversion - novel versus conventional left atrial parameters

Funding Acknowledgements

Type of funding sources: None.

Background

 The successful electrical cardioversion (EC) in patients with atrial fibrillation (AF) improves cardiac mechanical function and enables early assessment of atrial activity by echocardiography.

Purpose

 To analyze conventional and novel parameters characterizing left atrium (LA) within 24 hours after the restoration of sinus rhythm (SR) and their prognostic value during 2-years follow-up.

Methods

 Prospective study involved 71 patients with nonvalvular AF (mean age 64 ± 13 years, 61% male). All patients underwent echo 24 hours after conversion to SR. In addition, standard echocardiographic and Doppler parameters were assessed. Using speckle-tracking method we analysed LA longitudinal strain in reservoir and contractile phase. The clinical endpoint was predefined as AF recurrence.

Results

 During a 24-months follow-up we noticed AF recurrence in 48 (68%) patients. The median time-to-event was 2.4 months (IQR 1 to 6.9). Standard echo measurements revealed a median of LV ejection fraction 55% (IQR 45-58) and median of LA volume indexed to body surface area 42 ml/m2 (IQR 34-51). Median mitral A wave was 0.46 m/s (IQR 0.39-0.5) vs 0.35 m/s (IQR 0.28-0.5) in patients without and with AF recurrence, respectively (p = 0.04). Patients without AF recurrence had also higher mitral annular A’ velocity obtained by tissue Doppler imaging (7.4 ± 2.8 cm/s vs 3.5 cm/s, IQR 2.8-4.8; p &lt; 0.0001), LA reservoir strain (19.4 ± 7.3% vs 11%, IQR 9.6-15.3; p = 0.0003) and LA contractile strain (9.4 ± 4.1% vs 2.8%, IQR 1.2-4.4; p &lt; 0.0001). The table presents results derived from univariate Cox regression analysis.

Conclusion

 LA activity assessed early after the restoration of sinus rhythm is the predictor of AF recurrence. The strongest association was proven for LA contractile strain. Abstract Figure. Univariate Cox regression analysis

Percutaneous closure of atrial appendage with thrombus - a strategy shift? Report of a case series

Funding Acknowledgements

Type of funding sources: None.

Background. Percutaneous closure of left atrial appendage (LAAO)  is a recent preventive modality in atrial fibrillation. (AF) However, presence of thrombus which is a strong stroke risk multiplier represented a standard contraindication to purely percutaneous approach. 

Aim. To test the safety and feasibility of LAAO in patients (pts) with appendage blood stasis and distal thrombus.

Methods. Using a novel generation transvascular device allowing "shallow dive" implantation we tested the feasibility of LAAO in pts with appendage blood stasis and distal thrombus. Additionally, hybrid transvascular approach with arch protection device was also tested. Indications included development of heart failure in AF or recurrent cerebral events in pts with LAA thrombi.

Results. We successfully performed 3 procedures in pts (2F, 1M, age 73-76) with distal LAA thrombus confirmed in 3D TEE / CT. After 3D echocardiographic sizing omitting appendage angiogram, occluder was implanted from right femoral venous access via septal puncture. In 2 patients right radial access was additionally used to introduce commercially available arch protection device. In all cases the occluder did not engage distal appendage zone and was appropriately deployed. However in patients with arch protection 1-2 mm debris was captured by protection device. No neurological sequelae were noted.

Conclusion. Our initial experience documents safety and feasibility of percutaneous LAAO in presence of appendage blood stasis and distal thrombus based on 3DE sizing and novel genertaion device with optional percutaneous aortic arch protection. The long term efficacy of such unorthodox has yet to be determined in the setting of severely prothrombotic milieu, abnormal left ventricular function but with potential for risk reduction or even reopening options of cardioversion. Abstract Figure. Occlusion of LAA appendage with thrombus

Clinical Value of Stress Transaortic Flow Rate During Dobutamine Echocardiography in Reduced Left Ventricular Ejection Fraction, Low-Gradient Aortic Stenosis: A Multicenter Study

BACKGROUND

Low rest transaortic flow rate (FR) has been shown previously to predict mortality in low-gradient aortic stenosis. However limited prognostic data exists on stress FR during low-dose dobutamine stress echocardiography. We aimed to assess the value of stress FR for the detection of aortic valve stenosis (AS) severity and the prediction of mortality.

METHODS

This is a multicenter cohort study of patients with reduced left ventricular ejection fraction and low-gradient aortic stenosis (aortic valve area <1 cm² and mean gradient <40 mm Hg) who underwent low-dose dobutamine stress echocardiography to identify the AS severity and presence of flow reserve. The outcome assessed was all-cause mortality.

RESULTS

Of the 287 patients (mean age, 75±10 years; males, 71%; left ventricular ejection fraction, 31±10%) over a mean follow-up of 24±30 months there were 127 (44.3%) deaths and 147 (51.2%) patients underwent aortic valve intervention. Higher stress FR was independently associated with reduced risk of mortality (hazard ratio, 0.97 [95% CI, 0.94-0.99]; P=0.01) after adjusting for age, chronic kidney disease, heart failure symptoms, aortic valve intervention, and rest left ventricular ejection fraction. The minimum cutoff for prediction of mortality was stress FR 210 mL/s. Following adjustment to the same important clinical and echocardiographic parameters, among the three criteria of AS severity during stress, ie, the guideline definition of aortic valve area <1cm² and aortic valve mean gradient ≥40 mm Hg, or aortic valve mean gradient ≥40 mm Hg, or the novel definition of aortic valve area <1 cm² at stress FR ≥210 mL/s, only the latter was independently associated with mortality (hazard ratio, 1.72 [95% CI, 1.05-2.82]; P=0.03). Furthermore aortic valve area <1cm² at stress FR ≥210 mL/s was the only severe aortic stenosis criterion that was associated with improved outcome following aortic valve intervention (P<0.001). Guideline-defined stroke volume flow reserve did not predict mortality.

CONCLUSIONS

Stress FR during low-dose dobutamine stress echocardiography was useful for the detection of both AS severity and flow reserve and was associated with improved prediction of outcome following aortic valve intervention.

Early increase of high-sensitivity cardiac troponin predicts mortality in cancer patients undergoing chemotherapy

Introduction

High-sensitivity cardiac troponin test (hs-TnT) reveals subclinical myocardial damage in many cardiac conditions. We hypothesized that elevated hs-TnT may predict a development of cancer therapy-related cardiac dysfunction and clinical outcomes linked with antineoplastic therapies. We aimed to evaluate the predictive value of hs-TnT for all-cause mortality in a group of patients (pts) with recent diagnosis of cancer.

Material and methods

We included 80 pts (mean age 57±13 years; 98% women) with recently diagnosed cancer (78 breast cancer, 1 colon cancer, 1 DLBCL lymphoma). Transthoracic echocardiography and hs-TnT tests were performed at baseline and after 3, 6 and 12-months. Pts with LVEF &lt;50% and significant valvular disease were excluded.

