Depression in Heart Failure with Reduced Ejection Fraction, an Undervalued Comorbidity: An Up-To-Date Review

Introduction: Depression is a common and severe comorbidity among individuals with heart failure (HF). Up to a third of all HF patients are depressed, and an even higher proportion have symptoms of depression. Aim: In this review, we evaluate the relationship between HF and depression, explain the pathophysiology and epidemiology of both diseases and their relationship, and highlight novel diagnostic and therapeutic options for HF patients with depression. Materials and Methods: This narrative review involved keyword searches of PubMed and Web of Science. Review search terms included ["Depression" OR "Depres*" OR "major depr*"] AND ["Heart Failure" OR "HF" OR "HFrEF" OR "HFmrEF" OR "HFpEF" OR "HFimpEF"] in all fields. Studies included in the review met the following criteria: (A) published in a peer-reviewed journal; (B) described the impact of depression on HF and vice versa; and (C) were opinion papers, guidelines, case studies, descriptive studies, randomized control trials, prospective studies, retrospective studies, narrative reviews, and systematic reviews. Results: Depression is an emergent HF risk factor and strongly relates with worse clinical outcomes. HF and depression share multiple pathways, including platelet dis-reactivity, neuroendocrine malfunction, inappropriate inflammation, tachi-arrhythmias, and frailty in the social and community setting. Existing HF guidelines urge evaluation of depression in all HF patients, and numerous screening tools are available. Depression is ultimately diagnosed based on DSM-5 criteria. There are both non-pharmaceutical and pharmaceutical treatments for depression. Regarding depressed symptoms, non-pharmaceutical treatments, such as cognitive-behavioral therapy and physical exercise, have shown therapeutic results, under medical supervision and with an effort level adapted to the patient's physical resources, together with optimal HF treatment. In randomized clinical studies, selective serotonin reuptake inhibitors, the backbone of antidepressant treatment, did not demonstrate advantage over the placebo in patients with HF. New antidepressant medications are currently being studied and could provide a chance to enhance management, treatment, and control of depression in patients with HF. Conclusions: Despite the substantial link between depression and HF, their combination is underdiagnosed and undertreated. Considering the hopeful yet unclear findings of antidepressant trials, further research is required to identify people who may benefit from antidepressant medication. The goal of future research should be a complete approach to the care of these patients, who are anticipated to become a significant medical burden in the future.

Cardiorenal syndrome: Pathophysiology as a key to the therapeutic approach in an under-diagnosed disease

Cardiorenal syndrome is a clinical condition that impacts both the heart and the kidneys. One organ's chronic or acute impairment can lead to the other's chronic or acute dysregulation. The cardiorenal syndrome has been grouped into five subcategories that describe the etiology, pathophysiology, duration, and pattern of cardiac and renal dysfunction. This classification reflects the large spectrum of interrelated dysfunctions and underlines the bidirectional nature of heart-kidney interactions. However, more evidence is needed to apply these early findings in medical practice. Understanding the relationship between these two organs during each organ's impairment has significant clinical implications that are relevant for therapy in both chronic and acute conditions. The epidemiology, definition, classification, pathophysiology, therapy, and outcome of each form of cardiorenal syndrome are all examined in this review.

Impact of Age and Heart Rate on Strain-Derived Myocardial Work in a Population of Healthy Subjects

Background: The influence of age and gender on strain-imaging-derived myocardial work (MW) was recently investigated in healthy subjects. No information is available on the impact of heart rate (HR) on MW. Methods: 177 healthy subjects (47% men, mean age 42 years) underwent an echo-Doppler exam, including quantification of global longitudinal strain (GLS). Cuff blood pressure was used as a surrogate of left ventricular peak pressure to estimate global work index (GWI), global constructive work (GCW), global wasted work (GWW) and global work efficiency (GWE). Statistical analyses were performed according to age and HR tertiles. Results: GWW was higher in the third HR tertile, i.e., ≥74 bpm (74.7 ± 33.6 mmHg %) than in the first HR tertile (<66 bpm) (61.0 ± 32.5 mmHg %) (p < 0.02). In the pooled population, by adjusting for systolic blood pressure, GLS, E/e’ ratio and left atrial volume index, age was independently associated with GCW (β = 0.748) and GWI (β = 0.685) (both p < 0.0001) and HR with GWW (β = 0.212, p = 0.006) and GWE (β = −0.204, p = 0.007). Conclusions: In healthy subjects age shows a mild influence on GCW. HR exerts an independent negative impact on GWW and GWE: the higher HR the greater wasted work and lower myocardial efficiency.

58 Effects of sodium–glucose co-transporter 2 (SGLT2) inhibitors on major cardiovascular events in Type 2 diabetic patients: a meta-analysis of randomized controlled trials

Aims

Sodium–glucose co-transporter-2 inhibitors (SGLT2i) reduce cardiovascular (CV) events in diabetic patients, with a consistent effect on heart failure (HF) related outcomes. However, the effects on ischaemic CV events appear less certain, in particular in patients with history of HF. The aim of this meta-analysis is to investigate CV benefit of SGLT2i and to assess the effects in patients with and without established atherosclerotic cardiovascular disease (ASCVD), with and without HF, and with estimated glomerular filtration rate &lt; or ≥ 60 mL/min.

Methods

We searched PubMed, Embase, Cochrane, ISI Web of Science, SCOPUS, and clinicaltrial.gov databases. We performed a systematic review and meta-analysis of randomized, placebo-controlled, cardiovascular outcome trials (CVOT) of SGLT2i in diabetic patients, assessing the effects of SGLT2i on 3-point MACE [CV death, non-fatal myocardial infarction (MI), non-fatal stroke] and composite of HF hospitalization or CV death.

