Long-term heart function in cardiac-arrest survivors

Purpose

To assess outcomes and predictors of long-term myocardial dysfunction after cardiac arrest (CA) of cardiac origin.

Methods

We retrospectively included consecutive, single-center, prospective-registry patients who survived to hospital discharge for adult out-of-hospital and in-hospital CA of cardiac origin in 2005-2019. The primary objective was to collect the 1-year New York Heart Association Functional Class (NYHA-FC) and major adverse cardiovascular events (MACE).

Results

Of 135 patients, 94 (72%) had their NYHA-FC determined after 1 year, including 75 (75/94, 80%) who were I, 17 (17/94, 18%) II, 2 (2/94, 2%) III, and none IV. The echocardiographic left ventricular ejection fraction was abnormal in 87/130 (67%) patients on day 1, 52/123 (42%) at hospital discharge, and 17/52 (33%) at 6 months. During the median follow-up of 796 [283-1975] days, 38/119 (32%) patients experienced a MACE. These events were predominantly related to acute heart failure (13/38) or ischemic cardiovascular events (16/38), with acute coronary syndrome being the most prevalent among them (8/16). Pre-CA cardiovascular disease was a risk factor for 1-year NYHA-FC > I (P = 0.01), absence of bystander cardiopulmonary resuscitation was significantly associated with NYHA-FC > I at 1 year.

Conclusion

Most patients had no heart-failure symptoms a year after adult out-of hospital or in-hospital CA of cardiac origin, and absence of bystander cardiopulmonary resuscitation was the only treatment component significantly associated with NYHA-FC > I at 1 year. Nearly a third experienced MACE and the most common types of MACE were ischemic cardiovascular events and acute heart failure. Early left ventricular dysfunction recovered within 6 months in half the patients with available values.

Korean Society of Heart Failure Guidelines for the Management of Heart Failure: Definition and Diagnosis

The Korean Society of Heart Failure guidelines aim to provide physicians with evidence-based recommendations for diagnosing and managing patients with heart failure (HF). In Korea, the prevalence of HF has been rapidly increasing in the last 10 years. HF has recently been classified into HF with reduced ejection fraction (HFrEF), HF with mildly reduced ejection fraction (EF), and HF with preserved EF (HFpEF). Moreover, the availability of newer therapeutic agents has led to an increased emphasis on the appropriate diagnosis of HFpEF. Accordingly, this part of the guidelines will mainly cover the definition, epidemiology, and diagnosis of HF.

Korean Society of Heart Failure Guidelines for the Management of Heart Failure: Definition and Diagnosis

The Korean Society of Heart Failure guidelines aim to provide physicians with evidence-based recommendations for diagnosing and managing patients with heart failure (HF). In Korea, the prevalence of HF has been rapidly increasing in the last 10 years. HF has recently been classified into HF with reduced ejection fraction (EF), HF with mildly reduced EF, and HF with preserved EF (HFpEF). Moreover, the availability of newer therapeutic agents has led to an increased emphasis on the appropriate diagnosis of HFpEF. Accordingly, this part of the guidelines will mainly cover the definition, epidemiology, and diagnosis of HF.

Comparison of visual estimation and quantitative measurement of left ventricular ejection fraction in untrained perioperative echocardiographers

BACKGROUND

Perioperative evaluation of the left ventricular systolic function is essential information to help diagnose and manage life-threatening perioperative emergencies. Although quantifying the left ventricular ejection fraction (LVEF) is recommended to determine the left ventricular function, it may not always be feasible in emergency perioperative settings. This study compared the visual estimation of LVEF (eyeballing) by noncardiac anesthesiologists with the quantitative LVEF measured using a modified Simpson's biplane method.