Results

In the study group 44% pts had arterial hypertension, 54% dyslipidemia, 9% diabetes mellitus; 94% pts were treated with anthracyclines, 30% with trastuzumab, 54% with hormone therapy, 71% with radiotherapy. A significant decrease of LVEF were observed during follow-up (LVEF at baseline, 3, 6 and 12 months: 61.7±2.0%; 60.9±2.0%*; 60.8±2.9%*; 59.9±2.9%*; *p&lt;0.05 vs baseline). A significant reduction of global longitudinal strain was found only at 6-month follow-up (−19,2±2,2% vs −18,6±2,0%; p=0,003). In 38 pts at least a twofold (fourfold in37) increase in hs-TnT &gt;99th percentile was observed. A rise of hs-TnT was most often seen at 3 month (n=35; 43,8%). During median 1056 (221–1906) days off follow-up 18 (24%) pts died and ROC curve analysis revealed that early (0–3 months) hs-TnT increase more than 10 pg/ml [AUC=0,693 (0,545–0,806); p=0,017)] represented a predictor of death [OR=3,4 (1,99–11,87)].

Conclusions

Increase in hs-TnT in cancer patients detected at 3rd month of chemotherapy predicts mortality.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Atrial fibrillation as a risk factor of severe course of COVID-19

Background

Coronavirus disease (COVID-19), the pandemic caused by severe acute respiratory syndrome coronavirus, influences on morbidity and mortality and results in changes of human life. It seems that comorbidities play a vital role in severe course of COVID- 19. Nevertheless, how chronic diseases affect respiratory failure is poorly validated.

Purpose

Our aim was to compare the severity of the course of COVID-19 and the prognosis in patient with and without atrial fibrillation (AF).

Methods

We analyzed 199 patients (72 female, mean age 67±13 years) with COVID-19 hospitalized in our Department since November 2020, including, 68 patients with AF (28 female, mean age 74.5±8 years). Although, only 45 patients took anticoagulants before, the treatment was initiated to all patients with AF on admission to the hospital. Patients with AF were characterized by lower left ventricle ejection fraction than those without AF (49% vs. 54%, p=0.0007).

Results

The severe course of COVID, defined as saturation below 90%, lung involvement above 50% in computer tomography, the need for high- flow oxygen therapy, was noticed in 98 patients (36 pts with AF, 32 pts without AF, p=0.27). Moreover, there was no difference between the groups among separately the need for high- flow oxygen therapy, saturation below 90% and lung involvement above 50% in computer tomography. The absence of atrial fibrillation, with a significance of p=0.01, predisposes to a better prognosis based on the patient's discharge. In multivariate analysis, the factors suggesting a poor prognosis, defined as death or transfer to Intensive Care Unit, were severe course of COVID (p=0.01) and the need for high- flow oxygen therapy (p=0.042).

Conclusions

It is noticed that the presence of AF is associated with a poor prognosis in COVID. Further analysis is still needed to prove this statement.

Funding Acknowledgement

Type of funding sources: None.

Atherosclerosis risk factors may be underestimated in patients with pulmonary hypertension associated with congenital heart disease – results of Polish snapshot registry

Introduction

Classic risk factors of atherosclerosis may contribute to cardiovascular (CV) risk in patients (pts) with pulmonary hypertension associated with congenital heart disease (PAH-CHD), but their prevalence is poorly studied.

Purpose

We evaluated a large cohort of Polish PAH-CHD patients (PAHpts) treated with specific therapies with regard to prevalence of classic risk factors for atherosclerosis.

Methods

A multicenter observational snapshot registry was conducted under the auspices of Polish Cardiac Society to study PAH pts, identified in centers treating &gt;5 such pts in years 2008–2018. The analysis included 250 PAH-CHD pts, including non-corrected CHD – predominantly Eisenmenger Syndrome (Gr. 1, 224 pts, mean age 42±2 years, 63% females) and pts after heart disease correction (Gr. 2, 26 pts, mean age 42±6.5 years, 62% females). The incidence of classic CV risk factors was compared in both groups.

Results

The prevalence of risk factors was considerable considering young age of the cohort and statistically similar in both groups (Figure). Hypertension was present in 14% in Gr. 1 and 15% in Gr. 2. The incidence of diabetes was comparable in both groups (3% vs. 4%). Hyperlipidemia was nearly numerically twice as frequent in Gr. 1 (23% vs. 12%, p=0.18). Current smokers (1%) were only present in Gr. 1, while history of smoking was 4% in both groups. Symptomatic atherosclerosis of peripheral arteries was twice as frequent in Gr. 1 (8% vs. 4%, p=0,71). There was no difference regarding prior stroke (3,6% vs 4%, p=0,63). Chronic kidney disease and atrial fibrillation were one and a half more often in Gr. 1 (respectively, 12% vs. 8%, p=0,81; 12% vs. 8%, p=0.75). Mean heart rate was 72±2 bpm in Gr. 1 and 77±7 bpm in Gr. 2. Gastrointestinal bleeding was reported only in Gr. 1 (2.7%). SCORE calculated risks were low due to low age, but high risk was identified in 9.3% of Gr. 1 and 20% of Gr. 2 (p=0.096).

Conclusions

Based on our data from national survey, classic atherosclerosis CV risk factors are not uncommon in the population of relatively young patients with PAH-CHD, parallel to improved longevity. Selected pts from both groups present with elevated risk of death from atherosclerotic complications. This finding may influence the overall mortality risk in PAH-CHD population and reflects new challenges in management despite progress in specific therapies of pulmonary hypertension.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Diagnostic value of coronary flow reserve assessment by dynamic 99mTc-MIBI SPECT-CZT gamma camera for the detection of coronary artery disease

Background

Coronary flow reserve (CFR) obtained by dynamic acquisition of myocardial blood flow using 99mTc-MIBI SPECT-CZT gamma camera may be useful to diagnose myocardial perfusion defects in patients with coronary artery disease (CAD).

Purpose

To assess the feasibility and diagnostic value of SPECT-derived CFR in patients with suspected of confirmed CAD.

Methods

The study group comprised 55 patients (pts) (43.6% females, mean age 64.6±8.4 years) with suspected CAD who were referred for scheduled coronary angiography. All pts underwent myocardial perfusion study with solid-state CZT nuclear camera (dipyridamole stress protocol) to calculate myocardial blood flow reserve. We measured total CFR, as well as CFR in three coronary territories: left anterior descending artery (LAD CFR), right coronary artery (RCA CFR) and left circumflex artery (LCx CFR).

Results

On coronary angiography 27 pts were found to have significant CAD (at least one major coronary artery ≥70% narrowed). Mean total CFR in pts with CAD was lower than in pts without CAD (1.73±0.59 vs 2.09±0.56, respectively, p=0.02). Similar differences were noted in LAD territory (1.47±0.57 vs 2.00±0.57; respectively, p=0.004) and RCA territory (1.55±0.54 vs 2.01±0.62; respectively, p=0.03). However, the differences in LCx CFR between CAD and no-CAD group did not reach statistical significance. Modest, but significant correlations were detected between LAD CFR and the percentage of LAD stenosis (r=−0.3; p=0.02). Total CFR has acceptable diagnostic value for detecting significant CAD (AUC=0.672; p=0.03). The criterion with the highest diagnostic accuracy was CFR &lt;1.8 – its sensitivity was 63%, specificity 71.4%, and overall accuracy 67%. In analysis of coronary territories the highest diagnostic value was achieved for CFR LAD (AUC=0.744; p=0.007).