Results

Of 205 articles, 7 CVOTs were included in the meta-analysis. Compared to placebo, SGLT2i significantly reduced by 10% the risk of 3-point MACE (HR 0.90; P = 0.025) (Figure panel A) and the risk of CV death or HF hospitalization by 24% (HR 0.76; P &lt; 0.001) (Figure panel B). SGLT2i significantly reduced HF hospitalization by 30% (HR 0.70; P &lt; 0.001), with consistent effects in all subgroups analysed, CV death by 17% (HR 0.83; P = 0.035) and all-cause mortality by 18% (HR 0.82; P = 0.024). No significant effects were observed on MI and stroke.

Conclusions

SGLT2i significantly reduce CV outcome in diabetic patients. SGLT2i remarkably and consistently reduce HF hospitalization, in patients with and without HF at baseline and independently on the presence of ASCVD.

An Emergent Form of Cardiotoxicity: Acute Myocarditis Induced by Immune Checkpoint Inhibitors

Immune checkpoint inhibitors (ICIs) are monoclonal antibodies that activate the immune system, aiming at enhancing antitumor immunity. ICIs have shown great promise in the treatment of several advanced malignancies. However, therapy with these immunomodulatory antibodies may lead to a wide spectrum of immune-related adverse events in any organ and any tissue. Cardiologic immune-related events include pericarditis, pericardial effusion, various types of arrhythmias including the occurrence of complete atrioventricular block, myocardial infarction, heart failure, and myocarditis. Although relatively rare, myocarditis is associated with a very high reported mortality in comparison to other adverse events. Myocarditis often presents significant diagnostic complexity and may be under-recognized. When confronted with an unexpected change in the clinical picture, the physician must differentiate between immune-related adverse events, cancer worsening, or other causes unrelated to the cancer or its therapy. However, this is not always easy. Therefore, with the increasing use of checkpoint inhibitors in cancer, all providers who care for patients with cancer should be made aware of this rare, but potentially fatal, cardiologic immune-related adverse event, and able to recognize when prompt consultation with a cardiologist specialist is indicated. In this review, we evaluate currently available scientific evidence and discuss clinical manifestations and new potential approaches to the diagnosis and therapy of acute myocarditis induced by ICIs. Temporary or permanent discontinuation of the ICIs and high-dose steroids have been administered to treat myocarditis, but symptoms may worsen in some patients despite therapy.

Epidemiology, prognosis, and clinical manifestation of cardiovascular disease in COVID-19

INTRODUCTION

At the end of 2019, a novel coronavirus was identified as the cause of a pneumonia cluster in Wuhan, China. Since then, the contagion has rapidly spread all over the world resulting in a global pandemic. Since frequent cardiovascular (CV) system involvement has soon been detected in patients occurring coronavirus disease 2019 (COVID-19), we would provide a simple review available to cardiologists who are going to be involved in the management of COVID-19 patients from several levels: from diagnosis to prevention and management of CV complications.

AREAS COVERED

We investigate the role of CV diseases in COVID-19: from the incidence of CV comorbidities to their negative impact on prognosis. We also search Literature in order to identify the main CV manifestations in patients occurring virus infection and their management by cardiologists.

EXPERT OPINION

Specific treatments for CV involvement associated with COVID-19 are still debated. Results from ongoing trials are needed to further clarify issues about the therapeutic approach, which is constantly changing according to the continuous flow of published evidence. Finally, it seems necessary to sensitize all population to raise awareness on CV diseases in the COVID era, to hinder the underestimation of both new-onset acute CV diseases and the consequences of chronic mistreated CV diseases.

P291 Additional value of myocardial work in detecting subclinical systolic dysfunction in patients with bicuspid aortic valve and left ventricular hypertrophy

Background

An impairment of speckle tracking derived left ventricular (LV) global longitudinal strain (GLS) has been observed in patients with bicuspid aortic valve (BAV) and referred to abnormalities of aortic elasticity properties. The impact of LV mass on myocardial deformation has still not been investigated. This issue can be now better addressed by myocardial work software, which incorporates both deformation and hemodynamic load in the analysis.

Aim of the study

To analyse the impact of both deformation and strain derived myocardial work in BAV patients with and without LV hypertrophy (LVH).

Methods

Sixty-five patients with BAV underwent a comprehensive echo exam, including speckle tracking derived calculation of GLS (in absolute value). Parameters of myocardial work such as global work index (GWI), global constructive work (GCW) global wasted work (GWW) and global work efficiency (GWE) were measured according to standardized procedures. Patients with reduced LV ejection fraction and with more than mild aortic stenosis and/or regurgitation were excluded. Other exclusion criteria included coronary artery disease, concomitant valvular heart disease, heart failure, primary cardiomyopathies, permanent and/or persistent atrial fibrillation and inadequate echo images. BAV patients were divided according to presence of LVH: 10 with LVH (LV mass index &gt;47 g/m^2.7 in women and &gt;50 g/m^2.7 in men) and 55 without LVH.

Results

The two groups were comparable for sex, age and heart rate whereas systolic blood pressure (p = 0.006) and pulse pressure (p = 0.002) were higher in patients with LVH, who also had higher relative diastolic wall thickness (p &lt; 0.02). No significant difference in ejection fraction (p = 0.56), transmitral E/A ratio (p = 0.504) and E/e" (p = 0.311) was found between the two groups. GLS (19.1 ± 2.5 in LVH group and. 20.0 ± 2.4% in patients without LVH, p = 0.290), GWI (p = 0.356) and GCW (p = 0.396) did not differ significantly whereas GWW was higher (119.5 ± 72.9 vs. 72.3 ± 38.7 mmHg%, p = 0.003) and GWE lower (94.4 ± 3.0 vs. 92.2 ± 1.6%, p = 0.007) in BAV patients with LVH (Figure). In the pooled population, LV mass index was related with GWW (r = 0.26, p = 0.03) and GWE (r=-0.30, p &lt; 0.01) but not with GLS (r=-0.22, p = 0.08). The relation between GWE and LV mass index remained significant even after adjusting for pulse pressure (partial r=-0.28, p &lt; 0.02).