METHODS

Transesophageal echocardiographic (TEE) studies of 35 patients were selected and 3 different echocardiographic views (the mid-esophageal four chamber view, the mid-esophageal two chamber view, and the transgastric mid-papillary short axis view) were recovered from each study and displayed in random order. Two cardiac anesthesiologists certified in perioperative echocardiography independently measured LVEF using the modified Simpson method and categorized LVEF into five grades: hyperdynamic LVEF, normal, mildly reduced LVEF, moderately reduced LVEF and severely reduced LVEF. Seven noncardiac anesthesiologists with limited experience in echocardiography also reviewed the same TEE studies and estimated the LVEF and graded LV function. The precision of the LV function classification and the correlation between visual estimation of LVEF and quantitative LVEF were calculated. The agreement of measurements between the two methods was also assessed.

RESULTS

Pearson's correlation between the LVEF estimated by the participants and the quantitative LVEF using the modified Simpson method was 0.818 (p < 0.001). Of a total of 245 responses, 120 (49.0%) responses were correct grading of the LV function. Participants were able to classify the LV function more accurately in the LV function grades 1 and 5 (65.3%). The 95% level of agreement of the Bland-Altman method was - 11.3-24.5. -21.9-22.6, - 23.1-26.5, - 20.5-22.0 and - 26.6-11.1 for LV grade 1 to 5, respectively.

CONCLUSION

Visual estimation of LVEF in perioperative TEE has acceptable accuracy in untrained echocardiographers and can be used for rescue TEE.

Global longitudinal strain: an early marker for cardiotoxicity in patients treated for breast cancer

BACKGROUND

Patients treated with anthracyclines and trastuzumab are at increased risk of developing heart failure. Early diagnosis and treatment may prevent irreversible left ventricular (LV) dysfunction. This study investigates whether subclinical deterioration of global longitudinal strain (GLS) is a more reliable early predictor for LV dysfunction than three-dimensional (3D) LV ejection fraction (LVEF).

METHODS

Adult patients receiving anthracyclines and trastuzumab for breast cancer who had serial echocardiographic follow-up were included in this retrospective study. The primary endpoint was the necessity to temporarily pause chemo- or immunotherapy due to declining LVEF (decline in 3D LVEF of > 10 percentage points to < 53%). Linear mixed-effects models were used to assess the longitudinal evolution of 3D LVEF and GLS over time.

RESULTS

Fifty-one women were included, mean age 54 (50.5-57.6) years, with a total of 216 follow-up echocardiograms (mean follow-up 1.1 ± 0.45 years). GLS and 3D LVEF were significantly correlated (Spearman's rho: -0.36, p < 0.001). A decrease in GLS significantly predicted a lower LVEF on the subsequent echocardiogram [ß -0.6, 95% confidence interval (CI) (-1.0 to -0.2), p < 0.006]. Conversely, prior LVEF did not significantly predict GLS on the subsequent echocardiogram [ß -0.04, 95% CI -0.1 to -0.01, p = 0.12]. Nine patients reached the primary endpoint. On average, patients who reached the primary endpoint had a relative decrease of 15% GLS at day 205 and an absolute 10% decrease of LVEF to LVEF < 53% at day 235.

DISCUSSION

GLS is able to identify subclinical LV dysfunction earlier than 3D LVEF measurement in women undergoing treatment for breast cancer with anthracyclines followed by trastuzumab.

Interamerican Society of Cardiology (CIFACAH - ELECTROSIAC)/Latin American Heart Rhythm Society (LAHRS): multidisciplinary review on the appropriate use of cardiac resynchronization therapy in heart failure

Epidemiological studies suggest that approximately half of the patients with heart failure (HF) have reduced ejection fraction, while the other half have normal ejection fraction (EF). Currently, international guidelines consider QRS duration greater than 130 ms, in the presence of ventricular dysfunction (EF < 35%), as a criterion for selecting patients for cardiac resynchronization therapy (CRT). CRT helps restore intraventricular and auriculoventricular synchrony, improving left ventricular (LV) performance, reducing functional mitral regurgitation, and inducing reverse LV remodeling. This is evidenced by increased LV filling time and left ventricular ejection fraction, decreased LV end-diastolic and end-systolic volumes, mitral regurgitation, and septal dyskinesia. Because the mechanisms of dyssynchrony may be heterogeneous, no single measure may accurately predict response to CRT. Finally, CRT has been progressively shown to be safe and feasible, improves functional status and quality of life, reversely remodels the LV, decreases the number of hospitalizations, total mortality in patients with refractory HF, LV dysfunction, and intraventricular conduction disorders; is a pacemaker-based therapy for HF and thanks to current technology, safe remote monitoring of almost all types of cardiac devices is possible and provides useful alerts in clinical practice.

