Ratio of Transmitral Early Filling Velocity to Early Diastolic Strain Rate Predicts All-Cause Mortality in Heart Failure with Reduced Ejection Fraction

AIMS

The ratio of early mitral inflow velocity to global diastolic strain rate (E/e'sr) has recently emerged as a novel measure of left ventricular (LV) filling pressure. This new measure has demonstrated to have prognostic value superior to E/e'. This study aimed to investigate the prognostic value of E/e'sr in a large cohort of patients with heart failure with reduced ejection fraction (HFrEF) in relation to all-cause mortality.

METHODS

We retrospectively studied 897 HFrEF (mean age 66 ± 12 years, 73% male, 59% ischemic cardiomyopathy) patients who underwent speckle tracking echocardiography where E/e'sr along with novel and conventional echocardiographic parameters were obtained. The primary endpoint was defined as all-cause mortality.

RESULTS

During follow-up (median: 40 months IQR: 22-57), 137 (15.3%) patients died. Both E/e'sr and E/e' were significantly associated with mortality (E/e'sr: HR 1.03 95%CI [1.02-1.04], p<0.001, per 0.10m increase) and (E/e': HR 1.04 95%CI [1.02-1.06], p = 0.001, per 1unit increase). E/e'sr remained an independent predictor in a multivariable model after adjusting for age, gender, mean arterial pressure, heart rate, BMI, total cholesterol, diabetes mellitus, ischemic cardiomyopathy, LVEF, LVIDd, LVMI, LAVI, TAPSE and LV-GLS (HR 1.02 95%CI [1.01-1.03], p = 0.007) whereas E/e' did not (HR 1.01 95%CI [0.98-1.04], p = 0.57). Furthermore, E/e'sr provided incremental prognostic information beyond a model including known risk factors: age, gender, total cholesterol, mean arterial pressure, heart rate, BMI, smoking status and E/e' (Harrell's C-statistics: 0.72 (0.68-0.77) vs 0.70 (0.66-0.75), p = 0.047).

CONCLUSIONS

In HFrEF patients, E/e'sr provides independent and incremental prognostic information regarding all-cause mortality superior to E/e'.

Safety of Stress Echocardiography Supervised by Registered Nurses: Results of a 2-Year Audit of 15,404 Patients

BACKGROUND

Stress echocardiography has traditionally been performed under the supervision of physicians. In the last decade, at some institutions, specially trained registered nurses have taken on the task of directly supervising and conducting these stress tests with appropriate physician involvement and assistance.

METHODS

The safety of 15,404 stress echocardiograms that were performed under the direct supervision of registered nurses during a recent 2-year period was evaluated.

RESULTS

The stress modality was treadmill exercise in 8592 (56%), dobutamine in 6755 (44%), and transesophageal atrial pacing in 57 (0.04%) patients. The mean age was 65 +/- 13 years, and 54% were male. A total of 55 patients (0.36%) had complications related to stress echocardiography, including 26 patients (0.18%) who were subsequently transferred to hospital. Complications included atrial fibrillation (n = 28, 0.18%), other supraventricular tachycardias (n = 9, 0.06%), sustained ventricular tachycardia (n = 4, 0.03%), and ventricular fibrillation (n = 2, 0.01%). Eight patients (0.05%) were hospitalized for markedly positive tests or prolonged chest pain and 4 patients (0.03%) for symptomatic hypotension. No patient had cardiac rupture or died. Complications were more common with dobutamine stress echocardiography (DSE) (47/6755; 0.7%) compared with exercise echocardiography (8/8592; 0.09%) or transesophageal atrial pacing stress echocardiography (0/57) (P < .0001). Arrhythmias were more commonly associated with DSE (39/6755, 0.58%) than exercise echocardiography (4/8592, 0.05%). Potentially life-threatening ventricular arrhythmias occurred in 6 of 6755 patients who underwent DSE (0.09%) and in none of the patients who underwent exercise echocardiography. Patients who underwent DSE were, on average, older, and had more comorbidities compared with those who underwent exercise echocardiography.

CONCLUSIONS

Stress echocardiography, when supervised directly by specially trained registered nurses, can be performed safely; complications are uncommon (1/280 stress tests) and these complication rates are comparable with previously reported studies evaluating the safety of stress echocardiography supervised by physicians.

[Study of the left coronary trunk by 2-dimensional echocardiography in ischemic cardiopathy]

The study of the left main coronary artery (LMCA) obstruction is very important in view of the risk that it represents for coronarography, the high mortality that it has and its indication of early surgical treatment. For these reasons we studied LMCA obstruction by two-dimensional echocardiography (2-D Echo). The study was blind, prospective and included of 50 unselected patients with coronary artery disease proved by coronarography. The LMCA obstruction was recognized in 5 patients (10%) by 2-D Echo, in two of them it was seen as non-obstructive atheroma and in 3 as a significant obstruction. This LMCA correlated with angiographic findings. We had not false negatives. The patients with LMCA obstruction had higher frequency of positive treadmill test and anteroseptal myocardial infarction. Three patients had bypass surgery with good results. Two had not surgery, one of them died and the other one has angina and heart failure. The 2-D Echo is a useful procedure in the study of LMCA obstruction.