Conclusion

In patients with BAV, LVH plays a detrimental effect on LV systolic function which cannot be identified by ejection fraction and GLS assessment but is unmasked by the application of myocardial work. In presence of LVH, the wasted work of BAV patients is increased and myocardial efficiency is substantially reduced, it being negatively related to LV mass even after adjusting for a raw index of aortic stiffness such as pulse pressure.

Abstract P291 Figure. GLS, GWW and GWE according to LVH

Prognostic Value of Hormonal Abnormalities in Heart Failure Patients

The model used to explain the pathophysiologic substrate and progressive worsening in chronic heart failure (CHF) is based on the hyperactivity of renin-angiotensin-aldosterone system and adrenergic pathway. Although the neurohormonal medical approach has many advantages, it has several pitfalls, as demonstrated by high rates of CHF mortality and hospitalization. A growing body of evidence has led to the hypothesis that CHF is a multiple hormone deficiency syndrome, characterized by a reduced anabolic drive that has relevant functional and prognostic implications. The aim of this review is to summarize the evidence of reduced drive of main anabolic axes in CHF.

Diabetic Cardiomyopathy: Definition, Diagnosis, and Therapeutic Implications

A strict bidirectional relationship exists between diabetes mellitus and heart failure. Diabetic cardiomyopathy is a specific cardiac manifestation of patients with diabetes characterized by left ventricular hypertrophy and diastolic dysfunction in the early phase up to overt heart failure with reduced systolic function in the advanced stages. The pathogenesis of this condition is multifactorial and recognizes as main promoting factors the presence of insulin resistance and hyperglycemia. Diabetic cardiomyopathy exerts a negative prognostic impact in affected patients and no target treatments are currently available. More efforts are needed to better define the diagnostic and therapeutic approach in this specific setting.

Changes in serum uric acid levels and cardiovascular events: a meta-analysis

BACKGROUND AND AIMS

The association between serum uric acid (SUA) levels and cardiovascular (CV) risk or all-cause death has been repeatedly reported. However, it has not been assessed whether reduction of SUA levels is associated with reduced CV risk. The aim of the current study was to evaluate the relationship between changes of SUA levels and CV events as well as all-cause death.

METHODS AND RESULTS

Randomised trials reporting SUA at baseline and at the end of follow-up and clinical end-points (all-cause death, myocardial infarction (MI), stroke, heart failure (HF) and CV death) were included in the study. Meta-regression analysis was performed to test the relationship between SUA changes and clinical end-points. Eleven trials enrolling 21,373 participants followed up for 2.02 ± 1.76 years and reporting 4533 events were included. In meta-regression analysis, no relationship between SUA changes from baseline to end of follow-up and the composite outcome including CV death, stroke, MI and HF was found (change in Tau(2) (t) = -0.64; p Tau (p) = 0.541). Similarly, no relationship was found between SUA changes and single components of the composite outcome (MI: t = -0.83; p = 0.493; stroke: t = 0.46; p = 0.667; HF: t = 2.44; p = 0.162; CV death: t = -0.54; p = 0.614) and all-cause death (t = -0.72; p = 0.496). Results were confirmed by sensitivity analysis. No heterogeneity among studies or publication bias was detected.

CONCLUSIONS

Changes in SUA levels observed during pharmacologic treatments do not predict the risk of all-cause death or CV events. As SUA levels are associated with increased CV risk, additional studies with direct xanthine-oxidase inhibitors are requested.

Natriuretic peptide-guided therapy in chronic heart failure: a meta-analysis of 2,686 patients in 12 randomized trials

Background

The role of cardiac natriuretic peptides in the management of patients with chronic heart failure (HF) remains uncertain. The purpose of this study was to evaluate whether natriuretic peptide-guided therapy, compared to clinically-guided therapy, improves mortality and hospitalization rate in patients with chronic HF.

Methodology/Principal Findings

MEDLINE, Cochrane, ISI Web of Science and SCOPUS databases were searched for articles reporting natriuretic peptide-guided therapy in HF until August 2012. All randomized trials reporting clinical end-points (all-cause mortality and/or HF-related hospitalization and/or all-cause hospitalization) were included. Meta-analysis was performed to assess the influence of treatment on outcomes. Sensitivity analysis was performed to test the influence of potential effect modifiers and of each trial included in meta-analysis on results. Twelve trials enrolling 2,686 participants were included. Natriuretic peptide-guided therapy (either B-type natriuretic peptide [BNP]- or N-terminal pro-B-type natriuretic peptide [NT-proBNP]-guided therapy) significantly reduced all-cause mortality (Odds Ratio [OR]:0.738; 95% Confidence Interval [CI]:0.596 to 0.913; p = 0.005) and HF-related hospitalization (OR:0.554; CI:0.399 to 0.769; p = 0.000), but not all-cause hospitalization (OR:0.803; CI:0.629 to 1.024; p = 0.077). When separately assessed, NT-proBNP-guided therapy significantly reduced all-cause mortality (OR:0.717; CI:0.563 to 0.914; p = 0.007) and HF-related hospitalization (OR:0.531; CI:0.347 to 0.811; p = 0.003), but not all-cause hospitalization (OR:0.779; CI:0.414 to 1.465; p = 0.438), whereas BNP-guided therapy did not significantly reduce all-cause mortality (OR:0.814; CI:0.518 to 1.279; p = 0.371), HF-related hospitalization (OR:0.599; CI:0.303 to 1.187; p = 0.142) or all-cause hospitalization (OR:0.726; CI:0.609 to 0.964; p = 0.077).

Conclusions/Significance

Use of cardiac peptides to guide pharmacologic therapy significantly reduces mortality and HF related hospitalization in patients with chronic HF. In particular, NT-proBNP-guided therapy reduced all-cause mortality and HF-related hospitalization but not all-cause hospitalization, whereas BNP-guided therapy did not significantly reduce both mortality and morbidity.