Management strategies in heart failure with preserved ejection fraction

The diagnosis and therapy of heart failure with preserved ejection fraction (HFpEF) remain challenging. Currently, there are ongoing discussions on whether the diagnosis of HFpEF should be based solely on left ventricular ejection fraction, which may not account for the heterogeneity of HFpEF syndrome. This aspect has been addressed by the recently proposed HFA-PEFF and the H2FPEF algorithms, which take numerous diagnostic modalities into account to establish the diagnosis of HFpEF. Moreover, this review focuses on the adequate treatment of comorbidities and risk factors in HFpEF that should be an essential part of any HFpEF therapy. Furthermore, the management of fluid level in HFpEF patients is pointed out, as it plays an important role in symptom control. In addition, the value of LCZ696 therapy in HFpEF is discussed. Although LCZ696 had neutral effects in the large PARAGON-HF trial, it had previously been granted an extended indication by the Food and Drug Administration. Since the publication of the EMPEROR-Preserved trial, empagliflozin now represents the first drug to significantly improve the prognosis of HFpEF patients. Therefore, the role of SGLT2 inhibitors in HFpEF management is highlighted. Overall, this review aims to enhance the knowledge on the diagnostic processes and best treatments available for HFpEF patients.

Variation in intraabdominal pressure in patients with acute heart failure according to left ventricular ejection fraction. Results of an intraabdominal pressure study

BACKGROUND

The increase in intraabdominal pressure (IAP) has been correlated with increased creatinine levels in patients with heart failure with severely reduced left ventricular ejection fraction (HFrEF). However, IAP has not been examined in more stable patients or those with heart failure with preserved ejection fraction (HFpEF).

PATIENTS AND METHOD

We conducted an observational, prospective descriptive study that measured the IAP of patients hospitalised for decompensated heart failure (HF). The sample was stratified according to left ventricular ejection fraction (LVEF), with a cut-off of 50%. The objective was to analyse the IAP, the baseline characteristics and degree of congestion using clinical ultrasonography and impedance audiometry.

RESULTS

The study included 56 patients, 22 with HFrEF and 34 with HFpEF. The patients with HFrEF presented a higher prevalence of ischaemic heart disease (11% vs. 6%; p = 0.010) and chronic obstructive pulmonary disease/asthma (6% vs. 2%; p = 0.025). The IAP was higher in the patients with HFrEF (17.2 vs. 13.3 mmHg; p = 0.004), with no differences in renal function at admission according to the LVEF (CKD-EPI creatinine) (HFrEF 55.0 mL/min/1.73 m² [32.6-83.6] vs. HFpEF 55.0 mL/min/1.73 m² [44.0-74.9]; p = 0.485). The patients with HFrEF presented a more congestive profile determined through ultrasonography (inferior vena cava collapse [26% vs. 50%; p = 0.001]), impedance audiometry (total body water at admission, 46 L vs. 41 L; p = 0.052; and at 72 h, 50.2 L vs. 39.1 L; p = 0.038) and CA125 concentration (68 U/mL vs. 39 U/mL; p = 0.037).

CONCLUSIONS

During the decompensation episodes, the patients with HFrEF had a greater increase in IAP and a higher degree of systemic congestion.

Short-term rapid weight loss induced by bariatric surgery improves ventricular ejection fraction in patients with severe obesity and heart failure

BACKGROUND

Obesity is a major risk factor for the development of metabolic syndrome, coronary artery disease, and heart failure (HF). Rapid weight loss following bariatric surgery can significantly improve outcomes for patients with these diseases.