Conclusions

SPECT-derived CFR provides acceptable diagnostic accuracy for the detection of significant CAD.

Funding Acknowledgement

Type of funding sources: None.

March, September and December months with the greatest influence of atmospheric pressure on blood pressure in patients with hypertension

Objectives

For a long time, science has searched for the relationship between weather and human health. Atmospheric pressure is the most objective weather factor because, regardless of whether the objects are outdoors or indoors, it affects all objects in the same way. In cardiology, we often look for factors that worsen blood pressure control. Could atmospheric pressure be one of them?

The main objective of our research was to assess the relationship between atmospheric pressure and blood pressure in patients with treated hypertension in different months in the moderate climate of Central Poland.

Material and methods

The study group consisted of 4191 patients with arterial hypertension, divided into 2 near equal groups due to a lower or higher average value of atmospheric pressure when blood pressure was recorded. Blood pressure was monitored by a means of 24-h ABPM. Atmospheric pressure was recorded with the frequency of 1 measurement per minute using a meteorological station. The observations were conducted in the years 2009–2019. Comparisons between blood pressure values in the 2 groups were performed using the Mann-Whitney U test.

Results

We observed a significant difference in blood pressure recorded during the periods of lower and higher atmospheric pressure: for systolic blood pressure during the days of September (125.01±14.99 vs 120.14±12.83, p&lt;0.001) and December (124.22±15.45 vs 127.50±14.35, p&lt;0.05), for diastolic pressure during the days of March (72.24±10.92 vs 69.81±9.13, p&lt;0.02) and for diastolic pressure during the nights of March (61.53±8.96 vs 59.58±9.17, p&lt;0.04).

Conclusions

A significant inverse relationship between atmospheric pressure and blood pressure was observed; during March days and nights for diastolic blood pressure and during September and December days for systolic blood pressure.

This finding may be important for the understanding of why during some months the pharmacological control of blood pressure is poor, and of the consequences of this fact.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): own resources

The reinvented old player – an antazoline is effective in pharmacological cardioversion of atrial fibrillation

Introduction

Antazoline (ANT) is an old antihistaminic medication with antiarrhythmic properties. After intravenous administration ANT exerts rapid antiarrhythmic effect often resulting in conversion of atrial fibrillation (AF) to sinus rhythm (SR) and is widely used in Poland for this purpose in the last years. However, published data on its effectiveness, safety and clinical utility for rapid AF termination are limited and ANT is not recognized as a cardioversion drug.

Aim

To assess the real-world efficacy of ANT for pharmacological cardioversion of paroxysmal and persistent non-valvular AF.

Methods

Our single center, retrospective, observational study included patients (pts) with history paroxysmal or persistent AF episode lasting less than 6 months, in stable cardiopulmonary condition who were qualified for elective pharmacological cardioversion with intravenous ANT. The primary end-point was the conversion of AF to SR confirmed in electrocardiography (ECG) during the 6-hours observation.

Results

A total of 176 pts (mean age 68.4±12.0 years, 49% male) were enrolled into the study. In 93 patients (52%) AF duration was shorter than 48 hours and median AF duration time was 24 (7–432) hours. The overall success rate of pharmacological cardioversion of AF with intravenous ANT was 45.5% (80/176 pts). The mean used dose of ANT was 250.9±65.4mg. The subgroup analysis, regarding the AF duration, suggested the effectiveness of ANT mainly in in short-lasting AF (effectiveness of antazoline based cardioversion for AF lasting &lt;48h vs others: 75.3% vs 12.0%, p&lt;0.001). In multivariable logistic regression model AF duration (for every 24h in AF – OR=0.97; 95% CI 0.96–0.98), the left atrium antero-posterior diameter (OR=0.92; 95% CI 0.86–0.99) and the serum creatinine level (OR=0.15; 95% CI 0.03–0.73) were identified as independent predictors of antazoline based pharmacological cardioversion effectiveness, even after adjustment for comorbidities. The ROC curves revealed that the optimal cut-off value for AF duration time predicting ANT's effectiveness was 48h (AUC=0.876; 95% CI 0.815–0.922) – Figure 1. There were only one episode of bradycardia &lt;45 bpm related to ANT administration.

Conclusions

Antazoline is effective and safe in rapid pharmacological cardioversion of paroxysmal AF, especially in the short-lasting AF (&lt;48 hours) and in patients without the left atrium enlargement and significant renal disease.

Funding Acknowledgement

Type of funding sources: None. Figure 1. ROC curve analysis

Clinical profile and in hospital mortality of invasively managed patients with suspicion of acute coronary syndrome during the COVID-19 pandemic

Background

The pandemic of COVID-19 significantly changed the treatment of patients with suspicion of ACS and COVID-19 infection. Access to cardiology department and possibility of invasive diagnosis and treatment of ACS are still significantly impaired.

Aim

Our aim was to evaluate the characteristic and prognosis of patients with suspicion of ACS and COVID-19 infection.

Materials and methods

Our department of cardiology was transformed for Covid unit and was dedicated for diagnosis and treatment of patients with suspicion of ACS. COVID-19 confirmed cases were defined by a positive SARS-CoV-2 polymerase chain reaction (PCR) test. From 14th of October 2020 to 14th of March we performed 39 coronary angiographies. We included 39 patients (27 men) with mean age 69±8.5. In that group 11 patients had NSTEMI, 10 patients had STEMI, 2 patients Tako-Tsubo and 16 unstable angina. All patients underwent coronary angiography, and in 27 patients we performed PCI.

Results

In hospital mortality rate was 35% (14 patients). Cardiac arrest was present in 3 (8%) patients and cardiogenic shock in 4 (10%) patients. The rate of NSTEMI was higher in patients who died 7 vs 4 (p=NS) and STEMI were comparable in both groups 4 vs 6, (p=ns). The IL 6 levels in patients who died were 389±278pg/mL, in compare to 101±93pg/mL (p=0.3) who survived. Independent predictors of death were: sex with the OR=1,1 (95% CI: 0.6–2.4), p=0,03 and IL-6 level on admission OR=1,4 (95% CI: 0.6–2.4), p=0,04. There were no statistically significant differences regarding age, left ventricle ejection fraction, CRP levels and oxygen saturation od admission.

Conclusion

This study confirms the higher risk of death in patients with ACS and SARS-CoV-2. In the multivariable analysis only sex and Il-6 level on admission were the independent risk factors of the in hospital death. Further investigations of the underlying physiopathological relations between COVID-19 and ACS are needed.

Funding Acknowledgement

Type of funding sources: None.

Speckle tracking-derived left atrial stiffness predicts adverse events after successful electrical cardioversion

Background

Atrial fibrillation (AF) impairs cardiac mechanics and leads to adverse remodelling. Increased left atrial (LA) stiffness reflecting LA reservoir function and left ventricular (LV) filling pressure is one of the symptoms of LA remodelling.

Purpose

To analyse LA stiffness within 24 hours after successful electrical cardioversion and its prognostic value during 2-years follow-up.