Restless legs syndrome in a group of patients with Alzheimer's disease

BACKGROUND

Restless legs syndrome (RLS) is a neurological disorder characterized by the urge to move the legs associated with peculiar unpleasant sensations during periods of rest and inactivity that are relieved by movement. A few studies analyzed RLS in neurodegenerative diseases such as Alzheimer's Disease (AD). The aim of our study was to assess the prevalence and the clinical characteristics of RLS in a cohort of AD patients.

METHODS

Three hundred and thirty-nine subjects with a diagnosis of AD were recruited. Cognitive, functional, and neuropsychiatric measures were collected at baseline and six-monthly for a 2-years follow-up

RESULTS

Fourteen subjects met the RLS criteria. RLS subjects were more frequently male (p:0,006) and younger than AD subject without RLS (p:0,029). MMSE, ADL and IADL were not significantly different. NPI total scores did not differ significantly, however, AD patients with RLS were found to be more apathetic (p:0,001) than AD subjects without RLS.

CONCLUSION

RLS prevalence in our AD cohort was estimated to be about 4%. RLS appeared to be associated with neuropsychiatric symptoms such as apathy. RLS and apathy might share a common pathophysiological basis represented by a dysfunction of the central dopaminergic system.

Percutaneous treatment of patients with heart diseases: selection, guidance and follow-up. A review

Aortic stenosis and mitral regurgitation, patent foramen ovale, interatrial septal defect, atrial fibrillation and perivalvular leak, are now amenable to percutaneous treatment. These percutaneous procedures require the use of Transthoracic (TTE), Transesophageal (TEE) and/or Intracardiac echocardiography (ICE). This paper provides an overview of the different percutaneous interventions, trying to provide a systematic and comprehensive approach for selection, guidance and follow-up of patients undergoing these procedures, illustrating the key role of 2D echocardiography.

Myocardial perfusion scintigraphy and echocardiography for detecting coronary artery disease in hypertensive patients: a meta-analysis

PURPOSE

This meta-analysis summarized the accuracy of stress myocardial perfusion scintigraphy (MPS) and stress echocardiography for the diagnosis of coronary artery disease (CAD) in patients with arterial hypertension.

METHODS

We searched for studies in which stress MPS or stress echocardiography were performed to detect CAD in hypertensive patients, with coronary angiography used as the reference test, published from January 1980 to December 2010. Studies performed in patients with known CAD, acute coronary syndrome and previous revascularization procedures were excluded.

RESULTS

Of 1,263 studies, 13 met the inclusion criteria. Pooled summary estimates showed that stress MPS had a sensitivity of 0.90 [95% confidence interval (CI) 0.82-0.95] and a specificity of 0.63 (95% CI 0.53-0.72). For stress MPS, the area under the curve (AUC) at the summary receiver-operating characteristic (SROC) graph was 0.83 (95% CI 0.80-0.86). At meta-regression analysis, the presence of positive stress electrocardiography as inclusion criterion was the only significant effect modifier (p < 0.01). Pooled summary estimates showed that stress echocardiography had a sensitivity of 0.77 (95% CI 0.69-0.83) and a specificity of 0.89 (95% CI 0.83-0.93). For stress echocardiography, the AUC at SROC was 0.91 (95% CI 0.88-0.93). At the meta-regression analysis no significant effect modifier was detected.

CONCLUSION

MPS has high sensitivity for detecting CAD in hypertensive patients, with specificity comparable to that reported in the general population, whereas stress echocardiography shows higher specificity but substantially reduced sensitivity compared to MPS.

N-terminal pro-b-type natriuretic peptide and left atrial function in patients with congestive heart failure and severely reduced ejection fraction

AIMS

Amino-terminal portion of pro-B-type natriuretic peptide (NT-pro-BNP) is a valuable diagnostic and prognostic marker in congestive heart failure (CHF). In CHF patients, elevation of natriuretic peptide levels correlate with decreased left ventricular (LV) ejection fraction (EF) and increased left atrial (LA) volumes, but a correlation with LA function that is a determinant of haemodynamic and clinical status in CHF with independent prognostic value has never been investigated. Aim of this study was to evaluate the relationship between cardiac neurohormonal activation and LA function in patients with CHF due to dilated cardiomyopathy.

METHODS AND RESULTS

One hundred and one patients (86% males; mean age, 64 ± 11 years) with dilated ischaemic or non-ischaemic cardiomyopathy, LV EF ≤45% (mean LV EF, 33 ± 8%), and New York Heart Association class II-IV underwent transthoracic echocardiography to evaluate LA fractional active and total emptying from M- and B-Mode images, and, on the same day, venous blood sample collection to dose NT-pro-BNP. By univariate analyses, NT-pro-BNP significantly correlated to age, LA dimensions, LA function indexes, EF, and functional class. At multivariate analysis, LV EF and M- or B-Mode indexes of LA function were the only independent predictors of NT-pro-BNP values. A NT-pro-BNP cut-off of 1480 pg/mL identified LA dysfunction with 89% specificity and 54% sensitivity.

CONCLUSION

In CHF patients with severely impaired systolic function, NT-pro-BNP levels reflect LA and LV dysfunction. These data should prompt studies to investigate the relationship between changes of LA function and NT-pro-BNP levels and their clinical value as prognostic and therapeutic targets in CHF.

Percutaneous approach to treatment of coronary disease in a patient with uremic cardiomyopathy

Uremic cardiomyopathy is chronic ischemic left ventricular dysfunction characterized by heart failure, myocardial ischemia, hypotension in dialysis and arrhythmia. This nosologic entity represents a leading cause of morbidity and mortality among patients with end-stage renal disease receiving long-term hemodialysis. It is intuitive that revascularization in the presence of coronary artery disease in these patients represents an effective option for improving their prognosis. Although the surgical option seems to be followed by the best clinical outcome, some patients refuse this option and others are not good candidates for surgery. The present report describes the case of a patient affected by uremic cardiomyopathy and severe coronary artery disease in whom revascularization with percutaneous coronary angioplasty was followed by a significant improvement in quality of life.