OBJECTIVES

To assess whether bariatric surgery improves ventricular ejection fraction in patients with obesity who have heart failure.

SETTING

Private practice, United States.

METHODS

We conducted a retrospective review of echocardiographic changes in systolic functions in patients with obesity that underwent bariatric surgery at our institution. Patients were divided into 2 groups, those (1) without known preoperative HF and (2) with preoperative HF. We compared the left ventricular ejection fraction (LVEF) before and after bariatric surgery in both groups. Common demographics and co-morbidities were also analyzed.

RESULTS

A total of 68 patients were included in the analysis: 49 patients in group 1 and 19 in group 2. In group 1, 59.2% (n = 29) of patients were female, versus 57.9% (n = 11) in group 2. The excess body mass index lost at 12 months was 52.06 ± 23.18% for group 1 versus 67.12 ± 19.27% for group 2 (P = .0001). Patients with heart failure showed a significant improvement in LVEF, from 38.79 ± 13.26% before to 48.47 ± 14.57% after bariatric surgery (P = .039). Systolic function in patients from group 1 showed no significant changes (59.90 ± 6.37 mmHg) before and (59.88 ± 7.85 mmHg) after surgery (P = .98).

CONCLUSION

Rapid weight loss after bariatric surgery is associated with a considerable increase in LVEF and a significant improvement of systolic function.

Variation in intraabdominal pressure in patients with acute heart failure according to left ventricular ejection fraction. Results of an intraabdominal pressure study

BACKGROUND

The increase in intraabdominal pressure (IAP) has been correlated with increased creatinine levels in patients with heart failure with severely reduced left ventricular ejection fraction (HFrEF). However, IAP has not been examined in more stable patients or those with heart failure with preserved ejection fraction (HFpEF).

PATIENTS AND METHOD

We conducted an observational, prospective descriptive study that measured the IAP of patients hospitalised for decompensated heart failure (HF). The sample was stratified according to left ventricular ejection fraction (LVEF), with a cut-off of 50%. The objective was to analyse the IAP, the baseline characteristics and degree of congestion using clinical ultrasonography and impedance audiometry.

RESULTS

The study included 56 patients, 22 with HFrEF and 34 with HFpEF. The patients with HFrEF presented a higher prevalence of ischaemic heart disease (11% vs. 6%; p = 0.010) and chronic obstructive pulmonary disease/asthma (6% vs. 2%; p = 0.025). The IAP was higher in the patients with HFrEF (17.2 vs. 13.3 mmHg; p = 0.004), with no differences in renal function at admission according to the LVEF (CKD-EPI creatinine) (HFrEF 55.0 mL/min/1.73 m2 [32.6-83.6] vs. HFpEF 55.0 mL/min/1.73 m2 [44.0-74.9]; p = 0.485). The patients with HFrEF presented a more congestive profile determined through ultrasonography (inferior vena cava collapse [26% vs. 50%; p = 0.001]), impedance audiometry (total body water at admission, 46 L vs. 41 L; p = 0.052; and at 72 h, 50.2 L vs. 39.1 L; p = 0.038) and CA125 concentration (68 U/mL vs. 39 U/mL; p = 0.037).

CONCLUSIONS

During the decompensation episodes, the patients with HFrEF had a greater increase in IAP and a higher degree of systemic congestion.

Evaluation of high-sensitivity C-reactive protein and uric acid in vericiguat-treated patients with heart failure with reduced ejection fraction

Aims

The effects of vericiguat vs. placebo on high‐sensitivity C‐reactive protein (hsCRP) and serum uric acid (SUA) were assessed in patients with heart failure with reduced ejection fraction (HFrEF) in the Phase 2 SOCRATES‐REDUCED study (NCT01951625).