Methods

Prospective study involved 71 patients with nonvalvular AF (mean age 64±13 years, 61% male). All patients underwent echo during 24 hours after conversion to sinus rhythm. We analysed standard echocardiographic and Doppler parameters. Using speckle-tracking method we assessed peak LA longitudinal strain in 4- and 2-chamber view. LA stiffness was calculated as the quotient of peak LA longitudinal strain (LA reservoir function) and mean E/E' ratio. The clinical endpoints were predefined as AF recurrence and cardiovascular hospitalization.

Results

Median time of current AF episode was 2 (IQR 0.4–5) months. Standard echo measurements revealed median of LV ejection fraction 55% (IQR 45–58) and median of LA volume indexed to body surface area 42 ml/m2 (IQR 34–51). During follow-up we noticed AF recurrence in 48 (68%) patients and cardiovascular hospitalization in 43 (61%) patients. Median time-to-event was 2.4 (IQR 1 to 6.9) and 7 (IQR 2.1–11) months, respectively. Receiver operating characteristic curve analysis revealed that LA stiffness &gt;0.53 (AUC=0.821; p&lt;0.0001) and &gt;0.95 (AUC=0.788; p&lt;0.0001) were the optimal cut-off values for predicting AF recurrence and cardiovascular hospitalization. Figure presents Kaplan-Meier survival analysis for AF recurrence (A) and for hospitalization (B). Moreover LA stiffness remain statistically significant in multivariate Cox regression analysis even after adjustment for betablockers, antiarrhythmic drugs, coronary artery disease, heart failure and mitral regurgitation. Relative risk was 1.51 (95% CI 1.09–2.09), p=0.01 for AF recurrence and 1.49 (95% CI 1.05–2.13) for cardiovascular hospitalization.

Conclusions

Speckle tracking-derived LA stiffness assessed early after the restoration of sinus rhythm independently predicts AF recurrence and cardiovascular hospitalization.

Funding Acknowledgement

Type of funding sources: None.

Pocket-size ultrasound devices may improve the prompt assessment of Covid-19 patients

Introduction

Clinical usefulness of pocket-size ultrasound device [PSUD] was previously confirmed in numerous clinical scenarios. During the previous year Covid-19 patients have become a focal point of the cardiology and internal medicine wards. However, there is no data on the use of PSUD in this scenario.

Purpose

To asses if PSUD may be useful in providing additional information in Covid-19 patients.

Methods

In 63 patients (41 men, mean age 63±11) with confirmed Covid-19 the scope of physical examination was expanded with bedside assessment performed with PSUD equipped with dual probe. PSUD examination included: right ventricle measurement, automated LVEF assessment, 4-point compression ultrasound test of lower limbs and lung ultrasound (presence of B-lines, lung consolidations or thickening of pleura). Subsequently, within the next 24 hours all patients underwent chest CT scan, CT pulmonary angiogram and full echocardiographic examination performed on a high-end stationary device.

Results

Lung lesions typical for Covid-19 were confirmed in CT in 53 (84%) patients. The sensitivity and specificity of bedside PSUD examination for diagnosing lung involvement was 92% and 90%, respectively, when presence of any pathology on lung ultrasound was considered as a positive criterion. Increased number of B-lines had a sensitivity of 81%, specificity 83% for the ground glass symptom in CT detection, (AUC 0,82; p&lt;0,0001). Pleural thickening was diagnosed by PSUD with a 95% sensitivity and 88% specificity (AUC 0,91, p&lt;0,0001), whereas lung consolidations with a 71% sensitivity and 86% specificity (AUC 0,79, p&lt;0,0001). In 20 patients (32%) pulmonary embolism was confirmed by angioCT – in 10 among them embolism was limited to subsegmental arteries. RV was found to be dilated in PSUD examination in 27 patients (43%), CUS was positive in 1 patient. Thus, RV enlargement treated as a marker of PE had low sensitivity and specificity (60% i 65% respectively), AUC=0,62, p=0,06. Mean LVEF in standard echocardiography was 46±12%, but during PSUD examination automated LV function analysis software failed to calculate LVEF in 29 (46%) cases due to suboptimal image quality.

Conclusion

In Covid-19 patients PSUD is particularly useful for lung ultrasound and the detection of lung pathologies. RV enlargement observed during PSUD examination has relatively low sensitivity and specificity for the detection of pulmonary embolism in Covid-19. Furthermore, due to low quality of images automated LV function assessment failed to provide any result in almost half of patients.

Funding Acknowledgement

Type of funding sources: None.

Impact of COVID-19 pandemics upon pulmonary hypertension patients: insights from BNP-PL national database

Introduction

COVID-19 pandemic has caused not only an increase in overall and cardiovascular mortality, but also hindered access to health care, diagnosis and treatment of diseases other than coronavirus infection.

Aim

Assessment of the impact of the SARS-CoV-2 pandemic on the rate of diagnosis and therapy of pulmonary hypertension (PH) in Poland, along with an analysis of the incidence and course of COVID-19 among patients (pts) diagnosed with PH, treated under the National Health Fund program, registered in the national BNP-PL database.

Methods

The records of the complete population of Polish pts treated under the National Drug Program of PH (PAH and CTEPH), registered in the national database of BNP-PL, updated on an ongoing basis by all PH centers, were analyzed. The frequency of SARS-CoV-2 infections, the clinical severity of their course and the mortality were reviewed, taking into account the specific therapies used. The basic clinical characteristics of the group of sick and deceased patients were compared to the remaining patients registered in the BNP-PL database. The rate of increase of new diagnoses ended with inclusion in the Drug Program between March and December 2020, compared to the corresponding periods of the previous year, and the change in the treatment profile were compared.

Results

The analysis included 1704 pts (PAH 1134, CTEPH 570). The incidence of SARS-CoV-2 infections was 3.8% (n=65), including PAH 2.7% (n=46) and CTEPH 3,2% (n=18). 32 patients (49%) required hospitalization. Mortality rate was 28% (18/65) – including 7/18 outside of hospital. Those who died due to COVID-19 were older (mean age 68.4±15.8 vs. 50.8±18.8 yrs; p&lt;0,001), had higher WHO class and more cardiovascular comorbidities (4±2,06 vs. 2,66±1,8; p=0,01) (Table 1). During the pandemic the number of new diagnoses of PH markedly decreased compared to the corresponding period in 2019 (total 150 vs. 203, PAH 90 vs. 123, CTEPH 60 vs. 80, respectively). A significant increase in total mortality was also observed in the PH group (9,72 vs. 5,85%). Moreover, escalation of specific PH therapy decreased significantly (14,7% vs. 21,6%). Incidence of COVID-19 study group was lower than estimated for general Polish adult population (3,8% vs. 6,5%).

Conclusions

COVID-19 pandemic deeply influenced the diagnostic and therapeutic process of pulmonary hypertension by reducing the number of new diagnoses, escalation therapy and increased overall mortality in this population. This may be due in part to the conversion of some PAH centers into hospitals treating patients infected with SARS-CoV-2, as well as to patients' fear of admitting to hospital despite clinical deterioration. Pulmonary hypertension is linked to markedly increased mortality in COVID-19, similarly for PAH and CTEPH. Intriguing finding of lower infection rate may be linked to protective lifestyle or specific therapies.