Recurrent pulmonary and cerebral thromboembolism in an adult patients following incomplete removal of ventriculoatrial shunt for congenital hydrocephalus

A 34-year-old man was admitted to our hospital's department of neurology because he had experienced a cryptogenic stroke followed by a transient ischaemic attack. The patient suffered from congenital hydrocephalus which was treated by ventriculoatrial shunt at 8 months of age. Twelve months later, because of recurrent infections, the catheter was partially removed and the distal segment was left in place. At admission, the transoesophageal echocardiogram showed severe pulmonary hypertension (80 mm Hg confirmed by invasive measurement). The distal tip of the catheter had migrated into the left atrium through a patent foramen ovale inducing a massive right-to-left shunt. We surgically removed the catheter and closed the interatrial defect. At 1 and 6 months follow-up the patient was asymptomatic with a reduced pulmonary hypertension (50 mm Hg). Since there was no other clinical finding responsible for the recurrent thromboembolic events, both at the pulmonary and cerebral level, the catheter was removed to prevent further complications.

Rest-redistribution 201-Thallium single photon emission computed tomography predicts myocardial infarction and cardiac death in patients with ischemic left ventricular dysfunction

The prognostic role of rest-redistribution 201-Thallium imaging has not been extensively investigated in patients with left ventricular ischemic dysfunction.

OBJECTIVE

The aim of this study was to evaluate the ability of rest-redistribution 201-Thallium single photon emission computed tomography to predict cardiac death and occurrence of acute myocardial infarction in patients with ischemic mild-to-moderate left ventricular dysfunction.

METHODS

One-hundred and twenty-six patients with chronic coronary artery disease and mean left ventricular ejection fraction 39 +/- 11% were followed-up for 30 +/- 17 months after a rest-redistribution 201-Thallium imaging single photon emission computed tomography. Cardiac death and acute myocardial infarction were considered as major cardiac events.

RESULTS

During the follow up, 11 (9%) cardiac deaths and 9 (7%) acute myocardial infarctions occurred. The only variable showing significant difference between patients with and without events was the number of severe irreversible defects (1.7 +/- 1.9 versus 0.9 +/- 1.2, respectively; P = 0.02). By Kaplan-Meier analysis, the presence of three or less, or more than three severe defects was selected as the best cutoff to identify patients with longer event-free survival from cardiac death or acute myocardial infarction (log rank 19.84; P < 0.0001). When only cardiac death was considered as clinical event, the presence of at least two severe defects best separated patients who died from those who survived (log rank 8.68; P = 0.0032).

CONCLUSION

Rest-redistribution 201-Thallium single photon emission computed tomography provides prognostic information in coronary patients with mild-to-moderate left ventricular dysfunction. The number of severe irreversible defects per patient is a powerful predictor of prognosis.

Latent left ventricular outflow tract obstruction induced by abnormal hypertrophic papillary muscle caused myocardial ischemia

Left ventricular outflow tract (LVOT) obstruction is a typical recognized feature in hypertrophic cardiomyopathy. However, it has been shown in other clinical scenarios such as acute ischemia. In some patients, LVOT obstruction may only be detectable with provocation testing such as exercise stress. Accurate and timely diagnosis, therefore, relies on recognizing an echocardiographic substrate in which LVOT obstruction may occur, such as ventricular hypertrophy. This report describes the case of a patient presenting with effort ECG and signs of myocardial ischemia, with no significant narrowing of coronary arteries but with latent LVOT obstruction due to the presence of an abnormal hypertrophic papillary muscle instead of a typical ventricle hypertrophy.

The identification of reversible dysfunctional myocardium is influenced by the severity of contractile dysfunction and by the length of follow-up

OBJECTIVES

To evaluate the influence of the severity of regional myocardial dysfunction and of the length of follow-up on the identification of myocardial viability with rest-redistribution Tl single photon emission computed tomography (SPECT) and low-dose dobutamine echocardiography (LDDE).

METHODS

Twenty-six patients with chronic coronary artery disease and wall motion abnormalities, candidates for revascularization, were included in this study. All patients underwent, in the same week, Tl SPECT and LDDE for pre-revascularization evaluation of myocardial viability. Reversibility of regional dysfunction was assessed by two-dimensional echocardiography, 40+/-20 days (early follow-up) and 12+/-5 months (late follow-up) after revascularization.

RESULTS

In a/dyskinetic segments, Tl SPECT showed similar values of sensitivity (78% vs. 71%, P=NS) and slightly higher values of specificity (43% vs. 18%, P<0.01) compared to hypokinetic segments, in predicting functional recovery at early follow-up. No significant changes were observed in the diagnostic accuracy of Tl SPECT at late follow-up. On the contrary, LDDE provided significantly lower values of sensitivity (56% vs. 94%, P<0.05) and higher values of specificity (73% vs. 9%, P<0.01) in a/dyskinetic compared to hypokinetic segments. Specificity of LDDE in a/dyskinetic segments significantly increased from early (73%) to late follow-up (95%; P<0.05). Similarly, positive predictive value in a/dyskinetic segments significantly increased from early (69%) to late follow-up (96%; P<0.05).

CONCLUSIONS

The severity of regional dysfunction and the length of follow-up significantly influence the diagnostic accuracy of LDDE but not of rest-redistribution Tl SPECT in the identification of myocardial viability.

Low dose dobutamine echocardiography for predicting functional recovery after coronary revascularisation

OBJECTIVE

To evaluate the effects of chronic coronary occlusion on the accuracy of low dose dobutamine echocardiography in predicting recovery of dysfunctional myocardium after revascularisation.

DESIGN

Retrospective study.

SETTING

Tertiary referral centre.

PATIENTS

53 consecutive patients with >/= 70% stenosis of the left anterior descending coronary artery (LAD) and regional ventricular dysfunction (group 1, non-occluded LAD; group 2, occluded LAD) who underwent dobutamine echocardiography.

INTERVENTIONS

26 patients underwent coronary artery bypass grafting and 27 had percutaneous transluminal coronary angioplasty.