Methods and results

Changes from baseline hsCRP and SUA values at 12 weeks with placebo and vericiguat (1.25 mg, 2.5 mg, 5.0 mg and 10.0 mg, respectively) were assessed. The probability of achieving an hsCRP value of ≤3.0 mg/L or SUA value of <7.0 mg/dL at week 12 was tested. Median baseline hsCRP and SUA levels were 3.68 mg/L [interquartile range (IQR) 1.41–8.41; n = 335] and 7.80 mg/dL (IQR 6.40–9.33; n = 348), respectively. Baseline‐adjusted mean percentage changes in hsCRP were 0.2%, −19.5%, −24.3%, −25.7% and −31.9% in the placebo and vericiguat 1.25 mg, 2.5 mg, 5.0 mg and 10.0 mg groups, respectively; significance vs. placebo was observed in the vericiguat 10.0 mg group (P = 0.035). Baseline‐adjusted mean percentage changes in SUA were 5.0%, −1.3%, −1.1%, −3.5% and −5.3% in the placebo, and vericiguat 1.25 mg, 2.5 mg, 5.0 mg and 10.0 mg groups, respectively; significance vs. placebo was observed in the 5.0 mg and 10.0 mg groups (P = 0.0202 and P = 0.004, respectively). Estimated probability for an end‐of‐treatment hsCRP value of ≤3.0 mg/L and SUA value of <7.0 mg/dL was higher with vericiguat compared with placebo. The effect was dose‐dependent, with the greatest effect observed in the 10.0 mg group.

Conclusions

Vericiguat treatment for 12 weeks was associated with reductions in hsCRP and SUA, and a higher likelihood of achieving an hsCRP value of ≤3.0 mg/L and SUA value of <7.0 mg/dL.

The impact of trans-catheter aortic valve replacement induced left-bundle branch block on cardiac reverse remodeling

BACKGROUND

Left bundle branch block (LBBB) is common following trans-catheter aortic valve replacement (TAVR) and has been linked to increased mortality, although whether this is related to less favourable cardiac reverse remodeling is unclear. The aim of the study was to investigate the impact of TAVR induced LBBB on cardiac reverse remodeling.

METHODS

48 patients undergoing TAVR for severe aortic stenosis were evaluated. 24 patients with new LBBB (LBBB-T) following TAVR were matched with 24 patients with a narrow post-procedure QRS (nQRS). Patients underwent cardiovascular magnetic resonance (CMR) prior to and 6 m post-TAVR. Measured cardiac reverse remodeling parameters included left ventricular (LV) size, ejection fraction (LVEF) and global longitudinal strain (GLS). Inter- and intra-ventricular dyssynchrony were determined using time to peak radial strain derived from CMR Feature Tracking.

RESULTS

In the LBBB-T group there was an increase in QRS duration from 96 ± 14 to 151 ± 12 ms (P < 0.001) leading to inter- and intra-ventricular dyssynchrony (inter: LBBB-T 130 ± 73 vs nQRS 23 ± 86 ms, p < 0.001; intra: LBBB-T 118 ± 103 vs. nQRS 13 ± 106 ms, p = 0.001). Change in indexed LV end-systolic volume (LVESVi), LVEF and GLS was significantly different between the two groups (LVESVi: nQRS -7.9 ± 14.0 vs. LBBB-T -0.6 ± 10.2 ml/m2, p = 0.02, LVEF: nQRS +4.6 ± 7.8 vs LBBB-T -2.1 ± 6.9%, p = 0.002; GLS: nQRS -2.1 ± 3.6 vs. LBBB-T +0.2 ± 3.2%, p = 0.024). There was a significant correlation between change in QRS and change in LVEF (r = -0.434, p = 0.002) and between change in QRS and change in GLS (r = 0.462, p = 0.001). Post-procedure QRS duration was an independent predictor of change in LVEF and GLS at 6 months.

CONCLUSION

TAVR-induced LBBB is associated with less favourable cardiac reverse remodeling at medium term follow up. In view of this, every effort should be made to prevent TAVR-induced LBBB, especially as TAVR is now being extended to a younger, lower risk population.