Funding Acknowledgement

Type of funding sources: None.

Left ventricular longitudinal strain impairment at rest correlates with reduction of SPECT-derived coronary flow reserve in patients with suspected coronary artery disease

Background

Speckle tracking echocardiography (STE) may be useful for the detection of subclinical systolic function abnormalities. Dynamic acquisition of myocardial blood flow using 99mTc-MIBI SPECT-CZT gamma camera allows the calculation of coronary flow reserve (CFR).

Purpose

The aim of our study is to assess the relationship between left ventricular longitudinal strain (LS) and CFR in patients with suspected coronary artery disease (CAD).

Methods

55 patients (pts) (43.6% females, mean age 64.6±8.4 years) with suspected CAD underwent transthoracic echocardiography with assessment global and local LS by STE. We calculated mean global left ventricular LS (GLS), as well as LS of individual coronary artery territories (LAD LS, LCx LS and RCA LS). All pts underwent myocardial perfusion study with novel solid-state CZT nuclear camera (dipyridamole stress protocol). We measured CFR of the left ventricle and individual coronary territories.

Results

Mean absolute GLS in pts with total CFR &lt;2 was significantly lower than in pts with CFR &gt;2 (median value −13.9 vs −18.3; p&lt;0.001). Similar differences were observed in all three coronary territories (p≤0.01). Modest but significant correlations were detected between total CFR and GLS values (r=−0.56; p&lt;0.001), LAD CFR and LAD LS (r=−0.54; p&lt;0.001), RCA CFR and RCA LS (r=−0.36; p=0.007), LCx CFR and LCx LS (r=−0.53; p&lt;0.001). GLS at rest had good diagnostic value for detecting total CFR &lt;2 (AUC=0.767; p&lt;0.001). The criterion with the highest diagnostic accuracy was GLS &gt; (−15.8) – its sensitivity was 68%, specificity 77.7%, and overall accuracy 73%.

Conclusions

Indices of left ventricular longitudinal function obtained by speckle tracking echocardiography correlate with SPECT-derived CFR in patients with suspected CAD.

Funding Acknowledgement

Type of funding sources: None.

Prognostic value of stress echocardiography assessed by the ABCDE protocol

AIM

The aim of this study was to assess the prognostic value of ABCDE-SE in a prospective, large scale, multicentre, international, effectiveness study. Stress echocardiography (SE) was recently upgraded to the ABCDE protocol: step A, regional wall motion abnormalities; step B, B lines; step C, left ventricular contractile reserve; step D, Doppler-based coronary flow velocity reserve in left anterior descending coronary artery; and step E, electrocardiogram-based heart rate reserve.

METHODS AND RESULTS

From July 2016 to November 2020, we enrolled 3574 all-comers (age 65 ± 11 years, 2070 males, 58%; ejection fraction 60 ± 10%) with known or suspected chronic coronary syndromes referred from 13 certified laboratories. All patients underwent clinically indicated ABCDE-SE. The employed stress modality was exercise (n = 952, with semi-supine bike, n = 887, or treadmill, n = 65 with adenosine for step D) or pharmacological stress (n = 2622, with vasodilator, n = 2151; or dobutamine, n = 471). SE response ranged from score 0 (all steps normal) to score 5 (all steps abnormal). All-cause death was the only endpoint. Rate of abnormal results was 16% for A, 30% for B, 36% for C, 28% for D, and 37% for E steps. During a median follow-up of 21 months (interquartile range: 13-36), 73 deaths occurred. Global X2 was 49.5 considering clinical variables, 50.7 after step A only (P = NS (not significant)) and 80.6 after B-E steps (P < 0.001 vs. step A). Annual mortality rate ranged from 0.4% person-year for score 0 up to 2.7% person-year for score 5.

CONCLUSION

ABCDE-SE allows an effective prediction of survival in patients with chronic coronary syndromes.

Age-changes in right ventricular function-pulmonary circulation coupling: from pediatric to adult stage in 1899 healthy subjects. The RIGHT Heart International NETwork (RIGHT-NET)

The present study analyzes age-specific changes in RV function and RV-PA coupling in a large cohort of apparently healthy subjects with a wide age-range, to identify reference values and to study the influence of clinical and echocardiographic cofactors. 1899 Consecutive healthy subjects underwent a standardized transthoracic echocardiographic examination. Tricuspid annular plane systolic excursion (TAPSE) and systolic pulmonary artery pressure (SPAP) were measured. Ventriculo-arterial coupling was then inferred from the TAPSE/SPAP ratio. A quantile regression analysis was used to estimate quantiles 0.05, 0.10, 0.50 (median), 0.90, and 0.95 of TAPSE, SPAP and TAPSE/SPAP. The association between age and each of these values was determined. The mean age of the group was 45.2 ± 18.5 years (range 1 to 102 years), 971 were males. SPAP increased with age, whereas TAPSE and TAPSE/SPAP ratio decreased. Upon multivariate modeling, the most significant positive associations for TAPSE were body surface area (BSA) driven by the pediatric group, stroke volume (SV), E/A and negatively heart rate and E/e' ratio. SPAP was positively associated with increasing age, SV, E/A, E/e' and negatively with BSA. TAPSE/SPAP ratio was negatively associated with age, female sex, and E/e' and positively with BSA. A preserved relationship between TAPSE and SPAP was found across the different age groups. TAPSE, SPAP and TAPSE/SPAP demonstrate important trends and associations with advancing age, impaired diastolic function, affected by female sex and BSA However the relationship between TAPSE and SPAP is relatively well preserved across the age spectrum.

Hemodynamic Heterogeneity of Reduced Cardiac Reserve Unmasked by Volumetric Exercise Echocardiography

Background: Two-dimensional volumetric exercise stress echocardiography (ESE) provides an integrated view of left ventricular (LV) preload reserve through end-diastolic volume (EDV) and LV contractile reserve (LVCR) through end-systolic volume (ESV) changes. Purpose: To assess the dependence of cardiac reserve upon LVCR, EDV, and heart rate (HR) during ESE. Methods: We prospectively performed semi-supine bicycle or treadmill ESE in 1344 patients (age 59.8 ± 11.4 years; ejection fraction = 63 ± 8%) referred for known or suspected coronary artery disease. All patients had negative ESE by wall motion criteria. EDV and ESV were measured by biplane Simpson rule with 2-dimensional echocardiography. Cardiac index reserve was identified by peak-rest value. LVCR was the stress-rest ratio of force (systolic blood pressure by cuff sphygmomanometer/ESV, abnormal values ≤2.0). Preload reserve was defined by an increase in EDV. Cardiac index was calculated as stroke volume index * HR (by EKG). HR reserve (stress/rest ratio) <1.85 identified chronotropic incompetence. Results: Of the 1344 patients, 448 were in the lowest tertile of cardiac index reserve with stress. Of them, 303 (67.6%) achieved HR reserve <1.85; 252 (56.3%) had an abnormal LVCR and 341 (76.1%) a reduction of preload reserve, with 446 patients (99.6%) showing ≥1 abnormality. At binary logistic regression analysis, reduced preload reserve (odds ratio [OR]: 5.610; 95% confidence intervals [CI]: 4.025 to 7.821), chronotropic incompetence (OR: 3.923, 95% CI: 2.915 to 5.279), and abnormal LVCR (OR: 1.579; 95% CI: 1.105 to 2.259) were independently associated with lowest tertile of cardiac index reserve at peak stress. Conclusions: Heart rate assessment and volumetric echocardiography during ESE identify the heterogeneity of hemodynamic phenotypes of impaired chronotropic, preload or LVCR underlying a reduced cardiac reserve.