MAIN OUTCOME MEASURES

Baseline studies before revascularisation included cross sectional echocardiography at rest and during dobutamine infusion (5-10 microgram), and coronary angiography. The dobutamine study was performed mean (SD) 35 (28) days before revascularisation. Echocardiography at rest was repeated 90 (48) days after revascularisation.

RESULTS

Of 296 dysfunctional segments, 63 in group 1 (43%; 63/146) and 69 in group 2 (46%; 69/150) (NS) improved at follow up. Mean (SD) regional wall motion score index decreased from 1.97 (0.48) (95% confidence interval (CI) 1.01 to 2.93) before revascularisation to 1.74 (0.52) (95% CI 0.70 to 2.78) at follow up in group 1 (p = 0.001), and from 2.12 (0.41) (95% CI 1.30 to 2.98) to 1.88 (0.36) (95% CI 1.16 to 2.60) in group 2 (p = 0.0006). In group 1, sensitivity (87% v 52%; p < 0.0001), negative predictive value (88% v 65%; p = 0.001), and accuracy (77% v 64%; p = 0.01) were all significantly higher than in group 2, despite the angiographic evidence of collaterals in patients with occluded vessels.

CONCLUSIONS

Dobutamine echocardiography shows reduced sensitivity in predicting recovery of dysfunctional myocardium supplied by totally occluded vessels. Thus caution should be used in selecting such patients for revascularisation on the basis of a viability assessment made in this way.

Diagnostic accuracy of low-dose dobutamine echocardiography in predicting post-revascularisation recovery of function in patients with chronic coronary artery disease: relationship to thallium-201 uptake

It is known that contractile reserve may be blunted if perfusion and coronary flow reserve are reduced. Thus, it is conceivable that the predictive accuracy of dobutamine echocardiography may differ according to perfusion tracer uptake. The aim of this study was therefore to assess the relationship between the level of thallium-201 uptake and the accuracy of dobutamine echocardiography in identifying reversible dysfunction. Sixty-nine patients (age 59+/-8 years, ejection fraction 40%+/-11%) with chronic coronary artery disease scheduled for coronary revascularisation were studied. All patients underwent rest 201Tl single-photon emission tomography and two-dimensional echocardiography at rest and during low-dose dobutamine infusion on the same day before revascularisation and repeated echocardiography at least 30 days thereafter. At follow-up, recovery of function was observed in 49% of 339 dysfunctional segments. The percentage of segments with post-revascularisation recovery of function and the percentage with contractile reserve increased in parallel with 201Tl uptake both in the total group of segments (chi2=35.5, P<0.0001 and chi2=35.9, P<0.0001, respectively) and among the 183 akinetic segments (chi2=44.4, P<0.0001 and chi2=14.6, P<0.05, respectively). The dysfunctional segments were divided into three groups according to 201Tl uptake: (a) uptake <65%, (b) uptake between 65% and 79%, (c) uptake >80%. The positive predictive value increased significantly with the level of 201Tl uptake, and was suboptimal (46%) in akinetic segments with severely reduced 201Tl uptake. The negative predictive value decreased significantly with 201Tl uptake, and it was less than suboptimal (29%) in akinetic segments with normal tracer uptake. Sensitivity was lower in the subset of akinetic segments (42%-63%) than in all dyssynergic segments (63%-76%), whereas specificity was very high in akinetic segments (80%-84%). It is concluded that the accuracy of low-dose dobutamine echocardiography in predicting reversibility of regional dysfunction varies considerably according to 201Tl uptake at rest and to the severity of regional dysfunction.

Prediction of improvement in global left ventricular function in patients with chronic coronary artery disease and impaired left ventricular function: rest thallium-201 SPET versus low-dose dobutamine echocardiography

Accurate assessment of myocardial viability permits selection of patients who would benefit from myocardial revascularization. Currently, rest-redistribution thallium-201 scintigraphy and low-dose dobutamine echocardiography are among the most used techniques for the identification of viable myocardium. Thirty-one consecutive patients (all men, mean age 60 +/- 8 years) with chronic coronary artery disease and reduced left ventricular ejection fraction (31% +/- 7%) were studied. Rest 201Tl single-photon emission tomography (SPET), low-dose dobutamine echocardiography and radionuclide angiography were performed before revascularization. Radionuclide angiography and echocardiography were repeated after revascularization. An a/dyskinetic segment was considered viable on 201Tl SPET when tracer uptake was >65%, while improvement on low-dose dobutamine echocardiography was considered a marker of viability. Increase in global ejection fraction was considered significant at > or = 5%. In identifying viable segments, rest 201Tl SPET showed higher sensitivity than low-dose dobutamine echocardiography (72% vs 53%, P<0.05), while specificity was not significantly different (86% vs 88%). In 17 patients, global ejection fraction increased > or = 5% (group 1) while in 14 it did not (group 2). A higher number of a/dyskinetic segments were viable on 201Tl SPET in group 1 than in group 2 (2.6 +/- 1.9 vs 0.6 +/- 1.2, P < 0.005), while no significant differences were observed on low-dose dobutamine echocardiography (1.7 +/- 1.6 vs 1.1 +/- 1.6). A significant correlation was found between the number of a/dyskinetic segments viable on 201Tl SPET and post-revascularization changes in ejection fraction (r = 0.52, P < 0.05), but such a correlation was not observed for low-dose dobutamine echocardiography. Using as the cut-off the presence of at least one viable a/dyskinetic segment, rest 201Tl SPET had a higher sensitivity (82% vs 53%, P = 0.07) and showed a trend towards higher accuracy and specificity (77% vs 58%, and 71% vs 64%, respectively) as compared with low-dose dobutamine echocardiography. In conclusion, these findings suggest that when severely reduced global function is present, rest 201Tl SPET evaluation of viability is more accurate than low-dose dobutamine echocardiography for the identification of patients who will benefit most from revascularization.