Extraction of left ventricular ejection fraction information from various types of clinical reports

Efforts to improve the treatment of congestive heart failure, a common and serious medical condition, include the use of quality measures to assess guideline-concordant care. The goal of this study is to identify left ventricular ejection fraction (LVEF) information from various types of clinical notes, and to then use this information for heart failure quality measurement. We analyzed the annotation differences between a new corpus of clinical notes from the Echocardiography, Radiology, and Text Integrated Utility package and other corpora annotated for natural language processing (NLP) research in the Department of Veterans Affairs. These reports contain varying degrees of structure. To examine whether existing LVEF extraction modules we developed in prior research improve the accuracy of LVEF information extraction from the new corpus, we created two sequence-tagging NLP modules trained with a new data set, with or without predictions from the existing LVEF extraction modules. We also conducted a set of experiments to examine the impact of training data size on information extraction accuracy. We found that less training data is needed when reports are highly structured, and that combining predictions from existing LVEF extraction modules improves information extraction when reports have less structured formats and a rich set of vocabulary.

Epicardial CRT-P- and S-ICD Implantation in a Young Patient with Persistent Left Superior Vena Cava

Persistent left superior vena cava is known to be a challenging anatomic abnormality for transvenous cardiac device implantation. In the a case of a young man presenting with dilative cardiomyopathy with severely impaired left ventricular ejection fraction (LVEF) and second-degree atrioventricular block (AV block), cardiac resynchronization therapy (CRT) with defibrillator (CRT-D) implantation was indicated. A transvenous approach was attempted, but placement of the right ventricular lead was not successful due to anatomic abnormalities. Therefore, epicardial CRT leads were implanted via a left mini-thoracotomy. For primary prevention of sudden death, the patient was also fitted with an additional subcutaneous implantable cardioverter defibrillator (S-ICD). Any cross-talk between the devices was ruled out both intraoperatively and by ergometry prior to discharge. The combination of epicardial CRT-P with S‑ICD implantation might be a safe and effective alternative in patients with cardiac anatomic abnormalities.

Diastolic dysfunction in the critically ill patient

Left ventricular diastolic dysfunction is a common finding in critically ill patients. It is characterized by a progressive deterioration of the relaxation and the compliance of the left ventricle. Two-dimensional and Doppler echocardiography is a cornerstone in its diagnosis. Acute pulmonary edema associated with hypertensive crisis is the most frequent presentation of diastolic dysfunction critically ill patients. Myocardial ischemia, sepsis and weaning failure from mechanical ventilation also may be associated with diastolic dysfunction. The treatment is based on the reduction of pulmonary congestion and left ventricular filling pressures. Some studies have found a prognostic role of diastolic dysfunction in some diseases such as sepsis. The present review aims to analyze thoroughly the echocardiographic diagnosis and the most frequent scenarios in critically ill patients in whom diastolic dysfunction plays a key role.

[Blood pressure monitoring - Status quo and future : A contribution to the personalized medicine]

Sustainment of life demands that the heart create sufficient pressure to maintain enough flow to keep the body healthy and oxygenated. Blood pressures can be easily measured, while volume measurements required additional invasive procedures. In analogy to volumetrically determined ejection fraction, a pressure ejection fraction EF(P) may be calculated. When standardized to heart rate and body surface area, a new, effective performance metric may be defined. These metrics enable the long-term monitoring of the critically ill patient. When presented in a performance diagram, the metrics contain prognostic implications and enable a real-time evaluation of the efficacy of therapeutic measures. Until now, pressure-related prognostic statements were based on statistical averages, which by definition apply to groups. With this new analytical approach, we have the ability to provide patient-specific therapeutics in an area of medicine that requires individualized treatment. Here, we show preliminary results of applying a mathematical risk analysis to blood pressure metrics to assess therapeutic risk.

