P4354Regional Strain Pattern Index - A novel technique to predict CRT response

Background

Cardiac resynchronization therapy (CRT) reduces morbidity and mortality in heart failure individuals. Despite many efforts 30–40% patients with CRT still do not respond to therapy.

Purpose

The purpose was to propose and evaluate a novel dyssynchrony scoring system – Regional Strain Pattern Index (RSPI) in prediction of response to CRT.

Methods

Forty-nine HF patients (age: 66.5±10 years, LV ejection fraction: 24.9±6.4%, QRS: 173.1±19.1 ms, NYHA class II/III: 34.7%/63.3%, ischemic aetiology: 57.1%) underwent CRT implantation. Transthoracic echocardiography was performed before and 15±7 months after CRT implantation. Baseline dyssynchrony was studied by standard indices, strain pattern analysis and novel, author's index- RSPI. RSPI constitutes a method of quantification of LBBB-related strain curve pattern analysis. RSPI was calculated using longitudinal strain by 2D speckle tracking as the sum of dyssynchronous components across 12 segments from all three apical views. In one view, four components were assessed: 1) the contraction of the early-activated wall, 2) the prestretching of the late activated wall, 3) the contraction of the early-activated wall in the first 70% of the systolic ejection phase and 4) the peak contraction of the late-activated wall after aortic valve closure. One point was attributed to each component, thus the maximum was 12 points. RSPI was prospectively evaluated in predicting response to CRT. The response to CRT was defined as ≥15% reduction in the left ventricular end-systolic volume after 15 month follow-up.

Results

Thirty-six (73.5%) patients were responders. There were no significant differences in the baseline demographics, clinical, echocardiographic parameters between responders and non-responders. The mean RSPI in the overall population was 5.39±2.9 and higher RSPI values were observed in responders (5.86±2.9) than in non-responders (4.08±2.4, p=0.044). The ROC curve indicated that RSPI significantly predicted CRT response (area under curve, AUC=0.691, p=0.014) with the cut-off value at 7 points. Therefore, study population was divided into two groups according to RSPI score: ≥7 points (19 patients, 38.8% of population) and <7 points (30 patients, 61.2%). In univariate logistic regression analysis, among all of the dyssynchrony indices only RSPI≥7 points predicted the positive response to CRT (OR: 12; 95% CI=1.33–108.17; p=0.0036) with specificity of 92.3%, sensitivity of 50%, positive of 64.7% and negative of 40% predictive value for CRT response.

ROC curve for RSPI

Conclusion

RSPI constitutes a novel, valuable predictor for CRT response.

Acknowledgement/Funding

Grant for scientific research in the field of CRT efficacy funded by Medical University of Silesia.

Efficacy of trimetazidine in patients with recurrent angina: a subgroup analysis of the TRIMPOL II study

OBJECTIVES

The revascularization procedures become more and more popular to treat coronary artery disease, in many countries. Some patients are free of angina after revascularization, without any documented re-stenosis present with recurrent angina symptoms after a period of time. The aim of this work was to assess the efficacy of trimetazidine in the subpopulation of patients with a history of PTCA or CABG, who were included in the TRIMPOL II study.

METHODOLOGY

A subgroup of 94 patients was retrospectively analysed from the TRIMPOL II study, a multicentre, double-blind randomised placebo-controlled trial in 426 patients with stable effort angina. These patients have a history of revascularization for coronary artery disease, and they are still symptomatic after 6 months despite a treatment with metoprolol (50 mg twice daily). They were randomly allocated to receive either trimetazidine (20 mg 3 times daily) or placebo for 12 weeks, on top of the beta-blocker. Exercise test parameters, clinical efficacy and safety were assessed. Results were analysed using the Student test, the Mann-Whitney test or the Shapiro-Wilk test.

RESULTS

Compared to placebo, the 12-week treatment with trimetazidine significantly improved: time to 1 mm ST segment depression (385.1 s +/- 144.6 s versus 465.0 s +/- 143.8 s [p < 0.01]); exercise test duration (466.9 s +/- 144.8 s versus 524.4 s +/- 131.5 s [p = 0.048]), total workload (9.0 m.e. +/- 2.4 m.e versus 10.1 m.e. +/- 2.4 m.e [p = 0.035]) as well as time to onset of angina (433.6 s +/- 164 s versus 508.1 s +/- 132.4 s [p = 0.031]). Weekly number of angina attacks and nitrate consumption were significantly reduced in the trimetazidine group when compared to placebo. Three mild gastro-intestinal side-effects were reported in the trimetazidine group.

CONCLUSION

These results show that trimetazidine provides anti-anginal efficacy in post-revascularized patients with recurrent angina despite a monotherapy with metoprolol. The treatment was well accepted.