Identification of viable myocardium in patients with chronic coronary artery disease using rest-redistribution thallium-201 tomography: optimal image analysis

With the widely used 50% threshold, sensitivity is high, but specificity is low in detecting viable myocardium on 201Tl SPECT. In this study, we sought to identify the best threshold for semiquantitative 201Tl analysis.

METHODS

Rest-redistribution 201Tl SPECT was performed in 46 patients with chronic coronary artery disease before and after myocardial revascularization. Regional function was evaluated by two-dimensional echocardiography before and after myocardial revascularization using a 3-point scale (1 = normal, 2 = hypokinetic, 3 = a/dyskinetic). Myocardial segments with abnormal systolic function were defined as viable if the systolic function score decreased > or = 1 after myocardial revascularization. A second group of 12 patients with chronic coronary artery disease constituted the validation population. Sensitivity-specificity curves, as well as receiver operating characteristic curves, for rest and redistribution mages were generated by varying the 201Tl uptake threshold.

RESULTS

A 65% threshold uptake using resting images was found to be the best for detecting a/dyskinetic segments that improve after myocardial revascularization from those that do not improve. Sensitivity was lower with a 65% threshold (75%) than with a 50% threshold (90%, p < 0.05), but specificity was higher (76% versus 26%, p < 0.05) resulting in better accuracy (76% versus 57%, p < 0.05) and positive predictive value (77% versus 55%), while the negative predictive value was not different (69% versus 75%, p not significant). The area under the receiver operating characteristic curve was significantly (p < 005) larger for rest (0.80 +/- 0.05) as opposed to redistribution (0.72 +/- 0.05) images. Similar results were obtained in a subgroup of patients with low ejection fraction. Significant correlations between the percentage of revascularized viable segments and both the change in ejection fraction and in postrevascularization ejection fraction were found. When these findings were applied in the validation group, a gain in specificity, accuracy and positive predictive value was obtained with the 65% threshold compared with the 50% threshold.

CONCLUSION

This study demonstrated that analysis of resting images and use of the 65% 201Tl uptake threshold is preferable for separating viable from not viable dyssynergic myocardial segments in patients with chronic coronary artery disease.

Combined evaluation of rest-redistribution thallium-201 tomography and low-dose dobutamine echocardiography enhances the identification of viable myocardium in patients with chronic coronary artery disease

The purpose of this study was to evaluate whether combined evaluation by discriminant analysis of rest-redistribution thallium-201 tomography and low-dose dobutamine echocardiography enhances the accuracy in identifying viable myocardium in patients with chronic coronary artery disease. Rest-redistribution 201Tl has high sensitivity but low specificity in identifying viable myocardium, while the opposite is true for low-dose dobutamine echocardiography. Forty-six patients underwent low-dose dobutamine echocardiography and rest-redistribution 201Tl tomography on the same day. Rest echocardiography was repeated at least 30 days (mean 40+/-20) after myocardial revascularization. Discriminant analysis was applied to the results of 201Tl tomography and dobutamine echocardiography to classify a/dyskinetic segments as viable or non-viable. In 92 a/dyskinetic segments that were revascularized, rest-redistribution 201Tl tomography yielded an accuracy of 75%, while the accuracy of dobutamine echocardiography was 70% (P<0.05). When discriminant analysis was used, the combined evaluation gave an accuracy of 83% (P<0.05 vs both tests). These findings demonstrate that low-dose dobutamine echocardiography and 201Tl imaging are useful and complementary techniques for identifying viable myocardium in patients with chronic coronary artery disease. Combined evaluation by discriminant analysis significantly improves accuracy, although the cost-effectiveness of such an approach remains to be determined.

Effects of myocardial revascularization on regional thallium-201 uptake and systolic function in regions with reverse redistribution on tomographic thallium-201 imaging at rest in patients with chronic coronary artery disease

OBJECTIVES

There is growing evidence that myocardial segments with reverse redistribution are viable in patients with chronic coronary artery disease. The aim of this study was to assess the effects of myocardial revascularization on systolic function and thallium-201 uptake in such segments.

METHODS

Rest-redistribution thallium-201 tomography before and after myocardial revascularization was performed in 47 patients with chronic coronary artery disease. Regional function was evaluated by two-dimensional echocardiography before and after revascularization according to a 3-point scale (1 = normal, 2 = hypokinetic, 3 = a/dyskinetic). Improvement of dysfunctional segments was defined when systolic function score decreased > or =1 after revascularization. Reverse redistribution was defined as >8% decrease in relative thallium-201 uptake between rest and redistribution images.

RESULTS

Reverse redistribution was found in 27 (57%) of 47 patients, corresponding to 60 (11%) of 564 myocardial segments. Of such segments, 24 (40%) had normal systolic function, 19 (32%) were hypokinetic, and 17 (28%) were a/dyskinetic. Thirty-six segments underwent myocardial revascularization, and reverse redistribution was no longer present in 86% of them subsequent to the procedure. Of 26 dyssynergic segments with reverse redistribution subjected to revascularization, 18 (69%) improved at follow-up.

CONCLUSIONS

The findings of the present study indicate that reverse redistribution is a reversible phenomenon and is often associated with improvement of systolic function following revascularization in patients with chronic coronary artery disease.

Assessment of myocardial viability in patients with chronic coronary artery disease. Rest-4-hour-24-hour 201Tl tomography versus dobutamine echocardiography

BACKGROUND

To date, late redistribution after resting 201Tl injection has not been evaluated. In addition, the concordance between resting 201Tl imaging and dobutamine echocardiography in identifying viable myocardium has not been assessed.