Cinderella drug: an antazoline is effective in pharmacological cardioversion of atrial fibrillation - Single center experience

Funding Acknowledgements

Type of funding sources: None.

Introduction

Antazoline (ANT) is an old antihistaminic medication with antiarrhythmic properties. After intravenous administration ANT exerts rapid antiarrhythmic effect often resulting in conversion of persistent atrial fibrillation (AF) to sinus rhythm (SR). However, published data on its effectiveness, safety and  clinical utility for rapid AF termination are limited and ANT is not recognized as a cardioversion drug. 

Aim

To assess the real-world efficacy of ANT for pharmacological cardioversion of paroxysmal and persistent non-valvular AF. 

Methods

We conducted a single center, retrospective, observational study including patients (pts) with history paroxysmal or persistent AF episode lasting less than 6 months, in stable cardiopulmonary condition who were qualified for elective pharmacological cardioversion with intravenous ANT. The primary end-point was the conversion of AF to SR confirmed in electrocardiography (ECG) during the 6-hours observation. 

Results

A total of 176 pts (mean age 68.4 ± 12.0 years, 49% male) were enrolled into the study. In 93 patients (52%) AF duration was shorter than 48 hours and median AF duration time was 24 (7 – 432) hours. The overall success rate of pharmacological cardioversion of AF with intravenous ANT was 45.5% (80/176 pts). The mean used dose of ANT was 250.9 ± 65.4mg. The subgroup analysis, regarding the AF duration, suggested the effectiveness of ANT mainly in in short-lasting AF (effectiveness of antazoline based cardioversion for AF lasting &lt;48h vs others:  75.3% vs 12.0%,  p &lt; 0.001). In multivariable logistic regression model AF duration (for every 24h in AF - OR = 0.97; 95% CI 0.96 – 0.98), the left atrium antero-posterior diameter (OR = 0.92; 95% CI 0.86 – 0.99) and the serum creatinine level (OR = 0.15; 95% CI 0.03 – 0.73) were identified as  independent predictors of antazoline based pharmacological cardioversion effectiveness, even after adjustment for comorbidities. The ROC curves revealed that the optimal cut-off value for AF duration time predicting ANT’s effectiveness was 48h (AUC = 0.876; 95% CI 0.815 – 0.922). There were only one episode of bradycardia &lt;45 bpm related to ANT administration. 

Conclusions

Intravenous antazoline administration is effective and safe in rapid pharmacological cardioversion of paroxysmal AF, especially in the short-lasting AF (&lt;48 hours) and in patients without the left atrium enlargement and significant renal disease. Abstract Figure.

What can we find in the ECG recording in convalescent from COVID-19 with mild and moderate course

Funding Acknowledgements

Methods

Results

Feasibility of semi-recumbent bicycle exercise Doppler echocardiography for the evaluation of the right heart and pulmonary circulation unit in different clinical conditions: the RIGHT heart international NETwork (RIGHT-NET)

Exercise Doppler echocardiography (EDE) is a well-validated tool in ischemic and valvular heart diseases. However, its use in the assessment of the right heart and pulmonary circulation unit (RH-PCU) is limited. The aim of this study is to assess the semi-recumbent bicycle EDE feasibility for the evaluation of RH-PCU in a large multi-center population, from healthy individuals and elite athletes to patients with overt or at risk of developing pulmonary hypertension (PH). From January 2019 to July 2019, 954 subjects [mean age 54.2 ± 16.4 years, range 16-96, 430 women] underwent standardized semi-recumbent bicycle EDE with an incremental workload of 25 watts every 2 min, were prospectively enrolled among 7 centers participating to the RIGHT Heart International NETwork (RIGHT-NET). EDE parameters of right heart structure, function and pressures were obtained according to current recommendations. Right ventricular (RV) function at peak exercise was feasible in 903/940 (96%) by tricuspid annular plane systolic excursion (TAPSE), 667/751 (89%) by tissue Doppler-derived tricuspid lateral annular systolic velocity (S') and 445/672 (66.2%) by right ventricular fractional area change (RVFAC). RV-right atrial pressure gradient [RV-RA gradient = 4 × tricuspid regurgitation velocity² (TRV)] was feasible in 894/954 patients (93.7%) at rest and in 816/954 (85.5%) at peak exercise. The feasibility rate in estimating pulmonary artery pressure improved to more than 95%, if both TRV and/or right ventricular outflow tract acceleration time (RVOT AcT) were considered. In high specialized echocardiography laboratories semi-recumbent bicycle EDE is a feasible tool for the assessment of the RH-PCU pressure and function.

Does automated left ventricular ejection fraction assessment available on handheld ultrasound devices represent improvement in the diagnostic accuracy?

Funding Acknowledgements

Type of funding sources: None.

Purpose

To assess the accuracy of an algorithm for automated measurement of the left ventricular ejection fraction (LVEF) available on handheld ultrasound device (HUD).

Methods

112 patients admitted to the cardiology department, who were referred for the conventional echocardiographic examination, underwent additional assessment performed with HUD (Vscan Extend, GE Vingmed Ultrasound, Horten, Norway). In each case 4 – chamber apical view was obtained and LVEF was calculated by means of the LVivo software. Imaging quality was assessed in a 4-grade scale. Subsequently, during the examination performed with the use of the stationary echocardiograph the three-dimensional (3D) measurement of LVEF was recorded.

Results

Ultimately 96 (53 men, mean age 63 ± 11) patients were enrolled into the study group  In the remaining 16 cases (14%) 3D image quality was not sufficient to allow the calculation of the LVEF. LVivo software was unsuccessful in calculating LVEF in all these 16 patients and in additional 20 patients, who remained in the study group due to satisfactory 3D image quality.

The quality of images acquired with the use of HUD was assessed as optimal in 25 (26%) patients, good in 37 (39%), acceptable in 24 (25%), poor in 10 (10%).

The average LVEF value was 46%±14 with the 3D LVQ measurements and 48%±14 using the LVivo software. The correlation coefficient between  the LVEF values obtained with the two methods was  r = 0,92; (P &lt; 0,0001). Using paired samples t-test we found that the difference between these two techniques was not significant (mean difference 4,5± 3,4%; P = 0,35).

LVivo software EF assessment is based on a single apical view and for this reason we have assumed that the differences in EF can be larger in patients with regional wall motion abnormalities, in whom LVEF values derived from different apical views can significantly vary. For this reason the group of patients with history of myocardial infarction (40pts, 42%) was analysed separately and we found that the difference between LVivo and 3D LVEF was also not statistically significant (mean difference 6,1± 3,3%; P= 0,14). The correlation coefficient equalled  r = 0,78; (P &lt; 0,0001).