Combination treatment in stable effort angina using trimetazidine and metoprolol: results of a randomized, double-blind, multicentre study (TRIMPOL II). TRIMetazidine in POLand

AIMS

To assess the antiischaemic efficacy and tolerability of the metabolic agent trimetazidine in combination with metoprolol in patients with stable effort angina.

METHODS

This was a randomized, multicentre, double-blind, placebo-controlled parallel group study. A total of 426 male and female patients with stable, effort-induced angina and documented coronary artery disease received either placebo or trimetazidine 20 mg three times daily in addition to metoprolol 50 mg twice daily. Treadmill exercise tests were performed at weeks (-1), 0, 4 and 12.

RESULTS

After 12 weeks, there were significantly greater improvements in the metoprolol + trimetazidine group than in the metoprolol + placebo group in: time to 1 mm ST segment depression, total workload, time to onset of angina, maximum ST segment depression, mean weekly number of angina attacks, mean weekly nitrate consumption, and grade of anginal pain. There was no evidence of any development of tolerance to trimetazidine. The tolerability of trimetazidine was excellent.

CONCLUSIONS

Therapy with trimetazidine plus metoprolol produced significant improvements in exercise stress tests and the symptoms of angina relative to metoprolol alone. With its metabolic effect, devoid of any haemodynamic action, trimetazidine is useful for combination therapy in patients with stable angina insufficiently controlled by monotherapy with a beta-blocker.

[Surgical revascularization of the myocardium in patients with chronic coronary disease and depressed left ventricular function: 1-year observation]

Many reports confirm the importance and benefit of the surgical revascularization (CABG) in patients with ischemic heart disease and severely depressed left ventricular (LV) systolic function. This mode of treatment is better than medical therapy in patients with very low LV ejection fraction (LVEF) and can prolong the life. However, the effect of CABG on LV hemodynamics is still unclear. The aim of the study was: 1) to assess the effect of CABG on LV hemodynamics in patients with low LVEF and 2) to examine the influence of two types of cardioplegia-crystalloid (CC) and blood (BC) cardioplegia--on LV function during 1 year follow-up. 122 patients with stable angina pectoris qualified for CABG were included in the study. Patients were divided into two groups: group I-47 pts with LVEF < or = 40% and group II--75 pts with LVEF > 40% and then patients were randomized for two types of antegrade-retrograde cardioplegia (CC--subgroups Ia, IIa and BC--subgroups Ib, IIb). Before operation and 4 times after CABG (after 2-6 weeks, 3 months, 6 months and 1 year) echocardiographic examination was performed. Diameters of left atrium and ventricle, LVEF and wall motion score index (WMSI) were calculated. During 1 year 8 patients died (5 of them during perioperative period and 3 patients during follow-up). Patients in group I before operation were in higher NYHA and CCS class and had more often myocardial infarction. During each of the five echocardiographic examination the values of LVEF and WMSI did not differ between subgroups Ia vs Ib and IIa vs IIb. In group I, especially in patients with very low LVEF < or = 30%, the values of LVEF and WMSI improved significantly (p < 0.001) during 1 year of follow-up. But in group II a transient deterioration of LVEF (p < 0.05) 2-6 weeks after CABG was noted. We conclude that surgical revascularization in patients with severe depressed hemodynamics improves LV systolic function during 1 year follow-up. The use of CC or BC did not seem to make any difference to the early and long-term hemodynamic effect of the revascularization.

Heart rate variability: its association with hemodynamic function of the left ventricle in patients with coronary heart disease

Patients with heart failure secondary to coronary heart disease (CHD) are characterized by an imbalance of the autonomic nervous system, which can be assessed by analysis of the heart rate variability (HRV). However it is still unclear whether all patients with CHD reveal suppression of HRV and if it is related to hemodynamic function and contractile disturbances of the left ventricle. To answer these questions data from 105 consecutive patients were analyzed and compared with 17 healthy subjects. All study participants underwent 24-hour ambulatory ECG recordings with calculation of HRV parameters and angiographic examination after collection of clinical data and other noninvasive evaluations. Time- (SDRR, SDANN, SD, pNN50) and frequency- (LF, HF) domain parameters of HRV were assessed. All ventriculographic and hemodynamic measurements were used in the analysis. Highly significant correlations were found between all HRV parameters, and left ventricular ejection fraction (LVEF) and left ventricular end-diastolic pressure (P < 0.001). Patients with LVEF < 40% were characterized by significantly lower values of HRV and impairment or lack (LVEF < 20%) of diurnal variation of frequency-domain measurements of HRV. Patients with segmental akinesis or dyskinesis also had lower values of HRV. The group with dyskinesis was characterized by significantly lower diurnal rhythms of LF and HF, independent of LVEF.