Amelioration of persistent left ventricular function impairment through increased plasma ascorbate levels following myocardial infarction

PURPOSE

Percutaneous coronary angioplasty (PCA) has been demonstrated to reduce mortality and morbidity and thereby improve the prognosis of patients undergoing acute myocardial infarctions (AMIs). However, this procedure paradoxically increases the initial damage as the result of a condition known as 'myocardial reperfusion injury'. Oxidative stress may contribute to the mechanism of this injury. The goal of the present study was to ascertain whether high plasma ascorbate levels could ameliorate the reperfusion injuries that occur after the successful restoration of blood flow.

METHODS

Patients from three clinical centers of the public health system were included in the study. The groups were formed by either-sex patients with a diagnosis of ST-segment elevation myocardial infarction with an indication for primary PCA. Only the patients who presented with their first myocardial infarction were enrolled. Ascorbate was administered through an infusion given prior to the restoration of the coronary flow, which was then followed by oral treatment with vitamin C (500 mg/12 hours) plus vitamin E (400 IU/day) for 84 days. The left ventricular ejection fraction (LVEF) was determined by using cardiac magnetic resonance on days 6 and 84 following the onset of the reperfusion. In addition, the microvascular function was assessed by an angiographic evaluation using the Thrombolysis In Myocardial Infarction (TIMI) myocardial perfusion grade (TMPG). The results were grouped according to the plasma ascorbate concentration achieved immediately following the onset of reperfusion into either the HA group (high ascorbate, >1 mmol/l) or the LA group (low ascorbate, <1 mmol/l). The biochemical parameters were analyzed throughout the protocol.

RESULTS

The LVEF of the HA group was significantly higher than that of the LA group, values on day 84 in the HA group were 33% higher than those of the LA group. The amelioration of the LVEF was accompanied by an improvement in the microvascular dysfunction, after PCA, 95% of the patients in the HA group achieved a TMPG of 2-3, in the LA group only 79% of patients showed a TMPG of 2-3.

CONCLUSIONS

These data are consistent with the protective effect of high plasma levels of ascorbate against the oxidative challenge caused by reperfusion injury in patients subjected to PCA following an AMI. Further studies are needed to elucidate the mechanism accounting for this beneficial antioxidant effect.

A Robust e-Epidemiology Tool in Phenotyping Heart Failure with Differentiation for Preserved and Reduced Ejection Fraction: the Electronic Medical Records and Genomics (eMERGE) Network

Identifying populations of heart failure (HF) patients is paramount to research efforts aimed at developing strategies to effectively reduce the burden of this disease. The use of electronic medical record (EMR) data for this purpose is challenging given the syndromic nature of HF and the need to distinguish HF with preserved or reduced ejection fraction. Using a gold standard cohort of manually abstracted cases, an EMR-driven phenotype algorithm based on structured and unstructured data was developed to identify all the cases. The resulting algorithm was executed in two cohorts from the Electronic Medical Records and Genomics (eMERGE) Network with a positive predictive value of >95 %. The algorithm was expanded to include three hierarchical definitions of HF (i.e., definite, probable, possible) based on the degree of confidence of the classification to capture HF cases in a whole population whereby increasing the algorithm utility for use in e-Epidemiologic research.

Role of cardiac CTA in estimating left ventricular volumes and ejection fraction

Left ventricular ejection fraction (LVEF) is an important predictor of cardiac outcome and helps in making important diagnostic and therapeutic decisions such as the treatment of different types of congestive heart failure or implantation of devices like cardiac resynchronization therapy-defibrillator. LVEF can be measured by various techniques such as transthoracic echocardiography, contrast ventriculography, radionuclide techniques, cardiac magnetic resonance imaging and cardiac computed tomographic angiography (CTA). The development of cardiac CTA using multi-detector row CT (MDCT) has seen a very rapid improvement in the technology for identifying coronary artery stenosis and coronary artery disease in the last decade. During the acquisition, processing and analysis of data to study coronary anatomy, MDCT provides a unique opportunity to measure left ventricular volumes and LVEF simultaneously with the same data set without the need for additional contrast or radiation exposure. The development of semi-automated and automated software to measure LVEF has now added uniformity, efficiency and reproducibility of practical value in clinical practice rather than just being a research tool. This article will address the feasibility, the accuracy and the limitations of MDCT in measuring LVEF.