Conclusion

The LVivo software despite its limitations is capable of the accurate LVEF measurement when the acquired views are of at least good imaging quality. Such expanded capabilities of HUDs can potentially lead to the overall improvements of the diagnostic accuracy of the ultrasonographic examinations, particularly when in hands of the non-expert echocardiographers.

Early assessment of left atrial function after cardioversion predicts recurrence of atrial fibrillation

Funding Acknowledgements

Type of funding sources: None.

Background

The restoration of sinus rhythm (SR) improves the mechanical function of the heart.

Purpose

To assess left atrial (LA) function before and within 24 hours after successful electrical cardioversion (EC) and its prognostic value for atrial fibrillation (AF) recurrence during 24 months follow-up.

Methods

Prospective study involved 71 patients with non-valvular AF (mean age 64 ± 13 years, 61% male). All patients underwent echocardiography before and after EC. We analysed standard parameters in two-dimensional echo, pulse-wave Doppler and tissue Doppler echocardiography. Using speckle-tracking method we assessed peak atrial longitudinal strain (PALS) and peak atrial contraction strain (PACS).

Results

During follow-up we noticed AF recurrence in 48 (68%) patients. Median time to AF recurrence was 2.4 (IQR 1 to 6.9) months. Left ventricular ejection fraction as well as E/E’ and PALS assessed during AF were statistically insignificant as potential predictors in univariate regression model. Receiver operating characteristic curve analysis revealed that left atrial volume index &gt;37 ml/m² (AUC = 0.811, p &lt; 0.0001), E/A ratio &gt;2.1 (AUC = 0.828, p &lt; 0.0001), A wave ≤0.4 m/s (AUC = 0.662, p = 0.01), mean E/E’ ratio during sinus rhythm &gt;8.5 (AUC = 0.815, p &lt; 0.0001), mean A’ wave of ≤5.5 cm/s (AUC = 0.848, p &lt; 0.0001), PALS-SR ≤14.1% (AUC = 0.767, p &lt; 0.0001), PACS ≤4.3% (AUC = 0.883, p &lt; 0.0001) were the optimal cut-off values for predicting AF recurrence.

Conclusions

The assessment of LA and diastolic function conducted within 24 hours after successful cardioversion predicts long-term maintenance of sinus rhythm.

Clinical value of stress transaortic flow rate during dobutamine echocardiography in low-gradient aortic stenosis

Funding Acknowledgements

Type of funding sources: None.

BACKGROUND/INTRODUCTION

The clinical value of rest transaortic flow rate (FR) has been shown previously in low-gradient aortic stenosis (LGAS) for the prediction of outcome. However limited data exists on the prognostic value of stress FR in LGAS following low-dose dobutamine stress echocardiography (LDDSE).

PURPOSE

We aimed to assess the value of stress FR in patients with LGAS in the diagnosis of AS severity and the prediction of mortality.

METHODS

This is a multi-centre cohort study of patients with low left ventricular ejection fraction (LVEF) and LGAS (aortic valve area –AVA &lt;1cm²) who underwent LDDSE.

RESULTS

Of the 287 patients (mean age:  75.1 ±10 years, males: 71%) over the mean follow-up of 24 ±30 months there were 127 (44.3%) deaths and 147 (51.2%) patients underwent aortic valve intervention. Lower stress FR was independently associated with increased risk of mortality (HR= 0.99, 95%CI= 0.99-0.999, p= 0.02) after adjusting for age, chronic kidney disease, presence of symptoms (NYHA II-IV), aortic valve intervention, rest LVEF and guideline-defined severe AS (AV mean gradient- AVMG ≥40mmHg with AVA &lt;1cm² at peak stress).  The minimum cut-off for prediction of mortality was stress FR 210ml/sec. Among the different criteria of AS severity during stress, i.e. guideline-defined criterion, or stress AVMG ≥40mmHg, or stress AVA &lt;1cm² at stress FR ≥210ml/s, only the latter was independently associated with mortality (HR= 1.81, 95%CI= 1.04-3.2, p= 0.04) (Table 1) and was the parameter of AS severity that predicted improved outcome following aortic valve intervention (p &lt;0.005) (Figure 1). Guideline-defined stroke volume flow reserve did not predict mortality.

CONCLUSIONS

Assessment of stress FR during LDDSE is important for the detection of both AS severity and flow reserve.

Table 1 Multivariable analysis for prediction of all-cause mortality (N = 287) for the different criteria of aortic stenosis HR 95%CI p Age 1 0.98-1.03 0.84 Chronic kidney disease 1..84 1.13-2.99 0.01 Aortic valve intervention 0.37 0.22-0.61 &lt;0.005 Presence of symptoms (NYHA II-IV) 1.87 0.66-5.31 0.24 Rest LVEF (by 1%) increase 0.97 0.95-1 0.06 Stress AVA &lt; 1cm&sup2; with stress AVMG≥40mmHg 1.02 0.31-3.34 0.97 Stress AVMG≥40mmHg 0.57 0.2-1.59 0.28 Stress AVA &lt; 1cm&sup2; at stress FR≥210mmHg 1.81 1.04-3.2 0.04 Abstract Figure 1

A multicentric quality-control study of exercise Doppler echocardiography of the right heart and the pulmonary circulation. The RIGHT Heart International NETwork (RIGHT-NET)

Purpose

This study was a quality-control study of resting and exercise Doppler echocardiography (EDE) variables measured by 19 echocardiography laboratories with proven experience participating in the RIGHT Heart International NETwork.

Methods

All participating investigators reported the requested variables from ten randomly selected exercise stress tests. Intraclass correlation coefficients (ICC) were calculated to evaluate the inter-observer agreement with the core laboratory. Inter-observer variability of resting and peak exercise tricuspid regurgitation velocity (TRV), right ventricular outflow tract acceleration time (RVOT Act), tricuspid annular plane systolic excursion (TAPSE), tissue Doppler tricuspid lateral annular systolic velocity (S’), right ventricular fractional area change (RV FAC), left ventricular outflow tract velocity time integral (LVOT VTI), mitral inflow pulsed wave Doppler velocity (E), diastolic mitral annular velocity by TDI (e’) and left ventricular ejection fraction (LVEF) were measured.

Results

The accuracy of 19 investigators for all variables ranged from 99.7 to 100%. ICC was > 0.90 for all observers. Inter-observer variability for resting and exercise variables was for TRV = 3.8 to 2.4%, E = 5.7 to 8.3%, e’ = 6 to 6.5%, RVOT Act = 9.7 to 12, LVOT VTI = 7.4 to 9.6%, S’ = 2.9 to 2.9% and TAPSE = 5.3 to 8%. Moderate inter-observer variability was found for resting and peak exercise RV FAC (15 to 16%). LVEF revealed lower resting and peak exercise variability of 7.6 and 9%.

Conclusions

When performed in expert centers EDE is a reproducible tool for the assessment of the right heart and the pulmonary circulation.