METHODS AND RESULTS

Forty patients with coronary artery disease underwent rest-4-hour-24-hour 201Tl tomography and dobutamine echocardiography (5 to 10 micrograms.kg-1.min-1). Late redistribution occurred in 46 (21%) of 219 persistent defects at 4 hours. Systolic function and contractile reserve were similar among persistent defects at 4 hours with and without late redistribution. Contractile reserve was more frequent in segments with normal 201Tl uptake (59%), completely reversible defects (53%), or mild to moderate defects at 4 hours (56%) compared with severe defects (14%; P < .02 versus all). Of 105 hypokinetic segments, 99 (94%) were viable by 201Tl, and 88 (84%) showed contractile reserve. In contrast, of 155 akinetic segments, 119 (77%) were viable by 201Tl, but only 34 (22%) had contractile reserve. Concordance between 201Tl and dobutamine was 82% in hypokinetic segments but 43% in akinetic segments. In 109 revascularized segments, positive accuracy for functional recovery was 72% for 201Tl and 92% for dobutamine, whereas negative accuracy was 100% and 65%, respectively. Sensitivity was 100% for 201Tl and 79% for dobutamine.

CONCLUSIONS

Late redistribution occurs in one fifth of persistent defects at 4 hours, and it does not correlate to systolic function or contractile reserve. Dobutamine and 201Tl yield concordant information in the majority of hypokinetic segments, whereas concordance is low in akinetic segments. Dobutamine demonstrates higher positive accuracy and sensitivity in predicting recovery of dysfunctional myocardium, whereas 201Tl shows higher negative predictive accuracy but reduced positive accuracy.

Inotropic stimulation by dobutamine increases left ventricular regional function at the expense of metabolism in hibernating myocardium

The mechanism by which dobutamine increases the contraction of chronically dysfunctional myocardium and its effects on metabolism are still unknown. The aim of this study was to assess regional myocardial metabolism at rest and during an intracoronary dobutamine infusion in patients with hibernating myocardium. Eleven asymptomatic patients with single proximal stenosis of the left anterior descending coronary artery and persistent left ventricular dysfunction at rest (undergoing percutaneous transluminal coronary angioplasty [PTCA]) were studied prospectively. Regional left ventricular function was assessed by two-dimensional (2D) echocardiography and regional perfusion by thallium-201 single-proton-emission computed tomography. Great cardiac vein and aortic blood samples were obtained for measurements of lactate and plasma free fatty acid (FFA) concentrations. Inotropic challenge, obtained by using intracoronary dobutamine infusion, increases regional left ventricular function. However, the arteriovenous AV lactate difference was 0.206 = 0.070 mmol/L at rest, and it decreased to 0.018 = 0.069 mmol/L (p < 0.05 vs baseline) and 0.066 = 0.068 mmol/L (p < 0.05 vs baseline) at 4 and 10 minutes of dobutamine infusion, respectively. Thus the hibernating myocardium does not produce lactate at rest. However, when regional contraction is stimulated, dobutamine-induced inotropic challenge may cause a perfusion-contraction mismatch with an activation of anaerobic glycolysis.

Dobutamine echocardiography predicts improvement of hypoperfused dysfunctional myocardium after revascularization in patients with coronary artery disease

BACKGROUND

In patients with coronary artery disease, dysfunctional hypoperfused myocardium at rest may represent either necrotic or viable hibernating myocardium. The accuracy of inotropic stimulation in identifying hypoperfused, reversibly dysfunctional myocardium has not been extensively investigated.

METHODS AND RESULTS

Eighteen patients with stable chronic coronary artery disease underwent, while off drugs, quantitative 201Tl single-photon emission computed tomography after rest injection (2 to 3 mCi), two-dimensional echocardiography at rest and during dobutamine (5 to 10 micrograms/kg per minute i.v.), and radionuclide angiography. Single-photon emission computed tomography and echocardiography at rest were repeated 34 +/- 10 days after coronary revascularization, and radionuclide angiography was repeated 45 +/- 13 days after revascularization. Resting hypoperfusion was defined as 201Tl uptake < 80% of maximal activity. Systolic function was scored from 1 (normal) to 4 (dyskinesia), and functional improvement was defined as a score change > 1 grade. Of 79 dysfunctional hypoperfused segments, 48 (61%) improved function after revascularization. In 42 (88%) of these latter segments, function had improved during dobutamine. Conversely, systolic function after revascularization did not improve in 31 segments, and in 27 (87%), it had not improved during dobutamine. Functional improvement after revascularization was observed in 42 (91%) of 46 segments manifesting an improvement during dobutamine as opposed to 6 (18%) of 33 segments that did not improve during dobutamine. Resting 201Tl uptake (% of maximal activity) before revascularization (65 +/- 9%) significantly increased at follow-up in segments where function improved (70 +/- 12%, P < .005), whereas it did not change significantly in segments with unchanged systolic function after revascularization (from 57 +/- 13% to 60 +/- 17%, P = NS). In 10 patients with prerevascularization ejection fraction < 45%, left ventricular ejection fraction significantly increased from 36 +/- 7% before revascularization to 42 +/- 7% at follow-up (P < .05).

CONCLUSIONS

Inotropic stimulation using dobutamine echocardiography identifies hypoperfused reversibly dysfunctional myocardium. Functional improvement during dobutamine is highly predictive of improvement after revascularization.

[Coronary angioplasty for the recovery of myocardial function after acute myocardial infarction: mid- and long-term results]

Sixty-three patients with previous myocardial infarction and documented hypoperfused reversibly dysfunctional myocardium after 201thallium tomography and/or echo-dobutamine were candidates to coronary angioplasty. Patients were enrolled at four hospitals (Naples, Milan, Pisa and Varese) and evaluated by different study protocols, while endpoint (presence of myocardial viability and efficacy of coronary angioplasty to improve dysfunctional myocardium) was similar. Sixty-two patients underwent successful angioplasty, and early evaluation (between 1 and 3 months after procedure) showed the ability of either 201thallium tomography and/or dobutamine echocardiography, to identify hypoperfused reversibly dysfunctional myocardium. Ten patients underwent late (after 8 +/- 2 months) evaluation of both wall motion and myocardial perfusion showing a sustained improvement in 25/32 hypoakinetic myocardial segments. Our data confirm the efficacy of revascularization of hypoperfused dysfunctional myocardial segments by coronary angioplasty. Further studies are warranted to obtain a better patient stratification and to evaluate the long-term results.