Predictors of recovery of left ventricular systolic dysfunction after acute myocardial infarction: from the korean acute myocardial infarction registry and korean myocardial infarction registry

Background and Objectives

We investigated the predictors of the recovery of depressed left ventricular ejection fraction (LVEF) in patients with moderate or severe left ventricular (LV) systolic dysfunction after acute myocardial infarction (MI).

Subjects and Methods

We analyzed 1307 patients, who had moderately or severely depressed LVEF (<45%) on echocardiography soon after acute MI and who underwent a follow-up echocardiography, among 27369 patients from the Korea Working Group on the Myocardial Infarction Registry. Patients were categorized into two groups according to recovery of LVEF: group I with consistently depressed LVEF (<45%) at the follow-up echocardiography and group II with a recovery of LVEF (≥45%).

Results

Recovery of LV systolic dysfunction was observed in 51% of the subjects (group II, n=663; ΔLVEF, 16.2±9.3%), whereas there was no recovery in the remaining subjects (group I, n=644; ΔLVEF, 0.6±7.1%). In the multivariate analysis, independent predictors of recovery of depressed LVEF were as follows {odds ratio (OR) [95% confidence interval (CI)]}: moderate systolic dysfunction {LVEF ≥30% and <45%; 1.73 (1.12-2.67)}, Killip class I-II {1.52 (1.06-2.18)}, no need for diuretics {1.59 (1.19-2.12)}, non-ST-segment elevation MI {1.55 (1.12-2.16)}, lower peak troponin I level {<24 ng/mL, median value; 1.55 (1.16-2.07)}, single-vessel disease {1.53 (1.13-2.06)}, and non-left anterior descending (LAD) culprit lesion {1.50 (1.09-2.06)}. In addition, the use of statin was independently associated with a recovery of LV systolic dysfunction {OR (95% CI), 1.46 (1.07-2.00)}.

Conclusion

Future contractile recovery of LV systolic dysfunction following acute MI was significantly related with less severe heart failure at the time of presentation, a smaller extent of myonecrosis, or non-LAD culprit lesions rather than LAD lesions.

The relationship between heart rate recovery and brain natruretic Peptide in patients with chest discomfort: a study for relationship between heart rate recovery and pre-exercise, post-exercise levels of brain natruretic Peptide in patients with normal systolic function and chest discomfort

Background and Objectives

The correlation between brain natruretic peptide (BNP) level and cardiac autonomic function has been studied in type 2 diabetic patients. However, there is limited data from patients with normal systolic function. We evaluated the association between heart rate recovery (HRR) representing autonomic dysfunction and three plasma BNP levels: pre-exercise, post-exercise, and change during exercise in patients with normal systolic function.

Subjects and Methods

Subjects included 105 patients with chest pain and normal systolic function. HRR was defined as the difference between the peak heart rate and the rate measured two minutes after completion of a treadmill exercise test. We measured plasma BNP levels before exercise, 5 minutes after completion of exercise, and during exercise (absolute value of difference between pre- and post-exercise BNP levels).

Results

Patients with abnormal HRR values (≤24 beats for the first 2 minutes of HRR) had lower high-density lipoprotein, lower peak heart rates, and higher pre- and post-exercise BNP levels than patients with normal HRR values. The patients with coronary artery disease (CAD) had abnormal HRR. However, no significant differences were found between the two groups in terms of history of hypertension (HTN), diabetes, and peak systolic blood pressure (SBP) and diastolic blood pressure (DBP). HRR was significantly associated with pre-exercise BNP (r=-0.36, p=0.004) and post-exercise BNP (r=-0.27, p=0.006), but not BNP changes. Further, pre-exercise BNP levels showed a greater association with HRR than post-exercise BNP levels.

Conclusion

HRR is independently associated with pre-exercise and post-exercise BNP levels, even in patients with normal systolic function.