Feasibility and functional correlates of left atrial volume changes during stress echocardiography in chronic coronary syndromes

An enlarged left atrial volume index (LAVI) at rest mirrors increased LA pressure and/or impairment of LA function. A cardiovascular stress may acutely modify left atrial volume (LAV) within minutes. Aim of this study was to assess the feasibility and functional correlates of LAV-stress echocardiography (SE) Out of 514 subjects referred to 10 quality-controlled labs, LAV-SE was completed in 490 (359 male, age 67 ± 12 years) with suspected or known chronic coronary syndromes (n = 462) or asymptomatic controls (n = 28). The utilized stress was exercise in 177, vasodilator in 167, dobutamine in 146. LAV was measured with the biplane disk summation method. SE was performed with the ABCDE protocol. The intra-observer and inter-observer LAV variability were 5% and 8%, respectively. ∆-LAVI changes (stress-rest) were negatively correlated with resting LAVI (r = - 0.271, p < 0.001) and heart rate reserve (r = -.239, p < 0.001). LAV-dilators were defined as those with stress-rest increase ≥ 6.8 ml/m², a cutoff derived from a calculated reference change value above the biological, analytical and observer variability of LAVI. LAV dilation occurred in 56 patients (11%), more frequently with exercise (16%) and dipyridamole (13%) compared to dobutamine (4%, p < 0.01). At multivariable logistic regression analysis, B-lines ≥ 2 (OR: 2.586, 95% CI = 1.1293-5.169, p = 0.007) and abnormal contractile reserve (OR: 2.207, 95% CI = 1.111-4.386, p = 0.024) were associated with LAV dilation. In conclusion, LAV-SE is feasible with high success rate and low variability in patients with chronic coronary syndromes. LAV dilation is more likely with reduced left ventricular contractile reserve and pulmonary congestion.

Lung Ultrasound and Pulmonary Congestion During Stress Echocardiography

OBJECTIVES

The purpose of this study was to assess the functional and prognostic correlates of B-lines during stress echocardiography (SE).

BACKGROUND

B-profile detected by lung ultrasound (LUS) is a sign of pulmonary congestion during SE.

METHODS

The authors prospectively performed transthoracic echocardiography (TTE) and LUS in 2,145 patients referred for exercise (n = 1,012), vasodilator (n = 1,054), or dobutamine (n = 79) SE in 11 certified centers. B-lines were evaluated in a 4-site simplified scan (each site scored from 0: A-lines to 10: white lung for coalescing B-lines). During stress the following were also analyzed: stress-induced new regional wall motion abnormalities in 2 contiguous segments; reduced left ventricular contractile reserve (peak/rest based on force, ≤2.0 for exercise and dobutamine, ≤1.1 for vasodilators); and abnormal coronary flow velocity reserve ≤2.0, assessed by pulsed-wave Doppler sampling in left anterior descending coronary artery and abnormal heart rate reserve (peak/rest heart rate) ≤1.80 for exercise and dobutamine (≤1.22 for vasodilators). All patients completed follow-up.

RESULTS

According to B-lines at peak stress patients were divided into 4 different groups: group I, absence of stress B-lines (score: 0 to 1; n = 1,389; 64.7%); group II, mild B-lines (score: 2 to 4; n = 428; 20%); group III, moderate B-lines (score: 5 to 9; n = 209; 9.7%) and group IV, severe B-lines (score: ≥10; n = 119; 5.4%). During median follow-up of 15.2 months (interquartile range: 12 to 20 months) there were 38 deaths and 28 nonfatal myocardial infarctions in 64 patients. At multivariable analysis, severe stress B-lines (hazard ratio [HR]: 3.544; 95% confidence interval [CI]: 1.466 to 8.687; p = 0.006), abnormal heart rate reserve (HR: 2.276; 95% CI: 1.215 to 4.262; p = 0.010), abnormal coronary flow velocity reserve (HR: 2.178; 95% CI: 1.059 to 4.479; p = 0.034), and age (HR: 1.031; 95% CI: 1.002 to 1.062; p = 0.037) were independent predictors of death and nonfatal myocardial infarction.

CONCLUSIONS

Severe stress B-lines predict death and nonfatal myocardial infarction. (Stress Echo 2020-The International Stress Echo Study [SE2020]; NCT03049995).

Feasibility and value of two-dimensional volumetric stress echocardiography

BACKGROUND

Stroke volume response during stress is a major determinant of functional status in heart failure and can be measured by two-dimensional (2-D) volumetric stress echocardiography (SE). The present study hypothesis is that SE may identify mechanisms underlying the change in stroke volume by measuring preload reserve through end-diastolic volume (EDV) and left ventricular contractile reserve (LVCR) with systolic blood pressure and end-systolic volume (ESV).

METHODS

We enrolled 4735 patients (age 63.6±11.3 years, 2800 male) referred to SE for known or suspected coronary artery disease (CAD) and/or heart failure (HF) in 21 SE laboratories in 8 countries. In addition to regional wall motion abnormalities (RWMA), force was measured at rest and peak stress as the ratio of systolic blood pressure by cuff sphygmomanometer/ESV by 2D with Simpson's or linear method. Abnormal values of LVCR (peak/rest) based on force were ≤1.10 for dipyridamole (N.=1992 patients) and adenosine (N.=18); ≤2.0 for exercise (N.=2087) or dobutamine (N.=638).

RESULTS

Force-based LVCR was obtained in all 4735 patients. Lack of stroke volume increase during stress was due to either abnormal LVCR and/or blunted preload reserve, and 57% of patients with abnormal LVCR nevertheless showed increase in stroke volume.

CONCLUSIONS

Volumetric SE is highly feasible with all stresses, and more frequently impaired in presence of ischemic RWMA, absence of viability and reduced coronary flow velocity reserve. It identifies an altered stroke volume response due to reduced preload and/or contractile reserve.

Feasibility and value of two-dimensional volumetric stress echocardiography

BACKGROUND

Stroke volume response during stress is a major determinant of functional status in heart failure and can be measured by two-dimensional (2-D) volumetric stress echocardiography (SE). The present study hypothesis is that SE may identify mechanisms underlying the change in stroke volume by measuring preload reserve through end-diastolic volume (EDV) and left ventricular contractile reserve (LVCR) with systolic blood pressure and end-systolic volume (ESV).

METHODS

We enrolled 4,735 patients (age 63.6 ± 11.3 yrs, 2800 male) referred to SE for known or suspected coronary artery disease (CAD) and/or heart failure (HF) in 21 SE laboratories in 8 countries. In addition to regional wall motion abnormalities (RWMA), force was measured at rest and peak stress as the ratio of systolic blood pressure by cuff sphygmomanometer/ESV by 2D with Simpson's or linear method. Abnormal values of LVCR (peak/rest) based on force were ≤1.10 for dipyridamole (n=1,992 patients) and adenosine (n=18); ≤2.0 for exercise (n=2,087) or dobutamine (n=638).

RESULTS

Force-based LVCR was obtained in all 4,735 pts. Lack of stroke volume increase during stress was due to either abnormal LVCR and/or blunted preload reserve, and 57 % of patients with abnormal LVCR nevertheless showed increase in stroke volume.

CONCLUSIONS

Volumetric SE is highly feasible with all stresses, and more frequently impaired in presence of ischemic RWMA, absence of viability and reduced coronary flow velocity reserve. It identifies an altered stroke volume response due to reduced preload and/or contractile reserve.